In July 1965 George Sheldon began his first year of surgical residency at the University of California, San Francisco. He completed his surgical training in 1969 and spent the next 2 years as a National Institutes of Health fellow in surgical biology at Brigham Hospital in Boston. He then joined the faculty at San Francisco General Hospital, moving from assistant professor to professor before he left to become Chairman of Surgery at the University of North Carolina. During the period of his tenure in San Francisco rapid and dramatic changes were taking place in the city-county hospital where he worked, many the result of his academic leadership. Many of these changes were mirrored in other public hospitals throughout the United States [1].
In order to appreciate this revolution in indigent medical care, it is appropriate to review the history of public hospitals in the United States. Initially, in the British colonies in America when populations were small and primarily rural, care for the indigent sick was primarily in the home. As cities developed and grew, however, poverty intensified. Gradually, as the burden of care increased, particularly among the migrant and immigrant poor, buildings were set aside as almshouses. The first almshouse was opened in 1732 in what was then the largest American city, Philadelphia. Local officials found themselves responsible for the care of the aged, the chronically ill, the prematurely disabled, homeless women before and after childbirth, foundlings, orphans, the feeble minded and mentally ill, the alcoholic, and those with medical and surgical illness. These unfortunates were collected into almshouse-workhouses where those who could were forced to work to earn their keep.
The indigent sick consisted of only a small portion of those admitted and the line between sickness and dependency was poorly defined. Healthy and convalescent inmates were expected to work to offset the cost of their care. The initial Philadelphia almshouse had one ward devoted to the indigent ill, another to the insane, and the remainder to the indigent poor. Gradually the almshouses evolved to more sharply define the sick and separate them from the healthy indigent. These became the first public hospitals, funded by cities and counties, to take care of the indigent sick. When bacterial disease was recognized at the turn of the century communicable disease hospitals evolved which were separate from but part of the public hospital system. Tuberculosis cases were not isolated from the general medical wards in San Francisco until 1908, for example.
Hospitals in the 19th and the first part of the 20th century were primarily public and devoted to the indigent ill. The development of private hospitals lagged well behind public hospitals because private patients could be taken care of adequately in the home where medicines could be as easily administered as in the hospital. Even surgery could be carried out in the home using kitchen tables if necessary. This was stimulated by the fact that hospitals tended to disseminate infection and had overtly high mortality rates. Before the knowledge of the germ theory of disease, the hospital was an extremely dangerous place to have an obstetrical delivery or an operation.
The first medical schools tended to be organized around the public hospitals. In 1864 Hugh Toland built his new medical school in San Francisco adjacent to the county hospital. This school would become the University of California Medical School in 1872. In 1865 Toland was granted permission to use the county hospital for medical student teaching. A new policy negotiated in 1879 gave the medical school, now under the University of California, responsibility for professional care and staff appointments and allowed medical students to care for patients for the first time. Shortly thereafter Cooper Medical College (later to become Stanford) was given similar responsibility. At this point the county hospital added four internship positions, two for each medical school.
As regards postgraduate education, this developed slowly in the 1920s and 1930s at San Francisco General (SFGH) and only became organized along modern lines following World Ward II. A medical doctor in California was licensed as a physician and surgeon and an internship was all the postgraduate training most physicians had before entering practice. The resident physician was the equivalent of the chief of the medical staff and was paid a salary to live in the hospital and supervise the medical care provided by the interns and attending staff. Initially this position had indefinite tenure and at times the resident physician also served as hospital administrator.
In the 1920s, the two universities sharing SFGH negotiated 1-year postgraduate positions above that of the intern. These were referred to as house officers. Whereas the internship was a general position rotating through all services, the house officerships, of which each university had four, provided the first specialty training at SFGH. There was one for obstetrics-gynecology, one for pediatrics-infectious disease, one for medicine and one for surgery. At this point the resident physician appointment was limited to 1 year. The selection of the new resident was now limited to one of the surgical house officers. At this point the resident position was rotated annually between UC and Stanford.
In the mid 1930s a chief surgical resident was negotiated for both services and after World War II the residencies of both services were given a structure similar to that of today. The difference was that the junior and senior residents all competed in pyramid fashion for the one chief surgical residency.
Interns and house officers up through the mid 1960s were provided room and board, uniforms and laundry and a small stipend of $10 to $20 a month. Until the end of World War II they were expected to live in the hospital and could not be married. After World War II many of the older returning veterans were married and the requirement was abanded. Nonetheless, on the medical and surgical services, call was 3 nights out of 4 on alternate emergency weeks and every other night when the opposite university service took emergency call. Salaries remained minimal and either the wives worked or the military veteran had the GI bill, which provided an education subsidy.
