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THE CHILDREN'S HOSPITAL OF PHILADELPHIA

 

PHILOSOPHICAL STATEMENT
By

Dr. C. Everett Koop.
Surgeon-in-Chief

Now that the contracts have been signed for the final phase of
the building of the new Children's Hos pital-Child Guidance Medical |
Center, the phySical plant which we have looked forward to for so
long now seems to be a certainty. It is not one day too early to
consider the decade which follows our occupancy of the new building.
We will enter the plant with an entirely different set of circumstances -
than existed even at the time when the - plans for the building were drawn,
These differences exist not only for The Children's Hos pital of
Philadelphia, but they alsy exist in the local community and in the
nation as well. |

Insofar as the hospital is concerned, we will enter a greatly
enlarged facility with a staff that is not commensurately enlarged.
Our endowment and its income will have been. diminished because of the
building program. We will have taken a large portion, of the charitable
. dollar from the local community and may face a reduction in giving in.
some categories of annual revenue. We will be in a plant so large, so
“expensive, that some wonder how it can be Supported. |

In just the few years in which the hospital was a-building, the
community has come alive politically and now demands a part in the
‘planning of health care, The black community, particularly, will not
tolerate being treated as second class citizens. The immediate. com-

munity of the CHOP will be a black population which is a minority
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on the national scene but which locally represents a majority of the
citizens. We may face, as some communities. have, a growing population
of another minority group, the Puerto Ricans, and they will not only
have their own set of demands, but will expect answers in Spanish.
Philadelphia will be dotted with a number of hospitals, some of them
first rate teaching institutions and many of them associated with the
five medicals schools in Philadelphia, each of which must be competitive
in reference to financial survival and the obligations of teaching medi~
cal students and graduate physicians. Each will be experiencing its
own set of financial woes, and will be taking innovative steps to correct
them, Surrounding: Philadelphia there will be several rings of competent, _
attractive community hospitals, many of which deliver high grade medical
care and many of which already have an affiliation with one of the city's.
.medical schools,

On the national scéne only a miracle will have altered the in- |
flationary economic picture. Unions will continue to be active, parti-
cularly Se aliong hospital workers involved in the delivery of health
care. This may well include nurses, Children's hospitals across the .
country with one or two exceptions are already facing the problems of
a declining census. Many of the young activists currently enrolled as
medical students will have graduated and might well be practicing as
graduates. what they preached as medical students ~~ namely, an adequate
spread of medical care to the impoverished and underprivileged in the
city's ghettos and in the country's rural areas. No one is quite cer-
tain what the Situation will be in reference to government supported
research, It is unlikely that money will be available as it was five
years ago, and even if funds are more liberally disbursed, it will take
several years before the research organizations So well established a

decade ago can be tonled up for productive work. Presidential or
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Congressional directives may see fabulously expensive crash programs
undertaken in the direction of finding a cure for cancer, seeking an
answer to transplantation riddles, or just better medical care across
the board to certain groups of citizens, Finally, almost every medical
service will be paid for on some basis -- either prepayment or fee-for-
service or some variation thereof. | |

In this particular climate, the CHOP has sahil choices con~-
cerning its own development in the decade which lies ahead, Those di-
rections Getermined by the CHOP Should be instituted now -- not at the
time of the move, Depending upon the decisions that are made, the end
of the decade will see CHOP as a viable institution or one which has
withered on the vine and died. If CHOP continues to develop ina
straight line patterned upon experience of the past, it will face crises
with expediency and I believe its demise is inevitable. ‘if, on the
other hand, its trustees, administration and staff 100K | on the future
with some vision as well as with a sense of reality, the institution will
not only be viable, but might well be one of two or three surviving ,
outstanding centers for pediatric care.
Cooperation with the Under privileged Community

CHOP is probably ahead of many children's hospitals because of the
present Rebound and Head-Start programs. Nevertheless, active planning
with the black community is absolutely essential for the days that lie
ahead, Either we tiake medical care attractive, pleasant and productive.
for them (and incidentally keep our institutions viable because of finan-
cial support ) ox these people might well burn us out. This means that
we have to look into the black community very hard to find leaders who
are visionary but not contentious and who are acceptable to. their own
people and not regarded as "Uncle Toms". Philadelphia has several such -

*Already recommended since this writing.
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people; the Rev. Leon Sullivan and the Rev. Thomas Ritter have .proven
themselves both locally and nationally. Their cooperation should be
sought. Through action on the part of the hospital, properly advertised
in the black community, we can become the medical center for these
people. It means, however, consideration of surface transportation to
the hos pital, parking for those who can drive, attractive surroundings
in the hospital, ample facilities for snacks and meals, etc, It is
quite likely that we should plan on a 24 hour, adequately manned, non-
appointment ambulatory service clinic.

The Suburban Community and Beyond

In attracting patients from the suburban community and beyond,
the Children's Hospital has to be attractive not only to patients but
to referring physicians. From the patient's family's point of view,
transportation again to and from railroad stations and bus terminals,
For emergency services, there is no Gourt that a helicopter should
be cons idered and there are ways of asking industry in the community
to support such a venture for the public service involved as well as
for the advertising that would be available each time such service
might be used. One hospital in the nation has appealed to a combine
of industries Griticized for their part in the war effort. They were
quick to see the propaganda value of this service to children. All
those attractive facilities mentioned above in reference to the black
community apply, of course, to the suburban community and beyond. The
attractiveness of CHOP to the referring physician is a problem in ite
self and will be cons idered below.
Relationship of the Hospital to Referring Physicians

Some mechanism must be found to relate physicians in outlying
areas to the Children's Hos pital in some meaningful way. There are

Several possibilities: (1) An organic: relationship of physician to
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hospital where the physician might teach community medicine and pedi-
atrics to medical students and house officers. (2) increase the ed-
ucational role of the hospital by periodically having such superb
teaching sessions that physicians would be attracted to the new facility.
(3) TV outlets in Delaware County, southern New Jersey, etc. of grand
rounds, etc. (4) The primary care pediatricians or general practi-
tioners (including os teopaths ) must be locked into a referral patten ©
to CHOP for which they must receive a compensation (aid in laboratory
and x-ray diagnosis, transport of patients, computer billing, and most
important of all -- prestige). (5) Establishment of a paramedical
training program, the trainees in which. and the graduates of which
would be used in CHOP, in the ambulatory satellites, and in the prac-
tices of the primary care Physicians noted above,.

