The Future of Medicine 5 The Specialist

In every trade or profession there are specialists, men recognised either for special knowledge and experience in the whole subject with which they are concerned or in a particular branch of it.   It is clear that as any of man’s activities develop and especially those on a scientific basis, a certain number of men will tend to become specialists and their prominence in their particular pursuit should be the result: and not the cause of their specialist knowledge.   The larger the body of information concerning a scientific profession the greater will be the tendency for subdivision to appear and for men who have a general knowledge of the subject to acquire a position of especial eminence in one part.

There have been definite reasons why specialisation should have arisen in Medicine.  In the quite early stages of medical history there was a division of all those practising the profession into two  classes— physicians and  surgeons. The surgical side developed slowly, but after efficient anaesthetics had been discovered, and particularly with the advent of aseptic surgery, exceedingly rapid development in technique took place, and surgery itself became divided up as men specialised in certain operations or diseases, or sections of the human body.   Few people realise how many diseases may  afflict human flesh or how many exceedingly detailed surgical techniques are now used for dealing with each organ of the body.  At the same time as surgery was thus developed other branches of medical science, in particular bacteriology and the investigation of disease and its effects by biochemistry,  added many more specialists to the growing list of those concerned with healing.

Specialisation was further concentrated by the increase in the numbers of intricate instruments arid machines attached to each special branch. It thus became impossible for the man who was skilled in the use of the microscope for the isolation of germs to be equally at home or even familiar with diagnostic apparatus such as the electrocardiograph already described, or the modern X-ray plant, which requires a technique which is different for every part of the body and varies with every patient. Even if a man could carry out all the manipulations and calculations which these machines re­quire, unless he was constantly using them in the actual diagnosis of disease he would find the interpretation of the results beyond his powers. It has therefore come about that X-ray departments are usually quite separate from the rest of; the hospital, and the clinical pathologist with his apparatus for blood-counts and other technological procedures is to be found in a laboratory which other doctors still look upon with awe.

In addition Medicine has been particularly avid in its use of knowledge from sciences not primarily concerned with Medicine. The use of radium for the treatment of cancer has led to the employment of expert physicists; the search for means of identifying viruses, so minute as to be beyond the magnifying power of the finest microscope, has brought in the optical expert; the quest for vitamins and the isolation of hormones, those curious chemical compounds which in infinitely small amounts control our bodies, and the need for better drugs, have attracted to. Medicine skilled chemists in large numbers; the recognition of the importance of diet has produced new experts on food; the electrician has been called upon to contribute to diagnosis and treatment; in short medical research calls for the-co-operation of an army of people skilled in technological procedures which at first sight do not appear related to Medicine.

In surgical matters two points with general implications of great importance must be noted. On the one hand there has been a tendency to specialisation almost inconceivably detailed. The technique of surgery is much the same whatever part of the body has to be operated upon, but as surgeons have become more daring and as experience has shown how much the human body can stand, operations have developed to such an extent that even the finest general surgeon will admit that there are certain operations he does not care to tackle. An example is the surgery of the brain, which at one time was considered too delicate for surgical interference, but which in the hands of some of our modern experts is beginning to yield results comparable with those of other parts of the body. The brain is often the seat of tumours which greatly disturb the whole nervous system, producing paralysis, blindness, arid so on, but many of these can be removed with benefit to the sufferer. Superb technique is required as any­one with imagination can guess, to remove part of the skull, to open up the delicate membranes protecting the brain, to isolate and remove the growth, and to restore the tissues to a normal condition. While such operations call for the highest degree of specialisation, there are others in which growths are removed from vital organs and which call for the greatest skill and coolness.

In the second matter the surgeon illustrates the new spirit which is spreading to the whole of medical science and will provide a basis for the future. No surgeon works unaided, and in the operating theatre is to be seen the finest example of team-work shown in any profession. The assistant surgeons, the theatre sister with her knowledge of surgical technique and the instruments required for each operation;, as well as an understanding of the personality of the surgeon with whom she works, the theatre nurses whose duty it is to see that instruments and all other apparatus are sterile, and above all the anaesthetist, combine in a team which has the one aim— to reach a successful result with the minimum of shock and pain for the patient. The anaesthetist is also in many hospitals a specialist, for the day has long passed when the words “anaesthetic” and “chloroform ” were synonymous. Chemists have given us many substances which have miraculous power of suspending all sense of pain, and for long and difficult operations great skill in the use of these different drugs is necessary. The whole conduct of a difficult operation is a lesson in team-work, which suggests the true basis of Medicine.  With­out the deft, quiet, and assured hands of his assistants the surgeon could never hope to tie bleeding vessels, to remove the life-threatening growth, and restore tissues to normal function. Without the knowledge and experience of the surgeon the other members of the team could not hope to achieve their ambition of restoring the sick to health.

