ARE OUR DOCTORS QUALIFIED?

...Some physicians made an effort to differentiate between viral and bacterial respiratory infections...

...There were three grades in this category—poor, intermediate, and very good...

...Income figures are given for 83 of the 88 physicians studied...

...Thus, for instance, no red blood cell count was done in 53 per cent of the cases and no white blood cell count on 45 per cent of the patients...

...In another 17 per cent, the chest was "thumped perfunctorily...

...In 43 per cent of the cases, the doctors studied were observed using improperly sterilized instruments, with the consequent danger of transmission of serum jaundice...

...Only in 17 per cent of the cases were "very good" clinical records of each patient's illness kept...

...These 83 doctors had an average net income of $15,720 a year, which compares favorably with available figures for the country as a whole...

...V (outstanding), 7. More than 44 per cent of the 88 doctors were thus found to be doing poor work...

...Some physicians, it was reported, took "histories that gave little evidence of clinical knowledge or skill...

...In 67 per cent of the cases, the doctors failed to recognize obesity as "a clinical problem" or gave inadequate dietary advice to overweight patients...

...The only honest answer that can be given to this question is that nobody really knows, which is in itself pretty disquieting...

...Many of the doctors, the report of the study said, "did not really understand the values and limitations of these drugs...

...III (intermediate or average), 27...

...The study, the first of its kind ever conducted in the United States, was jointly sponsored by the Rockefeller Foundation and the University of North Carolina, and its report has been published as a special supplement to the Journal of Medical Education, the official publication of the Association of American Medical Colleges...

...The report had this to say about the treatment of hypertension (high blood pressure) in 57 per cent of the cases: "Assessment of hypertensive disease poor or limited to blood pressure determination only...

...The methods of patient care used by the physicians ranked in group I were summarized as follows: "They evinced almost uniformly a superficiality and lack of thoroughness in their approach to the clinical problems encountered in practice...

...In 60 per cent of the cases, this was not done at all, despite the fact that many of the patients were suffering from respiratory infections...

...The physicians were scored according to the things they did right in a number of procedures, or did wrong, or failed to do at all when they should have done them...

...But in 86 per cent of the cases the breasts were not even "routinely examined...

...These gave little evidence that the physician was thinking in terms of probable diagnoses...

...Substantial support for this point of view is lent by the findings of a study of the quality of some of the medical care in North Carolina made under auspices of unimpeachable standing...

...It is therefore all the more significant that, although more than a year has elapsed since the publication of this illuminating report, our big magazines of national circulation have either missed it altogether or chosen to ignore its highly disturbing implications...

...Found were "tremendous variation in the quality of medical care" and a high proportion of poor performance...

...And here the man who has obtained his M.D...

...They were then given an overall ranking in five classifications...

...These are obviously questions of considerable moment, to which we shall return at a later date...

...by SELIG GREENBERG fT^he proudest boast of the propo-nents of the status quo in the health field is that medical care in this country is the best in the world and that in medicine, as in other lines of endeavor, free enterprise and high quality go hand in hand...

...In fact, while there are certain generally accepted professional standards, there are no definite criteria for measuring the quality of medical practice and no machinery for applying whatever criteria are available...

...The study found no direct correlation between the quality of medical care provided by a physician and his income...

...They were not planned or designed to explore the function of specific organs or physiological units...

...He is the winner of the Associated Press Managing Editor's Association Award for his series of articles on the problems of the aged...

...Other physicians recognized the problem but failed to provide adequate management...

...Essential laboratory procedures also were found to be frequently neglected...

...Patients were seldom undressed or laid down for examination...

...One of the physicians who conducted the survey remarked that "the common practice of treating pregnancy as a somewhat humorous situation might well increase a mother's difficulties in adjusting to an unplanned and sometimes unwanted pregnancy...

...In 47 per cent, "minimal information about positive findings and medications" was recorded...

...Other physicians used these drugs in treating colds on the assumption that they are harmless or might prevent complications...

...In the opinion of thoughtful observers of the American medical scene, it is one of the most important documents in years to shed light on some of the things wrong with our present system of medical practice...

...The doctors practicing good medicine, the report said, "obtained thorough histories and performed careful, competent physical examinations of each patient...

...Although X-ray examination is basic to adequate diagnosis, in 18 per cent of the cases there was "no radiographic work performed and patients not referred for these procedures...

