The 15-year-old kid has been nicked in the shin by a bullet meant for someone else, but he doesn’t let that keep him down. As paramedics whisk him through the automatic doors to the emergency room of D.C. General Hospital, he’s half out of his stretcher, re-enacting the scene of that afternoon’s shooting at Metropolitan Police Department headquarters. “And the gunman turned like this…,” he’s saying, wheeling his torso around and taking aim with an imaginary TEC-9 before a nurse presses him gently back onto the sheet.
Pretty soon, he’s unconscious and his black denims have been cut away, exposing the superficial wound, which a resident swiftly treats. He awakens in the Minor Trauma unit of the ER, next to a heavily sedated man who lost a chunk of leg flesh to his own Rottweiler. Standing over the kid are two uniformed D.C. cops and a detective wearing a suit, who shoos me away. Blood seeps slowly through the gauze on the kid’s leg and pools on the bedsheet. The cops go back to debating the pros and cons of Rottweilers as a breed.
Every patient seems to have his or her own police escort here, which is just one of the things about D.C. General Hospital that surprised acting Executive Director Dennis Gowie when he took over the hospital last August. The gleam of handcuffs on a blue-gowned patient is an everyday sight at D.C. General, which is the primary care provider for D.C. inmates. I watch a corrections officer lead a shackled prisoner onto an elevator, while another keeps an eye on a prisoner in the trauma unit who attempted to hang himself at Lorton, failed, and is now handcuffed to his stretcher.
A cop lounges outside a small room that contains yet another handcuffed prisoner, slumped unconscious over a chair. The cop is talking to a Department of Corrections officer. Both of them try to ignore the young woman strapped to a bed in the psychiatric observation room, screaming, “For the love of Jesus!” over and over at the top of her lungs, as she noisily attempts to break free.
“I got $10 says she gets out of that bed,” says the corrections officer, finally, and the cop shakes his head and smiles.
Throughout its 188-year existence, the institution now known as D.C. General has provided de facto universal health care to the residents of the District. Or at least it has tried to; typically, only people with no alternative have taken advantage of its services. But it has always seemed inadequate to this colossal mission. It has flirted, at various times, with bankruptcy and excommunication from the respectable medical community. Never, until now, has it faced both at once.
As is well known, the hospital is hanging by a fiscal thread, crippled by massive operating deficits. What is less widely recognized is that it is struggling medically as well, having only this summer survived a threat to its accreditation under the Medicaid and Medicare programs—its largest sources of revenue by far. At the same time, it manages to be both expensive and, in some areas, only marginally competent.
Of course, the hospital has always been a drain on District coffers. It was founded as the city poorhouse, and that’s what a poorhouse is supposed to do: cost money. Worth remembering, however, is that D.C. General was running a small surplus as recently as 1987, even as its annual subsidy from the D.C. government was being slashed. Since then, it has accumulated a deficit fast approaching $100 million—and that’s just the hospital. Its losses for fiscal 1994 are expected to total $36 million, even with a $48-million city subsidy.
So what the hell happened to D.C. General? And what should be done to save it? As the fixers and health care policy types debate how to rescue D.C. General, its story serves as a cautionary tale of how not to run a hospital—particularly, how not to run a large, urban, public hospital. By any rational stand ard, the place should simply be closed: Its beds are not needed, its usage is declining, and the money poured into it could purchase better care for more people through existing hospitals and clinics and health maintenance organizations (HMOs).
Closing is possible, particularly if the city falls under federal receivership, but pretty unlikely. In the meantime, someone will have to untangle this unpretty collision of the city’s two primary problems: bureaucracy and poverty. If history is any guide, the hospital will continue to be plagued by the malaise and misfortune that have bedeviled it since its establishment. There’s no escaping the curse of D.C. General.
Out in the waiting room, about three dozen people wait in chairs, bundled against the chill that blows through the sliding doors, and seemingly resigned to a long wait. Their complaints, according to the register of incoming patients, traverse a wide spectrum of misery: They include a broken arm, a sprained ankle, a body rash, a “trauma to mouth” and a “trauma to head,” a detox case, two chest pains, and three colds—in addition to the kid’s gunshot wound (“GSW,” in hospital shorthand).
Time creeps by. A few patients try to nap in chairs that seem specifically designed to thwart sleep. The television blares, but the magazine rack is empty. A week ago, it held exactly one periodical: an old issue of Home Office Computing whose cover story was headlined “Clients From Hell.”
