PEDIATRICS
FOR
THE
CLINICIAN
Professional
Courtesy
Lee W. Bass, MD, and Jerome H. Wolfson, MD
From the University of Pittsburgh School of Medicine, Pittsburgh
Professional courtesy is a concept and practice that has prevailed among physicians for perhaps 2,500 years. Yet, it is an aspect of medical practice that is rarely discussed despite the fact that it has a great deal of significance for every physician and his family. It may well be that professional courtesy interferes with appropriate utilization of medical care and results in less than optimal attention to the physician patient and his family. This is related to the constraints that are felt by a physician in
seeking care, as well as the constraints that are felt in giving care to a physician. In recent years,
changes in life style and social values have raised questions as to the validity of professional courtesy. Increasing costs, increasing third party participa-tion in the financing of medical care, adequate salaries for interns and residents and, most impor-tant of all, increasing recognition of medical care as
a right rather than a privilege raise the question of whether professional courtesy is a luxury that both the giver and the receiver can truly afford.
HISTORY
The earliest known code of ethics appears in the laws of Hammurabi, King of Babylon, about 2200
BC. Fee codes were set, the principle of lex talionis
(the law of retaliation-an eye for an eye) was applied, and an attempt was made to protect the
public from the physician. No mention was made of professional courtesy.
The Oath of Hippocrates,’ about 550 BC, felt by most physicians to be the basis of medical ethics, contains no direct mention of professional courtesy. It reads in part:
Received for publication June 22, 1979; accepted August 9, 1979. Reprint requests to (L.W.B.) The University of Pittsburgh School of Medicine, Pittsburgh, PA 15261.
PEDIATRICS (ISSN 0031 4005). Copyright © 1980 by the American Academy of Pediatrics.
I swear to reckon him who taught me the art equally dear
to me as my parents, to share my substance with him and relieve his necessities as required; to regard his offspring
as on the same footing with my own brothers, and to teach them this art if they should wish to learn it without
fee or stipulation.
This paragraph is undoubtedly the basis for
physi-cians’ attitudes towards each other and subse-quently for the concept of professional courtesy as well. Edelstein’’5’ in his analysis ofthe Hippocratic
oath stated that it dealt with rules for treating disease and the relationship of pupil to teacher and the latter’s family. Regarding the doctor’s philan-thropy, the writings of the Hippocratic precepts’78 speak of “his kindheartedness and his willingness to accomodate his fees to the patient’s circumstances.
He should also treat strangers and paupers, even if
they are unable to pay him. That is, he should be
charitable.” In his book on decorum2, Hippocrates called medicine “a form of wisdom applied to life
and directed towards decorum and good repute.
Any wisdom having some scientific method is hon-orable if it is not tainted with a base love of gain
and unseemliness” and specifies that it “has in it all the requirements for wisdom, indifference to gain, steadfastness, modesty and humility.” These were references made to money and fees but there was
no specific reference to professional courtesy.
