C. Everett Koop Papers Separation Sheet (2 copies - 1 to `Removed From' folder, 1 to `Transferred To' folder) Item Title: Children's Hospital of Philadelphia Philosophical Statement (includes 2003 remarks by Dr. Koop) Description /Notes: Removed From: Transferred To: Date: 4 Sep 2003 Date: 4 Sep 2003 Processed By: MIA Processed By: MIA Series: Speeches Series: metadata entry and scanning Subseries: Subseries: Folder: Children's Hospital of Philadelphia Folder: Philosophical Statement [includes 2003 UZ s'. GLa&m~ remarks by Dr. Koop], ca. 1971-72 Box # mkbti Box # 113a Folder # Folder # 1 Additional Processing Activity (Date - Action - Processed By) NLM/HMD/DMP - S/l 8/99 etf CHILDREN'S HOSPITAL DF PHILADELPHIA /VI- /5 2, i?,. 1' PHIiZSDPHICAL 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 Hospital-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 Hcspital of Philadelphia, but they also, 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 ,301lar 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 ex@,ensive, 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 -2- :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 have their own set of demands, but will expect answers will not only 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 schbols in Philadelphia, each of which must be competitive . in reference to financial suruival 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.Philadel,phia 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 scene only a miracle will have altered the in-' fiationary economic picture. Unions will continue to ,be active, parti- cularly so'among hospital workers involved in the. delivery of health care., This may well include nurses. Childrenjs hospitals across the. country with one or two exceptions are already facing the problems of a declining census. Many of the young activis.ts 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- ta.in 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, i.,t will take several years before the research organizations so well established a decade ag5 can be tooled up for productive work. Presidential or CongreSSional undertaken in directives may see fabulously expensive crash programs 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 th,is particular climate, the CEOP has several choices con- . cerning its own development in the decade which lies ahead. Those di- rections determined 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 in a 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 look on the future with some vision as not only be viable, outs tanding centers well as with a sense of reality, ,the institution will but might well be one of two or three surviving for .pediatric care. Cooperation with the Underprivileged 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 make medical care attractive, pleasant and productive for then (and incidentally keep our institutions viable because of finan- cjal support) or 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 Tams", Philadelphia has several such *Already recommended since this writing. -4- 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 tr,ansportation to the hospital, 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 SuburbanCommunity and Beyond In attr,&ting patie,nts 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 doubt that a helicopter should be considered and there are ways of asking industry i," 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 criticized for their part in the war effort. They were quick to see the propaganda value of this service to children. .A11 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 it- self and will be considered below.' Relationship of the Hospital to Referring Physicians Some mechanism must be found to relate physicians in outlying areas to the Children's Hospital in some meaningful way. There are several possibilities: (1) An organic.relationship of physician to -5- hosp;tal where the physician might teach community medicine and p&i- . 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 ro.unds, etc. (4) The primary care pediatricians or general practi- tioners (including osteqpaths) 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 relationshi.ps to referring physicians is a su,perb system of public relations, and this has nothing to do with the public relations department of the hospital. Each physician who refers a patient to the Children's Hospital must be considered by'the receiving, physician or clinic as a very important individual in delivering health care to this patients. Se should be kept informed, by telephone or in writing at ap,propriate 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 t0 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 Tf full time hospital staff is 'practically never the answer to th,is problem, but proper se\ection of a few full time supervisors of medical -6% a& surgical staff might be essential to tbe proper * referring physicians in the long run. In any event relationship and an emphasis that has not been part relationship with it will require a 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 s.eeking new avenues of service. This fits in well with the claimed desire of students these days to eventually take medical care to the peo.ple. This sounds like decentralization and an emphasis away from the center. One of the facts of life that t.ies in, with this trend is'the pre- diction that within this decade there will be ,500 surplus pediatric beds in Delaware Valley. Pediatric units ingeneral hospitals are expensive to operate, but are essential in community hospitals if one is to giv.e 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 tq substitute for them out-patient ambulatory pediatric centers to be staffed in part by community hospital physicians and part by CHOP personnel at both the house staff and visiting- staff levels. This, would provide superb ebulatory care in tbe community, eliminate from.the com- munity the unrealistic cost of providing in patient care in local hospi- tals, prevent the current drain financially on the Children's Hospital because of-its extensive ambulatory services, anc provide adequate uti- lization of our in-patient unit which would be tbe recipient of referrals * L from the outlying satellite ambulatory care centers. It is important to remember that our administration bas declared itself able to cope with ' in-patient finances but finds 'it hard to do the same with out-patient facilities. -7- &dical Development for the Future Any teaching, research, service 'institution as com.plex as'CHCP 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 will be a problem of major proportions in days to come. Therefore, we should'not set a course on tbe 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 cliqical in- vestigation is essential. Such people, properly selected and des.ignated, could well be part of reimbursible care'in the developing medical -8- complex. These thoughts essentially only scratch the surface of the - . fantastic 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 than it has been-in the past as it seeks to predict the future on the- basis of the rapidly changing present. eager for clinical service Such vision cannot be put into practical use without funds. I cannot believe that innovative community effort'for the delivery of health care under University-CHOP auspices could not be funded by such foundations as Ford, Kellog, Kresge, John A. Hartforg 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. I We should not only have an answer but also'think seriously of how three schools might participate in the educative aspect of our institution.