Whether or not someone put that magazine there on purpose, it has a point. The city’s only public hospital serves its hardest cases: the tiniest babies, the severest infections of tuberculosis and syphilis, the most bullet-riddled victims of urban gunplay. Its client base comprises the poorest, unhealthiest people in one of the sickest cities in the nation, and it treats more than its fair share of the drunkest and the craziest. D.C. tops the national charts in hepatitis, gonorrhea, syphilis, TB, infant mortality, and the spread of HIV, according to the Centers for Disease Control, and ranks well above the national averages for deaths by cancer, heart disease, and liver ailments.
The statistics and the surveys and the morbidity and mortality reports become real here in the waiting room, into which 169 people walk, crawl, or are carried on an average day. The numbers are personified in the battered face and body of one man in particular, a stooped, bearded gentleman who shuffles up to a nurse in the waiting area. His red leather shoes and black woolen overcoat retain some of their former elegance, but his breath is boozy and his walk unsteady, despite the assistance of a cane. His bloodshot eyes peer out of a face swollen and crisscrossed with scars, testament to a life lived in medieval misery. He clearly suffers from ailments that are worse, in the long run, than the swollen, purple thumb he cradles.
“I’m in pain,” he moans. “I been here for two hours, and they ain’t gave me nothin’.” The hospital can’t give him a painkiller until he’s been seen by a physician, explains Naomi Brody, the ER supervisor, and the doctors are all busy now. The waiting room is almost full, and besides, there seems to be some confusion as to the man’s precise ailment. His thumb was slammed in a car door, he says, and it certainly looks mashed, but on the inpatient log he’s listed as complaining of abdominal pain.
“I’m in pain,” he moans again, returning dispiritedly to his seat. “I’m in pain.”
In June, patients were complaining of emergency room waits as long as seven hours—and not just for sprained ankles, but for serious abdominal pain accompanied by vomiting. A botched delivery at D.C. General recently resulted in a $3.1-million jury verdict against the city. And the hospital’s death rate for Medicare patients was the highest in the city until 1991, when the federal government stopped releasing such data. The horror stories are old hat, almost: in 1951, a man in his 50s died in the waiting room, where he’d been sitting for eight hours.
On the other hand, it’s a miracle that D.C. General treats those people at all. The hospital recorded almost 200,000 visits last year, about a third by people with no other option. If D.C. General doesn’t treat them, nobody else will. Unique among District hospitals, D.C. General pledges to treat all residents of the District, regardless of ability to pay. And it does its job well enough that some people will wait weeks to get an appointment and then hours on the day of that appointment, rather than suffer the shabby neighborhood clinics run by the Department of Human Services. (Not the man with the purple thumb, however. By the time his name is called, he is long gone.)
While D.C. General was intended to serve the entire city, the place is as familiar to one half of Washington as it is alien to the other half. “I’ve had more people ask me where it is, in the last few weeks,” says Barry Passett, the former chief of Greater Southeast Community Hospital, who is studying D.C. General for Mayor-elect Marion Barry. “It’s too bad nobody in Washington goes over there and knocks around and sees the place.”
It’s not hard to find. Drive east on Massachusetts Avenue, and eventually the avenue delivers you to the hospital’s gate. To the right loom the twin squat towers of the D.C. Jail, their mean windows surveying the hospital’s always-full parking lots; to the left, off in the distance, are the Armory and RFK Stadium. In front of you sprawls the jumbled mass of brick that is D.C. General.
Buildings seem to blend into each other and spread out in every possible direction; it’s not always easy to tell where one structure ends and its neighbor begins. Actually, D.C. General is comprised of nine buildings, from the brand-new Ambulatory and Critical Care Center (ACCC), which houses the emergency room and intensive care units, to the utterly decrepit Archbold Hall, a relic of the ’20s. Once a state-of-the-art hospital, Archbold now contains only a few administrative offices. The roof leaks incessantly and not a single window appears to hang straight in its frame, which is why the building is slated to be closed next year.
D.C. General maintains only 303 inpatient beds, but its huge physical plant could house a hospital five times that size. Indeed, its vast scope and its deteriorating buildings—a constant throughout its history—are costly. Their upkeep accounts for 40 percent of the hospital’s nonpersonnel costs, the Rivlin Commission found in 1990, which is why D.C. General’s maintenance expenses run twice as high as the average for public hospitals.
Inside, a visitor is impressed by the corridors that seem to stretch beyond the horizon, and the tunnels that seem to descend into the center of the earth, where the kitchen is shrouded in clouds of steam. Residents and nurses hurry from room to room, dodging patients on stretchers and orderlies pushing carts loaded with disused-looking and inexplicable medical equipment. Quite a few people seem to be missing limbs or digits, and everyone keeps a safe distance from the patients under police guard.
