My Life and Work
When they graduate, places are always open for them in the shops at good
wages. The social and moral well-being of the boys is given an
unobtrusive care. The supervision is not of authority but of friendly
interest. The home conditions of every boy are pretty well known, and
his tendencies are observed. And no attempt is made to coddle him. No
attempt is made to render him namby-pamby. One day when two boys came to
the point of a fight, they were not lectured on the wickedness of
fighting. They were counseled to make up their differences in a better
way, but when, boy-like, they preferred the more primitive mode of
settlement, they were given gloves and made to fight it out in a corner
of the shop. The only prohibition laid upon them was that they were to
finish it there, and not to be caught fighting outside the shop. The
result was a short encounter and--friendship.
They are handled as boys; their better boyish instincts are encouraged;
and when one sees them in the shops and classes one cannot easily miss
the light of dawning mastery in their eyes. They have a sense of
"belonging." They feel they are doing something worth while. They learn
readily and eagerly because they are learning the things which every
active boy wants to learn and about which he is constantly asking
questions that none of his home-folks can answer.
Beginning with six boys the school now has two hundred and is possessed
of so practical a system that it may expand to seven hundred. It began
with a deficit, but as it is one of my basic ideas that anything worth
while in itself can be made self-sustaining, it has so developed its
processes that it is now paying its way.
We have been able to let the boy have his boyhood. These boys learn to
be workmen but they do not forget how to be boys. That is of the first
importance. They earn from 19 to 35 cents an hour--which is more than
they could earn as boys in the sort of job open to a youngster. They can
better help support their families by staying in school than by going
out to work. When they are through, they have a good general education,
the beginning of a technical education, and they are so skilled as
workmen that they can earn wages which will give them the liberty to
continue their education if they like. If they do not want more
education, they have at least the skill to command high wages anywhere.
They do not have to go into our factories; most of them do because they
do not know where better jobs are to be had--we want all our jobs to be
good for the men who take them. But there is no string tied to the boys.
They have earned their own way and are under obligations to no one.
There is no charity. The place pays for itself.
The Ford Hospital is being worked out on somewhat similar lines, but
because of the interruption of the war--when it was given to the
Government and became General Hospital No. 36, housing some fifteen
hundred patients--the work has not yet advanced to the point of
absolutely definite results. I did not deliberately set out to build
this hospital. It began in 1914 as the Detroit General Hospital and was
designed to be erected by popular subscription. With others, I made a
subscription, and the building began. Long before the first buildings
were done, the funds became exhausted and I was asked to make another
subscription. I refused because I thought that the managers should have
known how much the building was going to cost before they started. And
that sort of a beginning did not give great confidence as to how the
place would be managed after it was finished. However, I did offer to
take the whole hospital, paying back all the subscriptions that had been
made. This was accomplished, and we were going forward with the work
when, on August 1, 1918, the whole institution was turned over to the
Government. It was returned to us in October, 1919, and on the tenth day
of November of the same year the first private patient was admitted.
The hospital is on West Grand Boulevard in Detroit and the plot embraces
twenty acres, so that there will be ample room for expansion. It is our
thought to extend the facilities as they justify themselves. The
original design of the hospital has been quite abandoned and we have
endeavoured to work out a new kind of hospital, both in design and
management. There are plenty of hospitals for the rich. There are plenty
of hospitals for the poor. There are no hospitals for those who can
afford to pay only a moderate amount and yet desire to pay without a
feeling that they are recipients of charity. It has been taken for
granted that a hospital cannot both serve and be self-supporting--that
it has to be either an institution kept going by private contributions
or pass into the class of private sanitariums managed for profit. This
hospital is designed to be self-supporting--to give a maximum of service
at a minimum of cost and without the slightest colouring of charity.
In the new buildings that we have erected there are no wards. All of the
rooms are private and each one is provided with a bath. The rooms--which
are in groups of twenty-four--are all identical in size, in fittings,
and in furnishings. There is no choice of rooms. It is planned that
there shall be no choice of anything within the hospital. Every patient
is on an equal footing with every other patient.
