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Specialization in medicine
Honored Speaker's Address
Specialization in medicine C. Rollins Hanlon, M.D., F.A.C.S.*
Chicago, III.
JL am keenly aware of the great privilege which attends an invitation to address you as the Honored Speaker today. With this honor and privilege, there is joined an immense responsibility to present an essay worthy of this distinguished platform. Let me say how grateful I am for the invitation, which I cherish as an expression of friendship on the part of our esteemed President. That I did not decline is evident; the decision was based not only on my friendship with John Strieder but on my respect and affection for this Association, beginning with my initial hesitant appearance at its lectern some three decades ago in Toronto. This affection has not diminished during subsequent years, as I have attended every meeting except those during the war years of the middle 1940's. There appears, nearly without exception in lectures such as this, a segment concerned with self-justification of the speaker for his subject matter. In this connection I shall borrow a prefatory thought from Dickinson Richards,1 the perceptive Nobel laureate, whose work in cardiac catheterization contributed so much to the advancement of the specialty of thoracic and cardiovascular surgery. He pointed out that the purpose of a lecture is to instruct and entertain, asserting that the lecture which merely instructs is rarely listened to and never remembered. One might reasonably conclude, with Read at the Fifty-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., May 1, 2, and 3, 1972. •Director, American College of Surgeons.
Richards, that the primary function of a lecture is to entertain. However, entertainment is not enough in these days when people yawn before entertainment spectacles on television and disdain to pause before live color television portrayals of their follow men in the act of significant scientific research on a neighboring planet. Hence the need for some substance in this lecture, because my rhetoric and elocution are insufficient to furnish adequate entertainment on their own merits. My message of advocacy is simple to state but admittedly difficult to bring to fruition. It proposes surgical privileges for those with recognized credentials and demonstrated competence. The corollary is similarly proposed: that we restrict privileges for those whose major claim to them is self-styled specialization, with an alleged competence based on arrogance and the misguided notion that a physician may undertake any procedure to which his patient consents, without regard to the judgments and restrictions of his peers. I 2 made these proposals in a publication a decade ago and received intense critiscism from some of my erstwhile students and others who felt that such advice gored their personal ox. We are talking now of the complex and difficult problem of quality control, the exercise of which I am unwilling to hand over to federal bureaucracy. I am similarly unwilling to see it drift along unresolved by our profession, thereby giving support to those who say that government must take over because the medical profession bickers endlessly over its personal 179
The Journal of
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Hanlon
goals without addressing the public good. While I disagree with this appraisal, I recognize that we need more productive discussion, based on solid data such as those which the Study on Surgical Services for the United States is now developing. This discussion must involve the vigorous and tolerant participation of all the specialties, including the lately constituted specialty of family practice. In my remarks on specialization, I am appropriately constrained to avoid too general an approach to this huge topic. I have selected a restricted, historical approach, conscious of my deficiencies in historiography and aware that my convictions and prejudices dominate this essay. Despite the maunderings of the sociologic technicians and the bureaucratic attack which categorizes our profession as part of a health-care industry, the care of patients by physicians remains an intensely personal relationship, inappropriately characterized as industrial. It is a relationship conducive to strong convictions and deep loyalties, with solid merits inherent in a voluntary association that is fundamentally grounded in the ideal of service to man. This is our objective and this is the strength of our position as a profession—that we provide, as our profession has done for several millenia, a vital therapeutic service for our individual patients, with the added dimension today of participating in and guiding the social movements of which our profession is so important a part. In the neat phrase of surgeon John Pool,3 ". . . the specialist physician needs to spend his time for the general weal as well as the individual woe." This broader dimension of participation in the over-all enterprise now known as health-care delivery is not enthusiastically embraced by all members of our profession. Some consider themselves purely as individual or group practitioners, too busy in caring for their own patients to involve themselves with political and management affairs, in which they have little background and less interest. If, on the other hand, some physicians profess an interest and concern for
Thoracic and Cardiovascular Surgery
involvement in the construction of national policies for health, they are dismissed by certain officials and by other self-appointed health planners with the glib cliche that health is too important to be left to the doctors. This opposition to the rational and legitimate involvement of a professional group in the broad managerial aspects of its particular sphere of activity is not new, although its present intensity and organized character are unprecedented. Ever since the service professions developed, and this applies particularly to medicine, they have fought an incessant war against control by government from above and against the incursion of nonprofessionals and charlatans from below. These assaults by government and quackery have often been complementary, as exemplified by chiropractic today. The government, ostensibly dedicated to the protection of its citizens by the maintenance of standards, may be persuaded that these standards must be relaxed in the interest of providing for some degree of unmet need. The good faith of the profession, in insisting on standards, is attacked by declaring such standards to be a device for protection of the financial interests of the professionals. At the same time, the charlatan and irregular practitioner seek to subvert the standards of certification or licensure by boldly asserting a competence which he does not possess and which he is unable to validate, although he may substantiate it by successful lobbying for unduly permissive legislation. When specialization in medicine began, it was based not on scientific knowledge but merely on topography of disease. This is suggested by the organization of the ancient Egyptian papyri and by the quotation from the historian Herodotus in the sixth century B.C. "Each physician," wrote Herodotus,4 in his Persian Wars, "applies himself to one disease only, and not more. All places abound in physicians; some physicians are for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal disorders." An even earlier evidence of presumably
