PRESENT STATUS AND PROBLEMS OF OUT- 
PATIENT WORK. 
By Michael M. Davis, Jr., Ph.D., 
Director of the Boston Dispensary. 
Report of Committee on Out-Patient 
can Hospital Association. 
The dispensaries and out-patient dep 
hospitals of the United States are gr 
importance as a part of medical serv; 
The Federal Census of 1910 reports the 
dispensaries and out-patient departments treating 
2,349,000 patients during the year. Only six years 
previously, when in 1904 a special report of benevolent 
institutions was issued by the Census Office, there were 
but 156 of these institutions, and the number of 
patients was only 1,611,000. Thus in six years the 
number of dispensaries and out-patient departments 
increased near four-fold. The number of patients in- 
creased of course much less rapidly, as the newer insti- 
tutions are largely for tuberculosis, and are small in 
size; yet, even so, the increase in patients treated is over 
50%. 
STATISTICS OF OUT-PATIENT WORK. 
As a matter of statistics the figures reported by the 
Census Bureau for 1910 are undoubtedly too small. 
There has been considerable confusion, in the reports 
made to the Census Bureau, between the number of pati- 
ents treated and the visits paid by these patients and 
also-surprising as it may seem-between out-patients 
and bed-patients. The officials of the Census Bureau 
tell me in correspondence that they have done their 
best to get the hospitals to report bed-patients as bed- 
patients and out-patients as out-patients, and not to 
swell the number of hospital cases by putting out- 
patients within that total. In the present state of out- 
patient statistics, it is perhaps beyond sane expectation 
to think that when a hospital does not accurately dis- 
tinguish in its report between bed-patients and out- 2 
patients, it will give attention to such a relatively 
subtle matter as to discriminate between patients 
treated in the dispensary and visits paid by these 
patients. But the millennium will come sometime! 
Meanwhile, a comparison made with reports of local 
authorities in certain states and the Census figures 
show the Census figures to be below the truth. In 
Massachusetts the State Board of Charity receives re- 
ports from all hospitals and dispensaries and the same 
practice exists in New York. The Massachusetts re- 
port indicates that the Census figures for patients treat- 
ed is about 20% too low; and the New York figures are 
15% too low. It is probable that 2,750,000 to 3,000,- 
000 individual out-patients were treated during 1910 
and surely 3,000,000 are annually treated in this country 
at the present day. 
The printed report of the Census Office, giving the 
1910 figures, has not yet appeared, and I am indebted to 
the officials of the Census Bureau for the advance sum- 
mary which they have kindly furnished me and for 
helpful correspondence concerning the method by which 
the statistics were gathered. 
Out-patient work is not evenly distributed over the 
country In 1910, just two-thirds of all the dispen- 
saries and out-patient departments were in New York, 
New Jersey, Pennsylvania or in the six New England 
states; 60% were in New York and Pennsylvania alone. 
In the six years between 1904 and 1910 the number 
in New York trebled; in Massachusetts, doubled; in 
Maryland, doubled; in Illinois, a little more than 
doubled; in Ohio nearly trebled; in Missouri more than 
trebled; in the District of Columbia more than quad- 
rupled; and in Pennsylvania the number of dispen- 
saries increased twelve times. This remarkable 
growth in the number of institutions is in a consider- 
able degree accounted for by the use of the dispensary 
in the national anti-tuberculosis campaign. Nearly all 
of the increase in Pennsylvania and fully half of the 
increase in the United States as a whole is due to this 
factor. The establishment of dispensaries has thus 
far been chiefly in the large cities, but there are indi- 
cations that this will not remain the case. Tuberculosis 
dispensaries are established in every county in Pennsyl- 3 
vania; and, under a new law, are to be established over 
all the state of Massachusetts. With the exception of 
these tuberculosis dispensaries, the typical out-patient 
work of course is to be found in the larger cities. 
This increase in dispensary work places before the 
medical profession and hospital authorities certain 
serious problems, of which competition with private 
practice is one. These problems must be faced and 
solved; but the ultimate test on which the general pub- 
lic, which supports all the institutions, will base its con- 
tributions or its tax levies, will be the service of these 
institutions to public health. We must not reach 
decision upon any of the important problems of dispen- 
sary service with any narrower vision of it than as a 
part of the public health movement. 
LACK OF ATTENTION TO OUT-PATIENT DEPARTMENT. 
In view of the remarkable development of out-patient 
service, it is all the more noteworthy that most hos- 
pitals which conduuct out-patient departments have 
paid so little attention to them. The dispensary might 
be described as the dark horse of the medical institu- 
tion kept hidden under a blanket! 
Fifty-six annual reports of well-known hospitals 
have been examined to see what they said about their 
out-patient work.* The out-patient departments of 
these 56 hospitals had under treatment last year over a 
million persons; yet three-quarters of the annual 
reports made absolutely no mention of the fact that 
the hospital has an out-patient department, except such 
indication as is to be found in a brief statistical table 
of patients and visits. 
