PACEMAKER: Centennial 1998

Skyrocketing clinical advances fuel transition to specialty care

Hospitals of the 18th and 19th centuries were often little more than sick houses for the poor and indigent. At best they offered clean beds, decent meals, nursing care, and the attention of qualified physicians. Few if any offered medical services beyond what most doctors could provide in their own offices or in visits to patients at home.

The social transformation of hospitals from nursing-based charitable institutions to technological and scientific workshops dominated by physicians was a long and complicated one. This transition was more nearly complete by the time the new General Hospital opened on the west side of the Iowa River in 1928.

X-ray and electrocardiogram machines, as well as laboratory equipment such as centrifuges to separate blood and microtomes to slice tissue samples, are examples of hospital based technology that developed and came into use in the first three decades of the 20th century. Likewise, surgical procedures that depended on improved anesthesia and power tools represented significant advances over the kitchen table amputations and bone-settings that had been the 19th century surgeon's stock in trade.

The concept of the university teaching hospital as a center of scientific and technological innovation continued to develop. The University of Iowa Hospitals and Clinics (UIHC) and its faculty physicians, for example, pioneered major developments in child nutrition, urological surgery, blood transfusion and storage, and other clinical advancements in the years before World War II.

Nevertheless, the hospitals' largely indigent patient base meant that many patients came there to receive routine services they might have obtained elsewhere had they been able to pay.

Several trends combined after World War II to propel University Hospitals toward sophisticated, regional specialty care. First, the nation's investment in medical research, fueled by the federal government and directed mainly at universities, skyrocketed; as knowledge of basic disease processes grew, so did clinical innovations.

Second, the federal government began to finance construction of community hospitals throughout the country. With new community hospitals able to deliver routine medical services, leaders such as UIHC Superintendent Gerhard Hartman proposed a new role for University Hospitals: providing specialty care not available elsewhere.

Third, the demand for health services began to expand as private insurance became more common, largely the result of its widespread inclusion as a benefit of employment. Enactment of the federal Medicare and Medicaid programs in 1965 also greatly expanded this consumer market, which fed upon the medical innovations coming out of academic research centers like the University of Iowa.

Finally, statewide health services planning in the early 1970s resulted in the clear definition of three levels of care-primary, secondary and tertiary-and a rational system of delivering the different services. Iowa's planning council, led by UI associate medical dean John C. MacQueen, placed University Hospitals at the apex of this stratified system; there it would concentrate on providing highly sophisticated services in a comprehensive array of medical specialties and subspecialties for "unusual and complicated" cases, as well as on training specialist physicians.This philosophy guided UIHC planning for most of the next two decades. In addition to organ transplant services-perhaps the best known example of tertiary care-UIHC developed a long list of high-tech specialty care services. Cardiac catheterization, cochlear implants, specialized eye care, burn care, high-risk obstetrical care, neonatal intensive care, microsurgery, laser surgery, and end stage kidney dialysis practically defined UIHC for many Iowans.

By the 1990s the growing influence of managed care prompted new strategies to provide Iowans with a full spectrum of health services in partnership with Iowa’s community-based physicians and hospitals. These services range from the most basic to the most sophisticated. UIHC thus begins its second century by establishing facilities to offer women's health services, family care and geriatric care, establishing a new continuity of comprehensive service to all Iowans.