The Talmud raised the issue of the value of service rendered, “The doctor who heals free of charge is worth nothing,” and “Look to your pay,
oh physician; for that for which nothing is paid, the
same never cures.”3
Other medical codes appearing throughout the
ages specified proficiency requirements and sug-gested fee patterns. In 1772, John Gregory delivered
a series titled “Lectures on the Duties and
Qualifi-cations of a Physician” to medical students in
Edin-burgh.4 These lectures laid the ground for a formal
etiquette, the personal qualities of the physician, and his duties toward his colleagues. It was not
until 1803, however, that Thomas Percival wrote a code of medical ethics for the Manchester Infirmary that spelled out the concept of professional
cour-tesy.5
Current medical historians, 0. Temkin, P. D. Olch, C. R. Burns, and R. WoLfe (personal commu-nications, 1977), and King,6 all agree that Percival’s Code of 1803 seems to be the first documented discussion of professional courtesy. Wolfe stated that “Percival was so explicit that I suspect that he
was merely formalizing a custom that may have been going on for a long time.” Burns considered that “Percival wrote his code of ethics in order to improve relationships between physicians, apothe-caries, and surgeons at the Manchester Hospital. It may be that he thought a pattern of professional courtesy would be one way to encourage greater
cooperation among these three types of practition-ers.” King wrote that “Our present ethical codes arose not from Hippocrates and Hammurabi or from the fragmentary medieval regulations that have survived but directly from Thomas Percival who wrote at the end of the 18th century. Percival
tried to resolve the wrangling and discord which had punctuated the entire century and which in turn had developed out of a definite socioeco-nomic background. Medical practitioners faced cer-tam concrete difficulties relating to their profes-sional brethren and the lay public.” Percival’s code
stated:
AU members of the profession, including apothecaries as well as physicians and surgeons, together with their wives
and children should be attended gratuitously by any one or more of the faculty residing near them, whose
assist-ance may be required. For as solicitude obscures the judgement, and is accompanied with timidity and irreso-lution, medical men, under the pressure of sickness, either
as affecting themselves or their families, are peculiarly dependent upon each other. But visits should not be obtruded officiously, as such unasked civility may give
rise to embarrassment, or interfere with that choice, on which confidence depends. Distant members of the
fac-ulty, when they request attendance, should be expected
to defray the charges of travelling. And if their circum-stances be affluent, a pecuniary acknowledgement should not be declined. For no obligation ought to be imposed, which the party would rather compensate than contract.
Following the publications of Percival’s code in 1803, with the first reference to professional cour-tesy, various states and cities in the United States published their own codes-starting with the Bos-ton Medical Police and including the following states and cities: New Hampshire, Washington, DC,
Cincinnati, New York, Ohio, Baltimore, and Phila-delphia, none of which could boast originality.
Many were almost verbatim replication of
Perci-val’s code.
In 1847, the American Medical Association, at its
first meeting, adopted a code of ethics which also replicated Percival’s code-almost verbatim in the professional courtesy section.
Flint7 wrote in 1884:
Naturally and properly, medical services rendered to
members of the profession should be gratuitous. The rule with regard to an honorarium, however, is a sound one in the application: namely, one has no right to impose a pecuniary obligation when it is distinctly against the
wishes of the party receiving the services. This rule is
applicable here as in other cases. A request to present a bill for services, however, should never be made. Such a request implies an expectation that it will not be complied with. Any pecuniary acknowledgement by a member of the profession for medical services should be made strictly
as an honorarium. But if a distant member of the faculty, whose circumstances are affluent, request attendance, and an honorarium be offered, it should not be declined; for no pecuniary obligation ought to be imposed which the party receiving it would wish not to incur.
The AMA code8 has been revised and now reads:
Professional Courtesy-The following guidelines are of-fered as suggestions to aid physicians in resolving ques-tions related to professional courtesy.
1. Where professional courtesy is offered by a physi-cian but the recipient of services insists upon payment, the physician need not be embarrassed to accept a fee for his services.
2. Professional courtesy is a tradition that applies solely to the relationship that exists among physicians. If a physician or his dependents have insurance providing benefits for medical or surgical care, a physician who renders such service may accept the insurance benefits without violating the traditional ethical practice of
phy-sicians caring for the medical needs of colleagues and
their dependents without charge.
3. In the situation where a physician is called upon to render services to other physicians or their immediate
families with such frequency as to involve a significant
proportion of his professional time, or in cases of
long-term extended treatment, fees may be charged on an
adjusted basis so as not to impose an unreasonable burden
upon the physician rendering services.
4. Professional courtesy should always be extended without qualification to the physician in financial
hard-ship, and members of his immediate family who are
dependent upon him.
TRENDS
Professor Temkin referred us to Moll’s9 1902
pub-lication from Berlin. He discussed the issues of
professional courtesy: “Intellectual labor has
physicians’ reluctance to reveal their profession be-cause they wanted to be treated like every other patient and be able to pay for care. The only
argu-ment for professional courtesy is the fact that it is embarrassing to be paid for service to a colleague. Moll felt that with only one reason for and many against professional courtesy, it was justified that every physician pay for his treatment as every other patient. He also felt, as did Flint, that payment could be in the form of an honorarium.