Volume 6A Number 2 August, 1972
partial specialization is found in the funeral inscription on the tomb of an Egyptian court physician of the Sixth Dynasty, 200 years before Herodotus. This man, Pepi-Ankh, was described as "the physician of the belly of Pharao, the guardian of the anus, the physician of the eyes and the surveyor of physicians."5 One might characterize him today as a proctologist and ophthalmologist who did some peer review work on the side. (If alive today he would be applying for the conjoint Egyptian Board of Proctophthalmology.) Hippocrates, on the other hand, was a generalist who recorded and codified his precise clinical observations, laying the foundation for a scientific practice which embraced both medicine and surgery. The introduction of such rationalism was obviously no guarantee of its acceptance; Martial,6 the epigrammatist in the first century A.D., speaks satirically of multiple specialists for the teeth, for hernia, and for other specific ailments. These so-called specialists were unscientific practitioners; such quackery dominated specialty practice until the seventeenth century, as exemplified by the herniotomists, the lithotomists, and those who couched for cataracts. In 1858 a Fellow of the Royal College of Surgeons, Frederick Davies,7 published an extended essay entitled: The Unity of Medicine: Its Corruptions and Divisions by Law Established in England and Wales, Their Causes, Effects and Divisions. Davies reported the existing division of the medical profession into physicians, surgeons, and apothecaries as arising from three great periods of corruption in medicine. First came the invasion of medicine by priests and monks during the sixth and seventh centuries. The seventh to the sixteenth centuries constituted the period of priest-physicians. In 1518 medicine was emancipated from priests and monks, and the pure physician was re-established. Davies' second "period of corruption" began in the twelfth and thirteenth centuries with the invasion of the barbers. The period of the barber-physician lasted until the eighteenth century. The
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"pure surgeon" reappeared in 1745. The third great "period of corruption" began with the rise of the apothecaries in the seventeenth and eighteenth centuries. Davies' book is a vehement call for "purity and unity" in medicine, emancipating the physician from the apothecary and uniting him again to surgery as the only acceptable remedy for such corruptions as excessive fees and the indiscriminate prescribing of dangerous drugs. The second edition of his book extended his original analysis to include Ireland and Scotland, contrasting the desirable fusion of medicine and surgery in these countries with their continued separation in England and Wales. Based on the 1851 census figures, he recorded 1,771 physicians, 13,470 surgeons and apothecaries, and over 14,000 chemists and druggists in England and Wales. In Ireland, by contrast, there were more than 1,200 physicians and a similar number of surgeons, with less than 1,000 apothecaries, druggists, and chemists combined. In Scotland the figures were somewhat less striking in regard to unification, but they still contrasted sharply with England and Wales; there were 511 physicians, 1,576 surgeonapothecaries, and 1,227 chemists and druggists. The British medical and lay press of the time commented at length on Davies' book, and in his second edition he included some "opinions of the press." One journal, The Critic, recommended the book to Members of Parliament, stating: "It will give them a mass of valuable information on a subject upon which they are now legislating, with, we fear, very imperfect knowledge." It would seem medicine is a subject of perennial interest to legislatures in various countries and centuries, and the press (among others) maintains a regularly unenthusiastic stance regarding the wisdom of legislative deliberations. Less emotional and more balanced in its view of specialization was the presentation of another Fellow of the Royal College of Surgeons in 1878. In an address delivered at the opening of the winter session of St.
The Journal of
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Hanlon
Thomas's Hospital, Edward Nettleship,8 a specialist in ophthalmology, spoke "On the Gains and Losses of Specialism in Medicine." He distinguished three stages in the history of medical specialization. The first was the empirical stage, based on the need for manual dexterity in the treatment of certain difficult and important diseases. This corresponds to the topographic phase which I referred to in early Egyptian medicine; it is clearly conducive to the unscientific excesses of the barbers and mountebanks. Second, Nettleship identified the early scientific or encyclopedic stage, in which natural systems of classification were discovered and the affinity of all branches of medicine was affirmed. Because of the moderate size of the corpus of knowledge, it was possible for one man to grasp it; this was the objective so zealously espoused earlier by Davies in his plea for unity in medicine. The third or later scientific stage began in the nineteenth century and has continued to the present. With the increase in knowledge and elevation of health standards, it was Nettleship's9 view that "most men who hope to do work of high quality are obliged to content themselves with cultivating only a part of the field." However, he did not feel that a man should set out with the intention of being a specialist; rather he should evolve into specialization by gradual cultivation of a special area in his over-all practice. The intellectual requirements for success in a general consulting practice were considered by Nettleship to be greater than the cerebral demands of specialization. "It is possible," he10 said, "that many a man may make a very respectable medical specialist whose brain power is not enough to carry him far into the large domain of general modern medicine and surgery." While this nineteenth century appraisal may amuse the modern generalist, its validity is doubtful in the context of the highly scientific medicine of the late twentieth century, when specialization appeals to students and practitioners in part at least, because of its intellectual challenge.
