The Specialization Rackets

There is a popular definition of the word specialist that with much truth aptly describes medical specialization. It reads:

"The specialist is a person who knows more and more about less and less. The perfect specialist therefore is the man who knows everything about nothing."

For a long time it has been said that medical specialization is the outcome of the vastness of medical science. This is false. For medical science, in the sense of pertinent facts actually known about man and his diseases, is very limited. It can be readily mastered in a relatively short time. The limitation of the science of the medical specialties is in some instances almost grotesque.

The specialists in skin diseases specialize in a field that lies on the surface of the body. Nevertheless nothing basic or fundamental is known to medical science about the skin; and little more is known by the dermatologists about its diseases. Nothing is known concerning the true nature and cause of such common skin diseases as psoriasis, except that the administration of chrysarobin ointments may sometimes clear up the lesions temporarily. But they invariably recur, for no known reason.

The specialty of dermatology consists principally of hurling names at diseases—some of them bad names, but invariably a multitude of names. An assembly of dermatologists can get very excited about flinging these names. But in many cases they can do little or nothing to relieve the patients ailments.

The nose and throat specialists know little more about the cause and nature of colds, the commonest ailment in their domain, than does the rest of the populace. They may do much to aggravate the condition, or to mutilate the patient's nose by oft needless operations. But they can no more certainly prevent a cold than they can cure it. The cure is left to the great specialist—Nature.

My recent researches on colds dictate the discard of most of the medication, manipulations and operations which have been the backbone of the "sinus racket." They reveal that the majority of colds do not begin as infections as the "authorities" now allege. They are caused by mechanical obstruction of the nose due to faulty breathing and faulty diet. The nasal obstruction and the colds can be prevented or cleared up by breathing exercises and a proper diet in the great majority of cases. Incidental to the improvement of the nasal obstruction, the rings about the eyes that are formed by the varicose veins which it causes, also vanish. This discovery enables each man to be his own rhinologist and may wipe out much of the specialty of rhinology.

The specialty of allergy is another instance of high-sounding name serving to cover dismal ignorance and to impress the gullible public. All that is now termed allergy used to be classed under the name "hypersensitivity." This commonplace name failed to impress or to yield the high fees that resounding "allergy" nets its "specialists." About the fundamental causes and the true nature and treatment of "hypersensitivity," alias "allergy," there is still known little or nothing.

Public health work is an instance of specialization that would be absurd if there did not lie behind it a deliberate design. Public health work consists of applying some simple phases of the science and art of medicine to the prevention of disease in large groups, i.e. "mass production." Much of it is a simple, mechanical routine. But public health officers dominate many phases of commerce, such as the distribution of milk. To insure domination of public health officials by milk and other industrial interests, public health work is being made a full-time specialty controlled by those interests as has been related.

JUSTIFICATIONS FOR SPECIALIZING

Each and every part of the body is a part of the whole organism and influences the balance of its parts; and, vice versa, every part of the body is influenced by the body as a whole. A competent specialist must know all of medicine; he must therefore not be a specialist at all. Also the more versed a man is in the entire meager realm of medical science, the more competent he is to serve as specialist.

In some phases of the art of medicine a justification for a relative degree of specialization is to be found in that they require special technical training and experience in kindred arts and sciences, or elaborate, costly and bulky apparatus. Thus x-ray work requires technical training in physics and photography as well as expensive equipment.

As a rule, there is little or no justification for specialization either in the extent of medical science or in the technical demands of the application of its art. Most diseases do not confine themselves to specialty zones. Disease of the pancreas, for instance, may cause disease of the eye or foot. Disease or deformity of the nose may cause the disturbance of sexual functions. The man who specializes in diseases of a single region of the body often disregards the remote parts of the body which give rise to the disease under treatment and is doomed to failure.

The practice of general medicine with special interest in some region of the body, for the purpose of study and research, constitutes a basis for intelligent and justifiable specialization. It is this form of specialization and research that is most productive of results.

