When I was a resident physician the chief of cardiology often argued that there should only be two departments in a hospital – medicine and trauma. I’ve often thought about that view over the ensuing decades as the number of medical specialties proliferated like mushrooms after a downpour.

How many specialties would be needed if a political, social, or economic crunch necessitated maximal downsizing? I think a hospital could be run under those far from optimal conditions with just two physicians – an internist and a trauma surgeon. I’m assuming that this shrunken medical center had an adequate supply of nurse practitioners and physicians assistants. At the end of this piece I’ll conditionally allow a third doc. Obviously, people get sick, they need time off, or they’re called away for other reasons. I’ll ignore the need for backup.

First the medical specialist, actually a generalist. The person picked to handle all the problems that don’t need immediate surgical intervention has to know a lot of medicine, both internal and external. Recall, that pediatrics is just internal medicine for children. While no one can know all of medicine, there are a few physicians who know about as much as possible for an individual to master. The internet places the sum total of medical knowledge a few keystrokes away. Thus, a really smart, experienced, and computer savvy internist can do all the thinking needed to run a medical center under the austere conditions I’ve predicated.

The doctor charged with all things medical should be at least 35 years old. This minimum age requirement is to allow sufficient time after the completion of training to have passed to allow enough practice experience to accumulate. As no manual dexterity is necessary for this position I would have a mandatory retirement age of 70. I’d check performance very carefully at all ages, but especially after 60. Even the slightest hint of loss of hyperacute thinking would result in a generous, but insistent, retirement.

Who would judge performance? The entire staff will meet regularly and decide who should go and who should stay. Non-physicians easily and correctly can tell which doctor is up to speed and who isn’t. Thus, the staff and the two doctors would regularly meet and make decisions about who stays and who goes. I realize that personal pettiness and emotional reactions are part of the human condition, but the arrangement I’ve just described is likely the best we can do regarding staffing and retention.

The trauma surgeon would best be prepared by having a year of general surgery and then learning trauma surgery via an extended orthopedic residency. As there would be no elective surgery in our barebones hospital, our solo surgeon would have to handle every emergency surgery that came his way. He’d have to do the appendectomies and treat other intrabdominal catastrophes. Of course, his job would be made doable by all the paramedical support he’d have. His orthopedic background would allow treatment of all the broken bones and damaged joints that show up at frequent but unpredictable intervals. Anesthesia would be administered by a nurse anaesthetist.

The age range for this surgeon is 40 to 60. Experience is critical in a surgeon who is going to make rapid life-death decisions. But surgeons are like athletes, their physical skills decay with age. After 60 fine two point discrimination goes downhill. Of course there’s a lot of variability in the rate of skill decline, but 60 seems the right age to retire the surgeon. The compensation for this key player would have to be considerable considering how long it would take him to reach an optimum skill level and how short his career would be.

Obstetrical care would be provided by as many nurse midwives as necessary. Gynecological emergencies would be handled by the trauma surgeon.

What about imaging? The best medical practice requires that doctors read all the imaging studies (X-rays, CT scans, MRIs, etc) done on their patients. Many are too lazy to do so and rely entirely on the reports of radiologists rather than comparing the reading by the radiologist with their own. In our two physician hospital there will be no radiologist, so our two doctors will of necessity read all the imaging studies done on their patients. Reading X-rays and scans is not that hard to learn if you make the effort to acquire the skill.

Ophthalmology. It’s become such an arcane subject full of wonderful technology while being so far removed from the rest of medicine that I don’t think it necessary to go to medical school to become an expert eye specialist. From high school to eye school is what I think the visual path should be. Thus, we can have several highly trained eye technicians at our minimalist hospital, all without MD degrees and with salaries appropriate for their high level of training and eye expertise.

As for psychiatric or behavioral medicine, the nurse midwives can handle panic attacks and psychotic breaks. If things get really out of hand, the medical doctor can administer haldol or the like.

A argument could be made for the addition of an interventional radiologist and a pathologist. Poking needles into organs and catheters in blood vessels is purely a technical skill. A PA or Nurse Practitioner can easily learn the techniques required, thus obviating the need for a physician to do such procedures.

The medical doctor can easily supervise the clinical laboratory; so no need for a clinical pathologist. I don’t know if enough biopsies will be done at our skinny medical center to justify a pathologist, so I leave this position hanging.

I’ve left the least for last — an administrator. There will have to be someone to supervise the paperwork or rather the computer work. A young accountant can do the job. He’d be under the supervision of the two MDs. He’ get a small office and a distant parking space, rather than the palatial work accommodations now provided to a hospital administrator. His salary would also be appropriate for the low status of the job.

So there you have it. How to structure a hospital on the cheap. I don’t seriously believe that such an institution will be operated short of a near total collapse of society. The purpose of this exercise is to show the bloat that surrounds the typical hospital. Short of a collapse it demonstrates that there’s a lot of fat in our medical system that could be easily eliminated.

A parting thought. How to pay for this hospital? Eliminate insurance of any type. Cash on the proverbial barrelhead. Prices will plummet and medical care will cost no more than food, housing, or transportation. But that’s a subject for another time. Stay well.