Thoracic and Cardiovascular Surgery
Indeed, Lord Cohen of Birkenhead, President of the General Medical Council in Great Britain, has criticized the behavior of the General Medical Council in continuing to specify until a few years ago that specialty practice should be founded on a base of experience in general practice. This viewpoint, which held sway in Britain for a century until 1967, was reflected in a governmental commission report in 1944 that the medical curriculum "should have a definite bias toward the needs of the future general practitioner," 11 as originally posited in the Medical Act of 1886. In 1948 a Committee of the British Medical Association published a report on "The Training of a Doctor," which made it clear that the Committee did not accept . . . in its full implications the oft repeated view that the aim of the curriculum should be to produce a competent general practitioner. General practice is a special form of practice which must be founded on general basic principles and appropriate postgraduate study. In the Committee's view, theundergraduate medical course should be primarily concerned with the training in those basic principles of medicine which are a necessary foundation for all forms of medical practice.*
This report was severely criticized and ultimately rejected by the British Medical Association as a whole. However, the 1948 Committee view gradually prevailed, and the 1967 Recommendations of the General Medical Council recognized that specialty practice need no longer be erected on a foundation of general practice. Despite the reversal of this educational concept, the general practitioner in Britain still remained as the primary contact physician under the National Health Service. As such he had a well-defined, albeit not wholly satisfactory, relationship to patients and to specialists. In the United States, by contrast, as the number of specialists increased enormously after 1940, the number of general practitioners steadily declined. *From The Training of a Doctor, Committee Report, British Medical Association, 1948. Cited by Lord Cohen of Birkenhead, Br. J. Anaesth. 4 1 : 269, 1969.
Volume 64 Number 2 August, 1972
Various specialists assumed an increasing role in primary care, aided by the actions of patients who bypassed the general practitioner to make a primary (and not necessarily appropriate) visit to the specialist of their choice. The number of part-time specialists and general practitioners fell from 120,000 in 1931 to less than half this number by 1969, while the number of full-time specialists rose from less than 25,000 in 1931 to about 200,000 by 1969—an eightfold increase. Without a clearly defined role for the general practitioner in the evolving system of care in the United States, which might have stabilized his position and retarded the decline in his numbers, the generalists in the United States concentrated in 1947 on organization of the Academy of General Practice. This organization grew rapidly to 10,000 members by 1950 and more than tripled this number in the following 20 years. It worked, both independently and within the American Medical Association's Section on General Practice, to ensure hospital privileges for generalists and to ensure representation in the medical school for education in primary care. It tried, unsuccessfully, to ensure some period of mandatory general practice preceding specialization. Finally, in 1965, it partially resolved its internal disagreements and began to urge a specialty board of family practice, which was finally approved in 1969. Family medicine is now a specialty, defined as "comprehensive medical care in which the physician accepts continuing responsibility, regardless of the age of the patient."12 The educational content of the training program has been specified, examinations have been given and certificates issued, and the American Academy of General Practice has become successively the American Academy of Family Practice and the American Academy of Family Physicians. Moreover, it has representation on the Council of Medical Specialty Societies (CMSS) and in the Interspecialty Council of the American Medical Association. Here we see an interesting example of
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a latter-day nominalism which reverses the customary meaning of specialization—i.e., a restriction and intensification of one's interest—setting in its place the sincere but specious assertion that the new breed of family physician is "a specialist in breadth rather than in depth." One may politely assent to this terminology while reserving judgment on the definition, recalling the deprecatory comment of the internist, Marion Blankenhorn, when asked if his impression of a certain cutaneous lesion coincided with the tripartite Latin diagnosis of the attending dermatologists: "I share their confusion," he said dryly, "but not their terminology." Some of us may share this public terminology while holding fast to our private notion that specialization connotes a restriction of professional attention and activity so as to allow deeper knowledge, improved competence in a restricted field, and within those bounds (one would anticipate) better therapeutic results. Past experience teaches us that some men have been true encyclopedists, but we are unlikely to see again the day when the Encyclopedia Britannica could be written by one man or even by a handful. If Sir William Osier, giant that he was, should return to authorship in 1972, he could scarcely hope to write again, singlehandedly, the classic text which it was possible for one man to engender in the early part of this century. What Osier could write, I am sure, would be a dispassionate but inspiring analysis of the present state of specialization in our land. With his keen sense of history and his sympathetic knowledge and love of Canada, the United States and Great Britain, he could write of the good and the bad in the British National Health Service, of the alarming lessons to be learned from the experience in Quebec, and of the way in which the medical profession in the United States might profit by cessation of its interprofessional jealousies and strife in the short time available to us before a militant consumerism and an ill-advised bureaucracy may combine to take away our professional
