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Oversupply of Physicians
AMERICAN JOURNAL OF OPHTHALMOLOGY P U B L I S H E D MONTHLY 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 LAWRENCE T. POST, Editor H. ROMMEL H I L D R E T H 524 Metropolitan building, Saint Louis 824 Metropolitan building, Saint Louis W I L L I A M H. CRISP, Consulting Editor PARK L E W I S 530 Metropolitan building, Denver 454 Franklin street, Buffalo EDWARD JACKSON, Consulting Editor M. U R I B E TRONCOSO 350 West 85th street, New York 1120 Republic building, Denver M. F. WEYMANN HANS BARKAN 903 Westlake Professional building, Los Stanford University Hospital, San Fran cisco Angeles J O H N M. W H E E L E R HARRY S. GRADLE 58 East Washington street, Chicago 30 West Fifty-ninth street, New York EMMA S. BUSS, Manuscript Editor Address original papers, other scientific communications including correspondence, also books for review and reports of society proceedings to Dr. Lawrence T. Post, 524 Metropolitan building, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan building, Denver. Subscriptions, applications for single copies, notices of change of address, and com munications with_ reference to advertising should be addressed to the manager of subscrip tions and advertising, 508 Metropolitan building, Saint Louis. 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 editor. Twenty-five reprints of each article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Com pany, 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.
OVERSUPPLY OF PHYSICIANS V i e w i n g t h e practice of medicine as a c o m m o d i t y , t h e n u m b e r of p h y s i c i a n s in t h e c o m m u n i t y has been l a r g e l y r e g u lated b y t h e law of s u p p l y a n d d e m a n d . T h e r e are a few w h o still m a i n t a i n t h a t control of medical practice s h o u l d de pend e n t i r e l y u p o n this principle, a n d t h a t t h e licensing of p h y s i c i a n s is a m i s take. T h e y argue that the community should be left to d e m o n s t r a t e t h e w i s dom or folly of individual j u d g m e n t s as to medical efficiency u p o n t h e evolu t i o n a r y principles of t h e survival of t h e fittest; in o t h e r w o r d s , t h e u l t i m a t e de t e r i o r a t i o n or e x t i n c t i o n of t h o s e families in w h i c h p o o r j u d g m e n t in se lection of a p h y s i c i a n is c o m m o n l y manifested! T h e c u s t o m of licensing in itself re s t r i c t s t h e o p e r a t i o n of t h e l a w of s u p ply a n d d e m a n d . B u t , as b e t w e e n differ ent c o u n t r i e s , t h e r e h a s been w i d e v a r i a tion in t h e e x t e n t to w h i c h t h e r i g h t to practice t h e h e a l i n g art w a s limited b y s t a t u t e or o t h e r w i s e . 442
_ In S w e d e n , one of t h e m o s t h i g h l y civilized c o u n t r i e s in t h e w o r l d a n d one w i t h an excellent record as to health a n d longevity, t h e r e is only one p h y s i cian for every 2,890 i n h a b i t a n t s , w h e r e as in t h e U n i t e d S t a t e s t h e r e is one li censed physician for e v e r y 780 p e r s o n s . I t is i n t e r e s t i n g to n o t e t h a t in one of t h e m o s t i m p o r t a n t factors of h e a l t h control, n a m e l y t h e p r e v e n t i o n of child b i r t h m o r t a l i t y , S w e d e n is g r e a t l y ahead of t h e U n i t e d S t a t e s . I n E n g l a n d the ratio of p h y s i c i a n s to population is s l i g h t l y m o r e t h a n onehalf of t h a t found in t h e U n i t e d S t a t e s , the ratio in t h e former c o u n t r y b e i n g o n e to 1,490. I n t h i s connection it m a y be a p p r o p r i a t e to r e m a r k t h a t , in com parison w i t h g e n e r a l s t a n d a r d s of liv i n g a m o n g t h e middle-class p o p u l a t i o n s of t h e t w o countries, t h e a v e r a g e social a n d e c o n o m i c s t a t u s of t h e E n g l i s h physician is p r o b a b l y s u p e r i o r to t h a t of his A m e r i c a n colleague. T h e r e are p a r t s of t h e U n i t e d S t a t e s in w h i c h t h e relative n u m b e r of p h y s i -
