MEDICINE IN EUROPE

Germany

German medicine has been under federal control since Bismarck. Hitler multiplied by three the annual output of doctors. Germany is now two separate nations.

East Germany represents the ultimate in socialism. Medical care there can best be illustrated by the fact that the famous university city of Leipzig, a cultural center of 600,000 people, does not have a single pediatrician. Doctors— a group fortunate enough to carry their means of livelihood in their heads-have emigrated to West Germany.

West Germany has instituted the most aggressive free-enterprise economy in all Europe, and has the prosperity to show for it. Its medical care program has neither free enterprise nor prosperity. In fact, it is on the verge of collapse. Understanding that the Germans are the best disciplined and most scientific people in the world and that the supply of doctors is adequate, one cannot avoid blaming the socialized system for the failure.

Competing political parties have granted one increase after another in social welfare benefits, which despite incredibly high taxes are not covered by income. Costs are uncontrollable. Doctors are dissatisfied under a system of payment that encourages inferior practice. Mortality of the newborn and maternal mortality are the worst in the Western World. All services are overutilized and hospitals are bankrupt, but the public wants no reform that does not include the principle of "free service."

Great Britain

Socialized medicine spread over most of Europe by gradual Government intrusion and absorption of private insurance and private facilities. Such was not the case in England, where, by act of Parliament, medicine suddenly became the ward of the state in 1948. The opposition of British doctors was almost unanimous, but they were not organized and remained passive. The proponents of socialism, being unencumbered by busy medical practice, had plenty of time to guide their program through Parliament. Action by the doctors was slow, and by the time they were organized, it was too late.

The program is called insurance. It is hardly that, since the individual contribution covers only 12 percent of its cost. The remainder comes from taxes, mostly income taxes. First-year costs were four times the amount estimated by Government advocates of the system.

I asked the assistant secretary of the British Medical Association if medical care were better now than before, and if the British people were receiving medical benefits which they lacked heretofore. The answer was, "No; they're just paying more for the same thing." The cost of the program has now risen to 20 percent of the national budget, and, according to the same gentleman, it is impossible to control the costs of such a system in a democratic country. Hospitals are used a great deal more than is necessary; the waiting time for elective admissions is sometimes 2 years. There has not been sufficient capital to build one new hospital in the 15 years since the war. Private clinics are appearing now to perform surgery for pay, and interest in private health insurance is rising. That people are willing to pay double, membership in the National Health Service being compulsory, is certainly a significant repudiation of the Government scheme. The financial problems of the National Health Service are insoluble, but no politician who wants to remain in office would dare suggest a change. The voters like "free" medicine.

Holland

Statistically, Holland is among the world's leaders in health. The death rate is low, and maternal and neonatal mortality figures are excellent-better than in United States. Most deliveries are done in the home; 40 percent are done by midwives. Compulsory insurance covers the low-income group. Most of the remainder of the people are insured in private programs. Private bodies exert control over all aspects of medical care in Holland-preventive medicine, compulsory insurance, and private insurance Government-subsidized programs are privately controlled for the most part.

Scandinavian

Denmark, Norway, and Sweden have a system of socialized medicine which began a hundred years ago, as private insurance associations were gradually absorbed by Government.

In Denmark the patient makes absolutely no direct payment for medical care. His taxes and insurance contribution cover the cost. Control of the patient is established by strong authority vested in the doctors; the patient cannot leave his assigned doctor unless referred. The program is not compulsory in Denmark. Ten percent of the people do not belong to the system. In Norway and Sweden, control of the patient is established by having the patient pay a large part of the initial bill and a small part of later bills. Night calls and extra services are charged directly and heavily. The people of the United States would never agree to the disciplinary control that is possible in a small country containing a single national ethnic group.