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Hanlon
freedom, thereby losing their own freedom in the process. Earlier in these comments I spoke of quality control and of my disinclination to see it handed over to a bureaucratic apparatus, such as the five-man national body described with chilling clarity in Mr. Kennedy's Senate Bill 3327. High standards and the control of quality are the hallmarks of genuine specialization, coupled with pride in the practice of a skilled profession. In our day, professionalism and professional associations are being vigorously challenged by "management," personified by the medical administrator who prefers to deal with "tasks" in "manipulating the work force." As an example of this philosophy I quote from a recent article on allied health manpower. "All health institutions should have the power and skill to reorder work, to use new people to do old jobs, to reassign tasks, to create or eliminate jobs. Management must gain a say in the allocation of tasks and the composition of the work force. . . . Professional structures must be aggressively attacked."* It is apparent that the managerial philosophy portrayed in this quotation envisions total control of all 3Va million workers in occupations allied to health. The justification for this control is "to add to the total efficiency of the industry," and to redirect it "to a new social responsibility."* In the face of these monstrous plans and sobering prospects, it seems trivial and witless for a great and noble profession to occupy itself with bitter arguments over such issues as specialty jurisdiction in anatomic regions of the human body. As a further example, it is difficult for me to comprehend why the various surgical specialty boards give lip service to so logical and necessary a concept as the basic surgical examination, only to retreat into evasions and circumlocutions when the time comes for implementing the concept. *From Robbins, A.: Allied Health Manpower: Solution or Problem, N. Engl. J. Med. 286: 923, 1972.
Thoracic and Cardiovascular Surgery
The various specialty boards and the American College of Surgeons have been faulted for setting up high standards but paying no attention to regulating the production of surgeons. While there is validity in these criticisms, they take inadequate notice of the vast resistance which the Boards and the College encountered in initiating their pioneer activities in certification. Moreover, they neglect the immense and continuing contribution of the College to the regulation of surgical practice. Despite these defensive remarks, it is clearly time for our profession to attend vigorously to quality control and to patterns of production and distribution for surgeons. For the past two years the College, in conjunction with the American Surgical Association, the various specialty societies, and the regional surgical organizations, has been heavily committed to the joint Study on Surgical Services for the United States— SOSSUS. The participants and sponsors of this study are now addressing the complex and controversial issue of how these valuable data, after their transmission to the governing bodies and memberships of the College and other involved organizations, may be put to use in dealing with the problems of credentials and quality control, as well as the even more difficult issues of numbers and distribution of specialists. We are witnessing at present in this country the development of new liaison committees in medical education, in which the specialist will play a significant part, influencing the nature of medical practice a few years hence. We see the renamed and strengthened American Board of Medical Specialties, the Council of Medical Specialty Societies, and the rising influence of specialties in the structure and decision making of the American Medical Association. All of this suggests a growing recognition that medicine must unify rather than further divide its separate segments so that they may attack in concert the staggering task of providing the best possible medical care within the finite limits of our total re-
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Number 2 August, 1972
sources. In so doing, let us, in the words of Vannevar Bush,13 ". . . maintain and enhance the characteristic which should be central in every profession: dedicated service to the people, exercised with pride and dignity." REFERENCES
1 Richards, D. W.: Medical Priesthoods, and Other Essays. Privately printed. Library of Congress Catalogue Card 73-122039. 2 Hanlon, C. R.: Who Should Get Surgical Privileges in Hospitals? Hosp. Progr. 42: 55, 1961. 3 Pool, J. L.: The Role of the Specialist in Medicine and Society, Am. J. Roentgenol. Radium Ther. Nucl. Med.. 105: 3, 1969. 4 Cary, H.: Herodotus: A New and Literal Version, London, 1854, p. 125, quoted by Mattler, C. C : History of Medicine, Philadelphia, 1947, The Blakiston Co., p. 321. 5 Junker, H.: Giza 1 (-xii) Bericht tiber die . . . Grabungen auf dem Friehhof des Alten
6 7 8 9 10 11 12 13
Reiches bei den Pyramiden von Giza, Akad. Wissensch. Wien, 1929. Castiglioni, A.: A History of Medicine, Krumbharr, E. B., translator, New York, 1941, Alfred A. Knopf, Inc. Davies, F.: The Unity of Medicine, London, 1858, J. E. Adlard. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 4 ff. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 4. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 15. Report of the Interdepartmental Committee on Medical Schools (Goodenough), London, 1944, His Majesty's Stationery Office. Stevens, R.: American Medicine and the Public Interest, New Haven, 1971, Yale University Press, p. 313. Bush, V.: Science Is Not Enough, New York, 1967, William Morrow & Co., Inc., p. 158.
Specialization in medicine C. Rollins Hanlon, M.D., F.A.C.S.*
Chicago, III.