It should be noted that in the hospital maternity section team-work is also the keynote, for hospital babies are born under conditions in many ways analogous to those of the operating theatre. The obstetrical officer, the anaesthetist, the midwife, and the nurses are all at the service of the mother and the new-born infant. Under conditions like these and with the skill of obstetrical officers of long experience, mid­wifery becomes a very different affair from that of the general practitioner hurrying through the darkened streets with his midwifery bag to houses lacking in every facility and amenity. The public must not think of the country as the place where the doctor finds conditions in which normal healthy babies would seem impossible. It is in our great cities that houses exist without space, without air,  lacking water and means of  heating, and in squalor that is at once the cause and the effect of greater squalor.

Up to the moment we have used the word specialist without making any effort to define it.   It is indeed exceedingly difficult to give a clear definition which will cover every branch of Medicine and every section of the profession;   To most patients specialists or consultants, or “professors” as they are called in at least one part of the country, are physicians and surgeons called in to give a second opinion to the general practitioner, to operate, to indicate treatment, or to arrange for  hospital admission.   In another sense they are the doctors  “who occupy expensive consulting rooms in Harley Street and the corresponding neighbourhoods in large provincial towns and receive large fees each time they are consulted.” Used in this way, as Britain’s Health gives it, “the terms consultant and specialist therefore have no standard technical application and do not necessarily imply possession of any higher medical qualifications.” Despite this most of them, and in particular those whose specialty is a very narrow one, are men who either are or have been on the honorary staff of a voluntary hospital as consultants in a particular subject, A specialist should, moreover, stick to his own consultative work and see patients only when called upon by the patient’s own doctors.

The; consultants are the section of the profession which earns the highest Incomes; and it is generally recognised that this position is best obtained by an appointment as an honorary. Indeed this has been said to be “the hall-mark of the consultant,” and those who read A. J. Cronin’s book TheCitadel may remember his vivid description of: the astonishment and perplexity with which the hero discovered that some very wealthy Harley Street friends had apparently built up their practices without this hall mark.

His astonishment that they should have earned such high incomes without honorary appointments at one or more large voluntary hospitals was not because these appointments would have carried large salaries, for few honorary posts carry any payment whatsoever.   If the work implied by the honorary appointments is carried out wholeheartedly and with constant attention it may absorb a considerable part of the time and energy of the doctor concerned, and despite all talk of altruism this work is not done for purely philanthropic reasons. These appointments bring prestige, and offer opportunities for research and experiment which would be obtained nowhere else. The honorary in a teaching hospital, too, hopes that he will gain a reputation with his students, which will ensure a steady flow of patients when they become general practitioners. The honorary who, for example, sees a large-number of out-patients need not worry that doctors are denied the opportunity of advertising, for patients he has seen give him a legitimate excuse for writing to the doctors who sent them to hospital.

If every patient seen by the consultant paid an appropriate fee the resulting income would be considerable. But those at the hospital pay him nothing, so he has to earn the bulk of his income from those who consult him in private. For such a consultation he is unlikely to charge less than three guineas, and in the case of the surgeon who carries out a major operation fees of 100 guineas are common; so that in pre-war Harley Street incomes running into five figures could be earned. There is, of course, an element of insecurity, for the continuance of a specialist practice depends on so many factors that a man is lucky who suffers no financial setback. As one writer has put it: “A slump in the City may have a serious effect on Harley Street.” And there are variations also in the public’s liking for certain types of specialist.

It is maintained that in thus making the fees of the more wealthy patients pay for the service rendered to the sick poor who attend hospitals, the consultants show a  spirit which is  worthy of preservation. A more rational attitude would be to question whether in these circumstances the poor (who, as we have already noted, often pay quite high sums to the hospital to obtain the opinion of the honorary) would not be much better off if the services of these same specialists were available as part of an organised scheme based on the general practitioner. There have been many criticisms of the way in which honoraries place their private practice and consultations before their hospital work, and while one does not wish to generalise it is clear that the greater the success brought to a man by his hospital appointments the less time he will have for these unremunerated hospital visits which were at one time so necessary for building up his experience and clientele. It is impossible to describe in detail the way in which young doctors who have done well as students and as resident officers get their first foot on the ladder of success by an appointment as the most junior member of the out-patient staff of a hospital. The method of their selection is partly fortuitous and partly by personal favour and recommendation, and since it may be as long as ten years before they will have built up a reputation sufficient to put them into the high income class, there is an obvious tendency for those who have private means to go for these appointments. The exceptions are of course those who are particularly gifted with a capacity for work which enables them to do a variety of income-carrying work during the waiting period. Ultimately all those who reach consultant status in the London area find it necessary to have an address in the Harley Street district, and the concentration of specialists in that: area has caused the term “Harley Street” to become almost synonymous with a specialist in some branch of Medicine.

