The State And The Medical Profession
( Originally Published 1918 )
AT INTERVALS during the last quarter of a century committees of the Houses of the Legislature and specially appointed commissions have occupied themselves with the affairs of the medical profession. Much evidence has been taken, much wrangling has gone on over the reports of these bodies; and sometimes much trouble has been taken to get measures based upon all this work through Parliament, but very little has been achieved. [an error occurred while processing this directive]
The Bill introduced last session was not more fortunate than several predecessors. I suppose that it is not right to rejoice in the misfortunes of anything, even a Bill; but I confess that this event afforded me lively satisfaction, for I was a member of the Royal Commission on the report of which the Bill was founded, and I did my best to oppose and nullify that report.
That the question must be taken up again and finally dealt with by the Legislature before long cannot be doubted; but in the meanwhile there is time for reflection, and I think that the non-medical public would be wise if they paid a little attention to a subject which is really of considerable importance to them.
The first question which a plain man is disposed to ask himself is, Why should the State interfere with the profession of medicine any more than it does, say, with the profession of engineering? Anybody who pleases may call himself an engineer, and may practice as such. The State confers no title upon engineers, and does not profess to tell the public that one man is a qualified engineer and that another is not so.
The answers which are given to the question are various, and most of them, I think, are bad. A large number of persons seem to be of opinion that the State is bound no less to take care of the general public than to see that it is protected against incompetent persons, against quacks and medical impostors in general. I do not take that view of the case. I think it is very much wholesomer for the public to take care of itself in this as in all other matters; and although I am not such a fanatic for the liberty of the subject as to plead that interfering with the way in which a man may choose to be killed is a violation of that liberty, yet I do think that it is far better to let everybody do as he likes. Whether that be so or not, I am perfectly certain that, as a matter of practice, it is absolutely impossible to prohibit the practice of medicine by people who have no special qualification for it. Consider the terrible con-sequences of attempting to prohibit practice by a very large class of persons who are certainly not technically qualified—I am far from saying a word as to whether they are otherwise qualified or not. The number of Ladies Bountiful—grandmothers, aunts, and mothers-in-law—whose chief delight lies in the administration of their cherished provision of domestic medicine, is past computation, and one shudders to think of what might happen if their energies were turned from this innocuous, if not beneficent channel, by the strong arm of the law. But the thing is impracticable.
Another reason for intervention is propounded, I am sorry to say, by some, though not many, members of the medical profession, and is simply an expression of that trades unionism which tends to infest professions no less than trades.
The general practitioner trying to make both ends meet on a poor practice, whose medical training has cost him a good deal of time and money, finds that many potential patients, whose small fees would be welcome as the little that helps, prefer to go and get their shilling's worth of "doctor's stuff" and advice from the chemist and druggist round the corner, who has not paid six-pence for his medical training, because he has never had any.
The general practitioner thinks this is very hard upon him and ought to be stopped. It is perhaps natural that he should think so, though it would be very difficult for him to justify his opinion on any ground of public policy. But the question is really not worth discussion, as it is obvious that it would be utterly impracticable to stop the practice "over the counter" even if it were desirable.
Is a man who has a sudden attack of pain in tooth or stomach not to be permitted to go to the nearest druggist's shop and ask for something that will relieve him? The notion is preposterous. But if this is to be legal, the whole principle of the permissibility of counter practice is granted.
