The Massachusetts Medical Society and Socialized Medicine

Annual Oration 1939

By Elliott P. Joslin, M.D.

Each member of the Massachusetts Medical Society is a unit in medicine and each doctor has been a unit in social medicine from the days of Hippocrates. Intertwined with his zeal to heal the body he has had "the desire for removing human error, clearing human confusion and diminishing human misery." But today individuals are apt to count for too little and the public looks to groups or to the state itself for guidance. So in medicine it either pays little attention to the single doctor or overrates him, while it stares at the armies of organized medicine in the United States, the medical societies and the medical schools. I, for one, believe in the unit, believe in the individual, love his initiative, admire his competitive spirit and above all trust his conscience, though I am not unmindful of the demand of the public that we as a profession exemplify in our societies and in our medical schools by measures and acts our highest aspirations, and I hope we shall not be judged by our ofttimes pitiful performances. There is no gainsaying the necessity for our societies and our schools to be as jealous of their reputations as we as individuals are of our own.

This need for the medical society and the medical school to express convictions and give advice is all the stronger because a generation ago the influence of the doctor as a unit in social medicine was far greater than it is today. This was largely because at that time the number of educated men in the community was so much smaller and the standing of the lawyer, the minister and the doctor carried more weight. Their opinions were sought more, and each one dealt more intimately with the social problems of his circle than did representatives of other groups. It is natural that with the expansion of education among all classes, the influence of the doctor in molding society and determining its action has decreased. Former President Lowell has often deplored this fact and urged doctors to take a far more active interest in civic affairs, and in this we will all agree, but besides this we must see to it that our groups of doctors in their medical gatherings do so too, and by their enlightened action demonstrate their altruism and their desire for the common good. If we doctors do not have as much influence among our fellows as a century ago, it is to some degree our own fault because we have become too much engrossed in our own individual medical lives. It is not strange that our medical societies and schools have been far too much concerned with purely technical medical problems, because these have become so manifold with the rapid development of medicine.

Each member of the Massachusetts Medical Society who, like Dr. Homer Gage or Dr. George Sears, takes up hard, trying and often thankless tasks for his city not only deserves our constant admiration, but serves as a stimulus for the rest of us in lesser ways and in smaller environments to exert an influence for good. These have made the public aware how earnest and self-sacrificing doctors can be, just as the work of the Massachusetts Department of Public Health is a constant reminder of the purpose of our state to safeguard the health of its citizens. More duties are constantly being placed upon the department so that perhaps at this moment it is more active in promoting sound medicine than ever before.

Thus far you perceive that I have been talking about social medicine, and in so doing I stand on solid ground. I much prefer this term, "social," to that of "socialized medicine," which I think few of us want and most of us hope through the advancement of social medicine can be deferred and time thereby allowed for a revision of methods proposed, which if promulgated today might engulf us.

It is difficult to estimate the individual doctor's efforts in social medicine, and I doubt the desirability of doing so. Although your committee finds that a single doctor probably treats nearly a hundred patients a year without any financial return, and if working in a hospital, many hundreds, consuming six to ten hours a week in the process, it is a question in my mind if he may not do more and actually better social medicine when he treats his other patients either at reduced cost, enabling them to save their self-respect, or even the remainder at full rates. You cannot measure a doctor's social value by what he does for the poor alone. He may exercise a far higher type of social medicine when he raises the morale of a capable but discouraged manufacturer or salvages both the soul and body of a millionaire. The survey of the committee on the number needing medical care appears to show that those unable to secure it in this state is really very small indeed.

Health Councils

Certain units of our medical society several years ago took a strong stand in favoring the creation of health councils. In these were represented all those agencies which were concerned in the health, and often charitable, activities of a given community. As an example I may cite the Massachusetts Central Health Council. Obviously any association which brings together all societies working in any way toward health is an advantage, because it promotes efficiency and reduces cost. Already in Springfield such a council has been established under the name of the Health Promotion Council of Springfield, and still another on Cape Cod under the designation of the Cape Cod Council of Health and Social Agencies. The Massachusetts Central Health Council represents eighteen different organizations, and some of these are made up of many constituent parts. This Massachusetts Central Health Council has cooperated closely with the Massachusetts Medical Society in its efforts to raise medical standards and guide legislation along progressive and sensible lines.

