- Email: [email protected]
Can Medical Practice Be Standardized?
American Journal of Ophthalmology P U B L I S H E D M O N T H L Y BY T H E O P H T H A L M I C P U B L I S H I N G COMPANY EDITORIAL
STAFF
W I L L I A M H. CRISP, editor HANS BARKAN 530 Metropolitan building, Denver 490 Post street, San Francisco E D W A R D JACKSON, consulting editor E D W A R D C. E L L E T T 217 Imperial building, Denver Exchange building, Memphis, Tennessee CLARENCE L O E B , associate editor HARRY S. GRADLE 1054 Tower Road, Hubbard Woods, Illinois 58 East Washington street, Chicago L A W R E N C E T. POST, associate editor M. U R I B E T R O N C O S O 524 Metropolitan building, Saint Louis 515 West End avenue, New York City J O H N M. W H E E L E R 30 West Fifty-ninth street, New York City Address original papers, other scientific communications including correspondence, also books for review and exchange copies of medical journals to. the editor, 530 Metropolitan building, Denver. _ Reports of society proceedings should be sent to Dr. Lawrence T. Post, 524 Metro politan building, Saint Louis. Subscriptions, applications for single copies, notices of change of address, and commu nications with reference to advertising should be addressed to the manager of subscrip tions and advertising, Jean Matteson, Room 1209, 7 West Madison street, Chicago. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Authors' proofs should be corrected and returned within forty-eight hours to the edi tor. Twenty-five reprints of each original article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip street, Menasha, Wisconsin, if ordered at the time proofs are re turned. But reprints to contain colored plates must be ordered when the article is accepted. CAN MEDICAL PRACTICE B E STANDARDIZED? T h e p o i n t s of v i e w of t w o classes of People o c c u p y i n g t h e r e s p e c t i v e posi t i o n s of a n i n t e r d e p e n d e n t r e l a t i o n s h i p can n e v e r q u i t e a g r e e . T h u s t e a c h e r a n d s c h o l a r a r e n o t likely t o a s s u m e 1( ientical a t t i t u d e s t o w a r d c e r t a i n p r o b l e m s in r e g a r d t o w h i c h o n e is t h e leader a n d t h e o t h e r t h e m o r e or less w i l l i n g a n d o b e d i e n t follower. E v e n c l e r g y m a n a n d c o n g r e g a t i o n will be critical of ° n e a n o t h e r a n d will often d i s p l a y con flicting s t a n d a r d s of t h o u g h t a n d con duct. T h e e x t r e m e s of w e a l t h a s s u m e t h e e x i s t e n c e of p o v e r t y , a n d rich a n d Ppor c a n n o t fail t o d e v e l o p d i s c o r d a n t v i e w p o i n t s on m a n y p h a s e s of life. I t is d o u b t f u l w h e t h e r one w h o h a s Practiced m e d i c i n e for y e a r s or a life t i m e can ever k n o w e x a c t l y t h e p o s i t i o n which h e a n d h i s a r t o c c u p y in t h e m i n d s of t h e l a i t y ; a n d t h e m a j o r i t y of P a t i e n t s a r e far from s e e i n g eye t o eye w i t h u s c o n c e r n i n g c e r t a i n a s p e c t s of the professional r e l a t i o n s h i p w h i c h
h a v e b e c o m e a s t h e fiber of o u r exis tence. A s d i c t a t e d b y t h e p h y s i c i a n ' s ideals, or b y t h e a b s e n c e of t h e m , t h e c o m m u n i t y a t l a r g e is e i t h e r h u m a n i t y in n e e d of h e l p o r a m a s s of m a t e r i a l which awaits exploitation. T h e kind of skill r e q u i r e d in t h e fulfilment of h u m a n i t a r i a n m o t i v e s is n o t q u i t e t h e s a m e as t h a t d e m a n d e d in t h e e x p l o i t a tion of a field of c o m m e r c i a l e n t e r p r i s e . H e r e lies t h e difference b e t w e e n t h e es sentially professional and t h e typically b u s i n e s s o u t l o o k , b u t it is n o t t o b e s u p p o s e d t h a t m o s t p h y s i c i a n s will d i s p l a y one of t h e s e a t t i t u d e s t o t h e e n t i r e e x clusion of t h e o t h e r . T h e s a v i n g g r a c e in t h e p h y s i c i a n is t o t h i n k of himself as t h e p a t i e n t . " G i v e n t h e k n o w l e d g e t h a t I p o s s e s s , as to health and disease, as to the uncer t a i n t i e s of t r e a t m e n t , a s t o t h e r i s k s of life a n d d e a t h , a s t o t h e p r e c i o u s n e s s of t h i s or t h a t o r g a n in its n a t u r a l i n t e g r i t y or as modified b y s u r g i c a l skill or b u n g l i n g , h o w s h o u l d I like t o h a v e t h i s p a r -
1003
1004
EDITORIALS