JL am keenly aware of the great privilege which attends an invitation to address you as the Honored Speaker today. With this honor and privilege, there is joined an immense responsibility to present an essay worthy of this distinguished platform. Let me say how grateful I am for the invitation, which I cherish as an expression of friendship on the part of our esteemed President. That I did not decline is evident; the decision was based not only on my friendship with John Strieder but on my respect and affection for this Association, beginning with my initial hesitant appearance at its lectern some three decades ago in Toronto. This affection has not diminished during subsequent years, as I have attended every meeting except those during the war years of the middle 1940's. There appears, nearly without exception in lectures such as this, a segment concerned with self-justification of the speaker for his subject matter. In this connection I shall borrow a prefatory thought from Dickinson Richards,1 the perceptive Nobel laureate, whose work in cardiac catheterization contributed so much to the advancement of the specialty of thoracic and cardiovascular surgery. He pointed out that the purpose of a lecture is to instruct and entertain, asserting that the lecture which merely instructs is rarely listened to and never remembered. One might reasonably conclude, with Read at the Fifty-second Annual Meeting of The American Association for Thoracic Surgery, Los Angeles, Calif., May 1, 2, and 3, 1972. •Director, American College of Surgeons.
Richards, that the primary function of a lecture is to entertain. However, entertainment is not enough in these days when people yawn before entertainment spectacles on television and disdain to pause before live color television portrayals of their follow men in the act of significant scientific research on a neighboring planet. Hence the need for some substance in this lecture, because my rhetoric and elocution are insufficient to furnish adequate entertainment on their own merits. My message of advocacy is simple to state but admittedly difficult to bring to fruition. It proposes surgical privileges for those with recognized credentials and demonstrated competence. The corollary is similarly proposed: that we restrict privileges for those whose major claim to them is self-styled specialization, with an alleged competence based on arrogance and the misguided notion that a physician may undertake any procedure to which his patient consents, without regard to the judgments and restrictions of his peers. I 2 made these proposals in a publication a decade ago and received intense critiscism from some of my erstwhile students and others who felt that such advice gored their personal ox. We are talking now of the complex and difficult problem of quality control, the exercise of which I am unwilling to hand over to federal bureaucracy. I am similarly unwilling to see it drift along unresolved by our profession, thereby giving support to those who say that government must take over because the medical profession bickers endlessly over its personal 179
The Journal of
18 0
Hanlon
goals without addressing the public good. While I disagree with this appraisal, I recognize that we need more productive discussion, based on solid data such as those which the Study on Surgical Services for the United States is now developing. This discussion must involve the vigorous and tolerant participation of all the specialties, including the lately constituted specialty of family practice. In my remarks on specialization, I am appropriately constrained to avoid too general an approach to this huge topic. I have selected a restricted, historical approach, conscious of my deficiencies in historiography and aware that my convictions and prejudices dominate this essay. Despite the maunderings of the sociologic technicians and the bureaucratic attack which categorizes our profession as part of a health-care industry, the care of patients by physicians remains an intensely personal relationship, inappropriately characterized as industrial. It is a relationship conducive to strong convictions and deep loyalties, with solid merits inherent in a voluntary association that is fundamentally grounded in the ideal of service to man. This is our objective and this is the strength of our position as a profession—that we provide, as our profession has done for several millenia, a vital therapeutic service for our individual patients, with the added dimension today of participating in and guiding the social movements of which our profession is so important a part. In the neat phrase of surgeon John Pool,3 ". . . the specialist physician needs to spend his time for the general weal as well as the individual woe." This broader dimension of participation in the over-all enterprise now known as health-care delivery is not enthusiastically embraced by all members of our profession. Some consider themselves purely as individual or group practitioners, too busy in caring for their own patients to involve themselves with political and management affairs, in which they have little background and less interest. If, on the other hand, some physicians profess an interest and concern for
Thoracic and Cardiovascular Surgery
involvement in the construction of national policies for health, they are dismissed by certain officials and by other self-appointed health planners with the glib cliche that health is too important to be left to the doctors. This opposition to the rational and legitimate involvement of a professional group in the broad managerial aspects of its particular sphere of activity is not new, although its present intensity and organized character are unprecedented. Ever since the service professions developed, and this applies particularly to medicine, they have fought an incessant war against control by government from above and against the incursion of nonprofessionals and charlatans from below. These assaults by government and quackery have often been complementary, as exemplified by chiropractic today. The government, ostensibly dedicated to the protection of its citizens by the maintenance of standards, may be persuaded that these standards must be relaxed in the interest of providing for some degree of unmet need. The good faith of the profession, in insisting on standards, is attacked by declaring such standards to be a device for protection of the financial interests of the professionals. At the same time, the charlatan and irregular practitioner seek to subvert the standards of certification or licensure by boldly asserting a competence which he does not possess and which he is unable to validate, although he may substantiate it by successful lobbying for unduly permissive legislation. When specialization in medicine began, it was based not on scientific knowledge but merely on topography of disease. This is suggested by the organization of the ancient Egyptian papyri and by the quotation from the historian Herodotus in the sixth century B.C. "Each physician," wrote Herodotus,4 in his Persian Wars, "applies himself to one disease only, and not more. All places abound in physicians; some physicians are for the eyes, others for the head, others for the teeth, others for the parts about the belly, and others for internal disorders." An even earlier evidence of presumably
