Institutions & Individuals

Sociology and Medicine met head on this week when the Committee on the Costs of Medical Care finally published its recommendations for the re-organization of the practice of medicine in the U. S.

President Hoover went out of his way to "commend a careful study of this report to the professional and community leaders throughout the United States."

Traditionally U. S. doctors, like U. S. farmers, are pugnaciously individualistic. Their practice has been on a personal doctor-&-patient basis. To maintain this, doctors have banded themselves into one of the most powerful and beneficial institutions on the U. S. scene--The American Medical Association. But the A. M. A. has been unable to prevent inequalities in the distribution of medical services to the entire population or of payments to all the doctors. Complaints have alarmed both doctors and sociologists.

Five years ago certain philanthropic institutions* provided $1,000,000 to study the costs of medical care in the U. S. An able, conscientious committee took form. Chairman has been Dr. Ray Lyman Wilbur, Secretary of the Interior, president of Stanford University, trustee of the

Rockefeller Foundation, past president of the A. M. A. Chairman of the executive committee has been Yale's Professor of Public Health, Dr. Charles-Edward Amory Winslow. For custodian of the $1,000,000 the committee organizers chose President Winthrop Williams Aldrich of the Chase National Bank, charitarian brother-in-law of John Davison Rockefeller Jr. They picked Economist Harry Haskell Moore, to direct the study.

Investigators probed every health activity they could learn of. brought to analysis thousands of statistics. Examples: The 1929 U. S. health bill was $3,647,000,000;* 1,082,550 persons were engaged in providing medical care and medical commodities; 38.2% of the population were getting no medical care whatsoever; average doctor's annual income is $5,300; 47,000 doctors earn $50 a week.

The majority of the Committee on Costs decided that if the $3,647,000,000 U. S. annual sick bill were equitably spent, every inhabitant of the nation would get adequate medical attention, every person connected with the practice of medicine would earn an adequate living. To accomplish this, they candidly point out, would require a complete reorienting of U. S. Medicine, a thoroughgoing socialization of the profession. Despite the vigorous objections of several members of the Committee, the majority agreed upon and last-week recommended these principles:

"1) The Committee recommends that medical service, both preventive and therapeutic, should be furnished largely by organized groups of physicians, dentists, nurses, pharmacists, and other associated personnel. Such groups should be organized, preferably around a hospital, for rendering complete home, office, and hospital care. The form of organization should encourage the maintenance of high standards and the development or preservation of a personal relation between patient and physician.

"2) The Committee recommends the extension of all basic public health services--whether provided by governmental, or non-governmental agencies--so that they will be available to the entire population according to its needs. This extension requires primarily increased financial support for official health departments and full-time trained health officers and members of their staffs whose tenure is dependent only upon professional and administrative competence.

"3) The Committee recommends that the costs of medical care be placed on a group payment basis, through the use of insurance, through the use of taxation, or through the use of both these methods. This is not meant to preclude the continuation of medical service provided on an individual fee basis for those who prefer the present method. Cash benefits, i. e., compensation for wage-loss due to illness, if and when provided, should be separate and distinct from medical services.

"4) The Committee recommends that the study, evaluation, and coordination of medical service be considered important functions for every state and local community, that agencies be formed to exercise these functions, and that the coordination of rural with urban services receive special attention.

"5) The Committee makes the following recommendations in the field of professional education: a) that the training of physicians give increasing emphasis to the teaching of health and the prevention of disease; that more effective efforts be made to provide trained health officers; that the social aspects of medical practice be given greater attention; that specialties be restricted to those specially qualified; and that postgraduate educational opportunities be increased; b) that dental students be given a broader educational background; c) that pharmaceutical education place more stress on the pharmacist's responsibilities and opportunities for public service; d) that nursing education be thoroughly remoulded to provide well-educated and well-qualified registered nurses; e) that less thoroughly trained but competent nursing aides and attendants be provided; f) that adequate training for nurse-midwives be provided; and g) that opportunities be offered for the systematic training of hospital and clinic administrators."

Trustees of the American Medical Association had ample forenotice of these recommendations. Members of Committee on the Costs include Dr. Olin West. A. M. A. secretary; Dr. George Edward Follansbee. chairman of A. M. A. judicial council; Dr. Malcolm LaSalle Harris, "loyal" A. M. A. past president. They guided the phrasing of a potent minority report which they expect every private practitioner of medicine in the U. S. to maintain as his gospel. That minority report reads:

"i) The minority recommends that government competition in the practice of medicine be discontinued and that its activities be restricted a) to the care of the indigent and of those patients with diseases which can be cared for only in governmental institutions; b) to the promotion of public health; c) to the support of the medical departments of the Army and Navy, Coast and Geodetic Survey, and other government services which cannot because of their nature or location be served by the general medical profession; and d) to the care of veterans suffering from bona fide service-connected disabilities and diseases, except in the case of tuberculosis and nervous and mental diseases.

"2)The minority recommends that government care of the indigent be expanded with the ultimate object of relieving the medical profession of this burden.

"3) The minority joins with the Committee in recommending that the study, evaluation, and coordination of medical service be considered important functions for every state and local community, that agencies be formed to exercise these functions, and that the coordination of rural and urban services receive special attention.

"4) The minority recommends that united attempts be made to restore the general practitioner to the central place in medical practice.

"5) The minority recommends that the corporate practice of medicine, financed through intermediary agencies, be vigorously and persistently opposed as being economically wasteful, inimical to a continued and sustained high quality of medical care, or unfair exploitation of the medical profession. . . .

"7) The minority recommends the development by state or county medical societies of plans for medical care."

Under its present regime the A. M. A. is forehanded. It anticipates attack against its integrity, cohesion and liberty. With all its mighty might it protects the interests of the private practitioner. Those 142.000 doctors of medicine the A. M. A. trustees this week exhorted in their Journal: "The alinement is clear--on the one side the forces representing the great foundations, public health officialdom, social theory--even Socialism and Communism--inciting to revolution; on the other side, the organized medical profession of this country urging an orderly evolution guided by controlled experimentation which will observe the principles that have been found through the centuries to be necessary to the sound practice of medicine. The physicians of this country must not be misled by Utopian fantasies of a form of medical practice which would equalize all physicians by placing them in groups under one administration. . . ."

For the present at least the snorting A. M. A. is making its own tempest. The Committee on the Costs of Medical Care ceases existence with this year. Its money is spent. The foundations who furnished the money have made no provisions for putting the majority recommendations into practice. Nonetheless, sad-eyed Secretary -President - Trustee-Chairman-Dr. Wilbur, who is about to quit political administration in Washington and return to education administration at Palo Alto, hopes "that a continuing organization may immediately be formed to promote experimentation and demonstrations in local communities."

*Carnegie Corporation, Josiah Macy Jr. Foundation, Milbank Memorial Fund, New York Foundation, Rockefeller Foundation, Julius Rosenwald Fund, Russell Sage Foundation, Twentieth Century Fund, Social Science Research Council, Vermont Commission on County Life. *Including "$125,000,000 . . . spent for the services of osteopaths, chiropractors, naturopaths and allied groups, and faith healers, and $360,000,000 for patent medicines. Much of the former sum and practically all of the latter are wasted."

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