ticular problem treated, what risks should I care to assume, into whose hands should I prefer to commit myself, and what standards of training should I demand in those who assumed respon sibility for my physical well-being?" Or " W h a t should I want done if this particular problem arose in one of my family?" Looking at the question frankly, the physician would often demand for him self something better than he gives his patients. He would wish for extreme care, extreme skill, the minimum of risk which the circumstances would allow, and above all he would demand that the physician or surgeon whom he em ployed was not one of mediocre train ing'even if this were the usual quality of professional training in the com munity in which he lived, but rather a physician of the best training, one with the highest standards of education and equipment in the applied science of medicine or in the special branch of medicine involved. These considerations should influ ence our decisions as to what is to be done to the patient, our advice to him, our recommendation for consultation with professional colleagues. H o w far have we gone toward real standardization of the practice of medi cine as a whole or in any of its special ties? Not, it is to be feared, very far. The graduate of a medical college, wide though the scope of his study has be come, and making due allowance for the fact that he can not possibly master all technique in all the specialties, too often steps out into the active practice of medicine without proper knowledge of many important specialized details of technique which it should have been practicable for him to acquire, and the understanding of which by the general practitioner is highly desirable for the welfare of the patient. For example, under proper teaching, it is not difficult to impart to the undergraduate a valu able basic understanding of the use of the ophthalmoscope, yet how many of the medical graduates of this or any other country carry such understanding with them into their practice?
The more dependent the profession and the community become upon the administrations of specialists in various branches, the more necessary it. is that any physician recognized as practicing a given specialty shall be reliable in knowledge and practice. Yet it is in re gard to special practice that the most flagrant disregard of the principles of standardization exists. Several reasons hinder adequate standardization of those who in one way or another hold themselves out as practicing specialties within the field of medicine. One is the unwillingness of the physician to make the necessary ex penditure of time, money, and effort to equip himself; a second is the fact that inadequate provision.is made for fur nishing the training which he needs; and a third is the fear, too often pres ent in the individual, that requirements for standardization would deprive him of more or less tangible special privi leges which he enjoys in the communi ty, but which are based upon the rela tively inadequate fact that he has a medical diploma and a license to prac tice medicine, neither of which testifies to his ability to perform in a field of specialization. How many of those who undertake intraabdominal operations could dem onstrate before a strict but fair and im partial board of surgical examiners that they possessed the training which the health and safety of their patients de mand? How high a percentage of rhinologists in country towns or even in the larger cities could show a thor ough acquaintance with the intricate anatomy, the diagnosis, and the deli cate surgery of the nose, the nasal sinuses, the larynx and the ear? Com ing nearer home, how far have we really gone in the establishment of reliable standards of ophthalmic practice? It is true that the American Board for Ophthalmic Examinations, supported by the three important national bodies devoted to this specialty, was the pion eer in standardization of special prac tice in this country. It is also true that the activities of the Board, particularly in relation to the requirements of the
EDITORIALS American Ophthalmological Society and of the American Academy of Ophthalmology and Otolaryngology, have materially advanced the cause of standardization in preparation for ophthalmic practice. But the road is only just begun. Ultimately, it is probable that no one will be allowed to hold himself out as a specialist in any well denned branch of medicine and surgery without hav ing presented clearly authenticated evidence of a minimum period of train ing in an institution properly equipped and designed to furnish this kind of postgraduate study, and without hav ing shown a satisfactory aptitude in mastering the necessary details of in formation and technique. It will not be sufficient for the candi date to state that he has attended such an institution or that he has acted as assistant to some reputable practitioner of the specialty. H e will have to pre sent credits just as