262
made us suspect in the eyes of my great-aunt Katharine,we are still members of a learned profession, and, inwords never used by the private soldier, " we won’tbe badgered about."The present organisation of medicine is wasteful,
expensive and inefficient, and something will have tobe done about it ; but that something isn’t necessarilybureaucracy. A unified medical service under a nationalmedical council, largely elected by the medical pro-fession, and responsible only to Parliament is an
obvious and simple alternative. The officials of theMinistry of Health, threatened with government byexperts who will control them instead of politicianswhom they can easily control, are seriously alarmed bythe idea, and like the little fishes reply, "W er cannotdo it, sir, because-"
* * *
The patient, in fact, is insisting on a voice in theconsultation. He is pointing out that he has beenfairly useful so far and would like to go on being usefulin something like the same old way. The operationmust not be too drastic. As the advice of the minis-terial surgeon to rush the patient to the theatre andamputate his brains has apparently been outvoted,this year’s students will perhaps have the final say.It will be an interesting operation and a still moreinteresting convalescence. " Mind you come up-theregular way-don’t get blown up."
IN THE NEAR FUTURE(LICENTIATE OF THE COLLEGE SPEAKING)
As it will be ? P The old men will decide that, just asthey always did. We do not even know what we want.We do not know how much we want, since money-valuesdepend on social values-the importance attached byother people to a good address or a good school. I canimagine, if the public school system continues, decidingthat I need an extra 2250 a year for each of my children-which means 2500 a year at the present income-tax ;and while that uncertainty remains I certainly cannotimagine what will be a fair wage-scale for the medicalprofession. At present I am as rich as can be on22 10s. a week ; I jqst never seem to get out to spendit. But that doesn’t mean a thing, except that I likeit. It leaves me travelling off into one of those Utopias,Avalons, apple-islands, we travel towards all our lives,ever since we wanted to be grown up-or qualified.That is one reason why the future does not seem to
hold any concrete financial proposals ; there are otherstoo. It is hard for my immediate generation to forgetthat their services have been paid for already, by thebodies of men no stronger and brains no less trained.It is difficult to say that we deserved it, even when itwas part of a well-laid, state-planned calculation. Wewere reserved, held out of the line, while Jock (whowas trained as a diplomat) took his platoon behind theenemy lines to destroy thirty-six aeroplanes and waskilled by a bleeding artery on the way home ; andMichael died when he led his company on to the lastobjective at El Alamein (he had passed his final examina-tions before ordination) ; and Melvin bombed the damwhen he could have stayed comfortably in the RAF inAmerica. If such people had not given up their jobsand gone to war we should not be doctors now. It ismy salutary misfortune to remember how much theyentertained the world without trying, and helped theworld without the special equipment of medicine.
* * *
It seems to me that in different times there are twostabilising aims in a life, the wish for friends and thewish to do well. In both of these I am confused.Friends are impermanent, outside medicine ; they areabroad or under ground. My own wish to do well wasalways ill-defined. In my most selfish years I had theidea of doing enormous good, or else maybe of entering’a monastery and contemplating-you know, like St.John of the Cross. Then there was a time when it wasimportant merely to have enough money to continuestudying ; but it was a substance surprisingly easy tocome by when the urge was as strong as that. It allleaves me not knowing what I mean by
"
doing well " ;my standards and my idea of success have seldom beenmore malleable. And nowadays I cannot ask Jock or
Michael what they think ought to be done. I writepersonally because the big realities are beyond me.
