Refer to: Moser RH: An anti-intellectual movement in medicine.
West J Med 122:433-449, May 1975
Anti-Intellectual Movement in Medicine
ROBERT H. MOSER, MD, Chicago
IT IS NOT NEWS that Western man is reentering a before; and now that I have come to the big
climate of anti-intellectualism-a new Dark Age city and begun to wander about, and to take the
wherein some fight fear with long since discarded pulse of American medicine, the fears have be-
devices. We have witnessed the return of mysti- gun to crystallize.
cism as reflected in the reemergence of the black
and white magic of the Tarot, the simplistic non- First Signs of Change
sense of astrology and a wave of perfervid reli- It is a little like watching animals react to a
giosity. If these methods had ever worked, they small fire in the forest. The whiffs of smoke were
would not have been reassumed and discarded detected by sensitive creatures about five or ten
myriad times in the history of civilizations. years ago. You are all familiar with the tremors
We are in a state of chaos, but it is nonsense that were felt by the academic community. Some
to blame the mess on the clean, flourishing, logical whispered that our research and educational
and technical disciplines of science. Rather, it is, establishments had become badly out of joint
once again, the lagging of practical humanism re- with the times. There were murmurings about
flected in failure of social and political systems to excess fat in research budgets, escalating costs of
implement scientific knowledge that has created medical care and maldistribution of professional
a gestalt inimical to the health of the individual talent-geographically and socioeconomically.
person and, therefore, to the health of society. But just as you and I had, the bright young gradu-
And I fear the wave of anti-intellectualism has ates of the 60's continued to swarm the ivory
begun to encroach upon the borders-if not the towers and populate the specialties, while the vast
heart-of medicine. mass of patients-those who were less-than-vio-
Let me explore this. lently ill or less-than-interestingly ill-were all
but forgotten in the academic scramble. And all
One year ago I was battling the problems of of this had significant fallout.
providing patient care in an urban-rural com- Patients obliged to wait several hours in offices,
munity, with night calls, house calls and all the clinics and emergency rooms agreed most readily
joys and agonies attendant thereto. And one can- when they were told we were in the midst of a
not obliterate certain perspectives and attitudes doctor shortage. And for many lower and middle
simply by switching chairs: in this case, to one income groups good medical care was scarce, if
behind an editor's desk. So I would like to rumi- not unknown. The news media were replete with
nate some things that had begun to worry me stories of dramatic progress in the science of
The author is Editor, The Journal of the American Medical medicine but little of this was perceptible, little
Association, and Director, Division of Scientific Publications,
The American Medical Association. filtered down to the vast mass of the less affluent
Presented to the Calfornia Academy of Medicine, San Francisco, sick. Words such as relevance and social responsi-
September 28, 1974.
Reprint requests to: R. H. Moser, MD, Editor, The Journal
of the American Medical Association, 535 North Dearborn Street,
bility began to creep into the conversations of our
Chicago, IL 60610. medical young.
THE WESTERN JOURNAL OF MEDICINE 443
Meanwhile, many medical schools, still basking or the vertical ghettoes of Detroit after they've
in the warmth of their post-Flexner era bonanza, seen Massachusetts General or the National In-
began to sense the distant smoke, and some re- stitutes of Health or Scarsdale or San Francisco
acted. Incoming classes were doubled and tripled; or Maui?"
selection committees reached out for minority And what about the graduates of the late 50's
group students; curriculum committees sought and 60's?
new dimensions. Schools with unfamiliar names Some of us anachronistic curmudgeons-erst-
mushroomed throughout the land. while bedside clinicians-could be heard to mutter
Some clinical teachers became concerned about darkly about the new breed of graduates and their
the capability of the existing, relatively finite pool tutors, mechanical and otherwise. Nasty phrases
of medical educators to accommodate the surge like laboratory-oriented myrmidons, molecular
of new students, and still maintain traditions of biology buffs, disease rather than patient-oriented,
excellence in classroom and clinic. But these bereft of human virtues, assembly line products
fears were assuaged with assurances that the new crept into our cloakroom conversations.
