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British Discussion of Socialized Medicine
EDITORIALS
1307
suggest that many of the letters "contain much individual prejudice, and are writ ten as though their opinions and state ments were self-evident facts." Dr. H. Guy Dain, Chairman of Council of the B.M.A., speaking before the pro fession at Bristol, calls attention to the BRITISH DISCUSSION O F wide contrasts between those physicians SOCIALIZED MEDICINE who would take no part whatever in a For some months past the columns of government service, however organized, the British Medical Journal, the organ of and those of the other extreme who be the British Medical Association, have car lieve that the best service would be by ried an abundance of discussion of the whole-time salaried officers; and between "White Paper," the document which of those who argue that the state service fered for open debate an outline of the should be for everybody in the country, British Government's proposals for a gen-. "irrespective of means, age, sex, or occu pation," and those who believe in limita eral system of socialized medicine. The views expressed are many. More tion to a certain income level. Dain points frequently they are unfavorable to, or at out that private practice is beginning to least severely critical of, the British Gov reappear even in Russia, and that in Nor ernment's proposals. But, in leading ar way, notwithstanding a system of state ticles, reports of speeches, and, above all, hospitals, voluntary hospitals have entered in that open correspondence which is so the field. Whatever arrangement is made, striking a feature of British journalism, Dain suggests, it must provide for the freedom of the patient to go where he de all shades of opinion are represented. sires for his doctoring and to pay for it if In the columns of a periodical officially he wishes to do so. representing the British Medical Associa tion it is refreshing to find a number of We find one writer stating that the gen letters expressing frank and occasionally eral British public has welcomed the rather bitter criticism of that medical or scheme; and another declaring that one ganization. The Association, through its hundred percent of his office patients have Council, while condemning the Govern voted against it. ment scheme in certain principles and de One correspondent writes at some tails, has shown a disposition to offer con length to draw a parallel between the structive criticism for improvement in the attitude taken by the British Medical proposals. In this connection it is im Association in 1911, when Mr. Lloyd portant to remember that the British Gov George introduced his National Insurance ernment has announced its firm policy to Bill, and the situation today. It is sug adopt a general scheme of medical-social gested that the British Medical Associa ization, but issued the White Paper as an tion then fought what at first appeared to avowed basis for free public and pro be a losing battle but in the end worked fessional discussion before the actual in out not so badly for the profession. This troduction of a parliamentary bill. writer quotes a British gibe to the effect Very blunt is the attitude of the gentle that "The National Insurance Act gave man who speaks of the "apostasy of the the doctors their motor cars." In 1911, B.M.A.," but a speaker who has leanings while the National Insurance Bill was be in the other direction finds it necessary to ing fought in Parliament, the British
ond vice-president; and Major Brittain F. Payne, third vice-president, and Dr. Charles D. Blassingame, member of the Council. Lawrence T. Post.
1308
EDITORIALS
Medical Association "obtained the sig natures of twenty-seven thousand doctors to a pledge that they would not accept service under the Bill except on terms in accordance with the Association's policy, and that they would not enter into any contract except through a local medical committee representative of the local pro fession." Today, says the same writer, the British profession has the advantage of considering a preliminary scheme in stead of fighting a bill already introduced into Parliament. Surgeon Vice-Admiral Sheldon Dud ley, Medical Director-General of the Navy, delivering the Harveian Lecture before the Harveian Society of London, pointed out that the oldest and most com prehensive medical services were those of the Navy and Army. Speaking as to the possible effect of a set salary upon the quality of the physician's work, Admiral Dudley said that in the British Navy there were very few medical officers who did as little work as possible, and he argued that "on the whole, self-respect, the de sire to do well in the eyes of the herd, a natural sympathy with sick people, and a praiseworthy desire for promotion would outweigh the alleged stultifying effect of a fixed salary." He suggested the experi ence of the Navy showed that "a patientdoctor relationship of the best type was possible on a salaried basis of remunera tion and without free choice." British municipal hospitals have come in for a good deal of abuse as contrasted with the voluntary hospitals. Yet the ac commodations provided in the voluntary hospitals are far from adequate, as dem onstrated by the fact that there is usually a long waiting list of applicants for ad mission. One of the most interesting products of the British controversy as to the Govern ment's proposals takes the form of a vote by medical students upon a number of