Inside the labyrinth, one finds clinics and facilities of every imaginable sort. Two pharmacies hand out free prescription drugs. There’s a physical rehabilitation ward, a cardiac catheterization lab, a urinalysis lab, and a radiology lab. There’s an outpatient clinic run by Howard University, and another staffed by Georgetown University postgraduates, plus a dental clinic. There are five intensive care units, and no fewer than three emergency rooms: pediatric, obstetric, and general. One entire building is devoted to pediatrics. In another building, a wing of one floor is given over to detox and substance-abuse treatment, where recovering addicts spend time making bas-relief paintings from plaster of Paris.
The hospital is huge because it must be, in order to make good on the D.C. Council’s generous promise when it wrested control of D.C. General from the mayor in 1977: “No D.C. resident will be refused care because he is unable to pay.” Build it, and they will come: Plenty of D.C. residents interpreted this as an offer of free medical care. Linda Ivey recalls using the ER in place of a regular doctor when she was a student, because it was free. “That’s what you did—you went to D.C. General,” says Ivey, now the hospital’s director of community relations.
D.C. General suffers from the same ambiv alence about health care that bolloxed the Clintons. We’re a society that won’t allow people to die in the streets, but we’re equally unwilling to pay for universal health care—unless it’s disguised as a general hospital. So D.C. General, like other urban hospitals, finds itself spending a lot of money on an emergency room to treat people with colds alongside victims of gunshot wounds and auto accidents, as well as people whose ailments are more mental than physical.
Such as the gaunt, bearded man who appears at the ambulance entrance, trailed at a hygienic distance by, of course, a D.C. police officer. The vomit encrusting the patient’s beard and coat leave little doubt as to the nature of his malady. He stands by the registration desk, looking lost, until someone vacates a chair for him and he sits down.
This is the other function of the ER: a refuge for people unable to care for themselves. “We’re like home to some of these people,” says the supervising doctor, a 40ish woman who would rather not be identified at a time when her colleagues are being RIFed. “We bathe them, feed them, and send them out to do it all over again.” Even if the vomit-crusted man wanted to go through alcoholism treatment, the 20-bed substance-abuse ward upstairs is always full.
The hospital serves as a high-priced shelter, or even a nursing home, as much as a medical facility. In one cubicle, a white-coated resident is yelling at an elderly woman lying on a stretcher, unconscious, immobile, her face frozen and her mouth gaping open. Her only signs of life are the irregular heaving of her chest and the blip of a green heart-rate monitor.
“Mrs. Baltimore!” the resident yells. “Mrs. Baltimore!”
No response. “Does she have anyone waiting for her outside?” Apparently not.
Gingerly the resident pulls back her sheet and examines the IV needle embedded in the withered flesh of her leg. “Oh, my God,” he says, to no one in particular.
Throughout its long and protean history, D.C. General has always been the last stop for the crazy, the drunk, the sick, the poor, and the dying, and it has always depended on some form of charity, whether private or governmental. It’s always been expensive, and always overburdened with its clients’ problems.
D.C. General’s pedigree is as long as it is checkered. This mutt of an institution is part poorhouse, part asylum, part hospital, part medical school, and part jail. Its earliest known ancestor, however, was the “Washington Infirmary,” established in 1806 at 6th and M Streets NW with a $2,000 handout from Congress. Nobody was fooled by the fancy, quasi-medical title, and the building was always known as the poorhouse.
In the 1840s, Congress converted a jail at Judiciary Square into an insane asylum, but then thought better of it and built a new asylum on the banks of the Anacostia River, at the eastern end of Massachusetts Avenue—the present site of D.C. General. The Judiciary Square building became a public hospital of sorts, to be used to teach medical students at Columbian College (now part of George Washington University). A little later, the hospital and the poorhouse were consolidated and moved to 19th and Massachusetts SE as well, along with a workhouse for offenders—a precursor to the D.C. Jail that is the hospital’s next-door neighbor. The whole compound became known as the “Washington Asylum Hospital.”
The institution expanded in a random, piecemeal fashion. Frame buildings sprouted all over the 60-acre compound, serving as barracks for wounded Union soldiers, wards for smallpox and tuberculosis sufferers, confinement for the insane, and housing for nurses. Some buildings were begun and never finished; the others burned down with some regularity.
Still, it grew faster than it was destroyed: Another smallpox quarantine building was built, and later converted to a TB ward; a new building went up to house the psychopathic; and a new jail opened. For a short time, jail and hospital were under a single administration.
Even then, the hospital had its critics: In 1897, the Board of Charities of the District of Columbia condemned the facilities as “wholly unsuitable for the purposes of the sick.” No money was appropriated to correct its defects, but the hospital did get a new name. In 1922, the patchwork institution was rechristened “Gallinger Municipal Hospital,” in honor of a senator (natch) from New Hampshire.
