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The A.M.A. has had only moderate success in choking back group practice and prepayment. Group practice is widespread, prepayment plans are growing, and there are numerous third parties in the medical complex. About 2,300 "multiple-specialty and general practice" groups have been formed, comprising 20,000 doctors, some in big cities, some in remote towns, some in hospitals or other large medical centers, some in a simple suite of doctors' offices.
By far the biggest and most successful group practice is Minnesota's famous Mayo Clinic, with 500 doctor-members. Most groups, with eight to a dozen members, comprise general practitioners or internists, pediatricians, obstetrician-gynecologists, a radiologist, a surgeon, an orthopedist and an ophthalmologist. The mix varies with local demand, but in each group a family doctor, the patient's first and continuing contact with the group, steers him to specialists as needed.
A Lifetime License
Year after year, the U.S. has fewer and fewer family doctors to do the steering. In 1930, G.P.s outnumbered specialists 70 to 30. Today the ratio is more than reversed, 21 to 79. The nation's medical schools have been increasingly geared to train specialists, and few graduates now go from internship into general practice.
Membership in a group practice, whether as G.P. or specialist, is no ironclad guarantee that a doctor is outstanding. But at least it ensures that he talks to other doctors regularly and is exposed to some of the ferment in medicine. The 50 states' licensing laws, and the attitude of the A.M.A. and most other professional organizations, offer no such assurance. Theoretically, it would be possible for a man to have graduated from medical school at 25 in 1934, to have been licensed after a year's internship, and to have practiced as a G.P. ever since then without having heard a professional word about most of modern medicine. There is no requirement that he ever read a journal, attend a medical meeting or even talk to another doctor. In practice, of course, the doctor's sense of duty and the growing sophistication (or hypochondria) of the public impel him to keep up. But there is no mandatory continuing education, and there is no reexamination. There is no law limiting his practice to his competence. A G.P. could legally do a heart transplant, if he were foolhardy enough. A license is for life.-Only the American Academy of General Practice (with 31,000 members among the nation's 72,000 G.P.s) expels members who fail to take required refresher courses.
In most smaller cities and towns, virtually every physician is listed as "on the staff" of one or more local hospitals. This does not mean that he is paid by the hospital, and it tells nothing about his qualifications. It does mean that he is a member of the county medical society, has the privilege of admitting his patients to the hospital, and is basically responsible for overall care thereafter. Many a big-city patient is denied this continuing contact with his own doctor. In New York City alone, some 5,000 physicians (close to one-third of the city's total) have no privileges at any voluntary hospital. They can either surrender their patient to the mercies of interns, residents and specialists who have never seen him before, or try to get him into a proprietary