mass media techniques would facilitate clinical Yet, the first significant militant protests against
teaching. Yet some of us were still worried about the educational grist mill came from the students.
relegating these critical responsibilities to mechani- It was their forthright demands for relevance in
cal surrogates. But our concerns were only small curriculum and for meaningful medical experience
eddies swirling against the mainstream. that arose in response to their expanding social
More Doctors, Faster awareness. Students-not teachers-were the ones
who scrutinized the academic tradition which had
Produce more doctors and do it faster was the taught disdain of the local medical doctor, the
watch word. We were advised that we were 30,000 LMD, and had extolled the virtues of the investi-
doctors short throughout the country-but few gative-teaching career pattern. Students were the
stopped to analyze this figure as it related to dis- ones who studied this philosophy-and found it
tribution and specialty. Yet on the basis of gross lacking, out of balance, out of synchrony with the
numbers alone the gates were thrown open to times. While our generation focused mainly on
foreign-trained physicians, and they came in individual patients, and accused our immediate
droves-to fill the need. This is not the time or successors of looking mainly at disease mecha-
place to discuss the merits or debits of this most nism, indeed recent graduates were the ones who
complex situation. But the fact is that this relaxed looked beyond both-at the need of society.
policy of medical immigration did little to take
the pressures off American medical schools. There is a requirement that all three aspects-
Thus, to accelerate the production of warm patient, mechanism and society-be kept in mind,
medical bodies, many medical schools condensed and they are not mutually exclusive. But it is a
the curriculum by emasculating or deleting "irrele- difficult balance to strike. However, the point had
vant" departments (clinical pharmacology was an been made.
early, costly casualty); some merely eliminated Admittedly, many perceptive educators had
vacation periods and began to churn out gradu- already began to suspect that perhaps the post-
ates in 36 months. Not much time for reflection, Flexner momentum had crested, and that under
or emotional growth, or evolution of the other in- their stewardship the thrust of medicine had
tangible elements that go to make up that elusive carried beyond its cardinal purpose-the care of
quality we call medical maturity. patients. They began to realize that concepts of
No one seemed to ask "What is the hurry?" patient care had become lost, sidetracked some-
Also no one paid much attention to where the where in the fascinating catacombs of scientific
warm bodies, foreign and domestic, gravitated. methodology. Educators began to realize that
And there was no perceptible change in the pat- through their teaching, diseases had replaced pa-
tern of physician distribution-geographically or tients in the priorities of education in medicine.
by specialty. No one faced the problem of "How
are you gonna keep 'em down on the farm-after An Awesome Body of Knowledge
they've seen Paree" or, to paraphrase, "How are But one must not forget; the smoke in the forest
you going to keep 'em down on the Indian reser- had originated in a most remarkable crucible. The
vation, or in the horizontal ghettoes of the delta, golden years of research and postgraduate clinical
444 MAY 1975 * 122 * 5
training that began after World War II had pro- present trends continue (the production of our
duced an incredible cadre of talent and an awe- medical schools plus the continued influx of
some body of knowledge. New pathophysiologic foreign medical graduates), within 12 years the
mechanisms had been identified. Dramatic dis- United States physician pool will number between
coveries in molecular biology, immunology, 495,000 and 520,000. By 1985 we will have 220
cytogenetics, and enzyme and hormone chemistry doctors per 100,000 population as compared with
had occurred. New diagnostic techniques and 160 in 1970. If you believe this projection (and
therapeutic tools were devised. All were products this numbers game has been the subject of great
of these marvelous years. debate) we are facing a doctor surplus.
