I entered medical school in 1969. Through a quirk of fate, I found myself part of an experimental program in medical education, the “Clinical Program,” as it was called. It was an off-the-wall endeavor, but I was forged by it. From my first day of medical school — before I had taken classes in anatomy or physiology, pathology or pharmacology — I was placed into clinical clerkships that traditional students do not enter until their third year of training. And since I knew nothing of the culture of medicine, its doctors or hospitals, my sole identification was with my patients. That first day I duly reported for my assigned clerkship: general surgery at the Philadelphia General Hospital (PGH). PGH, a city-financed facility for the underserved, had evolved from “Old Blockley,” established in 1732 as an almshouse for the poor, the sick, the elderly, and the insane. William Osler, the Father of Internal Medicine, during his time at Penn (1884–1888) regularly made rounds there. Historians consider Old Blockley to be the first hospital in what would become the United States. The surgery ward at PGH was a huge open space with large windows all around, though by 1969 they were covered in deep grime and only let in dim, gray light. Hand-cranked hospital beds lined two long opposing walls, with a painted metal nightstand by each one. Folding partitions would be placed around a bed when necessary, such as during examinations, therapeutic ministrations, or a patient’s death. At each end of the ward was a large table, the hub of nursing activity. Nurses, aids, and trainees worked 24/7 in the ward with the patients. I remember that the patients, if they were well enough, would socialize with each other, assist each other, and often help the nurses with physical tasks. I was told again and again by the doctors rotating through PGH during my one month there that I was witnessing history passing, the medical care from another century. “Good riddance,” they said to me. I was impressionable and idealistic, and my eyes were open: I felt there was something to take away from my experience at PGH. But PGH — after decades of neglect from publicly elected officials — had become a dilapidated, deteriorating mess. It closed permanently in 1977, then was bulldozed. Except for an ancient brick and iron fence to mark its place in medical history, no trace of PGH remains. Mega modern hospital facilities have risen in its stead. There no longer exist any public almshouses in America. The last to close was Laguna Honda in Los Angeles, originally opened in 1866 to help care for the gold rush seekers (though a modern hospital bearing that name remains). Dr. Victoria Sweet wrote about her years there as a staff member in her remarkable memoir God’s Hotel (Riverhead Books, 2012). This is how she described it:An almshouse [is] a kind of hospital from the Middle Ages … (as the French called it, Hotel-Dieu — God’s Hotel) that evolved as a way of taking care of those who couldn’t take care of themselves. At one time, almost every county in the U.S. had an almshouse … In practice, the almshouse had been a catchall for everyone who didn’t fit someplace else — it was a shelter, a farm for the unemployed, a halfway house, and a rehabilitation center, as well as a hospital. I spent the rest of my medical school training at the Hospital of the University of Pennsylvania, a poster child for the modern medical-industrial complex. I worked in state-of-the-art, specialized units: Medical ICU, Surgical ICU, Neuro ICU, CCU, Shock and Trauma, Neonatal, Pediatrics, Transplant, Renal Dialysis, and on and on. I learned, and I learned. And yet, all the time it seemed I was being drawn farther and farther away from what I believed I had gone to medical school to do: care for the patient. I moved to San Antonio, Texas, and in 1976 opened my office as a solo practitioner of general internal medicine. I worked in a small but modern nonprofit community hospital. It had a tiny emergency department and a single intensive care unit. A few accessible administrators oversaw the fiscal side, but the practicing doctors — though they were not the owners — ran the show. Nothing related to patient care happened without approval and oversight by a robust medical staff, all working for the benefit of “our” hospital and “our” patients. Despite the hours we put in outside of our clinical practices — for committee meetings and planning meetings and budget meetings — no doctor received any additional recompense for the time and effort. In my almost 40-year association with this hospital, I was an active observer and participant as it evolved into a mega complex, with services to rival any academic