Such intelligent specialization is highly unpopular with the rank and file of the medical profession, and a form to which official recognition is denied. "Accepted" specialization requires that the specialist shall confine his practice to one section of the body, such as the eye or the heart; or to one group of disorders, such as allergy; or to a single disease, such as diabetes. The specialist who transgresses the bounds of his specialty in treating the patient referred to him by colleagues finds that the word spreads around rapidly. His colleagues no longer refer work to him and his practice dies off. This form of specialization finds its root in commercialism and the intense struggle of the profession for existence.

SPECIALIZATION IMPOSED BY CLINICS AND HOSPITALS

Both organized medicine and the social service rackets have contributed largely to the development of the specialty rackets. The commercial exploitation of medicine by the social service forces in clinics operated for mass production lent the earliest impetus to specialization. The mere mechanics of the physical handling of the mobs of patients who are lured to the clinics with a pretense of rendering medical care requires a division of labor. In the clinic the specialist is the medical mechanic of "mass production"; and like a mechanic on the assembly line he must confine his activities and interest to a single series of motions, procedures and operations. Any other than the grossest defects outside of the specialty zone escapes him in the steady grind and routine of the clinic "assembly line."

A serious defect in "mass production" in medicine is the fact that the human organism differs radically from the usual objects of mass production. The interrelations of the parts of the human body are infinitely more complex than are those of the parts of an automobile. Many of these interrelations are not yet known or suspected. As a consequence the "assembly line" specialization in medicine leaves a whole mass of mankind and their ailments in a No Man's Land, shuffled about between specialists who dawdle with the local manifestations of a general disorder which is usually neither discovered nor suspected.

The "closed" hospital system also has served to impose specialization upon the medical profession for commercial reasons. In order that the doctors of the staffs of hospitals may enjoy maximum incomes and collect the maximum number of fees from the limited number of patients in their hospitals, each doctor is required to confine himself to a single subdivision or specialty of the patients' ailments. Medical specialization has become a covert and "approved" form of "fee-splitting" imposed upon the profession by the "closed" hospital system. Physicians seeking appointment to hospitals and clinics are required to select a specialty to which they will confine their activities.

The popularity of specialization that was thus foisted upon the profession has grown rapidly. For just as the mechanical routine of the assembly line in industry is admirably adapted to the average moronic intellect, specialization in medicine matches the wits of the modern medical graduates who are hand-picked on the basis of ability to pay graft to secure admission and "intelligence tests." To the mental level of these medical morons are attuned undergraduate, graduate and specialty education. Members of the profession who are capable of sufficient independence of thought to realize the evils of this specialty system are now regarded as "crack-pots."

Specialties in medicine consequently have bred and multiplied rapidly. It is regarded extremely unusual and "irregular" for any ailment, however minor, to confine itself within the zone of a single specialty, if the patient has any money. This proves very fortunate and profitable for the medical staff of the hospitals. Without specialization many of them would starve.

SPECIALTY BOARDS OR TRUSTS

Specialization has proved a bonanza for the merchants-in-medicine. Under the guise of protecting the public they have established numerous specialty organizations that serve the functions of chambers of commerce which boost their businesses and protect them from competition in much the same manner as does the American College of Surgeons. These organizations generally accept the domination of the A.M.A. and interlock with its specialty sections. The multiplication of organizations increases the advertising and publicity of their bosses to both the public and the rank and file of the profession and correspondingly enlarges their practices and their teaching businesses.

For restriction of competition in the specialties and for enhancement of incomes from Specialty teaching, the organizations in each specialty combine to form Boards. These Boards are self-appointed groups of specialists, generally in the post-graduate teaching business, who undertake to dictate who may practice the specialty and how it must be practiced. They constitute the backbones of Specialty Trusts. The members of the Boards make large incomes from the high fees paid by applicants for examination as well as from their allied teaching rackets which the applicants find wise to attend if they wish to pass.

