INTERCOURSE OF PHYSICIANS.[36]
The object of this chapter is to notice some points in relation
to the intercourse of physicians, which the community ought to
understand, and to correct some prevalent errors, which tend to
destroy the harmony of the profession, and to impair its usefulness.
Mistaken notions are very prevalent, even among thinking and
judicious men, both in regard to the object of consultations, and the
principles by which they should be regulated. These notions sometimes
exert a very injurious influence, and the patient is deprived of the
benefit to which he has a right, from the combined wisdom of those
who consult upon his case.
What then is the main object of a consultation, is an important
inquiry.
It seems to be considered by many as the chief object of a
consultation to decide the question, whether the patient will die
or recover. We hear ignorant people talk about a ‘jury of doctors,’
and they ask ‘what they gave in,’ as if a sort of verdict was to be
pronounced of a decisive, almost a binding, character, in regard to
the result of the case. The same erroneous ideas are, to some extent,
to be found among sensible and well informed people, though they are
expressed in a different way. Let me not be understood to say, that
the question, whether the patient will probably recover, should not
come up for consideration at all. But it is certainly a gross error
to suppose, that the decision of this question is a principal object
of the consultation. It is in fact a merely incidental object, and it
is profitable only as it may have some bearing upon the treatment,
as it sometimes does, though much less often, and to a less extent,
than is commonly supposed. Sometimes, I may say often, nothing like a
decision of this question can be arrived at. Farther developments in
the progress of the case must be waited for before this can be done.
Neither is it the object of a consultation to have the physician
who is called in prescribe to the attending physician what he shall
do; though this is often considered to be the object, especially
when the consulting physician is much older than the one who is in
attendance upon the case. _Dictation_ is certainly very far from
being consultation.
Again. It should not be among the objects of the friends of the sick,
in calling a consultation, to obtain the opinion of the physician who
is called in upon the course of treatment which has been pursued.
He has nothing to do with the past, except so far as it will aid
him in discovering the true nature of the case, and in fixing upon
the course to be adopted at the present time. He steps out of his
province altogether, if he says anything to the friends in regard
to what _has_ been done. This general rule applies not only to
criticisms upon practice, but to all expressions of approbation
also. The patronizing air, with which some physicians utter their
commendations of the course, which has been pursued by the attending
practitioner, is a most flagrant insult. It generally involves an
unwarrantable and ridiculous assumption of superiority. It is a
common trick resorted to by the dishonorable, to impress upon the
by-standers an idea of their greatness.
The friends of the sick often put the consulting physician in an
awkward position, by the inquiries which they make of him in regard
to the measures which have been pursued. If he really approves of
them all, of course there is no difficulty. But suppose that he does
not—that he cannot say with truth, that if he had been called to the
case at the first he should have adopted precisely the same course.
What answer shall he make then to the inquiries put to him? Shall he
reply to them fully and frankly? By no means. It would be cruel both
to the friends of the patient and to the physician to do so. He has
no right to take such a course, unless there be gross and palpable
mal-practice, which the good of the patient and of the community
requires should be exposed. This is the only case which can justify
such a measure. Where there exists merely that difference of opinion,
which results from the various individual notions and preferences and
doctrines of physicians, all such inquiries of the friends of the
sick should not be replied to.
There are also some exceptions to the rule in its application
to expressions of approbation. If for example an older and
well-established physician, on being called in to the patient of
a junior member of the profession, sees that the propriety of the
course, which has been pursued, has been called in question by some
of the friends or by busy bodies, it is his duty to volunteer in
the defence of that course if he can conscientiously do it. Older
physicians often have such opportunities of doing essential service
to meritorious young men.
It is only such cases as I have mentioned, which form the exceptions
to the rule laid down. The general practice of remarking upon what
has been done cannot be too severely reprobated, as opening a wide
door for cunning intrigue and ungenerous insinuation. The honorable
physician desires no such privilege, but the dishonorable prize it
highly, as one of the means of inflicting their base wounds upon the
reputation of their competitors. Such physicians are ever ready to
answer the inquiries of friends and neighbors, about the previous
treatment, in every case to which they are called. They commonly
prefer to do this in a corner, rather than openly. Whenever they
see that a stab can be given to the professional character of any
competitor they do it, and often so stealthily, that it is not seen.
A word, a look, a mere movement of the head may do it, and perhaps
oftener does it than any tangible expression of opinion. An open show
of the weapon that inflicts the wound the cunning and dishonorable
physician most studiously avoids.
