1401 PROFESSIONAL DISCIPLINE
profession that does not discipline itself will find itself disciplined by outside forces. This truism seems to be now apparent to the medical profession here, and the A.M.A. is about to publish the report of a committee which has been considering the matter. Meanwhile, in the wake of reports of gross malfeasances in the Medicaid programmes, the horrors of the socalled "Medicaid Mills", and the successive indictments of practitioners and nursing-home operators and contractors, the axe has fallen-with the New York State Commissioner of Health banning some 30 physicians from taking any part in the Medicaid system. And this looks as though it is only the beginning of a trend likely to extend rapidly. Already the payments made to physicians from the Medicaid programme are being published in the local Press, and though such notices do not distinguish between payments to individuals and to groups of physicians, the enormous size of some of these payments has aroused public concern, not to say derision. The A.M.A. has protested against the disclosure of fees paid, and the authorities have agreed that the payment of very large sums is not necessarily excessive. But a hard-pinched public is a little sceptical, especially when it takes into account the many fraudulent practices and gross inadequacies of medical treatment that are being revealed. This scepticism is reinforced when the facts become known about the slowness and ineptitude of the machinery for dealing with incompetent, unethical, or even sick medical practitioners. Attention has been drawn to the fact that in Arizona between 1969 and 1973 disciplinary action was taken in 250 cases by the State Medical Board, as opposed to only 4 such cases in the District of Columbia, and 10 in Iowa-States with comparable numbers of physicians. There is no known evidence of the superiority of the ethical and professional standards in the latter States, but it is perhaps notable that Arizona physicians are by law required to report errant colleagues, and without evidence of malice such reports are not actionable. Of course if disciplinary steps are left to the small locality and are not overseen by larger authorities then little progress can be expected; we have fifty State boards, with different laws, the same number of State medical societies, a plethora of county medical societies, and thousands of hospitals. Add to this the tendency to inaction, foot-dragging, and interference by local and federal Courts, and the limited facilities for inquiry, and the present unhappy situation is understandable. No wonder that, in New York State, with its board meeting only once a month and a shortage of investigative staff and money, it took 2tyears to revoke a doctor’s licence. It did not take a fraction of that time for the Commissioner to exclude the physicians from Medicaid practice, and perhaps this is a portent for the future. After all, we have an incoming Administration pledged to bring in some form of national health insurance, and these pledges have been reiterated. The shortcomings of Medicaid, despite (or perhaps because of) its monstrous bureaucracy, have been revealed, so at least we know something of what to avoid. Should we ignore the portents, and do nothing to improve professional discipline, the Administration may well take it upon itself to decide who shall and who shall not be allowed to provide the services. A
THE BARS GO UP
For years past
we
have been concerned with
physician
shor-
tage ; maldistribution has compounded the shortage, but there has been good evidence that there were simply not enough physicians
to
to
medical schools, and any resisters will have their Federal aid short. This has brought the deans of medical schools up to boiling point, for they have long been annoyed by congressional interference in their affairs. Some may resist the imposition, but beggars cannot be choosers, and the financially hardpressed will have to accept, however reluctantly. Finally, the bars are being put up against the admission of F.M.G.S, at least into the training cadres; eminent specialists may be admitted by invitation to fill vacancies which might otherwise go unfilled. It seems that after January, 1977, it will be difficult for any F.M.G. to enter this country except for a strictly limited time as a student or visitor. So in a few years time all will be well. We shall be turning out enough physicians to meet all the needs, they will be well distributed all over the country by means of positive incentives, they will be chiefly interested in primary care, and we shall not be needing F.M.G.S. It sounds too good to be true. cut
Christmas
Quiz
ANYONE READ THE LANCET? How well have you read The Lancet in the past year? 1. A hospital was lifted-a Herculean task. Where? 2. What, literally, rose from 1.3 to 4.3 in forty-five
years? 3. What is Ondine’s curse? 4. What are "regrettable necessities, and to be done without when they reasonably may"? 5. What price did the Russians put on William Harvey? 6.... and who played Harvey’s hands? 7. Kew this summer was the driest since when? 8. For what did the woodpecker model? 9. Who was the American Sydenham? 10. What does the Brahmin call his sacred thread? 11. In what did Sir Squire catch the beauty from Camberwell ? 12. Who said "but why think, why not try the experiment" ? 13. How did a peripatetic doctor diagnose his chest pain? 14. What operation symbolised Nurse Ratched’s victory? 15. What was Fanny’s "doleful ditty"?
