Medicine and Citizen

Dr. Marshall, Chairman of the Department of Microbiology at the University of California Medical Center, speaks here as a citizen. Though neither physician, dentist, pharmacist, nor nurse, he has taught prospective members of these professions for more than thirty years. He also was associated for many years with the political centers of two large departments of public health.

If trends mean anything, the citi­zens of the United States soon may be voting on the question of social­ized medicine. The outcome of such balloting might well depend on an understanding of four ma­jor principles of medical relation­ships.

Let the first be labeled a princi­ple of indoctrination. With the same root as the word “doctor,” meaning one who teaches, “indoc­trination” has come to signify the installation of a doctrine in the recipient, an imposition; whereas teaching, akin to education, is a leading out process, a guidance of the individual functioning under his own power.

Physicians and those engaged in related medical professions traditionally have shown a reluc­tance to teach or indoctrinate their patients. Though health de­partments have long had bureaus of public health education, these formerly functioned largely as passive distributing centers. A school wanting information on how to brush teeth would be pro­vided with a chart, or a lecturer would be assigned if a women’s club wanted to know about vac­cines. But the initiative was in the hands of the citizens. News arti­cles about medicine used to be generally regarded as morbid, in­decent, impertinent, or unethical. The principle of indoctrination had not yet developed.

More recently, however, a public health bulletin confides, “the more attractive the group is to its mem­bers, the greater the influence that the group can exert on its mem­bers.” This exemplifies a complete change in spirit. The public health man becomes, by his own fiat, the Man Who Knows, and thus his real job is to indoctrinate the populace with this wisdom. Great­ly concerned when the populace does not accept his dicta, he won­ders in what way his methods of indoctrination are inadequate. Bigger and better campaigns are planned, not aimed at education but aimed at victory, the sale of his point.

Medical indoctrination is not limited to public health. At least three other groups of indoctrina­tors fire at us citizens.

One, the advertisers, are out to sell. Though seldom going outside of medical journals, they resort in­creasingly to high pressure ap­peals. Informing the medical pub­lic is a worthy goal, but selling the product has become a greater one.

A second category, the medical writers, vary in their output from excellent—such as Greer Wil­liams’ Virus Hunters, highly in­formative, not sensational, and in good balance—to articles which are no more than dramatic shock­ers or bits of ebullient and mis­leading optimism. Since medicine to the layman is more emotional than scientific, only the best in medical writing has any place, and even then spots for it are few.

A third group of indoctrinators are the medical men who write for public consumption in the news columns and editorial pages. The world has grown callous to such ballyhoo and the dangers of a lit­tle knowledge. Because medicine is complex, an unprepared mind cannot put in its place a brief com­ment in lay terms. Try to consider hemorrhage as a topic and keep out of trouble: internal, external, sign of disease, minor traumata, surgical, risks of infection, clot­ting, hemophilia—even to a lay­man the list of complexities mounts rapidly. Hypochondriacs may enjoy wallowing in morbid­ity, but there is no need to force it upon all of us.

The principle of indoctrination in medical knowledge, even in a sense of teaching, has little to sup­port it; but the trend is toward more and more of it.

Compulsory Participation

The second principle, allied in thought to indoctrination, is the principle of compulsory participa­tion. To what extent can, should, or does an organized medical inter­est impose itself on citizens by legal force? This question arises in matters of compulsory medical insurance, compulsory vaccination, school legislation, and even in the clinic.

In the clinic, however, the feel­ing of compulsion is minimal. No one forces the patients who go past my window to come into the clinic. They are examined and perhaps an operation seems wise; but it is suggested, not demanded. Pa­tients may be told to come back in a week, but not all do; and no one sends a policeman after them. Even when a physician tells a pa­tient to stop drinking lest he drop dead, that patient is on his own after the warning.

Compulsion is not part of the language or the way of life of trained physicians. In public health, however, are to be found all sorts of born missionaries, compulsive thinkers.

“The new state law requiring compulsory polio shots for school children will not go into effect un­til….,” says a recent news item. The matter is of particular inter­est to me, and I had followed it, but this was my first information that such a law was even being considered. The compulsive think­ers, annoyed at the slow response to their publicized campaigns, had moved very quietly to the legis­lative halls. Instead of raising the question to find the truth, their goal is to convince the legislators that they, the proponents, are right in knowing what is good for all of us.

In this instance, one of the most open questions about the use of polio vaccine is the effect it has on the distribution of the virus of poliomyelitis. The inactivated vac­cine is generally known to be in­effective in stopping the distri­bution, yet some communities have barred unvaccinated children from public schools. This is bigotry, not medicine.

The live vaccine operates differ­ently and in theory might block some distribution of the virus (it will not stamp out the disease), but it also offers new risks. Its effect on a whole population cannot be known for some years because polio, despite all the advertising, is still relatively uncommon. Its outbreaks or ups and downs are notoriously uncertain. Based on the record, the injection of salt solution the year before would seem to have been effective in many years. Is it not odd that the urge to make a vaccine compulsory is so often associated with prod­ucts which would seem to work successfully, regardless of their value? Consider, for example, that a lump of sugar, backed by a little ritual, would seem to prevent polio 9,999 times out of 10,000 on the average. That is pretty good bat­ting!

