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what has been told them, and that that has greatly increased the value of the physician's examination. In other words, a real examination by the individual who has personal contact with the one examined is worth several times as much after it has been transmitted to some one who has never seen the patient.
These institutions not only tell the individual what the matter is with him, but acknowledge that they advise him as to his diet, as to his exercise, and as to the type of medical treatment which he should seek. If diagnosing the case, advising as to hygienic measures, diet, and any medical treatment which they might think he needs is not practicing medicine, none of us is engaged in the practice of medicine.
Some of these institutions claim that they are not commercial, and that the motive back of them is purely altruistic, but to show that the commercial idea has not been lost sight of, one of them is going to start branches in at least one new state in the near future and already has started a branch in one state. It is negotiating for a branch in another state; and its method of creating these branches, as I understand, is through the sale of stock, 7 per cent. preferred stock. It is to be presumed that the profits from the work will furnish ample means to pay ? per cent. interest on the stock issued. If that isn't a purely commercial proposition it would be difficult to find one. The idea seems to be to sell a part of this preferred stock to certain doctors in the neighborhood, who would thereby become a part of this organization and help it along.
The service furnished is an indirect one, and any indirect service to an individual is not furnishing him the kind of service to which he is entitled and for which he pays. That can be only a personal and direct service.
REPORT OF THE JUDICIAL COUNCIL You remember that the report which was presented by the Judicial Council at the last meeting of the House of Delegates excited considerable discussion and aroused members of one of the organizations in this kind of business to make a very vociferous denial. One of them became so excited that he sent telegrams to the A. M. A. that practically every statement made was untrue, and made with malicious intent. They were requested to kindly send us details of the misstatements, which they promised to do. Weeks went by, months went by; no report to us of details has ever been made. They did publish a little pamphlet which was distributed, so far as we know, to those on their examination list. This pamphlet was not received by anyone at the A. M. A. office until Oct. 24, 1924, after it had been received from indirect sources.
The Judicial Council met this week in Chicago and this pamphlet was considered. It was the opinion of the Council that its report to the House of Delegates stands unrefuted. I only wish that we had time here this afternoon to present to you and read to you the volume of facts that we have on file. It vould take two or three hours' solid time to read to you the evidence that we have.
THE PROFESSION SHOULD INFORMED
AROUSED Something must be done or the medical profession is to be deprived of a large amount of its personal service to the detriment of the individual who should receive it.
The point which we have to discuss here and which you have to take home to your various state and local societies is how to counteract the baneful influences of this indirect service and get the people to know that the only valuable service which they can get is the personal service of their own physicians, with consultants when necessary.
Many physicians don't realize what is happening in this propaganda for indirect service, and they must be educated to comprehend what is going on and how extensively this indirect service is growing, and what a loss it is going to be to their clientele.
To bring this home to the individual physicians is a matter which must be taken up, discussed and brought home to him.
Dr. Haggard has mentioned some of the points in this connection. We must convince the physician, first-I won't say of the need of periodic health examinations, because I think every intelligent physician realizes that this examination can be made only to the full benefit of the examined by personal service.
Some one whom the physician has known a long time comes and says, “Doctor, I would like to be examined.” He has become imbued with the periodic health examination and wants one made on him. The doctor says, “Oh, you are all right, you don't need an examination. There is nothing the matter with you.” The man is dissatisfied. He feels he isn't getting anything. He wants something, and if the doctor isn't giving it to him he goes to one of these institutions. That is the biggest asset that these indirect corporations have today. Too many doctors will not sit down and make a thorough examination which the patient wants.
THE VALUE OF RECORDS To make these examinations thorough and valuable it is necessary for the doctor to sit down and put down everything in writing on a blank, and make a thorough record of the case. If he doesn't, the value of the examination is practically lost.
We want to get before the physicians the necessity of making this examination--whether he has known the individual five, ten, twenty or twenty-five years is immaterial—but to make a thorough survey and put it down so that it becomes a permanent record. Who is to keep the record ? Not some corporation to make use of it. You want to get the information to the doctors that the American Medical Association provides these blanks—they have the blanks already for recording these examinations. There is also a little manual which will be sent to any physician who wishes one at a very nominal cost of 5 cents. The purpose of this little manual is not to make him feel that he doesn't know how to make an examination, but to show him how to do it systematically and in order ; how to record things systematically.
