To be or not to be – a doctor

The publication of the first number of Res Medica, the Journal of the Royal Medical Society, is a matter of great interest not only to past, present and future members of the Society, but to all teachers and students in the famous Medical School of Edinburgh. Accordingly, it was both an honour and a privilege to be asked by the Editor to contribute an article which contains a personal message to students and prospective students who may have doubts about the future of the medical profession. It also gives me the opportunity of expressing my best wishes for the success of this journalistic venture. Copyright Royal Medical Society. All rights reserved. The copyright is retained by the author and the Royal Medical Society, except where explicitly otherwise stated. Scans have been produced by the Digital Imaging Unit at Edinburgh University Library. Res Medica is supported by the University of Edinburgh’s Journal Hosting Service: http://journals.ed.ac.uk ISSN: 2051-7580 (Online) ISSN: 0482-3206 (Print) Res Medica is published by the Royal Medical Society, 5/5 Bristo Square, Edinburgh, EH8 9AL Res Medica, Winter 1957, 1(1): 11-15 doi:10.2218/resmedica.v1i1.286 TO BE OR NOT TO BE—A DOCTOR By SIR STANLEY DAVIDSON B .A ., M .D ., P .R .C .P .E ., F .R .C.P.(Lond.) Hon. Physician in Scotland to H .M . the Queen; Professor o f M edicine in the University o f Edinburgh t h e p u b l i c a t i o n o f the first num ber o f R e s M ed ica , the J o urn al o f the R o y a l M edica l S o c ie ty , is a m atter o f g r e a t interest not only to p ast , p resent and future m em b ers o f the S o c ie ty , but to all teach ers and s tu d en ts in the fa m o u s M edica l S ch oo l o f E d in b u rg h . A c c o r d in g ly , it w a s both an honour and a p r iv i le g e to be a sk e d by th e E d ito r to co n tr i­ bute an a rt ic le w h ich co n ta in s a personal m e s s a g e to studen ts and p ro s p e c­ tive stu d en ts w h o m ay h a v e doubts ab out the 'fu tu re o f the m edical p rofession . It a lso g iv e s m e the o p p o rtu n ity o f e x p r e s s in g m y best w ish es for the su ccess o f th is jo u rn a lis t ic venture. July 1948 w ill a lw a y s be rem em b ered in the a n n als of B ritish m edicine as the date on w h ich w a s sta rted the g r e a t e s t ex p e r im e n t in social m edicine the w o rld has e v e r seen. T e n y e a rs is too sh o rt a t im e fo r such a m ajo r sch em e to be firmly set on its feet or for a final e v alu ation to be m ade of its m erits or dem erits. It is in evitable th at “ te e th in g ” troubles should h a v e occu rred w hich h a v e cau sed a n n o y a n c e , incon ven ien ce and hardship to patien ts and to som e section s of the m edical profession . C ertain u n fortu n ate incidents h a v e led to acr im o n io us d isp u te s betw een su cc ess ive M in isters of H e alth and the rep resen tat iv es o f the g e n e r a l p ractit ion ers and the sp ecialists . U n fo r tu n a te ly reports o f th ese d isputes and n e go tia t io n s , o ften illinform ed and e x a g g e r a t e d , h a v e n ot been confined to the m edical jou rn a ls but h a v e occupied co n siderab le sp ace in the lay P ress. O n the w hole , the m edical p r o fe s s io n ’s c la im s h a v e not been well received by the la y P re s s and this, to g e th e r w ith the public exp ress ion by so m e doctors o f their d is sa t is fa ct io n w ith their term s o f serv ice , m ay w ell h a v e g iv e n rise to g r a v e d ou b ts in the m inds of p a re n ts and of p rosp ective m edical s tu d en ts a s to the w isdo m of e n te r in g the m edical p rofession . It is m y desire to try and pu t these m atte rs in proper p ersp ec­ tive b ec au se o f m y sin cere belief that the profess ion o f m edic in e h as a lw a y s been and still rem ains the m o s t a ttra c tiv e , in terest in g and r e w a rd in g of all profession s. T h e decision to d ev o te o n e ’s life to a n y p a rt icu lar profession , business or trad e is u su a lly reached fo r one o f three reasons. F irs t , the bo y or g ir l m ay feel th at he or sh e h a s been born w ith a p articu lar v o catio n in life, e .g . to be a d octo r or a nurse. T h is , h o w e v e r , is excep tion al. S e c o n d ly , a person m a y be influenced in his or her ch o ice o f occu p ation by e n viro n ­ m en tal c irc u m s ta n c e s , e .g . the father, m other, a near re la tive or a close friend w h o is g r e a t ly respected and adm ired m ay be a d octo r or a nurse. T h is is not uncom m on . T h ir d ly , p aren ts and their child m a y consider the choice o f a ca reer from the v ie w p o in t o f (a) financial rew ard , (b) secu rity of ten u re and conditions of se rv ice , or (c) in terest in the w o r k . T h e s e ' a re the co n sid era tio n s w h ich u su a lly influence the final decision, and a c c o rd in g ly it seem s to m e a p p ro p r ia te to co n sider them in so m e detail. F e w studen ts enter a m edical school w ith the idea o f m a k in g b ig


TO BE OR NOT TO BE-A DOCTOR
of the first number of R es Medica, the Journal of the R oyal M edical Society, is a m atter of g re a t interest not only to past, present and future m em bers of the Society, but to all teachers and students in the fam ous M edical School of Edinburgh.
