Once in a while I have to go to a hospital. Most people do. Of course, I go for medical reasons and don’t expect it to be a pleasure trip. Fortunately, the medical care I have received in New York hospitals is superb. But hospitals also function as hotels and restaurants. Patients must be lodged and fed in addition to being treated. The food and hotel services provided by hospitals are abysmal (though in rural hospitals they are a little better). Why?

Hospitals only grudgingly recognize that they are not solely medical institutions. “This is a hospital, not a hotel” is a familiar refrain—as though the two functions were mutually exclusive. History shows why bad food and discomfort have always accompanied good medical care. Hospitals started as eleemosynary institutions for the poor. Physicians did not want to go to the slums to see poor patients, who could not pay anyway, and so hospitals were founded to take care of them. Because the poor were grateful and undemanding—they certainly did not complain about a lack of comforts to which they were not accustomed anyway—hospitals grew used to offering only a minimum of comfort. They still do, and this eleemosynary tradition has remained very strong. Administrators are only fitfully becoming aware that they run a business, which includes hotel and restaurant functions in addition to medical care.

Consider some of the unnecessary discomforts which hospitals impose on patients. It takes only a few moments to register in a hotel. In a hospital, I, an ambulant patient, am sent from person to person with intermittent waiting for often an hour, just to register. Yet, my doctor has already reserved a place for me, and I—for that matter, most patients—came insured and with credit cards.

Private rooms are far smaller than any hotel would dare offer. There is a bed and a chair or two. No vase for flowers, no table, scant closet space, and no lamp over the bed which makes reading quite difficult, and no controls for patients to regulate heat or air conditioning. The beds are often uncomfortably narrow—supposedly to facilitate the tasks of physicians and nurses—but I have seen no services, or examinations, facilitated by the narrowness of the bed. The mattress is covered with plastic, which makes the patient slide around wildly. This is to protect it from incontinent patients (very few are). Nurses are not allowed to remove the plastic cover.

Rooms are first attended to by a worker who makes the bed, then by another who mops the floor, and finally by a third who empties wastebaskets and cleans bathrooms. They arrive at different times, disturbing patients at least three times a day. Hotels manage to merge these three operations into a single visit. It is almost impossible to persuade hospital personnel to knock before entering one’s room, or to close the door when leaving. For nonambulant patients this is quite a problem. But unnecessary deprivation of privacy seems de rigueur in hospitals.

Food has to be ordered 12 hours in advance and is available only three times a day at fixed mealtimes. (One cannot order beer or wine with meals.) Nor can one order anything—not a cup of coffee, a glass of juice, a sandwich, let alone a hot dish—outside mealtimes. Unlike hotel guests, patients cannot eat when and what they would like, and however willing one might be to pay, one cannot obtain items ordinarily on restaurant menus. On the other hand, full board is charged whether or not one wants to eat the meals provided. Patients who ask for the food they prefer are regarded as frivolous nuisances. They are reminded resentfully that “this is a hospital,” as though this justifies unnecessary deprivation and discomfort.

Hospitals also are remarkably noisy. Nurses’ aides and cleaners shout at each other from one end of the corridor to another. When they do not converse loudly, they whistle. (Hospitals in Switzerland, Italy, and Germany are very quiet places.) Doctors do not like the noise either, but feel powerless. They tell patients that the hospital unions make it impossible to discipline the custodial staff. However, hotels that have similar problems succeed and are much quieter than hospitals. But hotels are interested in the comfort of their guests—hospitals only in their health, conceived as though excluding comfort.

As mentioned before, privacy is routinely denied patients. They cannot even refuse to see visitors. Some years ago, a nurse from a local hospital called to tell me that a patient, in the intensive care unit with a heart attack, urgently wanted to see me. I protested that I did not know the patient and could not be of assistance. But the nurse insisted that the patient was dangerously agitated and that just visiting him would help. So I went.

The patient, whom I’d never seen before, explained that he had attended a lecture I gave and thought I would be able to help him. He was dying, and was also in the throes of a messy divorce. His ex-wife feared that he would disinherit her. She had hired an attorney. This lady came to the hospital every day to discuss her client’s demands and to ask the patient to sign papers. He did not want to see her; she upset him. He had so advised the nurses, but the undesired visits continued. I spoke with the nurse in charge, who told me that she had conveyed the patient’s desires to the visitor, but did not feel able to prevent the visits.

