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MEDICAL PRACTICE UNDER THE INSURANCE ACT.
1068
supply. Above all, there would be the advantage of rendering cooperation between the panel doctors both natural and easy. Incidentally this would tend to reduce the prevalence of malingering, and the panel doctors might secure for themselves much greater freedom by agreeing to deputise for each other. The great object to strive for at present was the abolition of the spirit of competition. Under the capitation system this to
MEDICAL PRACTICE UNDER THE INSURANCE ACT. OUR SPECIAL COMMISSIONER.) (BY (Continued from p. 996.)
XLII.-LONDON :
FAVOURABLE VIEWS
OF THE
ACT.
became my task to call on various practitioners who are on the panel and who approve of the Insurance Act. My first visit was to a popular practitioner living in the Fulham-road, who expressed himself as being quite satisfied. He had some 800 insured persons on his list and paid only about three visits a day. Out of 24 visits paid on the day of my call only two were to panel patients. Some came to his surgery from long distances when they were really too ill to go out, and he had to hasten them home and to bed. Nor did he get the numerous night calls he had feared; but very trivial cases did come to his surgery, people who complained that their corns hurt them or that they had warts. But there were, he said, in Fulham One some panel doctors with too long lists. of them was credited with a list exceeding 4000, and another 2500. Patients had used their right under the Act to put themselves on the list of practitioners whom they desired to see, and thus it was that some insured persons, whom he did not know before, had come to him. Nor had he found that his panel work interfered with his private practice. On the contrary, it had increased the number of his private patients, for now he was attending, and for the usual fees, the dependents of the insured. It would be a mistake, however, to conclude from the above optimistic view that because a doctor is on the panel and approves, in a general sense, of the Insurance Act, he is therefore quite at ease and quite satisfied. This is far from being the case, for numerous improvements are suggested and many IT
now
apprehensions
entertained. The
In
Group System.
different part of the metropolis, in Lewisham, I saw a well-known and popular panel doctor who anticipated the possibility of a State Medical Service as a solution of the problem of medical benefit. In the meanwhile, and though he did not use such terms as collective or cooperative effort, he strongly advocated the organisation of panel work in the " group" form. To him it was wasteful and injurious to turn private dwellings into surgeries. In rural districts, where the population was scattered and practitioners lived several miles away from each other, this could not well be avoided. But in densely populated industrial centres, in London especially, it was a scandalous waste of opportunity and of resources for every panel doctor to keep up a petty little surgery of his own. Panel doctors, he urged, should form groups numbering at least six and preferably more. Jointly these panel doctors should hire a house, or, if it be possible, they should have a building planned and constructed specially for their purpose. Here there would be one large well-appointed waiting room, and as many consulting rooms in communication with the waiting room as there Then there were panel doctors grouped together. would be other rooms for electric treatment,
quite
a
and bacteriological examinations, X rays, &c.; thus jointly many facilities could be secured that no one panel doctor could by himself afford
much more easy of attainment. on to say, the Insurance Act has already established a State Medical Service, at least as far as the patient is concerned, if this was not so much so in regard to the doctor. The idea of service to the State had got to take the place of the old notion of competition. The Insurance Act was not intended to facilitate "bottle of medicine practice." It was meant to bring into existence a great educational force. The panel doctor was given an independent position with a comparatively safe income, so that he might teach the ignorant masses that a bottle of medicine will not cure disease. They had to teach sanitation. This could be done better in medical centres, such as might be established by grouping panel doctors together, than in small private surgeries. If a doctor speaking in his own small, ill-ventilated, dingy surgery told his patient he must have exercise and more air, the patient would go away and tell his friends that the doctor was no good because he had given him no medicine. But if such lessons were enforced by several doctors grouped in a centre where an object-lesson of cleanliness and ventilation was given at the same time they would be better appreciated. was
rendered
Indeed, he went
Unsuitable
and Complaints against Panel Doctors. At present, in this part of the south-east of London, there is a panel doctor who examines his patients in the waiting-room before all the other patients. It is true that this is quite an exceptional case, but nevertheless, and though he has no place to see his patients in private, he has quite a long list of poor people who have selected him as their panel doctor. In other parts of London similar scandalous conditions obtain here and there. A section of the population is so down-trodden-poor, wretched people-so inured to rough treatment, that they do not resent lack of proper accommodation. On several occasions my attention has been drawn to a notorious case of this sort on the Surrey side in a thickly populated district. The question is, How long will it be before these forlorn sections of the poor discover that they are badly treated and that better treatment is within their reach if they will avail themselves of the opportunities the Act gives them ? Also, and on the other side, better men will come on to the panel when they see that a competence can be assured them, and this, too, without having to engage in any acute phase of
Surgeries
competition against
fellow
practitioners.