Psychiatrists and analysts were the first to dis-continue professional courtesy. Freud had cancer of the jaw for the last 16 years of his life.’#{176}In 1923, he made it a condition of his treatment by surgeon Hans Pilcher that care be paid for. In 1930, nine
years before his death, he also requested that his internist, Max Schur, charge a normal fee.
Anna Freud (personal communication, 1977),
writing of her father’s feeling regarding professional courtesy, said:
In Vienna as everywhere else there was of course the practice that medical people treated their colleagues and/ or their families without remuneration. I remember very well the arguments which prompted my father to change this habit in psychoanalytic practice.
To accept a patient for psychoanalysis means, and
meant, giving him one hour a day for very long periods,
certainly for one or two years or more. But one hour daily for an analyst represents one eighth or one ninth part of his working capacity and therefore such a gift would
really be too large. To have two patients of this kind
would mean to restrict the analyst’s earning capacity by
one fifth. This was the reason why my father felt it could
not be done, but of course if he could not offer professional courtesy in this way, he also felt quite unable to accept it.
Whenever he had the services of a medical colleague for
himself, he made quite certain that he would be able to
pay for it.
The same feelings were expressed by’
in 1938. Pinner,’2 in 1952, writing about his experi-ence as a patient stated that his physician discussed his case with him as if he were a consultant. The
physician failed to give definite orders and advice and tended to say explicitly or implicitly, “You
know what to do.” He suggests abandoning profes-sional courtesy for three reasons: because the phy-sician-patient is not allowed to pay,
He tends to hesitate to ask for medical help, he feels embarrassed because he is in the position of a beggar
instead of a purchaser. Even if this anomalous position does not cause undue delay in diagnosis and treatment
(as it frequently does) it is another burden on the patient’s mind; and any patient’s mind is vulnerable.
In 1954, McCabe,” writing about the role of the doctor’s wife, stated that professional courtesy may lead to “embarrassment, fear of imposing or reluc-tance to consult for what may be an imagined
ailment.” She spoke of the bugbear in the field of professional courtesy-how much and what type of
gift, “Doctor’s houses are loaded with unique items carefully selected by grateful colleagues which stand collecting dust.”
Benjamin Spock’4 first called the attention of pediatricians to the problem of professional cour-tesy in 1962. He viewed the problem from the points of view of the father (physician) and the mother
(wife). He referred to the boost to one’s ego to be
chosen by another physician for care and at the same time referred to the conflict of feelings in
seeking such care. The physician-patient is reluc-tant to ask for help. Is a symptom important enough? Should not the physician be able to handle it himself? It is often simpler to mush through with, perhaps, only a partial examination and the use of the nearest sample for treatment. Not being able to pay for care interferes with objective seeking and utilization of care. Spock, thus, makes a strong plea for the elimination of professional courtesy.
Review of literature from 1958 through 1974
re-veals a paucity of information on professional
cour-tesy. Only two articles were found in the past dec-ade.’5’6 In addition to Spock’s comments, Auer-back’7 wrote the first comprehensive report of the problem. This report included a historical review, a discussion of the conflicting opinions of the Judicial Council of the AMA and the Executive Council of the American Psychiatric Association. It also con-tains an analysis of a survey’8 of northern and southern California Psychiatric Societies, one of the eight such surveys reported from 1956 to 1974.125
He concluded that professional courtesy may be “a
barrier to good medical treatment by causing delay in seeking medical help and producing negative
feelings on the part of the patient physician and treating physician.”
Branch26 noted that the AMA survey in 1966 of
4,000 physicians revealed that 87% owned some sort of health insurance because “they felt better when carrying insurance. If the purpose of health insur-ance is to pay medical bills, as it obviously is, then it would appear that most physicians are disposed to make vigorous use of it as opposed to relying primarily on the professional courtesy principle.”
The most revealing part of the survey was the response to the question of whether professional
courtesy made physicians or their dependents hes-itant to seek medical care: 48% indicated that professional courtesy created some degree of hesi-tancy to seek help.
There have been two reports of attempts at dis-continuing professional courtesy. Steinman,27
number of physician families in his pediatric
prac-tice, he realized that free care was becoming a financial burden to him. The following letter was sent to all psychiatrists in his practice.