*A postal was sent to about 250 hospitals, selected as among 
the leading ones in the country from the membership list of the 
American Hospital Association. Some were taken from every 
state in the Union. The postal card asked that an annual re- 
port be sent. In return 93 reports were received. Thirty-four 
of the 93 hospitals which sent reports had no out-patient 
department. Of the remaining number (59) 56 annual reports 
were received in time for tabulation. 
All of the hospitals that did not send reports received a 
second postal card, so that 37% of responses represented the 
results of two requests. 
Reports were also secured from a number of dispensaries not 
connected with hospitals, these not being included in the above 
figures. 4 
A very well-known hospital in one of our largest cities 
issues a handsome report of 160 pages. The medical 
wards, the surgical, orthopedic, maternity, gynaecologi- 
cal, eye, children's, and neurological wards have each 
an "Auxiliary Committee," and each Auxiliary Com- 
mittee presents a report of its special work, needs and 
financial supporters. Altogether these wards treated 
over 4,500 patients last year. The out-patient depart- 
ment of this hospital treated just about three times 
as many; but the out-patient department has no Auxil- 
iary Committee; it has no special report; and, except 
for the statistical tables, one would only know that 
the hospital had an out-patient department from two 
sentences in the report of the President of the Board of 
Trustees to the effect that the dispensary service has 
been improved, that Social Service has been estab- 
lished, and that the patients in the dispensary have 
been supplied with individual drinking cups! 
The report of this Board of Trustees is exceptional 
in one respect, namely, that the dispensary is men- 
tioned at all. Only eight hospitals out of the 56 had any 
special report for the out-patient department in their 
annual report; and in three of these eight cases the 
"report" was merely a formal presentation of figures. 
There were also four hospitals which gave a little space 
to discussing the problems of the out-patient depart- 
ment, but did not dignify it by giving any special page 
or heading. Thus only 15% (nine out of 56) said 
anything about their out-patient department. Can it 
be true that an out-patient department may treat 1,000 
or 20,000 human beings in a year and not have any 
problems or any needs ? 
Without entering further into the details gathered 
from these annual reports,* enough has been said to 
*As to out-patient statistics, all the hospitals except one men- 
tion the number of patients treated, and all except two give 
also the number of visits paid by these patients. Nearly one- 
third (17 out of 55) of these hospitals, however, give only the 
total number of patients and visits, and do not divide them 
according to the different clinical departments. If one examines 
a number of hospital reports, one is also forced to note with pain 
that 73% of them (42 out of 56) have no index or table of con- 
tents, so that it is necessary to hunt through a report of from 
40 to 150 pages to find anything in it that one is looking for, such 
as out-patient statistics. 5 
show the small number of the crumbs which the aver- 
age hospital management throws to this poor relation 
at the hospital table, How can hospitals expect to get 
funds to improve out-patient work so long as they hide 
its light under a bushel ?t 
PRESENT FACTS OF OUT-PATIENT WORK. 
For this Committee Report, facts have been gather- 
ed, through correspondence, concerning the present 
methods of organization and work of out-patient de- 
partments and dispensaries. Information is available 
from 76 institutions, of which 49 are hospitals and 27 
dispensaries not connected with hospitals. While the 
number of hospitals is small, most of the large repre- 
sentative institutions having out-patient departments 
are included. 
The facts appear tabulated as Appendix IL The 
more important items are* :- 
All the hospital reports give the list of their medical staff, 
usually, though not invariably, classified under clinical depart- 
ments. The diseases treated in the out-patient clinic were pre- 
sented in a surprisingly large number of cases, considering the 
relatively small value of the information thus conveyed. Twenty- 
three out of 56 hospitals published a more or less extensive list 
of diseases treated, usually with the number of cases of each 
disease. 
The reports of finances are of great negative interest. Thus 
out of 56 hospital reports: 
7 gave no financial statement of any kind; 
33 presented a financial statement, but not classified in such 
a way that the expenses of the out-patient department were 
either given or ascertainable; 
16 presented a financial statement so itemized that the 
expenses of the out-patient department were separated. 
tA suggested outline of what the annual report of a hospital 
should present concerning its out-patient department is printed 
as Appendix I. 
*A printed blank was sent, with a return envelope, to the 250 
hospitals previously mentioned and to 34 dispensaries not con- 
nected with hospitals. Eighty-eight of these blanks were re- 
turned, and 76 were capable of tabulation. While this number 
represents a little less than a third of the out-patient depart- 
ments and dispensaries in this country, excluding tuberculosis 
dispensaries, it does include almost all the larger and more 
representative institutions. Of course it must be remembered 
that a large proportion of the 250 hospitals that were communi- 
cated with had no out-patient departments. 6 
1. Organization.-Seventy per cent. (31 out of 49) 
of the hospitals had no person in executive charge of 
the out-patient department. Of the 14 hospitals re- 
porting a "permanent superintendent of out-patient 
work," this official is evidently, in many cases, only a 
head nurse, and in others is an assistant superintendent 
of the hospital, who serves in the out-patient only for a 
fixed term. The out-patient department is, of course, 
under the authority of the superintendent of the hos- 
pital, but he obviously cannot undertake its actual 
supervision. Three well-known hospital superintend- 
ents have estimated the portion of their time which 
they charge financially to the out-patient department, 
presumably representing the amount of time directly 
given to out-patient supervision. These estimates 
were, respectively, 10%, 2% and 0%. 