Things were looking up. New, modern buildings were built, largely financed by Rockefeller heiress Anne Archbold. The building that bears her name, a 300-bed inpatient hospital, opened in 1929 and still stands, barely. When another 250-bed isolation building was opened to treat contagious diseases, the hospital reached a turning point. For more than a century, it had provided its services free to all comers; everybody who could afford to go someplace else did. In what today’s health systems managers would term a “revenue enhancement initiative,” all patients were thenceforth charged $3 per day.
Gallinger at least looked like a real hospital: It had a large surgical clinic, separate buildings for men and women, and almost 1,500 beds. It treated all of the fashionable down-and-outers’ diseases, with whole clinics devoted to venereal disease and syphilis, and a 226-bed building for sufferers of tuberculosis. And yet, much to its doctors’ frustration, Gallinger never quite outgrew its 19th-century roots as poorhouse, nursing home, and asylum.
Even then, Gallinger was the target of frequent investigations, which uncovered various unsavory practices: Clinicians quieted psychopathic patients by strapping them to their beds, and even beating them; and corruption was rampant, particularly in food service, where supplies mysteriously disappeared, forcing patients to subsist on bean soup for days. The Washington Post regularly deplored hospital conditions in editorials headlined “The Gallinger Mess” and “Gallinger Scandal.” An angry Senate removed its powerful superintendent, Edgar Bocock, in 1943.
A dozen years later, the place still festered. In a letter to the D.C. Commissioners in 1955, the hospital’s medical staff bemoaned the institution’s allegiance to an “obsolete concept of [its own] function,” and cited “critical and gross deficiencies existing at the hospital.” Specifically, the docs complained that Gallinger lacked modern research facilities, the ability to treat cancer, and a radioisotope lab (the sort of gear that D.C. General critics are proposing to eliminate today). It was sorely understaffed, and it faced chronic shortages of such essentials as insulin and clean sheets and towels.
“We feel it is a disgrace that the city hospital of the nation’s capital…should set such an example before the rest of the world,” they declared.
But that was long ago. Now, as in 1955, D.C. General stands before the world as an example of how not to run a public hospital, but for different reasons. In less than 40 years, the hospital that once suffered from a sheet-and-towel shortage has become a place that uses far too much linen, to name just one of its many inefficiencies. Last spring, a consulting firm hired by the city administrator’s office noted that D.C. General’s laundry plant processed almost 30 pounds of linen per patient per day, far more than the industry average of 18.5 pounds.
Such profligate sheet-soiling may seem like a trivial issue, but it is symbolic of the new D.C. General, whose current problems stem from too much money rather than too little. “I was used to having to trade three stretchers for four chairs, and to making my own message pads from scrap paper,” says one newcomer from another public hospital. “Here, I’m told, “Order this, that, and the other.’ ” The hospital seems to pay 50 percent more than it should for everything, from IV kits to the Marriott meal service: The hospital was paying more than $3 per meal, compared to an industry standard of $2.
“They’re on the high side of most measures” of efficiency and productivity, says John Green, a vice president of Medlantic, the hospital megachain. Green is co-chairman of a committee appointed by Mayor Sharon Pratt Kelly to try to figure out what to do about the hospital—actually, come to think of it, it would be hard to find someone in the Washington health care business who’s not part of some task force pondering the future of D.C. General. The distinguished committees and commissions hover like doctors around a chronically ill patient as they debate whether the hospital needs lip osuction, amputation, or Dr. Kevorkian’s little machine.
Meanwhile, the hospital lurches along from day to day, dysfunction to dysfunction, costing the city upward of $1.5 million each week. Staffers are used to its many glitches, but acting Executive Director Gowie, who was installed in August, is not.
“The surprises came day after day,” he says, in a voice that retains its Jamaican lilt after 40 years in the U.S. “Though I have been in institutions that have been in a really critical financial situation, and even in institutions that were poorly managed, there were a multiplicity of problems that I encountered here that I just couldn’t believe.”
The 63-year-old Gowie replaced Mark Chastang, who’d run the hospital since 1990, and who was widely perceived as a passive leader. Gowie brings to the job a track record of healing sick hospitals, and of weathering the resultant storms. He brought Baltimore’s Provident Hospital (now Liberty Medical Center) out of bankruptcy in the mid-’70s; most recently, he had been executive director of Metropolitan Hospital, a public hospital in East Harlem. His bearing is formal, his manner almost arrogant, but he speaks directly about the hospital’s problems.