The staff were all volunteer faculty who were provided a university clinical appointment. They served because of their love of teaching and because of the interaction with students and residents, tended to sharpen their own clinical skills. The chiefs of the major services usually received a small stipend from their university but all supported themselves in private practice. The services were resident run, the chief and senior residents supervising their juniors. The chief of each service visited and made rounds once a week and the junior attendings consulted with the chief resident and visited two to three times a week for a few hours. The residents did all the surgery. The attendings scrubbed when asked to help on a particularly demanding case. The chief of service would operate only when there was a particularly interesting or demanding case.
Medical insurance for all practical purposes did not exist. Two classes of patients made up the county hospital population. There were those problems of disease and neglect just referred to involving any age group, which had a high incidence among the indigent. Then there were the elderly. those who had worked all of their lives, were no longer employed, and developed the infirmities of aging Most could not afford private hospitalization for care of the degenerative disease which affected them after retirement. This latter group represented the nicest class of the ill and, if they did not resent their dependency on the charitable hospital, constituted a grateful group of patients. Patients with venereal disease were shunned by the private hospitals and had no place else to go. The care and treatment of infectious illness fell primarily on the public hospital. The police provided the primary delivery system, as they constituted the initial responder to most emergency medical problems
The public hospital has always had a major role to play in emergency care. For all practical purposes, until the late 1960s, private hospitals did not have emergency rooms. The reasons were pragmatic and economic; medical insurance was negligible and patients paid for medical care out of pocket. Provision of emergency care was costly. Private physicians were not anxious to work nights or weekends and most patients who presented to emergency rooms were needy and poor. Moreover it was difficult to collect a debt from a patient with whom no previous relationship had been established. Private patients, who had a previous relationship with a physician, could meet that physician at his office, where most minor emergency care was delivered or at the hospital, depending upon telephone screening.
San Francisco had a unique system of emergency care. It initiated a horse drawn ambulance system in 1895. As the city expanded and more ambulances were needed they were based in the various sections of the city where they could respond immediately to emergencies. A central dispatcher would phone the ambulance station nearest the emergency. The ambulance would leave its base, and, if the emergency were minor the casualty would be returned for evaluation and treatment to the ambulance station where a physician was located. If a major problem were encountered, the emergency patient was taken directly to the emergency room at San Francisco General Hospital. This constituted the city’s sole emergency ambulance system. All emergencies whether affluent or indigent were delivered to one of the city’s emergency rooms or ambulance stations. Once emergency treatment was administered and a patient needed further hospitalization he or she was transferred to a private hospital by private transport.
Medical care up through the mid 1960s was a two-tiered system. There was the private sector with their nice hospitals, abundantly staffed with nurses and private doctors. Then there were the county hospitals, which functioned with bare bones staff, marginal equipment and supplies. Hospital facilities were spartan. San Francisco General Hospital in the 1960s had 1,100 beds primarily located in open wards (Fig. 1).
Chief nurses, more than any other person, were responsible for the level of care. They ran these wards with martial discipline. When an intern or house officer entered the ward, they were well advised to check with her and follow her lead. Woe be the occasional house officer who crossed her. The chief of service was quick to point out that interns and house officers were expendable, the chief nurse was not. The open wards facilitated patient care where staff was limited. The nurse could look down the length of her ward and quickly note any patients in distress. At night there was usually one nurse for several wards.
Patients helped look after one another by notifying the nurse of anyone in trouble. In the wintertime the medical wards were crowded as beds were pushed together, separated only by a nightstand (Fig. 2). As needed, beds were placed longitudinally down the center of the ward, then down the corridor. There were two private rooms for dying patents or those requiring isolation. When circumstances were desperate, one of the two elevators might be stopped on the floor and used as an isolation room.
Interns were the go-fors. They pushed patients to radiology and located old charts. In addition to histories and physicals, they did the routine laboratory work, started all intravenous lines, changed dressings, and worked 12 to 14 hours on the days they were off.
When the city was short of money there would be a budget freeze. When nursing positions turned over no hiring was allowed until the budget was met. X-ray film purchases were cut back, laboratory services cut, and food, even in the doctors’ dining, room, was cut to basic subsidence.
This was the nature of things when George Sheldon came upon the scene. The county hospital was to represent nearly half of his University of California surgical experience.
Advent of Medicaid and Medicare
In November of 1965, 5 months after Sheldon started his surgical residency, the Medicare-Medicaid bill was passed by Congress. Medicare was designed to keep the aged population in the private health care system they had been able to afford when gainfully employed. Medicaid was passed to provide care for medically indigent persons when supplemented by matching State funds. Now in theory, there should be no need for public hospitals!