Also we have in preparation a larger manual, a more elaborate one, which will take up the various devices used in examinations and familiarize physicians themselves in how to make all these examinations. That manual soon will be issued, and will be provided for any physician who wants it at a very nominal cost.
When you go back to your states you must start this campaign locally. Get a good man who is thoroughly familiar with the subject of periodic health examinations, who is thoroughly familiar with the method of making them and thorqughly familiar with the reasons why these examinations must be made by the man's own physician if he is to get the kind of service to which he is entitled and for which he pays.
There is nothing that convinces the doctor so much of the need of these examinations as to have a group examined and the defects and diseases pointed out.
We all think we are perfectly well. We go along working from day to day and forget all about our physical condition. If the physicians in this room were to be examined today, we would all be surprised at what we should find. That is the most valuable impetus to the physicians--to insist on examinations of their own people.
The imperfect service rendered to the individuals by the indirect method is the most important thing in this periodic health examination. But there is another side to it, which is a perfectly legitimate side, and that is the great economic loss to the profession in the indirect service. The major part of the amounts paid for these examinations goes to the commercial organization, and the minor part to the physician who does all the work.
If the indirect service is permitted to grow it is going to be a great loss to the medical profession, and it is going to undermine what has been the foundation of
the practice of medicine from its inception, and that is individualism. The practice of medicine is founded on individualism, and when the individualism is gone the practice of medicine is gone.
DISCUSSION Dr. FRANK Billings: First of all, before I discuss this question of periodic health examination, I want to call attention to the dry clinic just for a second. I am sure that Dr. Haggard inadvertently left out what he must advocate. The dry clinic is a good way of teaching the practical method, teaching the latest methods of diagnosis. Incidentally it teaches practitioners to examine patients, but as I have attended dry clinics now for several years, I have been struck with the lack of one very important detail. Morbid anatomy and physiology are the foundation of diagnosis, the foundation stones, and we are getting away from morbid anatomy year after year. We don't pay half as much attention to it as we did twenty years ago. That is one reason why we emphasized morbid anatomy at the scientific exhibit this year. Those of you who attended the meeting this year must recall the wonderful exhibit of morbid anatomy that appeared there, with directors who explained every detail of the exhibit. Let me say that it did a lot of good. I heard many men speaking of how much they had learned and viewed morbid processes they had never seen before.
No one can be a good diagnostician unless he can mentally visualize something of the morbid anatomy that is present in any patient who has any morbid anatomy. Therefore, in every dry clinic, teachers should be saving the material they get from post mortems. That leads to the next thing, that even in hospitals they don't ask for post mortems enough. In Chicago we have been making in the last three years, an effort through a committee to in some way secure more post mortems in hospitals in Chicago, and our crusade has been of benefit, but even on our last year's report seventy-five per cent. was the highest of autopsies of any hospital.
Unless doctors study the end-results of disease of the patients they cannot know whether they have been right in the diagnosis. Physiology is just as important as morbid anatomy and there is no reason why in the dry clinic these fundamentals should not be taught. There is material enough of morbid anatomy in every city to serve the clinic, even if it doesn't quite apply to the cases presented.
I think that in some ways the biggest blessing that has come to us is the commercialism that has been prevalent for the last ten years in this so-called periodic health examination. It has brought us face to face with a reality, a condition which must be overcome. I don't say or believe that it is as harmful to the medical profession as it it to the public.
I wonder, as your Chairman said, if you are aware of the lack of physical examinaions of the sick. I am going to repeat what some of you heard me say once. A few years ago, just before we went into the war, my practice was confined entirely to patients referred to me, and to consultation, and yet I saw a good many people. I made a point never to take more than four new patients in any one day in my office. I saw some patients daily who had been to me before, but I wanted plenty of time to go thoroughly over new patients. I had always been struck by the fact that patients who stripped sometimes did it reluctantly and often made a remark that they had never been unclothed for examination before. So for two years I gave my secretary every night the number of new patients who had never been disrobed for examination before. During those two years there were approximately 500 patients, the members of doctors' families. Over 75 per cent. of the total patients, members of doctors' families included, had never had their clothes off in an examination and every one had suffered from a chronic disease.
