Medicine may find one of its greatest opportunities for service. In the intervals between the annual clinical weeks the Congress may interest various county hospitals somewhat removed from medical centers, to organize groups of physicians working therein. And when thoroughly organized with credentials acceptable to our fellows located in medical centers, certain of our fellows could then be designated to go to these country groups and there to hold clinical conferences on patients studied and presented by the men in the country group. In this way scientific progress could be brought to those unable for various reasons to journey to the medical center, and thus information and inspiration to keep abreast of progress would be imparted to such groups. The development of these Extension courses would moreover not be a difficult task for our Congress for we have already many competent members in every medical center in the country who, I am sure, would stand ready to journey forth to spread medical knowledge and enthusiasm amongst fellow workers in a common cause, the cause of suffering humanity. This, we feel should be one of our definite future objectives.

Next to our first main objective of post graduate medical education follows the second, that of the education of the public with respect to important problems of health especially in matters concerning medical legislation.

In conclusion, however, we shall merely touch on this subject as this question of medical legislation belongs more strictly under the jurisdiction of the American College of

Physicians, which body has already appointed a committee to consider and study this all-important theme in all its bearings. Suffice it to say that we in Missouri have had rather recently a most bitter experience resulting from our not having appreciated in time the paramount importance of safeguarding just laws regulating the practice of medicine. For in the twinkling of an eye, by the mere substitution of the words, "legally chartered," for that of "reputable" in the wording of our medical practice law, we medical men found ourselves in Jefferson City fighting a losing fight, for a pernicious bill was passed over our vehement but unfortunately all too-belated protests, and again graduates from "legally chartered" medical schools became competent to apply for licenses to practice medicine. In this way medical schools which had been closed as not meeting the requirements of the old law were reinstated, only to prove later to be those schools concerned in the subsequent Diploma Mill scandals. Fortunately, but only through hard fighting, have we regained our lost ground, through the repeal of the above iniquitous law and its substitution by Senate Bill No. 138 introduced by Senator Case and engrossed November 9, 1923, which through its wise provisions now makes it possible practically for only the graduate of a reputable medical school to apply for a license to practice regular medicine. But this happy result, as was said, has been attained by the sheerest hard work, and our former sad experience here in Missouri should be a warning to the medical profession as a whole,

first, that we physicans must dabble a little more in medical legislation, and must ever stand ready to defend our rights in our legislative halls, where we must always have our best interests watched by those competent to do so.

In this month's issue of the Southern Medical Journal there appear editorially the following pertinent suggestions:

The various states have their own laws governing the practice of Medicine, and these laws are by no means uniform. In order that the public may be protected against incompetent individuals who propose to treat disease the states shall have one law providing for the practice of Medicine, which fixes the standard of literary education to be required of a student for entrance into a medical school and also fixes the number of years of study in a medical school that must be complied with before an applicant may be granted a license.

When everyone who proposes to treat disease is required by a body, which is the

same in every state, to furnish evidence of having had at least two years of literary college work and a diploma from a chartered medical college which requires four years of study, then there will be no longer any place for the irregular who has been accustomed to complete his training in a few weeks or months. The regular profession does not need laws to protect its members from irregulars, but the public does need protection against incompetent irresponsible individuals who are professing to treat the sick. It is for the medical profession to sponsor increasingly more adequate means of supplying this need. If the proposed cabinet office controlling health and education were instituted, this problem could be solved best by it.

The key-note thus sounded by the Southern Medical Journal should inspire all to work hard and unceasingly for uniform laws regulating the practice of medicine in this country of ours, and also to ever cherish the hope and keep up a concerted effort for the establishment of a medical man in our President's Cabinet.

FO

JOR several years there has been a tendency in all walks of life for individuals to associate themselves in order to function more economically and efficiently or to secure other advantages by concentrated action. With physicians this has evidenced itself in Medical Societies and Hospital Staffs, and more recently as the so-called Clinical Groups or Clinics.