EDITORIALS cians is greatly below that for the whole country. Thus, Matas has shown that several parishes in Louisiana have only one doctor to 1,800 of the population. But, in the whole country, according to figures quoted by Bierring (American Medical Association Bulletin, 1934, volume 29, page 17), there is at present a surplus of approximately 35,000 physicians, and, in spite of greatly im proved standards and requirements for medical education, the oversupply is steadily increasing. While the economic problems of the medical profession have been intensified during the financial depression of the last few years, the disturbing influences of an oversupply in the number of physicians were felt in times of general prosperity. In most individuals the ex act measure of honesty depends upon the pressure of circumstances. Econom ic desperation encourages the worst manifestations of fee splitting, un scrupulous and suicidal price cutting, the performance of unnecessary or dan gerous "services," and especially the at tempt to undertake surgical work for which the practitioner is not qualified. Bierring calls attention to a recent full-page advertisement in a Chicago newspaper, according to which more than three hundred Chicago physicians, surgeons, and dentists offer "complete eye, ear, nose and throat, heart and lungs, neurologic, gynecologic, roentgen, and laboratory examinations" at fees "so low as to be inconsistent with the type of service promised in the ad vertisement." In the long run, the public and the physician alike suffer from the demor alization created by oversupply. In the Province of Alberta, Canada, the situa tion has been met by passage of a law that no more physicians will be regis tered in the Province until the ratio of physicians to population has reached one in 1,200. Obviously such a remedy, taken alone, would not be generally ap plicable. Our own specialty has not escaped the destructive results of oversupply. From time to time we are assured that the number of well equipped ophthal mologists may be greatly increased
443
without creating an oversupply, but calculations of this sort lose sight of the fact that a great proportion of the com munity will never employ an ophthal mologist outside the walls of a chari table institution. Good refraction work was very poor ly paid for, even at the average prices prevailing before the financial slump. The opportunity to urge upon the pa tient unnecessary operations is certain ly more restricted in ophthalmology than in some other surgical specialties, but it is apt to be encouraged by an ex aggerated struggle for existence. Against artificial control of the num ber of physicians, it is argued that un der democracy there should be equal opportunity for all who wish to enter the learned professions. Yet in other matters bearing strongly upon public welfare it has been thought entirely proper to avoid destructive competition. Moreover, there is something to be said for the contention that, after the very great expenditure of time and money in volved in modern preparation for medi cal practice, the physician is entitled to some protection at the hands of the pub lic which he serves, and that the public owes itself the duty of seeing that its own share in the cost of medical train ing shall not be wasted. Entry to many important govern ment services is by competitive exam ination for which the number of en trants always greatly exceeds the num ber accepted. Many medical colleges are already rejecting a large percentage of those presenting themselves for ma triculation. This is chiefly upon the basis of limited accommodation and fi nancial resources. In principle, is there anything unsound in the suggestion that the total number of candidates for medical training throughout the whole country should be definitely limited from year to year in accordance with estimated need ? Sooner or later, in spite of all objec tions to centralization, the regulation of medical practice is likely to become a matter for federal rather than local con trol. In many respects it is certainly an interstate problem. In the meantime the question of oversupply will continue to
444
EDITORIALS
be studied by such organizations as the Commission on Medical Education, and the Council on Medical Education and Hospitals, of the American Medical As sociation. As a measure of voluntary control, it might be thought well to establish a na tional advisory board from which each year the medical colleges of the country would receive recommendations as to the number of matriculants to be ac cepted for the next college year. Alike for physician and patient, ex cessive dependence upon the law of sup ply and demand as regards the number of medical practitioners is likely to de velop more harm than good, and arti ficial control may prove necessary in the interest of all concerned. W . H. Crisp. MEETING AT SALT LAKE CITY The American College of Surgeons has nearly 2,000 Fellows who restrict their practice to ophthalmology and