questions submitted to them by the British Medical Students' Association. About one fourth of the total number of students re plied. Forty-nine percent of them thought that the quality of the country's medical service would be enhanced by the pro posed National Health Service, thirty-six percent thought it would suffer, fourteen percent "did not know." Seventy-two per cent thought that complete medical serv ices, including hospital and specialized services, ought to be available to everyone free of charge. Eighty-nine percent ap proved of the principle of health centers. Fifty-three favored payment by a small basic salary plus capitation fees. Sixtythree percent made a statement that it would not be possible for them to set up in practice without incurring a debt. Fiftyone percent reacted on the whole favor ably to the Government's White Paper, forty percent unfavorably, and seven per cent "did not know." Incidentally it may be mentioned that of those whose fathers were physicians fifty-two percent reacted unfavorably to the document and only thirty-eight percent were definitely favor able. From medical students a similar vote would rather likely be obtained in the United States, since those who have not yet attained the position of special priv ilege associated with established practice are still preoccuped with the problem of buttering their daily bread. A British physician "under forty" suggests that the White Paper offers the young doctor two important advantages which should not be forgotten in discussing the future health services; namely, the opportunity to undertake general practice unburdened by financial considerations, and the ex istence of many more openings for the doctor who wishes to specialize. What part does ophthalmology play in this general discussion of the British Gov ernment's proposals? Plans for an oph-
1309
BOOK NOTICES
thalmic service have brought up the ques tion whether refraction shall be carried on entirely by ophthalmic physicians or shall enlist the cooperation of sight-test ing opticians. One writer points out that against seven thousand opticians at pres ent officially recognized as qualified to undertake National Health Insurance work, there are throughout the country only about one thousand ophthalmic medi cal practitioners, a part of whose time is taken up with other eye work. These fig ures were the basis of a recent recom mendation by the Ophthalmic Group Committtee's draft scheme for a National Eye Service, which suggested that it would be necessary to call in the aid of optician refractionists who would work under the supervision of medically quali fied specialists. The suggestion that in a few years time a sufficient number of physicians could be trained to do the re fraction work is derided by the corres pondent on the ground that "men are not going to take the six years medical course, then specialize in ophthalmology, and spend the rest of their lives doing refrac tions." The correspondent would establish eye clinics each "staffed by a medical eye specialist, who will have under him two or more optician refractionists," with sometimes the help of a nurse, clerical assistants, and possibly an orthoptist. The ophthalmic specialist would do only "diffi cult refractions or those requiring a cyclo plegic." The writer assumes that in the course of years most sight-testing op ticians will either "decide to go over to the dispensing side of the business or be ab sorbed as refractionists in the eye clin ics." Some readers will admire ( !) the faith of this correspondent in the ability of the subordinate refractionist to deter mine which refractions are difficult and which will require the use of a cycloplegic. If a system of socialized medicine is adopted in the United States, very thorny will be this problem of who shall do re
fraction in the public clinics or wherever it may be done out of the funds provided under the law. W. H. Crisp.
BOOK NOTICES I W A N T E D T O SEE. By Borghild Dahl, with a Foreword by William L. Benedict, M.D. New York, The Macmillan Co., 1944. Price $2.00. Some two years ago Dartmouth College published a book, "Motivation and visual factors," based upon an intensive study of a large goup of college students. The con clusion of the authors, in brief, is that visual handicaps as such can be considered only in relation to the entire personality, specifically to the motivating drives of the individual. The motivation seems to be the dominant factor in any successful or unsuccessful adjustment to the presence of visual anomalies. No stronger corroboration of the soundness of this conclusion can be found anywhere than in the personal narrative of Miss Dahl, in her volume, "I wanted to see." Here is a woman who from her earliest childhood was totally blind in one eye, had vision of only 4/60 in the other eye, and yet by sheer will and tenacity of purpose managed to get almost everything she strove for, and she aimed high. She would have done wonderfully if she had managed merely to get through grammar school. But Miss Dahl completed a regu lar high school course, a full college and university course, with the Bachelor and* Master of Arts degrees, became a suc cessful high school teacher, anl later a college professor. She also managed to win a fellowship from the American Scandinavian Foundation, which, ac claiming her as a distinguished student in sociology, sent her for a year's study to Norway. And this is not all. We could go on discoursing on her extracurricular ac complishments ; for example, being chosen
