LEGISLATION CREATING CIVIL POSITIONS FOR

PHYSICIANS.

By JOHN B. McALISTER, M.D., Harrisburg, Penna., President of the Medical Society of the State of Pennsylvania.

One of the best signs of the medical times is the awakening of the medical profession to the importance of its interests. Medical journals throughout the United States are publishing editorials and articles by leading physicians in which the question is asked "What is the matter with our profession?" The query differs slightly in the method of the asking, but recurs so continually that clearly enough something radically wrong exists between the profession we represent and the public.

The answer to the question: “What is the matter with the medical profession," is of vital moment for more than one hundred thousand physicians in the United States. They are all agreed that they do not receive adequate pay for the services they give the public-be that service rendered in the family, hospital or dispensary; whether they treat, investigate or prevent, not only the ordinary ills flesh is heir to but contagious or epidemic diseases.

In both hospital and private practice the physician is the chief ally of the Board of Health and other departments of the state to which he has to report all communicable, epidemic or industrial diseases, births and deaths, under a penalty of a fine for neglect; he is called upon to assist in the investigation of the various causes, treatments, and prevention of disease; to present his practical experience thus gained in recitations before his medical society, or to publish them in journals devoted to medical lore. Finally, he is expected to disseminate his accumulated knowledge among his patients for their use and benefit. He is a storehouse of scientific and useful information in health or sickness, which belongs to the public merely for the asking. He thus literally serves the state, but, unlike all other servants of the state, receives nothing for his services. On the contrary, every effort

he makes to prevent disease or to remove disease conditions helps to diminish his income.

As soon as a physician receives his coveted degree he becomes an interne in a hospital or an assistant in a dispensary. At the same time he becomes an altruist and a philanthropist, although these latter titles are not commonly recognized. Upon entering into practice, he begins his own destruction and annihilation, for in this age of preventive medicine whereby disease will ultimately be eliminated, the physician will be superfluous and the necessity for him will no longer exist.

Until that happy era for the public be attained, the physician may be excused if he be permitted to look a little to his interests, be they professional or legislative.

It is doubtful if the public ever would have had its attention called to the threatened plight of physicians, or if the physicians themselves had fully realized the precipice toward which they were trending had it not been for the fact that half of the total number of physicians in the United States had not organized themselves into the great and influential body known as the American Medical Association. This organization has been carrying on a campaign of education in order that the public may better understand what the modern physician is trying to do for humanity's sake and how he is hampered personally while earnestly trying to prevent and cure disease.

It is estimated that probably twenty to twenty-five per cent. of a physician's work is done for charity, either directly in dispensary or hospital work, or in private practice for which he is not paid. Thus it is that to-day the living to be made from the practice of medicine is a precarious one, due to the diminution of disease and the enormous amount of medical charity, expected and demanded from the physician.

If more civil positions with adequate remuneration were open to physicians, one of the greatest evils against our profession would be removed the doing of work gratuitously for which patients are able to pay. Why should not physicians be compensated as are other employees of hospitals and dispensaries? Since the time of Hippocrates the physician has been trained

to become an altruist, to treat fees with indifference, if not with contempt. This legendary custom, this noble but impractical idea, does not seem to square well with the 20th century needs.