It is not at all certain whether hospitals as they are now managed exist
for patients or for doctors. I am not unmindful of the large amount of
time which a capable physician or surgeon gives to charity, but also I
am not convinced that the fees of surgeons should be regulated according
to the wealth of the patient, and I am entirely convinced that what is
known as "professional etiquette" is a curse to mankind and to the
development of medicine. Diagnosis is not very much developed. I should
not care to be among the proprietors of a hospital in which every step
had not been taken to insure that the patients were being treated for
what actually was the matter with them, instead of for something that
one doctor had decided they had. Professional etiquette makes it very
difficult for a wrong diagnosis to be corrected. The consulting
physician, unless he be a man of great tact, will not change a diagnosis
or a treatment unless the physician who has called him in is in thorough
agreement, and then if a change be made, it is usually without the
knowledge of the patient. There seems to be a notion that a patient, and
especially when in a hospital, becomes the property of the doctor. A
conscientious practitioner does not exploit the patient. A less
conscientious one does. Many physicians seem to regard the sustaining of
their own diagnoses as of as great moment as the recovery of the
patient.
It has been an aim of our hospital to cut away from all of these
practices and to put the interest of the patient first. Therefore, it is
what is known as a "closed" hospital. All of the physicians and all of
the nurses are employed by the year and they can have no practice
outside of the hospital. Including the interns, twenty-one physicians
and surgeons are on the staff. These men have been selected with great
care and they are paid salaries that amount to at least as much as they
would ordinarily earn in successful private practice. They have, none of
them, any financial interest whatsoever in any patient, and a patient
may not be treated by a doctor from the outside. We gladly acknowledge
the place and the use of the family physician. We do not seek to
supplant him. We take the case where he leaves off, and return the
patient as quickly as possible. Our system makes it undesirable for us
to keep patients longer than necessary--we do not need that kind of
business. And we will share with the family physician our knowledge of
the case, but while the patient is in the hospital we assume full
responsibility. It is "closed" to outside physicians' practice, though
it is not closed to our cooperation with any family physician who
desires it.
The admission of a patient is interesting. The incoming patient is first
examined by the senior physician and then is routed for examination
through three, four, or whatever number of doctors seems necessary. This
routing takes place regardless of what the patient came to the hospital
for, because, as we are gradually learning, it is the complete health
rather than a single ailment which is important. Each of the doctors
makes a complete examination, and each sends in his written findings to
the head physician without any opportunity whatsoever to consult with
any of the other examining physicians. At least three, and sometimes six
or seven, absolutely complete and absolutely independent diagnoses are
thus in the hands of the head of the hospital. They constitute a
complete record of the case. These precautions are taken in order to
insure, within the limits of present-day knowledge, a correct diagnosis.
At the present time, there are about six hundred beds available. Every
patient pays according to a fixed schedule that includes the hospital
room, board, medical and surgical attendance, and nursing. There are no
extras. There are no private nurses. If a case requires more attention
than the nurses assigned to the wing can give, then another nurse is put
on, but without any additional expense to the patient. This, however, is
rarely necessary because the patients are grouped according to the
amount of nursing that they will need. There may be one nurse for two
patients, or one nurse for five patients, as the type of cases may
require. No one nurse ever has more than seven patients to care for, and
because of the arrangements it is easily possible for a nurse to care
for seven patients who are not desperately ill. In the ordinary hospital
the nurses must make many useless steps. More of their time is spent in
walking than in caring for the patient. This hospital is designed to
save steps. Each floor is complete in itself, and just as in the
factories we have tried to eliminate the necessity for waste motion, so
have we also tried to eliminate waste motion in the hospital. The charge
to patients for a room, nursing, and medical attendance is $4.50 a day.
This will be lowered as the size of the hospital increases. The charge
for a major operation is $125. The charge for minor operations is
according to a fixed scale. All of the charges are tentative. The
hospital has a cost system just like a factory. The charges will be
regulated to make ends just meet.
There seems to be no good reason why the experiment should not be
successful. Its success is purely a matter of management and
mathematics. The same kind of management which permits a factory to give
the fullest service will permit a hospital to give the fullest service,
and at a price so low as to be within the reach of everyone. The only
difference between hospital and factory accounting is that I do not
expect the hospital to return a profit; we do expect it to cover
depreciation. The investment in this hospital to date is about
$9,000,000.
If we can get away from charity, the funds that now go into charitable
enterprises can be turned to furthering production--to making goods
cheaply and in great plenty. And then we shall not only be removing the
burden of taxes from the community and freeing men but also we can be
adding to the general wealth. We leave for private interest too many
things we ought to do for ourselves as a collective interest. We need
more constructive thinking in public service. We need a kind of
"universal training" in economic facts. The over-reaching ambitions of
speculative capital, as well as the unreasonable demands of
irresponsible labour, are due to ignorance of the economic basis of