The typical arrangement, however, is for the out- 
patient department either to have in charge somebody 
who is interested in it, as a policeman is in his beat, to 
see that nothing goes wrong during his short period of 
incumbency; to have a head nurse or registrar, who 
does the best that a nurse or a clerk can do without 
authority or training to do more; or, finally, to have the 
dispensary run by its several departments, according 
to the method in which the ancient kings of Ireland 
are said to have conducted their affairs. 
A very few institutions have recently placed a quali- 
fied person in responsible charge of the out-patient, 
with permanent tenure. How can an organization hav- 
ing a large working staff and dealing with thousands of 
persons, be efficient or progressive without an execu- 
tive head, with real responsibility? 
Of the 27 dispensaries not connected with hospitals, 
two-thirds (18 out of 27) say they have a "permanent 
Superintendent." In most cases, however, this person 
is only a registrar or admitting clerk, and the dispen- 
sary really has as many executive heads as it has clin- 
ical departments. 
2. Payment of the Medical Staff.-Six out of 49 hos- 
pitals pay all of their out-patient staff; three more pay 
some of them. All but two of these are out-patient 
departments of large general hospitals. A salaried 
staff is naturally much more frequent among the dis- 
pensaries unconnected with hospitals, only half of 7 
which do not pay at least some of their medical men. 
Further facts indicate that while an apparently grow- 
ing number of hospital and dispensary men desire a 
paid out-patient staff (if they had money to pay them!) 
there is a very considerable number (nearly half of the 
hospitals) who say that they do not believe in paying 
salaries to out-patient men. 
3. Social Service Department.-Such departments 
are reported from 59% of the institutions, and are 
favored by 94%. 
4. Records.-Seventy-two per cent, state that they 
make some record every time a patient visits the 
clinics; but only 60% have a list of the names and 
addresses of their patients. 
5. Technique of clinical work.-Is it part of the rou- 
tine, in medical clinics, to make laboratory tests of 
urine and blood for each patient, and to make a record 
of weight? In round numbers, 40% of the clinics 
report that they do this in some cases; 20% that they 
do so in all cases; and 40% that this work is not done 
at all. The proportions vary slightly between the tests 
of urine, blood and weight; urine being tested most 
frequently, weight next most frequently, and blood least 
frequently of the three. These figures refer in nearly 
all instances to the medical clinics only. 
"Are physical examinations made, and recorded as a 
matter of routine, on the clinical record of each 
patient?" Forty-seven out of 76 institutions report 
that this is done in all cases,* 15 say it is done in some 
cases that seem specially to call for it; 12 admit that 
it is not done at all. 
6. Dispensary Abuse.-So much material has been 
collected on this topic that it will be published as a 
separate paper. The subject has been discussed with 
more length and more heat than any other in this field. 
One little group of facts must be included here. 
Thirty-six institutions-mostly very representative 
ones-have reported the number or percentage of appli- 
cants who were excluded from admission, in a given 
period, because they were "not proper subjects"; i.e., 
were thought able to pay a private physician. These 
♦While not always so specified in the returns, this undoubtedly 
refers in nearly all cases to the medical clinics only. 8 
36 institutions treated approximately 520,000 out- 
patients last year:- 
3 of the 36 excluded between 5% and 20% of the 
applicants. 
5 of the 36 excluded between 2% and 5%. 
7 " " " " 2% and l/2 of 1%. 
21 " " " less than 1/2 of 1%. 
In other words, four-fifths of these 36 institutions 
excluded less than 2% of the applicants, and more than 
half refused a merely negligible number. 
May not this conclusion be drawn? The protection 
of the institutions and the medical profession from 
abuse by the small per cent, of improper subjects for 
out-patient treatment, is a necessary task; but the pro- 
vision of efficient treatment for the 90% or 99% of 
patients who are admitted is a first essential. Local 
conditions vary, and in some cities and some institutions 
this problem is larger than in others; yet, in general, 
what the out-patient service needs is a constructive pro- 
gram. 
This further may be said, that the lack of agreement 
not only as to what can be done, but also as to what 
should be done, is nowhere more apparent in out- 
patient work than in dealing with this bugbear of 
"abuse." 
7. Cost and cost accounting.-Schedules have been 
collected from six well-known institutions, showing 
how the superintendent estimated the cost of the out- 
patient service and of its various divisions. To present 
the details of these schedules, would suggest unfair 
comparisons. The following points may be made: 
(1) The typical hospital does not maintain a con- 
sidered segregation of the expenses of its out-patient 
department. Forty out of the 56 hospital annual 
reports (71%) previously referred to did not give the 
dispensary cost items separable from the hospital items. 
