“DELIVERING THE GOODS”.
Much has been said (but less written) about the cause of the drift of the public away from the medical profession. It is a frequent topic of discussion between physicians who intelligently observe the signs of the times and reflect upon them.
That such a drift exists and is making itself keenly felt in the medical profession is obvious.
Witness the rapid increase in numbers and power of all the numerous non-medical cults, including osteopathy and chiropractic, and the medico-political opposition to them.
Witness the feverish political activities of Federal, State and municipal “official medicine,” continually seeking more power that it may be exercised to compel compliance with its edicts and enable the medical organization to retain control.
Witness the widespread literary propaganda in the public press, inspired by “the organization,” constantly calling attention to the wonderful discoveries and accomplishments of modern medical men and institutions, presented in the most attractive and popular style, designed to arouse public interest in their doings. Good writing, too-much of it.
“Theres a reason.” In fact, there are many reasons, some of which are carefully kept in the background and seldom referred to.
Come straight to the point and let us face the situation squarely.
The main reason, from the publics point of view, is that the medical men are not “delivering the goods”.
Hence, the “drift” to non-medical practitioners.
As vendors of supposedly curative remedies they are too often guilty of the crime of “substitution”. Instead of individualized therapeutic service and curative medication, too many physicians are passing over the counter, at a high price, specious imitations of both, in the form of hurried interviews, three-minute “examinations,” superficial opinions, diagnoses which are merely guesses, “standardized” medical and surgical procedures, “snapshot” prescriptions and “bluff.”
Or they are going to the other extreme and beguiling the patient into submitting to a round of elaborate and expensive special examinations and tests, most of which are quite unnecessary and lead to the employment of costly medical or surgical measures which have no curative relation to the disease process itself-if it exists-but are directed toward some mere product of the disease; hence are merely palliative.
“Laboratory workers” are constantly making discoveries, by so-called “research,” of new “specifics” for various diseases which are duly brought to the attention of the ubiquitous reporter, who is allowed to write them up for the benefit of the public with just the right amount of judicious censoring (so that the requirements of professional modesty may be met), and just the right number of discreet reservations (in order that a quick shift may be made if the therapeutic dart turns out to be a boomerang) Meanwhile the advertising agencies, the manufactories and “laboratories” thrive, and the exploiters “wax and grow fat”.
Is the public really as dense and as gullible as it appears to be? Or is it beginning to see through this fog of delusion and mis-representation?
Two recent incidents, involving both schools of medicine and selected from among many of a similar character in the personal experience of the writer, may throw some light on the situation.
In a case which has been under the care of a prominent homoeopathic physician of long experience and excellent reputation, inquiry was made as to why a change of physicians had been made.
The reply was that, first, the patient (a woman) had “not been well since an attack of influenza four months before.” During which time several “complications” had developed; second, that the physician had not seemed to be interested in the medical features of the case and would not take time to listen to symptoms nor make proper examinations.
“His examinations were too cursory,” said the husband. “He would come in, glance at the patient, ask about the temperature, cut short or ignore any attempt to relate the history since his last visit, hurriedly put up some medicine and leave before he had been in the house five minutes”.
When surprise was expressed, the patient said, half apologetically: “Well, what could you expect? He is too busy and sees too many people. You know he charges only one dollar at the office and two dollars at the house and a great many people go to him for that reason. He is always rushed”.
She then went on to relate that she had been at his office repeatedly, always finding his waiting room full of patients, and that several times she had seen him, at the close of his office hour, leave the house to make outside visit, while several angry patients yet remained who had not been attended.
“How can anyone expect to get or give good service under such conditions?” she asked.
“I stood it a long time,” she continued, “because I liked him so much as a man. But when I found myself getting no better and gradually getting into a chronic state, I made up my mind it was time to call in someone who would take some interest in me medically and give time enough to the case to enable him to treat it properly.
“I believe Dr.________is an able physician and a well meaning man,” she continued, “but he is working under a wrong policy and does not realize it. If he would charge three times as much and see one-third as many patients they would be satisfied and he would be happier, get better results and be just as well or better off financially”.