“There are certain things you take for granted when you go into an institution,” he continues. “You expect certain things to occur, or certain things not to occur. D.C. General is, well, unique. You expect that at a time like this, an age of computerization and computer-assisted functions, that a hospital in 1994 would have the necessary computer systems. We do have an expensive, very costly system, but it assists and does nothing!”
The $8-million computer system was purchased in 1991, and terminals were installed in every department, each outfitted with custom-made software. Unfortunately, according to Gowie and other hospital officials, the different softwares do not communicate well with each other. This lack of centralized data, Gowie says, is a metaphor for the scattered and unaccountable operation of the hospital as a whole, not to mention its impenetrable, insular culture.
“Management allowed control to slip away—how, I have no idea, but it did occur,” he says. “Control was diffused, it was all over the place, and yet management was held accountable.”
As hospital staffers try to salvage the computer system, which costs $2.5 million a year to operate, Gowie is up against more than just buggy software. Mayor Kelly’s outside consultants concluded that “the organizational culture is one in which inefficiency and resistance to innovation have become entrenched; one in which incompetence is regarded with complacency and in which excellence is not rewarded,” according to a confidential draft.
Incompetence is by no means universal, the draft notes. Indeed, many hospital staffers, from orderlies up to doctors, are drawn to their work by idealism and a commitment to serving the poor. Walking through the intensive care ward one night, I meet one such nurse, a man named Scott Weinstein, whose braided ponytail hangs over his shoulder and halfway down his chest. “I’d rather work here than someplace across town, where I’d be hustling croissants all the time,” he says.
The consultants prescribed a plan for resuscitating D.C. General, which Kelly adopted. Gowie was brought on board to implement the recommendations in the $600,000, 268-page report, a task that might be easier if the mayor would give him a copy. “I still need a copy of that report,” he says.
The report outlines the hospital’s problems in minute detail, from the laundry to patient billing to the way bedpans are purchased and distributed. The Marriott contract has been renegotiated, among other relatively minor changes, but D.C. General’s basic problems run deeper. Ultimate responsibility for the sorry state of the hospital lies with its owner for the past 180-plus years: the District government itself.
The government-run, full-service hospitalis fast becoming a relic, and for good reason. From Chicago to Philadelphia to New York, the municipal hospital was often simply an extension of the local political machine. D.C. General is no exception, and its staffers, particularly the doctors, have longstanding ties to the mayor and the council. It suffers from basic bureaucratic inefficiencies, as well. Hospital staffers are civil servants with virtual lifetime tenure, regardless of competence, and are protected by vocal unions.
The consultants recommend cutting 386 full-time positions from the staff of about 2,300. (“About 2,300” because the hospital itself does not know exactly how many people it employs; the D.C. Council authorized 2,562 positions for fiscal 1994, but more than 200 workers have taken buyouts or retired.) Gowie has vowed to cut even deeper, bringing total staff reductions to as many as 600 through retirements and buyouts. The effort seems to be working, judging from the retirement-party notices plastering the corridors.
The most deeply entrenched staffers are the nearly 300 doctors, including residents from Georgetown and Howard University, on the hospital payroll. The civil service pay scale caps physicians’ salaries at a relatively low $90,000, but D.C. General doctors are also permitted to maintain private practices. (City lawyers, by contrast, may not represent private clients.) That may account for the rather low productivity, as measured by the number of staff physicians per 10,000 patient visits. D.C. General employs 3.8 doctors for every 10,000 visits, well above the 2.7 that is the norm for urban public hospitals. Put another way, D.C. General has almost as many doctors as beds.
D.C. General has not one, but two medical-school teaching programs, one run by Georgetown University and the other by Howard. The schools’ outpatient clinics are adjacent to each other, but for some reason they need separate administrative staffs and separate on-call rooms, where residents can rest during night shifts—two of everything, it seems. “Like Noah’s ark,” says one observer.
For decades, the hospital has relied on arbitrary city subsidies to cover the costs of indigent care and services to D.C. prisoners. In recent years, the subsidy amount has ranged from $45 million to $69 million. When the money ran out, the hospital could always turn to the city for a cash infusion. Since 1987, the last fiscal year in which it broke even (on paper, anyway), D.C. General has racked up more than $85 million in debt on top of its subsidy. For its part, the city recorded such payments as off-budget “loans,” even though the hospital had neither the means nor the intention of repaying them, until the deception was exposed by the General Accounting Office in June.
“People who have a history with the hospital say, “Gee, we always come out, the city always comes up with the money,’ ” says Gowie. “The hospital has never been faced with a crisis of this magnitude.”