(1) A relatively small number of hospitals do make 
a careful segregation of out-patient expenses; but each 
has its individual system, so that the expenses cannot 
be safely compared in detail. 
(3) The average cost per visit of an out-patient is 
the best unit of expense, so far as a unit is desirable. 9 
(4) Costs per visit vary widely, even among the 
institutions of high medical standing. The following 
table presents certain figures on this point:- 
COMPARISON OF AVERAGE COST PER VISIT AT SlX OUT-PATIENT 
Departments. 
Hospital 
Aver'ge cost 
or 
Visits 
Expen t res 
per visit 
Dispen'y 
last year 
last year ( 
in cents) 
Remarks. 
A 
51,000 
$26,600 
52c. 
A dispensary not con- 
nected with a hospital. 
B 
69,600 
23,500 
33.8c. 
An O.P.D. of a large 
general hospital. 
C 
115,000 
55,000 
47.8c. 
A dispensary with a 
small hospital 
I) 
132,000 
24,009 
18c. 
Same remark as for B. 
E 
136,000 
' 78,200 
57c. 
>, „ >» » 
F 
236,000 
43,700 
18.5c. 
Thus of these six institutions giving the detailed 
schedules referred to, three spend approximately the 
same amount on out-patient service-$25,000 a year. 
But the visits paid by patients to these three are, 
respectively, 51,000, 69,000 and 132,000; and the aver- 
age cost per visit, therefore, respectively. 52 cents, 33 
cents and 18 cents. Institutions D and E have approxi- 
mately the same number of visits-a little over 130,000 
-paid by patients during the year; but one of these 
two institutions is spending $24,000 in the year in its 
out-patient, and the other $78,000, the average cost 
per visit being, therefore, 18 cents and 57 cents- 
(5) Differences in average cost per out-patient visit 
are due partly to differences in organization, character 
of equipment, extent of medical teaching, etc.; partly to 
actual differences in standards of efficiency; and, finally, 
are partly factitious, owing to different methods of 
accounting. 
(6) Although for these reasons comparisons of aver- 
age cost per visit must be made with great caution when 
different institutions are compared, this cost unit is of 
the utmost value to every dispensary and out-patient 
department in the annual study of the progress of its 
own work. The greatest value of keeping good dis- 
pensary accounts is in self-criticism rather than in 
comparison. 
(7) What shall we do about this matter of cost? If 
accurate and uniform cost figures for hospitals are still 10 
difficult to get, must not accurate and uniform out- 
patient figures be inconceivable? The inconceivable, 
however, happens when it becomes necessary. With 
the rapid growth of out-patient work, and its assump- 
tion by municipal and state authorities, segregated dis- 
pensary accounting is a near necessity. 
To draw up a form in which dispensary accounts 
should be classified, appears to be one of the most 
important and desirable pieces of work in this field. 
Such an assistance in accounting is needed, not only by 
out-patient departments of hospitals, but by the 
rapidly increasing number of dispensaries unconnected 
with hospitals. Such a form should not be compli- 
cated ; but its preparation needs much care, and should 
be undertaken by a committee, as I shall suggest later. 
PRESENT QUESTIONS AND PROBLEMS. 
I take this occasion to speak of some needs of out- 
patient work which specially merit discussion because 
they are now, as it were, on the firing-line. 
1. Should not every out-patient department or dis- 
pensary of any size, have a permanent Superintendent 
in responsible charge? 
2. More continuous and closely organized medical 
service. The question of the payment of a physician 
for out-patient work arises here On this point differ- 
ences of opinion undoubtedly exist. A majority of 
those answering the question in the schedule believe 
that payment of physicians is desirable. The very 
respectable minority who gave a negative opinion may, 
it is true, have been partly impelled to do so by the 
belief that it is foolish to say you believe in paid 
doctors when you have no hope of getting money to 
pay them. 
It is undoubtedly true that the increase in the 
amount of out-patient work which has come so rapidly, 
and the demand for higher standards of work which is 
certain to come-both contribute to increase the dif- 
ficulty of securing enough good medical service without 
payment. The pressure falls first and most severely on 
the dispensaries not connected with important hospitals, 
but having teaching. Large hospitals, well known in 
their communities, and associated with medical schools, 
are likely to feel the pressure less or later. 11 
There can be little doubt that a steady movement in 
the direction of paid services will take place. There 
can also be no doubt that the money to provide for paid 
services cannot be secured until the public is more fully 
and intelligently informed about the needs and the im- 
portance of out-patient work. 
3. Social Service Departments must be largely devel- 
oped and organized closely in conjunction with the 
nursing service in the clinics and in the patients' homes. 
