A Week In The Life Of... ...A Hospital

By NANCY GIBBS

A hospital may be the most fascinating place we never want to visit. We know there are triumphs here: fingers reattached, lungs replaced and babies born, small enough to bathe in a big teacup, who would have had no chance 10 years ago but who now go home and grow up. Maybe they will become doctors too. But it is also a war zone, and if you are not fighting the enemy or loading the weapons or plotting the next campaign, you can hardly understand what a brave, brutal, mysterious place this really is.

That is one reason it has been possible for hospitals to reach a point of crisis without most of us knowing how it happened. When your child is lying on a stretcher, or your spouse is worrying about a lump, there is no time to learn about how these places work. You just want them to take care of you. One of the great democratic privileges of American society is the premise that all people have a right to the best possible care, regardless of whether they have the means to pay for it; the law requires hospitals to treat anyone who walks in the door. But today that promise is caught in a collision between money and medicine that is occurring in hospitals all over the country--nowhere more than in the elite academic medical centers that have always led the way in training the next generation of doctors, inventing the next generation of cures, and providing them to those who could least afford to pay.

When TIME set out to tell the story of what is happening, not just on the front lines but also in the backrooms of American medicine, we sought out the kind of institution best equipped to solve the insoluble problem: a world-class teaching hospital where the same urgency and intellect that is applied to saving lives is assigned nowadays to saving the institution itself. All across the country, teaching hospitals are trying to figure out how to marry progress with profits, how to come up with the money that will let them continue to lead the world in death-defying discoveries, without going bankrupt in the process.

Duke University Medical Center is one of the crown jewels of American medicine. In the labs, wards and classrooms spread out over the 210-acre medical campus in the North Carolina Piedmont, doctors are pushing hard against the limits of our imagination: tiptoeing electronically through the brain in search of hidden tumors, inventing vaccines that might turn lethal cancers into treatable ones, even breeding animals whose organs could one day be harvested for transplant to make up for the shortfall in human donors. These men and women muscled their way through college and medical school and internships and fellowships, just for the chance to work 100-hour weeks, live on hospital food, only rarely find time to see their families or to exercise, and drive cars that are not as fancy as the ones owned by their colleagues down the road at the fancy for-profit hospital. They chose Duke largely because of the scientists here and the work they do; yet they have come to realize that today their survival depends on decisions being made by the suits down the hall in the business office.

As amazing as the medicine is, the money behind it is just as stunning. The medical center's total budget is $1.3 billion a year, and it has to come from somewhere. Not long ago, hospitals such as Duke relied on a neat juggling act: they would charge private insurers a little extra for a heart operation or a box of paper tissues and funnel the profit into all the extremely unprofitable things they do: teach students, do research and treat the poor. It worked fine, until managed-care companies and government cutbacks began shrinking those payments, and for-profit hospital chains started buying up community hospitals and competing for patients and revenues.

This means the same doctor who spends her morning treating a child for a leukemia that would surely have killed him five years ago has to spend the afternoon arguing with the insurance company over whether it will pay for what she has done. The revolution in how medicine gets paid for is moving so fast that "virtually no one knows what is going on," says Duke medical-center chancellor Ralph Snyderman, who has watched the assault on hospitals from inside and out. "The whole managed-care system has the potential to kill us," he says. Now that the most obvious waste has been wrung out of the system, even the strictest health-care companies are having trouble maintaining their profits. In 1994, 90% of HMOs reported profits. By the third quarter of last year, only 49% did so. And hospitals like Duke are sprinting to keep up with the pace of change.

Duke's leaders are blunt about its condition. "If we were a business, we'd go under," says Peter Kussin, chief medical officer of the hospital. "We're not patient friendly. We're not market sensitive. We're profligate, wasteful and arrogant. We have to change. But that doesn't mean we have to sell our souls." What it does mean, however, is throwing out every assumption they bring to the table about what a teaching hospital does. Or as Kussin says, "You've got to tear the mother down."

In its place, Duke is building an enormous spider web across the Piedmont, pulling people into the Duke University Health System. Rather than treating only the sickest patients with the rarest diseases, it is buying up, merging or affiliating with doctors' practices, a community hospital, a hospice, a home-care agency and even its own managed-care operation. The idea is to insure a steady stream of patients into the system; to build a network that ensures that no one stays in an expensive intensive-care-unit bed who could be moved down to the wards or even out to a skilled-nursing facility; to develop enough market clout to negotiate discounts with suppliers and insurers; and to place enough emphasis on preventive care and public education so diseases are caught early, before they require the kind of expensive care that has driven costs so high.

In some ways, the Duke experiment runs against everything we assume about the fight over paying for health care. "The best medicine," Snyderman says flatly, "will be cost-effective medicine. And we're betting the hospital on that." Duke has been cutting $30 million a year for each of the past five years. It is why it is opening clinics in high schools and in poor neighborhoods, staffed largely by nurses and physician assistants, in hope that it is more convenient for a poor working mother to bring her sick kid to a clinic around the corner than wait hours in the emergency room, where everything costs more. It is why the orthopedic surgeon rebuilding the shattered wrist is thinking about which set of rods and pins will do the job but cost the least. It is why the surgeon who pioneers a new way to fix a shoulder by using tinier instruments to make smaller incisions is a hero to his bosses as well as his patients: they can go home sooner, and the endoscopic-surgery unit is partly subsidized by U.S. Surgical, a huge medical-equipment manufacturer, which is delighted by any promising new procedure that will create a demand all over the country for new precision instruments.

It all makes sense on paper, but no one can safely predict that this is really going to work in practice. Only in theory does prevention save money, and there is an argument that the opposite is true. Everyone is going to die of something; helping people avoid heart attacks and strokes may well mean the patients will wind up with more chronic illnesses that cost more money to treat over the course of their lifetime.

Good scientists have faith in their ability to solve even impossibly complex problems; that's the world they live in, where the disease that killed their parents is unknown to their children. The hospitals will survive somehow because we need them to: our lives and safety depend on it. But the challenges they face are not just medical: they are about economics and social policy, ethics and politics, and the solutions are unlikely to emerge from any one laboratory, or without considerable pain.

TIME tracked this struggle for a week, up close, around the clock. To walk these halls is to watch the practice of medicine as it changes before our eyes, and to realize that when doctors talk about blood on the floor, they don't mean only the patient's.