I remember a time once, though, when I knew whatmedicine was for ; it was in America, which I had beentaught was the home of materialism. We were studentsin a school built by the money of some of the greatermaterialists, with a hospital attached whose beautifulequipment was paid for by the materialists of the town.Those were real buildings, not much like the poky,half-equipped, money-harassed place I work in now,The secretary, so far as I know, did not have to spend’his time sucking up to influential people ; I cannotremember any talk about the beauties of the charitysystem. Living in a democracy, it was assumed thateveryone ought to have the best; even the hospitalfood was edible. And we were taught there thatmedicine was a subject with a history, and research thebeauty of medicine. I expect there were a lot ofdisadvantages ; so many people, since I came back toEngland, have told me about the Americans and thebizarre treatments they think up. In those daysRicketts and Minot and Best and Harvey Cushing werethe gods they held up as examples to us-and Sher-rington, Lewis, Houssay and Noguchi. We were taughtmedicine as a priesthood, not as a trade. We workedvery hard at it. When I think of my apple-island,inevitably I want to get back to that time of purposeand contentment.Certainly the’life of a successful consultant does notseem the right way. I can never see how anyone cansafely be asked to earn a hard living while at the .sametime working for nothing in a hospital, serving oncommittees, teaching and helping students, and havingenough free time to remain a reasonable man. Thatsome of them-about half, as far as I can see here-stay the great men they should be increases my admira-tion for man. Unfortunately one more usually getsexasperated with the ones who cheat, never againsttheir own advantage, and acquire the glory withoutdoing the work.But then that is negativism, and it is impossible to
make a Utopia out of negations of the present. All Ican deduce from these denials is that I would like to domedicine as itself, without being tempted by the moneywhich might make me value one patient more thananother, and without being led on by the desire for famewhich my friends so lightly lost. State medicine, toadd one mone denial, seems to me a lousy answer ; weall know the nurses who only do things because other-wise matron would be annoyed, and the complex paperforms which are designed to show us how to reduceeverything to a steady level of accustomed and auto-matic treatment. I would fit in admirably and dutifullyand abominably with such a system.We must have something better than that in my
Utopia, something worthy of those friends. A systemin which we can do medicine without being afraid eitherfor our purses or for our chances of making the nextstep up the scale, or of a printed admonition from aman in an office.
’
* * *
I think that group medicine is the answer-as wellas to a purely medical problem, my own inefficiencyand incompetence. At present I could not serve mypatients properly singlehanded. Often I can’t do avenepuncture on a child ; I miss diagnoses ; it takesme too long to get a transfusion going ; I know nothingabout complicated midwifery and pretty little aboutfractures. Yet in theory, and but for the war, perhapsin practice I should be doing all those things. Itwould inevitably mean that some of my patients-theones I hadn’t quite the honesty or timidity to send tomy betters-suffered for my defects as a doctor. Butif we worked in groups I think we should get somewhere.There would be a man who did know about the com-plicated fractures, and another who really liked gynee-cology (fantastic), and it is on the cards that I shouldhave a detailed knowledge of my own. We should saveon equipment and surgery-space and nurses andsecretaries ; but that would be nothing to the savingin the service we gave to the patients. We would takeit in turns to be on at night, because no-one can functionpolitely and efficiently if he is really tired. We mighteasily avoid turning into those hard-working, self-
263
sacrificing men who labour to put into practice outworntreatments because they have no time to read of thenew. I think it would be a future to like, and I don’tmuch care what they pay me to live it.
I don’t know if we’ll get it. We might. We are a
generation that the old men, and our own easiness,havef deceived. But I do not think we shall fall intothe nihilism and let’s-laugh-at-it attitude of the inde-cisive years. We have seen something interestinghappen: a people who were said to be slack and
degenerate,. rise up and fight a war ; men who hadfallen for the success-story throw it aside for serviceand death. We ought to have grown pretty tough ondisaster; we are a generation that might even getwhat it wanted, if we knew what that could be..
We don’t know. I think group medicine is beingslowly accepted as a good idea ; we give lip-service atleast to the doctrine that every individual deserves thebest of treatment, but the mechanism is lost in theobscurities of the future. Who is going to pay for thework we do ? If the patients, can they possibly allinsure themselves for the same flat rate ? If the localauthorities, can we keep them from messing up our taskwith forms and papers, and special cases and politicalissues ? If the government, will they work it so thatthe patient has freedom of choice ?
.
There it.is: uncertainty. I only know for sure thatI want colleagues to help me and not as rivals, time tospare for reading and walking, good enough equipment,money enough to live, and a lot more experience. Some-thing to maintain medicine as an art and not as atrade, a background against which I can at least dosome of the good my friends would have done and did.These islands in the mist have always been the devil.Meanwhile I shall get down off my soap-box and see
if I can’t make the needle stay in for three bottleswithout getting blocked.
The Defence Services
THE Central Medical War Committee of the BritishMedical Association is responsible for the supply of alldoctors for the defence services, and the Celltral DentalWar Committee for the supply of dental surgeons.
Royal Naval Medical ServiceThe usual regulations governing entry of medical and
dental officers to the Royal Naval Medical Service aresuspended during the war and the only medical officersbeing admitted are those granted temporary commissionsin the Royal Naval Volunteer Reserve. After the warany vacancies will probably be filled by selection ofofficers from among those who have served in theRNVR during the war. A small number of womenmedical officers are serving as surgeon lieutenantsRNVR and one as surgeon lieutenant-commanderRNVR (at Medical Department, Admiralty).Candidates for the Roval Naval Dental Service must
be registered under the Medical or Dental Acts and mustalso have a registrable qualification in dental surgery.The position respectingl entry is similar to that existingfor medical officers.