oto-laryngology. But the "General Sur geons," who control the policy of the organization, have been slow to recog nize that these "specialists" had as real and deep an interest in raising profes sional standards as those who under took operations on any part of the body, and claimed special right to the surgical prestige and traditions of the past. These leaders, impressed by the im portance of annual clinical congresses and the great numbers of surgeons brought by such congresses into opera tive clinics in the large eastern cities, have never been willing to undertake one of these annual gatherings west of the Mississippi River. But, to com pensate Fellows who live far from the eastern cities, for lack of opportunity to join the throngs that crowd the clinics of the Annual Congresses, Sectional Meetings have been established, where the Fellows who live in a group of states can have the advantage of seeing and hearing some of those who direct the affairs of the College from the cen tral office, and other prominent sur geons invited to these gatherings. Such a Sectional Meeting has been held for the first time in Salt Lake City, February 27 to March 1 inclusive. The
states constituting this section are Utah, Idaho, Wyoming and Colorado. A similar meeting was held previously in Oklahoma City; and others followed in Spokane, Los Angeles and Phoenix. These meetings all illustrate the real in terest and eagerness of the profession to utilize every opportunity for gradu ate study. The local specialists, with visitors from the adjacent states, at tended the meetings and clinics, in num bers greater than were gathered by either of the national special societies The clinics at the four approved hospi tals were given to presentation of cases by local men; which were then made subjects of questions and discussions by those present. A boy, blind with sympathetic oph thalmia, illustrated the special dangers of this disease to children. There was a case of alternating exophthalmos of high degree, associated with thyroid disease. The photography of cases was illustrated. Treatment of detachment of the retina came in for the usual discus sions. The most striking feature of the meeting was the evening meeting, on health interests for the public. This filled the Tabernacle, holding ten thou sand, and an overflow meeting of about fifteen hundred in another hall. It was the largest meeting of the kind ever held in America, and the audience stayed three hours to hear the ad dresses, which were given in both the auditoriums. Moving pictures made the people familiar with the work of hos pitals ; as, in the scientific sessions, they illustrated operations on the eye. Edward Jackson. INTERSTITIAL KERATITIS, A MODERN ANACHRONISM Interstitial keratitis is one of the most intractable and one of the least satis factory diseases to treat. It frequently reaches the ophthalmologist after the cornea has been so involved that the restoration of good sight is impossible. It is one of the most common causes of defective vision and of blindness. It is also one of the most preventable of the eye diseases.
EDITORIAL STAFF LAWRENCE T. POST, Editor H. ROMMEL H I L D R E T H 524 Metropolitan building, Saint Louis 824 Metropolitan building, Saint Louis W I L L I A M H. CRISP, Consulting Editor PARK L E W I S 530 Metropolitan building, Denver 454 Franklin street, Buffalo EDWARD JACKSON, Consulting Editor M. U R I B E TRONCOSO 350 West 85th street, New York 1120 Republic building, Denver M. F. WEYMANN HANS BARKAN 903 Westlake Professional building, Los Stanford University Hospital, San Fran cisco Angeles J O H N M. W H E E L E R HARRY S. GRADLE 58 East Washington street, Chicago 30 West Fifty-ninth street, New York EMMA S. BUSS, Manuscript Editor Address original papers, other scientific communications including correspondence, also books for review and reports of society proceedings to Dr. Lawrence T. Post, 524 Metropolitan building, Saint Louis. Exchange copies of medical journals should be sent to Dr. William H. Crisp, 530 Metropolitan building, Denver. Subscriptions, applications for single copies, notices of change of address, and com munications with_ reference to advertising should be addressed to the manager of subscrip tions and advertising, 508 Metropolitan building, Saint Louis. 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 editor. Twenty-five reprints of each article will be supplied to the author without charge. Additional reprints may be obtained from the printer, the George Banta Publishing Com pany, 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.
