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Statement on Social Medicine

         by

      Alan Gregg

The issues and interests of social medicine center around the ques-

tions:

larger number of people?

phpicians and allied professional personnel?

ical care be controlled?

best administrator of a system involving the distribution of medical care?

In these questions there is general agreement that medical art and

What can be done to extend the benefits of good medical cnre to a

How can we best provide reasonable remuneration for

How should the mzrketing of med-

Is the individual physician the best judge or the

neclical science are extremely valuable when skillfully applied: that good med-

ical care is expensive; t'nat the quality of medical care and medical training

should not suffer.

ion, regarding such questions as:

for rendering care of good quality at reasonable cost?

the organization of medical care and who should fix the cost thereof and how it

shall be Faid?

cal care?

eqert to do a Job and then send a layman after him to see if it's well done.

But attitudes differ, expressed in varying shades of opin-

How can the physician's services be organized

Who should determine

And what ought to be the criteria or basis for receiving medi-

One is reminded of Napoleon's observation that you should send an

On the one side of the argument are those who accept, as they believe,

the lessons of the past.

that the relationship of physician to patient is prsonal and inviolable,

brooking no interference from outside, that the patient must be free  to choose

his &,ysician and the physician free to deal with his patient as he thinks best,

that the best government is no government, that modern man is rational, free and

They hold that human nature has always been the same,

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able to choose what is best for him and that he must live by the sweat of his

brow and not

seek protection from the State "from the

womb to the tomb."

On the other side are those who challenge the lessons of the 9st as

a sole guide for the potentialities of the p-esent, who believe t+ht the con-

ditions of medical practice, as well as its content, have changed and that new

arrangements are called for, that group practice provides better care than indi-

:Tidual practice, that medical care should be distributed more wisely,  more eco-

nomically and more efficiently by some measure of control fn its administration,

improvement of its quality and a collective responsibility for its cost.

********

That medicine has greatly progressed is a truism.

What is not under-

stood is that this progress has extensive corollaries.

offers two great advances:

detemined exactly; and the other, that many new forms of treatment have been

found to relieve or to cure diseases whose cause is known or still unknown. By

so much, too, as one bows the exact primary cause of the disease it has been

possible to recognize secondary or contributing causes. As an emqle, the

exact cause of what used to be called consumption is now known to be the tubercle

bacillus.

discovery of that bacillus and its role as a primary cause of tuberculosis.

hercrowding and the resulting inhalation of dried sputum 'became recognized as

a contributing or favoring secondary cause of the development of tuberculosis.

The treatment of cancer by radium or x-ray is an example of improved treatment

of a disease whose exact causation is still unknown. The number of diseases

whose precise causes have been discovered in the last fifty years is very large.

The number, also, of drugs or other therapeutic agents of proven efficacy has

Progress in medicine

one, that the causes of many diseases have been

The real fall in the rate of tuberculosis began shortly after Koch's

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also grown                    Thus the physician of today is equipped to

give semices that are at once more varied, more compehensive, and more pre-

ventive as we11 as more effective than in tines gone 3y.

to a formidable degree,

Blende& with the progress in the efficiency of medicine and surgery

md also mte&.ting it,

Christian tradition - of charity in giving medical aid to the poor and to the

unfortumte. This tradition is so obvious that we need not pause to establish

its reality, but rather proceed to note the way in which an evolution has come

to kospital services. There hrts been progress in the treatnent of the unfor-

tunate in hospitals. Hospitals have purchased eqensive equipment. Hospitals

have ilot only enabled but encouraged specialization, and the overhead expense

of costly equipment and specialization have found justification in hospitals by

the increase  in the volume of patients treated.

boards of trustees in hospitals in increased numbers and the ccareer of hospital

superintendent has been opened to laymen who have looked upon the hospitals'

efficiency in terms of cost and distrihtion of  services.  Hosi>itals started

from the motive of religious piety have emphasized of late pears business effi-

ciency.

scientific institutions rendering medical care to a11 groups of society.  This

change has not  failed to influence physici,ms and patients in their attitudes

toward disease. Not only has there been this change in hospital work, but con-

currently there have developed in the business life of the countrj the changes

that have characterized public utilities, which have slowly 5ut surely learned

that services of essential im2ortance to many citizens mst be rendered with an

eye to "public relations .tl

methods and the outlook of mass production, with its inevitable recognition that

nuns the hospital tradition - one might say the

Business men have come on the

Starting as charitable institutions caring for the poor they have become

Manufacturing has tended increasingly towards  the

4.

the weakest link is likely to be distribution rather than the costs  of manufac-

ture of a well-standardized product.

insurance has gained wider and wider acceptance, so that we see all around the

&rsician and his work examples of efficient organization in other fields of

activity that set interesting and at times cogent examples. If other forms of

loss and danger which strike unpredictably and unevenly can be mitiga.ted,why

c,am.cot illness costs be spread too by insurance?