Socialized medicine is more efficient in Scandinavia than in Germany and Britain, possibly for these reasons: the smallness and homogeneity of population; the absence of pressure groups; a different political organization from that of Britain, Germany, or the United States; participation in private insurance plans; the use of local governing bodies; the strong authority of doctors, and the self-reliant, hardy character of the people. Chiefly, the medical program works well because the doctors have retained a large measure of control and have stoutly resisted attempts by Government to wrest it from them. It is still true, however, that this system, even in its ideal execution, lays a heavy hand on medicine and on society. While being proud of their medicine and their country, my medical informants in Scandinavia preferred the U.S. system. (They did say

that not having to collect bills was pleasant.) Somebody has to collect the bill at the end of the year, however. In Scandinavia it is the tax man who does so, and he cuts the life out of the economy. It is unthinkable that this system, costly as it is, will ever return to private hands.

Summary of medicine in Europe

A government monopoly now controls medical care in northern Europe. Its permanence is assured by the belief tha it is free. Far from free, it is costly beyond the early imaginings of any of its proponents. Cost control is impossible to attain. All available money is spent to maintain basic services. In the search for funds, taxes have risen so high that the citizen cannot accumulate savings. Capital is no longer in the possession of individuals, but belongs to government. The consequent rigidity of the economy inhibits medical care just as it restricts the entire society. European economy has lost the flexibility needed to change, adapt, shape, or better its medical program. The dual relationship between doctor and patient is now a triple one, with the government calling the tune.

Medicine is not "free" in Europe. It costs more.

There is less freedom for medicine, for the individual, and for the group when the government owns all the money. I urge the members of this society to study European medicine in order to improve our own.

Medicine in the United States

The essence of the free enterprise system of the United States is that it leaves some of the capital, and therefore some of the power, in the hands of individnals. Society gains from the flexibility granted by that system. The United States gives more materially to its citizens than any other nation. That includes medical care. Yet we too are moving toward state medicine, a system that will give less. Only one group in the country has the power to stop the drift to Government ownership of health care. Unhappily, however, that group the doctors-is not leading but following the movement of medicine today. They are characterized by newspapers and politicians as being against much, but not for anything.

Devoting themselves to the scientific aspects of their profession, doctors have ignored the social. They have abdicated a grave responsibility. Doctors must stop being technicians and start being executives. The biggest problems facing medicine today are not in the laboratory or on the wards. They are not clinical. They are socioeconomic. The chief objection of the physician is to assume his rightful place as the leader in medical planning. Only he is qualified to understand and solve these problems. Instead, medical planning is now being done mostly by uninformed laymen whose concepts are unrealistic and generally involve intervention by a third party. It is the duty of the medical profession to set up its own program and refuse to participate in any other. The times call for radical thinking and aggressive action.

Suggested changes

1. The doctor must become an executive instead of a technician.—The first step in that direction is to make better use of his time and acquire some leisure. Night calls and weekend calls should be put on a duty-roster system. Piecework medical practice must be abandoned. Industry would be appalled at the antiquated way in which we do our job. Assembly-line obstetrics must take the place of our present method, whereby four doctors sit around a delivery suite at 2 a.m. waiting for deliveries which one could handle alone. Some of the art of medicine would be lost, but I suspect that much of what we've been calling art is really only the indulging of some selfish and demanding patient at the expense of others, and at the expense of time that could be spent in planning and supervising.

2. We must create a new order of medical practitioner.-Many young people who could never pass the didactic medical curriculum have a zeal to practice medicine and ought to be allowed to do so. With special training they could become "medical assistants" and render a valuable service. One-third of the cases and 90 percent of the deliveries could be handled by a practitioner of less than graduate status. Our present approach to medical care is archaic. The imminent shortage of physicians makes it imperative that personnel below the M.D. level be utilized.

3. Doctors in all fields must sign up on a night-call and weekend roster. The entire membership of the county society under 50 years of age should participate instead of leaving this onerous responsibility to the general practitioner, internist, and pediatrician. Recently an internist treated a case of testicular pain at 2 a.m., then referred the case at 9 a.m. to the urologist. Why should not the urologist return the favor by handling a nocturnal case of gastorenteritis for the internist? Having the dermatoligist, the otolarynogolist, and the radiologist serve once a month on night-call duty would benefit them and the profession. Participation in comprehensive medical care of the community is the duty of all doctors. Medical care would gain by the fresh ideas of these men.