This was reflected in gigantic growth in capa- Listen to the words of Dr. Charles C. Edwards
bility for quality patient care. Admittedly, the at the Association of American Medical Colleges
distribution and availability of this care were far meeting in 1973, "I think that clearly we have
from optimal, however-as I said earlier-social moved beyond the point at which concern about
and economic implementation always lags behind a shortage of physicians was genuine if somewhat
advancement in sciences. But the capability was exaggerated. Even more significant is the possi-
there. (I sometimes suspect that in the grand bility we may well be facing a doctor surplus in
scheme of life, there are times when such sudden this country." Later he said "The task the medical
spurts of genius and productivity must occur to schools now face is to work toward solution of
maintain viability. But always, something else problems that relate not to aggregate numbers of
must be sacrificed.) physicians, but to specialty and geographical mal-
Thus, despite this flush of success in science, distribution, physician productivity, and the under-
some of us felt that during these grand years of representation of women and minorities among
progress in hard science, something had been lost the health professions . . . "
along the way. Perhaps it was that bedside senses
were being neglected and were becoming dulled. The Government and Medical Education
We thought that some training programs were out
of balance; there was too much mechanization; This can be translated into the fact that the
too much stress on nuts and bolts-too little stress government is taking a hard look at its philosophy
on people. In the passionate effort to master the of financing medical education. The holders of the
vast new knowledge, students were being deprived federal purse strings are not satisfied with the cur-
of something vital and wonderful and satisfying in rent efforts by medical schools to meet the prac-
medicine: the joy of eyeball-to-eyeball, personal, tical needs of the citizenry. Another example:
one on one, longitudinal communication with pa- There was a bill (S-3585, Kennedy-Javits) which
tients. The humanity of medicine was all too often was approved by the Senate Labor and Educa-
shunted aside in the headlong pursuit of hard tion Committee. In its original form it would have
science. There was more to be learned, and less provided almost 2 billion dollars over a three-
time to learn it. Something had to be sacrificed, year period in federal aid for medical and other
and we felt the choice, although it was perhaps health profession schools. This bill would have
inevitable, was unfortunate. In many cases the art given the federal government power to allocate
of medicine was left on the curriculum cutting- and limit postgraduate training for physicians. It
room floor. included a provision designed to curb the reliance
But the smoke in the wind became even more on foreign medical graduates and to increase the
perceptible about three or four years ago. Things number of primary-care physicians. It would have
began to shift back toward the bedside. Preceptor- required the Department of Health, Education
ships, neglected for 25 years, were being redis- and Welfare to limit the number of postgraduate
covered. Most clinicians viewed this with cautious training positions in hospitals to no more than
pleasure. A balance was being struck between 10 percent above the total of domestic medical
and osteopathic school graduates of that year, and
bench and bedside. But in recent months, my to assign the total number of physicians to various
delight has begun to fade. It has been replaced categories of specialty and subspecialty training.
by something close to alarm. Let us look at what
is happening. Among other provisions of this bill were those
We are told by people who should know that that would require all young physicians to serve
despite the current overall physician shortage, if for two years in a sort of domestic peace corps
THE WESTERN JOURNAL OF MEDICINE 445
program, whether or not they received federal internists, pediatricians and obstetricians. So
loan or scholarship help. Also, within two years evidently there is a long way to go to meet the
the Department of Health, Education and Wel- current need in numbers-as well as in distribu-
fare. would establish national standards for li- tion.
censure of physicians and dentists. Under this bill, But in recent months have experienced a dim
licensure renewal would occur at least every six sense of uneasiness. I have detected a subtle anti-
years. A physician or dentist licensed to practice intellectual, antispecialty, antiresearch movement
in any state would qualify in any other state in developing at several levels, and it is expanding.
which the national standards are in effect. If a Some might say that we had it coming-after
state had standards exceeding the national stand- years of pejorative comment about the LMD on
ards, a physician coming into that state would our wards and in our clinics. Yet, while we all
have to meet the additional requirements. advocate more family physician training, I can
Thus it was designed to require all recent see no useful or rational purpose in denigrating
medical graduates to serve in shortage areas, to investigative or specialty medicine, while pursuing
limit the number and variety of postgraduate posi- this new venture. I have heard such things as "stu-
tions and to ensure the relicensing of all physi- dents with good science grades do not necessarily
cians. The final, much modified version-as make good doctors." This may apply to some
amended by Beall of Maryland-was passed on few, but it is the implication of the statement that
September 24 by the Senate, 81 to 7. It would is disturbing. It has an anti-intellectual ring. No
provide federal aid to medical and dental schools one can deny that there is a need in the selection
that agree to allocate 25 percent of their class- process to seek out students who have qualities
room spaces for students volunteering to serve in of compassion and human warmth. Also this
urban slums or rural areas short of medical care aspect of personality must be nurtured and en-
workers. In return for their service, the students couraged during the years of education in medi-
would be entitled to government scholarships. cine, yet one must not ignore the seminal im-
The bill would require one year of service for each portance of a firm foundation in the sciences.