In my judgment the intervention of the State in the affairs of the medical profession can be justified not upon any pretence of protecting the public, and still less upon that of protecting the medical profession, but simply and solely upon the fact that the State employs medical men for certain purposes, and, as employer, has a right to define the conditions on which it will accept service. It is for the interest of the community that no person shall die without there being some official recognition of the cause of his death. It is a matter of the highest importance to the community that, in civil and criminal cases, the law shall be able to have recourse to persons whose evidence may be taken as that of experts; and it will not be doubted that the State has a right to dictate the conditions under which it will appoint persons to the vast number of naval, military, and civil medical offices held directly or indirectly under the Government. Here, and here only, it appears to me, lies the justification for the intervention of the State in medical affairs. It says, or, in my judgment, should say, to the public, "Practice medicine if you like—go to be practiced upon by anybody"; and to the medical practitioner, "Have a qualification, or do not have a qualification if people don't mind it; but if the State is to receive your certificate of death, if the State is to take your evidence as that of an expert, if the State is to give you any kind of civil, or military, or naval appointment, then we can call upon you to comply with our conditions, and to produce- evidence that you are, in our sense of the word, qualified. Without that we will not place you in that position." As a matter of fact, that is the relation of the State to the medical profession in this country. For my part, I think it an extremely healthy relation; and it is one that I should be very sorry to see altered, except in so far that it would certainly be better if greater facilities were given for the swift and sharp punishment of those who profess to have the State qualification when, in point of fact, they do not possess it. They are simply cheats and swindlers, like other people who profess to be what they are not, and should be punished as such.
But supposing we are agreed about the justification of State intervention in medical affairs, new questions arise as to the manner in which that intervention should take place and the extent to which it should go, on which the divergence of opinion is even greater than it is on the general question of intervention.
It is now, I am sorry to say, something over forty years since I began my medical studies; and, at that time, the state of affairs was extremely singular. I should think it hardly possible that it could have obtained anywhere but in such a country as England, which cherishes a fine old crusted abuse as much as it does its port wine. At that time there were twenty-one licensing bodies—that is to say, bodies whose certificate was received by the State as evidence that the persons who possessed that certificate were medical experts. How these bodies came to possess these powers is a very curious chapter in history, in which it would be out of place to enlarge. They were partly universities, partly medical guilds and corporations, partly the Archbishop of Canterbury. Those were the three sources from which the license to practice came in that day. There was no central authority, there was nothing to prevent any one of those licensing authorities from granting a license to any one upon any conditions it thought fit. The examination might be a sham, the curriculum might be a sham, the certificate might be bought and sold like anything in a shop; or, on the other hand, the examination might be fairly good and the diploma correspondingly valuable; but there was not the smallest guarantee, except the personal character of the people who composed the administration of each of these licensing bodies, as to what might happen. It was possible for a young man to come to London and to spend two years and six months of the time of his compulsory three years "walking the hospitals" in idleness or worse; he could then, by putting himself in the hands of a judicious "grinder" for the remaining six months, pass triumphantly through the ordeal of one hour's viva voce examination, which was all that was absolutely necessary, to enable him to be turned loose upon the public, like death on the pale horse, "conquering and to conquer," with the full sanction of the law, as a "qualified practitioner."
It is difficult to imagine, at present, such a state of things, still more difficult to depict the consequences of it, because they would appear like a gross and malignant caricature; but it may be said that there was never a system, or want of system, which was better calculated to ruin the students who came under it, or to degrade the profession as a whole. My memory goes back to a time when models from whom the Bob Sawyer of the "Pickwick Papers" might have been drawn were anything but rare.
Shortly before my student days, however, the dawn of a better state of things in England began to be visible, in consequence of the establishment of the University of London, and the comparatively very high standard which it placed before its medical graduates.
I say comparatively high standard, for the requirements of the University in those days, and even during the twelve years at a later period, when I was one of the examiners of the medical faculty, were such as- would not now be thought more than respectable, and indeed were in many respects very imperfect. But, relatively to the means of learning, the standard was high, and none but the more able and ambitious of the students dreamed of passing the University. Nevertheless, the fact that many men of this stamp did succeed in obtaining their degrees, led others to follow in their steps, and slowly but surely reacted upon the standard of teaching in the better medical schools. Then came the Medical Act of 1858. That Act introduced two immense improvements: one of them was the institution of what is called the Medical Register, upon which the names of all persons recognized by the State as medical practitioners are entered : and the other was the establishment of the Medical Council, which is a kind of Medical Parliament, composed of representatives of the licensing bodies and of leading men in the medical profession nominated by the Crown. The powers given by the Legislature to the Medical Council were found practically to be very limited, but I think that no fair observer of the work will doubt that this much attacked body has exerted no small influence in bringing about the great change for the better, which has been effected in the training of men for the medical profession within my recollection.