With such a willing patron, the hospital has had few incentives to generate revenue on its own. The federal Medicare and Medicaid programs, for example, provide the bulk of the hospital’s revenue—almost $60 million in 1993. Yet the hospital loses untold millions by treating, for free, patients who might qualify for federal benefits, only inquiring about their eligibility after discharge. By that time, the patients’ incentive to complete the 10-page Medicaid questionnaire may have evaporated. Of those who do, more than two-thirds are rejected. Often, patients registering at the hospital are not even asked to sign the required form acknowledging their responsibility to pay their bill.
And then there is the basic question of rates, for those relatively few patients with private insurance or the ability to pay their own bills. Most hospitals pad their charges, to cushion the costs of caring for the uninsured and to make up for unpaid bills. D.C. General’s rates are among the lowest around: It charges $36 for a chest X-ray that costs $51 at comparable hospitals. Five hours in a D.C. General labor room runs a mere $218.90, compared to a norm of $485. Providing cheap medical services is part of the hospital’s mission, but Gowie has instituted an across-the-board fee hike of 15 percent, with another 5 percent increase planned for next year. Yet the hospital provides more than twice as much free care as any other facility in town, according to 1993 data from the D.C. Hospital Association.
But low rates may not matter if D.C. General continues to lose its paying patient base, and even its Medicaid patients, to HMOs and other hospitals. As of April, District Medicaid/Medicare patients have been organized into an HMO-like group, allowing benefit recipients to choose their doctors and hospitals. Long a captive clientele, D.C. General’s patients now have a choice. D.C. General’s doctors don’t seem willing to participate: Less than a dozen had signed up to treat Medicaid patients, Gowie said at a council budget hearing last month.
For the first time in its history, D.C. General has to actually market itself. To that end, Gowie has negotiated an agreement with Chartered Health Plan that would make the hospital a “preferred provider” for the District-based HMO and its 25,000 members. “A large segment of our population lives in that area,” says Chartered Health Plan spokeswoman Beverly Downs.
“I will also be moving to seek contracts with other managed care plans,” Gowie says. “If your services are good, people will buy it.”
But how good are D.C. General’s services? Its dismal reputation is not entirely unjustified. Gowie may need not only to restore its financial health, but to make it a decent hospital—a goal that may be even more elusive.
Nobody will ever know exactly what went wrong at Russell Blackwell’s birth, but it is clear that something went very wrong indeed. What is known is that his mother, Rhonda, went into D.C. General’s obstetrics ward on Dec. 9, 1989. After 16 hours of drug-induced labor failed to produce a child, residents performed an emergency Caesarean section. Russell was born almost dead, with his mouth full of his own first bowel movement.
Russell Blackwell was only one of thousands of risky babies born at D.C. General. As many as 90 percent of births there are classified as “high risk,” because of the youth of the mother, her health, or her habits. Many of the low-birth-weight babies spend time in the Neonatal Intensive Care Unit, on the fourth floor of the pediatrics building.
The unit is screened from the corridor by big glass windows. Visitors must don yellow paper gowns before entering the large, bright space, which is crowded with bassinets. About half of the infants are further protected by plastic oxygen tents. The bassinets are outfitted with protective hoods and heating strips, much like the heat lamps used to warm french fries at Roy Rogers. Bright displays monitor pulse and body temperature, and buzzers keep quietly going off.
Each baby is more impossibly tiny than the next. With their little wizened faces and long, skinny limbs, they look a century old, but the oldest is about three months. Tubes protrude from their mouths, wrists, and twiglike ankles. I watch a nurse prepare to change a dressing on a baby who was born at less than a pound, according to the identification card taped to the hood. The child kicks her tiny foot into the bedding.
Will she make it? I ask. The nurse shrugs and says maybe. “Black females are very strong,” she says.
Some of the babies die, some survive and eventually go home, and a small number are abandoned by their mothers at the hospital, usually after a first, shocking visit. These graduate to the boarder baby unit, a small dark room smelling faintly of urine and currently occupied by three otherwise normal-looking babies. All three lie face down, perhaps to avoid Dan Rather’s blathering visage on the television. The oldest has been here four months.
They are the babies no one wants, from the patients no one wants, but they are luckier than Russell Blackwell. Now 5 years old, Russell is permanently disabled, suffering from microcephaly, severe retardation, and spastic quadriplegia, according to court documents. Last March, a D.C. Superior Court jury awarded the Blackwells $3.1 million for malpractice by D.C. General, but the events surrounding his birth remain shrouded in mystery—another manifestation, perhaps, of the curse of D.C. General.
One reason that nobody will know what went wrong five years ago is that Russell’s fetal monitoring strips, which record every vital sign of the fetus and mother during labor, were lost. Another reason is that Rhonda Blackwell was apparently left unattended for long periods, according to court documents. Even though her cervix had been too small for her previous child, doctors attempted a vaginal delivery this time around, using a labor-inducing drug. But the attending physician in charge of obstetrics was not consulted, although hospital policy requires him to be present when such a decision is made.