As for compulsory insurance, listen to the proponents as they try to play God. They claim, for instance, that some improvident folk will never take out insurance unless they are forced. The im­plication is that “of course you and I would not be so foolish.” Once on a time a U. S. citizen had a constitutionally respected right to be foolish, and a corresponding duty to abide by the consequences. We are developing a race in which everyone seems slightly annoyed at his own duties. Under this at­titude we are ready to save the other fellow’s soul at the drop of a hat.

In Whose Jurisdiction?

This brings us to a third cate­gory, the principle of trespass. One of the oldest debates in the realm of public medicine arose when federal agriculturalists, in charge of food and cows, found themselves embroiled in problems of health over which others claimed jurisdiction. Is the use of weed killers, sprays, preservatives, freezing methods, or milk from tuberculosis cows a problem for the Department of Agriculture or for the Department of Health, Educa­tion and Welfare? With no ab­solute answer demonstrable, polit­ical jockeying decides the issues.

In medicine the “general practi­tioner” is in a sort of gentlemanly opposition to the specialists: sur­geons, heart specialists, otorhinolaryngologists, ophthalmologists, and so on. But physicians are by no means so sure of the answers as they may seem.

True, distinctions among spe­cialists may rest on profound dif­ferences. A surgeon is likely to be a decisive person, a chooser of blacks and whites, whose decisions are as clean as his wounds: the leg may come off or it may not, but it will never come half way off. The general practitioner on the other hand, is likely to be more palliative, gray, less sure, more tolerant to theory, able to feel optimistic about treatments in which cause and effect are almost never clearly related as they are with the surgeon.

But most general practitioners call on specialists quickly when the going gets tough; and most specialists check on background, relating their tasks to the whole patient. In their puzzling and oft­en puzzled relationships with lay­men, physicians prefer not to tres­pass outside their fields even as much as they should.

Again, public health affords a prime exhibit of trespass. Public health education was pedestrian, so it shifted from education to indoctrination. Calling some of its problems essentially solved—safe milk and water, quarantine, marked reduction in tuberculosis, less spectacular epidemics—pub­lic health sought other fields of glory.

Does the health official admit that the perfect measure of his progress would be the rate of re­gression of his staff and duties? Not by a joyful! And so the health official seeks drama and a basis for expansion. He trespasses, grasping everything in medicine which is not tied down.

Property is condemned by a health department, unless the city officials own it—the same health department that moans because agriculture trespasses. Epidemics of measles still occur, but health officials rather scoff at such and talk preferably about the epidemi­ology of heart disease and cancer, problems strictly in the realm of physicians. They talk about auto­mobile accidents. Schools of pub­lic health, engaged in data-collect­ing—busywork which is always available for rainy days in all walks of life—take over statis­tics, a mathematical field notably unsafe out of the hands of mathe­maticians and not always safe then.

Organizational Problems

The fourth principle of opera­tional medicine is the principle of organization. Both “rugged indi­vidualists” and “organization men” tend to agree that we need (a) some answer to socialized medicine, (b) some outlook which will put hospitals on realistic foot­ing with medical practice, (c) some basis by which medicine can be kept in the hands of those trained instead of being trampled in legislative halls, and (d) some method for policing medicine.

From my ringside seat I have seen, I think, that medical men had pretty well ironed out the sociology of medicine. They are completely baffled by an uprising of a citizenry for which they have been caring, a citizenry which has little if any concept of the medi­cal problems involved.

Hospital bills are astronomical compared to the bills of physi­cians, for reasons some of which are crystal clear. Hospital in­surance, for example, is ungov­erned and means that neither doctor nor patients concern them­selves with needs and costs. Hos­pital administration, for another example, is garbled, because most doctors or other superintend­ents are not trained for hotel management.

As for nonmedical interference, consider New York, 1947. A man with smallpox came to town and went through streets, subways, stores, and hospital waiting rooms and wards. In the course of two months a dozen cases occurred; the first case and his wife died. A huge campaign led to some 6,000,­000 vaccinations in a few weeks. Only a few men claimed to know what was good for everyone; but the campaign was ruled by the Mayor, columnists, radio broad­casters, professional publicists who were weak in medicine, strong in causes and indoctrinations. The small outbreak, hardly deserving that name, killed fewer persons than the literally countless vac­cinations. Several hundred vac­cinations, if that many, would have restrained the spread (what spread?) of the disease, because this was 1947 and a high percent­age of the population had had vac­cine. The situation supported the normal vaccinating program; it was against hysteria. After spend­ing seven to twelve years in train­ing, on top of whatever years have been added by experience, a phy­sician in cases of public hysteria is literally not allowed to use his best medical judgment, the thing for which he is trained and paid. To his own mental tortures raised by the medical problem are added those unbearable additional ones which society imposes.