Another source of improvement must be recognized in the Scottish Universities, and especially in the medical faculty of the University of Edinburgh. The medical education and examinations of this body were for many years the best of their kind in these islands, and I doubt if, at the present moment, the three kingdoms can show a better school of medicine than that of Edinburgh. The vast number of medical students at that University is sufficient evidence of the opinion of those most interested in this subject.
Owing to all these influences, and to the revolution which has taken place in the course of the last twenty years in our conceptions of the proper method of teaching physical science, the training of the medical student in a good school, and the examination test applied by the great majority of the present licensing bodies, reduced now to nineteen, in consequence of the retirement of the Archbishop and the fusion of two of the other licensing bodies, are totally different from what they were even twenty years ago.
I was perfectly astonished, upon one of my sons commencing his medical career the other day, when I contrasted the carefully-watched courses of theoretical and practical instruction, which he is expected to follow with regularity and industry, and the number and nature of the examinations which he will have to pass before he can receive his license, not only with the monstrous laxity of my own student days, but even with the state of things which obtained when my term of office as examiner in the University of London expired some sixteen years ago.
I have no hesitation in expressing the opinion, which is fully borne out by the evidence taken before the late Royal Commission, that a large proportion of the existing licensing bodies grant their license on conditions which insure quite as high a standard as it is practicable or advisable to exact under present circumstances, and, that they show every desire to keep pace with the improvements of the times. And I think there can be no doubt that the great majority have so much improved their ways, that their standard is far above that of the ordinary qualification thirty years ago, and I cannot see what excuse there would be for meddling with them if it were not for two other defects which have to be remedied.
Unfortunately there remain two or three black sheep licensing bodies which simply trade upon their privilege, and sell the cheapest wares they can for shame's sake supply to the bidder. Another defect in the existing system, even where the examination has been so greatly improved as to be good of its kind, is that there are certain licensing bodies which give a qualification for an acquaintance with either medicine or surgery alone, and which more or less ignore obstetrics. This is a revival of the archaic condition of the profession when surgical operations were mostly left to the barbers and obstetrics to the midwives, and when the physicians thought themselves, and were considered by the world, the "superior persons" of the profession. I remember a story was current in my young days of a great court physician who was travelling with a friend, like himself, bound on a visit to a country house. The friend fell down in an apoplectic fit, and the physician refused to bleed him because it was contrary to professional etiquette for a physician to perform that operation. Whether the friend died or whether he got better because he was not bled I do not remember, but the moral of the story is the same. On the other hand, a famous surgeon was asked whether he meant to bring up his son to his own calling; "No," he said, "he is such a fool, I mean to make a physician of him."
Nowadays, it is happily recognized that medicine is one and indivisible, and that no one can properly practice one branch who is not familiar with at any rate the principles of all. Thus the two great things that are wanted now are, in the first place, some means of enforcing such a degree of uniformity upon all the examining bodies that none should present a disgracefully low minimum or pass examination; and the second point is that somebody or other shall have the power of enforcing upon every candidate for the license to practice the study of the three branches, what is called the tripartite qualification. All the members of the late commission were agreed that these were the main points to be attended to in any proposals for the further improvement of medical training and qualification.
But such being the ends in view, our notions as to the best way of attaining them were singularly divergent; so that it came about that eleven commissioners made seven reports. There was one main majority report and six minor reports, which differed more or less from it, chiefly as to the best method of attaining these two objects.
The majority report recommended the adoption of what is known as the conjoint scheme. According to this plan the power of granting a license to practice is to be taken away from all the existing bodies, whether they have done well or ill, and to be placed in the hands of a body of delegates (divisional boards), one for each of the three kingdoms. The license to practice is to be conferred by passing the delegate examination. The licensee may afterward, if he pleases, go before any of the existing bodies and indulge in the luxury of another examination and the payment of another fee in order to obtain a title, which does not legally place him in any better position than that which he would occupy without it.
Under these circumstances, of course, the only motive for obtaining the degree of a University or the license of a medical corporation would be the prestige of these bodies. Hence the "black sheep" would certainly be deserted, while those bodies which have acquired a reputation by doing their duty would suffer less.
