by Gerald D. Klee, M.D.
[February 1995; Vol. 22 No. 1]
Within a few short years, managed care, in one form or another, has altered the practice of medicine in the United States in alarming ways. As doctors and patients are swept up in these changes, many look back nostalgically to the Golden Days of medical practice, when managed care was unknown. If historians ever study the matter they may find, however, that there were early precursors to managed care, going back at least for decades.
I will share a reminiscence of an early experiment in managed care, which I observed first hand, in 1954, forty years ago, as this is written. This story may sound far fetched, but it really happened! It took place at a large veterans hospital that was devoted chiefly to psychiatric patients. At that time, the hospital was a major university affiliated training site for psychiatrists. The associated medical school had no had in the hospital administration. The patients, most of them chronic, were housed in a number of different buildings scattered over a large rural campus. One building was devoted exclusively to women veterans. Most of the patients in this unit were diagnosed as suffering from chronic schizophrenia. All were extremely psychotic and suffered from symptoms such as hallucinations, delusions, catatonia and so on.
The treatments that could be offered in those days were of limited effectiveness. Insulin treatments were applied in a few cases. Some received hydrotherapy. Occupational and recreational therapy were also provided. Efforts were made to engage many of the patients in individual and group psychotherapy. Psychotherapeutic approaches were usually handicapped by the fact that many of the patients were mute or their conversation consisted of word salads or strange symbolic language. Thorazine had just been introduced and its use was limited. Probably the most effective treatment these patients received was from the nursing staff, who attended to the patients in a devoted fashion, providing them with warm, supportive human contact and teaching them basic social skills.
One of the most fundamental social skills the patients learned from the nursing staff was toilet training. Some of the patients, although neurologically intact, had not been accustomed to routinely using toilet facilities. Instead, they had soiled themselves, the beds or the floors. The nursing staff, under the direction of the dedicated chief nurse, Mrs. Sweet, painstakingly trained most of these patients to use the toilet when they had to relieve themselves. This was a major achievement, therapeutically and socially. The toilet facilities were adequate. Bathrooms were left open 24 hours a day and the patients were free to use them whenever the need arose. This worked well except for ore small problem. It seems that some of the patients would put things into the toilet that did not belong there. Sometimes the toilets would get stopped up with various objects, such as bed sheets. This did not happen with great frequency, but it happened often enough to disturb the hospitals head of maintenance, who had more clout than any of the doctors.
One day a directive, addressed just to our building, arrived from the Clinical Director of the hospital (Dr. 0) who had rarely, if ever, visited the building himself. I have forgotten the exact wording, but this is how it went. The directive announced that patients had been given far too much freedom to use the toilets whenever they felt like it, and this was no way to run a hospital. Many of the patients, the directive went on, had abused the privilege and had caused the hospital too much trouble and expense in fixing the toilets. This is bad for the toilets, bad for the hospital and surely must be bad for the patients as well. Better discipline is needed. These practices must cease at once. Henceforth the toilets will be unlocked 4 hours per day, at most. Patients will not be permitted to go to the toilets any time they feel like it, but only when the toilets are open. When toilets must be used during other times, patients will be escorted by staff members.
This directive came as a complete surprise. There had been no discussion of the subject beforehand, and none was permitted after the directive was distributed. These were the rules! No ifs ands or buts! They must be followed! There was considerable dismay in the building. All the years of effort on the part of the nursing staff went down the drain, while the patients evacuations once again went onto the floor. The low discharge rate of patients dropped even further. Morale was low. People were angry about the situation but there was nothing that could be done.
Mrs. Sweet, however, turned out to be even more resourceful than we ever imagined. She figured out a way to obey the letter of the law while still permitting the patients fairly free access to the toilets. This was achieved by having the toilets closed and locked during the times when most of the patients were out of the building for various activities, and at other hours, such as when patients were in bed for the night. Sometimes the rules were broken when no one was looking. Using imagination and flexibility, the nursing staff usually succeeded in providing the patients with continued access to the toilets without openly violating the letter of the new regulation.
But this misadventure took its toll. Patients suffered. Staff morale was damaged. There must have been a financial price as well due to the setback in patient care. But all the administration noticed was a small drop in plumbing costs, which would have made the experiment appear to be a success.
Anyone acquainted with the problems of treating patients under managed care today will see a similarity between this historical account and what is going on now on a massive scale. They may even detect a familiar odor. It is said that those who don’t study history are doomed to repeat it. Is history being repeated by our modern managed health care system?