the outlook in medicine
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LONDON: SATURDAY, AUGUST 25, 1923.
THE OUTLOOK IN MEDICINE.THE prospect in medicine for the newly qualified I
man or woman has in these days become very wide,and we set out in the present issue signposts to anumber of different careers which may be chosen.The choice is largely a matter of personal bent, for inno single direction is there any doubt that averageability combined with diligence and good health willproduce an economic return. But the zest associatedwith any particular career will depend more thananything else upon the practitioner’s relation to hisenvironment. The true spirit of medicine is the loveof humanity associated with the love of craft, and thefree and unfettered practice of his craft has been
profoundly modified by the happenings of the last20 years. The relation between the State and thedoctor is changing ; apart from the fact that he maybe called upon to undertake official duties in the
public service, the doctor is liable under statute inthe following respectsl :—
1. He must certify births and deaths (Births and DeathsRegistration Act, 1874), and notify all births within 36 hours(Notification of Births Acts, 1907-15) ; he must notify casesof infectious disease (Infectious Diseases Notification Acts,1889 and 1899, and special notification regulations as issued),of industrial poisoning (Factory and Workshop Act, 1901),and of verminous children (Children Act, 1908). He mustalso be ready to vaccinate (Vaccination Acts, 1871-1907) and Ito certify the removal of infectious cases to hospital (PublicHealth Act, 1875).
2. He may be called upon to inspect and certify for housedisinfection (Public Health Act, 1875, and Infectious DiseasePrevention Act, 1890), and be prepared to issue certificatesfor the removal and burial of dead bodies (Ibid.).
3. He may be required to inspect and condemn in regardto nuisances and insanitary house property (Public HealthAct, 1875, or Amendment Act, 1907), or inquire into un-healthy or insanitary areas (Housing of the Working ClassesAct, 1890).
4. He must know something of the ill-effect upon health ofdangerous or offensive trades (Public Health Act, 1875), andof unsound food (Public Health (Unsound Food) Regulations,
I1908). ,5. He must be competent to diagnose all forms of mental
disease (Mental Deficiency Act, 1913).6. He must be available to respond to the requirements of
the local sanitary authority for the provision of medicalassistance and treatment for the poorer inhabitants of thedistrict in which he lives (Public Health Act, 1875, s. 133).
7. He is liable for a series of duties in regard to workmen’scompensation (Workmen’s Compensation Act, 1906, s. 8),superannuation, and pension claims (Ministry of PensionsAct).
8. He may be called in by a midwife to assist in cases ofemergency (Midwives Act, 1918, s. 25).
9. The local education authority may avail themselves ofhis services in connexion with the treatment of children andyoung persons (Education Act, 1918, s. 25).
Besides these obligations which no practitioner canescape there are others which he can voluntarilytake upon himself. Systematic provision has beeninitiated for tuberculosis, venereal disease, andmaternity and infant welfare ; the organised treat-ment of early mental affection, of orthopedic cases, andof industrial diseases is under discussion, while therational Insurance Act of 1911 brought at one stroke12 million insured persons into medical benefit, to beprovided under contract by some 12,000 doctors.The Act imposes obligations and privileges on both Isides which can hardly be enforced without continuous
1 Sir George Newman : Introductory Address at a meeting ofthe British Medical Association.
supervision, and this is distasteful2 to a body of com-petent and qualified medical men. Their voluntaryexclusion from this service does not imply " itsirremediable failure," but those who feel with thenon-panel advocate will not find congenial occupationwithin the boundaries of the Act, and should not try todo so. Submission to various kinds of interference is acondition of many of the careers enumerated. The
regime of the medical departments of the three fightingservices and of the Indian Medical Service, not asstrict as it was, is still precise, and in any branch of thePublic Health Service the doctor acts under theinstruction of his official superior, who is finallyresponsible to the Public Health Committee of the area,a body which may consist wholly of laymen, and fromwhich even the medical officer of health has no right ofdirect appeal to the council of which he is the servant.But the immunity of the individual practitioner from
interference is largely illusory. Individualism in the
past, desirable as it was in many respects, resultedin the sweating and exploitation of practitioners byfriendly societies and clubs, while any form ofcollective bargaining does away to some extent withthe liberty of the individual bargainer. The feeling ofindividual security received a rude shock two yearsago when an action was brought against an inde-pendent practitioner for alleged negligence in thetreatment of a fractured femur. Though evidencewas brought forward to show that the case was
treated on approved modern methods, the juryreturned a verdict against him with damages to theamount of 750, the total costs of the action amountingto 2250. The practitioner, being unprotected bymembership of any defence society, would havehimself incurred this great loss, had not the medicalprofession as a whole come to his aid and voluntarilycontributed a sum of over JE1730. Able himself tosmile at bad fortune, "for," as he wrote, "the Fatessingled him out to try his courage," the obviouslesson of his misfortune has not been lost, for the
present membership of the two English medicaldefence societies exceeds 17,500 and is increasing at therate of 100 or more a month. One of these societieshas now raised to E3000 the amount of damageagainst which the practitioner can insure, and thereis also a Scottish protection society. In the coroner’s
court, too, the individual practitioner must count on:appearing more frequently and on receiving at timesmuch greater attention in the lay press. No doubt,in all these matters the right course for the practi-tioner is " to preserve such a character that if accusedthe presumption will be in his f avour.’ 13 Nevertheless,he needs to be well versed in the laws of evidence andshould add to his r6le of well-informed and truthfulwitness some ophidian readiness in repelling hostileattack. For the conduct of practice itself the GoldenRule and the desire to do his best for his patient willsuffice; the less said about these obvious professionalvirtues the better, but we doubt whether the abortivediscussion of three years ago at the General MedicalCouncil on the teaching of medical ethics shouldnot be revived now that other urgent educationalmatters have been dealt with. Room in the cur-riculum might be found for instruction in the respon-sibilities of the medical man towards the State, andit is reasonable for the students to receive duringpupillage information upon the working of theMedical Acts and upon all rules and regulationswhich will form the conditions of any State serviceundertaken later.
2 Dr. A. Blackhall-Morison: " The Failure of the PanelSystem," The English Review, August, 1923.
3 Dr. Robert Saundby: "Medical Ethics," 1907.