...degree and his license to practice is to a large extent his own judge and jury...

...To all intents and purposes, this is wholly a matter of his professional competence and personal conscience...

...But the poor doctors, who made up nearly half of the total, "practiced from their desk chairs...

...An occasional physician used sterile instruments with unwashed hands while others failed to wash their hands after obvious or presumptive contamination...

...Management not skilled, neglect of simple therapeutic procedures such as weight reduction, rest, and salt restriction...

...On medical history taking, which is essential to a proper diagnosis, only 86 of the 88 doctors were graded...

...In some practices, clinical histories were normally so brief that they were manifestly unsatisfactory...

...IV (pretty good), 15...

...In discussing resort to potentially dangerous medications, it was reported that "use of tetanus antitoxin without prior testing for sensitivity was encountered" and that "sex hormones were sometimes used more freely than necessary...

...How good, actually, is the level of professional work done by some of our physicians...

...II (poor but not quite as bad as group I), 23...

...The scope of work he undertakes is usually limited only by his personal assessment of his own limitations...

...Percussion [tapping] of the chest is one of the examinations which has become symbolic of the doctor's work," the report said...

...A common finding was the automatic association in the physician's mind between a fever or a cold and penicillin...

...Although it was felt that "disrobing for a physical examination is so necessary to its accomplishment that it may be regarded as laboring the obvious to raise the question," the study found that in 45 per cent of the cases examinations were performed with the patient fully or almost completely dressed...

...SELIG GREENBERG, writer on medical problems for the Providence Journal and Evening Bulletin has twice been honored by the Lasker Foundation for distinguished writing on medicine...

...But the bulk of medical practice is carried on outside of the hospital...

...But few doctors would be willing to acknowledge that the current system of free enterprise in medicine may sometimes also mean freedom to be incompetent and to get away with it...

...The doctors studied were then graded according to the quality of their performance...

...The lack of attention to the patient's safety was demonstrated by unsterile technique in performing veni-punc-tures [punctures of a vein] and hypodermic injections...

...Must we continue to allow the medical profession to police itself, which often means letting it go virtually unpoliced, or is the public entitled to some safeguards and should it have some say about the conditions which tend to foster poor medical work...

...If he is backed into a corner, the more enlightened physician may admit that the problem of how medical care is to be paid for is still far from solved...

...Many physicians completely failed to recognize these problems in their practices...

...The purpose of the project was "to obtain information and understanding about the problems of the general practitioner in the hope that his educational, training, and organizational needs would become clearer...

...Or is it our right and duty to protect ourselves...

...Emotional problems," the study report commented, "appear to constitute an enigma for the practicing physician...

...Fifty-two doctors were scored as poor on history taking, 26 as intermediate, and eight as very good...

...The laboratory tests performed by these physicians were few, often poorly performed, and showed the same lack of direction...

...Although these efforts frequently involved the use of imperfect criteria, they were indicative of the physician's knowledge concerning the ineffectiveness of antibiotics against viral infections...

...In some practices the observer felt that potentially serious complaints were explored in a superficial manner or their seriousness not grasped...

...The laboratory, which was usually manned by a trained technician, was used skillfully as an adjunct to the practice...

...this decision was frequently reached before the patient had been examined...

...The physical examination was usually sketchy and it was frequently difficult to understand, in view of the patient's history, why one area was chosen for examination and another ignored...

...No effort was made to judge surgical or obstetrical techniques...

...It is nevertheless the considered opinion of competent authorities that— given the conditions under which many doctors work, the growing drawbacks of the traditional system of fee-for-services practice under the impact of the mounting complexity and fragmentation of medicine, and the lack of outside controls—there is every reason to believe that there is a considerable amount of superficial and sloppy performance...

...Drugs poorly selected or administration unskilled...

...He may concede that we have yet to find the solution for the steadily mounting costliness of medicine and that, despite the phenomenal growth of voluntary health insurance, many Americans are still faced with the threat of financial disaster in the case of serious illness...

...Despite the high proportion of poor performance brought to light in the survey, it was found that "general practitioners in North Carolina receive ample rewards for their labors...

...Treatment of anemia, it was reported, "was rarely selective and definitive...

...or improper, careless use including attempts at procedures beyond doctor's skill and training...

