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PerspectivesThe art of medicineThe Doctor in early Cold War AmericaTo commemorate the semi-centennial of the UK’s national health service (NH S) in 1998, The Lancet published a full-page reproduction of Sir Luke Fildes’ painting The Doctor under the heading “NH S at 50”. It seemed to capture a message that for more than a century has been attached to the image: here was a visual embodiment of the physician’s devotion to patients, and, in this instance, the state’s commitment to guarding the health of the people.From the perspective of a historically informed American eye, however, the choice was staggeringly ironic. For The Doctor had a pivotal role in blocking the creation of a counterpart to the NHS in the USA. In the late 1940s and early 1950s, it was under a banner graced with this image that the American Medical Association (AMA) successfully led the battle against universal government health insurance. Widely circulated during the early Cold War, the image became a lightning rod for clashing conceptions of the medical profession as an American institution, the doctor-patient relationship, and the ways that access to health care should defi ne the nation.Fildes’ painting was commissioned by H enry Tate and fi rst exhibited in 1891 at the Royal Academy in London. In the USA engravings quickly appeared in doctors’ waiting rooms; it was recreated in tabl eaux vivant, and, in 1911, was the subject of a fi lm by Thomas Edison. At the 1933 Chicago World’s Fair, Petrolagar Laboratories exhibited a life-size diorama of the scene, celebrating “the ideal relationship between physician and patient—‘The H uman Touch’”; the exhibit then went on tour and was viewed by at least 5 million people. During the Depression, the painting appeared widely in popular media lamenting the passing of the family doctor.Between 1943 and 1950, a series of national health insurance bills were debated in the US Congress. In 1947, The Doctor appeared on a postage stamp commemorating the AMA’s centenary. And AMA activists went on to deploy the painting as emblematic of all that would be lost if the state were to impose what they called “socialised” medicine, and, in the same breath, “fascist” health care. The Doctor appeared in pamphlets, print advertisements, and, at medical conventions, on gigantic banners, all with the slogan, “Keep politics out of this picture”.This is a surprising choice, not least because it fl ew in the face of the reigning imagery of the Golden Age of American medicine—reductionist high-tech medical science, pursued by researchers in laboratories and practised by specialists in the modern hospital. Indeed, historians regard the sheer success of the medical profession in linking its public identity to the image and ideals of laboratory science as key in the public esteem it enjoyed from the 1920s through to the 1950s. Yet, experimental laboratory science is conspicuously absent from this sentimental late-Victorian work. The setting is a small cottage, not a hospital; this is quintessentially the solo general practitioner, not a team of specialists; medical technology is absent; money is not an issue (this seems to be an act of charity); and, above all, there is time. “There is something in that picture”, a publicist told doctors gathered for the AMA’s annual convention, “which represents one of the most priceless possessions you men of medicine have in your fi ght against assembly line medicine. In that doctor’s face there is compassion, there is a personal concern for the welfare of his patient, there is personal loyalty to the patient as a human being.”In 1948 the AMA engaged the Whitaker and Baxter public relations firm to sell its message to the American people. Clem Whitaker and Lenore Baxter, a husband and wife team, had successfully fought for the California Medical Association against a state health insurance plan. “Your profession is in the front lines in one of the most critical struggles in the history of this Nation”, Whitaker told doctors: “This is a cold war, right here in America.” Whitaker and Baxter proceeded to launch one of the great public relations campaigns of modern American politics, with The Doctor as its centrepiece. Their message was placed on roadside billboards and on stickers for doctors to use in their correspondence. Strategically cultivating the image of a grass roots campaign, they coached medical societies on how to proselytise within their communities. “The Doctor arrived”, one Ohio physician reported in his hand-written thank you note for the poster (in the fi rm’s papers at the California State Archives in Sacramento). “He is in my waiting room witnessing eff ectively against the socialization of the practice of medicine.”At the time, this was the most expensive lobbying eff ort in American history. By the end of the fi rst year, Whitaker and Baxter had distributed 100 million pieces of literature. They worked through Women’s Auxiliaries to sponsor lectures, display The Doctor in hospitals, and hold dinner parties (with a copy of the pamphlet on each plate). They provided scripts for radio “interviews” with doctors, written in a way that would sound like they were taking questions from an audience (but entirely scripted). They provided thousands of newspapers with ready-made feature stories, templates for editorials, and cartoons. And they sponsored talks from disgruntled British doctors they called “exiles” or “refugees” from socialised medicine, and made sure the press got their message that in the NHS doctors could spend only 3 minutes with each patient. At the 1949 AMA annual convention, the backdrop to the stage was a huge reproduction of the painting—7 metres tall.PerspectivesFurther readingBarilan YM. The