In this connexion I may remark, that the bandying about of the
opinions of this and that physician, in regard to different cases,
by their partizans, is one of the chief causes of the jealousies
and quarrels among the members of our profession. If the friends
of the sick would ask simply for the result of the consultation,
instead of endeavoring to obtain the opinions of each physician in
regard to the various points of the case, it would manifestly shut
out all opportunity for intrigue at such times. And it is to this
result alone that they have any right under ordinary circumstances.
When a consultation is held, it is expected that some definite
conclusion is to be arrived at, in relation to the nature of the
case, and the treatment of it. It is the result of a _deliberative_
body, no matter of how few, or how many it consists. The individual
opinions expressed in the deliberations leading to this result are
wholly confidential; and whoever reveals them without the consent
of the parties is guilty of a breach of confidence. So long as the
attending physician is alone in the case, he acts as an individual;
but when a consultation is called individual action ceases, and he is
now to act in obedience to the result of the consultation—his duty
is simply to carry out that result. He is the _executive_ of the
acts of the deliberative body. He alone is to give the directions
in the management of the case. If the consulting physician gives
any directions either voluntarily, or in answer to the inquiries of
the friends, he usurps authority which does not belong to him. His
business is simply counsel, deliberation, and not action; unless, as
in some surgical cases, he is called in for both purposes.
The chief object of consultation, which is to fix upon the best
course to be pursued in the treatment of the patient, is to be
secured by thorough and free investigation and discussion of the
different points of the case. Anything which interferes with this
mode of attaining the object has a tendency to defeat it. If, for
example, jealousy exist—if one physician feels that the other is
disposed to take advantage of anything that may occur, which can
possibly be turned to his own benefit, there can be none of that
frankness which is so essential to the accomplishment of the object
proposed. A consultation between enemies is generally a failure,
though the friends of the patient may not always know it. At the
same time, let it be remembered, that the mere fact that physicians
are competitors does not necessarily make them enemies. If the
competition be an honorable one, and neither is disposed to treat the
other in an ungentlemanly manner, there is nothing to hinder their
consultation from being free and unembarrassed.
Physicians should always be alone in a consultation.
The presence of others would prevent that freedom of discussion,
which in some cases is so necessary. For each physician, knowing that
his individual opinions will be reported by those who are present,
would be very cautious in expressing them, and there would therefore
be none of that freeness of suggestion and discussion, which is so
desirable in a consultation. And farther than this, while the honest
and high-minded physician would be simply embarrassed under such
circumstances, the selfish and unprincipled physician would, on the
other hand, express his opinions with a view to their effect upon his
own standing with those who are present, while the welfare of the
patient would be altogether a secondary object. His main object would
not be consultation based upon a rigid investigation of the case,
but an exhibition of his skill and knowledge to the non-professional
listeners.
The reasons which I have thus briefly given, are, I trust, sufficient
to show the reader the reasonableness of the rule, which excludes the
friends of the sick from the consultations of the physicians. But it
is sometimes spoken of as unreasonable, and a strict adherence to it
is considered by some as implying a want of frankness and candor.
Tattlers and busy-bodies are ready to attribute some sinister design
to this bar which is put upon their curiosity; and some physicians,
especially in the country, where there is apt to be less regard to
strict rules in medical intercourse, than in our cities, sometimes
flatter this prejudice, and assuming an air of frankness in the
expression of their opinions, adroitly throw the responsibility of
the exclusion upon some of their brethren.
The intrigues, which are practised by the cunning and dishonorable in
connexion with consultations, are very numerous. I will notice a few
of them.
Sometimes, when there is perfect agreement between physicians in
a consultation, the friends of the patient in some way get the
impression that their views of the case are really different. They
therefore sound the consulting physician on the subject. If he be
an honorable man, he will at once say that they have agreed upon
the course to be pursued, that he approves of it entirely, and that
the attending physician will carry it into effect. But if he be
unprincipled and intriguing, he will increase the impression, or even
create it if it do not already exist, that there is disagreement;
and he will do it so adroitly, that, while he will say nothing that
is tangible, he will yet excite curiosity to know his views more
fully, and feed the desire, which perhaps some partizan of his has
awakened by his representations, that he shall take charge of the
patient. If he thus gets possession of the case, as is often done, he
will perhaps adopt the very course agreed upon in consultation with
his brother physician, from whom he has filched it, and will alter
only the _form_ of the medicines, so as to give the appearance of an
actual change in the treatment.
If after a consultation the patient improves, and the change is
attributed by his friends to some particular remedy, credit is
sometimes acquired by the dishonorable physician, by producing the
impression that the remedy was suggested by himself. He makes perhaps
no distinct assertion to that effect, especially if there be no
ground for it, but in his conversations with the patient and his
friends, he throws out such hints, and manifests so much interest
and delight in speaking of the effects of the remedy, that the
desired impression is made.