...In 36 per cent, "only information concerning medications, fees, or isolated data such as blood pressure" was recorded...

...Abdominal examinations were performed with patients sitting in a chair...

...Under these conditions the indications for specific treatment were usually lacking or unclear, and the treatment ordered gave ample evidence of this uncertain state of affairs...

...For instance, the belief that antibiotics are effective in treating the common cold was found to be widespread...

...At the outset of the study, the report said, it was assumed that at least most of the doctors picked for the survey performed complete physical examinations on all new patients and all old patients who had not been seen recently...

...Until readily used methods for judging quality are established and some means of controlling the level of medical practice are devised, the proportion of good and poor work now being done by physicians must largely remain a matter of conjecture...

...When it came to evaluating the therapeutic measures used by the doctors picked for the survey, the observers found that these physicians were giving antibiotics "indiscriminately" for upper respiratory infections to two-thirds of their patients...

...Although in theory certain disciplinary powers are vested in the state licensing authorities and in the professional organizations of his own peers, these are rarely exercised and there is no way of passing judgment on the quality of what he is doing in his individual practice...

...The survey was conducted entirely from the viewpoint of internal medicine...

...The same instrument," it was reported, "was sometimes used repeatedly for successive patients, and inadequate sterilization was done between each use...

...Similarly, several physicians failed to recognize the impossibility of feeling a soft, rounded liver edge through several layers of heavy clothing...

...Greenberg on some of the implications of the findings of the North Carolina study and the degree to which competent authorities believe they hold true of American medical practice in general will appear in an early issue of The Progressive...

...In only 15 per cent was the "therapy related to the type of anemia...

...In fact, some of the poorer doctors earned more money than some of the better ones...

...Physcians were observed attempting to perform ascultation of the heart or lungs [listening to sounds within the body either directly or through a stethoscope or other instrument] through several layers of clothing or dropping the stethoscope chest piece down through the open neck of the clothing in this attempt...

...Histories were almost non-existent and the few questions asked were often irrelevant...

...But the observing physicians discovered that "complete head-to-toe examination was the exception rather than the rule...

...Examination of the breasts of female patients is a simple, rapid procedure which one might expect to be extremely popular in view of the considerable publicity given to breast cancer at the present time," the report observed...

...In order to get such information, specially assigned physicians observed the work of the 88 doctors "as closely as possible throughout their daily routines in the office, on hospital rounds, and house calls...

...References to malingering, hypochondriacs, 'problem patients' or 'getting them out of the office quickly' were frequently heard...

...We do know that staff organization in our better hospitals assures adequate control over the level of professional performance within the hospital...

...The demand by the patient or his family for a "shot of penicillin" obviously increased the pressure on the physician...

...Granting that the consumers of medical care now lack such criteria, does it mean that we must throw up our hands and resign ourselves to medical incompetence and its consequences...

...that most frequently employed was one of several proprietary multivitamin and mineral compounds...

...There was no bacteriological work done in 58 per cent of the cases...

...A second article by Mr...

...Throughout the handling of each patient this lack of direction and purposefulness made it difficult for the observer to follow the physician's reasoning...

...In history taking, questions were few, usually disconnected and lacking in incisiveness...

...Eighty-eight North Carolina general practitioners were picked at random as a "representative" sample for the study, which took nearly two years and was conducted with the cooperation of the state medical society...

...In 74 per cent of the cases, the doctors either did not examine the patients' eyes at all as a means of detecting possible disease or limited such examination to an inspection of the mucous membrane lining the inner surface of the eyelids...

...In the treatment of anemia, medications described in the report as "shotgun preparations" were used in 85 per cent of the cases...

...The deluge of advertising material undoubtedly influences the physician's choice of therapeutic agents...

...This was manifested by the immediate preparation of an injection of penicillin upon learning that the patient had a fever...

...Examples were found," the report said, "where patients with diabetes or hypertension specifically asked the doctor about the relationship between these diseases and obesity, only to be assured by the doctor that none existed...

...This is hardly surprising," the report continues, "in view of the fact that the lay public has few valid criteria for assessing a physician's competence...

...In some instances the almost random, unrelated questions put to a patient indicated that the physician was, at best, not systematic...

...The breakdown was: I (uniformly poor), 16...

...Others, while recognizing the problems, were either indifferent to them or appeared to be made uncomfortable by patients with such problems...