I wish in this chapter to record the results of a study of the elements of an effective system of scientific medicine in the United States. The question is important and timely. Within the last quarter-century several hundred million dollars have been spent in the development and application of scientific medicine for our country. And yet the facts and rules which must govern a comprehensive and effective system are often misunderstood or ignored. Not a little misdirection and waste is due fundamentally to a profound and nearly universal misconception of the spirit and aim of medical science and research.
Their aim is by no means to multiply physicians, or hospitals, or medical schools. There are already too many of these, as we shall see. It is not more but fewer and better physicians, hospitals, and medical schools that we need. It is these only that will bring more and speedier cures of sickness, but even the beneficent work of curing the sick is not the primary aim of scientific medicine. Of course the sick want to get well, their distressed families want them to get well, and medical science will do its best to get them well. Could anything be better? Yes, one thing. Medical science has up its sleeve a higher aim still. Were it not better for the patient, instead of having been sick and cured, not to have been sick at all? By keeping well he avoids all the cost, suffering, and anxiety of his illness. By keeping well he enjoys all the employments, pleasures, and financial gains of continuous health. Even the layman can see that the fundamental aim of medical science must be not primarily the cure, but primarily the prevention, of disease. Such not only ought to be, but actually is, the conscious aim of medical science. It is to prevent sickness altogether. It is to usher civilization into a new world, a world at last of universal health.
Of course such an ideal is impossible of complete realization even in the remotest future. Though medical science were perfected, human frailty, folly, and crime would still be with us to bring sickness and suffering. But if preventive medicine can never prevent sickness wholly, it is certainly a hundred fold more effective than merely curative medicine could be, in reducing suffering to the minimum. It would be a mistake to imagine that all this is merely a pleasing flight into the clouds of speculation. Nothing is more concrete and actual.
I quote from the charter of the Rockefeller Institute:
“The object of said Corporation shall be to conduct, assist and encourage investigations in the science and arts of HYGIENE, medicine and surgery and allied subjects in the NATURE AND CAUSES of disease and the methods of its PREVENTION and treatment, and to make knowledge relating to these various subjects available for the PROTECTION OF HEALTH and the improved treatment of disease and injury.”
I have put the key words in capitals. They are first, Hygiene, which is the science of the protection of health; second, inquiry into the Nature and Causes of disease; third, Prevention of disease; fourth, Protection of Health. The treatment of disease and injury is recognized, as it should be all the way through, but always as secondary to the Protection of Health. In other words, Prevention of 111 Health.
Now if preventive medicine really and truly dominates the science, as I am saying it does, that fact ought to govern the daily activities of the research laboratories of the country. Let us go back to the Rockefeller Institute for a moment. The Institute studies the diseases severally. It first tries to trace each to its territorial source, or origin, then to trace the lines along which it spreads (frequently from East to West), and the vehicles by which it transmits itself; then how the disease may be prevented. When once this is ascertained, it becomes the duty of the Institute to proclaim the fact to all centres of medicine. Not a word as yet of cure. The forces of prevention are first set to work by all responsible agencies everywhere. Then at last comes the cure, when found, to be applied to such sporadic cases as have not been or cannot be prevented. The above is the logical order of procedure. As with the Rockefeller Institute so with all other general laboratories of research. It is preventive medicine that dominates the governing factor in any national system of medicine.
The medical school for teaching and research is perhaps the most important factor in any national system of medicine. The aim of the science of medicine being to promote the national health, such must also be the aim of every medical school which is truly scientific. The cost of such schools, with necessary grounds, buildings, and equipment, is very great, amounting as a minimum to at least Fifteen or Twenty Million Dollars each. It follows that they cannot be very numerous, for they must be located in the great centres of wealth.
Up to the year 1900, young men and boys were made into doctors in America by proprietary medical schools. Of these there were many hundreds. The property of each, usually trifling, was owned by a group of local practicing physicians. The school year ran from a few weeks to a few months. The schools were run for the personal prestige and private profit of the groups of physicians that owned them. The more students, the more the profit. Accordingly the requirements for admission were nominal at best, no more than a district school could furnish. Before the presidency of Dr. Eliot, some of the students admitted to the Harvard Medical School could not sign their applications for admission.
With the advent of medical science, practically all of our states required at least two years in college before admission to any medical school. These laws in twenty-five years reduced the number of medical schools from several hundred to about sixty, and of the sixty at least forty are needless. Twenty first-class medical colleges is all the country needs at present.
All modern medical schools must rely for their upbuilding on local wealth, and therefore must be located in cities. Besides, the colleges must have a great variety and abundant supply of purely local clinical material and this cities only can furnish.