Our fellow member, Dr. Michael A. Tighe, in a radio broadcast on December 14, 1938, set forth very strongly the benefits which accrue from the organization of a health council. He brought out not only the desirability but the necessity for such councils, and touched upon many of the problems in which our members should take a more active interest. This endeavor to promote the improvement of sanitation and health, housing, nursing and medical care of the poor of a town, a city or a county requires more than the work of an individual; it requires the laborious, united and unremitting endeavor of groups of individuals and societies. Doctors, by actively taking part in all such agencies seeking the betterment of health, may demonstrate their availability and willingness to co-operate. Their experience and wisdom, so necessary in the plain everyday details of relief work, whether medical or otherwise, will become known and appreciated if they enter wholeheartedly into the work of all charitable societies. Only by joining in such work can one learn and be able to point out how present facilities can be more wisely used. Incidentally, in this manner the doctor will learn on a large scale, what his clientele has taught him on a small scale, the social as well as the medical wants of the indigent, and so he can drive home the idea that just as food, clothing and housing are contributed to the needy, medical aid should be provided as well, and not wholly as a matter of charity by the doctor. By utilizing these forums of the health councils, established in communities throughout the State, members of our society can emphasize that there is not so much a lack of medical facilities as there is the need, as Dr. Tighe says, for their better distribution.

It is unfortunate that more of these health councils have not been organized. Only those who have participated in their meetings can fully understand the good which they do. Unquestionably they are composed of our friends, but sometimes even our friends have not understood completely the desires of doctors, either individually or collectively, to improve medicine, simply because we doctors may object to some special measure which, although perhaps good in itself, we believe to be impractical for execution at the moment.

Associated Hospital Service Corporation

The avidity with which the public has taken advantage of the provisions of the hospital-service corporations is a good index of the kind of socialized medicine which the people want. This type of organization is still in its infancy but in the United States during the last few years the membership has grown so rapidly that 3,500,000 individuals were enrolled on April 1, 1939. The Massachusetts unit is the fourth in size in the country and by the first of May this year the enrollment totaled 181,881 individuals. When more than 3,000,000 of the citizens in this country take up a project of this kind so quickly, it is self-evident that it has filled a need. In consequence we may anticipate that it, or a modification of it, will be adopted by many more millions. That the organization has been developed as a private agency instead of a public undertaking and is not political is all the more in its favor. That there is interest enough in the plan to have aroused a desire for hospital insurance at ward rates as well as for semi-private accommodations should encourage everyone, because this is evidence that an increasing number of our population wish to be independent and self-supporting. Nothing has heartened me more in the work at camps for diabetic children than the wish of the parents to bear a portion of the costs. People do not like to be on the dole or on anything which suggests it. I am sure all of us are eager for the Associated Hospital Service Corporation to extend itself.

By no means can the medical profession claim all the credit for the good this organization is doing, but fortunately the medical profession has shared in its activities. Not the least of the many benefits from this new trend in medicine is the opportunity which this organization has presented to study on a relatively small scale what is likely to happen if similar facilities on a large scale should be offered the public. At first it appeared as if the corporation's assets were accumulating too rapidly, and then the trustees extended the benefits of membership. It is perhaps fortunate this spring that the reverse became true, and I know of nothing which will lead to more careful and sober thought about the extension of benefits conferred by medical-service organizations than the fact that it has been necessary to defer hospital payments 25 per cent in New York City and 20 per cent here in Massachusetts. So great had been the surplus early in the year that an extension of services was arranged so that payments originally covering actual hospital cost were increased to include costs for x-ray as well. I am sorry that the hospitals concerned were not consulted before this decision was reached. When we remember that the trustees, who are in charge of the organization here and of similar organizations elsewhere, are citizens of the highest type and wide experience, and yet that the possibilities of deficit were not adequately foreseen, it proves to each one of us the necessity for careful deliberation before extending the scope of any plans for the simplification of medical care. The Associated Hospital Service Corporation has the good wishes of us all. We know that its directors are exercising their best judgment. If the plan runs into pitfalls, as it did this spring when colds became more prevalent and people sought to get back their money's worth by a good rest in a hospital, that is all the more to the good, because it teaches us how easily funds are exhausted. When such a scheme temporarily fails, moreover, we realize that any deficit must be borne by the doctors and nurses and hospital employees, rather than by those who execute the undertaking.