With rare discernment this highly intelligent woman had put her finger upon one of the commonest and most virulent points of “focal infection” in the medical body. Look at the situation for a few moments.
Here is a man of genial personality, good native ability, of excellent training as a prescriber, long experience in medicine and surgery, high reputation in his community and popular among his patients, who has allowed himself to become overcrowded with work, hasty and superficial in his examinations, inaccurate in his prescribing and unsuccessful as to result-and all largely because of a bad financial policy.
It is known that this physician charges the same fees today that he did thirty years ago. The evidence goes to show that he has made little or no progress in professional skill and technical efficiency during that time-has in fact retrograded; also, that some of his patients know it.
It is reasonable to assume that under an enlightened financial policy and a consistent program based upon right ethical and financial principle, conscientiously carried out, it would have been possible for him to make substantial progress in skill and technical efficiency and become an honor to the profession. Under such conditions his services would now be worth at least five times as much as they were thirty years ago, and he not only would be justified, but would have no difficulty, in charging and collecting proportionately larger fees-provided he actually rendered the service and got the results.
Here, by the way, is about the only saving feature of this case-that he had not yielded to that particular form of greed which has led others to charge high fees while failing to give the kind and quality of service that alone justifies them. Probably his “Inward monitor” has been able to make its voice heard distinctly enough occasionally to restrain him in this respect.
It would have been better for all parties concerned if he communed with that higher and wiser self more frequently. As things are, he is charging very small fees for very poor service- in which there is a kind of consistency-but it is still open to question whether the service he gives is really worth anything. This particular patient did not consider it worth anything to her and frankly said so; and she will not fail to tell others. Who will say that she is not right?.
The other instance refered to was in connection with the case of a baby, six months old, the child of wealthy parents who live in a New Jersey town. The case presented certain puzzling features which had baffled the skill of the conscientious young allopathic local physician. He had finally advised the parents to employ a New York specialist (allopathic), whom he recommended highly as his former teacher, the author of books on the treatment, care and feeding of infants, and of high standing as a pediatrist.
The mother narrated how she had taken her baby to New York, had been received by a uniformed attendant and ushered to the desk of an assistant physician whose duty it was to register the case and make a preliminary examination and diagnosis. He occupied about two minutes in the performance of this duty. He then called a nurse, who took the card which he had written, escorted her to the waiting room and left her, stating that she would be called in her turn.
The lady counted eighteen patients already awaiting their turn, took out her watch, noted the time and began to wonder how long she would have to wait. At the end of forty minutes the nurse conducted her into the presence of the great man and introduced her, handing him the registration card at the same time.
He shook hands with the mother, told her how pleased he was to see any patient of his former student, glanced at the baby in her arms and then read the card-half aloud: “Ah! Six months-inability to retain food-vomiting-gastric insufficiency-um-ah-I see”.
(Turning to the nurse): “Miss R, please bring Mrs. M formula number six from file number one”.
Turning to the mother, he glibly instructed her to prepare the babys food exactly according to the printed formula; to hold the baby in her lap at an angle of forty-five degrees while feeding; to keep the baby at about the same angle when it was in bed and not to “jiggle it” when laying it down or taking it up, “so that the food would stay down”.
“Then it will be all right,” he assured her as he shook hands with her again, instructed her to call in a week and bowed her out.
The nurse escorted her to the cashier, who collected the fee of fifteen dollars (first consultation0 for a three-minute interview (five dollars per minute), without examination, question or even inspection, and without permitting the mother-a highly intelligent and cultured woman-to tell him anything of the history or symptoms of the case.
The mother followed instructions scrupulously and returned at the appointed time-to find about the same number of patients waiting; to go through the same routine; to report that there had not been the slightest improvement-that in fact the baby was worse-and to receive another three-minutes interview and printed formula without further examination. She was charged the regular office fee of ten dollars.
