LARGE FEES
AND HOW TO GET THEM
---
A BOOK FOR THE PRIVATE USE
OF PHYSICIANS
---
BY
ALBERT V. HARMON, M.D.
WITH INTRODUCTORY CHAPTER BY
G. FRANK LYDSTON, M.D.
W. J. JACKMAN, PUBLISHER
121–127 PLYMOUTH COURT
CHICAGO
------------------------------------------------------------------------
Copyright, 1911
By W. J. JACKMAN
------------------------------------------------------------------------
LARGE FEES
AND
HOW TO GET THEM
------------------------------------------------------------------------
CONTENTS
-------
CHAPTER I.
MEDICINE AS A BUSINESS. Why Medicine as 11
Ordinarily Followed Is a Failure From the
Business Standpoint—Physicians Themselves
Mainly Responsible—Queer Ideas About
Philanthropy—Poor Business Methods—Tactics
that Pauperize One-half the
Patients—Doctors Easy Prey for
Sharpers—Evils of Medical
Colleges—“Charitable” Hospitals Injure
Regular Practitioners—Free Clinics and
Dispensaries—The Medical “Tin
God”—Absurdities of Ethics—How Some
Physicians Get Notoriety—Freaks of the
Profession—Things the Young Practitioner
Should Avoid
CHAPTER II.
THE PHYSICIAN WHO SUCCEEDS. Qualifications 31
for a Big Fee-Getting Practitioner—The Kind
of Men Who Make Money in the Practice of
Medicine—Business Mistakes in the
Profession—Why Many Doctors
Fail—Old-Fashioned Ideas as to Set Fees—No
Reason Why Physicians Should Not Use
Judgment in Placing a Monetary Value on
Their Services—Prompt Collection of Bills
an Important Item—Attorneys, Architects,
and Other Professional Men Afford Good
Examples of Business Sense—The Beard and
Its Dangers—Necessity for Scrupulous
Cleanliness—An Experience in Iowa—Reasons
Why Many Physicians Fail—Psychological
Factor an Important One
CHAPTER III.
THE BUGBEAR OF ETHICS. Intimidation of Young 43
Physicians—Overdoing the Ethical
Proposition—Spying on the Beginners
Illogical Advice—How Some Men Become
Wealthy and Famous by Doing the Very Things
They Denounce in Others—Clever Evasions of
the Code—Schemes by Which Valuable
Publicity Is Obtained—Actual Incidents
Illustrating Methods Prevalent Among
Physicians Who Keep Themselves Constantly
Before the Public—Working the
Newspapers—Employment of Press Agents—How
They Get Free Write-ups for Their
Principals—Fine Work by a Chicago Man in
Popularizing a New Treatment—The Making of
a Sensation—Newspaper Story that Made
Certain Ethical Gentlemen
Wealthy—Administration of Unknown
Preparations by High Apostles of Ethics
CHAPTER IV.
LAWFUL TO ADVERTISE. Publicity Within Certain 61
Lines Necessary and Legitimate—Progressive
Physicians Ignore Old Rule—Courts Uphold
Right of Doctors to Make Their
Qualifications Known in the Public
Press—Time Brings Radical Changes—Numerous
Reasons Why a Competent Practitioner Should
Advertise—Futility of “Ethical”
Opposition—Severe Judicial Rebuke for
Medical Society Leaders Who Attempt to
Debar and Discredit Men Who
Advertise—Finding in the Celebrated Dr.
McCoy Case—Indecent and Obnoxious
Advertising—The Proper Kind—How to Obtain
Valuable Publicity in a Dignified Manner
CHAPTER V.
GETTING COUNTRY PATIENTS. Making Connection 73
With Prospective Patients—Again, the
Intelligent Use of Newspapers—First Steps
to Be Taken in the Location of Good
Cases—Correspondence an Important
Feature—The Kind of Letters that Inspire
Confidence and Bring Patients to the
Doctor’s Office—What a Physician Should and
Should Not Say in His
Correspondence—Specimen Letters—The Danger
Line in Correspondence—Effect of the Right
Kind of Letters—Humoring the Family
Physician—Getting in Touch With the
Latter—How to Make Him a Friendly
Co-operator—Arranging for Country
Trips—Proper Method of Procedure—Working on
a Business Basis—Schedule for Receiving
Callers—Reception of Stranger
Doctors—Division of Fees to Secure Their
Support—Treatment of Country Patients—How
Big Fees Are Obtained
CHAPTER VI.
RECEPTION OF OFFICE PATIENTS. Attractive 93
Quarters the First Essential—How to Select
and Furnish Rooms—Reception of Strangers on
Arrival—Separation of Callers—Reception
Room Attendant an Important Factor—The Kind
that Wins—Hints on Treatment of
Callers—Recourse to Correspondence File
Vitally Essential—How Letters Should Be
Kept in Order to Get the Necessary
Information Speedily—Letters Frequently
Give Clues as to the Writer’s Business
Calling and Financial Responsibility—Object
in Making Callers Wait Before Physician
Receives Them—How the Reception Room
Attendant May Become a Valuable
Ally—Stenographers Should Be Kept Out of
Sight
CHAPTER VII.