But, as the majority report proposes that the existing bodies should be compensated for any loss they might suffer out of the fees of the examiners for the State license, the curious result would be brought about that the profession of the future would be taxed, for all time, for the purpose of handing over to wholly irresponsible bodies a sum, the amount of which would be large for those who had failed in their duty and small for those who had done it.
The scheme in fact involved a perpetual endowment of the "black sheep," calculated on the maximum of their ill-gained profits.' I confess that I found myself unable to assent to a plan which, in addition to the rewarding the evil-doers, proposed to take away the privileges of a number of examining bodies which confessedly were doing their duty well, for the sake of getting rid of a few who had failed. It was too much like the Chinaman's device of burning down his house to obtain a poor dish of roast pig—uncertain whether in the end he might not find a mere mass of cinders. What we do know is that the great majority of the existing licensing bodies have marvellously improved in the course of the last twenty years, and are improving. What we do not know is that the complicated scheme of the divisional boards will ever be got to work at all.
My own belief is that every necessary reform may be effected, without any interference with vested interests, without any unjust interference with the prestige of institutions which have been, and still are, extremely valuable, without any question of compensation arising, and by an extremely simple operation. It is only necessary in fact to add a couple of clauses to the Medical Act to this effect: (1) That from and after such a date no person shall be placed upon the Medical Register unless he possesses the threefold qualification. (2) That from and after this date no examination shall be accepted as satisfactory from any licensing body except such as has been carried on in part by examiners appointed by the licensing body, and in part by coadjutor-examiners of equal authority appointed by the Medical Council or other central authority, and acting under their instructions.
In laying down a rule of this kind the State confiscates nothing, and meddles with nobody, but simply acts within its undoubted right of laying down the conditions under which it will confer certain privileges upon medical practitioners. No one can say that the State has not of the right to do this; no one can say that the State interferes with any private enterprise or corporate interest unjustly, in laying down its own conditions for its own service. The plan would have the further advantage that all those corporate bodies which have obtained (as many of them have) a great and just prestige by the admirable way in which they have done their work would reap their just reward in the thronging of students, thence-forward as formerly, to obtain their qualifications; while those who have neglected their duties, who have in some one or two cases, I am sorry to say, absolutely disgraced themselves, would sink into oblivion, and come to a happy and natural euthanasia, in which their misdeeds and themselves would be entirely forgotten.
Two of my colleagues, Professor Turner and Mr. Bryce, M.P., whose practical familiarity with examinations gave their opinions a high value, expressed their substantial approval of this scheme, and I am unable to see the weight of the objections urged against it. It is urged that the difficulty and expense of adequately inspecting so many examinations and of guaranteeing their efficiency would be great, and the difficulty in the way of a fair adjustment of the representation of existing interests and of the representation of new interests upon the general Medical Council would be almost insuperable.
The latter objection is unintelligible to me. I am not aware that any attempt at such adjustment has been fairly discussed, and until that has been done it may be well not to talk about insuperable difficulties. As to the notion that there is any difficulty in getting the coadjutor-examiners, or that the expense will be overwhelming, we have the experience of Scotland, in which every University does, at the present time, appoint its coadjutor, examiners, who do their work just in the way proposed.
Whether in the way I have proposed, or by the Con-joint Scheme, however, this is perfectly certain: the two things I refer to have to be done: you must have the threefold qualification; you must have the limitation of the minimum qualification also; and any scheme for the improvement of the relations of the State to medicine which does not profess to do these two things thoroughly and well has no chance of finality.
But when these reforms are witnessed; when there is a Medical Council armed with a more real authority than it at present possesses; when a license to practice cannot be obtained without the threefold qualification; and when an even minimum of qualification is exacted for every license, is there anything else that remains that any one seriously interested in the welfare of the medical profession, as I may most conscientiously declare myself to be, would like to see done? I think there are three things.