In the past fifty years the principle of

Thus the doctor is faced with new preoccupations and responsibilities

which are in effect corollaries of his increasing masteq of disease.

past the physicianls services were  set in notion by pain or disability bringing

the patient to the doctor. 3Tow we see in increasing measure the doctor binself

deciding when and how to mobilize science in behalf of the lay ;xhlic before it

is either diseased or disabled.

assist his patient to reach an optimwn of performance - e.g., thc flight surgeon

tries to select and maintain optimum gerformance in the flier.  The nodern phy-

sician is not inclined to accept disease with resignation or fatzlintically.

His competence excuses him from so passive a role.

doctor's work was really uncertain, groping effort.  It was not highly technical

nor TJZS it very costly. Morris Fishbein says that 85 per cent of the cases seen

by t'ne ordinary doctor can be treated with what the doctor carries in his bag.

I doubt this statement since there is no question that therapeutic agents - x-ray,

bio-chemical tests, radium, surgical devices and the administration of effective

but dangerous drugs - are all more costly, more technical, more frequently used,

,ad more efficient thsln in kvs gone by.

ai accommodating.

sick in their hones.

In the

??e even see the concern of i%s Ihysician to

In the past mch of the

The old-style physician was generous

He spent much of his time on the way to and from persons

His practice was usually a general practice am3 his life

5.

and his relationships were individualistic.

sician, at least in the cities, works best in colla%oration, is himself special-

ized and exyects rightly that his patients will come to him or better to his

Groq for their diagnosis and their care.

reaches towards prevention, towards technical services and costly equipment,

toTiJards specialization, centralization and collaborative effort.

Nowadays it is obvious that a phy-

Certainly the trend of medicine

%at makes up medical care?

It has a personal aspect and a scientific

aslsct.

the -9atient's surroundings, his job, his ties, his ambitions, his feers, his

obligations, his past, his character. The scientific part of medical care con-

cerns the physician's control of the disease, its diagnosis,  treatment and the

prevention of spread or recurrence.  Scientific medical care depnds upon access

to and skill in the use of medicine, apparatus and laboratory ixocedure.

The personal side of medical care involves the doctor's bowledge of

     At the present time the rich get good personal care nearly always and

good scientific care usually.  The poor get good personal care only very rarely

but often good scientific care in the cities though in rural areas only in a

very small proportion of instances relative to their number,

gets good personal care usually and poor scientific care usually,  since it is

the foible of the middle class to insist on appearances at the expense of real

value,

Tne mifidle class

Now in the light of the present capscities of the doctor, the layman

eqects good performance from the doctor and the layman realizes that medical

conrgetence is dependent upon training and facilities and that both these cost

money.  The layman also expects that the physician's services will be available -

available in the double sense of being within reach of his purse and being

within reach of someboav's automobile, his own or the doctorls.

Just insofar, then, as medicine has secured reliable an6 efficacious

lmowlodge of the causes of diseases and of effective ways to cure diseases, the

&sician is now finding himself in a changed relationship to the rest of soci-

ety.  The old-school practitioner with services which made uy in patience, gen-

erosity, and sympathy, what they necessarily lacked in science and effectiveness,

is being succeeded by a doctor whose services are more effective, more real,

more business-like, more costly and yet more sought after.

has a more definable and more verifiable service to perform.

able to people and valuable to more people than before.

services are purchasable and yet almost beyond price they are coming to be

regarded like life, liberty and the -pursuit of happiness - a civic right, a

pblic necessity .

The modern physician

He is r.iore valu-

Because the doctor's

********

     The issues of social medicine pertain to the geographical accessibil-

ity and economic accessibility and to the organization and method of support of

medical services.  Obviously each of these factors influences the others.

the United States, tnough the  ratio of doctors to population is high,  it is not

uniform and the large cities show a far higher ratio of doctors to goplation

th the rural areas.

discrepancy between the availability of good medical care in city and country

constitutes a very serious criticism of the distribution of medical  services

to the population as a whole.  As to the economic availability of physicians

one notes the paradoxical fact that the average @ysician's income is too low

in relation to the cost  of his training and the value of his 2rofessional time.