As a member of the Medical Service Sub-Committee formed by the London Insurance Committee, my Lewisham informant explained he was in a position to inform me that the greater number of complaints made against panel doctors came from the poorer districts. This was natural, because it was just in such districts-Hoxton and Bethnal Green, for instance-that the panels were understaffed. The patients who were most apt to complain in all districts, and perhaps more especially in the better class districts, were those whose doctor has not gone on the panel. They had thus been obliged to
1069 a panel doctor whom they had never seen doctors enough in certain districts; now it should before; and this sort of compulsion was apt to be easier to induce practitioners to settle in those The general complaint was ’, districts. make them critical. When all the advantages were better that the doctor did not come quickly enough, known, a better supply of doctors would follow. especially if asked to call in the afternoon or even- But such a sweeping change as that brought about ing. But it must be remembered that in a crowded by the Insurance Act required several years to neighbourhood a panel doctor with a large list produce its full effects. Such, at any rate, were might well be detained in his surgery till ten in the the principal opinions and impressions that were set before me by friends of the panel system during evening.
send for
The Good that
Grumbling Does. whether justified or not, is grumbling, The will help to doing good. grumblers probably obtain in time a recognition of the fact that the panel patient is extraordinarily protected by publicity. Therefore in time the Act will give a guarantee of good service, because it is a public But for the service and a controlled service. present, at least in many instances, the control is inefficacious. As far as his own patients were concerned my informant had but little complaint to make. He had more than 1000 insured persons on his list, and many of them called on him as little as they possibly could. Of course, like all his colleagues, he was annoyed by trivial cases, but he did not find that the working class bothered him in that manner. It was the clerk earning 35s. a week who rushed off to the doctor on the slightest provocation. And by the side of the trivial cases he had work of the greatest scientific interest. He had one obscure case in particular which he would gladly have gone from one end of London to the other to see. Improved Conditions of Practice under the Act. I inquired at this point whether the Insurance Act could be utilised to check the spread of venereal disease. The reply was that so many practitioners stood in terror of the " unco’ guid that they dared not advise as to what precautionary or prophylactic measures, other than moral restraint, could be taken. But the Act would be, he maintained, a powerful instrument for the general prevention of sickness. When things had had time to settle down panel doctors would be less timid; they would think less and less about losing patients. A conscientious doctor would not lose more than a patient here and there, and under the capitation system this amounted to a very small It did not affect seriously the much sum. greater security of income now enjoyed. Of course, under the contract system there was a danger that some practitioners might drift into a groove, finding little to encourage them to improve their methods, and resting content to rub along in the easiest way. Would the glare of publicity be sufficient to prevent such neglect, or would the State institute compulsory post-graduate courses so that medical men in its service might be forced to keep abreast with the march of science ? Then there was also the question of private practice. In the case of this informant again the going on to the panel had not interfered in the least with his private practice. On the contrary, insured persons on his list had, on several
my visit to Lewisham. (To be continued.)