OVERSUPPLY OF PHYSICIANS V i e w i n g t h e practice of medicine as a c o m m o d i t y , t h e n u m b e r of p h y s i c i a n s in t h e c o m m u n i t y has been l a r g e l y r e g u lated b y t h e law of s u p p l y a n d d e m a n d . T h e r e are a few w h o still m a i n t a i n t h a t control of medical practice s h o u l d de pend e n t i r e l y u p o n this principle, a n d t h a t t h e licensing of p h y s i c i a n s is a m i s take. T h e y argue that the community should be left to d e m o n s t r a t e t h e w i s dom or folly of individual j u d g m e n t s as to medical efficiency u p o n t h e evolu t i o n a r y principles of t h e survival of t h e fittest; in o t h e r w o r d s , t h e u l t i m a t e de t e r i o r a t i o n or e x t i n c t i o n of t h o s e families in w h i c h p o o r j u d g m e n t in se lection of a p h y s i c i a n is c o m m o n l y manifested! T h e c u s t o m of licensing in itself re s t r i c t s t h e o p e r a t i o n of t h e l a w of s u p ply a n d d e m a n d . B u t , as b e t w e e n differ ent c o u n t r i e s , t h e r e h a s been w i d e v a r i a tion in t h e e x t e n t to w h i c h t h e r i g h t to practice t h e h e a l i n g art w a s limited b y s t a t u t e or o t h e r w i s e . 442
_ In S w e d e n , one of t h e m o s t h i g h l y civilized c o u n t r i e s in t h e w o r l d a n d one w i t h an excellent record as to health a n d longevity, t h e r e is only one p h y s i cian for every 2,890 i n h a b i t a n t s , w h e r e as in t h e U n i t e d S t a t e s t h e r e is one li censed physician for e v e r y 780 p e r s o n s . I t is i n t e r e s t i n g to n o t e t h a t in one of t h e m o s t i m p o r t a n t factors of h e a l t h control, n a m e l y t h e p r e v e n t i o n of child b i r t h m o r t a l i t y , S w e d e n is g r e a t l y ahead of t h e U n i t e d S t a t e s . I n E n g l a n d the ratio of p h y s i c i a n s to population is s l i g h t l y m o r e t h a n onehalf of t h a t found in t h e U n i t e d S t a t e s , the ratio in t h e former c o u n t r y b e i n g o n e to 1,490. I n t h i s connection it m a y be a p p r o p r i a t e to r e m a r k t h a t , in com parison w i t h g e n e r a l s t a n d a r d s of liv i n g a m o n g t h e middle-class p o p u l a t i o n s of t h e t w o countries, t h e a v e r a g e social a n d e c o n o m i c s t a t u s of t h e E n g l i s h physician is p r o b a b l y s u p e r i o r to t h a t of his A m e r i c a n colleague. T h e r e are p a r t s of t h e U n i t e d S t a t e s in w h i c h t h e relative n u m b e r of p h y s i -
EDITORIALS cians is greatly below that for the whole country. Thus, Matas has shown that several parishes in Louisiana have only one doctor to 1,800 of the population. But, in the whole country, according to figures quoted by Bierring (American Medical Association Bulletin, 1934, volume 29, page 17), there is at present a surplus of approximately 35,000 physicians, and, in spite of greatly im proved standards and requirements for medical education, the oversupply is steadily increasing. While the economic problems of the medical profession have been intensified during the financial depression of the last few years, the disturbing influences of an oversupply in the number of physicians were felt in times of general prosperity. In most individuals the ex act measure of honesty depends upon the pressure of circumstances. Econom ic desperation encourages the worst manifestations of fee splitting, un scrupulous and suicidal price cutting, the performance of unnecessary or dan gerous "services," and especially the at tempt to undertake surgical work for which the practitioner is not qualified. Bierring calls attention to a recent full-page advertisement in a Chicago newspaper, according to which more than three hundred Chicago physicians, surgeons, and dentists offer "complete eye, ear, nose and throat, heart and lungs, neurologic, gynecologic, roentgen, and laboratory examinations" at fees "so low as to be inconsistent with the type of service promised in the ad vertisement." In the long run, the public and the physician alike suffer from the demor alization created by oversupply. In the Province of Alberta, Canada, the situa tion has been met by passage of a law that no more physicians will be regis tered in the Province until the ratio of physicians to population has reached one in 1,200. Obviously such a remedy, taken alone, would not be generally ap plicable. Our own specialty has not escaped the destructive results of oversupply. From time to time we are assured that the number of well equipped ophthal mologists may be greatly increased
443