Every community owes to the doctor more protection than it bestows upon him. Instead of giving him such protection, the laws of many states put him on an equal footing with quacks and clairvoyants. If the present indifference to the educated physician's rights continues, the profession of medicine will cease to attract men of noble ideals and good preparatory training, for in this work-a-day world compensation must be obtained to meet the physical wants of the individual. Conscientious folk will soon be forced to say to every young man or woman who has a hankering after medical study, "Don't." There are lots of other ways of making a comfortable living beside medicine. While it is the noblest of professions it is the meanest of trades. It must be admitted that the public obligations to physicians are constantly disregarded in the unjust discrimination against them by our lawmakers. Power to remove this stigma rests with the people. In ordinary times and for ordinary matters, the people delegate the law-making functions of the national, state or municipal legislative bodies: the administrative to administrative bodies similarly divided; and the judicial functions to the judicial machinery. In time of great emergency, however, such differentiation is swept aside, and action lies solely with the people. Is it too much to hope that through the campaign of education put forward by the American Medical Association, by its series of lectures given in many County Medical Societies, besides lectures to Women's Clubs, Mothers' and Teachers' Organizations, Young Women's Christian Associations, Church and Settlement Clubs (10,000 such lectures since 1909) will bring its reward, leaving the physician's case to be acted upon by the people whom he has always so self sacrificingly served?

Medicine is more and more becoming a function of the State and physicians soon must look to the State for their support. Who is to teach the people the great truths of preventive medicine except they? Are they asking more than their just rights

that the State who depends so largely upon them should pay them a living wage? Public health is a science and one to be carried on by scientifically trained minds. To handle the vital problems of public health, to wage the battle against the powers of disease, and the pain with which they torture mankind, physicians and surgeons must take their places in the forefront. They are the captains who order the fights, discover the vulnerable points, map out the campaigns and lead the forces on to the battlefield. Men must be trained for this important work, and having been trained, have a moral and legal right to be placed in positions where they must serve mankind by applying this training they have so expensively and painstakingly acquired.

The important point of contact between the Law, Medicine, and the State is the Public Health Service as supervised by State and Local Boards of Health. In order to meet the new conditions this entire system needs change, enlarging and strengthening. It is a significant fact that although local and State Boards of Health are so dependent upon and so closely allied with the medical practitioners of the City or State, yet but 6 per cent. of those employed by such Boards of Health are regular physicians. Can war be waged successfully upon disease until the whole medical profession is under control of the State? Until such a consummation be reached, it is vain to hope that every individual in the community can be subjected to proper medical inspection or receive adequate medical treatment.

Heroic measures are necessary if the health of the State becomes the important part of the State administration it deserves. One of the first and most important requisites is the immediate organization of every medical institution and clinic in every city under one head. This head should preferably be a State Health Commissioner and a strong executive. A Board, or Committee, or Bureau, or whatever any aggregate or individual may be called, is never as successful in executive work as one person to whom much power is granted, of whom much is expected. He may be called anything the State desires, but his province should be to appoint his subordinates, who, as far as possible, should be efficient physicians trained in public health, and then pay them

salaries adequate to permit them to give their entire time to the service demanded of them.

The only obstacle in securing such an executive is the part politics plays in the appointment of civil positions. If anyone can devise a plan whereby politics be removed from civil positions, especially those with fair salaries attached-what seems an impossibility will become an easy probability. It remains for the people to waken up to a realization that their executive should work for the State and not for any political party.

Several states have minimized political complications by giving the organized medical societies an important place in the administration of their Health Department. It must be admitted that satisfactory health work has been accomplished in some of these states and under such a system, but it must also be recognized that equally good work has resulted from other forms of organization in other states.

At present the head of the State Health Department is appointed by the Governor in less than a third of the States. This seems a good plan in that responsibility is thus centered upon one man; and on the other hand, every time there is a new governor the executive of this important Health Department may be removed an unfortunate possibility, for surely he gains an added usefulness to the people every year he holds office and should not be removed except for personal derelictions or manifest unfitness for the office.

A Board of Health exists in every State in the Union except one. The State Health Officer is elected by this Board, a custom which prevails in thirty states. Such selection of the State Health Officer does not entirely remove the office from politics, but it does lessen its chances of becoming part of the patronage sys

tem.

Local health officers and their subordinates must be good men, trained by the State in all that pertains to their positions. How they are selected is of great importance and their selection should be decided by each State by carefully drawn-up legislation. Such legislation should be intelligent, uniform and accurate.

Legislation should take notice of the fact that even the best