Evolution of medicine and of the hospital. Through the centuries, the European hospital has gone through a real metamorphosis.
Starting from the “Hospitalis Domus”, the house where guests were received during the first centuries of our era, the hospital was primarily the place where Christian charity was exercised through all ages.
Hospitals, or hospices, developed according to the model of the abbeys which were founded and directly managed by its members. Under the reign of Louis XIV, Mazarino created a general public hospital in 1656, whose objective was not far from the existing Christian concept, that is, to give shelter and care to the poor. Often people went to the hospital to avoid having to beg for alms, and above all, to have a place where to die.
Medicine was absent then from the hospital; it was enjoyed exclusively in domicile by those who could pay for it. Popular cure, as it was appropriately called, developed among the “wise women” who handed it down to their daughters. The best example of this tradition is the midwife.
Towards the mid-19th century, with the development of surgical technique as a response to the consequences of war in Europe, and with the discovery of the cause of certain diseases, particularly infectious ones (Pasteur and Koch), Medicine engaged itself in systematic research, which developed along two main directions: fundamental research, and clinical research and the systematic description of important pathological patterns.
Clinical teaching ended up in obliging doctors to exercise their art in the hospital, where they found a “nursery” of patients. New techniques of investigation (the modern stethoscope, X-Ray) developed in parallel manner. World War II, with its multitudes of wounded people, highlighted the necessity of professional service in the places where soldiers were sheltered (after Florence Nightingale and the Crimean War). Rapid progress in new surgical and investigative techniques, as well as research for effective medicines (antibiotics, anaesthetics, analgesics), called for trained assistants.
The doctor, who up to that time, was no more than a simple hospital-goer, soon took on. Moreover, he had to work on the basis of structural studies, linked to the universities which were then considered as the most appropriate context for developing basic research.
Rapid strides in the comprehension of pathological mechanisms generated specializations within the medical profession, which multiplied far beyond the classical distinction between internal medicine and surgery.
The thrust toward specialization accelerated during the second half of the 20th century, up to the point that not only was there a specialist for every organ but also new health care figures entered the scene, such as the geneticist, the nutritionist, and the biological doctor.
The nursing professions evolved in parallel direction. Whereas during the mid-1950’s the nurse almost had the monopoly of the hospital, new professions had to be developed to keep pace with the technological boom – those of radiologists, medical technologists, anaesthetic nurses, psychiatric nurses, paediatric nurses, rehabilitation therapists, dieticians, logopedists, nursing aides, to mention just a few.
2. The hospital today
The hospital as we know it at the start of the 21st century, has gained the top position in terms of technology: technical installations for diagnosis through imaging (interventional radiology, NMR, Pet-scan), highly specialized departments for robot microsurgery, clinical biology laboratories utilizing the discoveries of molecular biology in routine laboratory analyses. Hospital logistics today offer refined hotel service to assure prevention of hospital-incurred sicknesses, necessary sterilized material is accumulated to give a semblance of care-giving, and an infrastructure of hospital pharmaceutical services, once unthinkable, is now an indispensable part of the hospital system.
To assure quality care, still other professional figures have been introduced, which often develop transversally within the structure, for example, the expert of permanent formation, the overseer of quality care, the hygiene specialist, etc.
To top it all, as a consequence of soaring costs in rendering the European health service system functionable (expenses constitute up to 50% of the total financial burden) the hospital financial manager has come into the scene, as a necessary although usually dominant figure.
Thus the hospital has turned into a banal business enterprise, as the aura that once enveloped it as a place offering patient care dissolved. However, no financially advantageous economic consideration, nor any imperative logic of efficiency, can comprehend the feelings, fears, suffering, risks of life and death to of the one for whom – after all - the whole system was conceived: the sick person.
Today over a hundred specialized professions flourish within the hospital complex, without counting the large number of “specialists” who get in-job training. Super-specialization, made necessary by the complex medical, nursing or administrative and logistical machinery – has inevitably led to focusing on consistency inside the hospital organization.
Specialized medical departments, veritable independent clinics within the hospital system – seemed to have evolved towards autarchy. Medical specialization tends to favour an attitude of closure nurtured by the conviction that the personnel in one’s own sector are the best. Such closure can be explained by the will to find one’s identity, to be able to say, “This house is mine”, even as the hospital complex gains more and more gigantic proportions. As cohesion of the department team is reinforced, openness to the outside, in particular to other departments, suffers.