Prepayment of Medical Care

It is only a step from the socialized—and this time not social—Associated Hospital Service Corporation to an organization for the prepayment of physicians' services. How quickly we move! Who would have thought of that a decade ago? And how skeptically such a plan would have been regarded! Yet after deliberations occupying less than a year, the Massachusetts Medical Society stands committed to it. It has gone still farther and voted not only to take the initiative in it as soon as an enabling act is passed by the legislature, but also to organize a corporation to carry it into effect. Such speed is spectacular. How valuable it is for critical study that there are so many organizations—I understand there are 450—throughout the United States which have in one way or another devised plans for the prepayment of doctors' fees. It is unfortunate that people generally are not better acquainted with these experimental efforts. Whether one or more organizations independently or in conjunction with the Massachusetts Medical Society will form corporations to take part in such prepayment plans is not essential. Possibly it might be better to have several undertake such activities, because each could profit from the mistakes or successes of the others. Furthermore, the members of each group might have had earlier experience in such undertakings based on contacts of a social, religious or professional nature. Again, just as in the case of the hospital service plan, one of the chief advantages of multiple prepayment medical service plans may be that they will furnish information which later might be of service to governmental units, large or small, when dealing with the care of the sick poor. The more errors we can discover on a small scale, the less catastrophes there will be on a large one.

The Wagner Act

In any discussion of socialized medicine before the Massachusetts Medical Society the Wagner Act must be mentioned. Few if any of us would approve of it in its entirety, and I think I voice the opinion of most of you when I say that the Society would like it to gestate in committee a long time. I suspect that you and I are opposed to it as it stands, first, because we as a society and as individuals are opposed to going into debt, and therefore cannot approve of the expenditure of nearly $100,000,000 the first year and approaching $1,000,000,000 a few years hence. Second, a nation that is in debt, like the individual, is subservient to someone else. We do not wish to be subservient to anyone, even to our government. We wish our independence. Third, the health of the people in the United States is so much better than that in other regions of the world, except in certain small nations, that no radical revision of health measures should be attempted which disregards and discards those which have already yielded so many benefits.

It may be claimed that we have more wealth and more natural resources than other countries, and that these facts and not our present medical customs are responsible for the health of our people, but that is our good fortune. It is surely true that our health is improving by leaps and bounds under our present conditions. I have studied one disease thoroughly and have seen it for myself in various countries, and I know, so far as that disease is concerned, that the United States can challenge the world. I am not aware of any area anywhere where the average of medical care of diabetic patients is better than in Massachusetts. As proof I can say that the new patients consulting me this year have already had the disease longer than their total life span twenty-five years ago. The illnesses which we encounter in those classes of the community and that stratum of society where the health is poorest are by no means wholly due to poor medical care or to poor doctors, but rather to unemployment, for which the doctors are not responsible. When business is good in this country, there is comparatively little complaint about poor health or inadequate medical care.

Fourth, even if one grants that socialized medicine, as we understand the term, is desirable, to extend it at one stroke to 40,000,000 people in the United States is dangerous, because we have not the medical personnel sufficiently trained to do the actual work, much less to supervise it. This danger is best foreseen by those who are most competent to judge, namely those who are actively concerned on the firing line in health work. The number of doctors in the United States Public Health Service was 2212 on April 8, 1939. There were 6230 other employees and 4823 doctors connected with state and county health departments holding appointments in the United States Public Health Service with nominal compensation at the rate of $1 per annum. One is appalled at the thought of the appointment of doctors by the Government sufficient to raise the number to 40,000 because at present competent doctors for the task have not been trained. Expansion of the work for the care of the sick must proceed slowly, especially if it is to be along lines which are entirely different from those which have been utilized in the immediate past.

Fifth, politics already play a part in health matters. Although recruits for important posts are available from the United States Public Health Service, they are passed over. I fear to turn 40,000 appointments into politics until the community as a whole has so emphatically expressed itself that politicians will not dare to tamper with the health of the people. If the army of 40,000 appointees came under the central authority at Washington or even at state capitals, think of the control which might be exercised through these political appointees on the 40,000,000 people for whom they would care! The political interference with the minor policies of the Boston City Hospital is an illustration of the petty politics which can make it so disagreeable to assume public office as to deter many able men from accepting positions of responsibility. On the whole, though, I am under the impression that the public sees through this campaign of innuendo and condemns it more today than it would have done a few years ago.