We have always had in this country a great overplus of medical students. About six times too many youthful minds are naturally fascinated with medicine. Of these who begin the study about two-thirds are graduated into practice. This yields four times too many doctors. Also, the commercialization of medicine has much enlarged the overplus with fortune seekers. The staffer legal requirements for entrance and graduation into practice which went into full effect in 1918 proved to be no permanent deterrent to numbers. In 1900 we had one hundred and sixteen thousand physicians in the regular practice. We now have one hundred and forty thousand. This is for us at least two and a quarter times as many doctors, according to population, as any country in Western Europe. And this is true, notwithstanding the fact that we have far less sickness than France or Germany because we have carried sanitary science, preventive medicine, and public health far beyond those countries.
We have enough doctors—not too many, but enough—in the rural districts, contrary to the popular impression, as our reports on the distribution of physicians demonstrates, both for the North and South. The overplus is, therefore, wholly congested into the larger towns and cities. Into these the modern graduates crowd, in numbers four or five times too great.
We are wasting the energies of a hundred thousand educated men in a profession in which they are supernumerary, who might otherwise have been usefully employed in this busy country. In the cities, doctors average a clientele of less than one hundred families of five. Such congestion is a serious public and private menace, and a source of demoralization to the profession. I spare the reader the painful stories of the fraud and crime of the ever tempted and weaker brethren of the profession, which fill printed volumes, to be borrowed from medical libraries. It is the duty of the Rockefeller philanthropies to avoid increasing this congestion by any action of ours tending to increase the number or the output of medical schools.
The harmful overcrowding of the medical profession is emphasized by the fact that two physicians can now easily do the work of five, in 1900, and do it much better. It is the laboratory expert who now does the doctor’s laboratory work, and with advantage to his patients. The hospital, no longer a bugbear, groups his patients largely under one roof, with all assistants and appliances at hand. Scores of instruments of precision open to his eye every organ of the body in action. Trained hospital experts frequently make his diagnoses. The telephone, rapid transit, the automobile, multiply the territory he can cover, by five. Of five doctors in 1900, two can now do all the work, and the remaining three must suffer for practice. Our policy should look to decreasing this distress; by decreasing, if we can, the overplus of medical schools and the numbers they foster.
Sanitary science and preventive medicine, enforced by health boards, and by county, state, and municipal ordinances, sustained everywhere by enlightened public sentiment, have doubled the index of public health and reduced sickness in the United States by half, since 1900. This has cut down correspondingly the practice of physicians. Whether we study, as I have done, the mortality rates, or the causes of death, as reported by the United States Census Bureau, or the statistics of insurance companies, or the kinds of cases which now occupy hospital beds, or the comparative reports of general hospitals, in long series, or similar series of detailed statistics of health boards, the findings correspond, in indicating that since 1900 sickness has declined in the United States by fifty percent, thus reducing the practice of physicians by half. But unfortunately the output of our medical schools has greatly increased.
The indirect results of preventive medicine are found to be, to our surprise, scarcely less effective in promoting health than the direct results. Sickness is often followed by serious sequences and supplementary ills, and always by weaknesses that open the doors, for the time, to other diseases. By preventing an illness, we automatically cut off all these consequential ills, and they might have been both numerous and damaging. Thus health, in a way, becomes contagious, like disease. It multiplies itself. A great body of statistical information now available shows that the most common diseases throughout the nation, such as cancer, Bright’s, tuberculosis, and others, that are as yet unsubdued by science, are, by the wholly indirect results of preventive medicine, being steadily reduced every year. Here again the practice of physicians and the need of medical schools is being cut down.
Another important medical fact is that big business is reinforcing preventive medicine on a great scale. Health is found, in a variety of ways, by great employers, to be a profitable investment. Employers of great groups, mercantile, manufacturing, banking, are learning that it pays to have in attendance a medical staff, with periodical physical examinations and domiciliary visits. Labor also must now submit to periodic medical examinations, on pain of discharge. Insurance has awakened to the value of prevention for all risks, and offers all the insured free periodic preventive examinations. So also schools, from the ward schools to the University, are making provision, on the campus, for health and against disease. This preventive medicine will multiply its forms everywhere, and will be carried to the point of saturation, because in so many unexpected ways it is found to be profitable. This will give salaried employment to sanitary science and to some doctors, but it will cut down still further the practice of physicians, and their number, and the need of medical schools.
In modern American medicine the average doctor is having a hard time to make ends meet. Even the practice that is left to him is largely fictitious. I have been asking candid physicians about their practice for forty years. They freely say that nine-tenths of their family summonses are for ailments that are either imaginary or so trivial as not to require a physician. The prescription is of the bread pill order, and purely psychological. I by no means condemn this fictitious practice. The first visit is highly desirable, and legitimately provides the general practitioner with a small income. This partly answers the question how, despite the fraud of some and the extortionate fees of such as charge “all the traffic will bear,” there are still left upright physicians who manage to get bread and butter. Physicians need to be thinned out and not multiplied.