Dear Doctor:
Beginning next month, we will bill you for care of your
children by our pediatric group. We realize you may
consider this a departure from the usual practice of extending professional courtesy to the families of
physi-cians. However, we would like to assure you that this is being done only after careful thought and long
delibera-tion.
Our practice includes quite a number of psychiatrists’
families. Several years ago, some of them recognized the
burden this imposes and requested on their own that we bill them for our services. We have done so and have found that parents have been quite pleased with the
arrangement.
Today, as the volume of our courtesy services continues to increase and, in fact, has now become a substantial part of our practice, we are compelled to ask all our
psychiatrists’ families to assume a similar arrangement.
For that reason beginning next month, you will be billed for services to your children, with allowance for the
customary professional discount.
Please let me know your feelings on this matter. Sincerely,
Philip D. Rockalte, MD
Psychiatrists were singled out because they had already begun charging other physicians and some of them had asked for the privilege to pay for care. Reaction to the move was sufficiently favorable, and this pediatric group began charging all physi-cians’ families “with allowance for the customary professional discount (20%).” Other physicians in this Main County suburb of San Francisco began similar charging, with acceptance by the commu-nity at large (P. Steinman, personal
communica-tion, 1977).
In Hollywood, Florida, E. J. Saltzman (personal
communication, 1977) reported an unsatisfactory experience with discontinuing professional courtesy in his pediatric practice in 1973. The letter below
was sent to all physician families.
Dear Dr and Mrs Blaze,
It is our privilege to provide to your children what we feel is the best pediatric care available.
In these troubled economic times when our expenses, as yours, have increased so drastically, we find ourselves in a difficult situation.
With the influx of so many families to our area-the
volume of pediatric responsibility has increased
consid-erably.
Sheer economic demands and pressures give us no
choice but to discontinue professional courtesy on a “no fee” basis, but we will offer a 20% discount.
This policy has been followed for some time in many areas of our country, including South Florida-to the mutual satisfaction of all concerned.
We realize that this is a delicate subject to introduce, but this will enable us to provide your families with the
professional time and attention that they require.
This policy will enable you to avail yourselves of our services without reticence and eliminate an often
ex-pressed reluctance to call upon us.
Sincerely yours,
Pediatric Associates, PA
The response was generally unfavorable. Some phy-sicians became “incensed,” others “offended.” One even took the matter to the ethics committee of the county medical society. Some switched to other pediatricians. Saltzman stated he experienced per-sonal difficulties in his social relationship with the medical community. He eventually returned to past practices.
In December of 1975, after much thought and
discussion, we decided to discontinue the practice of professional courtesy. We informed our physician patients of this with the following letter.
Dear Dr and Mrs Jones:
Over the years, it has always been our policy to provide service to our medical families without charge as a cour-tesy to our professional colleagues. We considered it a privilege to do so. We have now decided, however, to change this policy for both economical as well as philo-sophical reasons.
The volume of our professional practice has increased sufficiently over the years so that in these inflationary times the cost ofsupporting such a large group of patients
has become prohibitive and, this, in a sense places a large burden on our nonprofessional patients to support the actual costs of operation.
In recent years, because of increased major medical and other insurance coverages, many of our medical patients have asked on their own to be billed. It has been our observation that these families tend to use our pedi-atric services much more appropriately and avail
them-selves of care earlier than they did when they felt that
calling on us might be an intrusion. They seemed to feel much better about their doctor-patient relationship and we realized that we did also.
We have therefore decided that as of this date all of
our patients will be billed equally. If this policy creates a fmancial hardship for you or your family, please let us know.
Sincerely yours,
One year after our letter was mailed to 100
phy-sician families, a review showed that 85% of our
families had made a return visit to the office. All families were questioned regarding their reaction to the letter. All but one family spoke favorably about the change. The degree of enthusiasm for the new policy seemed to be directly related to the length of
time since graduation from medical school. The only negative response was from a first year resident
physician who said money was a problem. The
remainder of the responses, primarily from the
call or come for a visit. We have had no comment from the medical community at large. It is possible
that we have had fewer new physician families enter the practice but this has not been documented. However, there has been a recent influx of physi-cians who have come with the preknowledge that we charge. Of the remaining 15 families, five pre-sumably changed pediatricians, five left the city, and five had older children who did not return.