A well-publicized duty-call roster is a must. The public does not really care about heart operations and other esoteric miracles, but it is aware of the emotional security of knowing that a doctor is available and that he will make house calls, either day or night, when necessary.

4. Each county must create a clinic for indigents that is open 5 days a week and is staffed by all the doctors in the society, in rotation where indicated. All doctors can work there as general practitioners. Those who have forgotten the dosage of digitalis can relearn it. The population is increasing faster than the production of doctors. The simple duties of the general practitioner must be given to special assistants, the general practitioner must assume some of the routine load of the specialist, and the specialist must be a true consultant as he is in Europe.

5. We must save the general practitioner or junk him.—Young men are not going to choose that field when public health officers and specialists take over the day calls and leave for the general practitioner emergencies, house calls, nightwork, and an income half that of the 8-hour-a-day dentist. We must help him or prepare for his demise. All doctors share an obligation to attend the general medical needs of their community.

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6. We should establish a nursing school in every hospital of greater than 100 beds. If the nurses association doesn't approve it, let the medical association do A girl doesn't have to be trained at Duke, Chapel Hill, or Bowman Gray to be a good nurse. Some of the best nurses now practicing in North Carolina were trained in small nursing schools, many of which we foolishly permitted to be closed 20 years ago.

7. We must support voluntary prepayment plans and control unnecessary use of hospitals by group action.

8. Let us bring the churches back into medicine.-There is no more proper church activity than caring for the sick; indeed, that function was once entirely religious. Congregations can assist the work of indigent care, can act as nurse's aids, and sponsor hospitals and nursing homes. If churches would consolidate some of the money they spend on construction, no town would have to accept a penny of Federal funds to build a hospital. The American people have material things in plenty. Let us give them the opportunity to act in charity and gain the spiritual reward of doing something for others.

9. Most important, let's get into social medicine. The social problems of today are being considered by politicians and labor leaders (who are out for votes

and power), by sociologists and professors (who are theorists), and by laymen (who are honest but uninformed). Everybody is solving the social problems of medicine-everybody but the doctors. The world today expects some group to assume responsibility for the individual. Doctors must add to their responsibility for the physical animal responsibility for the social animal.

Every county medical society should form a social planning committee to study all aspects of social welfare. This committee should have State and National organization, and its function should be the creation of a social program of our own. Too long have we let others create the program and limited our own participation to reaction.

In espousing good causes, we can render a service and command respect and power. Locally, we need to make all citizens understand that medical care is freely available. We could give our committee initial recognition by campaigning for the nationwide adoption of the metric system, by setting up first-aid courses, and by publicizing the need for prophylactic immunization against teta

nus.

Beginning with innocuous and obvious activities such as these, we could later consider more serious problems and promote a positive program of solution. Medicine must act, not react. Until now we have been like the carnival man, his head through a hole in the tent, dodging baseballs. We make a good target because we never throw back. We must take the offensive and ask for something ourselves. Labor unions and the NAACP have demonstrated that what one asks for loudly enough one usually gets.

We must search for exotic ways to help finance medical care, as prophylaxis against the disease of Federal control. Why not have every county society demand a 1-cent tax on coffee, tea, and soft drinks, and a county tax of 50 cents on whisky, the proceeds therefrom to go to the hospital? Or, how about a County hospital lottery? Let's take taxes away from central government by giving them to local government.

SUMMARY

Government owns medicine in Europe and is gaining possession of it here. Concentration of the economy under a central authority is inefficient, wasteful, less productive, and destructive of freedom. The worldwide transfer of individual responsibility to the group, the desire of the average man to be led, and his dislike of direct medical payment all are factors hastening the advent of Federal medicine.

Prior to 1940 all phases of life in the United States were ruled by the philosophy of individualism. Since World War II collective or group rule has supervened. This is true in labor, government, business, school, and corporate life.

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Doctors have never really existed as a group. We have been disorganized and passive. In failing to unite, in failing to act we are derelict in our duty. ganization and activity will not harm our status as doctors. It is the disunity and passivity of medicine that makes us weak and invites assault by misguided politicians. It is the unity and aggressiveness of labor that makes it strong and feared by the politicians.