This is not an isolated case. As far back as 1980, Post reporter Susan Okie noted that it was standard practice for residents to perform C-sections without an attending physician present. In June, a team of federal and District surveyors descended on D.C. General for a surprise inspection. They found, not surprisingly, that residents were doing C-sections without supervision.
Federal regulators focused a lot of attention on D.C. General this year, and what they found was not reassuring. In March, the Health Care Financing Administration (HCFA), which administers Medicare and Medicaid, investigated complaints of patient dumping by the hospital. It was a curious allegation, since D.C. General is the recipient of much patient dumping from other hospitals, and the investigators could not substantiate it.
They did find, however, that the emergency room was slow in treating patients with potentially serious conditions—this, remember, in a hospital with almost one doctor per inpatient bed. One person who was brought in by ambulance, complaining of left-side chest pain, and having difficulty breathing, was sent to the walk-in clinic, normally used for minor ailments. A patient who arrived at 12:50 p.m. with frostbite of the foot was not called for treatment until after 8 p.m., while another patient who arrived at 1:50 p.m. with abdominal pain and vomiting was not called into the treatment area until after midnight. Both patients left without treatment.
In June, the federal regulators contracted the District’s Department of Consumer and Regulatory Affairs (DCRA) to conduct a full investigation of D.C. General. The 27-page report was the first public survey of the hospital in more than a decade, and it amply illustrates how “incompetence is regarded with complacence and excellence is not rewarded,” as Mayor Kelly’s consultants put it.
D.C. General failed one of the basic conditions for federal approval: “The hospital must have an effective governing body legally responsible for the conduct of the hospital as an institution.” When the investigators came through during the second week of June, they caught an anesthesiologist talking on the phone across the hall from the operating room, where surgery was under way. Foreign medical graduates were improperly credentialed by the hospital, and two nurses were prescribing drugs illegally.
Despite the hospital’s high staffing levels, some physicians seemed to be neglecting their duties. Attending physicians, who are supposed to supervise particular clinics, were often nowhere to be found. In the neurosurgery department, which opens at 8 a.m., only two of the four waiting patients had been seen by 11:40 p.m.; the attending physician was missing. Many patient records reviewed by the inspectors had not been signed by the attending physicians.
Quality assessment and quality control were nonexistent in many areas. Records were illegible, undated, and unsigned. The temperature in the pharmacy hovered near 90 degrees, which could damage certain fragile medications. Expired drugs and supplies were still in use. In one case, a routine lab test took more than nine weeks to report results. Infection control procedures were also inadequate. And despite its long history of quarantining smallpox and TB sufferers, the hospital lacked a proper isolation ward, the inspectors wrote.
“Failure to comply…may indicate a potential for a breakdown in the major services of this hospital,” wrote HCFA Regional Administrator Catherine McCoy in a July 20, 1993, letter to then-Executive Director Mark Chastang. “Continued non-compliance could jeopardize the hospital’s continued participation in the Medicare program.” Three days later, Chastang resigned.
For D.C. General old-timers, the threat was a chilling a flashback to 1975, when the hospital lost its accreditation from the Joint Commission for Accreditation of Healthcare Organizations (JCAHO), the nonprofit body that monitors hospitals. For three long, dark years, D.C. General lived on the brink of closure. It has been restored to medical respectability, and has kept its accreditation since then, but the new report raises the question: Can D.C. General absorb the drastic cuts it needs to survive, and still function as a hospital?
Perhaps Gowie can do it, but he too has run afoul of the watchdogs in the past. In July 1993, Newsday obtained JCAHO’s confidential report on New York’s Metropolitan Hospital, in which the commission downgraded the hospital because of lapses in its medical care. After the report became public, Gowie resigned along with his deputy, Surender Dhawan, who is now D.C. General’s chief financial officer. (Though both left in 1993, Gowie’s official bio states that he headed Metropolitan “from 1987-1994.”)
D.C. General is only one of several large pianos tied to the District’s ankles, but it is the heaviest, and its rope should have been cut long ago. Thomas Chapman, director of George Washington University Medical Center, stresses the urgency of D.C. General’s plight: Something should be done in “days,” he says, “like now. Months, I think, is too late.”
While other cities have dealt with their public-hospital dilemmas in recent years, the District is notable for its inaction. Philadelphia closed its public hospital completely, and many other cities have cut back public-hospital services, or placed their hospitals and medical clinics under some form of quasi-public corporation. Gowie’s former hospital was part of the city-owned New York Health and Hospitals Corp., which coordinated all the city health clinics and hospitals under one holding company.