Accordingly, it w as both an honour and a privilege to be asked by the Editor to contri bute an article which contains a personal m essage to students and prospec tive students who may have doubts about the 'future of the medical profession.
It also g iv es me the opportunity of expressing m y best wishes for the success of this journalistic venture.
July 1948 will alw ays be remembered in the annals of British medicine as the date on which w as started the greatest experim ent in social medicine the world has ever seen. Ten years is too short a time for such a m ajor scheme to be firmly set on its feet or for a final evaluation to be made of its merits or demerits.
It is inevitable that " teething" troubles should have occurred which have caused annoyance, inconvenience and hardship to patients and to some sections of the medical profession. Certain unfortunate incidents have led to acrim onious disputes between successive M inisters of Health and the representatives of the general practitioners and the specialists.
Unfortunately reports of these disputes and negotiations, often ill-informed and ex aggerated , have not been confined to the medical journals but have occupied considerable space in the lay Press.
On the whole, the medical profession's claims have not been well received by the lay Press and this, together with the public expression by som e doctors of their dissatisfaction w ith their terms of service, may well have g iv en rise to g ra v e doubts in the minds of parents and of prospective medical students as to the wisdom of entering the medical profession. It is my desire to try and put these m atters in proper perspec tive because of my sincere belief that the profession of medicine has alw ays been and still remains the m ost attractive, interesting and rew arding of all professions.
T h e decision to devote one's life to any particular profession, business or trade is usually reached for one of three reasons. First, the boy or girl m ay feel that he or she has been born with a particular vocation in life, e.g. to be a doctor or a nurse. This, how ever, is exceptional. Secondly, a person m ay be influenced in his or her choice of occupation by environ mental circum stances, e.g. the father, mother, a near relative or a close friend who is greatly respected and admired m ay be a doctor or a nurse. Th is is not uncommon.
Thirdly, parents and their child m ay consider the choice of a career from the view point of (a) financial reward, (b) security of tenure and conditions of service, or (c) interest in the work.
These ' are the considerations which usually influence the final decision, and accordingly it seems to me appropriate to consider them in som e detail.
F ew students enter a medical school with the idea of m akin g big money out of medical practice. Even prior to the inception of the National Health Service (N .H .S .) in 1948 it was well recognised that only a small percentage of specialists made an income of £ 10,000 to £ 30,000 per year. T h e majority of doctors had to be satisfied with an income of £ 1000 to £ 2000 per annum.
I believe that it would be difficult for anyone who has factual information regarding the income of the various pro fessions to deny that at the present time the average gross income of the doctor compares favourably with the average gross income of the cleric, the schoolmaster, the lawyer, the civil servant or the salaried executive in an insurance com pany, bank or business, of comparable age, experience and ability-even when the doctor's special responsibilities have been taken into consideration.
W h y then are many doctors dissatisfied with their remuneration ? The answer is that ow ing to high taxation one-third to two-thirds of a doctor's income may be required for income tax and surtax.
As a result of inflation the remaining income only purchases to-day about one half or less of the goods and services which it would have bought some ten to fifteen years ago.
H igh taxation is the price that all. W estern democracies have had to pay for the social services which are part of the so-called welfare state.
It is the price which has had to be paid for a bloodless revolution, which has greatly raised the standard of living of the w orking classes and reduced the standard of living of the middle and upper classes.
It is not surprising therefore that considerable dis satisfaction is expressed by the professional classes at their standard of living as compared with pre-war days.
H ow ever, for better or worse it is impossible to put the clock back and any political party that attempted to do so would never be elected to office. W hile no one can deny that some doctors are feeling the financial strain acutely and others are finding it difficult or impossible to bring up their families in the w ay they themselves were brought up, it must not be forgotten that this financial strain is felt by members of all other professions, and probably to an even greater extent, since their incomes are generally less than those of the medical profession.