To worsen such fragmentation is the emergence of territorial medico-technical structures. In the last decades the traditional shelter for the sick, which was the hospital, has been transformed into a lodging for “transients”, where clinical check-ups make up for the briefness of hospital confinement. The aim of deriving maximum profits from expensive machinery has largely contributed to shortening the medium duration of hospital confinement.
Where is the patient’s place in all this? He finds himself penalized and optimized through wisely studied “clinical itineraries” meant to render his hospitalization speedy, effective and efficient, to the point that the hospital enterprise is, until now, incapable of seeing, understanding and “taking him in”, in the etymological sense of the term.
4. Commitments to be assumed
1) Towards a new management of competencies.
The responsibility of the institution to dispose of adequate personnel at any time has deeply changed the politics of hiring of personnel. Preference is given to university graduates, and professionalism is gauged according to the degree earned by the applicant instead of formation acquired on field.
However, having a diploma today is no guarantee of expertise in the future. Added to the common responsibility of the individual to keep oneself updated on scientific developments, hospitals organize permanent internal formation courses which their collaborators in general are obliged to attend, be they medics, paramedics or technicians.
Such formation programs can no longer be limited to merely transmitting or incrementing professional skills. They are required to integrate two new branches that, in the cultural space represented by the hospital, are currently underdeveloped:
– Communication skills among people, services, and departments, both horizontal-wise and vertical-wise.
– Ethical knowledge, the question of public health, and the enterprise’s social responsibility towards its collaborators, and towards patients and their families.
2) Passing on to new organization models.
The unexpected emergence of super-specialization, calls for a deep reflection on the hospital’s way of functioning, in the face of the structural boom and the functional isolation of its various departments. Such reflection should have include ethical considerations in relation to solidarity and participation of collaborators as indispensable dimensions in the life of the enterprise.
A closer collaboration is currently developing among medical and surgical fields of specialization, which reunite in specialized centers treating specific bodily organs, such as gastroenterology and digestive system surgery, or tumor surgery and oncology. Bringing together the different actors concerned about treating a specific pathology results in benefits in terms of time-saving, transmission of knowledge, increased awareness of responsibility towards the patient and a net reduction of the risks incurred during hospitalization.
The constitution of a multidisciplinary staff around the patient, constituted not only by doctors such as the oncologist, the radiologist, the radiotherapist, the gynaecologist and the plastic surgeon in case of breast cancer, but also includes the clinical nurse, the social worker, the dietician, the psychologist and the specialist of pain therapy or of palliative care, makes a holistic approach in patient care possible.
Developing a mentality in this direction will, hopefully in the future, allow the patient to act as an informed and indispensable partner in making therapeutic decisions.
Another aspect to be considered in reflecting on the organization are the transversal functions involved in following up the patient, and how these can orient the patient to assume his or her responsibility within the hospital system.
3) Moving towards new paradigms of professional skills in the hierarchy of hospital management.
Excellence in one’s basic profession (medical, paramedical, administrative or logistic) does not necessarily guarantee excellence in directive functions.
Management service in the ever-changing hospital scene, in fact, requires a series of skills that are new and scarcely taught in the traditional medical or paramedical fields. Skills linked to pedagogy, human resources management, conflict management or resistance-to-change management are also necessary, and demands adequate and specialized formation at all hierarchical levels.
4) Towards a new culture of enterprise.
Since all hospital personnel have to be professionalized and their cohesion conserved in spite of their tendency to segregate, new approaches should be devised, such as elaborating an integrated value system to be shared by all collaborators.
This will give coherence to the hospital system and help counteract the continuous threat of structural fragmentation; as a consequence, appropriate patient care would be ensured.
Such values should support institutional aims regarding politics of care and suitable strategies needed to encourage initiatives directed at increasing patient awareness of their own responsibilities.
A change of paradigms is imperative on different levels:
– There should be a return to the hospital’s primitive objectives and the enterprise should be oriented towards the patient.
– There should be also a return to the patient as the center of institutional discussions, professional development efforts and all competencies.
– Attention should be focused on such results as patient satisfaction and improvement in their state of health, rather than on mere social prestige or economic profit.
– Patient care should be managed through evidence-based medicine and nursing instead of serving the actors’ social prestige.
– Efforts should be taken to create a working atmosphere characterized by joy and satisfaction among collaborators, as a result of having consciously given their best for the patient’s good by offering excellent quality care.
by YVONNE KREMMER