The dominant cliques in the specialties are placed on the accredited list by the Boards, and in return accept its jurisdiction for the purpose of protecting their businesses. All others must submit to examinations consisting of trick questions often on subjects that have not the slightest practical bearing on ability to relieve the ill. The answers must comply with the "accepted practice" fixed by the Boards; or in questions on which no such dogma exists, they must match the pet theories of the arbitrary examiners. Since there is no appeal from the judgment of the Boards, the applicant must waste much time and pay into the pockets of the examiners or their schools much money taking courses in which the examiners sell their views to prospective examinees. They travel about the country peddling "review conferences" at fifty or a hundred dollars a head.

Validity is given to the actions of the Boards by the imposition on "closed" hospitals of the rule that only specialists "accepted" by them may be appointed to staff positions. They are now seeking the passage of bills in various states that will give their Specialty Trusts the support of law, for more effective mulcting of the profession.

Thus when medical business began to slump in 1930, the medical specialty bosses got together and attempted to pass a bill in New Jersey which would establish a monopoly of specialists under their domination. An intensive publicity campaign, in which Lowell Limpus and the Daily News of New York played an active part, was undertaken in favor of the bill. But the bill so obviously violated public interest that it was defeated.

Boards have been organized in the specialties of ophthalmology (eye), otolaryngology (ear, nose and throat), obstetrics, dermatology (skin), psychiatry, pediatrics (children), radiology (x-ray work), orthopedics (bone), urology, general medicine, pathology, surgery, and anesthesia. More are constantly being organized. Specialties are being subdivided within themselves, and no doubt will give rise to new Boards. The Boards have joined in organizing an Advisory Board which publishes a volume that advertises the specialists who have been "accepted" by the Boards.

As in the case of the American College of Surgeons, the applicants are passed upon by a local group of competitors. Insiders who "belong" gain acceptance without regard to competence. All others can expect little grace or mercy. Many capable physicians who refuse to bow to the autocrats of the Board are being libeled systematically by publicity in newspapers, magazines, and other publications which insinuates that all specialists who have not been "accepted" by the boards are incompetent and not to be trusted. The Boards are some of the many devices that have been fashioned to force the medical profession into line for the profits of the rackets of organized medicine. However much I may be opposed to this Board racketeering, in a moment of weakness I accepted the dubious honor of certification by one of the boards.

SPECIALTY POST-GRADUATE EDUCATION

One of the favorite methods of restricting competition in the specialties is to make specialty education exorbitant in its cost, and to compel physicians who wish to enter the specialties to meet totally unwarranted requirements. The Boards and specialty bosses exert their influence to prevent the teaching of their specialties in the course of a regular medical education; and they carve out for themselves fortunes by operating post-graduate medical schools. These serve both as business ventures and as advertisements for their private practices.

The usual post-graduate course can be expected to net its professor numerous profitable operations and consultations derived directly or indirectly from advertisements or from students. The profit of the post-graduate institution for its bosses explains why some doctors are willing to pay thousands of dollars for professorships in those institutions. It is not unusual for doctors seeking professorships to invest twenty-five thousand dollars or more in these institutions. These were generally very profitable investments that in normal times often netted the investors as much as a half a million or a million dollars annually, mulcted from the public as well as from colleagues.

With the object of diminishing competition in the specialties the cost of specialty education is being raised higher each year. The graduate in medicine who has completed his internship has undergone a process which goes by the name of education during a period of twenty to twenty-five school years at an estimated cost of twenty to twenty-five thousand dollars. To enter some specialty, especially the surgical, he must be prepared to spend three years or more in a post-graduate medical school, during which time he receives no income but must pay from six to ten thousand dollars additional. During these years he will have much opportunity to draw pretty pictures and make clay models; to fill endless notebooks with lecture notes and with speculations and theories; occasionally to see a case of a patient suffering from a specialty disease, rarely if ever to operate on one.