distribute. So medical school enrolments have been
increased, many students, of high calibre but unable to gain admission here, are seeking to qualify in schools in other countries, and to meet urgent and pressing needs foreign medical graduates have flooded to this country, some to gain experience and
part of the medical services the people of this country have sought, while large numbers of such F.M.G.s are in the training grades supported by Federal money. But quite abruptly there has been a turnabout. The Carnegie Council on Policy Studies in Higher Education has issued a report with warnings of dangers ahead. It thinks we are developing too many new medical schools, that with the increasing output of students from existing medical schools and the return of those who have been forced to seek training abroad, the country’s needs for physicians can be met, and that we should cease to rely on F.M.G.s. Some go further and envisage that in a few years time there will be hordes of unemployed physicians roaming the country seeking work, and ripe for all sorts of mischief. They might form a sort of medical proletariat capable of being exploited by the Federal Government to correct maldistribution of physicians in ways that have been found unacceptable in the past. So we are to get ready for changes. The student exiles are to be tempted home and foisted willy nilly on the existing
return to
settle here.
their
own
country,
a
considerable number a great
Foreign medical graduates have provided
A prize, the game Advice (see In England Now this week ) will be awarded for the three most nearly correct solutions. Incomplete entries are eligible. Entries, which should be marked Christmas Competition and sent to the London office of The Lancet, will be held unopened until Monday, Feb. 7, to allow overseas readers to enter.
profession that does not discipline itself will find itself disciplined by outside forces. This truism seems to be now apparent to the medical profession here, and the A.M.A. is about to publish the report of a committee which has been considering the matter. Meanwhile, in the wake of reports of gross malfeasances in the Medicaid programmes, the horrors of the socalled "Medicaid Mills", and the successive indictments of practitioners and nursing-home operators and contractors, the axe has fallen-with the New York State Commissioner of Health banning some 30 physicians from taking any part in the Medicaid system. And this looks as though it is only the beginning of a trend likely to extend rapidly. Already the payments made to physicians from the Medicaid programme are being published in the local Press, and though such notices do not distinguish between payments to individuals and to groups of physicians, the enormous size of some of these payments has aroused public concern, not to say derision. The A.M.A. has protested against the disclosure of fees paid, and the authorities have agreed that the payment of very large sums is not necessarily excessive. But a hard-pinched public is a little sceptical, especially when it takes into account the many fraudulent practices and gross inadequacies of medical treatment that are being revealed. This scepticism is reinforced when the facts become known about the slowness and ineptitude of the machinery for dealing with incompetent, unethical, or even sick medical practitioners. Attention has been drawn to the fact that in Arizona between 1969 and 1973 disciplinary action was taken in 250 cases by the State Medical Board, as opposed to only 4 such cases in the District of Columbia, and 10 in Iowa-States with comparable numbers of physicians. There is no known evidence of the superiority of the ethical and professional standards in the latter States, but it is perhaps notable that Arizona physicians are by law required to report errant colleagues, and without evidence of malice such reports are not actionable. Of course if disciplinary steps are left to the small locality and are not overseen by larger authorities then little progress can be expected; we have fifty State boards, with different laws, the same number of State medical societies, a plethora of county medical societies, and thousands of hospitals. Add to this the tendency to inaction, foot-dragging, and interference by local and federal Courts, and the limited facilities for inquiry, and the present unhappy situation is understandable. No wonder that, in New York State, with its board meeting only once a month and a shortage of investigative staff and money, it took 2tyears to revoke a doctor’s licence. It did not take a fraction of that time for the Commissioner to exclude the physicians from Medicaid practice, and perhaps this is a portent for the future. After all, we have an incoming Administration pledged to bring in some form of national health insurance, and these pledges have been reiterated. The shortcomings of Medicaid, despite (or perhaps because of) its monstrous bureaucracy, have been revealed, so at least we know something of what to avoid. Should we ignore the portents, and do nothing to improve professional discipline, the Administration may well take it upon itself to decide who shall and who shall not be allowed to provide the services. A