4. Admission systems must be planned not only to 
keep the so-called "unworthy" out, but to reveal other- 
wise undiscovered needs of the so-called "worthy" who 
are admitted. A properly trained person at an admis- 
sion desk is in a strategic position to benefit every phase 
of the dispensary's work. The use of a member or 
members of the Social Service Department in this 
position is, and should be, increasing. 
5. Should patients be charged any fees? A speaker 
at last year's session of this Association answered this 
question in the negative. The reason was apparently in 
part from the belief that if a dispensary is a charity, 
it should not dispense charity at a price, but charity 
straight. Another argument purports to show that 
nominal fees cheapen medical service. A committee 
of the New York County Medical Society, in a recent 
report, suggested a further objection to the fee system; 
namely, that because the medicine and supplies used 
were thus paid for, the "burden of the charity of the 
dispensary" was "left exclusively on the medical pro- 
fession," and that "charitable institutions should dis- 
pense charity to the extent of their ability and no more; 
that they should not make money for the purpose of 
extending their work . . . We believe the dispen- 
sary should be maintained for the benefit of the poor 
only." The impulse toward this trend of thought may 
possibly have been a feeling that dispensary work has 
gone too far in New York, and that anything that can 
be done to limit it, such as cutting down the resources 
of the dispensaries by limiting fees, will be a good 
thing. 
Does "poor" mean destitute? Is not poverty a rela- 
tive term ? Are out-patient departments medical soup- 
kitchens ? Is the test of fitness for dispensary treatment 
the inability to pay ten cents, or the inability to pay for 12 
the medical care needed to maintain health and work- 
ing efficiency? 
Small fees paid by the patient at each visit, and for 
medicines, etc., are, if rightly managed, a boon to an 
out-patient department- They bring not only some 
money, but distinctive administrative advantages. 
They promote better records, tighten lines of responsi- 
bility, and necessitate some one in charge of the admis- 
sion system who has sufficient authority to decide who 
shall be admitted without fees. If no persons are let in 
who have too much money, and no persons are turned 
away who have no money, may we not satisfy both 
those who are anxious to prevent abuse and those who 
burn to do straight charity? 
6. Efficiency tests.-Business experts have come to 
the belief that when a man spends a thousand dollars 
for getting certain results, but does not spend one dollar 
for testing what those results are, he has wasted some 
of that thousand dollars. The out-patient departments 
and hospitals of this country are spending millions of 
dollars yearly in treating patients. How much are they 
spending in testing results of treatment? Are effici- 
ency tests practicable in such a complex and personal 
thing as the medical treatment of out-patients? With 
the understanding that all tests have to be applied 
with a common-sense view of their limitations, I think 
they are of value; in fact, are a necessitly. Three prac- 
ticable efficiency tests will be mentioned. 
(1) Number of visits per patient. If you find that 
35% of cases of acute gonorrhea pay only one visit to 
your men's genito-urinary clinic, and if 60% pay not 
more than two visits, will you consider the treatment in 
that clinic efficient? If in a certain medical service the 
average number of visits per patient is 1| and if during 
another service it is 3 plus, by which service would you 
rather be treated? 
The number of visits paid by a patient is a figure 
easily ascertained, wherever elementary records are 
kept. When the patients or their records are taken 
in groups in which all have the same diagnosis or 
similar diagnoses, we can arrive at valuable conclu- 
sions. Comparisons between clinics in different insti- 
tutions or even different services in the same clinic, 
must always be made with caution, but with reason- 13 
able safeguards in interpretation, rhe number of visits 
per patient, classified by diagnosis, will be found a high- 
ly useful efficiency index. The amount of waste work 
that is found to be spent on patients who pay only one 
or two visits, when effective treatment clearly calls for 
several visits, usually stirs up the medical and lay 
authorities of an institution as much as anything can. 
(2) Medical results analysed on consecutive cases. 
When records are carefully kept a clinical physician 
can take a number of patients with a given diagnosis 
and classify the results achieved as "cured," "materially 
improved," "pending" or "lost" because of failure to 
return. It is essential to take cases in consecutive 
order so as not to exercise selection. This test goes 
deeper than the preceding, but takes much more time 
and is too dependent upon full and accurate records 
to be generally available in out-patient clinics at pre- 
sent 
(3) Medical-Social Surveys of Clinical Work. A 
hundred or more cases may be taken (consecutively or 
at random) from a particular clinic, or from an insti- 
tution as a whole. Then, a certain period after the 
diagnosis has been made in the out-patient clinic, a visit 
may be paid by a properly trained nurse or social 
worker to the home, and a report made to the physician 
of the patient's condition, or the patient may be brought 
back and again examined. In either case this method 
makes it possible to study the work which was actually 
accomplished by the dispensary for a group of patients, 
the number who made one visit and never came back, 
the probable reason for the failure to return; at the 
other extreme the number who were cured or substan- 
tially benefited. Finally we shall get a glimpse of the 
home conditions of poverty, ignorance, unemployment 
or neglect, which very often militate against successful 
treatment by the physician, and which without the 
assistance of a social worker, cannot be overcome. 