If we could expand the United States Public Health Service gradually, I venture to say that much of the opposition to a rearrangement of the care of the indigent sick would melt away, because both doctors and the laity would have time to note the advantages and remedy the shortcomings of this metamorphosis of medicine.

Sixth, we are not satisfied with the present setup for the WPA or Social Security agencies, and it is conceded that changes should be made in the original acts. Why not attempt to perfect these huge departments of the Government before inaugurating a nation-wide health program soon to involve a billion dollars? Let us profit from failures in similar projects. There is no harm in a little delay, because the health of the country will be improving in the meantime. Here in Massachusetts beds for tuberculosis are beginning to be empty, and there is a diminishing cancer waiting list at our state hospitals.

Seventh, the allocation of medical funds causes apprehension. We fear that to certain states with relatively good health conditions—and these are particularly those states which furnish high revenues to the Government—where four dollars more or less are now appropriated per capita for health the allotment might be reduced to forty cents or thereabouts; and to those states expending forty cents per capita, four dollars might be assigned. Perhaps we should be so altruistic as to forget this possibility. Nevertheless we do not want to give a prize of four dollars a head to that state which shows it takes the poorest care of the health of its citizens.

Eighth, to institute an enormous hospital building program is disturbing and its advisability is questionable. Hospitals of a voluntary nature and also those of a public nature are increasing with astounding rapidity. It is reported that in 1938 the equivalent of a 101-bed hospital was erected each day in the year throughout the country. Yet at times nearly 30 per cent of the beds in voluntary hospitals are vacant. I am sure that all of us feel that available hospitals should be utilized before new hospitals are built. Arizona may need 1000 new beds for tuberculosis, but would it not be cheaper to utilize the 500 vacant beds for tuberculosis in Colorado for this purpose than to build sanatoriums for a disease which is diminishing at the rate of 5 to 10 per cent a year throughout the whole country? In Arizona the mortality rate from tuberculosis in 1925-1927 was 366.0 per 100,000, but it dropped 27.3 per cent or to 266.2 in 1935-1937. In 1938 the rate (provisional) from tuberculosis was 178.8 per 100,000.

Everyone agrees that medicine can improve now and forever, but let us look before we leap and not by mistakes undo the good that has been done. I hope our Washington friends will not hurry us doctors. If they will give us a little time, we shall save their constituents money and produce better medicine, and most of it at our own expense.

Education, Postgraduate and Undergraduate, in Massachusetts

The education of the doctor represents the highest type of socialized medicine which the Massachusetts Medical Society can foster. Upon the Society rests a distinct responsibility in this regard, because of the 7528 doctors in Massachusetts there are 5109 who belong to our organization. In other words, our members are directly responsible for the health of more than two thirds of the people in the State, and it is up to us to see not only that we take care of these people well, but that we throw our influence toward good care for the remaining third of the population. If it is the duty of one of our members to take an active interest in the medical affairs of the people in his immediate environment, it is equally important for our society, representing all its members, to take a strong stand for the improvement of conditions in the State as a whole. Education is a business in Massachusetts. Those outside the State realize that education is one of our chief undertakings; yet when it comes to education in medicine there are very few states in the Union which recognize those licensed by our board as fitted to practice within their borders. All will admit that such a condition is intolerable. Little is said about it, but I think the time has come to air the question openly.

Postgraduate Education

First of all I shall discuss the postgraduate education of the physician. This amounts to far more than the laity, the medical schools or we, as doctors, have begun to realize. A few days ago in St. Louis I learned that of eight questions propounded in one examination to a candidate for qualification as an internist, there was but one which could be answered by what he had learned during his four years in a Class A medical school. One of the chief functions of a medical school today, therefore, must be to warn its students that their education has just begun, and to show them how they can most easily and advantageously continue it.

We can be justifiably proud of the advances which have been made in the last five years, and indeed this very year, in Massachusetts. The New England Postgraduate Assembly held in Cambridge last fall attests the eagerness of our members for knowledge. As a Harvard Medical School graduate I am proud that Harvard University gave us Sanders Theater for the purpose. This year the two days of instruction should be even better, and I know that your committee is gathering ideas from neighboring states regarding the possibility of expanding this teaching into institutes along specialized lines continuing for some months of the year.