rigidly established as those which are carried from high school to college or from one university to another. This will involve the naming of in stitutions whose courses of postgradua t e study and whose demands upon the Postgraduate student are officially rec ognized as satisfactory; and this in turn w ill require creation of teaching staffs °f acknowledged efficiency. It will fur ther demand, on the part of the com munity or of the individual or of both, the expenditure of far more money than ls now being applied specifically to Postgraduate teaching and study. In ophthalmology, such official re quirements for standardization might w ell result in the creation of accepted text books dealing with individual Phases of the subject, such as refract1Qn, ophthalmoscopy, perimetry, ocu'ar histology and pathology, and ocular s urgery. It might involve organized cooperation between a national exam ining body (representing perhaps conJointly the leading institutions for ?Phthalmologic education and the lead ing ophthalmologic societies) and the ''censing boards of the separate states. *t might lead to the development of a
1005
group of teachers in ophthalmology whose activities were definitely aimed at meeting educational requirements for special practice. W e have already travelled far in pro cedure, although not so far in the lapse of years, from the days when no single state of this Union demanded a license for the legal practice of general medi cine. The proposal to require a special license for special practice will be sub ject to much criticism, and is likely to be slow of adoption. It could not fairly be made retroaotive, and would have to be limited to the new generation of specialists. But such a development is a need of our modern age, will prove an essential basis of continued public confidence in the profession of the heal ing art, and would place the practice of ophthalmology upon an even higher plane than it occupies today. W. H. Crisp. T H E U N K N O W N IN GLAUCOMA . In his introduction to the English translation of the Life of Pasteur, by Vallery-Radot, Sir William Osier wrote: "The Greek physicians, Hippo crates, Galen, and Aretaeus, gave excel lent accounts of many diseases; for ex ample, the forms of malaria. They knew, too, very well, their modes of termination, and the art of prognosis was studied carefully. But of the actual causes of disease they knew little or nothing, and any glimmerings of truth were obscured in a cloud of theory." It is not strange that with regard to glau coma a knowledge, first of the pain and blindness it causes, and then of the changes left in the optic nerve and eye ball, when it has run its course, should have preceded any knowledge of its "actual causes." In spite of its grave prognosis, gen eral ignorance of glaucoma has stood in the way of early recognition. The study of the pathologic anatomy of eyes removed after they had become entirely blind from glaucoma has tended to fix attention on the late results of the di sease; while its early manifestations and course have been ignored or forgot-
STAFF
W I L L I A M H. CRISP, editor HANS BARKAN 530 Metropolitan building, Denver 490 Post street, San Francisco E D W A R D JACKSON, consulting editor E D W A R D C. E L L E T T 217 Imperial building, Denver Exchange building, Memphis, Tennessee CLARENCE L O E B , associate editor HARRY S. GRADLE 1054 Tower Road, Hubbard Woods, Illinois 58 East Washington street, Chicago L A W R E N C E T. POST, associate editor M. U R I B E T R O N C O S O 524 Metropolitan building, Saint Louis 515 West End avenue, New York City J O H N M. W H E E L E R 30 West Fifty-ninth street, New York City Address original papers, other scientific communications including correspondence, also books for review and exchange copies of medical journals to. the editor, 530 Metropolitan building, Denver. _ Reports of society proceedings should be sent to Dr. Lawrence T. Post, 524 Metro politan building, Saint Louis. Subscriptions, applications for single copies, notices of change of address, and commu nications with reference to advertising should be addressed to the manager of subscrip tions and advertising, Jean Matteson, Room 1209, 7 West Madison street, Chicago. Copy of advertisements must be sent to the manager by the fifteenth of the month preceding its appearance. Authors' proofs should be corrected and returned within forty-eight hours to the edi tor. Twenty-five reprints of each original article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Company, 450-458 Ahnaip street, Menasha, Wisconsin, if ordered at the time proofs are re turned. But reprints to contain colored plates must be ordered when the article is accepted. CAN MEDICAL PRACTICE B E STANDARDIZED? T h e p o i n t s of v