When this process has been completed the graduate turns loose on the community and seeks to force it to pay him a return on this enormous and needless investment in time and money. Small wonder the public complains of the high cost of medical care at the hands of products of the specialty racket.

Things were not always so. In years gone by the specialties were learned, as was the balance of medicine, by young graduates who acted as assistants to older men in office and clinic, at home and abroad; or by serving an internship in a specialty hospital. After a number of years of apprenticeship during which the novice had sufficiently proved to the physician whom he assisted, that he could be entrusted with all phases of the specialty, he went off to some post-graduate institution or took a trip to Europe. This was primarily for the purpose of comparing notes and methods, and acquiring the glamour and halo of "study abroad."

For some the pace was more rapid. Tiring of general medical practice the physician decided to devote his interests to one phase of the profession which he had been practicing with special interest. Primarily for the marking of the transition between the two phases of his practice, general and special, and for "a breathing spell," the physician would go abroad and announce himself as a specialist upon his return.

If this group of self-declared specialists had originally enjoyed an adequate medical training and had conscientiously taken interest in their specialties, they might have become quite as competent as the balance of the crew. But their failure to pay tribute, in the form of thousands of dollars in tuition fees, to the bosses of the specialty gangs, and the competition which they offered, aroused intense antagonism on the part of vested specialty interests.

ABSURDITIES OF SPECIALIZATION

While this process of raising the barriers against acquiring education or experience in the specialties has been in progress, advances in medical and allied sciences have thrown in sharp perspective the absurdities of specialization.

A striking instance is a specialty of urology. Important aspects of the domain of the urologist and important sources of his income were kidney stones, enlargement of the prostate, and gonorrhea.

The usual treatment of kidney stone was operative interference. It has been shown recently by research workers in nutrition and general medicine that the formation of kidney stones can be prevented by a diet adequate in vitamin A and glandular therapy. Thus the kidney stone threatens to be thrown back into the domain of general medical practice.

The traditional treatment of enlargement of the prostate has been local manipulation and operation. Recent contributions to medicine have shown that enlargement of the prostate can be prevented or cleared up by treatment with endocrine glands, such as ovarian hormone, the hormone inhibin, or testosterone. Another domain of urology is being thrust back into general medicine.

The treatment of gonorrhea and its complications has been one of the chief sources of income of the urologist. If gonorrhea had no complications most urologists would starve. Recent success reported in the treatment of gonorrhea with sulfanilamide threatens to remove the treatment of this disease from the repertoire of urology to that of the general practitioner. This tragedy consummates the undoing of most urologists and their specialty.

A prominent urologist bitterly complained that the specialty is being wiped out by modern discovery in other fields of medicine. He seriously suggested that there should be a halt to medical discovery to avoid technologic unemployment in the specialties.

MEDICAL DISCOVERY VS. SPECIALTY RACKETS

The suppression of medical discovery in the interest of sustaining the incomes of racketeering specialists in medicine is exactly what is being accomplished by many of the specialty organizations. Original research motivated by the desire to dispel the abysmal ignorance of fundamentals that characterizes all the specialties is regarded by their overlords solely in a commercial light. They can be regarded as putting to themselves the question: "Will it further my business?" Suppression of discoveries that do not serve to enhance their businesses and their incomes, especially if they do not emanate from their cliques or cannot be stolen by them, is the universal practice. And so vast is their autocratic power that none of the rank and file dares to disobey their dictates and use methods which they do not sanction.

It has been related elsewhere how bitterly the highly successful medical treatment of chronic ear infections and chronic disease of the mastoid is being fought by the specialists in otology to protect their operative income.