At the end of the second week, the baby having steadily grown worse, the lady decided that she would disregard the instruction to “come again” and call a physician known to take sufficient time and pains to properly examine and prescribe for his patients and to give “value received” for the liberal fees which he charges and is ungrudgingly paid.
Here is a man who is seeing a patient every three minutes and collecting on an average, over two hundred dollars per hour for -what? Will anyone say that such service is worth two hundred flock to him. His office is always crowded. He is said to be about to retire from practice-in the prime of life?.
How does he “get away with it”? How, if not by trading upon a reputation gained in his early, better years; by ostentatious display and assumption of a superior air; by flattery and unctuous reassurance; by the subtle suggestion of professional eminence conveyed by the fashionable location, elaborate equipment and personnel of his establishment; by his large fees; by the publicity given him by those who knew him in the days when he was building a reputation by really good work, but who do not know that he has yielded to cupidity and the lure of money and degenerated into a mere faker.
The man has ability and there was a time when he deserved confidence, but that time has passed, never to return. The lire of money too great.
The similarity of the two cases is evident. Both men are well along in years. Both have native and acquired ability. Both are deceiving themselves and their patients and rendering service which is worthless. Both are trading upon reputation gained in the earlier years of their practice. Both are “bluffing”.
Their followings remain large for the time being, partly because of the momentum gained in their gulled-for a while. People “follow the crowd” to a popular doctor much as they do to a circus, but when they get into the big tent and find that the program consists principally of handing out peanuts and pink lemonade many of them will not go again. Eventually these “canny” ones become a crowd. When they do, then look out!.
The bearing and influence of a physicians schedule of fees upon the character of the service he renders to his patients is commonly overlooked.
Beyond adopting without question the rates that prevail among the physicians in his vicinity; or perhaps deciding that he will charge less or more than the customary rates, according to his notion of how best to get and keep a lucrative practice for himself, the physician usually gives the subject of fees little or no thought. He usually looks at it merely from the monetary side.
He does not realize that the rate of compensation he establishes and the principles which determine it will have a powerful psychological influence for good or evil upon him and his patients, affecting both the character of his work and its results. It may be well to briefly consider the subject in some of its broader aspects in the hope of leading to the adoption by physicians of a broader and more enlightened financial policy.
It is pretty well understood and agreed among men of affairs that three intangible things are necessary to success in any undertaking-sound principles, an enlightened policy and a good, workable program-and that these three must agree. Great care is taken by them to make sure that each of these necessary factors is definitely worked out, clearly expressed and thoroughly understood before anything else is done.
Having laid the foundation, secured capital and created an organization, it becomes the business of the executive to see that every department is co-ordinated and in working order, and that standards are maintained.
Modern business men are also agreed that service is the only basis of organization and capitalization and that the only service which will succeed and pay dividends in the long run is honest, efficient and useful service. They never forget that the public-their patrons-are “investors” seeking for “dividends” as well as themselves, and that they will not continue long as patrons if they do not receive them in some form of satisfactory results.
It would be well if more medical men followed the example of the leaders in modern “big business” in these respects. Medicine has a business side, but physicians are notoriously poor business men. Not only do their names occupy a disproportionately large space in the “sucker list” of nearly every fake enterprise-oil schemes, wild-cat mines, pharmaceutical fad factories, city lot swindles, etc., but their business is too often conducted with singular disregard of the principles and policies which make for legitimate professional financial success.
Although great progress has been made by many physicians in raising their standards of business and professional ethics, in adopting and maintaining policies based upon the idea of honest and efficient service and in educating the people along these lines, there are still too many who give no evidence of having ever heard of such ideas, or of having been influenced by them if they have heard of them.
It is significant that the most flagrant examples of theses derelictions are found among the men who have the largest followings, who are the most popular with the laity and whose reputation, even in the profession, is often high, as already illustrated. But there are many younger and less prominent men who are headed in the same direction.