When, on the other hand, a case terminates fatally, and, as often
happens, the friends of the patient are disposed to find fault,
and fix upon some remedy, or measure, as the chief cause of death,
the intriguing practitioner seeks to make capital for himself by
fastening the blame upon the physician who had the management of the
case. He does this, not by any direct and open attack upon him, for
then he would be exposed, but by slyly ministering to prejudices
which he finds awakened against him, or by exciting such prejudices
by insinuations, and remarks of so indefinite a character, that he is
effectually screened from detection.
Physicians who are called in consultation often have opportunities
of defending the reputation of the attending physician from unjust
attacks. And if they fail to make the defence when truth demands it,
they may be quite as guilty as they would be if they volunteered the
attack themselves, for they give to it their sanction; and yet, by
doing no positive act, they shield themselves from blame. Lending a
listening ear to aspersions upon the reputation of a medical brother,
negative as the act is, is under some circumstances more base, and
does more harm, than any open and bold attack.
An artifice, which is not unfrequently employed by the dishonorable
physician after being called in consultation, is this. On meeting
some friend of the patient he inquires very particularly about the
case, asks whether this or that medicine or measure has been tried,
expresses by word, or perhaps only by his manner, some surprise
at being answered in the negative, though he really has no reason
for doing so, and says that he will see the attending physician in
relation to the matter. He does not see him—he has no intention
to do so. His only object is to create dissatisfaction, or, if the
patient dies, to produce the impression, that the measures which he
alluded to were agreed upon, and ought to have been followed, and if
they had been, they perhaps would have saved the patient.
The selfish and cunning physician is apt to make comparisons between
the cases to which he is called in consultation, and some of his
own cases of the same complaint, which he speaks of as having been
very severe, though they terminated successfully. His object is to
set forth his own skill, and in doing this he commonly very much
over-estimates the severity of the disease in his own cases.
Some physicians _manifest_ a deep interest in the patients of their
brethren, and make many inquiries of their friends, in regard
to the nature of the disease, and the mode of treatment. And if
their services are requested in consultation, they are exceedingly
attentive at the time, and make some very friendly calls afterwards.
This undue attention, assuming the guise of great kindness and a
lively interest in the welfare of the patient, though a burdensome
and pains-taking trick, is nevertheless a very common one.
Sometimes a physician is called in consultation in a case which is
not of a grave character, because the friends of the patient think
that the attending physician places too low an estimate upon the
severity of the disease. If he be an honorable man, he will under
such circumstances have no hesitation as to his duty, but will at
once say, that the attending physician is right in his views of
the case, and that they are unnecessarily alarmed. The cunning and
dishonorable practitioner pursues a different course. He makes a
great show of examining the case thoroughly, asking many utterly
needless questions; and, though he may sooth the anxieties of the
family of the patient, and express the belief that he will recover,
he does it in such a way as to favor the impression, that the
attending physician was not really aware of the magnitude of the
case, but that _he_ on the other hand, has estimated it aright, and
has looked into it as it should be done.
The dishonorable physician often makes difficulty, by attempting to
hold on to the patient of another, when he has been called in a case
of emergency. His plain duty under such circumstances is to give up
the patient to the family physician when he arrives, or to request
that, for this purpose, he should be sent for, if it has not already
been done. And in all cases, in which the physician is doubtful,
whether he has been called accidentally or from choice, he should
take measures to remove the doubt. Some, in their eagerness to get
practice, make no effort to settle this question, but disregard all
the evidence which may appear against their claim to the patient;
and, taking it for granted that the case is theirs, proceed at once
to its treatment, and hang on to it till they are actually driven
from the ground. And if they have a good share of assurance, they
manage by this dishonorable course to keep possession of many cases
which rightfully belong to their more modest neighbors. For many
persons, from the fear of giving offence, are reluctant to tell
them frankly that their services are needed only for the present
emergency, and the physician of the family feels that it would be at
least awkward for him to assert his rights under such circumstances.
Sometimes a second physician is sent for to see a patient without the
knowledge of the one in attendance. This may be done from the whim of
the moment, or from the earnest recommendation of some meddler, or
from a desire to obtain the opinions of another practitioner, which,
it is perhaps thought, will be more candid and unbiassed, without
a formal consultation. A strictly honorable man, when thus called
in, declines giving any opinion at all, for he considers that he has
no right to have anything to do with the case, unless he meets the
attending physician in consultation, or the case is fully and openly
transferred to his care. Not so with the dishonorable and intriguing
physician. Such calls furnish him with opportunities for exercising
his cunning, which are too good to be lost.
