Medicine: Nationalized Doctors?

(See front cover)

Only a handful of the 9,200 doctors who attended the convention of the American Medical Association last week at Atlantic City knew beforehand that President Roosevelt had been discussing a plan to Federalize their entire profession.

First intimation of that momentous idea occurred April 8 when the President sat down in the White House with three curious groups: 1) Mrs. Roosevelt and her friend Esther Everett Lape, manager of the American Foundation which Mrs. Mary Louise Curtis Bok finances out of Saturday Evening Post profits; 2) the Nation’s official doctors—Surgeon General Thomas Parran Jr. of the U. S. Public Health Service, Chairman Gary Travers Grayson of the Red Cross, and the President’s Personal Physician Ross Mclntire; 3) ten private practitioners, including Otologist Samuel Joseph Kopetzky of the New York State Medical Society, Surgeon Hugh Cabot of the Mayo Clinic, Internist Soma Weiss of Harvard, Internist John Punnett Peters of Yale, Syphilographer John Hinchman Stokes of the University of Pennsylvania, Surgeon Robert Bayley Osgood of Harvard.

The visiting doctors told the President that they had carefully studied a two-volume survey which Miss Lape had published three days prior. Called American Medicine—Expert Testimony out of Court* these books contained the recommendations of 2,000 doctors for remedying the state of U. S. Medicine, including the difficulties of sick people in getting good medical services and the difficulties of good doctors in earning a decent living. Deliberately omitted from those questioned were doctors who might have an ax to grind, such as the executives and trustees of the American Medical Association.

Gist of Miss Lape’s survey, said Dr. Osgood, who volunteered as spokesman for the President’s guests, was: 1) doctors want a Secretary of Health in the Cabinet, 2) doctors are willing to become executors of a Federal public health program which would look after the health of every U. S. inhabitant.

The President replied that he would not consider enlarging his Cabinet for the sake of any single pressure group like the doctors. He hinted, however, that he was considering this idea: that a sub-Cabinet officer like Josephine Roche, Assistant Secretary of the Treasury in charge of the Public Health Service, might well supervise all the public health and maternal and child welfare activities of the Government, now scattered in the Treasury, Interior, Commerce and Labor Departments.

As for socializing all doctors, the President told his guests to give him a plan which medical organizations, especially the A. M. A., approved. Dr. Kopetzky volunteered to develop such a plan.

Last week Dr. Kopetzky appeared at the American Medical Association convention with a set of public health axioms, based on Miss Lape’s survey and a survey by the New York State Medical Society. The A. M. A.’s executives and trustees were vigilantly prepared to balk Dr. Kopetzky’s plan—for the minor reason that Miss Lape had not consulted them, for the major reason that it predicated a drastic reversal of Orthodox Medicine’s most basic tenets.

Dr. Kopetzky’s axioms: the health of its citizens is the first concern of the State; indigence is a problem of a community and must be met out of taxes.

If the A. M. A. accepted these axioms as its own, Organized Medicine logically must accept the following corollaries: 1) Every one of the 150,000 U. S. doctors must become an officer in the Federal Public Health Service, the Government to pay for all the preventive medicine which they practice in their offices, such as immunizations against smallpox, diphtheria, typhoid.

2) Every person who expects to be unable to pay his doctor, nurse, drug or hospital bill must register with a Government bureau which will pay such bills out of tax money.

3) The Federal Treasury must pay the expenses of all public hospitals, and the deficits of all voluntary (supported by private charity) hospitals, and finance construction of new hospitals.

4) The Federal Treasury must pay the deficits of all first-class medical schools and subsidize the expansion of medical schools.

To orthodox doctors, Dr. Kopetzky’s plan (which was essentially Miss Lape’s) was startling. To orthodox doctors who pay taxes, as most of those present in Atlantic City certainly do, the plan was appalling.

Roared Dr. Morris Fishbein of Chicago, editor of A.M.A. publications and spokesman for medical orthodoxy: “The tradition of medicine since the earliest times has been one of service—a service dependent for its success in the curing of disease on mutual responsibility between the doctor and his patient. The American Medical Association has established principles which must govern this relationship between doctor and patient. The purpose of these principles is to maintain for the public the highest possible quality of medical service. As long as human beings are themselves not standardized it will not be possible to provide them with a standardized doctor. Every system of medicine and every change in the nature of medical practice which breaks down this relationship tends to lower the quality of medical service. It is characteristic of medicine, therefore, that it is practiced as an art and as a science, without any reference to hours of work or any fixed formula for its administration. These are the characteristics of the profession and the question which we must answer for ourselves and for the people is simply the question as to whether medicine shall remain a profession or become a trade.”