Volume 6A Number 2 August, 1972
partial specialization is found in the funeral inscription on the tomb of an Egyptian court physician of the Sixth Dynasty, 200 years before Herodotus. This man, Pepi-Ankh, was described as "the physician of the belly of Pharao, the guardian of the anus, the physician of the eyes and the surveyor of physicians."5 One might characterize him today as a proctologist and ophthalmologist who did some peer review work on the side. (If alive today he would be applying for the conjoint Egyptian Board of Proctophthalmology.) Hippocrates, on the other hand, was a generalist who recorded and codified his precise clinical observations, laying the foundation for a scientific practice which embraced both medicine and surgery. The introduction of such rationalism was obviously no guarantee of its acceptance; Martial,6 the epigrammatist in the first century A.D., speaks satirically of multiple specialists for the teeth, for hernia, and for other specific ailments. These so-called specialists were unscientific practitioners; such quackery dominated specialty practice until the seventeenth century, as exemplified by the herniotomists, the lithotomists, and those who couched for cataracts. In 1858 a Fellow of the Royal College of Surgeons, Frederick Davies,7 published an extended essay entitled: The Unity of Medicine: Its Corruptions and Divisions by Law Established in England and Wales, Their Causes, Effects and Divisions. Davies reported the existing division of the medical profession into physicians, surgeons, and apothecaries as arising from three great periods of corruption in medicine. First came the invasion of medicine by priests and monks during the sixth and seventh centuries. The seventh to the sixteenth centuries constituted the period of priest-physicians. In 1518 medicine was emancipated from priests and monks, and the pure physician was re-established. Davies' second "period of corruption" began in the twelfth and thirteenth centuries with the invasion of the barbers. The period of the barber-physician lasted until the eighteenth century. The
Specialization in medicine
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"pure surgeon" reappeared in 1745. The third great "period of corruption" began with the rise of the apothecaries in the seventeenth and eighteenth centuries. Davies' book is a vehement call for "purity and unity" in medicine, emancipating the physician from the apothecary and uniting him again to surgery as the only acceptable remedy for such corruptions as excessive fees and the indiscriminate prescribing of dangerous drugs. The second edition of his book extended his original analysis to include Ireland and Scotland, contrasting the desirable fusion of medicine and surgery in these countries with their continued separation in England and Wales. Based on the 1851 census figures, he recorded 1,771 physicians, 13,470 surgeons and apothecaries, and over 14,000 chemists and druggists in England and Wales. In Ireland, by contrast, there were more than 1,200 physicians and a similar number of surgeons, with less than 1,000 apothecaries, druggists, and chemists combined. In Scotland the figures were somewhat less striking in regard to unification, but they still contrasted sharply with England and Wales; there were 511 physicians, 1,576 surgeonapothecaries, and 1,227 chemists and druggists. The British medical and lay press of the time commented at length on Davies' book, and in his second edition he included some "opinions of the press." One journal, The Critic, recommended the book to Members of Parliament, stating: "It will give them a mass of valuable information on a subject upon which they are now legislating, with, we fear, very imperfect knowledge." It would seem medicine is a subject of perennial interest to legislatures in various countries and centuries, and the press (among others) maintains a regularly unenthusiastic stance regarding the wisdom of legislative deliberations. Less emotional and more balanced in its view of specialization was the presentation of another Fellow of the Royal College of Surgeons in 1878. In an address delivered at the opening of the winter session of St.
The Journal of
18 2
Hanlon
Thomas's Hospital, Edward Nettleship,8 a specialist in ophthalmology, spoke "On the Gains and Losses of Specialism in Medicine." He distinguished three stages in the history of medical specialization. The first was the empirical stage, based on the need for manual dexterity in the treatment of certain difficult and important diseases. This corresponds to the topographic phase which I referred to in early Egyptian medicine; it is clearly conducive to the unscientific excesses of the barbers and mountebanks. Second, Nettleship identified the early scientific or encyclopedic stage, in which natural systems of classification were discovered and the affinity of all branches of medicine was affirmed. Because of the moderate size of the corpus of knowledge, it was possible for one man to grasp it; this was the objective so zealously espoused earlier by Davies in his plea for unity in medicine. The third or later scientific stage began in the nineteenth century and has continued to the present. With the increase in knowledge and elevation of health standards, it was Nettleship's9 view that "most men who hope to do work of high quality are obliged to content themselves with cultivating only a part of the field." However, he did not feel that a man should set out with the intention of being a specialist; rather he should evolve into specialization by gradual cultivation of a special area in his over-all practice. The intellectual requirements for success in a general consulting practice were considered by Nettleship to be greater than the cerebral demands of specialization. "It is possible," he10 said, "that many a man may make a very respectable medical specialist whose brain power is not enough to carry him far into the large domain of general modern medicine and surgery." While this nineteenth century appraisal may amuse the modern generalist, its validity is doubtful in the context of the highly scientific medicine of the late twentieth century, when specialization appeals to students and practitioners in part at least, because of its intellectual challenge.