i e w of t w o classes of People o c c u p y i n g t h e r e s p e c t i v e posi t i o n s of a n i n t e r d e p e n d e n t r e l a t i o n s h i p can n e v e r q u i t e a g r e e . T h u s t e a c h e r a n d s c h o l a r a r e n o t likely t o a s s u m e 1( ientical a t t i t u d e s t o w a r d c e r t a i n p r o b l e m s in r e g a r d t o w h i c h o n e is t h e leader a n d t h e o t h e r t h e m o r e or less w i l l i n g a n d o b e d i e n t follower. E v e n c l e r g y m a n a n d c o n g r e g a t i o n will be critical of ° n e a n o t h e r a n d will often d i s p l a y con flicting s t a n d a r d s of t h o u g h t a n d con duct. T h e e x t r e m e s of w e a l t h a s s u m e t h e e x i s t e n c e of p o v e r t y , a n d rich a n d Ppor c a n n o t fail t o d e v e l o p d i s c o r d a n t v i e w p o i n t s on m a n y p h a s e s of life. I t is d o u b t f u l w h e t h e r one w h o h a s Practiced m e d i c i n e for y e a r s or a life t i m e can ever k n o w e x a c t l y t h e p o s i t i o n which h e a n d h i s a r t o c c u p y in t h e m i n d s of t h e l a i t y ; a n d t h e m a j o r i t y of P a t i e n t s a r e far from s e e i n g eye t o eye w i t h u s c o n c e r n i n g c e r t a i n a s p e c t s of the professional r e l a t i o n s h i p w h i c h
h a v e b e c o m e a s t h e fiber of o u r exis tence. A s d i c t a t e d b y t h e p h y s i c i a n ' s ideals, or b y t h e a b s e n c e of t h e m , t h e c o m m u n i t y a t l a r g e is e i t h e r h u m a n i t y in n e e d of h e l p o r a m a s s of m a t e r i a l which awaits exploitation. T h e kind of skill r e q u i r e d in t h e fulfilment of h u m a n i t a r i a n m o t i v e s is n o t q u i t e t h e s a m e as t h a t d e m a n d e d in t h e e x p l o i t a tion of a field of c o m m e r c i a l e n t e r p r i s e . H e r e lies t h e difference b e t w e e n t h e es sentially professional and t h e typically b u s i n e s s o u t l o o k , b u t it is n o t t o b e s u p p o s e d t h a t m o s t p h y s i c i a n s will d i s p l a y one of t h e s e a t t i t u d e s t o t h e e n t i r e e x clusion of t h e o t h e r . T h e s a v i n g g r a c e in t h e p h y s i c i a n is t o t h i n k of himself as t h e p a t i e n t . " G i v e n t h e k n o w l e d g e t h a t I p o s s e s s , as to health and disease, as to the uncer t a i n t i e s of t r e a t m e n t , a s t o t h e r i s k s of life a n d d e a t h , a s t o t h e p r e c i o u s n e s s of t h i s or t h a t o r g a n in its n a t u r a l i n t e g r i t y or as modified b y s u r g i c a l skill or b u n g l i n g , h o w s h o u l d I like t o h a v e t h i s p a r -
1003
1004
EDITORIALS
ticular problem treated, what risks should I care to assume, into whose hands should I prefer to commit myself, and what standards of training should I demand in those who assumed respon sibility for my physical well-being?" Or " W h a t should I want done if this particular problem arose in one of my family?" Looking at the question frankly, the physician would often demand for him self something better than he gives his patients. He would wish for extreme care, extreme skill, the minimum of risk which the circumstances would allow, and above all he would demand that the physician or surgeon whom he em ployed was not one of mediocre train ing'even if this were the usual quality of professional training in the com munity in which he lived, but rather a physician of the best training, one with the highest standards of education and equipment in the applied science of medicine or in the special branch of medicine involved. These considerations should influ ence our decisions as to what is to be done to the patient, our advice to him, our recommendation for consultation with professional colleagues. H o w far have we gone toward real standardization of the practice of medi cine as a whole or in any of its special ties? Not, it is to be feared, very far. The graduate of a medical college, wide though the scope of his study has be come, and making due allowance for the fact that he can not possibly master all technique in all the specialties, too often steps out into the active practice of medicine without proper knowledge of many important specialized details of technique which it should have been practicable for him to acquire, and the understanding of which by the general practitioner is highly desirable for the welfare of the patient. For example, under proper teaching, it is not difficult to impart to the undergraduate a valu able basic understanding of the use of the ophthalmoscope, yet how many of the medical graduates of this or any other country carry such understanding with them into their practice?