1307
suggest that many of the letters "contain much individual prejudice, and are writ ten as though their opinions and state ments were self-evident facts." Dr. H. Guy Dain, Chairman of Council of the B.M.A., speaking before the pro fession at Bristol, calls attention to the BRITISH DISCUSSION O F wide contrasts between those physicians SOCIALIZED MEDICINE who would take no part whatever in a For some months past the columns of government service, however organized, the British Medical Journal, the organ of and those of the other extreme who be the British Medical Association, have car lieve that the best service would be by ried an abundance of discussion of the whole-time salaried officers; and between "White Paper," the document which of those who argue that the state service fered for open debate an outline of the should be for everybody in the country, British Government's proposals for a gen-. "irrespective of means, age, sex, or occu pation," and those who believe in limita eral system of socialized medicine. The views expressed are many. More tion to a certain income level. Dain points frequently they are unfavorable to, or at out that private practice is beginning to least severely critical of, the British Gov reappear even in Russia, and that in Nor ernment's proposals. But, in leading ar way, notwithstanding a system of state ticles, reports of speeches, and, above all, hospitals, voluntary hospitals have entered in that open correspondence which is so the field. Whatever arrangement is made, striking a feature of British journalism, Dain suggests, it must provide for the freedom of the patient to go where he de all shades of opinion are represented. sires for his doctoring and to pay for it if In the columns of a periodical officially he wishes to do so. representing the British Medical Associa tion it is refreshing to find a number of We find one writer stating that the gen letters expressing frank and occasionally eral British public has welcomed the rather bitter criticism of that medical or scheme; and another declaring that one ganization. The Association, through its hundred percent of his office patients have Council, while condemning the Govern voted against it. ment scheme in certain principles and de One correspondent writes at some tails, has shown a disposition to offer con length to draw a parallel between the structive criticism for improvement in the attitude taken by the British Medical proposals. In this connection it is im Association in 1911, when Mr. Lloyd portant to remember that the British Gov George introduced his National Insurance ernment has announced its firm policy to Bill, and the situation today. It is sug adopt a general scheme of medical-social gested that the British Medical Associa ization, but issued the White Paper as an tion then fought what at first appeared to avowed basis for free public and pro be a losing battle but in the end worked fessional discussion before the actual in out not so badly for the profession. This troduction of a parliamentary bill. writer quotes a British gibe to the effect Very blunt is the attitude of the gentle that "The National Insurance Act gave man who speaks of the "apostasy of the the doctors their motor cars." In 1911, B.M.A.," but a speaker who has leanings while the National Insurance Bill was be in the other direction finds it necessary to ing fought in Parliament, the British
ond vice-president; and Major Brittain F. Payne, third vice-president, and Dr. Charles D. Blassingame, member of the Council. Lawrence T. Post.
1308
EDITORIALS
Medical Association "obtained the sig natures of twenty-seven thousand doctors to a pledge that they would not accept service under the Bill except on terms in accordance with the Association's policy, and that they would not enter into any contract except through a local medical committee representative of the local pro fession." Today, says the same writer, the British profession has the advantage of considering a preliminary scheme in stead of fighting a bill already introduced into Parliament. Surgeon Vice-Admiral Sheldon Dud ley, Medical Director-General of the Navy, delivering the Harveian Lecture before the Harveian Society of London, pointed out that the oldest and most com prehensive medical services were those of the Navy and Army. Speaking as to the possible effect of a set salary upon the quality of the physician's work, Admiral Dudley said that in the British Navy there were very few medical officers who did as little work as possible, and he argued that "on the whole, self-respect, the de sire to do well in the eyes of the herd, a natural sympathy with sick people, and a praiseworthy desire for promotion would outweigh the alleged stultifying effect of a fixed salary." He suggested the experi ence of the Navy showed that "a patientdoctor relationship of the best type was possible on a salaried basis of remunera tion and without free choice." British municipal hospitals have come in for a good deal of abuse as contrasted with the voluntary hospitals. Yet the ac commodations provided in the voluntary hospitals are far from adequate, as dem onstrated by the fact that there is usually a long waiting list of applicants for ad mission. One of the most interesting products of the British controversy as to the Govern ment's proposals takes the form of a vote by medical students upon a number of