Look at the excellence of the postgraduate courses given this winter and spring in eight districts of the Massachusetts Medical Society close to the offices of the doctors participating. The subjects were: anemia, Bright's disease and hypertension, heart disease, gonorrhea, syphilis, obstetrics and pediatrics. These courses and the attendance at them refute any idea that the doctors in Massachusetts after their graduation are backward.

Team play characterized the organization of these extension courses. The Massachusetts Medical Society, in co-operation with the Massachusetts Department of Public Health, the United States Public Health Service and the Federal Children's Bureau, united in effort. This represents socialized medicine at its best. But here I wish to state what I have been told authoritatively, that the above program was made possible largely through the help of the Massachusetts Department of Public Health, and that it was furthered wholeheartedly and actively by the present health commissioner, Dr. Jakmauh, and if we doctors want still more postgraduate instruction, I am confident we shall find the commissioner anxious not only to assist in the program but to secure the funds.

But do you realize that this official postgraduate instruction is not half the story of postgraduate teaching in this state? There is much of what would be called in academic circles extracurricular teaching. Hospital units are giving not only their own courses to the doctors on their staffs and neighboring doctors, all of whom are welcome, but also courses which are all the more valuable because they are open to the laity, and thus the whole level of medical knowledge is being raised. These are, in large part, outgrowths of the Sunday lectures to the laity at the Harvard Medical School and Dr. Henry Christian's clinics to doctors at the Peter Bent Brigham Hospital. It will not take long for the people themselves to learn how important it is to have up-to-the-minute physicians and surgeons. Students, Dr. Keen long ago pointed out, yelp at the heels of their teachers, but now the public is barking at the heels of us old practitioners.

The reason why Massachusetts has the distinction of a falling cancer death rate, so I am informed by those who know most about it, is explained by the instruction given to doctors and by them to the laity through the aid of our society and organized under the direction of Dr. Herbert Lombard, in charge of the Division of Adult Hygiene of the Massachusetts Department of Public Health. Just as Dr. Vaughn in Detroit has enlisted practicing doctors as his allies, so here you have been enlisted and in fact have become auxiliary health officers of Massachusetts. Please note that you are doing this without appointment or recompense from Washington!

Undergraduate Instruction

Our methods of postgraduate medical instruction place us in an enviable position, but what can be said of undergraduate medical instruction in Massachusetts? As an introduction to this discussion let us first of all consider how many yearly replacements are necessary in order to maintain the present number of doctors in Massachusetts. Granted we have doctors enough, how many additions are required to maintain the existing 7528 doctors? Let us assume that physicians begin the actual practice of their profession at the age of twenty-seven. The life expectancy of men in the general population at this age is forty years and of physicians it is essentially the same. This must be about right, because the average age at death of 3768 doctors in the United States for 1938 was 65.6 years and that would limit them to thirty-eight years of practice. But this estimate is far too high, in my opinion, because so many give up medicine, retire or follow other careers long before this age is reached. As a safer criterion for the determination of the number of yearly additions to the medical profession in Massachusetts I have adopted another method. In the year 1909 the number of graduates joining the 134,402 doctors then in practice in the entire United States was 7246, a ratio of 1:19. At that rate the replacement would be complete in nineteen years. In 1938 the replacement ratio was almost the same, 1:18—9527 to 169,628. Since these ratios are so constant we might assume on this basis that doctors practice on the average about twenty years, and therefore here in Massachusetts we should need 376 additions to our numbers every twelve months in order to maintain our quota. Where shall we secure these 376 doctors?

This leads to the question, Where have Massachusetts doctors secured their medical education? In the American Medical Directory for 1938 are the names of 7528 physicians in Massachusetts. Table 1 shows that they received their medical training in 193 schools. Harvard supplied the most with 1816 names, closely followed by Tufts with 1704; next came Boston University with 598, followed by Middlesex with 232. The College of Physicians and Surgeons of Boston had 151. The University of Vermont had 189 graduates in the list and Yale had 73, or a scant 1 per cent of the total number.