THE BARS GO UP
For years past
we
have been concerned with
physician
shor-
tage ; maldistribution has compounded the shortage, but there has been good evidence that there were simply not enough physicians
to
to
medical schools, and any resisters will have their Federal aid short. This has brought the deans of medical schools up to boiling point, for they have long been annoyed by congressional interference in their affairs. Some may resist the imposition, but beggars cannot be choosers, and the financially hardpressed will have to accept, however reluctantly. Finally, the bars are being put up against the admission of F.M.G.S, at least into the training cadres; eminent specialists may be admitted by invitation to fill vacancies which might otherwise go unfilled. It seems that after January, 1977, it will be difficult for any F.M.G. to enter this country except for a strictly limited time as a student or visitor. So in a few years time all will be well. We shall be turning out enough physicians to meet all the needs, they will be well distributed all over the country by means of positive incentives, they will be chiefly interested in primary care, and we shall not be needing F.M.G.S. It sounds too good to be true. cut
Christmas
Quiz
ANYONE READ THE LANCET? How well have you read The Lancet in the past year? 1. A hospital was lifted-a Herculean task. Where? 2. What, literally, rose from 1.3 to 4.3 in forty-five
years? 3. What is Ondine’s curse? 4. What are "regrettable necessities, and to be done without when they reasonably may"? 5. What price did the Russians put on William Harvey? 6.... and who played Harvey’s hands? 7. Kew this summer was the driest since when? 8. For what did the woodpecker model? 9. Who was the American Sydenham? 10. What does the Brahmin call his sacred thread? 11. In what did Sir Squire catch the beauty from Camberwell ? 12. Who said "but why think, why not try the experiment" ? 13. How did a peripatetic doctor diagnose his chest pain? 14. What operation symbolised Nurse Ratched’s victory? 15. What was Fanny’s "doleful ditty"?
distribute. So medical school enrolments have been
increased, many students, of high calibre but unable to gain admission here, are seeking to qualify in schools in other countries, and to meet urgent and pressing needs foreign medical graduates have flooded to this country, some to gain experience and
part of the medical services the people of this country have sought, while large numbers of such F.M.G.s are in the training grades supported by Federal money. But quite abruptly there has been a turnabout. The Carnegie Council on Policy Studies in Higher Education has issued a report with warnings of dangers ahead. It thinks we are developing too many new medical schools, that with the increasing output of students from existing medical schools and the return of those who have been forced to seek training abroad, the country’s needs for physicians can be met, and that we should cease to rely on F.M.G.s. Some go further and envisage that in a few years time there will be hordes of unemployed physicians roaming the country seeking work, and ripe for all sorts of mischief. They might form a sort of medical proletariat capable of being exploited by the Federal Government to correct maldistribution of physicians in ways that have been found unacceptable in the past. So we are to get ready for changes. The student exiles are to be tempted home and foisted willy nilly on the existing
return to
settle here.
their
own
country,
a
considerable number a great
Foreign medical graduates have provided
A prize, the game Advice (see In England Now this week ) will be awarded for the three most nearly correct solutions. Incomplete entries are eligible. Entries, which should be marked Christmas Competition and sent to the London office of The Lancet, will be held unopened until Monday, Feb. 7, to allow overseas readers to enter.