Many efforts were made by the private sector to stop construction of a new San Francisco General Hospital, which was badly needed to replace the outmoded facility. This was in the planning phase at the time Medicaid and Medicare bills were passed. “It is not necessary,” said the County Medical Society and the Private Hospital Association. “Give us the money that you are spending on the Hospital and we will take care of all of your patients.”
After the passage of Medicaid and Medicare there was an immediate change in the status of public hospitals in California as they too could bill Medicare and Medicaid for the services they provided. To do this, however, they had to comply with Medicare guidelines, as now there was to be only one standard of care. In order to bill, housestaff supervision had to be documented to ensure efficient delivery of services. The volunteer system of staffing by part-time physicians and surgeons had to be replaced by full time-staff. However, these services, as well as those of the house staff, could be billed for.
The stimulus to upgrade level of care in public hospitals was financial. In 1952–1953 the total SFGH budget was 11 million dollars of which 9 million came from the tax base. In the first year, following the onset of Medicaid and Medicare, one half of the budget previously supported by the tax base was now paid by state and federal governments. By 1970–1971 the total hospital budget had escallated to 65 million, of which only 8.5 million came from the tax base.
This recognition of the beneficence of the federal and state programs resulted in several immediate dramatic events. The nurses at San Francisco General Hospital initiated the first nursing strike in the country. Nurses in 1966 represented the stability and continuity of programs. House staff and attending physicians came and went but the senior nurses constituted the basic core of patient care. These women, particularly the chief ward nurses, had to be devoted to the poor to withstand the hardships and long hours taking care of their many challenging problems for minimal pay. At the time of their strike they noted that the salaries of the janitors and the street sweepers exceeded theirs. Unions protected the former; the nurses had no such protection and were exploited everywhere. This first strike at San Francisco General was successful and nursing salaries and working conditions were moderately improved. This strike at SFGH precipitated a national wave of strikes that resulted in improvement in nursing salaries and working conditions in both the public and private sectors. However, further rounds of strikes and threatened strikes were required before nursing salaries began to reach some semblance of parity with equivalent training in other industries.
Another major change occurred when the house staff demanded a living wage, laboratory support and more regulated hours. With the advent of Medicaid and Medicare, all physicians were eligible to receive pay for the indigent care that most of them had previously provided free. Why, under these circumstances should interns and residents work for little more than room or board? Many of them were married; many had debts left from the expense of medical school. Why shouldn’t they receive a living wage? Hospitals protested but the argument was hard to counter and gradually house staff wages and benefits escalated so they and their families could subsist outside the hospital. Menial, nonrewarding chores were gradually taken over by others.
George Sheldon probably saw his salary escalate from that of $30 a month as an intern, to $120 as a first year resident then as the results of house staff activism to $1,200 to $1,500 as a chief resident—now a livable wage but still barely so. If calculated on the basis of hours worked it was still below minimum wage.
The wave of closing of public hospitals that was predicted did not occur. Small county hospitals entered into contracts with local private hospitals and closed. However, with one major exception, Philadelphia General Hospital, almost all of the major city public hospitals “hunkered down” and survived. Those public hospitals that survived and did the best were those that developed special programs which had public appeal and political support. In this regard, San Francisco General was one of the first to develop a specialized trauma program and in 1968 was the first to develop a comprehensive city-county trauma system in which George Sheldon played a major role.
Several things were happening simultaneously in San Francisco as Medicare and Medicaid were passed and implemented in 1965–1966. The first of these was the Vietnam War. In 1964 communist North Vietnam allegedly fired on American ships. This gave the Johnson administration the excuse to commit American troops to support the South Vietnamese against the communist North. This resulted in the need to draft young men in this increasingly controversial conflict. In 1966 young protestors of the war began to accumulate in the Haight-Ashbury district of San Francisco to demonstrate against the war and the establishment that was supporting it.
Simultaneously psychiatrists had determined that incarceration of the mentally ill was no longer necessary, because mind-altering drugs were available that could control depression and agitation. As the result, the psychiatric wards at San Francisco General Hospital, which contained several hundred patients, were emptied into the street and where the mentally ill were to receive therapy in widely distributed clinics. This was at least partially responsible for introducing the drug culture into the city. The protestors in the Haight-Ashbury eschewed alcohol, the drug of the previous generation, in favor of the “uppers and downers” now available on the streets.