It cannot be assumed, however, that all doctors who have addresses in Harley Street have any qualification, experience, or hospital appointment which might justify their presence there. One of Dr. Cronin’s Harley Street experts had been lucky enough to marry the daughter of a millionaire, and she probably got sufficient reward for setting up her husband in Harley Street from the favourable comments of those of her own circle on whom he danced attendance. There are others without this financial asset who have set up in Harley Street because they are prepared to take advantage of those hypochondriacal patients who exist primarily among the wealthy and who spend much of their time in visiting different doctors. There are some 60,000 doctors oh the British register, and it is no slur on the profession as a whole to admit that among so many there must be a few who are unscrupulous and prepared to take advantage of the gullibility and ignorance of a certain class of patient.

They are assisted by a tendency among patients to side track the general practitioner, and, having made their own preliminary diagnosis, to seek the advice of someone in Harley Street whom they have heard spoken, of as an expert in their supposed condition. Such patients often meet a plausible but unscrupulous physician who prescribes a course of treatment both costly and inefficacious. One of Dr. Cronin’s characters, when told that a certain type of infra-red ray apparatus which he proposed to use had no ray content, indicated his opinion both of the apparatus and of his patients with the remark “No; but they have a hell of a lot of three-guinea content.” When this attitude of mind is combined with a readiness to send every patient seen to another specialst (in return for reciprocal consultations) for an opinion on some particular bodily system, the unwise patient may pay many guineas to discover that even in the medical profession there are black sheep.

Even if Harley Street housed only the highest brains and the most scrupulous members of the profession, we would still be justified in criticising this concentration of such an important section of the profession in one place. The concentration of wealth in the West End and accessible suburbs of London has made it imperative that those who would earn high incomes as specialists must live in of not too distant from Harley Street, arid, this has had important repercussions. Thus it has been stated that some of the great London hospitals situated in noisy, overcrowded areas from which the population of sick poor they were supposed to serve has long since moved, might have been rebuilt in healthier and cheaper areas outside the city but for the fact that the consultants would then have been divided between their private Harley Street practice and their hospital departments and beds. It has also led many country practitioners to send their cases to the teaching hospitals at which they were trained, and quite large numbers of the patients in voluntary hospitals come from districts far removed.

The specialists of the medical profession would have given a much better service to the country as a whole had they been divided over a wider area and could have worked at hospitals more closely related to the density of the population.This has been clearly shown by the effect of the war on Harley Street for the Emergency Hospital Service has called on many men who formerly practised in the centre of London and whose skill and experience are now available in districts far outside the area of the metropolis. For those who remain, private practice is no longer the lucrative business of pre­war days, for that class on which they most depended have largely moved to distant country and seaside districts for safety. The opinion is widely expressed that these present changes, combined with any post-war rebuilding of hospitals which may be necessary, probably spell the end of “Harley Street.” Even more powerful may be the effect of higher taxation and the general levelling of incomes which the war may produce. This, it may be noted, will also affect the number who are in a position to make large donations to the voluntary hospitals and if lowered incomes lead to their deterioration, the importance of honorary positions will be  considerably lessened. Besides, many men who thought they could never exist away from Harley Street have found a new faith in Medicine through the quality of work they can do as part of the staff of our Emergency Hospital Service.

We have already mentioned the tendency for certain patients to go direct to specialists, and this often leads to the paying of fees for services which might as easily and much more cheaply have been obtained from the general practitioner. On the other hand we have seen that the service of specialists is denied to those in actual need of them unless they go into hospital.   It is clear that no accepted relationship between the general practitioner and the specialist has yet been worked out, and the British Medical Association have long been afraid that the public’s desire and need for specialist services, and particularly the provision of more of these at public clinics, would lead to the disappearance or the submergence of the general practitioner. It has been suggested, however, that this problem is at once solved if we make the services of every type of specialist available to every citizen whenever and wherever necessary, but only so available through the agency of the general practitioner, and  only as part of an organised service. This is no Utopian ideal, for the war has compelled the Government to provide at least one type of specialised service on this basis. The Emergency Pathological Service in the London area includes nearly all hospital laboratories and almost every practising clinical pathologist in the area covered by the London emergency arrangements.   Through this service it is possible for every general practitioner to obtain the full services of a laboratory even in the home of the patient. Fees have been fixed for those examinations which cannot be obtained free through the local authorities, but even these are at the discretion of the officer in charge on the advice of the general practitioner. This service is not fully integrated with the needs of the population, but in setting it up the Ministry of Health have accepted very important principles as to the provision of Specialist services for every citizen and as to the relation between the general practitioner and the salaried officers engaged in this specialty.