without creating an oversupply, but calculations of this sort lose sight of the fact that a great proportion of the com munity will never employ an ophthal mologist outside the walls of a chari table institution. Good refraction work was very poor ly paid for, even at the average prices prevailing before the financial slump. The opportunity to urge upon the pa tient unnecessary operations is certain ly more restricted in ophthalmology than in some other surgical specialties, but it is apt to be encouraged by an ex aggerated struggle for existence. Against artificial control of the num ber of physicians, it is argued that un der democracy there should be equal opportunity for all who wish to enter the learned professions. Yet in other matters bearing strongly upon public welfare it has been thought entirely proper to avoid destructive competition. Moreover, there is something to be said for the contention that, after the very great expenditure of time and money in volved in modern preparation for medi cal practice, the physician is entitled to some protection at the hands of the pub lic which he serves, and that the public owes itself the duty of seeing that its own share in the cost of medical train ing shall not be wasted. Entry to many important govern ment services is by competitive exam ination for which the number of en trants always greatly exceeds the num ber accepted. Many medical colleges are already rejecting a large percentage of those presenting themselves for ma triculation. This is chiefly upon the basis of limited accommodation and fi nancial resources. In principle, is there anything unsound in the suggestion that the total number of candidates for medical training throughout the whole country should be definitely limited from year to year in accordance with estimated need ? Sooner or later, in spite of all objec tions to centralization, the regulation of medical practice is likely to become a matter for federal rather than local con trol. In many respects it is certainly an interstate problem. In the meantime the question of oversupply will continue to
444
EDITORIALS
be studied by such organizations as the Commission on Medical Education, and the Council on Medical Education and Hospitals, of the American Medical As sociation. As a measure of voluntary control, it might be thought well to establish a na tional advisory board from which each year the medical colleges of the country would receive recommendations as to the number of matriculants to be ac cepted for the next college year. Alike for physician and patient, ex cessive dependence upon the law of sup ply and demand as regards the number of medical practitioners is likely to de velop more harm than good, and arti ficial control may prove necessary in the interest of all concerned. W . H. Crisp. MEETING AT SALT LAKE CITY The American College of Surgeons has nearly 2,000 Fellows who restrict their practice to ophthalmology and oto-laryngology. But the "General Sur geons," who control the policy of the organization, have been slow to recog nize that these "specialists" had as real and deep an interest in raising profes sional standards as those who under took operations on any part of the body, and claimed special right to the surgical prestige and traditions of the past. These leaders, impressed by the im portance of annual clinical congresses and the great numbers of surgeons brought by such congresses into opera tive clinics in the large eastern cities, have never been willing to undertake one of these annual gatherings west of the Mississippi River. But, to com pensate Fellows who live far from the eastern cities, for lack of opportunity to join the throngs that crowd the clinics of the Annual Congresses, Sectional Meetings have been established, where the Fellows who live in a group of states can have the advantage of seeing and hearing some of those who direct the affairs of the College from the cen tral office, and other prominent sur geons invited to these gatherings. Such a Sectional Meeting has been held for the first time in Salt Lake City, February 27 to March 1 inclusive. The
states constituting this section are Utah, Idaho, Wyoming and Colorado. A similar meeting was held previously in Oklahoma City; and others followed in Spokane, Los Angeles and Phoenix. These meetings all illustrate the real in terest and eagerness of the profession to utilize every opportunity for gradu ate study. The local specialists, with visitors from the adjacent states, at tended the meetings and clinics, in num bers greater than were gathered by either of the national special societies The clinics at the four approved hospi tals were given to presentation of cases by local men; which were then made subjects of questions and discussions by those present. A boy, blind with sympathetic oph thalmia, illustrated the special dangers of this disease to children. There was a case of alternating exophthalmos of high degree, associated with thyroid disease. The photography of cases was illustrated. Treatment of detachment of the retina came in for the usual discus sions. The most striking feature of the meeting was the evening meeting, on health interests for the public. This filled the Tabernacle, holding ten thou sand, and an overflow meeting of about fifteen hundred in another hall. It was the largest meeting of the kind ever held in America, and the audience stayed three hours to hear the ad dresses, which were given in both the auditoriums. Moving pictures made the people familiar with the work of hos pitals ; as, in the scientific sessions, they illustrated operations on the eye. Edward Jackson. INTERSTITIAL KERATITIS, A MODERN ANACHRONISM Interstitial keratitis is one of the most intractable and one of the least satis factory diseases to treat. It frequently reaches the ophthalmologist after the cornea has been so involved that the restoration of good sight is impossible. It is one of the most common causes of defective vision and of blindness. It is also one of the most preventable of the eye diseases.