The efficient and The efficient and

economical medical care of associations or groups is not an innovation. Military medicine for example has been based on this principle for centuries, and large industrial concerns and charities have long supplied some form of treatment for their employees or wards. The more or less voluntary associations of individuals for health supervision and medical care are of more recent origin, and it is with these that I am at present concerned.

The German insurance societies, followed somewhat later by the English plan are the most conspicuous examples abroad. In this country for some time employees of large concerns have formed associations for medical and surgical care and health instruction. I am especially familiar with the Missouri Pacific Hospital Association. This association is an outgrowth

1 Presented before the American Congress on Internal Medicine, St. Louis, Mo., February 20, 1924.

of a surgical service installed by the railroad company to care economically for injured employees, and to reduce damage claims for such injuries to a minimum. From this the employees themselves have built up an association, now numbering about 40,000 members. This association assesses dues on a graduated scale, averaging a little over $1.00 per month for each individual. These assessments are regulated by vote of the various craftorganizations who have several times increased them by an overwhelming majority. For this each employee receives medical and surgical care for all but acute venereal diseases including hospital service. The association owns over $1,000,000 worth of property at various points along the system and is comparatively free from debt. The St. Louis Hospital has a capacity of 300 beds with complete modern equipment and a staff of about 40 physicians, representing every medical and surgical speciality. These physicians devote anywhere from full time to one hour per week to this work. Had this association not been successful from the standpoint of the patients it could not have survived nor would the members have submitted to constantly mounting assessments for its maintenance. While perhaps one of the largest and best organized associations of this type it is only one of many, not only

Another group of associations modelled along similar lines, which has very recently come into prominence is the Students' Organizations of our Colleges and Universities. In

answer to a questionnaire recently sent out by Washington University, some such association was found to exist in 26 colleges and universities, with a well-developed health and medical service for students in at least a dozen of these. The University of Minnesota will serve as an example. This University gives its students health instructions, and cares for practically all their medical and surgical diseases including hospitalizaton for a fee of $2.00 per quarter or at the rate of $8.00 per year. Full and part-time physicians, and surgeons and other specialists are employed. Considering the economy which a university can exercise in laboratories, hospital and parttime physicians, the fees closely approximate those assessed the employees of the Missouri Pacific Railroad. Other universities' assessments range between $2.00 and $10.00 per academic year, depending on the completeness of their organization.

To what is all this leading us? Should we as internists oppose or cooperate in these movements? Labor as a class opposed labor-saving machinery for fear of unemployment but instead it has meant added comfort and luxury, because it has opened new fields with consequent new demands. Hassig in the American Medical Association Bulletin objects to what he calls "Contract Practice," on the ground that many persons revel in prepaid medical service and make

physicians. He suggests that such cases would take care of themselves if they were compelled to pay a fee for each call. He feels that these patients make the practice monotonous and the physician does not take time to give proper study to individual cases; therefore he falls into the rut of routine prescribing and does not do scientific and careful work.

In most of the modern associations physicians do not make house calls except in emergency, and patients are treated either at dispensaries or in hospitals. Thus the physician can regulate his time and give proper attention to individual cases. Routine prescribing is reduced to a minimum by proper supervision of younger physicians and consultations at frequent intervals. The class that revels in prepaid medical service is largely the class who, through some mental instability, become introspective. This class if not familiarized with the best in medical examination and treatment drifts to the chiropractor, osteopath or christian scientist, and if by chance the psychology of a cult benefits them they become enthusiastic missionaries.

Such patients, if held to "prepaid medical service," soon learn the advantages of scientific medical diagnosis and treatment and are difficult to convince that the pseudoscientific cults can substantiate their claims. Thus instruction of large numbers of our intelligent wage-earners and students cannot help but be of great value in disseminating medical knowledge, and thus indirectly render a real service to physicians throughout the country. The greater number of physical

examinations and the more intensive study of cases require the employment of many physicians, so that in the end these associations at least break even with the Medical Professions in a

financial way. Certainly they will help to refute the statement so often heard, that only the very rich and the very poor can secure adequate medical examination and treatment.