If all the graduates in 1938 from Harvard, Tufts and Boston University (the three Class A medical schools in Massachusetts) settled in this state they would have furnished only 279 doctors, or 97 less than the quota of replacements. It is doubtful, however, if the ratio of new doctors coming from all these schools, compared to the total required, is any greater than the ratio in the State already practicing, namely 55 per cent. Reducing the total number of graduates, 279, to this percentage there would remain, therefore, only 153 doctors from Massachusetts Class A schools opening an office in the State, thereby making it necessary for us to obtain 223 doctors from other institutions. Is it not important for the Massachusetts Medical Society, if we hold ourselves responsible for the medical welfare of all who live in the State, to consider the educational backgrounds of these 223 men? How many of them will come from unapproved medical schools I do not know, but I venture to say nearly a half. Indeed it appears that Massachusetts welcomes doctors from unapproved schools far more than any other state in the Union. Thus for the five years 1934 to 1939 the total number of graduates from unapproved schools registered in the United States was 866, and of these, 311, or over 35 per cent, secured their registry in Massachusetts; although they have not necessarily remained here to practice medicine, the Commonwealth has in a way become a dumping ground for these graduates.

The educational qualifications of these men unfortunately are evidently even worse than the badge of an unapproved school would imply, if the results for all examinations held by the Massachusetts Board of Registration in Medicine are similar to that in March this year, when of the 193 taking the examination 112 were repeaters, and all these repeaters were from unapproved schools, in contrast to no repeaters from approved schools. With socialized medicine creeping on us in one form or another, it behooves the citizens of Massachusetts and the Massachusetts Medical Society, the guardian of its health, to see to it that we shall not receive and allow to practice here men with such obviously inadequate training, so inadequate in fact that they are practically excluded from participation in medical work in all but a few states.

Some years ago while conducting a clinic for a group of students I showed as one of my patients a two-year-old child. The story ran that at the age of one year and nine months, while at a summer resort, she became ill and her parents called in the only available doctor, who chanced to be a very young man. Nevertheless he grasped the opportunity, studied the situation carefully and asked for a specimen of urine. The child had diabetes. The symptoms and signs of the illness had not been particularly outstanding, but the alertness and thoroughness of the doctor resulted in that early diagnosis which is as important in diabetes as in tuberculosis. And now eight years after beginning to take insulin the child looks as healthy as her companions and perhaps even more so. The moral of this story, which I pointed out to the students, was not that the doctor was young, alert or painstaking, but rather that he graduated from Middlesex, where despite the meagre instruction offered he had learned enough to make a diagnosis.

I consider it appropriate, therefore, that I discuss from the point of view of socialized medicine the situation at the Middlesex University School of Medicine. This school was founded in 1849 as the Worcester Medical Institution, later was forced to suspend, reopened in 1914 as the Middlesex College of Medicine and Surgery, subsequently becoming Middlesex College, and in 1937 was absorbed by Middlesex University. The early records were lost in a fire, but from June, 1915, to date it has graduated 918 students. For the years 1934 to 1938 inclusive its graduates stand in numbers next to those of Harvard, Tufts and Boston University (Table 2).

Two hundred and thirty-two graduates of Middlesex were practicing in Massachusetts according to the American Medical Directory for 1938, and probably a considerably greater number, estimated at 640. Only a part of these doctors passed the state examination at their first trial, and I suspect many required three or more trials. Not a single one of these graduates was passed by the National Board of Medical Examiners because that board will not allow them to take the examination. Yet, according to the catalogue of the Middlesex University School of Medicine for 1939 and 1940, there are 304 students now in that school preparing to enter the practice of medicine, and they can hardly escape knowing that when they have finished their course they must settle in Massachusetts or in one of a few other states in the Union.

What are you as members of the Massachusetts Medical Society going to do about it? Before attempting to suggest an answer to that question I shall ask, What is Middlesex going to do about it? This is particularly important because in January, 1941, the school comes up before the authority which by law has been created to decide whether its graduates are to be admitted to Massachusetts examinations.

Middlesex University School of Medicine has wonderful opportunities before it, relatively far more, and also relatively far more easily attained, than those of Harvard, Tufts or Boston University. Will it seize them? In order for it to do so there seems to me to be certain essentials, which I shall enumerate.