I called the attorney, who responded noncommittally and called me back a little later to inform me that she had found me to be neither a physician nor a member of the bar (I had not pretended to be either) and that consequently she would ignore my request to stop the visits. I called the resident to inform him of the situation, and was told that he had no way of preventing the undesired visits.

In most hospitals, visitors are admitted by indicating whom they wish to see. hi other words, the patient’s consent for the impending visit is not requested. In fact, once a visitor is admitted to the hospital, he can enter any patient’s room he wishes. There is no effective way for a patient to refuse any visit from anyone.

Hospitals insist that they are liable for harm to patients and therefore must have access to the rooms at all times. This is why rooms cannot be locked. Indeed, a locked room could endanger some patients (who probably wouldn’t lock it anyway); but others could sign appropriate forms to immunize the hospital against liability. Further, nurses could have a master key. As it is, patients cannot have the privacy with their friends, wives, or husbands, which is a matter of course in hotels. Privacy would help preserve the dignity of patients as adults. Why can a hospital room not be protected from undesired non-medical visitors? A hotel room is.

It is part of traditional hospital culture for nurses and interns to be overworked. Why? Can’t hospitals hire sufficient personnel? Hotels do while charging much less. Indeed, hospitals make it hard even to ask for a service. Patients usually have call buttons near their beds which often do not elicit a response, and intercoms are rarely provided.

Even the simplest things (other than purely medical ones) are hard to obtain in a hospital. One evening I asked for an extra pillow at 8:00 P.M. It arrived at ten. I was awakened to receive it. The well known tale of the nurse who awakens the patient to give him his sleeping pill always struck me as an exaggeration. Not so. It actually happened to me.

Usually hospitals are run by physician administrators who focus on the medical aspect of hospitalization. They do not know, or care, much about the hotel aspects. But wouldn’t it be better if the medical and hotel aspects of hospitalization were managed separately? The provision of food and lodging might become the responsibility of a separate corporation billing independently. It seems unlikely that medical administrators ever will properly manage the hotel duties, just as unlikely as it is that hotel managers will ever properly administer medical services.

Although they now compete for patients, hospitals unavoidably have monopolistic features. Once you enter a hospital, you cannot easily leave, however bad the food or services rendered. The hospital resembles a closed institution not unlike a prison or insane asylum. To change hospitals, you would have to change doctors, but staying with your doctor is likely to be more important to you than comfort. Medical services are paramount in your choice, which makes it possible for hospitals to neglect patient comfort.

Moreover, physicians usually can practice in only one hospital. The patient’s choice of hospital is therefore determined by his physician and limited by his accreditation to this hospital. Thus, unless the patient is willing to give up his physician, he does not really have a choice. Must this be so? Couldn’t physicians be allowed to practice in more than one hospital? This change would be helpful to patients and not harmful to physicians. Similarly, the patient can get a private nurse only from the hospital registry. Couldn’t private nurses also be registered to practice in more than one hospital? why increase the monopolistic aspects of hospitalization beyond necessity?

Hospital charges are a mystery only precariously related to the services performed. Since most patients do not pay—insurance companies do—hospital charges are not effectively controlled. No wonder they are high. But there are also the peculiarities of hospital bookkeeping.

Hospitals make paying customers, or their insurance companies, bear the cost incurred by uninsured patients who cannot pay. In effect, paying patients are taxed for the nonpaying ones. Yet the cost of treating the latter is a social cost, properly borne by taxpayers. It seems inequitable and capricious to make insured or paying patients who happen to use hospital services pay this cost—just as it would be to make paying restaurant patrons pay for meals given to patrons who cannot pay. But the restaurant patrons can choose a different restaurant. The hospital patients cannot.

If hospitals must continue to charge the paying patients for the cost incurred by the nonpaying ones, hospital bills should list the price charged to the patient for the actual cost of the room, food, nursing care, etc. To the sum of these charges, the levy to pay for nonpaying patients should be added explicitly. At least the patient will know what he pays for.

A special note on hospital lodging is necessary. In accounting terms, each bed or room in a hospital is very expensive. However, the accounting terminology is misleading. It is not the bed or the room that costs a lot but the medical treatment, the charge for which is assigned to the room. Small rooms save the hospitals less than they would save a hotel—a negligible sum as a percentage of the total cost. Actually, given the total cost of hospitalization, the cost of space is even more negligible than it would be in a hotel. There is no more reason, therefore, for patients to share rooms than there is for hotel guests to do so. And there certainly is no reason at all for restricting the size of single rooms.

Going even to the best hospital will never be my heart’s desire. But why make it worse than it has to be?