The more dependent the profession and the community become upon the administrations of specialists in various branches, the more necessary it. is that any physician recognized as practicing a given specialty shall be reliable in knowledge and practice. Yet it is in re gard to special practice that the most flagrant disregard of the principles of standardization exists. Several reasons hinder adequate standardization of those who in one way or another hold themselves out as practicing specialties within the field of medicine. One is the unwillingness of the physician to make the necessary ex penditure of time, money, and effort to equip himself; a second is the fact that inadequate provision.is made for fur nishing the training which he needs; and a third is the fear, too often pres ent in the individual, that requirements for standardization would deprive him of more or less tangible special privi leges which he enjoys in the communi ty, but which are based upon the rela tively inadequate fact that he has a medical diploma and a license to prac tice medicine, neither of which testifies to his ability to perform in a field of specialization. How many of those who undertake intraabdominal operations could dem onstrate before a strict but fair and im partial board of surgical examiners that they possessed the training which the health and safety of their patients de mand? How high a percentage of rhinologists in country towns or even in the larger cities could show a thor ough acquaintance with the intricate anatomy, the diagnosis, and the deli cate surgery of the nose, the nasal sinuses, the larynx and the ear? Com ing nearer home, how far have we really gone in the establishment of reliable standards of ophthalmic practice? It is true that the American Board for Ophthalmic Examinations, supported by the three important national bodies devoted to this specialty, was the pion eer in standardization of special prac tice in this country. It is also true that the activities of the Board, particularly in relation to the requirements of the
EDITORIALS American Ophthalmological Society and of the American Academy of Ophthalmology and Otolaryngology, have materially advanced the cause of standardization in preparation for ophthalmic practice. But the road is only just begun. Ultimately, it is probable that no one will be allowed to hold himself out as a specialist in any well denned branch of medicine and surgery without hav ing presented clearly authenticated evidence of a minimum period of train ing in an institution properly equipped and designed to furnish this kind of postgraduate study, and without hav ing shown a satisfactory aptitude in mastering the necessary details of in formation and technique. It will not be sufficient for the candi date to state that he has attended such an institution or that he has acted as assistant to some reputable practitioner of the specialty. H e will have to pre sent credits just as rigidly established as those which are carried from high school to college or from one university to another. This will involve the naming of in stitutions whose courses of postgradua t e study and whose demands upon the Postgraduate student are officially rec ognized as satisfactory; and this in turn w ill require creation of teaching staffs °f acknowledged efficiency. It will fur ther demand, on the part of the com munity or of the individual or of both, the expenditure of far more money than ls now being applied specifically to Postgraduate teaching and study. In ophthalmology, such official re quirements for standardization might w ell result in the creation of accepted text books dealing with individual Phases of the subject, such as refract1Qn, ophthalmoscopy, perimetry, ocu'ar histology and pathology, and ocular s urgery. It might involve organized cooperation between a national exam ining body (representing perhaps conJointly the leading institutions for ?Phthalmologic education and the lead ing ophthalmologic societies) and the ''censing boards of the separate states. *t might lead to the development of a
1005
group of teachers in ophthalmology whose activities were definitely aimed at meeting educational requirements for special practice. W e have already travelled far in pro cedure, although not so far in the lapse of years, from the days when no single state of this Union demanded a license for the legal practice of general medi cine. The proposal to require a special license for special practice will be sub ject to much criticism, and is likely to be slow of adoption. It could not fairly be made retroaotive, and would have to be limited to the new generation of specialists. But such a development is a need of our modern age, will prove an essential basis of continued public confidence in the profession of the heal ing art, and would place the practice of ophthalmology upon an even higher plane than it occupies today. W. H. Crisp. T H E U N K N O W N IN GLAUCOMA . In his introduction to the English translation of the Life of Pasteur, by Vallery-Radot, Sir William Osier wrote: "The Greek physicians, Hippo crates, Galen, and Aretaeus, gave excel lent accounts of many diseases; for ex ample, the forms of malaria. They knew, too, very well, their modes of termination, and the art of prognosis was studied carefully. But of the actual causes of disease they knew little or nothing, and any glimmerings of truth were obscured in a cloud of theory." It is not strange that with regard to glau coma a knowledge, first of the pain and blindness it causes, and then of the changes left in the optic nerve and eye ball, when it has run its course, should have preceded any knowledge of its "actual causes." In spite of its grave prognosis, gen eral ignorance of glaucoma has stood in the way of early recognition. The study of the pathologic anatomy of eyes removed after they had become entirely blind from glaucoma has tended to fix attention on the late results of the di sease; while its early manifestations and course have been ignored or forgot-