year of scholarship aid. Human compassion and academic excellence
To say the least, all of this is most provocative are not mutually exclusive virtues. Some of us
-and I will not speculate upon it at this time. are egotistical enough to think that we have come
Suffice to say that it is perhaps an indication of close to this ideal. And we are many.
what is in the wind, a cardinal demonstration that This is not a time for intemperate generaliza-
the government is indeed concerned about prob- tions; these are indicators of panic and reaction.
lems of contemporary medicine in America at all It is the time for balance-rational creative plan-
levels. And I will not speak of the implications of ning and the initiative should come within the
Professional Standards Review Organizations, profession.
Health Maintenance Organizations or national
health insurance on medicine overall. But let us It is encouraging that many of our medical
return to the problem of medical education. young are highly motivated to family practice.
And we do need more of them. Yet we must
continue to produce a proper proportion of
New Educational Directions specialists and investigators to complement the
In an effort to anticipate this need to qualify health care team.
for such federal support of medical education, And I must express my concern that govern-
many schools have reevaluated their priorities in ment through its fiscal power over medical educa-
curriculum planning. One major thrust of all of tion is seeking means to control the input into
this has been the creation of departments of family medical specialties. It is antithetical to traditional
medicine-a welcome, long overdue development. American freedom of choice for government to
The popularity of these programs is evident exercise control over one's selection of his life-
through the progressive increase in positions and work. Yet unless medicine itself can solve this
applicants over the past three years. One estimate problem of specialty growth and distribution, it
by the Division of Manpower Intelligence places may well become a function of government. As I
the current shortage at 27,000 to 30,000 family- look ahead 10 to 20 years, my crystal ball be-
care physicians such as general practitioners, comes distressingly cloudy.
446 MAY 1975 * 122 * 5
Improving Physician Distribution them there long enough, they will find cures for
The problem of physician distribution is ad- cancer, heart disease and stroke."
mittedly difficult, but I do not think it is insur- Well, timetables may be applied to mathemati-
mountable. There are several possible options. cal and physical sciences. And the pharmaceutical
Federal subsidy of students with a mandatory sciences have been successful in the creation of
two year pay-back time is one possible solution. new molecules through a goal-directed orienta-
But again the implication of univers!l compulsory tion. Propylthiouricil and several synthetic anti-
service has ominous overtone. And, parentheti- biotics (most notably rifampin) have resulted.
cally, I might add that if indeed this comes to But biological arts do not work this way. In
pass for medicine, why should we be singled out? medical research there is, unfortunately, one
Why not dentists and lawyers and teachers and variable that cannot be manipulated: the patient.
perhaps even engineers, architects and plumbers? The myopic bureaucratic philosophy that seems
Certainly these services are also maldistributed to say "If we can get to the moon in ten years-
throughout the country. But I am wandering; certainly we can cure cancer in 15," was imple-
down this catacomb lies madness. mented through various mechanisms resulting in
Also regarding distribution, I am convinced a significant constriction of research funds, most
that there are many physicians who can be in- of which were diverted from "non-goal-oriented
duced to care for patients in less desirable geo- research." The alleged fat was trimmed merci-
graphical areas. This can be done by a reorienta- lessly. Those who could not be enticed or coerced
tion of philosophy and priorities, by offering a into "target-oriented" research began to drift
rewarding lifestyle, by a team approach, with away. It is probable that a significant portion of
perhaps three or four family-oriented physicians one or two generations of young investigators has
working in a group each trained in a different already been lost. It is a tragedy of dimensions
discipline-internal medicine, obstetrics-gynecol- that may never be fully appreciated, since it can-
not be measured. How do you evaluate something
ogy, pediatrics. that was never discovered?