A Reorganization of the Board of Trustees. The days of proprietary medical schools or of schools with the least semblance of control by a few interested, though excellent, doctors, especially by teachers on its faculty, have passed. The country will not tolerate them. The public demands that the trustees of medical schools shall be divorced from personal interests in the education of the students. Here lies, in my opinion, the first and greatest opportunity for Middlesex. If that medical school should have on its board of trustees men like Mr. Stuart Rand, who organized this year's Community Fund of Boston and is now, to the satisfaction of us all, a trustee of the Boston City Hospital, Father Robert Barry of the Catholic Charitable Bureau, whose name is a household word because of his unremitting interest in all our state and city charities, Dr. David Scannell, whose years of service on the Boston School Board and of devotion to the Boston City Hospital receive just acclaim, and Dr. Charles F. Wilinsky, whose lifelong work in many capacities, combined with extraordinary organizing ability, has been for the highest ideals of health for Boston, then most of the prejudice against Middlesex would disappear.

Better Equipment and More Funds for Teachers. The education of students at Middlesex is deficient, and in order to provide better education more money is needed for equipment and faculty even though it has built new buildings and added many full-time teachers. The students pay $410 yearly, and still larger sums if we add the amounts to which they are obligated by the purchase of books and other fees, but large as is the aggregate from 304 students, we know it is insufficient. It is said by some that the minimum amount per year per student necessary to furnish a suitable medical education is $1000. The medical schools of Harvard and Yale universities have budgets far in excess of this amount.

Yet if one may tread upon dangerous grounds, may I point out two facts? First, that so far as published very little of the money of Middlesex goes to research. The word "research" appears upon one page alone in its 1939-1940 catalogue, and ideal as it is to have research in a medical school, there is something to be said for the pedagogical education of medical students, pure and simple. It is true that at the schools with the highest budgets the education of the student is not a byproduct of medicine, but it happens that along with the teaching of medicine those schools have such an honorable history and their management is so trusted by men and women of means that they have been endowed with large sums for research which swell their budgets and in their administration help to raise the standard of education and ideals of its student body, although few would claim that they were absolutely essential to the education of students.

No one favors more, or seeks more zealously to promote, research in medicine than do I, but we are faced now with a definite dilemma here in Massachusetts in that we need good doctors; if the three Class A medical schools cannot or do not furnish them we must seek them elsewhere, and under the existing laws of the State it is certain that for the next six years at least a considerable proportion of these men will come from Middlesex.

Great improvement in the medical education offered at Middlesex could be accomplished without tremendous changes in its budget. If one of the larger medical schools in the country should strive to increase its budget 10 per cent, it might require $100,000 or the interest at 3 per cent on over $3,000,000, whereas if Middlesex increases its budget 10 per cent, the sum would be much smaller. That would not be enough, to be sure; but suppose Middlesex should expend next year $30,000 additional on equipment and teaching and the following year do the same or add another $30,000, what would you say to that? Probably you would reply that the budget would still be inadequate, and especially so, because Tufts and Boston University are each seeking an additional $1,000,000 in endowment although their budgets are greater than that of Middlesex. I grant your contention that a $1,000,000 endowment alone or its guaranteed equivalent of $30,000 a year for its budget would still be inadequate to make Middlesex a Grade A medical school. Something else is necessary.

High Standards for Admission of Students and Limitation of Enrollment. The number of students in Middlesex appears excessive according to generally accepted standards for the facilities offered. In the Middlesex 1939-1940 catalogue there are 107 students in the first-year class, 76 in the second, 54 in the third and 67 in the fourth. Many will take exception to the contrast between the number enrolled in the first-year and fourth-year classes, but this is largely due to the increasing size of the recently entering classes. Nevertheless, a limitation of students brought about by higher premedical requirements both in scope and passing marks for admission, and limitation of the total numbers of students in each class to an enrollment which is considered reasonable by the great majority of medical schools in the country would seem to be absolute requisites on the part of Middlesex if it is to gain the respect of both citizens and doctors in this state.

To make good doctors, one must start with good men. One can give good technical training to a man for four years and teach him much about medicine, but unless the man has native talent and ability, he will not be able to take his place in the community or in the field of medicine. In this regard, a college (premedical) course of at least two, and preferably three or four, years in a recognized college serves as an excellent proving ground. If the man survives this, makes good marks and shows evidence of good moral character, he is much more apt to make a good doctor.

More clinical facilities for the education of students are necessary before Middlesex medical students can receive what many believe to be sufficient medical education, and at the moment these facilities are not available to them. The students are in the position of the small boy whose mother says he must learn to swim, but does not arrange for him to go near the water. And yet there are plenty of clinical facilities in the State which are not utilized. With automobiles today one can travel far. Already we have sanatoriums for tuberculosis belonging to the city, the county and the State. We have state hospitals. There is Tewksbury, 25 miles from Boston, a state institution where a wealth of superb clinical material exists; and as everyone knows, as soon as students are admitted to a hospital, standards of treatment advance. I believe doors would swing open in other hospitals if the requirements listed above were met.

