Death of the clinician: requiem or reveille?

MICHAEL J. LEPORE, Death of the clinician: requiem or reveille?, Springfield, Ill., Charles C Thomas, 1982, 8vo, pp. xviii, 359, $27.50. This book is an autobiographical polemic which is, at times, disguised as history, about the organization and financing of medical education in the contemporary United States. Lepore is, however, an engaging storyteller. Many of his anecdotes will amuse readers, despite his numerous factual errors, lengthy paraphrases of idiosyncratically selected primary sources, and long quotations from primary sources that have been wrenched from their context. The doctors for whom Lepore claims to speak were trained in famous academic institutions and practise in hospitals that are affiliated with medical schools but are not major teaching centres. They derive all of their income from patients' fees. Although they long to teach, they see only occasional medical students on clerkships and too many house officers from foreign countries who have a shaky command of both the English language and modern medicine. Their resentment against this second-class academic citizenship has been reinforced since 1966, when the Federal laws subsidizing medical care for the elderly and the poor stimulated a rapid increase in the number of full-time faculty in clinical disciplines whose incomes are derived from a combination of a base salary from their school's education budget and some of the fees paid by third parties on behalf of their patients. Lepore seeks a historical explanation for his anger. His villains are the philanthropists, government officials, and doctors who promoted the establishment of full-time chairs in clinical disciplines and clinical research during the first half of this century. His heroes are the deans and professors who asserted that doctors have an inalienable right to retain all or most of their patients' fees. Lepore is frequently self-contradictory. He endorses free enterprise but deplores such results of marketplace medicine as high-priced surgeons, competition by hospitals for patients, and the establishment of local monopolies by radiologists and pathologists. He complains about the length of postgraduate training but wants the qualifying examinations for his own speciality to be more difficult and opposes speciality status for family medicine. Despite his belief that clinical education is deficient because salaried clinicians prefer research to patient care, he advocates more basic science in the medical curriculum. Death ofthe clinician would be a more interesting polemic if Lepore knew more history. It is unfortunate that he did not seek professional assistance; appalling that his publisher did not require him to obtain it. Daniel M. Fox Health Sciences Center State University of New York at Stony Brook