Such surveys have been conducted in at least two 
institutions and have proved to be of great benefit. 
This value is not merely in criticism; for such surveys 
give positive suggestions as to how existing resources 
may be used to improve treatment. They also serve to 
provide facts upon which appeals can be made for funds 
for more resources. 14 
7. Civic Problems. 
(a) Licensing of Dispensaries by State law. Mew 
York and Colorado are the only states which have done 
this, but with the growth of both reputable and dis- 
reputable dispensaries, such legal regulation is certain 
to extend elsewhere. 
(b) Regulation or supervision of dispensaries by the 
municipal Board of Health has appeared to some extent, 
and is also likely to increase. 
(c) Co-operative arrangements among the out- 
patient departments and dispensaries of a city. The 
Associated Out-Patient Clinics of New York City have 
made a notable beginning in this direction. Such asso- 
ciations must ultimately be brought about in all large 
cities, both for the purpose of mutual protection of 
reputable dispensaries against abuse and for the posi- 
tive aim of mutual assistance in establishing and main- 
taining high standards. 
(d) Municipal support or control of dispensary 
work. This subject received some attention in the Out- 
Patient Committee Report last year, but I am unable to 
agree entirely with the conclusion therein reached. 
The pressure for funds and the probability that the 
need of paying physicians for out-patient service will 
increase, have caused many persons to think seriously 
that the only solution of the financial question is the 
assumption of dispensary work by city authorities. 
The activities of government are widening rapidly in 
many directions, as we all know, but it seems to me that, 
in the few localities with which I am familiar, it is pre- 
mature to present a program of city ownership and 
control of dispensary work. 
At least, I am confident that the development of 
standards of dispensary work is a prior necessity. 
Methods of out-patient service are not yet sufficiently 
worked out, agreed upon and standardized, to expect 
that many municipalities can fairly be asked to take 
over all local out-patient departments and dispensaries 
and deal justly by them. Those of us who are now 
concerned with administering out-patient work, have 
the present responsibility of working out standards, 
before we are justified in coming forward with a general 
program for municipal dispensaries on a large scale. 15 
A COMMITTEE ON METHODS OF OUT-PATIENT SERVICE. 
Much has been said in this paper upon the need of 
standards, and with a few more words on it I shall 
conclude. It has seemed to me that the American Hos- 
pital Association bears a special responsibility in this 
matter. The American Medical Association has a com- 
mittee on "Dispensary Abuse," but there is nowhere a 
committee to do constructive work on the dispensary 
problem. The American Medical Association stands 
primarily for the interests of the medical profession. 
The Hospital Association, on the other hand, is in the 
peculiarly fortunate position of representing the joint 
interests of the medical profession and the lay public, 
through which the financial support of medical insti- 
tutions chiefly comes. Standards and methods used in 
out-patient institutions are a matter of interest to the 
general public because they vitally concern public 
health. It would seem fitting and practical if the Amer- 
ican Hospital Association should think it proper to have 
a Committee, say, of five members, appointed as a 
Committee on Methods of Out-patient Service. A com- 
mittee of one, which has been appointed during the last 
two years, is capable of presenting a report such as that 
which you are enduring, but a committee of one cannot 
be representative. 
What is needed now is a carefully-worked-out, con- 
crete statement of at least minimum requisites foi 
efficient service in an out-patient department or dis- 
pensary. There is nothing of this kind now available. 
I therefore urge that such a committee be appointed to 
present a report at the next meeting of this Associa- 
tion. 
Perhaps it will be said that the superintendents 
of hospitals and dispensaries know very well today what 
is needed to improve out-patient work-money. Money 
is a most convenient necessity, I admit; but money must 
be secured by persuading somebody to give it-either 
municipal or state legislatures or private individuals 
endowed with philanthropic instincts and means. It is 
not easy to get money for something which the public 
does not know much about, and which is not given much 
apparent consideration by those who are supposed to 
have expert knowledge of it. In just such a condition 16 
are the out-patient department and the dispensary 
today. 
Two things are required before adequate support for 
dispensary work can be expected: facts and a program. 
Facts we must have, showing what the results of dis- 
pensary work can be, what the results under existing 
conditions are, and what is needed to make the results 
better. Outlines, drawn up by recognized authority, 
suggesting the requisites for efficient results, will be 
the greatest possible leverage in the hands of those 
who wish funds from public or private sources to place 
dispensary work on a higher plane. Facts and stand- 
ards are the pre-requisites to a program of improve- 
ment. Public authorities and private givers like to 
know what is going to be returned for their money, and 
to have a definite program presented, before they are 
willing to do what the boys call "shell out." 