Thoracic and Cardiovascular Surgery
Indeed, Lord Cohen of Birkenhead, President of the General Medical Council in Great Britain, has criticized the behavior of the General Medical Council in continuing to specify until a few years ago that specialty practice should be founded on a base of experience in general practice. This viewpoint, which held sway in Britain for a century until 1967, was reflected in a governmental commission report in 1944 that the medical curriculum "should have a definite bias toward the needs of the future general practitioner," 11 as originally posited in the Medical Act of 1886. In 1948 a Committee of the British Medical Association published a report on "The Training of a Doctor," which made it clear that the Committee did not accept . . . in its full implications the oft repeated view that the aim of the curriculum should be to produce a competent general practitioner. General practice is a special form of practice which must be founded on general basic principles and appropriate postgraduate study. In the Committee's view, theundergraduate medical course should be primarily concerned with the training in those basic principles of medicine which are a necessary foundation for all forms of medical practice.*
This report was severely criticized and ultimately rejected by the British Medical Association as a whole. However, the 1948 Committee view gradually prevailed, and the 1967 Recommendations of the General Medical Council recognized that specialty practice need no longer be erected on a foundation of general practice. Despite the reversal of this educational concept, the general practitioner in Britain still remained as the primary contact physician under the National Health Service. As such he had a well-defined, albeit not wholly satisfactory, relationship to patients and to specialists. In the United States, by contrast, as the number of specialists increased enormously after 1940, the number of general practitioners steadily declined. *From The Training of a Doctor, Committee Report, British Medical Association, 1948. Cited by Lord Cohen of Birkenhead, Br. J. Anaesth. 4 1 : 269, 1969.
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Various specialists assumed an increasing role in primary care, aided by the actions of patients who bypassed the general practitioner to make a primary (and not necessarily appropriate) visit to the specialist of their choice. The number of part-time specialists and general practitioners fell from 120,000 in 1931 to less than half this number by 1969, while the number of full-time specialists rose from less than 25,000 in 1931 to about 200,000 by 1969—an eightfold increase. Without a clearly defined role for the general practitioner in the evolving system of care in the United States, which might have stabilized his position and retarded the decline in his numbers, the generalists in the United States concentrated in 1947 on organization of the Academy of General Practice. This organization grew rapidly to 10,000 members by 1950 and more than tripled this number in the following 20 years. It worked, both independently and within the American Medical Association's Section on General Practice, to ensure hospital privileges for generalists and to ensure representation in the medical school for education in primary care. It tried, unsuccessfully, to ensure some period of mandatory general practice preceding specialization. Finally, in 1965, it partially resolved its internal disagreements and began to urge a specialty board of family practice, which was finally approved in 1969. Family medicine is now a specialty, defined as "comprehensive medical care in which the physician accepts continuing responsibility, regardless of the age of the patient."12 The educational content of the training program has been specified, examinations have been given and certificates issued, and the American Academy of General Practice has become successively the American Academy of Family Practice and the American Academy of Family Physicians. Moreover, it has representation on the Council of Medical Specialty Societies (CMSS) and in the Interspecialty Council of the American Medical Association. Here we see an interesting example of
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a latter-day nominalism which reverses the customary meaning of specialization—i.e., a restriction and intensification of one's interest—setting in its place the sincere but specious assertion that the new breed of family physician is "a specialist in breadth rather than in depth." One may politely assent to this terminology while reserving judgment on the definition, recalling the deprecatory comment of the internist, Marion Blankenhorn, when asked if his impression of a certain cutaneous lesion coincided with the tripartite Latin diagnosis of the attending dermatologists: "I share their confusion," he said dryly, "but not their terminology." Some of us may share this public terminology while holding fast to our private notion that specialization connotes a restriction of professional attention and activity so as to allow deeper knowledge, improved competence in a restricted field, and within those bounds (one would anticipate) better therapeutic results. Past experience teaches us that some men have been true encyclopedists, but we are unlikely to see again the day when the Encyclopedia Britannica could be written by one man or even by a handful. If Sir William Osier, giant that he was, should return to authorship in 1972, he could scarcely hope to write again, singlehandedly, the classic text which it was possible for one man to engender in the early part of this century. What Osier could write, I am sure, would be a dispassionate but inspiring analysis of the present state of specialization in our land. With his keen sense of history and his sympathetic knowledge and love of Canada, the United States and Great Britain, he could write of the good and the bad in the British National Health Service, of the alarming lessons to be learned from the experience in Quebec, and of the way in which the medical profession in the United States might profit by cessation of its interprofessional jealousies and strife in the short time available to us before a militant consumerism and an ill-advised bureaucracy may combine to take away our professional