It has been related how the unscrupulous bosses of ophthalmology have resorted to suppression of publication, libel, slander, falsification of data, and to the imposing of censorship on such a representative scientific organization as the American Association for the Advancement of Science, in order to prevent the highly successful adrenal cortex medical treatment of glaucoma from becoming universally known and accepted. It matters not to the high-minded specialists that the treatment is the only method of preventing blindness in thousands of victims of the disease. The one thing that counts with them is that if the method should be accepted, the bosses of the ophthalmologic specialty would lose their high fees and incomes from blinding glaucoma operations. Such is the defect in the nature of the law, that a callous group of specialty bosses can force the profession to continue to blind, deliberately, knowingly and with impunity, thousands of victims each year with their operations; and can withhold from them the medical therapy which would save their eyesight by the mere device of refusing to acknowledge the truth—that the medical therapy is effective but would reduce their incomes.

Medical specialization has become a gigantic commercial racket, jointly maintained by specialty organizations, by the American College of Surgery, by the American Medical Association, by the Medical-Social-Service Trust, and by the educational institutions controlled by them. They serve enormously and needlessly to increase the cost of medical care; to block effective education of the medical profession for complete and rounded service to their patients; to prevent the public from enjoying the benefit of medical discoveries when those discoveries serve to reduce specialty incomes, especially by eliminating need for operations; briefly, to plot against public interest for their own private gain.

SPECIALTY PUBLICITY

The immense powers of the overlords of the specialties are greatly enhanced by the delegation to them by organized medicine and social service of the powers of control and censorship of both the medical and lay press in their fields. They use these powers to boost their business, to undermine their competitors and rivals, and to gloriously shield their nefarious activities with the shibboleth "protection of health and lives of the public." Scarcely a week passes by without the issuance to the press for publication releases drawn up by highly paid publicity men announcing that their competitors are in competent and require post-graduate instruction of the type that the gang has to offer.

In all of this publicity, each specialty group insists that the rank and file of the medical profession is incompetent to practice in its particular field. When one adds up the sum total of all the fields claimed by the specialties one begins to have serious doubts about the caliber of modern medical education. For one finds that there is nothing that they are willing to entrust to the unspecialized medical practitioner except the work of acting as business agent for the specialists.

The specialty business slumped heavily in 1930. The New York Academy of Medicine clique in its annual report adopted that year suggested that its simon-pure specialists alone should enjoy the medical business of New York. The report implied that none other could be trusted. It did not state that business was poor, which is what the report really meant.

On January 29, 1938, the New York Post-Graduate Medical School and Hospital announced in the press that medical specialists needed more training of the variety that the institution had to offer. The motive can be found in the fact that it has found business so lean in recent years that it was compelled to surrender its control to Columbia University in order to gain support. The newspapers' publicity gave the Post-Graduate many thousands of dollars of free advertising and undoubtedly boosted its business.

At the dinner from which this publicity was released Dr. Walter D. Dannreuther, F.A.C.S., professor at the Post-Graduate and member of the Board of Obstetrics and Gynecology, announced that more of the superior brand of specialists approved by his Board were required. The superiority of the recommended specialists and the success of the Board in raising specialty standards is made clear by a report made by its members a short time before this incident that indicated a steady rise of maternal mortality in the United States to the highest childbirth death-rate in the world. (The report was deliberately falsified, for it included deaths from abortions in the childbirth figures.) The mothers of the Nation probably feel that if there were many more of them, ever ready to grab a knife and to do a Caesarian section, their chances of survival would be reduced to nil.

Representatives of other specialty boards also held forth on the topic of the need for more education at the Post-Graduate Medical School of their various brands of specialists. With such intensive publicity and advertising, business should have improved at the Post-Graduate Medical School.

HYPOCRISY OF THE SPECIALISTS

If these specialist groups were really interested in protecting the health and lives of the public they would seek to make common knowledge to every member of the medical profession the specialties which they now seek to exploit as private monopolies. Instead of multiplying the costs and reducing the opportunities for the members of the medical profession to become versed in all the specialties, they would seek to make the knowledge freely available to them at no cost

Instead of shouting from the housetops that the medical profession, especially their competitors, are incompetent they would invite them into their schools and "closed" hospitals and teach them free of charge in the interest of improving the care of the ill. That is the purpose for which philanthropically inclined individuals have endowed the hospitals and medical schools.