There must be professional recognition by col- Throughout the history of art and science
leagues and an end to the denigration of the LMD. there have been some free spirits that cannot be
There must be realistic financial compensation
and rapid access to specialist backup. These phy-
tethered. They must be recognized, cherished and
sicians must also be provided a practical continu- given their heads. These have always been our
most creative people; this is the nature of art and
ing medical education program, perhaps through science. Alas, it is a concept alien to the bureau-
periodic sabbaticals, while they are replaced by cratic psyche.
someone of comparable background and training. And how much progress have we made in the
It is beyond the scope of this discussion to war against heart disease, stroke and cancer? We
consider the role of physician assistants in this are still a nation of slaves to cultural indolence;
plan. But their potential contribution to patient we are overindulgers in food, alcohol and ciga-
care in remote areas and in other sections where rettes, and underindulgers in exercise, seat belts
physician distribution is a problem, is another and self-restraint. No magic bullets have been
distinct aspect to the solution of the distribution forthcoming; no earthshaking breakthroughs from
dilemma. those locked into target-oriented research pro-
grams. There is statistical indication that there has
Changes in Investigative Medicine been some reduction in the deaths from myo-
Now let us talk about what has happened in cardial infarction over the past five years. And
investigative medicine. It was about seven years some have related this to a more rational diet
ago that we began to hear new words such as among American men. But aside from this glim-
targeted research and goal-oriented investigation mer of light, there is little evidence of success in
-words sprung from the lexicon of the bureau- other areas.
crat. It epitomized a pragmatic philosophy that Too often, solutions of medical problems are
seemed to say, "Trap the brightest investigators inextricably interwoven with cultural, social and
you can find; lock them in a laboratory with the economic phenomena. As all of us know, quite
finest equipment and limitless resources; feed, often major discoveries are the result of seren-
water and pet them occasionally. And if you keep dipitous observations in disparate disciplines-
THE WESTERN JOURNAL OF MEDICINE 447
seemingly unrelated-small discoveries made by to the absurd, each time we treat a patient with
bright, independent, non-goal-oriented people who an approved drug or submit him to a well-tried
just happen to meet and chat on boardwalks or in surgical procedure, it is indeed a miniature human
coffee shops. experiment. We speak of a risk-benefit ratio-this
is itself a euphemism for human experimentation.
Continued Support for Basic Research It is a truism that every significant advance
There is an urgent need for continued support throughout the history of medicine has been based
on human experimentation. One wonders how
of investigation in basic science and clinical re- Pasteur, Koch, Jenner, Reed, Florey and hundreds
search. Perhaps investigative medicine should not of others would have fared at the hands of some
be as unstructured and insensitive to fiscal reality
as in the past, but there must be a mechanism for protocol review committees? And should they
have been permitted to do such studies? Were
recognizing and encouraging investigative vir- they less moral, less sensitive? Was life worth less?
tuosity. This is the heart blood of medicine-the It would seem that at some periods in history
source of new knowledge. the rights of the individual person weigh more
We must not overreact by a return to pre-
Flexner attitudes-just as we must not continue heavily than those of society. Then the pendulum
will swing again. The dilemma is this: protection
an unrealistic spiral into superspecialties at the
of the rights of the individual balanced against
expense of primary care physicians. I will repeat
the good of mankind. Is there ever an occasion
-there is need for balance. when the civil liberties and moral rights of an in-
I believe there will always be room in medicine
for men and women of talent and dedication, and dividual can be set aside to achieve a greater
I think this essential freedom can be preserved good? Answer that, and all other factors fade
without limitation of professional options as seems into insignificance. It is impossible to generalize.