Attitude of Alumni. Finally, the attitude of the alumni of Middlesex toward medicine in general and their alma mater in particular will do more to advance that school than anything else. The alumni know best the disadvantage under which they labored in securing an education and the embarrassing situations in which they have been placed since graduation, when they are asked where they graduated, and the difficulties they have encountered in obtaining hospital training unless they have gone far afield to secure it—to Vienna, Germany, France or England. They more than any others can bring pressure on their alma mater to improve existing conditions, and more than any others can help by the combined expression of their views on the points I have raised and especially by securing funds to finance such a plan. There have been 918 graduates from Middlesex since 1915. Probably a half to two thirds of these are now living and practicing in this state. If it was demonstrated to these men that the school would be reorganized, changes made in its board of trustees, stricter scholarly requirements enforced for the admission of students, limitation of enrollment and an open-book financial policy adopted, I believe that those men could secure from their own number, their patients and friends guarantees of $30,000 yearly for the next two years toward the maintenance of the institution, and it would be for their own personal advantage to do so as well.

If Middlesex University School of Medicine could be raised out of the class of unapproved schools—and that is what I should like to see done—I suspect it would be as zealous as Harvard, Tufts, Boston University and the Massachusetts Medical Society to exert its influence in urging that Massachusetts follow the example of the country as a whole and forbid graduates of unapproved schools in the future from entrance to our state-board examinations.

The Attitude of the Massachusetts Medical Society Toward Middlesex

It is all very easy to say what Middlesex could or should do, but what shall be the attitude of the Massachusetts Medical Society toward Middlesex? First of all, may I point out what our society is already doing? One hundred and twenty-two of their graduates are already members of the Massachusetts Medical Society according to the American Medical Directory of 1938, and very likely twice or thrice this number. As soon as any others can meet all our requirements they should be admitted to membership. Once admitted, they are on an equal footing with all our members in our meetings and on our committees. They are fellow members, and for each fellow member of the Massachusetts Medical Society all its members have a personal interest and responsibility.

Second, the Massachusetts Medical Society is fostering graduate courses. These courses are steadily increasing in number, diversity and excellence. All are open to the graduates of Middlesex, whether or not they are members of the Society. This is an illustration of what we are doing to help physicians who may not have had all the opportunities they desire. And I may add here that of the 120 doctors attending the last three sessions of the special courses for graduates given by the Suffolk District Medical Society, 26 came from Middlesex. Middlesex was well represented on the committee which planned the courses. I consider it very essential to have this fact stated, namely, that the Massachusetts Medical Society is already doing a great deal in an educational way to help Middlesex graduates.

The Boston Medical Library opens its doors to the students of Middlesex, but I suspect that if certain policies at Middlesex were altered, it would welcome the opportunity to be of far greater assistance to that school.

It is true that Middlesex graduates cannot join the staffs of the larger hospitals without the hospitals, losing their rating by the American College of Surgeons. As a society we are not responsible for that situation. Whether under any and all conditions the large hospitals in our state should feel bound to conform to this ruling is a question which can well come up for discussion and careful deliberation. It is a fact that each Middlesex graduate who works to the utmost to improve his knowledge and practices medicine on the highest possible plane advances the day when he and his fellow alumni will be given an opportunity in institutions of this group. I am under the impression that ways can be found by which, if the members of the Massachusetts Medical Society and of Middlesex faculty and its graduates assiduously devote themselves to the problem, opportunities for better clinical facilities for the education of Middlesex students will be found. But I frankly do not believe that these changes and many, many other advantages can be brought about or offered until absolute evidence is presented before the State Approving Authority that greater efforts than hitherto manifest have been made to meet its standards.

If in what I have said it is recognized that I have tried to speak honestly, fairly and cooperatively, and have made real the problem of securing well-trained doctors for Massachusetts, I shall be content, because you members of the Massachusetts Medical Society, including also graduates of Middlesex, can do the rest.

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Joslin, Elliott P. "The Massachusetts Medical Society and Socialized Medicine." New England Journal of Medicine 221, no. 3 (1939): 85-95.

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