Sometimes, as the young Georgetown surgical trainee hurried down D.C. General's corridors past workmen banging away at renovations, a curious feeling came over him. He imagined they were doctors like himself, struggling to revive a patient whose heart had stopped.
"It's like when you resuscitate a patient who's going down the tubes," he said. "They pour a lot of money into D.C. General and I'm not sure how much they're getting out of it."
D.C. General has survived its cardiac arrest -- three years ago when it was unaccredited and close to death. Now, two years later, there has been progress. But tight funds, staff shortages and competition with private hospitals -- the chronic diseases of a city hospital -- still threaten its life.
Those who have watched the hospital since its darkest days in the mid-1970s say they are heartened by improvements in its administration, staffing, emergency room and other departments.
"For the first time in many, many years, D.C. General has a chance of becoming a real hospital," said Dr. Michael Rolnick, who did his intership there in 1972 and is now director of Georgetown University Hospital's emergency department.
But the future of D.C. General depends on how it meets a series of challenges:
Ending court jurisdiction. On May 29, U.S. District Court Judge Barrington D. Parker denied motion to end five years of monthly monitoring by the court. Instead, he asked for further proof by Oct. 29 that D.C. General can locate up-to-date medical records on its patients, and further improvements in nursing and the intensive care units.
Achieving lasting accreditation. Executive director Robert Johnson expects D.C. General to receive its third consecutive one-year accreditation this year rather than the customary two-year accreditation. This is the last year that the hospital can receive a one-year accreditation. If two-year accreditation is denied again next year for any reason other than building violations, D.C. General will lose its accreditation again -- and that means the hospital would lose federal funds, doctors and patients.
Improving the performance of doctors. Gilbert Hahn, the hospital commission chairman, said the hospital's next goal must be to upgrade the standards governing the residents (doctors in training) to work at D.C. General. Medical director Stanford Roman said that even with better residents, the staff doctors must shoulder more responsibilty for the patients.
Weathering the city's financial crisis. The hospital's 1980 budget has been cut by more than $1 million, and Johnson said the city's failure to pay D.C. General's bills is interrupting services, as suppliers refuse to provide needed chemicals and equipment.
Meeting the increasing medical needs of the poor. Medical and surgical beds at the hospital have been at 95 to 100 percent occupancy since last summer. Because beds were full, ambulance have been routed away from the hospital as much as 30 percent of the time in recent months. With the closing last month of three city-run clinics and the impending closing of a city psychiatric ward, administrators say D.C. General may be swamped -- particularly if the city cuts health benefits for the poor.
Setting its own priorities: should D.C. General break away from the city government, as Baltimore City Hospital is trying to do, to be run as a seperate corporation? Should it close under-used departments such as obstetrics and in-patient pediatrics? Should it expand its role as "family doctor" to southeast Washington? All these long-range questions confront hospital administrators as they deal with more immediate problems.
The class-action suit that put D.C. General under court jurisdiction in 1975 is viewed now by administrators as an unwanted blot on the hospital's record. Hahn said the suit forced improvements in care at D.C. General that have benefited patients. But he now wants "to get rid of that lawsuit on the ground that we are no longer in a category that calls for supervision by the court."
But Judge Parker is unconvinced. His May 29 order pinpoints two areas of continuing concern: medical records and nursing care.
A survey by the hospital a year ago hshowed that the medical records department, then in the process of converting its filing system, could find complete records for only 52 percent of patients scheduled for appointments at the hospital's clinics. Parker has ordered another survey this month to demonstate that at least 90 percent of the records are now available.
Administrators are confident the hospital can comply, although Dorothy A. Dinsmore, head of medical records, said that even under the new system, a few of D.C. General's 600,000 patient records still disappear on their way to the clinics. "It's as if there's gremlins around the place," she said.
Parker's demands for improvement in nursing may be harder for D.C. General to meet. He ordered the hospital to provide an average of almost five hours of nursing for each patient every day -- despite the continued nursing shortage.
He also said that by Oct. 29 D.C. General must meet its own standards of optimum numbers of nurses in intensive care units on 85 to 90 percent of daily shifts. The standards state that there should be no more than three patients for each registered nurse in the intensive care units, and enough nurses to provide 12 hours of nursing care a day for each intensive care patient.
As of last November, D.C. General was providing the optimum number of registered nurses on only one-third of the shifts in its cardiac intensive care unit.
If the hospital fails to comply by the Oct 29 deadline, it risks being held in contempt of court and enduring further legal battles. Administrators may appeal the May 29 order.
Even if D.C. General wins its fights with the court and the accreditors, it must continue to cope with deficiencies in the care provided patients.
Improving care means attracting better residents to train there, including more American medical graduates, Hahn said. Roman said that supervising large numbers of residents is difficult, since their medical training and fluency in English varies.
Howard University has succeeded in attracting more American graduates to its training programs at the hospital. But Georgetown's associate chief of medicine, Dr. Milton Corn, called the recruitment of trainees for Georgetown's medical residency at D.C. General "a very serious problem."