No Matter. what such organic relationships might be developed, .
the final key to all relationships to referring physicians is a Superb —
" system of public relations, and this has nothing to do with the public
relations department of the hospital. Each physician wno refers a
patient to the Children ' s Hospital must be considered by the receiving —
physician or clinic as a4 very important individual in. delivering health
care to this patients. He should be kept informed, by telephone or in
writing at appropriate intervals, The small expenditures involved in
providing copies of X-rays, photographs of operative Procedures or |
surgical Specimens do much to convince such a physician ‘of the superi-
ority of the center to which he sends his patients,

For such a system to work, experience {and statistics bear this
out) has shown that some element of free enterprise has to be part of
the practice of the physician working within the center, The addition
of full time hospital staff is practically never the answer to this

problem, but proper selection of a few full time supervisors of medical
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and surgical staff might be essential to the proper relationship with
xeferring physicians in the long run. In any event it will require a
relationship and an emphasis that has not been part of the major thrust
of the Children's Hospital in many areas in days gone by.
Decentralization of Pediatric Care

‘The magic phrase in public health these days is “delivery of medi-
cal care." With the de-emphasis of research because of the lack of
funds, clinical medicine is seeking new avenues of service. This fits
in well with the claimed desire of students these days to eventually take
medical care to the people. This sounds ‘Like decentralization and an
emphasis away from the center,

‘one of the facts of life that ties in with this trend is-the pre-
diction that within this decade there will be 500 surplus ‘Pediatric beds.
in Delaware Valley. Pediatric units in general hospitals are expensive
to operate, but are essential in community hospitals if one is to give
over-all comprehensive care, [I propose that we make an effort to en-
courage a number of hospitals to close their in- patient pediatric units
and tn substitute for them out-patient ambulatory pediatric centers to
be staffed in part by community hos pital Physicians and part by CHOP
personnel at. both the house staff and visiting staff levels, This would
provide superb ambulatory care in the community, eliminate from ‘the com—
munity the unrealistic cost of providing in patient care in local hos pi-

tals, prevent the current drain financially on the Children: S Hospital
because of its extensive ambulatory services, and provide adequate uti-
lization of our in-patient unit which would be the recipient of referrals
from the outlying satellite ambulatory care centers. It is important to
remember that our administration has declared itself able to cope with
in-patient finances but finds it hard to do the same with out-patient

facilities,
. Medical Devel t utu
| Any teaching, research, Service institution as complex as CHOP
is actually retreating if it is not advancing. It is essential that
we take a long look at the future and select those areas where medical
advance is likely to come about and where research is. likely to be
reflected in service which will be demanded by our patient load, We
have done this in reference to neonatal surgery and intensive care
for the respiratory problems in pediatrics, We must do the same in
planning for the future, |

For example, with advancing genetic knowledge, liberalized abor-
tion laws, etc,, it is unlikely that hemophilia wili be a problem of
major proportions in days to come. Therefore, we should not set a course
on the management of a vast number of hemophiliacs, Instead, we should ~
recognize the fact that some of the major advances that are produced
in the research laboratories are in the field of immunity, and that such
advances have clinical application in medical illness, in the cure of
tumors, and in the eventual conquering of the rejection phenomenon in
transplantation, Such is one area that should be developed. A com-
bined clinic (Ob~Ped) to handle obstetrical-pediatric problems in ‘high
risk pregnancies could be nationally advertised. Every division should
have in it, preferably at its head, an aggressive, confident. individual
dedicated to service and attracting patients to CHOP, |

Every new scheme, every pre-paid plan, every community effort
Should be investigated and joined if need be until deemed unprofitable -<
all to the end of cementing referral patterns. |

To maintain competence in any such developing field an adequate

mass of scientific personnel supported by laboratory and clinical in-
vestigation is essential. Such people, properly selected and designated,

could well be part of reimbursible care in the developing medical
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complex. These thoughts essentially only scratch the surface of the
“gantastic problems which we face as a hospital in view of expanding
medical knowledge and demand for medical Services on the one hand
‘and the inflationary economic trend and lack of government support
for research on the other. With teaching hospitals facing bankruptcy,
with medical schools seeking a way that they can close down, with
universities trying to divest themselves of the cost of medical care
as it is associated with a medical school, the crisis in health care
which we face is a real one, and can only be met by a visionary board
of trustees willing to Support a staff more eager for clinical service
than it has been-in the past as it seeks to predict the future on the
basis of the rapidly changing present. |

Such vision cannot be put into practical use without funds, Tf
cannot believe that innovative community effort’ for the delivery of
health care under Univers ity-CHOP auspices could not be funded by such
foundations as Ford, Kellog, Kresge, John A, Hartford and the Common—

wealth Fund.
It will not be long before some agency in the government, or
the community, ask why such a superb facility as the new CHOP.
should be the exclusive affiliate of. one medical school in a city
that boasts five medical schools.

. We should not only have an answer but also think Seriously of
how three schools might. participate in the educative aspect of our

‘institution.