We know better than any others what is best in medical care. It is our clear duty to provide the leadership and the planning that will fulfill our social responsibility to medicine, to the people, and to this Nation.

The CHAIRMAN. Thank you for bringing to us the views of the Medical Society of the State of North Carolina.

Are there any questions?

Thank you, sir.

Mr. MASON. I would say the views and activities of North Carolina. Dr. KERNODLE. Thank you.

The CHAIRMAN. All right. I will accept the amendment.

The next witness is Dr. Reynolds.

Mr. UTT. I would like to take this opportunity of welcoming Dr. Reynolds as one of the leading physicians of the State of California, having practiced medicine in the Oakland-East Bay area since 1926. He is an unusual physician in many respects since he is both a member of the American College of Surgeons and a member of the American Academy of General Practice.

He is a veteran of two wars, having served in World War II as Chief of Surgery in the U.S. Navy Hospital in New Hebrides.

He has a great deal of experience, having been president of the Alameda-Contra Costa Medical Society and is now, of course, president of the California Medical Association, and has been an official of the Blue Shield.

The CHAIRMAN. It seems a shame that our total time allocation makes it necessary to limit one with such a very fine background to 5 minutes, but you are recognized, sir, for 5 minutes and, if you have more in your statement than you can present in 5 minutes, all of your statement will be in the record.

STATEMENT OF T. ERIC REYNOLDS, M.D., PRESIDENT, CALIFORNIA MEDICAL ASSOCIATION

Dr. REYNOLDS. Thank you, Congressman. (The statement referred to follows:)

TESTIMONY OF T. ERIC REYNOLDS, M.D.,1 PRESIDENT, CALIFORNIA MEDICAL ASSOCIATION, CONCERNING H.R. 4700

Mr. Chairman and members of the committee, my name is T. Eric Reynolds. Since 1926 I have practiced medicine at Oakland, Calif. Although I trained in surgery and am a member of the American College of Surgeons, I have maintained a general practice. I am the president of the California Medical Association. For several years I was president of California Physicians' Service, California's Blue Shield plan. I recently served as chairman of a special committee of the California Medical Association on problems of the aged and I am appearing here on behalf of the California Medical Association.

Physicians in California have been mindful of the medical-care needs of our aged population and of the fact that all of us may expect a longer life span than our forefathers. To a great degree the medical problems of the aged are rooted in the mores of our culture. Also, to a great extent, our medical problems after the age of 65 are determined by such things as (1) the care of the individual before that time, (2) his or her attention to infections, (3) mental cultivation and relaxation, (4) physical fitness and exercise, (5) smoking habits, (6) the use of alcohol, (7) weight control and, lastly, food habits. Perhaps vitamins and hormones, both natural and synthetic, play some part, and certainly part of it is pure caprice, such as the factor of injury or exposure and stress and strain beyond the control of the individual. Heredity is definitely a factor in the medical problems of older people. Indeed, barring accidents, the choice of ancestors often determines whether an individual will qualify to reach that category.

It is my opinion that the two most prevalent difficulties of old age are (1) boredom and (2) loneliness, and that much of the medical attention that old people seek is traceable to these two underlying conditions.

There is a lot more to this problem than the passing of a compulsory insurance law and the spending of public money to provide certain hospitalization benefits. For persons who have spent 65 years developing a spirit of independence and self-reliance, we would advise, as physicians, that ways to present a continuing challenge to their minds and hearts should be developed. We believe that voluntary health insurance can well be one of the means by which people can continue to be self-reliant.

1 T. Eric Reynolds received his degree in medicine from the University of California School of Medicine in 1925 and is a member of both the American Academy of General Practice and the American College of Surgeons. He served as a line officer in World War I and retired with the rank of captain after World War II. Dr. Reynolds has also been on the faculty of the University of California School of Medicine. Except for his period of service during the second war Dr. Reynolds has been in continuous practice of medicine since 1926.

The California Medical Association is a voluntary organization composed of over 17,000 physicians in California.