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Hanlon
freedom, thereby losing their own freedom in the process. Earlier in these comments I spoke of quality control and of my disinclination to see it handed over to a bureaucratic apparatus, such as the five-man national body described with chilling clarity in Mr. Kennedy's Senate Bill 3327. High standards and the control of quality are the hallmarks of genuine specialization, coupled with pride in the practice of a skilled profession. In our day, professionalism and professional associations are being vigorously challenged by "management," personified by the medical administrator who prefers to deal with "tasks" in "manipulating the work force." As an example of this philosophy I quote from a recent article on allied health manpower. "All health institutions should have the power and skill to reorder work, to use new people to do old jobs, to reassign tasks, to create or eliminate jobs. Management must gain a say in the allocation of tasks and the composition of the work force. . . . Professional structures must be aggressively attacked."* It is apparent that the managerial philosophy portrayed in this quotation envisions total control of all 3Va million workers in occupations allied to health. The justification for this control is "to add to the total efficiency of the industry," and to redirect it "to a new social responsibility."* In the face of these monstrous plans and sobering prospects, it seems trivial and witless for a great and noble profession to occupy itself with bitter arguments over such issues as specialty jurisdiction in anatomic regions of the human body. As a further example, it is difficult for me to comprehend why the various surgical specialty boards give lip service to so logical and necessary a concept as the basic surgical examination, only to retreat into evasions and circumlocutions when the time comes for implementing the concept. *From Robbins, A.: Allied Health Manpower: Solution or Problem, N. Engl. J. Med. 286: 923, 1972.
Thoracic and Cardiovascular Surgery
The various specialty boards and the American College of Surgeons have been faulted for setting up high standards but paying no attention to regulating the production of surgeons. While there is validity in these criticisms, they take inadequate notice of the vast resistance which the Boards and the College encountered in initiating their pioneer activities in certification. Moreover, they neglect the immense and continuing contribution of the College to the regulation of surgical practice. Despite these defensive remarks, it is clearly time for our profession to attend vigorously to quality control and to patterns of production and distribution for surgeons. For the past two years the College, in conjunction with the American Surgical Association, the various specialty societies, and the regional surgical organizations, has been heavily committed to the joint Study on Surgical Services for the United States— SOSSUS. The participants and sponsors of this study are now addressing the complex and controversial issue of how these valuable data, after their transmission to the governing bodies and memberships of the College and other involved organizations, may be put to use in dealing with the problems of credentials and quality control, as well as the even more difficult issues of numbers and distribution of specialists. We are witnessing at present in this country the development of new liaison committees in medical education, in which the specialist will play a significant part, influencing the nature of medical practice a few years hence. We see the renamed and strengthened American Board of Medical Specialties, the Council of Medical Specialty Societies, and the rising influence of specialties in the structure and decision making of the American Medical Association. All of this suggests a growing recognition that medicine must unify rather than further divide its separate segments so that they may attack in concert the staggering task of providing the best possible medical care within the finite limits of our total re-
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sources. In so doing, let us, in the words of Vannevar Bush,13 ". . . maintain and enhance the characteristic which should be central in every profession: dedicated service to the people, exercised with pride and dignity." REFERENCES
1 Richards, D. W.: Medical Priesthoods, and Other Essays. Privately printed. Library of Congress Catalogue Card 73-122039. 2 Hanlon, C. R.: Who Should Get Surgical Privileges in Hospitals? Hosp. Progr. 42: 55, 1961. 3 Pool, J. L.: The Role of the Specialist in Medicine and Society, Am. J. Roentgenol. Radium Ther. Nucl. Med.. 105: 3, 1969. 4 Cary, H.: Herodotus: A New and Literal Version, London, 1854, p. 125, quoted by Mattler, C. C : History of Medicine, Philadelphia, 1947, The Blakiston Co., p. 321. 5 Junker, H.: Giza 1 (-xii) Bericht tiber die . . . Grabungen auf dem Friehhof des Alten
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Reiches bei den Pyramiden von Giza, Akad. Wissensch. Wien, 1929. Castiglioni, A.: A History of Medicine, Krumbharr, E. B., translator, New York, 1941, Alfred A. Knopf, Inc. Davies, F.: The Unity of Medicine, London, 1858, J. E. Adlard. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 4 ff. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 4. Nettleship, E.: On the Gains and Losses of Specialism in Medicine, London, 1878, J. E. Adlard, p. 15. Report of the Interdepartmental Committee on Medical Schools (Goodenough), London, 1944, His Majesty's Stationery Office. Stevens, R.: American Medicine and the Public Interest, New Haven, 1971, Yale University Press, p. 313. Bush, V.: Science Is Not Enough, New York, 1967, William Morrow & Co., Inc., p. 158.