If we read many signs of the times aright, the 
utilization of out-patient clinics for the treatment of 
sickness and the prevention of disease is going to in- 
crease rapidly. The out-patient department or dispen- 
sary is already playing a great and growing part in the 
anti-tuberculosis campaign; the campaign against the 
hook-worm has employed it on a large scale; the dis- 
pensary method has been adopted in the fight against 
infant mortality, and every summer now sees an in- 
crease in this field. Out-patient service is thrown more 
and more into the foreground by such influences as the 
rising cost of living; the increase in the cost of medical 
service; the recognized difficulty of providing competent 
specialists at prices within the reach of even the middle 
classes; and, perhaps more than all, the growing public 
demand for better care of the health of children. Work- 
men's Compensation laws, already established in many 
states, and other forms of social insurance which are in 
the field of political discussion-are bringing to this 
country, as they have brought to Germany, England, 
and other nations abroad, serious questions involving 
radical changes in the character of medical service to 
the mass of the people. These problems must be 
attacked from a broad standpoint which considers both 
the interests of the medical profession and those of the 
general public together. 17 
The establishment of higher standards of out-patient 
service; the elaboration of a technique by which the 
treatment of out-patients can be made thoroughly 
efficient-are the immediate problems which we are 
facing. The solution of these problems of efficiency is 
a pre-requisite to the larger utilization of the dispensary 
as a constructive and permanent agent of promoting 
public health. 
APPENDIX I. 
Suggestions of material which the Annual Report of 
a Hospital should contain, concerning its Out-Patient 
Department. 
1. Arrangement.-The opening portion of the An- 
nual Report should give an idea of all the divisions of 
the hospital, and should put them in some perspective. 
Every report should have a table of contents. 
2. A Special Report for the Out-Patient Department. 
-Every hospital in which the number of out-patients 
equals or exceeds the number of ward patients should 
give a special section of its report to the out-patient 
department, as a division of the hospital work. Such a 
report might be a section of the trustees' or superin- 
tendent's report, or it might be a report of a special 
committee on the out-patient department. Such a 
special report ought to contain:- 
An idea of the general organization of the dis- 
pensary and of its medical service. It is probably 
well to print detailed statistics of the dispensary in 
the statistical section of the report, and only the 
general figures here. 
Changes during the past year which have taken 
place in relation to such matters, as building, equip- 
ment, medical staff, executive staff, clinical methods, 
social service, etc. 
Something about the problems of the work. The 
public really ought to be given the impression that 
the authorities of the hospital are thinking a little 
about the dispensary as well as running off clinics. 18 
3. Out-Patient Statistics. The Report should state, 
for the period covered by it, (1) the number of patients, 
classified by clinical departments; (2) The number of 
visits made by these patients, classified by departments; 
(3) The average number of visits per patient for each 
department. 
Statistics of special work-X-Ray, social service 
department, etc., should be given.* 
4. Finances.-The cost of the out-patient department 
should be included in the Treasurer's Report, itemized 
so far as practicable. 
and the income from fees paid by patients, if any, 
5. Regulations Concerning Admission and Treat- 
ment.-The rules governing admission of out-patients, 
the days and hours on which clinics are open, the class 
of patients taken, and the fees charged, if any, should 
be stated succinctly in every Report. Ninety per cent, 
of the 56 reports give no such information. 
* The list of diseases treated is not included among the fore- 
going "requisites." The value of such a list, if carefully classi- 
fied, is not questioned; but the amount of labor in preparing it 
is relatively so great that, if a choice is to be made between 
presenting it and the facts above mentioned, it seems that the 
facts above mentioned ought to come first. 19 
spit's 12 Large Dispen'r's 15 Small Dispen'r's 
Totals 
Not 
ans. 
'artly Yes 
No 
Partly Yes 
No Partly 
Yes 
No 
Partly 
5 
3 
3 
3 
10 
2 
14 
52 
8 
2 
10 
2 
7 
5 
35 
24 
3 
14 
? 
10 
2 
9 
6 
• • 
32 
42 
1 
0 
8 
4 
6 
9 
• • 
41 
25 
0 
0 
12 
• . 
12 
2 
71 
3 
0 
2 
2 
4 
5 
8 
9 
3 
3 
46 
14 
16 
0 
1 
7 
2 
3 
11 
3 
1 
55 
10 
11 
0 
1 
6 
6 
8 
7 
44 
29 
2 
1 
7 
4 
? 
8 
3 
47 
12 
1 
1 
• • 
• • 
• • 
4 
• • 
• • 
15 
• • 
6 
4 
3 ? 
4 
3 
8 
4 
17 
26 
32 
1 
8 
2 
4 ? 
5 
3 
8 
4 
10 
31 
34 
1 
6 
5 
4 
3 
2 
9 
4 
10 
30 
30 
0 
Organization and Methods of Out-Patient Work in 76 Institutions. 
APPENDIX II. 
9 Large Hospitals 18 Small Hospitals 12 Special Ho 
Yes 
No 
Partly Yes 
No 
Partly 
Yes 
No P 
Paid doctors 
4 
12 
3 
1 
17 
1 
10 
Believe in or favor 
paid doctors .... 
9 
3 
3 
6 
9 
3 
5 
A permanent Supt. 
8 
11 
3 
15 
3 
8 
A Social Service 
Department .... 
