Evidence, Effectiveness and Efficiency in Health Care

What if Hippocrates, instead of saying that doctors must ‘do no harm’ to their patients, had said that they must only provide treatments known to work? Evidence-based policy making has been around for centuries – think of Roman engineering – but we think of it as a relatively modern concept. Medicine has progressed through trial and error, and there have been some spectacular, and serendipitous successes, but the ‘art’ of the physician and surgeon has been as important as the ‘science’ behind some of their practices.

While I’ve been here I’ve collected new research material for a book on the history of convalescence and lengths of hospital stays. I’m fascinated by the UK/US comparisons, and wrote an initial overview chapter in my co-edited book on hospital theory and practice in 2013. In the 1940s and 1950s there was trans-Atlantic sniping between surgeons, with the British suggesting that the Americans were unnecessarily risk-taking in their policy of ‘early ambulation’ after surgery. But both nations have been at the cutting edge (sorry) of reducing the length of stay for routine surgical procedures such as hernia repairs, hysterectomies and hip replacements.

It is impossible to understand the reductions in length of stay (from over three weeks for hip replacements in the 1950s to 24 hours now in some places) without considering how hospital medicine is funded. Although the US and UK health care systems have very different funding structures, they share similar historical concerns with the cost of care, and during the second half of the twentieth century have developed a number of techniques for assessing efficiency and effectiveness.

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The old surgical theatre, now used for lectures

Early in my visit I spent a morning with Dr John Stoekle, who in the 1950s pioneered the US version of hospital-based primary health care centres at the Massachusetts General Hospital here in Boston. He’s now in his 90s, but visits his office in the MGH every week, and is a wonderful source of oral history on how US hospitals have changed in response to rising costs of medical care, and the concept of the ‘ambulatory hospital’. He took me to see the ‘Ether Dome’ at the top of the old building (the dome being needed for light for surgery before the introduction of electricity). It was here on 16 October 1846 that a group of Boston doctors and dentists undertook the first successful surgery using ether as an anaesthetic. The MGH is duly proud of its role in medical history, and the surgical theatre is still used daily for grand rounds.

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Ernest Codman’s gravestone

On a trip to Mount Auburn, an amazing 175 acre landscaped cemetery in Cambridge, we came across lots of other worthy Boston medical pioneers. Some, such as Helen Taussig (1898-1986) the cardiologist who developed an effective surgical technique to treat ‘blue baby syndrome’, are well-known. But J spotted another character, not on the official cemetery guide map (look it up http://www.mountauburn.org) who deserves to be better known for his role in developing evidence-based medicine. Ernest Codman (1869-1940) was one of the first clinicians to routinely follow-up the outcome of his patients after they were discharged from hospital. But his colleagues at the MGH in the early twentieth century thought that this a step too far, and he was barred from working at the hospital. His gravestone is unduly pessimistic: by the 1960s health services were beginning to embrace more enthusiastically ‘evidence-based medicine’. I returned to Yale last week to continue working on the archived papers of key individuals involved in reforming hospital management, including John D Thompson who pioneered the Diagnosis-Related Group [DRG] in the late 1960s, and Milton Roemer who demonstrated that the more beds a hospital has, the more patients there will be to fill them.

I’m trying to wind-up my research here now. We spent the ‘Independence Day’ weekend in New York (which included a walking tour with Dan Fox, who naturally had lots of medical history related anecdotes). I have a last-minute rush to look at archives in the wonderful Countway Medical Library, which I will be very sad to leave, and maybe a final trip to the North End of Boston for more stuffed clams and ricotta cannoli…


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