All this
"
occasions, introduced him
to private patients. private practice had so increased, and his position was so much improved after working for one year on the panel, that he had just been able to exchange his bicycle for a new motor-car. Taking everything together, the outlook seemed encouraging to him. There was difficulty in some
His
parts of London. Even before the Act there
were
not
I
MOTORING NOTES. (FROM A SPECIAL CORRESPONDENT.) The Studebaker T-7vo-seater Cabriolet. To many people an American car denotes a cheap one which perhaps goes well and climbs hills excellently, but probably not for long. In fact, recently, when discussing with a colleague the purchase of such a car, he said : ’’ They are like some razors : not made to shave, only to sell." As a consequence of this and other conversations and inquiries, and also because the car in question seemed to possess qualities that adapted it well to the needs of a doctor, I spent a day in thoroughly examining and testing a Studebaker cabriolet, concerning which I see that a correspondent of THE LANCET has recently made inquiries.’ The cylinders a are cast en bloc, and have bore of 3t inches and The valves are all on the left side, a stroke of 5 inches. and are enclosed by a plate which is accessible and easily removable. The valves themselves are drop-forged with their stems electrically welded to the head. The operating push-rods are adjustable. The pistons are of grey iron with polished heads, and are fitted with three piston rings above the gudgeon pin. The connecting rods are of drop-forged steel. The gudgeon pin bearing is of phosphor bronze. The big ends are lined with cast babbitt metal, The and packing pieces are provided for adjustment. crank shaft is of chrome nickel steel, and all the bearing surfaces are ground to micrometrical exactness. Lubrication is by means of a plunger pump driven direct from the cam-shaft. A supply of oil is carried in a sump in the bottom of the crank case, and from here the pump forces it into four troughs, one under each connecting-rod. There is also a sight gauge-glass on the dashboard, from which oil is led to the timing gears at the front of the engine. This gauge serves as an indication that the pump An oil-level indicator fitted to is working correctly. the side of the crank case, which is easily visible, shows accurately at all times the quantity of oil in the sump. Ignition is by means of a single coil mounted on the off-side of the engine, and the current is derived from accumulators which are kept fully charged by the dynamo, and these also supply current for the lamps and the engine-starting electric motor. A dry battery is connected to the ignition coil as a standby in case of derangement of the main system. Cooling is by means of a gilled tube radiator with a fan behind it, and a large centrifugal pump. The carburetter is a Schebler, and a regulator is placed on the dashboard enabling the adjustment of the air supply to be varied according to climatic conditions. The clutch is a leather-faced cone, which, as a matter of fact, is probably as simple and as satisfactory as any. Flat steel springs are fitted underneath the leather to facilitate easy engagement. The transmission is by propeller shaft with two efficient universal joints. Three forward speeds and one reverse are provided, all operated by a single lever on the gate change system. The housing of the rear axle also contains the gearbox. The control is by throttle and spark levers on the top of the steering wheel, with a foot accelerator situated between the clutch and foot brake pedals. The brakes all act on the rear hubs-one set being by external contracting lined steel bands acting on steel drums, whilst the other set is by internal expanding shoes acting on the same drums. The electric self-starter is fitted on the off-side of the engine, and is connected, by means of a, suitable reduction gear and 1
THE LANCET,
April 4th, p. 1014.
supply. Above all, there would be the advantage of rendering cooperation between the panel doctors both natural and easy. Incidentally this would tend to reduce the prevalence of malingering, and the panel doctors might secure for themselves much greater freedom by agreeing to deputise for each other. The great object to strive for at present was the abolition of the spirit of competition. Under the capitation system this to
MEDICAL PRACTICE UNDER THE INSURANCE ACT. OUR SPECIAL COMMISSIONER.) (BY (Continued from p. 996.)
XLII.-LONDON :
FAVOURABLE VIEWS
OF THE
ACT.
became my task to call on various practitioners who are on the panel and who approve of the Insurance Act. My first visit was to a popular practitioner living in the Fulham-road, who expressed himself as being quite satisfied. He had some 800 insured persons on his list and paid only about three visits a day. Out of 24 visits paid on the day of my call only two were to panel patients. Some came to his surgery from long distances when they were really too ill to go out, and he had to hasten them home and to bed. Nor did he get the numerous night calls he had feared; but very trivial cases did come to his surgery, people who complained that their corns hurt them or that they had warts. But there were, he said, in Fulham One some panel doctors with too long lists. of them was credited with a list exceeding 4000, and another 2500. Patients had used their right under the Act to put themselves on the list of practitioners whom they desired to see, and thus it was that some insured persons, whom he did not know before, had come to him. Nor had he found that his panel work interfered with his private practice. On the contrary, it had increased the number of his private patients, for now he was attending, and for the usual fees, the dependents of the insured. It would be a mistake, however, to conclude from the above optimistic view that because a doctor is on the panel and approves, in a general sense, of the Insurance Act, he is therefore quite at ease and quite satisfied. This is far from being the case, for numerous improvements are suggested and many IT
now
apprehensions
entertained. The
In
Group System.