Our medical families seem more comfortable in the practice. We feel they avail themselves more readily of service, use the phone more freely, come to the office more frequently, and compliance seems improved. We28 find that the doctor-patient inter-action operates on a much better basis and our attitude toward our medical families is much more like it is with the rest of our patients.
Two pediatric groups in this city have recently discontinued professional courtesy-one charges 50% of normal fees and the other, full fee.
There are numerous disadvantages inherent in the care of physicians and their families. Physician-patients and their spouses are slow or even reluctant to seek health care.m33 Many feel it is an imposition or that they should be able to care for their own complaints. There are gaps and variations in record keeping. A parent or patient-physician may have special but hidden anxieties in view of his medical knowledge. The treating physician may rely on the patient-physician for part or all of the diagnosis and
treatment. Self-referral and self-treatment are corn-mon. History taking may occur in the hospital corridor or at cocktail parties.3#{176} The treating phy-sician may treat not only anxiously but more cau-tiously if he feels under scrutiny. The
patient-phy-sician may feel unable to complain about care or be reluctant to change physicians.3’ In general, both treating- and patient-physicians are more likely to behave in ways that are contrary to or deviate from
the behaviors prescribed by their traditional roles.32 Carey and Sibinga33 state that treating families of your social friends carries with it the disadvantage
of (1) unrealistic expectations and hidden motiva-tions, (2) trouble keeping social and medical rela-tionships separate, (3) difficulty handling dissatis-faction on the part of both parties involved. There are the advantages to the physician-patient of (1) knowing more about who is competent and (2) being able to seek competent attention promptly, but these advantages are far outweighed by the above mentioned disadvantages. Although profes-sional courtesy is not necessarily the sole underlying difficulty its role is instrumental in allowing the above disadvantages to occur.
Our policy now is not to charge medical students. Pediatric residents and interns at our Children’s Hospital of Pittsburgh and members of our
full-time medical staff also are not charged. We feel indebted to them because of the many services they provide for us and our patients. An explanation is made to all new physician families that we formerly gave professional courtesy but have discontinued the practice for the reasons mentioned in the letter.
At first these explanations seemed difficult and awkward to us but they are accepted so naturally by our patients that it is much easier for us now. The families seemed to accept the idea readily and with favor. The problem seemed to be our reluc-tance to discuss money matters in general and our concern about charging members of our own profes-sion, in particular.
Discontinuing professional courtesy has resulted
in improved attitudes on our part. It has eliminated
negative feelings that tend to arise toward families
because they are given professional courtesy. It is easier for us to lay down the ground rules for our relationship with the patient and the parent and
insist that families in our practice follow the rules. They are paying for their care and they deserve at least as good care as any other patient in our practice. By the same token, most of our families, particularly the mothers, find themselves in a much better position to call on our services appropriately
and get their “money’s worth” without feeling in-trusive or imposing.
Current text books of pediatrics fail to mention
fees or professional courtesy and, in fact, say noth-ing of “how to practice.” Thirty-one of 107 medical schools questioned by Veatch and Sollito do give courses in medical ethics, but specific discussion of professional courtesy and its ramifications is not
part of the curriculum. At a consortium of ten medical school faculties in July 1977, P. Drew of the University of Pittsburgh (personal communi-cation, 1977) found that none included discussion of professional courtesy in their curricula. Veatch, of the Institute of Society, Ethics and the Life Sciences, Hastings on the Hudson, New York, like others before him, considers the problem of profes-sional courtesy “more a matter of traditional eti-quette than of real ethical dilemma” (New York Times, April 24, 1977, The Week in Review, p 6). We feel that fees, professional courtesy, and other aspects of practice, such as office management, and dealing with people, should be covered in medical education. The neglect of these topics in our medi-cal education and our textbooks is a serious deficit in medical training.
CONCLUSION
Professional courtesy is a practice that has out-lived its usefulness. Today it stands in the way of a physician and his family getting the best care
REFERENCES
medical milieu defeats the noble purpose it was originally intended to serve. Physician attitudes toward each other and their patients should be an integral part of the ongoing ethical discussion, start-ing at the beginning of medical school and contin-uing on throughout one’s medical career. The con-cept and implications of professional courtesy should be included in these discussions because they go to the heart of getting and giving the best care available.