Mayor Kelly proposed a similar restructuring for D.C. General and the city health clinics, which are currently run by the Department of Human Services. Such a “public benefits corporation” would still require a city subsidy, but it would be free from civil service and procurement regulations, and its managers would theoretically have incentives to be efficient. The notion was a cornerstone of Kelly’s “Operational and Viability Plan” for the hospital, but her administration never submitted legislation to make it a reality, and so it will join all the other save-the-hospital plans and proposals and reports that have been issued over the decades, most of which went nowhere.
This general hospital’s story is itself a kind of soap opera, where crises are everyday but nothing ever changes. As long ago as 1974, Post editorialists were decrying the hospital’s “Old and Sorry Story.” So far, nobody’s had the guts to attempt more than minor surgery, trimming a few inpatient beds here, a couple dozen staffers there.
Or at least promising to cut. In 1988, when it was budgeted at 2,233 full-time equivalent positions, the hospital leaders vowed to trim 100 slots. By last year, its authorized staffing had grown to more than 2,500. What’s clear is that it needs much more than minor trimming, and the options are self-evident: Close it; downsize it, sell it or give it away; rebuild it; or continue to pay for it.
The first option is in some ways the most appealing. By closing D.C. General, the city would save millions, and snuff a bureaucratic culture that has run amok for decades. This proposal does not sit well with the other hospitals in town, which fear they would inherit D.C. General’s indigent patients. But Washington’s public-health problem does not stem solely from a lack of resources; the millions the city wastes on D.C. General might be better spent at these more efficient centers.
What the number-crunchers and the money-men and the opinion-makers seem to forget—because none of them actually use D.C. General—is that the hospital represents a last island of hope for the 150,000 Washingtonians who have no medical insurance. And its location is convenient for the city’s poorest neighborhoods. Nobody ever said running a poorhouse was cheap, after all, especially if it comes equipped with a CAT scanner.
Gowie has chosen the second option, the only one available to him. In addition to chipping away at the staff—with which he is decidedly unpopular—Gowie favors cutting its services, and his logic is admirably simple.
“We’re not here to provide free medical care,” he says bluntly. “Those who are not able to pay for it, or have it paid for by some insurance plan, will not be denied it—if it’s here. If it’s not here, it’s not here. I don’t think D.C. General was designed originally to be providing all these esoteric services. It was designed to provide basic medical services.”
The hospital has been withering in recent years, anyway. Contrary to popular belief, it is not swamped by a rising tide of urban violence and disease. In fact, most of its usage indicators have stayed the same or declined even as its deficit grew. Last year, 1,593 babies were born at D.C. General, down from an average of 2,000 each year during the ’80s. Its total patient days and emergency room visits have stayed the same since 1988. And the total number of beds continues to shrink, from an all-time high of more than 1,600 in the ’50s, to 410 in 1990, to just over 300 this year. Even its subsidy has remained about the same, in constant dollars, since 1974.
Late last month, Medical Director Lawrence Johnson floated a trial balloon, telling the Post that the hospital might close its trauma center, where the most serious gunshot and car-crash victims are treated (by law, ambulances take the injured to the nearest hospital). Greater Southeast closed its trauma center in 1987, much to its own financial good. But D.C. General’s trauma center is the only such facility east of the Capitol, and its trauma surgeons are among the city’s best. That wasn’t the sort of service cut Gowie had in mind anyway, no matter how much it might help the hospital’s (and the city’s) bottom line. But if the hospital cuts other services, its already unhealthy clients may suffer just as much, from lack of basic medical care. “There are going to be a lot of silent deaths in this area,” warns Scott Weinstein.
How appropriate, then, that the arbiter of the hospital’s fate will be Marion Barry. D.C. General is one bloated and inefficient local institution that can’t be blamed on the once and future mayor. Tight-lipped about the hospital’s future, Barry has been an inconstant ally in the past. As mayor, he regularly tried to cut its subsidy, and some years he succeeded. His budget director even suggested closing it, and paying other hospitals to take care of indigent patients. The idea was immediately shot down by the D.C. Council, but Chairman John Wilson brought it up again, just months before he died.
As early as 1980, Barry was talking about privatizing city health services under a municipal corporation, much the way New York did and the way Kelly proposed to do. Last year, Barry released a highly critical report that questioned both the hospital’s mission and its scope, but he stopped short of recommending drastic action—instead, he proposed yet another commission to study this most studied of local institutions. Indecision is a luxury the new mayor can no longer afford, and he has deputized Barry Passett to come up with the final answer.
“He’s got to be radical,” says Passett.
Art accompanying story in the printed newspaper is not available in this archive: Darrow Montgomery.