Bnd yet the cost to the patient of medical services is higher than a large

proportion of the population cnn afford.

In

If one considers also such facilities as hospitals, the

In point of the organization of medical

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service the essential dispute concerns the freedom that a physician should have

to determine the conditions under which he will exercise his expertness.

than the mere geographical distribution of physicians, but closely related to

it, the major issues of social medicine concern the economics and the organiza-

tion of medical care.

More

In the light of these issues much of the demand for social medicine

comes very naturally from the lay public and the reluctance to change comes

largely from the conservative medical organizations.

services finds their distribution wasteful, inefficient and costly.  Not a few

physicians agree with this criticism since they see  the traditional and estab-

lished system failing to reach large numbers of the population, especially the

low and middle income groups and those living in the country.

too, that the traditional system fzils to reach the middle class adequately and

makes only rarely an economical use of the @yysician's long training and expen-

sive equipment.

The consumer of medical

They realize,

Why is it that  social medicine is discussed so incessantly and insist-

ently now,days? Several reasons exist for this:

for able-bodied young physicians have created a scarcity of doctors.

this, the growth of communities devoted to war industries has been swift and

disordered and the number of available doctors in such communities is danger-

ously low, thus calling for a better organization of the services doctors can

render.  Increasing taxation is reducing the margin from which hospital bills

rtnd 13hysicians' fees are paid and probably reducing the gifts received by volun-

tary hospitals from loyal and hitherto affluent donors.  Furthermore, physicians

have become accustomed in larger numbers to accepting salaried positions in

industries and in the government agencies created to combat the degresslon.

The demands of Army and Navy

             Added to

Certainly the success of group practice which has extended considerably since

its conspicuous demonstration at the Mayo Clinic has taught many physicians the

advantages of collaboration and specialization. Probably the full-time teach-

ing organizations in the medical schools have demonstrated the effectiveness
(indeed in some instances the ideal effectiveness) of medical grnctice under

varying degrees of supervision and control,

already conducting group practice.

forceful are those of the wartime demands and the increase in taxation. By so

much as these two conditions become intensified the likelihood of ch,ange in the

practice of medicine becomes more certain.

In effect the medical schools are

Of all these factors the most clamant and

What is the technique of social medicine? Just how would it work?

Perhaps the existing institution nearest in methods and technique to social

medAcine is a medical school's teaching hospital.  The doctors there are on

salaw, their work is specialized yet collaborative, by centralization of

resources it is economical, through supervision and professional control, both

explicit and implicit, the quality of service is protected.

however, would present the added feature of voluntary or obligatory preppent

on an insurance basis for the cost of medical care, and to a very nuch greater

degree thaa any teaching hospital social medicine would assume resgonsibilfty

for home care, home visits and protective or preventive care.

objective of socialized medicine is the welfare of each and all citizens: to

accomplish this the physicians would have to be decently paid and the quality

of their preventive, therapeutic and alleviating care would have to be super-

vised and controlled, the practice of medicine would have to be group practice

in and radiating from hospitals acting also as health centers and places for

educating the public.

Social medicine,

The controlling

There is no likelihood that private ?ractice would

9.

disap;2ear or be prohibited but it is certain that the great majority of persons

not now reached by competent medical care would receive it.

from buying medical care as individuals and from individuals will follow differ-

ent patterns.  The full-time teaching hospital service is the first step. Group

practice has already shown its value at the Mayo Clinic. Public health work as

a government activity is already established. Prepayment hospital insurance

against the costs of hospitalization is now gaining rapid and widesyread accept-

axe. Probably the next advances will be in a somewhat similar insurance set-up

to pay the services of physicians through voluntary agencies assuming some form

of control over the quality and distribution of the Boctors' work,  as well. as

guar=-teeing the stability of financing the cost. More detailed d.escription

cannot be forecast for social medicine is moving and changing in its concrete

objectives and implementation.

The transition

     Let us now turn to a variety of obstacles and objections to the meth-

ods and goals of social medicine. It night be noted that the o'ostacles are not

the  same as the objections as they are listed here, but both of course act as

deterrents to any quick, orderly and intelligent change.

Among the obstacles, perhaps the first lies in the fzct tnat incurable

disease  still exists in many and many an instance despite progress mentioned in

tile earlier part of this memorandwn.  When a patient has an incurable disease

he and his family are not going to be content with the course of events and a

reorg'mization of medical care runs the risk of offering a singxe target for

the disappointment and recriminations that previously have been addressed to

numerous physicians and surgeons indivibuwltly. Then there is the obvious fact

that change is met with reluctance and inertia in most fields of human endeavor.