But the Kopetzky-Lape program embodied so much prudent common sense that for two days and a night some of the hardest heads in the U. S. wrangled. What would doctors get out of this? What their patients? Who would run U. S. medicine? A sentimental sociologist like Secretary of Labor Perkins or a political Relief Administrator like Mr. Hopkins? Or a doctor like Surgeon General Parran? Or a medical oligarchy like the A. M. A.’s Secretary-General Manager Olin West, Lobbyist William Creighton Woodward and Editor Morris Fishbein?

Air in the locked assembly room grew heavy from debate. Beards grew with the hours of the night. Sam Kopetzky & friends explained, reasoned, argued that: Doctors would get all their bills paid promptly. Family and clinic doctors would get certain, established fees. Specialists approved by medical societies would get higher fees. The Federal stipend would be the equivalent of a rebate on the taxes which they now pay the Government, and they would not be required to do any work for charity.

Patients would get the world’s best medical care, because they would not fear to consult a doctor on account of his bill. The Government would pay.

There probably would be a Secretary of Social Welfare in the Cabinet who might be a doctor, like Hoover’s Secretary of the Interior Ray Lyman Wilbur, Coolidge’s Hubert Work. There might be a sub-secretary in charge of health, analogous to President Roosevelt’s Josephine Roche.

Under the plan Government officials would simply be clerks to publish lists of fees for every medical service, keep books on expenditures. Doctors would continue to control the practice of medicine in the U. S. A board composed exclusively of doctors would pass on the qualifications of practitioners, nurses, hospitals and medical schools. Those boards would pass on the quality of medical practice, would discipline (with Federal authority) all quacks, malpractitioners, extortioners.

What doctors would control the boards was for the members of the American Medical Association to decide.

Into the dawn debates and dickers roared and muttered. By next noon the American Medical Association’s spokesmen officially came to this esoteric decision, which they sent to President Roosevelt: “The American Medical Association reaffirms its willingness, on receipt of direct request, to cooperate with any governmental or other qualified agency, and to make available the information, observations and results of investigation, together with any facilities of the Association.” This simply meant that Orthodox Medicine had succeeded in delaying matters until it could feel how the wind was blowing in Washington and arrange to fly in President Roosevelt’s slipstream.

As soon as the resolution was published, into Atlantic City popped the A. M. A.’s incredibly verbose Senate spokesman, whiskery little old James Hamilton Lewis of Illinois. This was his big moment to assure the doctors that he would take care of them in the parlous legislative future. Orated Senator ‘Lewis:

“As I left Washington I called the President and told him I was on my way to have a conversation with you gentlemen and I would like to deliver from the President of the United States a message coming direct with his authority. He said I was authorized to say to you he knew something of your meeting, he had been for some time observing the courses of the doctor necessarily, meaning (of course you know what he meant) that he was not far removed from constantly keeping up the features of the profession, and he wished you success as to your undertaking, and (if I use his exact words) he hoped that you would find a way to cooperate with him in such method as you would jointly find would be to the service of the helpless and afflicted within such province as you felt government should undertake. I deliver the message of the President and assure you it was a source of great pleasure that he understood I was to be here. . . .

“Do you know what is going to happen to you? You are going to have a sudden set of individuals who are shortly going to demand of you that there be a system of examination and application by the Federal Government upon every doctor of America to prove his right to be admitted to practice under the Federal law in addition to that which he is now enjoying under his local [State] acts. And then we will come about to the thing which I am utterly against and wholly abhor but which I tell you is on its way—the designation of a certain class of doctors named by the President or by some officers of the Federal Government who then become a board who are to pass upon their fellow doctors having the right to be admitted to be a practitioner under the Federal law.

“What method would you suggest as one of complete fairness to your profession concerning a system of appointees? . . .

“I have come to seek from you that you take charge of the subject and give advice to your Government, that you please offer counsel to us.” Senator Lewis then wiped his famous whiskers and stalked back to the train for Washington.

In Washington, President Roosevelt gently intimated that Senator Lewis was not the President’s spokesman in matters medical, that the White House at this time contemplates no Federalization of medicine. But Senator Hugo La Fayette Black of Alabama re-introduced a resolution for the Senate’s Labor Committee, of which he is chairman, to investigate or recommend legislation “to provide a national public health policy.” When such a resolution first was presented to the Senate, A. M. A. Lobbyist Woodward got it squelched. Now, said Senator Black, “the Association seems ready to co-operate.”

“The Association” meant Organized Medicine for whom Dr. Morris Fishbein speaks.