A basal fact in American medicine, a fact of revolutionary importance, a fact only recently discovered, is that the location of medical schools has no relation whatever to the distribution of physicians throughout the country. It has been assumed as axiomatic hitherto, that every region should have its own medical schools, in order to obtain its regional quota of family doctors. The recent publication of the General Education Board on the distribution of physicians shows this ancient tradition to be a complete fallacy. For illustration: the Rocky Mountain region from Canada to Mexico covers roughly not quite one-third of the area of the United States. That region has no clinical medical school. It has one physician for four hundred and ninety-eight people. The nineteen states east of the Mississippi, and north of the Ohio, including New England, have nearly half of the medical schools in the United States, and graduated three-fifths of the young doctors. Yet the average of physicians in the nineteen states was one doctor for six hundred and twenty-five persons, as against one for four hundred ninety-eight persons in the Rocky Mountain regions, with no medical school at all within a thousand miles of its center.
Doctors are footloose and migratory, and railroad fares are cheap. So sharp is the competition, and so congested with physicians are the centers of population, that doctors automatically distribute themselves, near and far, over the entire country, wherever they can find elbow room, or standing room, without the slightest reference to their birthplace or medical school. There is no state in this land, not even New York or Massachusetts, that could not lose at a stroke all its medical schools, without any diminution of practicing physicians within its own borders. Nor can any state—even Texas, Iowa, Wisconsin, Minnesota, Utah, Colorado, Washington, or Oregon—claim our aid on the basis of a regional need of physicians. Our boards have needlessly appropriated millions, many millions, on the regional illusion.
The science of medicine can be taught only in medical schools that have adopted the full-time or academic basis of organization. Historically, the schools that have not risen to the academic standards have been scientifically sterile. They do not breed scientific physicians. They are shams. Their history shows that they have not brought forth medical men of distinction, or made notable contributions to medicine. I have pursued Dr. Welch, and Dr. Simon Flexner for years, and recently Dr. Russell, with inquiries, and the exceptions are so few as to prove a startling confirmation of the rule. These medical schools are unable to impart the science of medicine because they do not know the science. But a wise man has said that medicine must always be either a science, or else a method of getting a living out of the confiding ignorance of one’s fellow men.
In 1919 Mr. Rockefeller gave the General Education Board Thirty- five Million Dollars for medicine. Since then the cry of the General Education Board has been for men properly trained in medicine. There is no basal fact in medicine more certain than that medical science in America, as always on the Continent, has been and can be taught only in schools that are on the academic basis. Our boards should make no contributions to medical schools which do not accept in advance the academic standards of our higher education.
Schedules of medical fees, generally fixed by law, sometimes by the medical guild, but fixed, are practically universal in Europe. Fixed fees are based on the principle that no two men, though one be a physician, have the right to bargain with each other about the life of either. Nor does it matter whether the bargain be made before or after the service, if the physician himself fixes the fee. The European principie of the fixed fee is based on the further fact that, whether the second party himself be sick or a member of his family be sick, he is helpless, he is no more legally competent to make a contract about the life in the balance than if he were held up by a highwayman. This practice of fixing his own fee in medicine and surgery granted to American physicians alone is scandalously abused by many, but endorsed and defended by the profession when summoned to testify in court. It is the greatest present American drawback to the usefulness of the science of medicine. For it confines the benefits of the science too largely to the rich, when it is the rightful inheritance of all the people alike, and the public health requires that they have it. If, as Johns Hopkins has done, the other leading schools adopt the fixed schedule, effective on their campus, public sentiment in no long time will enforce the schedules, if reasonable, throughout the country at large, and the greatest single service now possible to American health will have been performed.
The merest mention only can be made of the last basal fact, which is supplementary, covering graduate schools and specialties.
In research we have a great number of endowed laboratories, working exclusively on special diseases.
In post-graduate instruction, twelve institutions, among our best, have graduate schools, with instruction in all departments for ambitious physicians, and giving them higher degrees.
In specialties, thirty-two institutions besides the twelve give graduate instruction in forty-four specialties. Most of these instructions are confined to specialties and are not concerned with general practice.
In hygiene, public health, and preventive medicine, we have thirteen institutions giving special instruction.
These are powerful concurrent reinforcements to the science of medicine, without increase of medical schools, and constantly adding to the efficiency of medicine.
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The First Gates Lecturer: Robert Swain Morison, M.D.
Chapters In My Life 