465

THE LANCET.

LONDON: SATURDAY, AUGUST 26, 1922.

The Prospects of Medicine.LAST year Sir DONALD MACALISTER, in giving to the

General Medical Council the figures relating to theregistration of medical students for recent years,pointed out that the number registered in 1920 washigher than any-that had occurred previously savein 1919, the tendency having been steadily upwards ssince 1913. The figures to which he referred rangedfrom 1480 in 1913 to 3420 in 1919, and those whocould read meaning into the figures felt safe in

prophesying that a movement downwards in the

entry to the profession would take place. There couldbe no doubt that the number of aspirants to the medicalcareer, consecutive to the great part played by bothprevention and treatment in the war, was leading toa position in which there might be danger to profes-sional education, and perhaps to professional careers,through the mere mass. At the moment there was

difficulty in providing the training, and in the futurethere might be further difficulty in obtaining a liveli-hood, unembarrassed by downward competition. Forthe first time the suggestion that the medical profes-sion, undermanned though it might actually be,would soon be really overcrowded and not merelybadly distributed, received support from those

experienced in professional matters. And this

position, it would seem, has become clearer to thepublic and those who influence young men in thechoice of their careers, for last year only 1808 medicalstudents were registered, which is little more than halfof-the number two years previously. But 1760 menand women became qualified to practise medicine,that being the largest recent total, so that tem-

porarily the proportion, which experience tells us tobe reasonable, has been restored.Taking six years as the period in which to pass

from enrolling as a student to registration as a prac-titioner, the first definite sign of overcrowding in theranks of medicine should appear in 1925, so that it ismuch to be hoped that by that date the professionalposition will be in a more stable condition than it is atpresent, and that, later, those who are now joining ourranks will find themselves practising in more orderlycircumstances, and with some of those measures ofconsolidation, which all agree to be necessary, actuallyaccomplished. What the circumstances exactly willbe, and how far they may conform with our presentideals of the medical life, would be bold prophecy,but the struggles will have taken place before ournew recruits can be actively interested, though theirprospects are deeply involved in the results. At thepresent moment we have a National Insurance MedicalService which is labouring under considerable dis-abilities. It is doing effective work, but it is hamperedby inability to develop, and this at both ends of itsduties and responsibilities. It is not as yet properlyin touch with preventive medicine in the country, thelarger share of which lies necessarily in the hands ofthe State ; nor has it any facilities for the special orinstitutional treatment of the more serious conditionscoming under its care. The National Insurance Act

undoubtedly stabilised general practice in many

directions ; it did away with the need to possess acapital sum before embarking upon private practice,it provides a certain livelihood from the outset, andit has by this time familiarised the public to someextent with the aims of medical endeavour and thedirections of medical thought, so that cooperationfrom without is definitely increasing. So far, so good ;but during the next year or two, in which the numberof candidates for medical work of all kinds will be

large, and general economic conditions stringent, thesolidarity of medicine is a special need. The divisionsand subdivisions of our duties, which are the inevitableoutcome of their large range, require to be broughtinto definite and positive relation with each other, ifscientific medicine is to progress and the populationto receive the best that our equipment now enables usto offer. The public ought to receive from us an

example of the value of combination, and no morepractical move could be taken in this direction thanthe development of post-graduate teaching, to whichreference is made later in special connexion with themetropolis. Post-graduate work, by bringing the

periphery into contact with the centre-whetherinstitution, laboratory, or special clinic-provides acommon field of effort.We are for the moment assuming, as in past times,

that a majority of the new students proposes to jointhe ranks of the general practitioner ; and we maysay at once that we hope the day, which has beenobviously approaching, to be now arriving when nohard line can be drawn between the general practi-tioner and the consultant, the clinician and thepathologist, the private practitioner and the official.It is in this general fusion of professional effort that thesuccess of medicine, alike as a scientific and a publiccareer, will reside, and the Dawson Report remains anexcellent pattern of combined yet separated energiessuch as is required. It is daily experience to hearcandid criticism of the practice of medicine underthe scheme of National Insurance, and the hardsayings emanate equally from those attached to

voluntary hospitals and those who have chosen oneor other of the many branches of the public healthservice. We regard these differences, which are

largely due to misunderstanding, as very dangerousto the future of medical work. Prevention is now

regarded by many general practitioners as much aresponsibility as is cure, but the continued withholdingfrom medical benefit under the Insurance Acts offacilities for hospital treatment, consulting opinion,and means of laboratory diagnosis, is keeping backthe practitioner from the full development of hiswork as a preventive agent. There are still a fewareas in which inert practitioners are content torelieve symptoms by the exhibition of stock remediesand to allow no time for the full practice of theirprofession. We believe this number to be quite smalland to be daily growing smaller, but undoubtedly itsexistence constitutes a danger to future professionalprospects. The head of the Insurance Departmentat the Ministry of Health recently stated in publichis conviction that the overwhelming majority ofinsurance practitioners are sincerely desirous of makingthe service efficient and satisfactory. But there are

approved society officials-sometimes they are forcefulindividuals-who desire to dominate medical practice,as far as they are in contact with it, and who seekin our weakest spots for arguments to justify theirclaim. Reform from within will disconcert thereformers from without. The administration of healthby the laymen on local authorities will certainly notbe of the best unless they can command the helpand cooperation of all sections of medicine.