different part of the metropolis, in Lewisham, I saw a well-known and popular panel doctor who anticipated the possibility of a State Medical Service as a solution of the problem of medical benefit. In the meanwhile, and though he did not use such terms as collective or cooperative effort, he strongly advocated the organisation of panel work in the " group" form. To him it was wasteful and injurious to turn private dwellings into surgeries. In rural districts, where the population was scattered and practitioners lived several miles away from each other, this could not well be avoided. But in densely populated industrial centres, in London especially, it was a scandalous waste of opportunity and of resources for every panel doctor to keep up a petty little surgery of his own. Panel doctors, he urged, should form groups numbering at least six and preferably more. Jointly these panel doctors should hire a house, or, if it be possible, they should have a building planned and constructed specially for their purpose. Here there would be one large well-appointed waiting room, and as many consulting rooms in communication with the waiting room as there Then there were panel doctors grouped together. would be other rooms for electric treatment,
quite
a
and bacteriological examinations, X rays, &c.; thus jointly many facilities could be secured that no one panel doctor could by himself afford
much more easy of attainment. on to say, the Insurance Act has already established a State Medical Service, at least as far as the patient is concerned, if this was not so much so in regard to the doctor. The idea of service to the State had got to take the place of the old notion of competition. The Insurance Act was not intended to facilitate "bottle of medicine practice." It was meant to bring into existence a great educational force. The panel doctor was given an independent position with a comparatively safe income, so that he might teach the ignorant masses that a bottle of medicine will not cure disease. They had to teach sanitation. This could be done better in medical centres, such as might be established by grouping panel doctors together, than in small private surgeries. If a doctor speaking in his own small, ill-ventilated, dingy surgery told his patient he must have exercise and more air, the patient would go away and tell his friends that the doctor was no good because he had given him no medicine. But if such lessons were enforced by several doctors grouped in a centre where an object-lesson of cleanliness and ventilation was given at the same time they would be better appreciated. was
rendered
Indeed, he went
Unsuitable
and Complaints against Panel Doctors. At present, in this part of the south-east of London, there is a panel doctor who examines his patients in the waiting-room before all the other patients. It is true that this is quite an exceptional case, but nevertheless, and though he has no place to see his patients in private, he has quite a long list of poor people who have selected him as their panel doctor. In other parts of London similar scandalous conditions obtain here and there. A section of the population is so down-trodden-poor, wretched people-so inured to rough treatment, that they do not resent lack of proper accommodation. On several occasions my attention has been drawn to a notorious case of this sort on the Surrey side in a thickly populated district. The question is, How long will it be before these forlorn sections of the poor discover that they are badly treated and that better treatment is within their reach if they will avail themselves of the opportunities the Act gives them ? Also, and on the other side, better men will come on to the panel when they see that a competence can be assured them, and this, too, without having to engage in any acute phase of
Surgeries
competition against
fellow
practitioners.
As a member of the Medical Service Sub-Committee formed by the London Insurance Committee, my Lewisham informant explained he was in a position to inform me that the greater number of complaints made against panel doctors came from the poorer districts. This was natural, because it was just in such districts-Hoxton and Bethnal Green, for instance-that the panels were understaffed. The patients who were most apt to complain in all districts, and perhaps more especially in the better class districts, were those whose doctor has not gone on the panel. They had thus been obliged to
1069 a panel doctor whom they had never seen doctors enough in certain districts; now it should before; and this sort of compulsion was apt to be easier to induce practitioners to settle in those The general complaint was ’, districts. make them critical. When all the advantages were better that the doctor did not come quickly enough, known, a better supply of doctors would follow. especially if asked to call in the afternoon or even- But such a sweeping change as that brought about ing. But it must be remembered that in a crowded by the Insurance Act required several years to neighbourhood a panel doctor with a large list produce its full effects. Such, at any rate, were might well be detained in his surgery till ten in the the principal opinions and impressions that were set before me by friends of the panel system during evening.