Royal Army Medical Corps
No applications for regular commissions in the RAMChave been invited since the outbreak of war up to thepresent. It is expected when recruitment for regularcommissions is proposed, officers who served during thewar will be considered first. All war-time appointmentsare emergency commissions for the duration of thewar; no short-service appointments are being madeat present. Recently qualified doctors wishing tobe appointed to an emergency commission should applyto the secretary of the Central Medical War Committeeat BMA House ; or if resident in Scotland to the secretaryof the Scottish Central Medical War Committee, 7,Drumsheugh Gardens, Edinburgh, 3. Applicants shouldhave held an appointment either as house-surgeon orhouse-physician for 6 months.Women medical practitioners are required for
appointment to commissions in the Women’s Forces foremployment with the RAMC. They are required mainlyor general medical duties with the ATS. A number have
been selected for specialist duties. Women must beunder 46 and fit for general service. Applications mustbe made through the Central Medical War Committee.Applicants should have held an appointment either ashouse-surgeon or house-physician.ARMY DENTAL CORPS
No applications for regular short service commissionshave been invited since the outbreak of war, and it isexpected that vacancies will normally be filled bythe appointment of officers selected from those holdingwar emergency commissions who want to make the Armya career. All appointments are to war emergency com-missions while the war lasts, and recently qualified dentalsurgeons wishing to be appointed to such commissionsin the AD Corps should apply to the Dental War Com-mittee, 13, Hill Street, London, W.l, or if resident inScotland, to the Scottish Central Dental War Committee,c/o Dept. of Health for Scotland, Edinburgh, 1.
Women dental surgeons are appointed to commissionsin the Women’s Forces, mainly for general dental dutieswith ATS personnel. They must be under 46 and fitfor general service.
Royal Air Force Medical Branch e
Commissions in the medical branch of the RAF arenow given only to those appointed to the Royal Air ForceVolunteer Reserve for duration of the war. Shortservice and permanent commissions are in abeyance.Newly qualified medical officers are considered for
service in the medical branch of the Royal Air Forceafter having completed six months house appointment in acivil hospital. No appointments to commissions are madedirect by the Air Ministry; candidates must registerwith the Central Medical War Committee, which allocatesdoctors for interview and medical examination at theMedical Directorate, Air Ministry. Entry of doctorsto commissions in the Medical Branch of the Royal AirForce Volunteer Reserve is normally in the rank ofFlying Officer (corresponding to lieutenant in theRAMC) and promotion to flight lieutenant is automaticafter one year’s service providing recommendation forthe rank is satisfactory. There are from time to timea limited number of vacancies open to doctors holdingspecialist qualifications, and in selected cases a higherrank on entry is given. Medical officers on entry aregiven a short course of instruction at the MedicalTraining Depot and on completion of the course-
become available for posting. - Such postings may beto operational units, training units, recruits centres,general hospitals and station hospitals. In addition toordinary general medical work, there are the importantbranches of -aviation medicine and general preventivemedicine and hygiene. Medical officers are encouragedto make a special study of these. ,
There are now 81 women medical officers commissionedfor duty with the RAF as medical officers. They aremainly employed in the care of WAAF personnel.
There is a separate dental branch of the RAF, anddental officers are not appointed to the medical branch.During the war dental officers are being appointedthrough the Central Dental War Committee, which hasbeen organised by the British Dental Association.Entry into regular service has been suspended and allaccepted candidates are at present commissioned in theRAF Volunteer Reserve for the duration of the war.There are 19 women dental officers now serving.The Home Guard
The administrative structure of the medical serviceof the Home Guard has not altered appreciably sincelast year. Almost any practitioner will be welcome asa sub-unit officer with the rank of captain, or, if therebe a vacancy, as battalion medical officer with the rankof major. Above these there is a group medical adviserwho will have several battalions under his care, or a zonemedical adviser, a lieutenant-colonel having responsi-bilities three or four times as heavy. These medicaladvisers are the links between the HGMS and the ArmyMedical Services of the various Home Commands. TheHGMO wears the badge of his county regiment and untilrecently there has been nothing to distinguish him fromcombatant officers. He is now permitted, but notcompelled, to buy for himself and to wear a cherry