There is no comment necessary. These people came from Illinois and adjoining states and some from distant points. They were in age from childhood to the octogenarian that had never had their clothes off for medical examination until I stripped them in my office. That is only about ten years ago.
I was a practitioner here for over twenty years. I had a big practice. I kept records all my life. Some of them were very brief. In the beginning I had to learn how to make records as well as other things. As I got into the family practice I was asked questions by members of the family, just as every family doctor is. The head of the house might say to me, "Doctor, I have noticed that I have got a little backache today," or something like that. "What shall I do?”
"Come to the office and let me look you over." In that way I suppose I had on record in my office when I ceased that sort of work histories of healthy people not less than a thousand in number.
That was of benefit to me in attending to these families; it improved our relationship and it was of benefit to me in fees collected for every normal patient that I examined. I was kept busy, busier than I otherwise would have been. was of benefit to those families far greater than it was to me. Some of them lived to be very much older because some conditions were found incipient in character that were corrected, even tuberculosis that I had no suspicion of and that would not have been discovered then if the patient had not come of their own election when they found I was doing that sort of work. I made appointments for them the same as for patients. It is within the province of every doctor to do this.
Other county societies, urban and rural, can do just as Kings County, Brooklyn, N. Y., or any other large county can do it if it is properly conducted.
As Dr. Harris and Dr. Haggard have said, we have got to get it across, but you can't get it across unless you take it up with the doctors themselves. You may publish it all you please in the journals, state, national, what-not; they won't read it. If they do read it, it slips over. You must put it across through the county societies, and there must be unselfish leadership in the county and district society to put over an attractive program and teach members how to do the work.
Then we hear men say, “Why, the average practitioner can't do it.” Then we might as well come out and say that the average practitioner isn't fit to practice medicine, because if he isn't fit to make the examination of a healthy individual and find out whether he is approximately well, then he is unsafe to take care of a sick patient.
As Dr. Haggard said, one of the best post-graduate courses that a man could take is in this work, because if he keeps a record of his case and in a year from that time the individual shows some chronic ailment that was there there a year before, he has been shown up at his real standard and he is going to strive to learn how to do better work.
I want to emphasize what Dr. Harris said; the practice of medicine is individual if it is successful. We are too individualistic in a lot of ways. We are individualistic in not putting this program across as a group for the individual to do. We differ in our policies about it; we differ in details about it, and we don't stand together as a group in putting a big policy over for an individual to do. The practitioner must be individualistic.
In an article I wrote two or three years ago I said, "Give me the broadly educated, well trained, resourceful general practitioner against any group for efficient and humane practice for eighty per cent, of the sick and injured."
Dr. C. L. Booth, Portland, Ore. : We have standard fees for medical insurance examinations. What are the current fees for making these physical examinations of well persons ?
DR. McCORMACK: Apparently well persons ?
Dr. Booth: Well, apparently well persons. Is it customary to make a discount where they come back from year to year or every six months? Unless they have been changed recently, I believe the forms given out by the A. M. A. do not lend themselves readily to carbon copies. Is that not so? If these could be changed so we could have sheets in which we could insert a sheet of carbon paper, it might help us in keeping a record.
DR. J. M. Dodson, Chicago, Ill.: May I say in reply to that last question that the matter of using a carbon copy was very carefully considered by the original committee and by a committee since. The decision was against it for two reasons. In the first place, form A, the history, is usually made by the patient or the examinee himself. It it pretty difficult with any printing you can do to arrange that so that the entries will be accurate. The principal reason is that it is rare, we believe, that the examinee cares for a detailed report of all of the findings. What he does want is a summary of the findings, what they signify, and the advice given. That is to be written on a separate sheet, of which a carbon can be made and kept on file with the examination.
DR. FREDERICK L. VAN SICKLE, Harrisburg, Pa.: I just want to give a testimony. There used to be a time in our history when testimony giving was very popular.