Dr. Fishbein. At various times, various types of doctors have personified the American Medical Association. At one time it was a William Osler, learned, sympathetic bedside physician. At another time it was an austere, didactic experimenter like Simon Flexner. Now it is worldly, alert Dr. Morris Fishbein who writes 15,000 words a week, makes 130 speeches a year, edits the A. M. A. Journal and Hygeia, manages nine A. M. A. special journals, is publishing a book Syphilis next month, is finishing Diet & Health and Curiosities of Medicine for publication this autumn. He syndicates a health column to 700 newspapers.

Two months ago, after a long hard session of work, Dr. Fishbein suffered an attack of Bell’s palsy. The right side of his face hung slack as a bloodhound’s jowls. Anna, his wife, “was frantic.” He went to bed at once. Neurologists tickled him with electric currents, and an orthopedist stripped his face in a brace. This supported his facial muscles until the nerves recovered and took charge of muscular tone. After three and a half weeks Dr. Fishbein recovered with no residual grimace.

He was born in St. Louis, raised in Indianapolis, educated in Chicago. Since childhood he speaks with a Hoosier twang, as does Anna Fishbein whom he has known since childhood. She accompanies him on all his trips around the country, and on the road acts as his personal secretary and purchasing agent (ties, shirts).

They live in a big stone house near the University of Chicago, crowded with books, children, guests and servants. They like important people and every significant U. S. doctor has visited them.

The Fishbeins have three children— restless Justin, 11, who wants to play the saxophone but is permitted an accordion; sociable Marjorie, 17, who frittered away so much time at Tulane University last year that her parents will not let her return; and serious Barbara, 22, who graduated from the University of Minnesota’s course in medical technology last Monday and is going to marry a bright young Minnesota graduate who just won a surgical fellowship at the Mayo Clinic, Dr. Morris Friedell, on July 3. That event, the marriage of his firstborn, last week had worldly Morris Fishbein, 48, paternally atwitter.

High politics aside, the A.M.A.’s 1937 convention was notable for several other events and reports:

Contraception Approved. Of greatest sociological significance was the A.M.A.’s formal approval of contraception. After 21 years of prodding by Mrs. Margaret (Higgins) Sanger (Slee) and two years of actual argument among themselves the doctors last week decided that contraception was now such a prevalent and accepted U. S. custom that it was prudent for the profession to take charge of the nation’s 342 Birth Control clinics and $575,000,000 commerce in contraceptives. Medical schools hereafter will teach “how to space babies to protect the mother’s health and the father’s bank balance.”

Roman Catholic priests instantly set up a violent denunciation of this decision. Father Ignatius Wiley Cox, professor of ethics in Manhattan’s Fordham University, rushed to Atlantic City, assembled 75 members of the Federation of Catholic Physicians Guilds of America in a room at Crane & Co.’s plumbing exhibit and promised to “advocate a Legion of Decency with regard to firms dealing in contraceptives and doctors approving their use.”

This put two potent U. S. doctors in moral soup. Surgeon General Thomas Parran Jr. is a devout Catholic. William Irvin Abell, president-elect of the A.M.A., is Louisville’s foremost and richest Catholic. Before Dr. Abell begins an operation he kneels and prays.

In Sulfanilamide, medical name for the new drug tradenamed Prontylin and Prontosil, doctors believe they have a phenomenal, all-around specific against many bacterial diseases. In Atlantic City, one Johns Hopkins group reaffirmed it as a specific for hemolytic streptococci, septic sore throat, scarlet fever, erysipelas (TIME, Dec. 28). Another Johns Hopkins group continued to find it a rapid cure for gonorrhea (TIME, May 17). Dr. Ralph R. Mellon of Pittsburgh said it cured “certain types of pneumonia, typhoid, brain abscesses, scarlet fever, meningitis.” Dr. Henry F. Helmholtz of the Mayo Clinic, summarized the opinion of the A.M.A. convention thus: “We have only scratched the surface of the potentialities of sulfanilamide. The results to date have been so startling as to be fantastic. We still don’t know what this new drug really can do until the chemists have isolated the fraction which really does the work against these bacteria. This drug has not shown its effectiveness against those germs which result in the heart diseases, but it has given results in infections caused by the relatives of the germs causing the heart diseases. In my opinion, therefore, it is not presumptive to hope that when this drug and its actions are better understood, we may forge a weapon even against the heart diseases.”

Whatever sulfanilamide’s value in medicine and whatever its manner of curing disease, doctors are afraid of it. They do not know how much of it to give. They do know that if they give too much they will cause a loss of white blood cells (agranulocytosis) which the human system needs to fight germs and repair injuries. An excess of sulfanilamide also destroys red blood cells, causing a devastating anemia.

*American Foundation, 565 Fifth Avenue, New York.