N ow let me say som ething about securtiy of tenure and conditions of service. Doctors w ho receive at the present time all or a considerable part of their income from a university or from the National Health Service are much more secure than those whose income was derived almost entirely from private practice with all the severe competition which existed in this field prior to 1948. This is an undisputed fact which is held by certain people to be one of the harmful aspects of the N .H .S . Such individuals claim that this lack of competition stifles enterprise and encourages laziness.
In my opinion this aspect has been greatly exaggerated. T he income of a general practitioner or a part-time specialist still depends to a considerable degree on his ability to attract patients by his personality, technical efficiency, and capacity for hard work.
In addition, the present keen competition for a post of a principal or partner in a general practice or a specialist in hospital ensures the selection of persons of high quality who are not likely to lose initiative and become lazy.
Further, there is the stimulus of private practice and the merit award for specialists.
Another important condition of service should be mentioned, namely that at the present time those who receive all or a large part of their income from a university or from the N .H .S . continue to be paid when they are absent from w ork on grounds of sickness, when they visit medical conferences, or when they g o on holiday for periods up to six weeks per annum . In contrast, in the era prior to 1948 the specialist's income ceased when he was absent from duty for any reason. Mention m ust also be made of the fact that on retiral doctors in the N .H .S . or on a university staff receive a pension.
T h e am ount of this pension depends on the contributions paid by the doctor and by the State or university during his professional career. It is not based solely on his income from sessional fees or university salary, but also on his merit aw ard if he has been fortunate enough to have gained one.
T h e result is that the specialist who w as appointed in the a g e grou p 30-40 years on a full-time or part time basis can look forward to a handsom e pension on retiral at the a g e of 65.
A t t h e present time there are tw o groups of doctors who have a legiti m ate grievan ce with their conditions of service, namely, the assistant in general practice who finds it difficult to get a partnership, and the well trained senior registrar who is faced with excessive competition in his efforts to attain consultant status.
T his unfortunate state of affairs is due in the first place to over-production of doctors in the post-w ar era, and in the second place to a miscalculation by the Governm ent of the number of consultant posts which they proposed to create in the N .H .S . It is my belief that both these unsatisfactory conditions of service will be rectified within the next decade, by the reduced entry of medical students to the universities and the reduction in the number of senior registrars who will be trained in the future.
Lastly, it is im portant to realise that provided a doctor carries out his w ork in a reasonably conscientious and efficient manner and conform s to the regulations laid down by the General Medical Council he has com plete security of tenure for the duration of his contract, whether he is employed by the N .H .S . or by a university.
W h ile a reasonable financial reward and security of tenure are desir able, nay essential, if an individual is to g iv e of his best to his profession or business, a vital interest in one's w ork is of far greater importance to one's ultimate happiness.
M edicine alw ays will be a compound of science and art.
In what other profession can an individual enjoy such a thrill from scientific w ork as well as so m uch happiness and gratitude as a reward for his services? H o w I bless my good fortune in em barking on a medical career 45 years a g o at a time which coincided with an epoch of medical discoveries in the fields of diagnosis and treatment unequalled in the last 2000 years.
I still find it difficult to realise that during my professional life nutritional diseases such as pellagra, beriberi, and scurvy have disappeared from m any parts of the world ; that tropical diseases such as m alaria, which were the scourge of m any countries, have been eradicated or largely brought under c o n tro l; that infections such as diphtheria have been virtually eliminated in many lands; that tuberculosis is on the run and will soon be as rare in Great Britain as is diphtheria at the present t im e ; that patients who form erly died of pernicious anaem ia, diabetic com a, or thyrotoxic heart disease can now all be saved by modern m ethods of treatment.
A s one who was desperately ill with pneum ococcal pneumonia on no less than three occasions, I look with wonder at the patients in my wards similarly affected who now sit up and read within 48 hours of the com m encem ent of antibiotic treatment.
Equally rem arkable are the technical advances in midwifery, gyn aecolo gy and surgery, due largely to g rea t im provem ents in anaesthesia and the prophylactic use of antibiotics.
Th e brain, the lungs, and the heart have opened their portals to the surgical specialist.
These arc but a few of the am azin g advances in medicine which have occurred in m y lifetime.
H ow could anyone fail to be entranced and delighted to belong-to a profession which has achieved such rem arkable results? Nevertheless, these therapeutic triumphs should not blind us to the fact that m any important diseases are still beyond our control and that accordingly the tempo of research must continue unabated, with ever improved apparatus and with ever more skilled workers.
