THE DOCTOR’S HARDSHIPS
A review of the counts in the indictment I have brought against private medical practice will shew that they arise out of the doctor’s position as a competitive private tradesman: that is, out of his poverty and dependence. And it should be borne in mind that doctors are expected to treat other people specially well whilst themselves submitting to specially inconsiderate treatment. The butcher and baker are not expected to feed the hungry unless the hungry can pay; but a doctor who allows a fellow-creature to suffer or perish without aid is regarded as a monster. Even if we must dismiss hospital service as really venal, the fact remains that most doctors do a good deal of gratuitous work in private practice all through their careers. And in his paid work the doctor is on a different footing to the tradesman. Although the articles he sells, advice and treatment, are the same for all classes, his fees have to be graduated like the income tax. The successful fashionable doctor may weed his poorer patients out from time to time, and finally use the College of Physicians
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to place it out of his own power to accept low fees; but the ordinary general practitioner never makes out his bills without considering the taxable capacity of his patients.
Then there is the disregard of his own health and comfort which results from the fact that he is, by the nature of his work, an emergency man. We are polite and considerate to the doctor when there is nothing the matter, and we meet him as a friend or entertain him as a guest; but when the baby is suffering from croup, or its mother has a temperature of 104°, or its grandfather has broken his leg, nobody thinks of the doctor except as a healer and saviour. He may be hungry, weary, sleepy, run down by several successive nights disturbed by that instrument of torture, the night bell; but who ever thinks of this in the face of sudden sickness or accident? We think no more of the condition of a doctor attending a case than of the condition of a fireman at a fire. In other occupations night-work is specially recognized and provided for. The worker sleeps all day; has his breakfast in the evening; his lunch or dinner at midnight; his dinner or supper before going to bed in the morning; and he changes to day-work if he cannot stand night-work. But a doctor is expected to work day and night. In practices which consist largely of workmen’s clubs,
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and in which the patients are therefore taken on wholesale terms and very numerous, the unfortunate assistant, or the principal if he has no assistant, often does not undress, knowing that he will be called up before he has snatched an hour’s sleep. To the strain of such inhuman conditions must be added the constant risk of infection. One wonders why the impatient doctors do not become savage and unmanageable, and the patient ones imbecile. Perhaps they do, to some extent. And the pay is wretched, and so uncertain that refusal to attend without payment in advance becomes often a necessary measure of self-defence, whilst the County Court has long ago put an end to the tradition that the doctor’s fee is an honorarium. Even the most eminent physicians, as such biographies as those of Paget
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shew, are sometimes miserably, inhumanly poor until they are past their prime.
In short, the doctor needs our help for the moment much more than we often need his. The ridicule of Molière, the death of a well-informed and clever writer like the late Harold Frederic
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in the hands of Christian Scientists (a sort of sealing with his blood of the contemptuous disbelief in and dislike of doctors he had bitterly expressed in his books), the scathing and quite justifiable exposure of medical practice in the novel by Mr. Maarten Maartens entitled The New Religion: all these trouble the doctor very little, and are in any case well set off by the popularity of Sir Luke Fildes’ famous picture,
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and by the verdicts in which juries from time to time express their conviction that the doctor can do no wrong. The real woes of the doctor are the shabby coat, the wolf at the door, the tyranny of ignorant patients, the work-day of 24 hours, and the uselessness of honestly prescribing what most of the patients really need: that is, not medicine, but money.
What then is to be done?
Fortunately we have not to begin absolutely from the beginning: we already have, in the Medical Officer of Health, a sort of doctor who is free from the worst hardships, and consequently from the worst vices, of the private practitioner. His position depends, not on the number of people who are ill, and whom he can keep ill, but on the number of people who are well. He is judged, as all doctors and treatments should be judged, by the vital statistics of his district. When the death rate goes up his credit goes down. As every increase in his salary depends on the issue of a public debate as to the health of the constituency under his charge, he has every inducement to strive towards the ideal of a clean bill of health. He has a safe, dignified, responsible, independent position based wholly on the public health; whereas the private practitioner has a precarious, shabby-genteel, irresponsible, servile position, based wholly on the prevalence of illness.
It is true, there are grave scandals in the public medical service. The public doctor may be also a private practitioner eking out his earnings by giving a little time to public work for a mean payment. There are cases in which the position is one which no successful practitioner will accept, and where, therefore, incapables or drunkards get automatically selected for the post,
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but even in these cases the doctor is less disastrous in his public capacity than in his private one: besides, the conditions which produce these bad cases are doomed, as the evil is now recognized and understood. A popular but unstable remedy is to enable local authorities, when they are too small to require the undivided time of such men as the Medical Officers of our great municipalities, to combine for public health purposes so that each may share the services of a highly paid official of the best class; but the right remedy is a larger area as the sanitary unit.