doctor by Luke Fildes: an icon in context.J Med Humanities 2007; 28: 59–80Blumenthal D, Morone JA. The heart of power: health and medicine in the oval offi ce.Berkeley: University of California Press, 2009Brickman JP. MedicalMcCarthyism: the Physicians Forum and the Cold War. J Hist Med Allied Sci 1994; 49: 380–418Lepore J. The lie factory: how politics became a business. The New Yorker Sept 24, 2012: 50–59Warner JH. The humanising power of medical history:responses to biomedicine in the 20th century United States. Med Humanities 2011; 37: 91–96To our eyes, precisely what is going on in The Doctor may seem open ended. Is what comes next the child’s death, or the start of recovery? Is the doctor powerless, or will his vigilant care restore her to health? Other visual images in the campaign, however, left little doubt about how viewers were intended to read the narrative. Cartoons depicted doctors as puppets or robots—reduced to mere technicians. And the patient became a nameless unit on a factory assembly line—a machine, not a person. Under this system, the doctor would not have the time, commitment, or option of lingering watchful at his patient’s side.There were physicians—a small minority—who protested against this nostalgic celebration of the doctor-patient relationship that masked over the social and technological realities of modern medicine and the economic problems of health-care distribution. New York clinician Ernst Boas, head of the Physicians Forum, was among the most prominent critics of “the ultra reactionary stand of the AMA”, as he put it. “The day of the horse and buggy doctor who, with his unaided hands and eyes and little black bag, can cure all of the ills of mankind is past.” So too, one labour leader charged, “The little black bag kind of medical care portrayed in the AMA’s poster entitled ‘Keep Politics Out of This Picture’...is as obsolete today as the old Model T Ford.”The AMA’s main rejoinder was red-baiting—accusing all who opposed them of socialism. These years marked the heyday of McCarthyism and the height of fears about communist infl uence on American institutions. “American medicine has become the blazing focal point in a fundamental struggle which may determine whether America remains free, or whether we are to become a Socialist State, under the yoke of a Government bureaucracy”, the new AMA President asserted in his 1950 inaugural radio broadcast. Congressional debate was to be “The Battle of Armageddon—the decisive struggle which may determine not only medicine’s fate, but whether State Socialism is to engulf all America.”Whitaker and Baxter sought to rebrand the medical profession. Fildes’ painting was an enticing fantasy, a comforting fi ction that bore little resemblance to the relationship between most doctors and patients. But it captured yearnings many Americans shared, just as it played upon anxieties about the depersonalisation of modern medicine and replacement of the general practitioner by teams of anonymous specialists.By the early 1950s the AMA had triumphed. In the process it had also set up dangerously infl ated expectations of the doctor-patient relationship. “We have developed and fostered the concept of dedication until it has become a vulnerable point for attack”, one physician would refl ect in a 1964 letter to JAMA . “The picture of the tireless physician remaining at the patient’s bedside, such as portrayed in Fildes’ great painting, The Doctor , is cherished by the public as a nostalgic reminder of the unpressured, free,and leisurely atmosphere of the past...and anything that adversely aff ects the image will bring resentment.”And so it did. Popular disaff ection incited by the promises implicit in the Whitaker and Baxter campaign was already evident by the early 1950s. Americans wanted the devoted, personal attention they saw in the ubiquitous posters, pamphlets, and billboards displaying The Doctor , but that was not what they experienced. “The ideal doctor is gone”, a psychologist who undertook extensive interviews on the doctor-patient relationship concluded in 1950. Doctors are “like robots now”, a 26-year-old insurance agent typically told him. “They become automatic and lose their humaneness. They forget that the people they are treating are human beings.” The strategic deployment of The Doctor helped set the profession up for a fall, fostering unrealistic expectations that, when disappointed, contributed to public animosity against the biomedical establishment and the decline in the medical profession’s cultural authority in the 1960s and 1970s that ended what could be regarded as a Golden Age.The Doctor has been read in diverse ways—as a visual embodiment of the art of medicine, an iconic expression of the medical world we have lost, a moving portrait of medical powerlessness before the triumph of biomedicine. At mid-century, it was also the prime vehicle for politicising the doctor-patient relationship. And indeed, the politicised language attached to the ideal of a holistic doctor-patient relationship in the 1940s with the call to “keep politics out of this picture” was infused into the fabric of American culture, blocking moves for any profound government-led reorganisation of health care and leaving a legacy that continues today to shape US health-care politics.John Harley WarnerSection of the History of Medicine, Yale University School of Medicine, New Haven, CT 06520-8015, USAjohn.warner@Pamphlet from the Whitaker and Baxter campaign of 1949 featuring The Doctor with the caption “Keep politics out of this picture”, what one publicist called “the AMA battle message”R e p r o d u c e d w i t h p e r m i s s i o n o f t h e A m e r i c a n M e d i c a l A s s o c i a t i o n A r c h i v e s , C h i c a g o , I l l i n o i s。