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Public Health and Private Doctors

by Daisy Lee Worthington Worcester

Co-Author, Volume 15 of the Federal Investigation of Women and Child Labor

April 1934

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Metabolism Test

A basal metabolism test at Belvedere Health Center. The clinics have equipment not usually available in the offices of private physicians

Child and Doctor

A young hopeful initiated into the mysteries of Ear, Nose and Throat. Perhaps she didn't mind when the health centers stopped curative service

The Los Angeles County Medical Association takes full credit for this step. Writing in the Bulletin of the Association, February 15, 1934, Dr. Harry Wilson, its secretary, declares:

The San Fernando Plan which came into being as a result of the efforts of the County Medical Association, was the first definite step to break up the pernicious system of treating all indigents at health centers. In a short period of operation it has proved of decided benefit to the general practitioner. It has given no benefit whatsoever to the officers of the Association who gave unstintingly of their time in their efforts to have this program put into effect.

A state law also had to be shoved out of the way. Its provisions are definite: no member of a county hospital staff can be paid for his services. The law was designed to protect the public, to prevent politicians from using the county hospital as a means of paying off their debts to politically minded doctors. All of these doctors who came under the San Fernando Plan were placed on the staff of the County Hospital. Admission to that staff had been a high professional honor for which some of these doctors had few qualifications.

But how to get around the law to pay them? The problem was solved by the passage of an ordinance by the board of supervisors, which provided that the doctors in these former health-center districts should be paid, not for medical service„that was illegal„but for the use of their offices and equipment. The provision that they should be paid $1.50 for home visits and four cents a mile for the use of their cars has also been construed to mean "use of office and equipment." People once cared for in emergency hospitals of the health centers are now taken into the County Hospital in Los Angeles City, or placed in the private hospitals throughout the county, the cost being borne by the County Hospital.

Under the San Fernando Plan a social-service worker who is neither physician nor nurse really plays the role of diagnostician. A person who wishes medical care must first go to her, relate his symptoms and his economic condition, and then either be rejected or assigned to a specialist or a general practitioner, as the worker deems best. Each applicant may then make five visits to the doctor, then returns to be "socialed"„a lovely word. Two reasons were given for this provision: a check on the patient and a check on the doctor.

According to the doctors and some of the public officials, the plan is working well. "It has saved money for the taxpayers." Actually the San Fernando Plan has proved more costly to the taxpayers. A few weeks ago the County Bureau of Efficiency reported a study of comparative costs made at the request of the city council of San Fernando. Under the health department the average cost had been $1.06 per patient visit; under the new plan, for tte same period in the following year, it was $1.03 per patient-visit plus costs for home visits and contract care in local private hospitals formerly carried in large part by health-department doctors and nurses and the health-center emergency hospitals without additional cost to the county.

Mr. Will explained that savings are being made by eliminating chronic cases. "If some old fellow comes along with diabetes, which he had long before the depression, we just tell him that he can get along with his diabetes as well now as he did then. It is the same with teeth," he added. "Just because a man is out of a job is no reason for his getting his teeth fixed up free of charge. I've got teeth of my own that need fixing, but I manage to get along with them." Dr. Berman spoke of the reduced cost that came from eliminating nurses in the health centers; the doctors naturally provide their own nurses. But in the course of conversation it developed that none of the nurses who had been serving in the clinics during the preceding year had been dropped. In order to prevent opposition to the San Fernando Plan, all of them were brought into the County Hospital.

DOCTORS and some officials say that patients greatly prefer this plan; that they no longer have to endure the ignominy of going to a public clinic; that they walk into a doctor's office like any pay-patient; that the long waits which characterize clinics are now avoided. The patients, apparently, do not agree with the doctors and officials. Out in the San Fernando District, they succeeded in securing a grand jury investigation of their complaints, which were numerous and varied. They do not escape the ignominy of relying upon public charity; they have to go to the social-service worker still stationed in the health center building; they do not walk into the doctor's office like any pay-patient but are shunted off into a back room. (One of the doctors with whom I talked confirmed this complaint. "I couldn't have a lot of Mexicans, you know, sitting out there with my private patients.") They have to wait, they say, even longer than they did in the clinics, because the doctors see pay-patients first.

Another complaint was of the service. In speaking of this complaint, Dr. Berman said that they were able to convince the grand jury that it was unreasonable. "These people who had gone to the health centers were accustomed to a lot of things that were unnecessary," he said. "One woman complained that a smear hadn't been taken when her boy's eye was infected. The health doctors were always taking smears, you know. Well, this doctor knew that the eye was syphilitic, so he didn't need a smear." Undoubtedly some patients do prefer the present plan, but the grand jury investigation revealed that others do not.

What does the general public think of the situation? Mostly nothing at all. The average citizen is not aware of it. Not even the social workers outside the groups who are directly involved had any conception of what was taking place. An upheaval affecting the lives of thousands of people has been engineered by a handful of professional men and executed by a board of supervisors, without consultation of the general public, though it sets aside an investment that that public has made at the cost of millions of dollars.


Kay Davis, University of Virginia, © 2001-2003