Paradoxically, the protests against the violence in Vietnam introduced even more violence in American cities and resulted in far more injuries and deaths among the youthful protestors than were occurring in the war they were protesting. San Francisco, up until 1966, had been a benign place. People could walk the streets at night without fear. What violence did exist was primarily confined to the poverty stricken areas of the city. However, as the result of the introduction of the drug culture, crimes of violence doubled between 1966 and 1967, then doubled again the following year with the escalation continuing into the 1970s.
The drug culture initially was composed of individual entrepreneurs who fought among themselves; then organized crime arrived and wiped out the little guys. The big guys fought among themselves. In order to support their drug habits addicts resorted to theft and robberies. Drugs not only precipitated random acts of violence, but violence was also directed against the establishment and public institutions were attacked. There were riots on the campus of San Francisco State University and riots in the streets. Violent protests against the war led to police action and retaliatory violence directed against the police, with bombs being set off in police departments.
Anti-establishment gangs such as the Symbionese Liberation Army (SLA) who kidnapped and killed the black superintendent of schools and kidnapped the heiress Patty Hearst contributed to the mayhem. The casualties that developed involving police, rioters, and innocent bystanders kept San Francisco General in the headlines.
This excitement and the challenges associated with casualty management permitted the recruitment of the most outstanding graduates of the UC program for the SFGH surgical staff—Robert Lim, George Sheldon, Don Trunkey, and Frank Lewis. They came with innovative and creative ideas. Their suggestions for the most part were immediately put into practice as the city ambulance system provided SFGH with a monopoly of all the emergency cases in the City of San Francisco. Robert Lim reorganized the emergency room to facilitate evaluation and resuscitation of major casualties. One half of the surgical residents were assigned exclusively to the emergency room and the trauma service. (The remainder served in the clinics and did the elective surgery.)
At that time the standard means of resuscitation from cardiac arrest was the closed method of chest compression. This was fine when the cause was a cardiac death because blood volume accumulated in and behind the heart. However the exsanguinated patient did not respond to these measures. The chief of surgery was called urgently to the emergency room one day to find that one of his residents had opened the chest of a victim with a chest stab wound, had controlled the cardiac hemorrhage digitally and restarted the heart. He now wanted a little help putting everything back together. George Sheldon’s action precipitated the decision to open the chests of trauma victims who arrested in our emergency room. This initial success was never matched again because the ambulance attendants noticed these miracles of resuscitation and brought in long-dead victims for treatment. While still in residency Sheldon organized and drilled his team of residents, establishing a martial demeanor and improved the team approach to resuscitation.
Important patient support following the successful surgical treatment of massive trauma was critical care and those of us interested in this aspect of care identified the respiratory distress syndrome and how to differentiate it from congestive failure with which it was being confused. Victims of trauma who lost renal function were found to regain function if sufficient fluid was given. Many experts felt that pushing fluids under these circumstances was sure to increase mortality from lung failure. There were constant arguments with our anesthesia chief, who had also trained as an internist, over his refusal to provide more fluid during surgery. Only the advent of the Swan-Gantz catheter, which was still years away, finally convinced him that the edema associated with the respiratory distress syndrome was low-pressure permeability edema, as the surgical staff believed, not high pressure edema of excess fluid administration.
Having supported patients through the first round of trauma and respiratory failure the trauma service was confronted with the problem of patient nutrition. When there were massive abdominal injuries the gut could not be used and these patients gradually wasted away until lowered resistance to infection resulted in pneumonia and death. At this point in time, 1971, a savior emerged. George Sheldon was back from his 2-year stint in surgical metabolism and nutrition with Francis Moore in Boston. He initiated the hospital’s intravenous surgical nutrition program and founded the hospital’s nutrition service. This ability to support patients was the final addition to the life-saving measures necessary to optimize survival of trauma victims.
Following his return from Boston George Sheldon organized our program project grant in trauma and helped bring together all trauma related research which included his own nutritional research laboratory (Fig. 3). The local news media kept the trauma center in the limelight. The average citizen of San Francisco might not to go to SFGH for his or her regular care however most felt threatened by the epidemic of violence and were convinced that that was where they would want to be treated if they suffered injury.
As the result, the hospital’s annual budget presentation before the Board of Supervisors justified most all major expenditures, medical or surgical, as necessary to serve the trauma center. These budgets easily passed and the private sectors attempts to close the hospital fell on political deaf ears. The new San Francisco General Hospital was successfully opened in 1976. It contained the ambience, resources, and support services equivalent to the newest private hospital in the city.
The trauma service continued to expand and grow over the next several decades. It received many commendations for the quality of care and innovative techniques that developed from this rich clinical experience. The research program, initially led by Sheldon, has contributed numerous papers to the American Association for the Surgery of Trauma. The hospital has established itself as one of the leading trauma programs in the country and has since produced five presidents of our major trauma association.
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