It is a very common idea, that physicians are generally attached, to
a foolish degree, to the rules of etiquette in their intercourse.
Many talk as if the welfare of the sick, and sometimes even life, is
sacrificed to it. The physician is often entreated to lay it aside,
as being an obstacle in the way of his usefulness. When, for example,
he is sent for to visit the patient of another physician without his
knowledge, it is perhaps said to him, ‘we wish you to give up all
etiquette—if you can do any good to this poor sufferer, do it.’
The impression which is so common in regard to this subject is an
erroneous one. The rules of intercourse which govern the medical
profession abridge no man’s liberty. A strict adherence to them
favors freedom of intercourse, by maintaining mutual confidence;
while a disregard of them destroys this freedom, by engendering
mutual distrust. The truly honorable physician is therefore always
scrupulous in obeying them, while the dishonorable physician
prefers a lax observance, because it furnishes him with occasional
opportunities of obtaining by his manœuvres advantages over his
medical brethren.
I have thus noticed, as briefly as I could, some of the dishonorable
practices which are common among physicians, impairing the harmony
of their intercourse, and therefore limiting the usefulness of the
profession. I have done so, principally because the community do
not appreciate in any just degree the evil of these practices,
and therefore those who are guilty of them generally escape with
impunity, especially in the country, where there is no medical public
opinion to control them, as there is in the cities and larger towns.
It is well that the ‘tricks of the trade’ should be understood; and
that the public should be able to discriminate, better than it now
does, between those who are honorable practitioners, and those who
are not.
The differences, the jealousies, and the quarrels of medical men have
become proverbial. ‘Who shall decide when doctors disagree,’ is often
uttered as a reproach upon the profession, not only in regard to its
opinions but its practices also. It is manifest to every one, that a
jealous and quarrelsome spirit is more prevalent among physicians,
than it is in the other professions. The reasons for this I will
briefly notice.
These reasons are to be found in the peculiar circumstances which
attend the relations of physicians to each other, and the community.
As the reader has already seen, the public have, for the most part
at least, no _direct_ means of judging of the correctness of a
physician’s practice, for the whole science of medicine is to them a
mystery. He can commit the most gross and fatal errors, even while
his patients and their friends may be reposing the most unlimited
confidence in his skill and wisdom. His professional intercourse with
them is indeed wholly a matter of confidence. The positions advanced
by the lawyer can commonly be correctly appreciated by ordinary
intelligence; the doctrines proclaimed by the clergyman it is the
privilege and the duty of every man to examine by the light of the
Bible; but the prescriptions of the physician must for the most part
be taken upon trust. There is great room therefore for imposition;
and the more, because with all this ignorance of medicine, most
people are apt to think that they have no inconsiderable amount of
knowledge on this subject.
It is in this facility with which deception can be practiced upon the
community, that we find the principal circumstance that fosters the
jealousies, the disagreements, and the bickerings which disgrace the
medical profession. For it is this facility which tempts to the use
of all those arts and manœuvres, that are so common among physicians.
If the practice of these were confined to empirics, and to physicians
who have an established character as dishonorable and intriguing
men, the evil would by no means be as great as it now is. But it is
not thus confined. The facility for deception is so great, and the
temptations to turn it to profit are so many and constant, that many
physicians, who are in the main honorable, occasionally yield to the
temptation. This of course begets to some extent a general distrust,
and then circumstances from time to time produce jealousy, perhaps
disagreement and strife.
This state of things is promoted by the peculiar relations which
the physician sustains to his employers. They are generally his
warm friends, and are ready to act with zeal in his favor, and to
recommend him earnestly to those upon whom they have any influence.
The attachment of families to their physician is somewhat peculiar,
differing essentially from the preferences which are felt in regard
to other professional men. The result is, that each physician has
a party in the community composed of all classes and ages, and a
large portion of that party are active in urging his claims. This
of itself so affects the competition in which he is engaged with
his brethren, that it is apt to awaken distrust and jealousy. And
besides, interferences are sometimes practised which aggravate the
difficulty. Some attribute most of the strifes of physicians to these
interferences; and assert that if their friends would let them alone,
there would generally be no want of harmony among them. Though there
is some truth in this remark, yet it is certain that physicians are
often the prompters of these interferences. Some physicians always
have a troop of busy-bodies trumpeting their fame. They have a tact
in drawing such persons into their train, and they do it by precisely
the same means by which the quack accomplishes the same object. The
quack and the quackish physician are alike in this respect. The
prompting influence, thus exerted, may not always be obvious, and
sometimes is least so when it is the most effectual. The old adage,
that the highest evidence of art is in the concealment of art, is
applicable here.