At the last session of the Medical Society of the State of Pennsylvania, we tried this plan out under the administration of the committee on public relations. We sent out a bulletin to the county societies requesting not more than 100 candidates to be examined at the Reading session, examiners to be competent men selected by the committee, examinations to be made in private in the office of some of the physicians of Reading; and we trusted that the response would be prompt. Out of the whole number we had fiftysix offers.
Those examinations were made in Reading, and were eminently satisfactory; but out of 7,300 members of our state society we could only scare up fifty-six who wanted to know what was or was not the matter with them.
I want to emphasize that commercializing health examinations has been wrong. I believe we should have anticipated this some time ago ourselves. In Pennsylvania we are making a special drive through our committee on public relations to bring about such a state of affairs that the physicians of the state will be competent to make the examinations, and the people will be willing to come for those examinations.
Dr. David S. FAIRCHILD, Clinton, Iowa: I have had a limited experience in this kind oi work. Some years ago the different railway corporations required their old men, men beyond 50 years of age, to be examined. This raised opposition on the part of organized labor that the step was an effort on the part of the corporations to get rid of or find a way of getting rid of undesirable men, and, therefore, this examination had to be limited to certain classes of men only.
In the last two or three years a good many of these employees, say from 35 years of age up, have come to me personally, outside of the requirements of the railway companies, for a physical examination for the purpose of determining the significance of certain symptoms they felt. They began to observe, as time went on, that they were suffering from symptoms they had never recognized before; and so we have been encouraging these men to come to us for a physical examination on their own private account.
This has not been, and it has been understood not to be, in any way connected with the railway service. This applied to several important railway corporations with which I am associated, and it has been a very helpful and a very satisfactory thing to these men ; it is kept private; it is done for the use of the railway employees, and it is understood to be such; it has been a very helpful thing, and we are now endeavoring to get permission of these labor organizations to extend the examinations, officially, further than we have already done.
The work that I have done has been entirely private and has been a source of a great deal of advantage and satisfaction to the older class of high grade railway men.
DR. E. A. HINES, Seneca, S. C.: To further the campaign for Health Examinations in South Carolina I pursued the following plan:
First, I went to a good doctor on my birthday and had myself examined.
Second, I appeared before the State Board of Health and secured the Board's approval of periodic health examinations.
Third, I presented the matter in person before district and county societies.
Fourth, the Committee on Health and Public Instruction was appealed to to stress the necessity for Health Examinations in their report to the House of Delegates of the State Medical Association.
Fifth, I wrote to the Secretaries of all the County Societies requesting that one paper, on same phase of Periodic Health Examinations be placed on the program at each meeting until every doctor in the State should become familiar with the purpose of the campaign.
Finally, I have written many leading editorials in our State Medical Journal calling attention to periodic health examination as offering a wide field for constructive effort on the part of the general practitioner towards promoting preventive medicine in private practice.
Dr. Albert E. Bulson, JR., Fort Wayne, Ind.: It seems to me that we have lost sight of one point in Dr. Harris' discussion, and that is the fact that we are beginning to lose our individuality as practitioners of medicine as a direct result of the methods pursued by various organizations that are trafficking in professional services. Dr. Harris, as a representative of the Judicial Council of the American Medical Association, called attention to this matter at the Chicago session; and he has referred to it in a general way in his discussion today. Therefore, it strikes me that this tendency on the part of health institutes and various other organizations trafficking in medical services is a very serious problem, and one that merits the attention of the American Medical Association in its efforts to show the individual practitioner of medicine that the Association has his interests at heart.
As an instance of what is being done, I desire to call your attention to the fact that the industrial insurance companies are quietly but none the less effectively organizing for the purpose of controlling, in every phase, the medical and surgical services rendered in industrial cases. The industrial clinic, under the control of the insurance companies, which dictates to employers of labor where sick and injured are to be referred, is but a step in the program to dictate when, where, how and under what compensation, medical and surgical services in industrial cases are to be rendered. Under this plan, the doctor becomes a tool in the great scheme of commercial conquest, and he becomes a subservient employee, subject to autocratic dictation as to his work. The salaried surgeon for industrial insurance companies is no different from the salaried surgeon in Ford's Hospital