to have occurred in England and Sweden. And Must we begin to think in terms of lesser morality
I repeat-I fear the incursion of government into and greater morality? What is our moral obliga-
this seminal aspect of medical education-as it tion to women with breast cancer now, who might
fills a vacuum-a void left by the indolence and be tested with a drug that may arrest the tumor,
indifference of medicine. but may have significant toxicity-as opposed to
our moral obligation to untold future generations
Human Investigation and Morality of women who we know will die of breast can-
cer? How does one measure the morality of pres-
Finally, one other area deserves comment. The ent risk against future benefit? Clearly, it would
third direction of the anti-intellectual fire in the be immoral to stop research in cancer, stroke and
forest is human experimentation. This unfortunate heart disease.
expression seems to conjure up images of Buchen- And who are to be the volunteers who provide
wald. I will confine these remarks to research on informed consent (that nightmare of social, eco-
humans, the problems of abortus research, use nomic, psychologic and legal entanglement which
of materials derived from human sources and defies universal definition)? Should the volunteers
animal investigation would carry us far into the be restricted to research scientists? (Well, surely
night. But let us talk about human investigation. in this group there could never be a question
No rational person will deny the virtues of a about full awareness of present risk or full cogni-
sensitive but rational protocol review committee. zance of possible future benefit.) Are we ever
And there have been lapses in our vigil to pro- justified in the use of children (How do you in-
tect human individual rights. But I submit that form a child?); can a parent give consent for a
most often these lapses have been caused by child? How about prisoners (whose situation
carelessness, or overwork, or overenthusiasm always might be construed as intrinsic coercion)?
rather than by callousness. There are exceptions. As an aside, after publication of a recent edi-
No matter what semantic gambit one may wish torial in JAMA-an eloquent plea to protect
to employ, we are all in the business of caring for prisoners-we received several letters from
human beings. Therefore, we must learn about prisoners who expressed anger and frustration-
human beings. And in the final analysis, I know at the possible restriction of their rights as human
of no other way to do this than to try procedures beings to volunteer for medical research projects-
and therapies with human beings. To extrapolate in an effort to square themselves with society or
448 MAY 1975 * 122 * 5
to indicate their desire to cooperate with society from Helsinki-to vilify the investigators. To me,
or even just to earn extra money and privilege. this is destructive, purposeless sophistry.
So there is never black and white-in any situa- Thus, I submit, it is time to stop and take
And how about using the mentally retarded
(who may certainly be incompetent to give in- The Three Cardinal Issues
formed consent)? Are we justified in using any Some may say I have erected three men of
of these groups of persons who are less likely to straw-hobgoblins of my own nervous invention.
make a contribution to society than are research I hope this is true. But in my opinion postdoctoral
scientists? And who is to make such a judgment? education, research in general and human experi-
I pose to you an insoluble dilemma. All one mentation are cardinal issues, at risk in the
can ask is that each situation be studied with con- present and in the foreseeable future.
summate circumspection and be approached ra- I believe we stand at a major impasse. I see
tionally and compassionately. Again I am not a vast swampland of intellectual impoverishment
convinced that ironclad guidelines, even etched in medicine looming ahead. Yet scattered through-
in tablets from on high, will solve the problem. out I see tender saplings of what could become
One might say that no person has the right to a magical forest destined to flourish and bring the
involve another person in an experiment that bounteous blessings of an improvement in the
could maim or kill, regardless of the desire of the quality of life to all of our people.
volunteer or the probable benefit to mankind. So we must select our options with prudence
And this is a debatable point. It has more shades and circumspection. If we do less, if we falter
of gray than a charcoal drawing. and despair, one day we may all awaken clutched
Yet, we cannot let progress in medicine grind in the doughy embrace of pervasive mediocrity.
to a halt in a backlash of neurotic guilt and sancti- And so I say let us look to the forest.
mony. You know it has become almost fashion- Let us approach the future with courage, born
able-a herd instinct-for anonymous referees of the conviction that man is a most remarkable
of medical manuscripts and rare, timorous journal creature-capable of rising to the need of the
editors to respond to papers that include the use hour, capable of inspiration to solve his problems
of human volunteers (in almost any context) with vision and tenacity and practical genius.
with pharisaic castigation-hurling thunderbolts These have been the hallmarks of our species.
THE WESTERN JOURNAL OF MEDICINE 449