questions submitted to them by the British Medical Students' Association. About one fourth of the total number of students re plied. Forty-nine percent of them thought that the quality of the country's medical service would be enhanced by the pro posed National Health Service, thirty-six percent thought it would suffer, fourteen percent "did not know." Seventy-two per cent thought that complete medical serv ices, including hospital and specialized services, ought to be available to everyone free of charge. Eighty-nine percent ap proved of the principle of health centers. Fifty-three favored payment by a small basic salary plus capitation fees. Sixtythree percent made a statement that it would not be possible for them to set up in practice without incurring a debt. Fiftyone percent reacted on the whole favor ably to the Government's White Paper, forty percent unfavorably, and seven per cent "did not know." Incidentally it may be mentioned that of those whose fathers were physicians fifty-two percent reacted unfavorably to the document and only thirty-eight percent were definitely favor able. From medical students a similar vote would rather likely be obtained in the United States, since those who have not yet attained the position of special priv ilege associated with established practice are still preoccuped with the problem of buttering their daily bread. A British physician "under forty" suggests that the White Paper offers the young doctor two important advantages which should not be forgotten in discussing the future health services; namely, the opportunity to undertake general practice unburdened by financial considerations, and the ex istence of many more openings for the doctor who wishes to specialize. What part does ophthalmology play in this general discussion of the British Gov ernment's proposals? Plans for an oph-
1309
BOOK NOTICES
thalmic service have brought up the ques tion whether refraction shall be carried on entirely by ophthalmic physicians or shall enlist the cooperation of sight-test ing opticians. One writer points out that against seven thousand opticians at pres ent officially recognized as qualified to undertake National Health Insurance work, there are throughout the country only about one thousand ophthalmic medi cal practitioners, a part of whose time is taken up with other eye work. These fig ures were the basis of a recent recom mendation by the Ophthalmic Group Committtee's draft scheme for a National Eye Service, which suggested that it would be necessary to call in the aid of optician refractionists who would work under the supervision of medically quali fied specialists. The suggestion that in a few years time a sufficient number of physicians could be trained to do the re fraction work is derided by the corres pondent on the ground that "men are not going to take the six years medical course, then specialize in ophthalmology, and spend the rest of their lives doing refrac tions." The correspondent would establish eye clinics each "staffed by a medical eye specialist, who will have under him two or more optician refractionists," with sometimes the help of a nurse, clerical assistants, and possibly an orthoptist. The ophthalmic specialist would do only "diffi cult refractions or those requiring a cyclo plegic." The writer assumes that in the course of years most sight-testing op ticians will either "decide to go over to the dispensing side of the business or be ab sorbed as refractionists in the eye clin ics." Some readers will admire ( !) the faith of this correspondent in the ability of the subordinate refractionist to deter mine which refractions are difficult and which will require the use of a cycloplegic. If a system of socialized medicine is adopted in the United States, very thorny will be this problem of who shall do re
fraction in the public clinics or wherever it may be done out of the funds provided under the law. W. H. Crisp.
BOOK NOTICES I W A N T E D T O SEE. By Borghild Dahl, with a Foreword by William L. Benedict, M.D. New York, The Macmillan Co., 1944. Price $2.00. Some two years ago Dartmouth College published a book, "Motivation and visual factors," based upon an intensive study of a large goup of college students. The con clusion of the authors, in brief, is that visual handicaps as such can be considered only in relation to the entire personality, specifically to the motivating drives of the individual. The motivation seems to be the dominant factor in any successful or unsuccessful adjustment to the presence of visual anomalies. No stronger corroboration of the soundness of this conclusion can be found anywhere than in the personal narrative of Miss Dahl, in her volume, "I wanted to see." Here is a woman who from her earliest childhood was totally blind in one eye, had vision of only 4/60 in the other eye, and yet by sheer will and tenacity of purpose managed to get almost everything she strove for, and she aimed high. She would have done wonderfully if she had managed merely to get through grammar school. But Miss Dahl completed a regu lar high school course, a full college and university course, with the Bachelor and* Master of Arts degrees, became a suc cessful high school teacher, anl later a college professor. She also managed to win a fellowship from the American Scandinavian Foundation, which, ac claiming her as a distinguished student in sociology, sent her for a year's study to Norway. And this is not all. We could go on discoursing on her extracurricular ac complishments ; for example, being chosen