In the first place, even now, when a four years' curriculum is required, the time allotted for medical education is too brief. A young man of eighteen beginning to study medicine is probably absolutely ignorant of the existence of such a thing as anatomy, or physiology, or indeed of any branch of physical science. He comes into an entirely new world; he addresses himself to a kind of work of which he has not the smallest experience. Up to that time his work has been with books; he rushes suddenly into work with things which is as different from work with books as anything can well be. I am quite sure that a very considerable number of young men spend a very large portion of their first session in simply learning how to learn subjects which are entirely new to them. And yet recollect that in this period of four years they have to acquire a knowledge of all the branches of a great and responsible practical calling of medicine, surgery, obstetrics, general pathology, medical jurisprudence, and so forth. Anybody who knows what these things are, and who knows what is the kind of work which is necessary to give a man the confidence which will enable him to stand at the bedside and say to the satisfaction of his own conscience what shall be done, and what shall not be done, must be aware that if a man has only four years to do all that in he will not have much time to spare. But that is not all. As I have said, the young man comes up, probably ignorant of the existence of science; he has never heard a word of chemistry, he has never heard a word of physics, he has not the smallest conception of the outlines of biological science; and all these things have to be learned as well and crammed into the time which in itself is barely sufficient to acquire a fair amount of that knowledge which is requisite for the satisfactory discharge of his professional duties.
Therefore it is quite clear to me that, somehow or other, the curriculum must be lightened. It is not that any of the subjects which I have mentioned need not to be studied, and may be eliminated. The only alternative therefore is to lengthen the time given to study. Every-body will agree with me that the practical necessities of life in this country are such that, for the average medical practitioner at any rate, it is hopeless to think of extending the period of professional study beyond the taught the institutes of medicine, in two or three central institutions, it would be perfectly easy to have those subjects taught thoroughly and effectually by persons who gave their whole mind and attention to the subject; while at the same time the medical schools at the hospitals would remain what they ought to be great institutions in which the largest possible opportunities are laid open for acquiring practical acquaintance with the phenomena of disease. So that the preliminary or earlier half of medical education would take place in the central institutions, and the final half would be devoted altogether to practical studies in the hospitals.
I happen to know that this conception has been entertained, not only by myself, but by a great many of those persons who are most interested in the improvement of medical study for a considerable number of years. I do not know whether anything will come of it this half-century or not; but the thing has to be done. It is not a speculative notion; it lies patent to everybody who is accustomed to teaching, and knows what the necessities of teaching are; and I should very much like to see the first step taken—people making up their minds that it has to be done somehow or other.
The last point to which I may advert is one which concerns the action of the profession itself more than anything else. We have arrangements for teaching, we have arrangements for the testing of qualifications, we have marvellous aids and appliances for the treatment of disease in all sorts of ways; but I do not find in London at the present time, in this little place of four or five million inhabitants which supports so many things, any organization or any arrangement for advancing the science of medicine, considered as a pure science. I am quite aware that there are medical societies of various kinds; I am not ignorant of the lectureships at the College of Physicians and the College of Surgeons; there is the Brown Institute; and there is the Society for the Advancement of Medicine by Research, but there is no means, so far as I know, by which any person who has the inborn gifts of the investigator and discoverer of new truth, and who desires to apply that to the improvement of medical science, can carry. out his intention. In Paris there is the University of Paris, which gives degrees; but there are also the Sorbonne and the College de France, places in which professoriates are established for the express purpose of enabling men who have the power of investigation, the power of advancing knowledge and thereby reacting on practice, to do that which it is their special mission to do. I do not know of anything of the kind in London; and if it should so happen that a Claude Bernard or a Ludwig should turn up in London, I really have not the slightest notion of what we could do with him. We could not turn him to account, and I think we should have to export him to Germany or France.
I doubt whether that is a good or a wise condition of things. I do not think it is a condition of things which can exist for any great length of time, now that people are every day becoming more and more awake to the importance of scientific investigation and to the astounding and unexpected manner in which it every-where reacts upon practical pursuits. I should look upon the establishment of some institution of that kind as a recognition, on the part of the medical profession in general, that if their great and beneficent work is to be carried on, they must, like other people who have great and beneficent work to do, contribute to the advancement of knowledge in the only way in which experience shows that it can be advanced.