An equally important part of a doctor's life is the care of the sick and dying with all the consequent responsibilities both to patients and to relatives.
This demands that the doctor should have a high sense of vocation and duty if his work is to be carried out in the Hippocratic tradition.
His reward is the love and gratitude of his patients which more than com pensate him for the strain and long hours of work.
To carry out the w ork of a doctor properly, the medical profession needs men of high moral, intellectual, and scientific status.
T o achieve this the quality of students selected for training in the medical schools must be good and the standard of teaching both in the basic sciences and in the clinical subjects must be high.
H ow does the present day medical student compare with his predecessor 30 or 40 years a g o ?
As a teacher in the Universities of Edinburgh, Cam bridge, and Aberdeen during a period extending over 37 years, I feel I have had sufficient experience to try and answer this question. In the first place it should be remembered that a really good medical student will m ake a good doctor irrespective of the quality of his teachers, and that a bad medical student, if he m anages to achieve graduation, usually m akes a poor doctor no m atter how well he is taught.
It is on that large group of students who occupy the middle of the class examination lists that the effects of good or bad teaching are apparent.
Com paring this group of students with the same category at the university in my student days, I have no hesitation in saying that the average medical student of to-day is a more serious, hard-w orking person and that his know ledge and under standing of the basic sciences and of the clinical aspects of medicine are better.
It would indeed be surprising, and in fact most disturbing, if this were not the case, because the medical course has been lengthened by a year, the number of teachers has been greatly increased and the number of students greatly reduced.
In the pre-war years and in the post-war years of 1945 to 1950 the number of students entering medicine annually in the U niversity of Edin burgh and the Extra-M ural School of Medicine was approxim ately 225 and 80 respectively. T h e total number who started medicine in October 1957 in Edinburgh w as approxim ately 150-a 50 per cent, reduction. In addition it should be remembered that it is only recently that all medical students after passing the Final Exam ination have been compelled to work for a minimum of one year in hospital as a House Officer before being registered for independent practice, and many do two years or more. It is therefore not surprising that the a verage young doctor entering general practice to-day is better qualified than was his predecessor of 39 years ago.
For all the above reasons I am satisfied that on the grounds of financial reward, security of tenure, conditions of service and interest in one's work, the medical profession still remains the most interesting and most reward ing of all the professions.
Accordingly, I g iv e this m essage to all students and prospective students of medicine : Be of good c h e e r ; you will get a better training as a medical student to-day than ever before and thereafter you will become a member of a profession which will give you security, a reason able income and a good pension, and one which is the most interesting and rewarding of all professions because of the service it renders to mankind.
N ow I come to the second reason for accepting the E ditor's invitation to write this article, namely to wish him and his staff all good fortune for the success of R es Medica. As one who took part in launching the Scottish Medical Journal two years ago, I have some personal knowledge of the difficulties associated with the publication of a new journal.
The high cost of paper, printing, etc. m akes it difficult to finance a journal unless the revenue derived from its sale is greatly augm ented by income obtained from advertisements. The sponsors of journals with only a small and local circulation naturally find it difficult to persuade commercial firms to buy advertising space. T he high cost of production has resulted in the last few years in the cessation of publication of a number of monthly, weekly and daily journals catering for the general public.
However, courage and optimism are the perquisites of youth and M r Gray and his editorial committee are obviously supplied with these attributes in abundance.
H e has assured me that he has no doubt whatsoever about the success of this venture.
On behalf of a multitude of Edinburgh students and graduates of medicine I end this article by proposing the toast with which we conclude our medical dinners in Edinburgh, namely, FLOREAT RES MEDICA. " A Surgical G ossip." ' January 3 1-D i s s e r t a t i o n : A . W . D e illi p i a n i , Esq.

THE ROYAL MEDICAL SOCIETY
" H epatic C irrhosis." February 7-T a l k : Professor Sir W a l t e r M e r c e r , P .R .C .S .E .
" Russian Su rgery and Other T h in g s ." February 14-D i s s e r t a t i o n : A l a n M ii.n e , Esq.
" P oliom yelitis." February 21-A d d r e s s : Professor E . J. W a y n e , M .D ., F .R .C .P .
(Lond.), F .R .F .P .S . " The D iagnosis and Treatm ent of T h y roto xico sis." February 28-D i s s e r t a t i o n : J. J. C . C o r m a c k , Esq. " The S o cie ty's L ib ra ry ." March 7-P r e s i d e n t 's V a l e d i c t o r y A d d r e s s . W ednesday, March 12-A n n u a l E x t r a o r d i n a r y G e n e r a l M e e t i n g .
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