send for
The Good that
Grumbling Does. whether justified or not, is grumbling, The will help to doing good. grumblers probably obtain in time a recognition of the fact that the panel patient is extraordinarily protected by publicity. Therefore in time the Act will give a guarantee of good service, because it is a public But for the service and a controlled service. present, at least in many instances, the control is inefficacious. As far as his own patients were concerned my informant had but little complaint to make. He had more than 1000 insured persons on his list, and many of them called on him as little as they possibly could. Of course, like all his colleagues, he was annoyed by trivial cases, but he did not find that the working class bothered him in that manner. It was the clerk earning 35s. a week who rushed off to the doctor on the slightest provocation. And by the side of the trivial cases he had work of the greatest scientific interest. He had one obscure case in particular which he would gladly have gone from one end of London to the other to see. Improved Conditions of Practice under the Act. I inquired at this point whether the Insurance Act could be utilised to check the spread of venereal disease. The reply was that so many practitioners stood in terror of the " unco’ guid that they dared not advise as to what precautionary or prophylactic measures, other than moral restraint, could be taken. But the Act would be, he maintained, a powerful instrument for the general prevention of sickness. When things had had time to settle down panel doctors would be less timid; they would think less and less about losing patients. A conscientious doctor would not lose more than a patient here and there, and under the capitation system this amounted to a very small It did not affect seriously the much sum. greater security of income now enjoyed. Of course, under the contract system there was a danger that some practitioners might drift into a groove, finding little to encourage them to improve their methods, and resting content to rub along in the easiest way. Would the glare of publicity be sufficient to prevent such neglect, or would the State institute compulsory post-graduate courses so that medical men in its service might be forced to keep abreast with the march of science ? Then there was also the question of private practice. In the case of this informant again the going on to the panel had not interfered in the least with his private practice. On the contrary, insured persons on his list had, on several
my visit to Lewisham. (To be continued.)
All this
"
occasions, introduced him
to private patients. private practice had so increased, and his position was so much improved after working for one year on the panel, that he had just been able to exchange his bicycle for a new motor-car. Taking everything together, the outlook seemed encouraging to him. There was difficulty in some
His
parts of London. Even before the Act there
were
not
I
MOTORING NOTES. (FROM A SPECIAL CORRESPONDENT.) The Studebaker T-7vo-seater Cabriolet. To many people an American car denotes a cheap one which perhaps goes well and climbs hills excellently, but probably not for long. In fact, recently, when discussing with a colleague the purchase of such a car, he said : ’’ They are like some razors : not made to shave, only to sell." As a consequence of this and other conversations and inquiries, and also because the car in question seemed to possess qualities that adapted it well to the needs of a doctor, I spent a day in thoroughly examining and testing a Studebaker cabriolet, concerning which I see that a correspondent of THE LANCET has recently made inquiries.’ The cylinders a are cast en bloc, and have bore of 3t inches and The valves are all on the left side, a stroke of 5 inches. and are enclosed by a plate which is accessible and easily removable. The valves themselves are drop-forged with their stems electrically welded to the head. The operating push-rods are adjustable. The pistons are of grey iron with polished heads, and are fitted with three piston rings above the gudgeon pin. The connecting rods are of drop-forged steel. The gudgeon pin bearing is of phosphor bronze. The big ends are lined with cast babbitt metal, The and packing pieces are provided for adjustment. crank shaft is of chrome nickel steel, and all the bearing surfaces are ground to micrometrical exactness. Lubrication is by means of a plunger pump driven direct from the cam-shaft. A supply of oil is carried in a sump in the bottom of the crank case, and from here the pump forces it into four troughs, one under each connecting-rod. There is also a sight gauge-glass on the dashboard, from which oil is led to the timing gears at the front of the engine. This gauge serves as an indication that the pump An oil-level indicator fitted to is working correctly. the side of the crank case, which is easily visible, shows accurately at all times the quantity of oil in the sump. Ignition is by means of a single coil mounted on the off-side of the engine, and the current is derived from accumulators which are kept fully charged by the dynamo, and these also supply current for the lamps and the engine-starting electric motor. A dry battery is connected to the ignition coil as a standby in case of derangement of the main system. Cooling is by means of a gilled tube radiator with a fan behind it, and a large centrifugal pump. The carburetter is a Schebler, and a regulator is placed on the dashboard enabling the adjustment of the air supply to be varied according to climatic conditions. The clutch is a leather-faced cone, which, as a matter of fact, is probably as simple and as satisfactory as any. Flat steel springs are fitted underneath the leather to facilitate easy engagement. The transmission is by propeller shaft with two efficient universal joints. Three forward speeds and one reverse are provided, all operated by a single lever on the gate change system. The housing of the rear axle also contains the gearbox. The control is by throttle and spark levers on the top of the steering wheel, with a foot accelerator situated between the clutch and foot brake pedals. The brakes all act on the rear hubs-one set being by external contracting lined steel bands acting on steel drums, whilst the other set is by internal expanding shoes acting on the same drums. The electric self-starter is fitted on the off-side of the engine, and is connected, by means of a, suitable reduction gear and 1
THE LANCET,
April 4th, p. 1014.