Policing of medicine has been tackled occasionally by the only proper policemen, the medical fraternity itself. Among 170,000 persons in any field, problems of discipline and policing are bound to arise. The rare medical groups which acknowledge this and at­tempt to do their own policing are very quiet; but the best police work is usually done quietly.

A noteworthy point about medi­cal practice is that patients do not have to inquire of Flunky A, who asks Manager B, who consults

Vice-President C, who phones to President D, who puts the question up to the Board of Directors. The patient gets to see the doctor, in person. This is the essence of medical practice, and it is signifi­cant.

Clearly, most physicians are not interested in organizational head­aches. I have faced over two thou­sand future M.D.’s in my classes and have seen many physicians in action. Almost to a man they are bored stiff by meetings of com­mittees. When they join in debates, they usually go directly to the is­sue. In their offices the patient, the physician, and the disease are paramount; neither person is in­terested in extraneous rituals. If doctors are not interested in the migraine brought on by emphasis on organization, can they be forced to function in it? I think not, successfully. They ignore it or rise above it, and go to a patient somewhere and talk about his mi­graine.

The generalization that phy­sicians are mercenaries is improp­er. Some of them make big in­comes. Now and then one of them fails to report all to the Internal Revenue officer, not necessarily deliberately, for income taxes re­quire organization. Even as stu­dents a few of them indicate that they will seek country club prac­tices and deal with patients with incidental chronic diseases, which bring in steady large incomes with no worries. But, as a group, a good case cannot be made that phy­sicians are mercenaries.

Beyond the shadow of doubt, their minds are filled with medi­cal problems most of the time. With certainty it can be said that most of them work long and odd hours, with rare vacations; being mercenary serves no purpose. The responsibilities they take, their relative availability, their period of training, their freedom of op­eration, the overhead carried in an office, the cost of equipment, their small but necessary payroll, all suggest that a substantial in­come is earned.

The Great Questions

With the two great questions, the status of public health and the status of socialized medicine, even with risks incidental to oversim­plification, conclusions seem con­spicuous.

Public health, as it stands to­day, is highly organizational, and physicians stand away. Their pa­tients are persons rather than pop­ulations. Public health as now managed calls for publicity, also anathema to physicians. It in­volves politics, still less desired. It calls for mass moves and com­pulsion, of debatable merit. Where­as public health originally stood for clean restaurants, understandable to and tolerated by phy­sicians, it has come to be a sort of maelstrom of unpredictable propa­ganda, not understandable at all.

Thus physicians do not under­stand public health folks, and vice versa. Several years ago a pharma­ceutical house discovered that, by advancing a product through pub­lic health instead of through the usual medical channel, they got free advertising and mass moves. Whereas public health stampeded prematurely for polio vaccine, phy­sicians then were saying quietly that they would like a few an­swers yet before giving it to their patients and families.

Public health might conceiv­ably be better off in the hands of physicians. Citizens could then perhaps pay for it, a prospect which seems so unlikely under policies of unlimited expansion. Matters which are strictly medi­cal would then have no interfer­ence from public health. Matters which are not medical in any way would be dropped or appropriately delegated. This suggestion, though radical, is not impossible. Public health is essentially a community affair, not a state or federal mat­ter. Doctors and patients intrin­sically are of the community.

As for socialized medicine, to­day’s compulsory approach is de­stroying the very practical and effective alternative we once en­joyed. The amount of wearing ef­fort or expensive time given away by physicians was colossal and is still significant.

Examine the effect of “social­ized medicine” on the hypochon­driacs who clutter up “free clin­ics” until physicians find ways to block them off; or weigh the best service of a physician who must sit up until midnight book­keeping instead of studying medi­cine, seeing a patient, or even re­laxing like other folk. Compare civil service employees as a so­cially bound class with those of a live organization, and then think of physicians as rule-bound em­ployees instead of as independent highly trained detectives on whom we depend for our lives. Weigh the rights of both patients and physicians and the degree to which they are stymied by organiza­tional maneuvers.

Without excessive organization and without noise, fuss, or feath­ers, physicians were doing fairly well until an untrained citizenry pointed its guns at them. So long as we have good physicians they will continue to smile and remain aloof in silence. When and if we should shift to mere trained tech­nicians and slaves of the state, medical efficiency would suffer basically for lack of the finest of all ingredients, the quality of those persons in the profession. The threat is already showing its ef­fects. The men and women of medicine inevitably make it what it is. Give them latitude and they will catch up with some criticisms; and we citizens may learn that many of our comments are unin­formed and narrow, invalid.

Medical men and women, hu­man and subject to the slings and arrows of the same fortunes that greet us, are the absolute best that we have to meet the physical woes which have to be met. They will remain our best bet so long as they are allowed the independence and dignity of a profession which, be it called noble or morbid, is one of our greatest needs.

 

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But They Found Freedom

Adults in George Washington’s time had no social security, job­less insurance, free food, socialized medicine, or public old-age assistance. Life was tough any way you look at it.