12 
2 
- - 
8 
5 
. - 
7 
5 
Favor Social Ser- 
vice Dept 
19 
16 
1 
12 
Rec'ds kept on cards 
13 
6 
6 
11 
5 
2 
9 
i 
Patients' visits re- 
corded 
12 
2 
5 
14 
3 
1 
11 
0 
Index of patients 
kept 
12 
6 
1 
8 
9 
10 
1 
Physical exam, re- 
corded in all cases 
13 
1 
8 
4 
- - 
4 
"In some cases". 
5 
• . 
5 
• • 
1 
• • 
Test of Urine a 
clinical routine.. 
2 
6 
11 
3 
8 
7 
5 
1 
Test of Blood a 
clinical routine. . 
1 
7 
11 
2 
10 
6 
2 
2 
Weighing Patient a 
clinical routine.. 
1 
7 
11 
3 
9 
6 
5 
1 20 
Visits per 
Patient 
MEDICAL RESULTS 
Total Number 
of Cases 
Per cent 
Continued 
Treatment, 
discharged cured 
Continued treatment 
ceased or was dis- 
charged improved. 
Ditto, not 
improved. 
Treatment 
pursued & now 
continuing'. 
Case tranferred to 
care of another Medica 
or Social Agency 
( Result unsatisfactory: 
patient failed to return for 
treatment. "Lost Cases 
Medical 
Outcome 
Unknown. 
One 
Two 
Three 
Four 
Five 
Six to 
Eight 
Nine to 
Twelve 
Over 
T welve 
Totals 
Percentages 
*Printed copies of these forms may be obtained by addressing the author at 25 Bennet Street, Boston, Mass. 
(b) Form* for classifying Medical Results correlated with number of visits paid. 
EFFICIENCY TEST IN DEPARTMENT 
for months of 191 
Diagnoses Tabulated 21 
Diagnosis 
NUMBER OF VISITS PER PATIENT 
Total Number 
of Cases 
One 
Two 
Three 
Four 
Five 
Six, Seven 
Eight 
Nine, Ten, 
Eleven, Twelve 
Over Twelve 
• 
- 
• 
- 
- 
APPENDIX III.-EFFICIENCY TESTS. 
(a) Form* for tabulating visits per Out-Patient, classified by diagnosis. 
EFFICIENCY TEST IN DEPARTMENT 
for months of 191 22 
DISCUSSION. 
President: This paper of Mr. Davis' is a very interesting and 
instructive paper. Perhaps the President will be excused if he 
makes one or two remarks. As to municipal control of dis- 
pensaries, would it not be well to wait until municipalities do 
well what they have undertaken now before they take up this 
work. As for dispensary abuse, of which we have heard so 
much, the older I grow and the more years that I have to do 
with out-patient departments of hospitals, the less sympathy I 
have witn this talk of dispensary abuse, and the more sympathy 
I have with the patient who is turned away and sent into the 
hands of some physician, or some medical institute where he 
will not get the care that he needs. I have less and less patience 
with this talk of dispensary abuse. Mr. Davis has made a 
recommendation that a Committee on Out-Patient Departments 
be appointed for the ensuing year. The by-laws call for a com- 
mittee of one. I take it that there will be no objection to the 
incoming President adding to this committee. It certainly is a 
most important subject and one which, as Mr. Davis has said, 
has been so far neglected in most parts of the country. There 
are a few hospitals in the country that have done out-patient 
work as they should do it and they have plenty of room for 
improvement. Is there any further discussion on this paper? 
Dr. Fowler: I beg the pardon of the meeting for appearing so 
often, but I am an enthusiast along hospital lines, and the 
remarks made by the distinguished essayist and the President 
have caused me to attempt to say something in response. As 
you know I am superintendent of the City Hospital of Louisville, 
Kentucky, and we treat on an average 125 people a day in our 
out-patient department and expend something like $15,000 per 
annum, and we think we do it well. We keep specific records, 
and four hours in the morning we put a staff officer in there, 
not an interne, and four hours in the afternoon, and the other 
four hours are taken care of by the internes, by the house staff; 
so we do not lose an hour in the day in treating those poor people 
that come from all over the city, some of them walking five or 
six miles, and we also honor every prescription marked 
"Charity" by any physician in the city, and in addition to that 
we furnish every nurse, all the district nurses, all the King's 
Daughters nurses, all the Jewish charity nurses, in fact, all 
those institutions, with anything that they demand, their daily 
supplies in visiting the poor over the city, and I believe that the 
city is the only one to get back to a movement of that kind. My 
experience has been with thp other organizations that that is 
why they came to us, that they could not raise the money, but 
my city has been extremely liberal and have authorized me as 
Superitendent never to stop at any expense. I have spent as 
much as $116 buying serum for one child. That is the remark 
that I desire to make. 
President: It is refreshing to hear of a city which is so well 
conducted. Are there any further remarks on Mr. Davis' 
paper? If not we will go to the next paper.