Roman said the future of the hospital's training programs -- and the care given patients -- will also depend greatly on whether staff doctors' longstanding practice of leaving most patient responsibility to residents can be changed.
He and other doctors at D.C. General hope that the formation of a doctors' corporation at the hospital -- planned for this October -- will increase the incentives for staff doctors to supervise residents. Staff doctors who choose to join the corporation would give up their status as salaried 40 hour-a-week civil servants. Instead, the physicians' group would contract with D.C. General to be paid for services they provide. Salaries thus would be related more closely to actual patient care, and specialists would be paid at a rate more competitive with private hospitals.
Day-to-day work at the hospital is suffering the effects of Washington's fiscal crisis. D.C. General's $32 million appropriation from the city for the year ending this Sept. 30 -- money that enables it to care for the 60 percent of its patients who have no health insurance -- has been cut by more than $1 million. Its 1981 appropriation, part of the city budget still being considered by Congress, may be shaved by a similar amount.
Executive director Johnson said the cuts bring the hospital close to where it must begin to reduce services. If Mayor Marion Barry decides to reduce the city's payments for Medicaid and the Medical Charities program -- which Barry has said he will not do this year -- Johnson fears the hospital could not handle the flood of patients who would be turned away by other District hospitals.
"Where would people go?" he said. "There's no other hospital that would be able to take them. The reason [other hospitals] send them to us is they can't take patients who are unable to pay."
Already, he said, the city's cash flow problem has caused it to delay paying D.C. General's bills, and the hospital is having trouble with suppliers. Its laboratory cannot do certain blood tests because a chemical firm has refused to deliver chemicals. Recently, an X-ray manufacturer refused to replace a broken tube. The hospital's advertisements for nurses temporarily stopped running in the Washington Post because a bill for several thousands dollars was unpaid by the city treasury.
Johnson is negotiating with the city about giving D.C. General its own account, so that hospital financial officers can pay bills instead of sending them through the city accountants.
"We just can't go on this way," he said. "Something's got to give."
If D.C. General gains greater financial autonomy, it would be one more step in the process of wresting control of the hospital from the District government.
Another would be passage for proposed changes to the D.C. Personnel Act, which would give the hospital's Commission authority to revise personnel rules and pay classifications for all employes -- effectively removing D.C. General from the civil service system. Johnson said this would speed hiring and firing, and "allow us to be competitive with other hospitals" in recruiting nurses, doctors and technicians.
A third step toward autonomy would be to allow the hospital to sign contracts directly with construction firms, rather than continuing to require the hospital's contracts to go through the city's Department of General Services. Johnson says that operating through the department adds from 7 to 20 percent to overhead, and denies hospital administrators input on planning renovations.
Ultimately, Johnson would like D.C. General to do what Baltimore City Hospital is on the point of doing -- sever the reins of city government, and turn over control of the hospital to an independent, non-profit corporation. That step has been endorsed by Baltimore's mayor, William Schaefer, and is being considered by the city council. If it passes, it will be voted on in Balitmore's election this November.
If the plan passes, Balitmore would continue to own the city hospital's land and buildings and to pay an annual subsidy, but the present hospital commission, appointed by the mayor, would be replaced by a board of trustees like that of any private hospitals.
Such a move at D.C. General, Johnson said, would provide the efficiency the hospital needs to compete with private hospitals -- and to survive. "We think we can do it and still meet the city's requirements . . . in a way that would be satisfactory to city government and the public," he said.
The survival of D.C. General may become increasingly important to the city. Since the closing last month of three city-run clinics -- the Upshur Street clinic in northwest Washington, the Parkside clinic in northeast, and the Arthur Capper clinic in southeast -- Roman said D.C. General doctors have already noticed an increase in the number of pregnant women using the hospital's obstetrics clinic.
He said in the past few months more patients are being admitted from the emergency room, putting a strain on the availability of intensive care beds.
Reduction of psychiatric services at the neighboring Area C mental health center is presenting D.C. General with another dilemma: dangerously psychotic patients come to the emergency room and doctors have nowhere to send them. Roman said D.C. General has no psychiatric ward, St. Elizabeths Hospital frequently will not accept transfers, and soon the Area C center will stop admitting psychiatric patients.
Roman said the hospital's planned expansion of outpatient services to southeast Washington residents, coupled with the city's cutbacks in other health programs, makes it impossible to predict what the future need for D.C. General will be.
"Anybody that tries to guess at how many beds D.C. General needs right now would have to be a soothsayer," he said.
Johnson said that as long as there are thousands of District residents without health insurance, the city will need D.C. General. He said there might be enough beds in Washington to hositalize patients if D.C. General should close -- but that private hospitals would not support the burden of caring for all those who cannot pay.
Hahn pointed out the irony of D.C. General's position: To survive, it must compete with private hospitals in efficiency and quality, yet it is handicapped by its mission to care for the patients other hospitals send away.
"No matter how much you say you want it to be like a private, non-profit hospital, it is, in the end, the hospital of last resort," he said.