The disposition to jealousy and strife in the medical profession
is also promoted by the associations which are sometimes formed by
physicians with each other, or with the community, for the sake
of furthering their own selfish ends. Professional cliques on the
one hand, and alliances with various societies, social, moral or
religious, on the other, when relied upon as means of advancing one’s
professional interests, are always inimical to the harmony of medical
men. They render competition unfair and dishonorable and therefore
contentious. The physician who calls to his aid the influence of a
sect, or a party, or an association of any sort, in so doing not
only places himself in an attitude to awaken distrust, but subjects
himself in maintaining the alliance to a necessity for employing
means of self-aggrandisement, which will conflict with the rights of
others, and will therefore involve himself in either a secret, or an
open warfare with his brethren.
It is peculiarly true of the physician, that he will always find
it for his interest and especially for his comfort, to obey the
injunction of the Apostle, ‘If it be possible, as much as lieth in
you live peaceably with all men.’ Sometimes it is hardly ‘possible’
even for the strictly honest and honorable to do so. It is sometimes
difficult to restrain the outburst of an honest indignation provoked
by the base tricks of physicians, who, in spite of such tricks, hold
an honorable position before the community. But it is best to do
it, if ‘possible.’ For even if the act complained of be clearly and
palpably a disgraceful one, the public, with their present ideas
of the rules of medical intercourse, will not generally appreciate
the true merits of the case. The friends of the physician who has
committed the act will be disposed to think him right; and those
who feel indifferent to the matter, will turn it off with the old
remark, ‘two of a trade cannot agree,’ as if that settled it. If one
who has been injured by a competitor manifest any sensitiveness,
and is earnest in denouncing the act, he will generally make the
matter worse for himself. And if his opponent keep still, and utter
the little which he does say very slily, he will be sure to gain an
advantage over his more honest, but less cunning, neighbor. It is
especially true of the medical profession, that one gives dignity to
a dishonorable opponent by stooping to quarrel with him. The artful
often endeavor to provoke the honorable to strife, managing at the
same time to produce the impression upon the public mind, that they
themselves have no disposition to quarrel. The best course therefore,
commonly is, to avoid as much as possible, and in a very quiet
way, having any intercourse with the artful and intriguing in the
profession.
I have spoken of the interferences of the friends of physicians as
occasioning jealousy and contention in the profession. It is proper
to remark that such interferences ought to produce no ill feeling,
unless they are prompted or justified by physicians themselves.
No physician should be held responsible for all the injudicious
or mischievous acts, which may be done by over-zealous patrons
in his behalf. I would also remark in this connection, that the
representations which are made by the friends of physicians in regard
to the acts or sayings of their competitors, which are so apt to
excite ill feeling, and foment so many quarrels, are very often to
be received with many grains of allowance, and sometimes are wholly
false.
When the medical man has arrived at that period of life, when, from
the amount of his experience through a long practice, he will be
called upon often by younger physicians in consultation, he may
stand in a very enviable position. He _may_, I say, for it depends
altogether upon those habits of intercourse which he has cultivated
from the beginning. If he has been governed by wrong principles
in his competition with his brethren, and has treated them in an
ungentlemanly manner, mutual distrust and jealousy will mark the
intercourse between him and younger physicians, and his situation
will be far from being a desirable one. His standing with the
community may give him the power of extracting from them the show of
respect, and some of them may be attached to him as partizans, from
mere motives of policy, but he cannot obtain from them a true respect
and attachment. It is melancholy sometimes to see the intriguing
practitioner, tottering on the brink of the grave, as busy as ever
with his petty arts in filching whatever he can get of credit, or
respect, or advantage, in his competition with his medical brethren.
If, on the other hand, the physician has been governed by honorable
principles in his intercourse, when he acquires the eminence which
the fact of having had a long and thorough experience gives him, the
respect of his younger brethren is cheerfully accorded to him, and
his declining years are made happy, being free from the strifes and
jealousies which so often disgrace our profession.
In concluding this chapter I remark, that neither controversy
in regard to opinions, nor competition in practice, necessarily
implies contention. Though the controversy may be earnest, and the
competition active, so long as the former is honest and candid, and
the latter is honorable, they will not impair the harmony of the
profession, and they will greatly promote the cause of truth, and the
interests of medical science.
FOOTNOTES:
[36] I have placed in the Appendix the Code of Medical Ethics adopted
by the American Medical Association, in which the reader will find
concisely stated the rules and principles, which I have endeavored to
illustrate in this and in some of the other chapters of this work.