On the other hand, a large patient population permits active research on a range of less common diseases; and the hospital serves a genuine function as a place of expert management in such illnesses. Similarly, highly technical procedures, requiring trained personnel and expensive machinery, can be supported in a large hospital, and these procedures can be carried out with a high degree of expertise. Patients who require open-heart surgery or sophisticated radiotherapy find the expensive equipment for such procedures here-and, equally important, staff that carries out such procedures daily.

As for the emphasis on curative measures directed toward established organic illness, two points can be made. First, the hospital's ability to continue to care for the patient once he has left the hospital is not as good as anyone would like. The MGH founded the first social-service department in America, in 1905, to look after such follow-up care in areas not strictly medical. These departments are now standard in most large hospitals. Similarly, the out-patient clinics are designed to provide continuity of medical care to ambulatory patients. But many patients are "lost to follow-up," to use the hospital's expression; they don't answer the social worker's calls, or they don't keep their clinic appointment Nor can they be wholly faulted in this regard, for the hospital's out-patient services are, in general, quite time-consuming for the person who wants to use them. Not only does the patient spend hours in the clinic itself, but he must take the time to travel to and from the hospital on each visit.

Second, by definition the hospital has not done much in the area of preventive medicine. No hospital ever has. Since the aesculapia, hospitals have defined themselves as passive institutions, taking whoever comes to them but seeking no one out.