medical center. Along the way it was acquired by a national hospital chain. So, too, were many of the medical practices, though not mine. The practicing medical staff is now “in charge” of nothing. A few have “graduated” to paid administrative positions and joined the legions of MBA types who micromanage all aspects of hospital operations. The staff meetings are but a rubber stamp on policies plotted by others, and they pertain mostly to maximizing profitability. Hired emergency department doctors, hospitalists, intensivists, cardiologists, nocturnists, and other “key” specialists render the emergency and inpatient treatment. But what they provide is not “hospital care” but technology — state of the art though it may be. When I use the term “care” I mean it in the way you would want to receive hospital treatment for yourself or a loved one. I wrote about the horrendous experiences my mother endured in “my” hospital after her stroke (Caring 2010;11[10]:22–23) and then after a hip fracture (Caring 2017;18[5]:10). “My” community hospital has not yet embraced the small but growing movement to provide geriatric emergency and inpatient care to at-risk elders in specialized units designed for this demographic. Very few hospitals have such facilities. Ask yourself: Why haven’t these caught on? Those of us doing our best to care for frail elders like my mother have many such stories to tell. In our workaday lives we have learned from often bitter experience to do anything and everything we can to avoid putting our patients and loved ones in the hospital. So when Ezekiel J. Emanuel, ethicist and vice provost at the University of Pennsylvania, asked, “Are Hospitals Becoming Obsolete?” (New York Times, Feb. 25, 2018), I was primed for the message. Even though today’s modern hospitals account for $1.1 trillion of spending — one-third of all medical expense — their numbers are in decline. The zenith for admissions occurred in 1981, with 39 million hospitalizations, but currently there is a lower rate of per capita admissions than in 1946. Hospitals have declined in number from 6,900 to 5,500. Those of us caring for the elderly are acutely aware that hospitals have reduced inpatient days by shifting complex and often less remunerative patients (the aged, the infirm, the poor) into other settings — rehabilitation facilities, long-term acute care facilities, skilled nursing facilities, and long-term care (LTC). And not only are our SNF and LTC patients sicker, requiring more acute services than in years past, we and our facilities are being penalized should we dare to send someone back into an acute care hospital too soon after they were sent to us. This is a malignant and intimidating message. Ask yourself: Who benefits from such policies? Maybe hospitals ought to become obsolete. After all, our view of hospitals has changed, compared with another century, as Emanuel pointed out:Hospitals now seem less therapeutic and more life-threatening. In 2002, researchers from the Centers for Disease Control and Prevention estimated that there were 1.7 million cases of hospital-acquired infections that caused nearly 100,000 deaths. Other problems — from falls to medical errors — seem too frequent … a hospital admission is not a rejuvenating stay … but a trial to be endured. Perhaps some of those to whom we minister might do better with “home hospital care” (see the study from Boston; Ann Int Med 2020;172:77–85). This is a 20-year-old idea, and its applicability to today’s increasingly frail and comorbidly aging population remains inadequately tested but worth further investigation. We now expect our LTC facilities to do what hospitals of yore routinely did. Yet for the most part they do not have (as featured in the Boston home hospital study) doctors who visit their patients daily or specialized nurses coming twice daily, not to mention the lack of “RT, infusion pumps, radiology services, and point-of-care blood diagnostics” (Ann Int Med 2020; 172:145–146). And let us not forget the growing number of the aged, the infirm, the poor who have inadequate or no insurance, who are homeless or ill-housed, ill-fed; who have no available family members to assist and oversee. Where do these people go for care in a world where hospitals try to exclude them for fiscal reasons? Should “cheaper and faster” be the mantra for a new paradigm of care, or should we look back in time? If only places like Old Blockley and Laguna Honda were still extant among us, perhaps we might learn something new. Again. Dr. Winakur practiced internal and geriatric medicine for 36 years, founded a hospital SNF, and taught medical ethics and humanities to medical students for 16 years.