Major criticisms against doing away with profes-sional courtesy are that this somehow denigrates
the medical profession, removes the aura of medi-cine, casts a shadow on its nobility, and somehow translates itself into the idea that money is what is good about medical care. We feel the central con-cept of the doctor-patient relationship (no matter who the patient is) should be a special sense of
caring. However, not charging for care makes it different for the patient and the physician. Both
may feel compromised. Both may feel the loss of
freedom to react. Charging for care says that the patient’s needs are significant, deserve attention, and that the doctor’s services have value.
Pediatrics, perhaps more than any other
spe-cialty, requires frequent communication and visits between physician and patient and entails extensive
use of the telephone. We feel that because of profes-sional courtesy many physician-parents and their
spouses are deterred from using pediatric services appropriately by timely office visits or telephone
calls. They therefore do not receive optimal care. In starting practice, the young physician must make a decision when he sees his first
doctor-pa-tient. Although he may have never been taught about the concept, somewhere in the back of his mind is a thought that Hippocrates said physicians should not charge other physicians for care, and so he establishes a precedent of professional courtesy that usually remains through a lifetime of practice and is very difficult to change or abandon. It is therefore at the start of practice that the
disadvan-tages of professional courtesy should be most
care-fully considered. We recommend not starting the custom. But even if it has already been started, we recommend that this anachronism be abandoned.
ACKNOWLEDGMENTS
We would like to thank the following people for their help with this paper: Claire Hahn, Drs Thomas K. Oliver, Richard L. Cohen, and Mark Ravitch for their critique of the paper; librarians, Susan Paul, Janet K. Sondecker, Jean R. Aiken, M. Fransiszyn, and Barbara Epstein, for reviewing the historical literature; and Drs Gerhard Wer-ner and Bruno Weber for translation of the articles
writ-ten in German.
1. Edelstein L: in Burns CR (ed): Legacies in Ethics and Medicine. New York, Science History Publications, 1977, pp 14, 15, 78
2. Phillips ED: Greek Medicine. London, Thames and Hudson,
1973, pp 118-119
3. Baas JH: Outlines of the History of Medicine and the Medical Profession, Handerson HE (trans). New York, WR Jenkins, 1910, p 38
4. Gregory J: Lectures on the duties and qualifications of a physician. Read before students in Edinburgh and London, 1772
5. Leake CD: Percival’s Medical Ethics. p 11, Baltimore, Wil-hams & Wilkins, 1927, p 11
6. King LS: The Medical World of the Eighteenth Century. Chicago, University of Chicago Press, 1958, p 228
7. Flint A: Medical Ethics and Etiquette. Commentaries on AMA Code of Ethics. New York, D Appleton & Company,
1883
8. Judicial Council Opinions and Reports. Chicago, American Medical Association, 1977, p26
9. Moll A: Arztliche Ethik, Die Pflichten des Arztes in Allen Beziehungen Seiner Thatigkeit, Stuttgart, Verlag Von Fer-dinand Enke, 1902, pp 388-390
10. Schur M: Freud: Living andDying. New York, International Universities Press, 1972, pp 408-409
11. Menninger, K: Theory of Psychoanalytic Technique. New
York, Basic Books, 1958, p 9
12. Pinner M, Miller BF: When Doctors are Patients. New York, WW Norton, 1952, p 26
13. McCabe K: The doctor’s wife, in Garland J (ed): The Phy-sician, His Practice. Boston, Little, Brown & Co, 1954, chapter 3, p 3
14. Spock B: Should not physicians’ families be allowed the comfort of paying for medical care? Pediatrics 30:109, 1962 15. Lipsitt DR: The doctor as patient. Psychiatric Opinion 12:
20, 1975
16. Schweisheimer W: Das Problemder Professional Courtesy.
Med KIm 71:1277, 1976
17. Auerback A: The psychiatrist looks at professional courtesy.
Read at the 118th Annual Meeting of the American Psychi-atric Association, Toronto, Canada, May 7-11, 1962. Am J
Psychiatry 119:520, 1962
18. Report of Ethics Committee of the Northern California Psychiatric Society, December 1960 (out of print)
19. Sherwood H C: How much professional courtesy for non-physicians. Med Econ 35:74, 1958
20. Hughes SC: When you give professional courtesy. Med Econ 35:154, 1958
21. Professional courtesy survey. JAMA 195:159, 1966 22. Owens A: How much unpaid service doctors still provide.
Med Econ 50(pt 2):88, 1973
23. Owens A: See how professional courtesy is changing. Med Econ 51(pt 1):79, 1974
24. Gifford JP: Professional courtesy, who gives how much to whom? Med Econ 39:81, 1962
25. Auerback A, Capeller WS: Should Psychiatrists Charge Other Doctors? Med Econ 40:173, 1963
26. Branch CHH: Professional courtesy: Our problem. Am J Psychiatry 123:8, 1967
27. Rockalte PD: Yes, we’ve started billing other doctors. Med Econ 42:85, 1965
28. Bass LW, Wolfson JH: Professional courtesy is obsolete. N EngI J Med 299:772, 1978
29. Sharpe JC, Smith WW: Physician, heal thyself: Comparison of findings in periodic health examination of physicians and
executives. JAMA 182:234, 1962
30. Kennell JH, Boaz WD: The physician’s children as patients. Pediatrics 30:100, 1962
31. White RB, Lindt H: Psychological hazards in treating
phys-ical disorders of medical colleagues. Dis Nerv Syst 24:304, 1963
32. Franklin RW, Goolishian HW, White RB: Psychological hazards involved in treatment of medical colleagues. Din
33. Carey WB, Sibinga MB: Should you provide pediatric care 35. Bass LW, Wolfson JH: The Style and Management of a to your friends? Pediatrics 42:106, 1968 Pediatric Practice. Pittsburgh, University of Pittsburgh 34. Veatch RM, Sollito 5: Medical ethics teaching: Report of a Press, 1977
national medical school survey. JAMA 235:1030, 1976
WHY CLINICAL RESEARCH IS FAILING
An important factor in the fossiisation of clinical research is the role of its journals and the formalisation of triviality which their editorial and refereeing policy impose. There is a paucity of worthwhile speculation in clinical papers of all sorts. Essential factual data need little or no comment: true research does. If a set of observations arising from a piece of research does not provoke reasonable and interesting new thoughts, then
either the author was not trying or the work was not worth doing or publishing. Surely it would be incumbent on the author to develop such ideas, however briefly? The problem
is that, if he does, the chances are that he will be asked by the editor to remove them.
“This is speculative and should be omitted,” says the editor and his reviewers. But why?
No reason is given; “this is speculative” is now considered an adequate reason. By
discouraging worthwhile creative speculation, the journals encourage the triviality of data collection to the detriment of real science. At a time when we are liable to be lost in the undergrowth of fact surely we must build more pathways of inspired hypothesis?
It comes as no surprise that the pattern of research in clinical medicine is profoundly influenced by the structure of its organisation. The two main influences are administration and career structure, both of which favour the execution of the more technological and simply defined projects rather than creative work.
Because much clinical research is supported by grants, the character of the work done
comes to resemble that which the grant-giving bodies will support as much as that which
the researcher might want to do. Successful applicants are those who understand the practical psychology of grant applications. When submitting an application, you have to remember that, apart from the specialist reviewers, perhaps only one or two people on the committee assessing the project have direct experience of the work you propose or of
your competence in the field. If you have a really hot idea you certainly don’t want to tell
the reviewers because they are potential competitors, while the others would probably miss the novelty and find it too provisional and delicate an idea to be worth supporting.
So the art of the grant application turns on the creation of a story whose originality is
mostly literary but whose logic can be understood by the committee members outside
the field without being too threatening or revealing to those inside and competing. True
creativity has to be hidden. Even without my cynical hyperbole it must be apparent that grant support inevitably leads to trivialisation and bias towards projects that will be
acceptable rather than desirable.
From Sam Shuster, Professor of Dermatology at Newcastle University, in New Scientist, October