In this instance the medical profession, which in the main has enjoyed public

10 .

confidence and freedon from interference, can voice its reluctance with a con-

siderable authority.

As a technical obstacle to the development of insurance

as a method of protection against the cost of illness, we have not until

recently possessed sufficient figures on normal morbidity rates.
lack experience to indicate the probable demand for &ysiciansl services -"_ -.- on

my new ~lan of (distribution.  These figures would provide the essential basis

for the organization of prepayment sickness insurance. Allom.nce nust be made

Ve still

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in the light of our general medical traditions for the dissatisfaction of some

patients who have hitherto had economic margin enough

to indulge in a relatively

free choice of their $ysi,cizn.

If it be admitted that social medicine will

require a larger nunber of practitioners or a wider use of the tine of existing

doctors then the examples of professional incompetence or inadequate training

will be cited as reasons against social medicine. Then, of course, it is true

that some of the ablest and most active physicians possessing great prestige

under the present system will face a loss of income and are ojJposed to change

for this reason, though they would greatly resent such an imputation as to

their motives. This in turn relates to the exceptional sensitiveness of the

average physician to critioism.

As has been said, "he is so surrounded by

frightened patients, adoring families and obsequious nurses that he is not

accustomed to having his opinion criticized by God or man."

Certainly in point

of polftical ,and Fblic relations doctors are at a considerable disadvantage,

especially in the United States where we have no General Medical Council to

re;xesent the interlocking interests of practitioners, public health officers,

-Urc*-rmb^- -

hospitals, boards of licensure and medical schools. In the United States each

of these inter-related groups concerned with medical. care has separate organ-

izations and the American Medical Association, though it has a section devoted

to medical education,  is in the main an organization representing merely a

summation of the opinion and interests of county and state medical societies

made up of private practitioners.

Among the objections to social medicine  is the insistence that it

would destroy freedom of the individual pkysician and the individual patient.

No less active as an objection is the distrust felt by physicians of the polit-

ical control and the concentration of power to determine the ways in which

medical care will be brought to the lay public.

medicine will increase the inherent %amptation of human nature to malinger, to

become dependent on government and to abuse the protection to be secured by

order of the physician.

group warn the public that man nust live by the  sweat of his brow and offer

other encomiums directed against the natural sloth and laziness of the human

race.

upn each physician a number of patients larger than he could give adequate

attention to, though this objection is bnsed upon the assumption that the num-

ber of physicians could not or should not be enlarged if the contention proved

valid.  Lastly, there is bitter resentment because lay critics seem to impugn

the motivation of the conservatives in rejecting social medicine and it is

insisted that the physician has always given an exemplary amount of his services

grat i so

It is predicted that social

Representatives of the conservative and- intransigent

Somewhat more tangible are the claims that social medicine would impose

Most of us can recall generous hard working unselfish doctors but the

fact remains that the lower half of the population in point of income  receives

scarcely half the amount of medical care per f,mily of that given to families
of $10,000 income.  There are said to be 50,000,000 people with incomes below
$1,000 annually, and another 50,000,000 between $1,001 and $2,500.  Certainly

12.

to these people decent and effective medical care at a cost of $100 to $120 a

yecx is not available .

      The above considerations cover most of the issues and interests of

social medicine. Insofar as medicine has secured new and reliable knowledge

of the causes of diseases and of effective trays to cure them, the doctor faces

a change in his relationship to his patients and the lay public generally,

status of the physicim is changing from that of being a private luxury to be-

coming a public necessity.

The

The ehanges taking place are curiously similar to those characterizing

the growth of the Fublic  school system in the United States.

free public primary and secondary education, later followed by free universities,

vas extraordinarily inclusive in its sweep. It, too, was a radical d-eparture

from the traditions of an earlier day. Public school education was challenged

by those who believed that education was an individual relationship and could

not be made a mass affair.

a high school education was decried as unbearable and its practicability denied

because of the inadequacy in numbers and training of teaching 17ersonne1,

have forgotten the long delays in the growth of public education, but after

more than a half-century of effort, growth and im:irovement there has come a

triumj?h for the original belief that a literate citizenry, even at a great cost,

is the best guarantee of a democracy.

more than suggest it) is a similar belief that ahealthy citizenry is an equally

iml3ortant gunrantee of a strong and effective nation.

The concept of

The cost of giving everyone a grammar school and

We

What is wanting (though wartime demands

June 7, 1943