Chapter Nine. A Frustrated Profession

"Whatever crushes individuality is despotism, by whatever name it may be called." John Stuart Mill C H A p T ER N I N E A Frustrated Profession TIN every compulsory set-up, the overwhelming majority of the medical profession lives in a never-ending feud with the administrators and their political backers. The feud may be simmering at one time or erupting at another, but this domestic Cold War is being carried on by both sides with a bitter, time-consuming intensity that diverts a great deal of energy into a totally unproductive channel. A REVEALING The following conversation, in June 1949, CONVERSATION with a distinguished member of the Netherlands' "social" bureaucracy is worth re cording: - "How much do your general practitioners earn?" A. "They are paid a capitation of 4.68 florins for each potential patient registered with them." - "You mean to say that the doctor receives a per capita fee of about $1.60 a year in American money?" (This was before the September, 1949, devaluation. It is $1.10 at present.) A. "That's it exactly."

- "How can he live on that?" A. "You speak like a doctor. He can have as many patients as he can handle." - "How many general practitioners are there in the country and how many members in your panel system?" 80 81 ] A FausTRATEJ> PROPES SION A. "Out of the total population of9}-'2 millions, the panels cover 6" million people and there are about·" 6,000 prac titioners." - "That gives an average of 1,000 patients per panel doc tor, or an annual income of some $1,600 for each ($1,100 by now). Presumably some have more and some less patients which still leaves the question open on how they exist in view of the fact that the' cost of living in Holland, controlled as prices are, is not very much lower than in the United States." A. "Well, the doctors should get what they need from their private patients. There still are some' 3~ million people left who are not panel members." - "What about the doctor in a working men's district where everybody is registered? He cannot have many private patients to speak of?"

A. "Then the number of his panel patients is the greater. Some of them have 4,000 or more." - "If so, how much time can a practitioner devote to each of them?" A., "We figure on an average of three minutes per consul tation. What is wrong with that? An experienced physician does not need more time on the average." - "That includes the time devoted to paper work such as filling out forms for sending the patient to a specialist or to a hospital, writing out prescriptions, etc.?" A. "It does." THE Private practice constitutes the professional MEDICAL Frontier under govemmentalized medicine. (Hol FRONTIER land now is planning to extend the scheme to the farm.) As the Frontier shrinks, so -do the profession's chances to supplement its earnings from, outside panel practice. What is more, its bargaining power vis-a-vis the govemmentalized set-up shrinks. More and more physicians become economically weak. in the literal sense and have to accept the terms offered or imposed by an all-powerful monopolist. They face a single. organization that "bargains"

with them on behalf of the vast majority, if not the totality, of all patients. The resultis'accordingly disadvantageous to them.

COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 82 As a matter of fact, a major objective behind the drive to expand medical compulsion is often to strengthen its strangle hold on the profession, ultimately to force it into governmental service at more or less uniform, always at relatively low,salaries. That is one reason why a man of such anti-capitalistic make-up as Aneurin Bevan is anxious to extend his benevolence into the richest home: to eliminate the private patient, the doctor's economic "backbone." Observers could not fail to note a similarity between this process and the Soviet technique in forcing the peasantry of the Satellite countries into the com munized kolchos: first by monopolizing the market for farm products and then by squeezing their prices until the peasants surrender. ' The further the schemes expand, the greater the financial strain and the more imperative the necessity becomes to econo mize. Needless to say that in every democracy the economy axe tends to fall-another law of political "dynamics"-on the group with the least political, vote-getting power.

SUPPLY OF The ever-lasting conflict between the obliga DOCTORS tory schemes and the practicing doctors creates a new sort of.class struggle. The Nestor of the German social insurance administration is responsible for the recent statement that the Number One social problem of his country is the problem of the doctors' survival. This is no exaggeration so far as Germany is concerned. From about 27,000 in that whole country in 1900, the number of doctors other than dentists in the Western Zones alone has risen to over 60,000, probably the highest ratio to population (1 to 700) in the world, this for one of the world's most impoverished nations. Also, 20,000 medical students are being "processed" presently in Germany, compared with 22,000 in the United States. The German doctors' economic status has slumped accordingly. The German panel bureaucracy is an exceptional one. It does not build polyclinics or ambulatoriums and it sympathizes with the doctors, verbally at least. Elsewhere, the officials (and the politicians, including the trade union bosses) are more or less openly hostile to them. The physicians are being denounced as ruthless egotists who prefer their profits to their humanitarian duties. Swiss sick panel managers assured this writer that 15 per cent of the physicians are plain negligent on 83] A FRUSTRATED PROFESSION dp,ty, and 10 per cent outright fraudulent-.. meaning that they userpore medic!l devices chargeable to the panels than is ab solutely necessary for the benefit of the patients. In .France and Belgium, the doctors are considered by the administrators and.·their following·as the number. OIle.. ,sickness,of.the respec tive health schemes..Even in public it has been hinted candidly, and not quite without foundation, (e.g., by the "father" of.the Frenchsocialinsurance,the formersenatorAntonelli) that the profession's resistance against "regimentation" is due to the fear of losingits chances of income tax evasion once its incomes are controlled.!