They would speed up dissemination of information on medical advances and discoveries in their fields and seek free distribution of that information and its publication in the press, instead of suppressing it.

To be sure the specialty bosses do invite the medical profession to lectures, to "Fortnightly Reviews," and to specialty conventions which are primarily designed to advertise themselves. But the data presented at those meetings are generally of ancient vintage and are to be found in any older textbook; and are so old as to be generally accepted in the specialty, and known to be not wholly true.

"ACCEPTED PRACTICE" DOGMAS "Standardization" and establishment of "accepted authority" and "accepted practice" constitute the prime functions of the Boards. The "accepted practices" are often legalized methods of committing mayhem and manslaughter. The absurdity of such "standardization" and authoritarianism in a field such as medicine, in which so little is definitely known, and so much of what has been regarded as true in the past has proved to be absolutely false, is too obvious to require comment.

The tendency toward authoritarianism in medicine and surgery, and the specialties, has become intensified in the last seven years of government authoritarianism. This movement increasingly threatens modern medicine with stasis and stagnation similar to that which it suffered in the Middle Ages. It violates the interest of each and every person, and a halt should be called.

As a phase of "standardization" of medical practice designed to serve the dual purpose of control of announcement of medical discovery to protect their reputations and vested interests, and of advertising themselves, the specialty bosses have established "Research Committees." These committees assign to each of their members the investigation of a designated subject and the establishment of the "accepted" faith and dogma for that domain. Once this "faith" has been established it may not be questioned with impunity; it must be accepted, however erroneous, until the committee decides to take cognizance of its error.

Historically autocracy and dogmatism in medicine have always retarded its advance and victimized the public. The ascendancy of Hippocrates and Galen, Jenner and his vaccination against smallpox, Semmelweis and his proof of the cause of puerperal fever and its prevention, Pasteur and his proof of the origin of disease, are classical instances of the sacrifice of millions of lives that authoritarianism, bred of commercialism in medicine, has cost mankind.

Today authoritarianism and commercialism in medicine have become intensified a thousand-fold in the name of the "protection of public health." The specialty rackets lead this development.

LURE OF SPECIALIZATION

It is not difficult to understand what lures the younger generation of physicians into medical specialties. They are forced into specialization by their hospitals and clinics. Specialists have opportunities to earn more than a mere living.

If a specialist sticks to his last, and either "splits" fees or repays his colleagues in other manners, he can even hope to make a fortune. Some of the extremes to which "fee-splitting" has gone in the specialty racket are illustrated by the case of the New York otolaryngologist who has adopted the practice of visiting general practitioners, looking over their furniture and announcing that he is ready to supply a needed item, as advance payment for cases to be referred to him at a future date. It is the keenness of competition which is primarily responsible for the denunciation of "fee-splitting."

SPECIALIZATION, THE LAW, AND THE PUBLIC

The public itself is largely responsible for the growth of the specialization rackets. It has been mal-educated in the belief that the specialist is the last cry in medical care, and is alone to be trusted. The public has acquired the habit of going directly to the specialist or demanding of a general practitioner that he refer them to the specialist.

Laws on specialization have been passed in some states. Such laws have reached the highest stage of absurdity and racketeering in the New York State Workmen's Compensation Act, which makes a special specialty of compensable injuries sustained by workers. Thus the injuries of a man who is struck by a car while at work belong to a different specialty than identical injuries sustained while not at work.

Instead of supporting such racketeering by law the state should seek to eliminate it entirely. It should seek to raise the caliber of medical education; should compel free access to hospitals of all physicians; should maintain free opportunities for post-graduate medical education; should provide the medical profession with literature and should arrange prompt publication of latest advances in the science of medicine; and should rigidly enforce laws which provide for proper punishment of malpractice and stimulate the provision of the most beneficial and least injurious methods of treatment known.