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Walsh: Medical regulation and financial conflicts: a view from the past
Medical education has a long history, much of which has been marked by regulatory milestones. Beginning with the Hippocratic Oath, leaders in medicine and medical education have sought to control the profession by setting out rules that physicians must follow [1]. Their motivations to do this have been multifold. Primary among such motivations have been the stated needs to protect the reputation of the profession and to protect the public. However, some have claimed that other, unstated, motivations have shaped the emergence of regulations. Foremost amongst these unstated motivations is money. Some claim that the motivation of those who have put regulations in place has been to create a form of protectionism, whereby only certain groups have a license to practice medicine and to charge patients for doing so.
Numerous reforms of medical regulation have taken place throughout history; however, an especially important reform was the Medical Act of 1852, which may be considered a dividing point between ancient and modern approaches to medical regulation. Medical regulations have undoubtedly changed considerably since 1852; however, most regulatory reforms since then have been evolutionary, rather than revolutionary, developments. The Medical Act of 1852 is thus especially important, and it is therefore interesting to look at the Act from the perspective of finance. Were the financial affairs of the medical profession and its members amongst the driving forces behind the Act? Is there tangible evidence that this was the case? In 1852, a paper was published in BMJ explaining the Act and outlining its provisions in full [2]. In this short article, I present the results of documentary research on this paper and analyse it from a positivist perspective. As financial issues are especially relevant in this context, I have concentrated on them. I have adhered closely to what can be objectively viewed and quantified.
The document is certainly genuine. It was written by senior members of the Provisional Medical and Surgical Association. All such members were, at the time, male. The son of the Founder of the Association—‘by profession a barrister’—helped compile the document. At face value, it seems unusual that the document would be written by such a group; however, it is clear that this is the provenance of the Act. The authors of the document straightforwardly expressed the reasons that they put it together; in essence, these reasons included the need for ‘uniformity of primary qualification,’ ‘protection to the public,’ ‘reciprocity of practice,’ and ‘protection against quackery and irregular practice, by means of registration.’ However, the authors are also clear that one of the purposes of the Act was to set up an insurance fund for physicians and their families in the event of illness or death. This particular purpose is mentioned last, although the authors explicitly state that it should be seen as no less important than the other provisions. Thus, it is clear that from the outset, financial interests were prominent in the physicians’ minds. It is notable as well that ‘protection against quackery and irregular practice’ was an explicit purpose of the Act. While it may be assumed that the purpose of this provision was to protect the public against quackery, it may equally be likely that the motivation was to protect physicians’ incomes from the competition of unlicensed practitioners.
One of the core purposes of the Act was to set up a medical council to regulate doctors. However, the membership of that council was to be chosen by a small number of organizations, including the University of Oxford, the University of Cambridge, the University of London, the Royal College of Physicians of England, the Royal College of Surgeons of England, and the Society of the Art and Mystery of the Apothecaries of the City of London. All these organizations and their members had similar interests, not least that they all wished to protect the profession and the financial interests of their members.
Thus far the influence of financial interests was implicit; however, the Act also makes explicit references to finances. All medical practitioners who had a degree in medicine and who registered were required to pay a fee of five shillings initially and then 20 shillings annually. All medical practitioners who did not have a degree in medicine and who wished to register were required to sit an examination, and those who passed were to pay a fee of £10. The Act states that registered medical practitioners are entitled to charge patients for their services. However, it goes further than this and states clearly that practitioners will be able to demand and recover by legal means any unpaid fees. In addition, the Act states that unregistered practitioners are not entitled to charge fees, and provides for a financial penalty against unregistered practitioners who attempt to practice.
It is also interesting to examine what the Act does not cover. It is clearly stated that the Act is not to affect the trade or business of chemists. It is also stated that nothing in the Act will deprive the Royal Colleges of Physicians or Surgeons their right to grant degrees or diplomas. Thus, what conclusions can be drawn from the document and the Act? Firstly, evidence of protectionism is clearly present. The document and Act were written by senior members of the profession and, indeed, by family members of those senior members. One of the core purposes of the Act was to provide an insurance fund for physicians and their families. The Act also states that membership of the new medical council was to be made up of the appointees of the elite medical universities and royal colleges. Secondly, the Act placed considerable barriers on potential competitors of the medical profession. Unregistered practitioners certainly faced great barriers to practice following the Act. Thirdly, the Act was explicit about the rights of medical practitioners to charge patients. Fourthly, and finally, the Act closed the circle by stating that although the Act would certainly affect the business of unregistered practitioners, it would not affect the business of what might be termed allies of the council—mainly the medical royal colleges.
As with all forms of documentary analysis, the challenge in this case is as much to discover what is missing as it is to analyse what is present. The document contains only one reference to the public and only one reference to patients. The reference to patients is in the context of the right of doctors to pursue them for unpaid bills. This is in contrast to the multiple references to finances and medical institutions. Thus, there is little doubt but that early attempts at the regulation of medical education were shaped by financial and professional conflicts.
One hundred and sixty years later, this continues to be important. Regulatory reforms to the present day have built on this milestone Act. Even though many reforms have been instituted, some problems remain. Medical schools and postgraduate medical education institutions continue to charge for the tuition and associated components that they bestow, and in some contexts these charges have risen [3,4]. In the UK, tuition fees cost up to £9,000 per year. Medical education is undoubtedly expensive, and yet it is worth considering whether the provision of education and qualifications justifies these costs, or whether they continue to represent a perhaps unconscious agenda of maintaining the exclusivity of the profession [5,6]. The rising cost of medical education is of considerable concern; however multiple forces are driving this and the rising costs of other forms of tertiary education, and financial protectionism is likely to be just one such force. The costs to the learner can result in an atmosphere of consumerism in medical education institutions, in which one of the goals of the learners is to obtain a qualification that will result in financial returns and in which one of the goals of the institutions is to increase its income [7]. Where do patients fit into this picture? Do they fit in at all? Or are they being set aside as they were over 160 years ago?

Notes

No potential conflict of interest relevant to this article was reported.

REFERENCES

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