It is unfortunate that the work of “popular” doctors does not have some of the pitiless light of publicity thrown upon it that the work of lawyers receives. If doctors and surgeons were compelled to examine and treat or operate upon their cases in public, before a judge and jury, and with keen-witted opposing counsel upon the other side, some of them would adopt different methods and conduct themselves quite differently. Bluff and cajolery would not carry them far under such conditions and they would not be able so often to “bury their mistakes six feet underground”.
Here, by the way, are the makings of a pretty play. Imagine what a satirist like G. Bernard Shaw and competent actors would do with one of these “popular” doctors, compelled to transfer his consulting room and patients to a public courtroom and go through his regular routine under such conditions!.
That the fees a physician habitually charges have a powerful influence not only in determining the character and value of the work he does, but in moulding his personal character, is not difficult to see.
Every honorable man desires to be well and justly compensated for his labor, to live well and usefully and to accumulate at least a competency for his declining years.
Money is the accepted measure of value and medium of exchange. Every man, consciously or unconsciously, sets a money value upon his time and labor and will strive to get the equivalent for it in money, goods or privileges.
No honorable man will demand or take money he has no earned- unless it be a gift expressing gratitude or affection-and that usually has been well earned.
If a physician, through poor judgment or mistaken policy, sets his fixed fees or rate of compensation too low and has not the wisdom or courage to raise them to the proper level, he will either suffer poverty, or (more frequently) as the number of his patients increases, instinctively or deliberately shorten the time devoted to each patient until he feels that it is commensurate with the fixed fee he has elected to receive.
This leads to the curtailment and deterioration of service, and, if persisted in, the loss of fine sense of honor which prompts a man to give the best there is in him. Good work cannot be skimped nor done carelessly and in haste-in medicine or in any other field. Time is an important factor.
If, on the contrary, a physician sets his fees too high, or out of proportion to the real value of his service, judged by a fair standard determined by the consensus of professional opinion, he is entering into temptation and violating professional ethics. He can only get them by pretending that he has skill, experience and ability which he does not possess; by deception and misrepresentations or fraud.
To do this is demoralizing and, in the end, ruinous. He may flourish for a time, but in the end he will pay the penalty. Incidentally he is bringing discredit upon medicine, the noblest of all professional. Let every physician,therefore, earnestly take these things into consideration.
Let him regard it, if he pleases, simply as a business proposition, to be worked out in accordance with the principles which have been determined by the consensus of opinion of honorable and successful business men. In doing that he cannot go far wrong.
Let him (theoretically) “capitalize” himself-put a value upon his knowledge, skill, reputation, experience, cash investment in education and equipment and “good will”-at such an amount as he believes he can honestly earn legal interest upon five years ahead and upon that basis compute the value of his time per hour. Let him establish a schedule rate per hour, to be used in estimating his fees for all cases requiring more than the average time (covered by the customary “fixed fee” charged by physicians in his vicinity) as in first examinations, long- distance visits or detentions.
Let him formulate a policy in respect to his mode of doing business-his attitude and demeanor toward his patient, his social relations, his style of living, his personal habits, including dress and manners, his office organization, equipment and technic-everything which goes to make up its “atmosphere”-his manner of receiving and dealing with his patients, his methods of conducting his financial affairs (charging, billing, collecting) and do all this with due regard for the principles of efficiency, equity, justice, reciprocity, modesty, honest and courtesy which, in the aggregate, constitute true service.
In ordinary work the customary fixed fees of his local colleagues of equal standing will be found to nearly correspond to the rate suggested, but a schedule rate per hour is flexible and will enable him to adjust his fee in special cases to the amount of time necessarily spent on them.
There will be cases, involving extraordinary care, responsibility or skill, in which an “honorarium” may properly be added to the regular fee based upon the time schedule.
At the end of the first five years, if the young man has conscientiously carried out this program, he would be justified in doubling his capitalization and rate of charges for the ensuing five years. At the end of ten years he may again proportionately increase his capitalization and raise his rates to correspond; and so on, as the years pass and he gains in knowledge, experience, skill and reputation.