Another advantage of public medical work is that it admits of organization, and consequently of the distribution of the work in such a manner as to avoid wasting the time of highly qualified experts on trivial jobs. The individualism of private practice leads to an appalling waste of time on trifles. Men whose dexterity as operators or almost divinatory skill in diagnosis are constantly needed for difficult cases, are poulticing whitlows,
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vaccinating, changing unimportant dressings, prescribing ether drams for ladies with timid leanings towards dipsomania, and generally wasting their time in the pursuit of private fees. In no other profession is the practitioner expected to do all the work involved in it from the first day of his professional career to the last as the doctor is. The judge passes sentence of death; but he is not expected to hang the criminal with his own hands, as he would be if the legal profession were as unorganized as the medical. The bishop is not expected to blow the organ or wash the baby he baptizes. The general is not asked to plan a campaign or conduct a battle at half-past twelve and to play the drum at half-past two. Even if they were, things would still not be as bad as in the medical profession; for in it not only is the first-class man set to do third-class work, but, what is much more terrifying, the third-class man is expected to do first-class work. Every general practitioner is supposed to be capable of the whole range of medical and surgical work at a moment’s notice; and the country doctor, who has not a specialist nor a crack consultant at the end of his telephone, often has to tackle without hesitation cases which no sane practitioner in a town would take in hand without assistance. No doubt this develops the resourcefulness of the country doctor, and makes him a more capable man than his suburban colleague; but it cannot develop the second-class man into a first-class one. If the practice of law not only led to a judge having to hang, but the hangman to judge, or if in the army matters were so arranged that it would be possible for the drummer boy to be in command at Waterloo whilst the Duke of Wellington was playing the drum in Brussels, we should not be consoled by the reflection that our hangmen were thereby made a little more judicial-minded, and our drummers more responsible, than in foreign countries where the legal and military professions recognized the advantages of division of labor.
Under such conditions no statistics as to the graduation of professional ability among doctors are available. Assuming that doctors are normal men and not magicians (and it is unfortunately very hard to persuade people to admit so much and thereby destroy the romance of doctoring) we may guess that the medical profession, like the other professions, consists of a small percentage of highly gifted persons at one end, and a small percentage of altogether disastrous duffers at the other. Between these extremes comes the main body of doctors (also, of course, with a weak and a strong end) who can be trusted to work under regulations with more or less aid from above according to the gravity of the case. Or, to put it in terms of the cases, there are cases that present no difficulties, and can be dealt with by a nurse or student at one end of the scale, and cases that require watching and handling by the very highest existing skill at the other; whilst between come the great mass of cases which need visits from the doctor of ordinary ability and from the chiefs of the profession in the proportion of, say, seven to none, seven to one, three to one, one to one, or, for a day or two, none to one. Such a service is organized at present only in hospitals; though in large towns the practice of calling in the consultant acts, to some extent, as a substitute for it. But in the latter case it is quite unregulated except by professional etiquet, which, as we have seen, has for its object, not the health of the patient or of the community at large, but the protection of the doctor’s livelihood and the concealment of his errors. And as the consultant is an expensive luxury, he is a last resource rather, as he should be, than a matter of course, in all cases where the general practitioner is not equal to the occasion: a predicament in which a very capable man may find himself at any time through the cropping up of a case of which he has had no clinical experience.
THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM
The social solution of the medical problem, then, depends on that large, slowly advancing, pettishly resisted integration of society called generally Socialism. Until the medical profession becomes a body of men trained and paid by the country to keep the country in health it will remain what it is at present: a conspiracy to exploit popular credulity and human suffering. Already our M.O.H.s (Medical Officers of Health) are in the new position: what is lacking is appreciation of the change, not only by the public but by the private doctors. For, as we have seen, when one of the first-rate posts becomes vacant in one of the great cities, and all the leading M.O.H.s compete for it, they must appeal to the good health of the cities of which they have been in charge, and not to the size of the incomes the local private doctors are making out of the ill-health of their patients. If a competitor can prove that he has utterly ruined every sort of medical private practice in a large city except obstetric practice and the surgery of accidents, his claims are irresistible; and this is the ideal at which every M.O.H. should aim. But the profession at large should none the less welcome him and set its house in order for the social change which will finally be its own salvation. For the M.O.H. as we know him is only the beginning of that army of Public Hygiene which will presently take the place in general interest and honor now occupied by our military and naval forces. It is silly that an Englishman should be more afraid of a German soldier than of a British disease germ, and should clamor for more barracks in the same newspapers that protest against more school clinics, and cry out that if the State fights disease for us it makes us paupers, though they never say that if the State fights the Germans for us it makes us cowards. Fortunately, when a habit of thought is silly it only needs steady treatment by ridicule from sensible and witty people to be put out of countenance and perish. Every year sees an increase in the number of persons employed in the Public Health Service, who would formerly have been mere adventurers in the Private Illness Service. To put it another way, a host of men and women who have now a strong incentive to be mischievous and even murderous rogues will have a much stronger, because a much honester, incentive to be not only good citizens but active benefactors to the community. And they will have no anxiety whatever about their incomes.
THE FUTURE OF PRIVATE PRACTICE
It must not be hastily concluded that this involves the extinction of the private practitioner. What it will really mean for him is release from his present degrading and scientifically corrupting slavery to his patients. As I have already shewn, the doctor who has to live by pleasing his patients in competition with everybody who has walked the hospitals, scraped through the examinations, and bought a brass plate, soon finds himself prescribing water to teetotallers and brandy or champagne jelly to drunkards; beefsteaks and stout in one house, and “uric acid free” vegetarian diet over the way; shut windows, big fires, and heavy overcoats to old Colonels, and open air and as much nakedness as is compatible with decency to young faddists, never once daring to say either “I dont know,” or “I dont agree.” For the strength of the doctor‘s, as of every other man’s position when the evolution of social organization at last reaches his profession, will be that he will always have open to him the alternative of public employment when the private employer becomes too tyrannous. And let no one suppose that the words doctor and patient can disguise from the parties the fact that they are employer and employee. No doubt doctors who are in great demand can be as high-handed and independent as employees are in all classes when a dearth in their labor market makes them indispensable; but the average doctor is not in this position: he is struggling for life in an overcrowded profession, and knows well that “a good bedside manner” will carry him to solvency through a morass of illness, whilst the least attempt at plain dealing with people who are eating too much, or drinking too much, or frowsting
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too much (to go no further in the list of in temperances that make up so much of family life) would soon land him in the Bankruptcy Court.