It is of interest to note that speakers of the Nuffield Provincial Hospitals Trust have especially mentioned laboratory services as an example of the benefits that would accrue from organisation. They have suggested that a fundamental principle of a modern pathological service is that every sick person, whatever his income, should be able to have any pathological examination which is required for diagnosis and treatment of disease. Even more important is their view that this service must be available to sick persons in their homes as well as in hospitals. They believe that this should include consultation in the home between general practitioners and pathologists and that such expert opinion should be free to all who cannot afford to pay. While objections have been raised to the Nuffield Trust conception of organisation, there is in the suggestions for laboratories a basic idea which may be widely accepted and may solve the problem of the specialist. That is the idea of full-time salaried consultants liberated— to paraphrase the words of the Nuffield Trust— from dependence on fees per specimen, and united in teams which will make effective the study of disease in communities and in individuals.

The true relationship between all specialists and the general practitioner can only be achieved when they are working in the one service.   The function of the general practitioner would then clearly be that of the family doctor who sees the patient as a person living in certain conditions and not merely as a case. This gives him a great advantage in judging the nature, course, and seriousness of the patient’s illness and either giving him the correct treatment or allocating him to an agency which can provide it. It is not true, however, to say that the general practitioner must be a specialist in diagnosis, for so many illnesses have their obscurities and so many diseases are relatively rare that only the more widely experienced hospital officer or other specialist may be in a position to establish the diagnosis. What the general practitioner must be a specialist in, and what he is pre-eminently suited for, is the recognition of the point at which an illness calls for any form of assistance, in treat­ment which is beyond his powers. When he reaches that point he must not have any difficulty in obtaining those forms of assistance; he must have no difficulty in calling whichever specialist he feels is required to the bedside of every patient; there must be no lay person such as a relieving officer, hospital almoner, or any other administrator to be consulted before those services are available to the patient; and he must be able to see his patient safely into hospital and the next stage of progress to recovery started. Such con­ditions are quite impossible today  except in one or two special schemes such as that provided in the Highlands of Scotland.

The Highlands and Islands Medical Service may yet be a source of pride to the people of this country when it is fully developed and they get to know about it.   An area with a very scattered population and comprising also many islands between  which   communication  is often   difficult   cannot support doctors by any of the methods we have discussed. Crofters and fisherfolk are poor— and healthy. They do not call for a doctor very’ often, and for a general practitioner to earn a living in such a community he must charge an average fee much higher than he would get in an urban area.   This has tended to attract to such districts only those doctors who have some independent means and like a quiet country life, or those who had failed to build up a practice in districts where the competition of others showed up their own deficiencies

For consultants the position was even more difficult. Specialists should be attached to a hospital, which in the case of the Highland area implies residence in Inverness. To reach patients in the whole of the area served by that hospital and to be remunerated on anything like a suitable scale meant fees far beyond the means of the average inhabitant.

The recognition of this and other difficulties has caused the evolution under Government control of a scheme which is still developing but which already provides most of the facilities of a modern medical service and ensures that these are within the financial reach of every citizen.   By a variety of financial measures doctors receive subsidies which attract to the area more highly skilled practitioners and enable the hospital to appoint more experienced and better qualified specialists.  For the patients this has meant an enormous improvement in the quality of the medical service they receive and a great easing of the financial burden. .The fees are so arranged as to constitute little hardship in most instances, and contrast with the demands that were  formerly made.

It has been said that before the inauguration of this scheme a crofter may have had to pay three guineas for an amount of medical care which in a large town would have cost those of similar income half a crown or five shillings.   The scheme also makes available the services of certain specialists whose opinion can be obtained in every part of the area at the call of the doctor, and who are paid on such a basis that no one is deprived of their services on economic grounds.

This and other experiments have provided us with grounds for the view that a medical service of a very different type from that of the present day is not only possible but rapidly becoming a necessity.