The undisguised animosity with which a statesman like Bevan treats the professionand the extensivepropaganda of un diluted abuse his Party has carried on against them are matters of well-known records. In this respect, too, Bevan's attitude 2 is similar to that of his congenial 'predecessor, Lloyd ·George. PAUPERIZATION AND The J?u!ch docto:s'case seems to ~e BARGAINING POWER the bmlt to which the ,systematIc pauperization of doctors has gone so far. Already, they are fighting back, demanding-a ten cent higher capitation (per year!). But their chances are meager. They ask·for raising the members' contributions, or cutting the panel administrators' salaries, or, exacting a subsidy from an unwilling Parliament. It takes a very strong pressure·group to get any such results; and the doctors in Holland are not even a closelyknit group. The law of supply and demand has a measure of application on the market for doctors as well. ,The fantastic increase in the demand for medical servicesin this generation's lifetime sQ.ould have worked out to the profession's economic benefit. But the compulsory systemsnot only attract flocks of men and women into medical work, sharpening the intra-professional competi tion, but actually foster a mass-production of doctors, as in Germany. (In Russia, they multiplied 'from 19,800 in 1913 to 85,900 in 1934.) Moreover, th~physicians are faced with a monopolistic super-power which they can scarcely match by their .own organization. Their bargaining power is greatly re duced by the fact that they are,· "natural" individualists, not fitted for unionization. As professionals devoted to their life COMPULSORY MEDICAL CARE AND THE WELFARE STATE [ 84 work, they often are "naive" in matters of politics and as a rule lack political leadership. Both their professional ethics and the pressure of public opinion work to their disadvantage when they are challenged by political forces. The German Hartmann bund repeatedly has threatened to strike, but never dared. In public opinion, the doctor still is, or should be, something of a Samaritan who works for the benefit of humanity. (Just what would have been the Good Samaritan's attitude to an onslaught of distressed hypochondriacs?) Once the politicians arouse public opinion in favor of a scheme, or of its expansion, the objection of the profession even if unanimous-falls on deaf ears. Typical is this example from New Zealand: the "violent" resistance of the doctors against the introduction of a new scheme accomplished no more than to raise their fees slightly.3 "By some perversity of nature, many men and women who willingly accept the clinical opinion of their doctors refuse to listen to their critical opin ion," commented an English magazine on the lack of support for the doctors' resistance against Bevan. Possibly, the public senses that the doctors have a vested interest in the matter.

If so, their sensitiveness toward the vested interest of the poli ticians is much less acute. DOCTORS' The source of greatest weakness in· the doctors' SURRENDER position is the fact of their readiness to compromise. A minority of them actually advocates compulsion, and even the majority is willing to cooperate, if only on its own terms. That makes them suspected, of course. Instead of taking the position of principle, they argue about technicalities and honoraria, overlooking the public reaction. They overlook two more things, as a rule. Once the principle of compulsion is accepted, the amount and terms are not being determined by the doctors or upon their advice. And even if the terms conform at the outset with the professional proposals, the schemes expand sooner or later far beyond the original intent.. . In the recent case of Britain, one reason why the doctors' resistance broke was the fact of defection in the medical ranks themselves. When it came to the showdown on the Bevan scheme, 35 per cent of the profession, including the top leader ship of the British Medical and Dental Associations, capitu85 ] A FRUSTRATEDPaoFEssION lated. (A chief executive of the latter has been promptly pro moted to a high rank in the. Ministry of Health.) But· the majority was railroaded into submissionby the threat that those who did not sign on the dotted lin~ would lose all claim to com pensation for the capitaLvalue of their practices. Nearly 19,000 out of 21,000 doctors .and 9,000 out of 10,000 dentists have signed up. (The latter were lured into the scheme by the prospect of unprecedented incomes-which are fading out gradually. ) The moral of this story is that in the final analysis the doctors can blame themselves if they lose out-· if ·their incomes are reduced at once by 25 per cent on the average, as under Bevan, and their professional standards lowered in an unmeasurable fashion-. just as a' nation can blame itself if it foregoes its liberties, be it by submitting to intimidation or by letting itself be bribed into "collaboration."