THE CORRESPONDENCE FILE. Proper Handling of 103
Correspondence One of the Vital Essentials
to Success—Life Blood of the Specialist’s
Practice—Right Kind of Correspondence Clerk
an Indispensable Ally—Method of Keeping
Letters on File So as to Secure Best
Results—Sample Letters that Bring Large
Financial Returns—Methods of a Competent
Correspondence Clerk—How He Makes Money for
His Employer—Tracing the Financial Rating
of Strangers—Securing Names and Addresses
of Prospective Patients—Utilization of
Newspaper Clippings—“Follow-up”
Systems—Advantage of Using Plain Envelopes
in Writing to Strangers—Obtaining
Testimonial Letters from Patients—Use of
These Letters in Attracting New
Comers—Conducting Correspondence With
People in Small Towns—Purpose in Avoiding
Duplication of Testimonials
CHAPTER VIII.
GETTING AT FINANCIAL STATUS. How to Ascertain 119
the Monetary Resources of Callers Who
Appear Unannounced—Line of Conversation
That Will Lead Any Man to Unwittingly
Reveal His Financial Standing—Free
Examinations and How Smart Specialists Make
of Them a Big Drawing Card—Bringing a
Caller to the Point of Submitting to an
Examination—Means by Which an Impression is
Made—Benefit in Keeping an “Assistant”
Within Handy Reach—Clinching the Caller as
a Patient—Avoiding the Naming of a Definite
Time for Treatment—Reasons Why Some
Specialists Fail to Obtain Good Fees—Lack
of Tact in Getting at a Caller’s Ability to
Pay a Reasonable Fee—Crude Tactics that
Defeat the Purpose of the Physician—Danger
in Too Much Haste and Rash Promises—Modesty
Properly Applied the Great Winner
CHAPTER IX.
DECIDING UPON THE FEE. Value of Psychological 131
Influence in Acting at the Right
Moment—Just as Easy to Get Big Fees as
Small Ones—Experience of a Young
Physician—Great Difference in Patients—An
Exhibition of “Gall”—Incubus of the Old
Dollar-Fee System—When to Name the Fee and
How to Fix Upon the Amount—What the
Practitioner Should Say and Do in Order to
Secure Large Payments—How Reduction May Be
Gracefully Made When a Patient Protests
Against the Amount—Dealing With “Tight
Wads”—How to Skilfully Dangle the Bait of
Health Without Actually Promising
Results—Taboo on the Word “Cure”—Bringing
the Caller Who Hesitates Down to the Point
of Positive Action—System to Be Followed in
Deciding Upon Amount of Fee a Patient Will
Pay
CHAPTER X.
GETTING FEES IN ADVANCE. How the Money May Be 141
Secured Before Treatment Is Started—Undue
Haste, or Evident Desire to Get the Cash,
Bad Policy—Putting the Patient’s Mind in
Condition to Make Advance Payment—A
Successful Fee Getter’s Line of
Talk—Creation of Confidence in the
Physician’s Ability and Honesty the Main
Factor—Making Sure of Payment When Partial
Credit Is Extended—Method of Drawing Notes
That Are Readily Negotiable and
Non-Contestable—Inducing Patients to Sign
Iron-Clad Notes—When and How to Act—Turning
Checks and Notes Into Cash—Weeding Out the
Payers and Non-Payers—What to Say When a
Patient Objects to Signing a Note—Smart Man
Easiest to Deal With—Instance in Which a
Banker Paid a $2,500 Fee Twice—How a
$10,000 Fee, Definitely Settled Upon, Was
Lost
CHAPTER XI.
GETTING ADDITIONAL FEES. Patients Who Have 153
Paid Big Fees for Treatment Almost
Invariably Good for a Second Payment—Lines
Upon Which More Money May Be Had—Men of 50
Years and Over Gold Mines When They Have
the Means—How to Handle Them—Dangling the
“Sexual Vigor” Bait in a Delicate and
Effective Manner—Suggestions of
Supplementary Treatments That Bring
Additional Fees—Arrangements With
Occulists, Pharmacists, Surgeons and
Instrument Dealers That Add Materially to
the Physician’s Income—How Patients Are
Induced to Patronize the Specialist’s
Allies—Secret Ciphers That Result in
Extravagant Charges—Division of the
Proceeds—Adventure With an
Undertaker—Doctors Who “Sponge” Upon Their
Professional Brethren
CHAPTER XII.
PROPER HANDLING OF NOTES. Kind of Note That 171
is Negotiable and Easily Discounted—Manner
in Which Such a Note Should be
Drawn—Defects in Ordinary Form of
Promissory Note—Ease With Which Payment May
Be Evaded or Delayed—Difficulties in the
Way of Enforcing Collection—An Iron-clad
Promise to Pay That Binds the
Maker—Avoidance of Litigation and Attendant
Expense—What to Do With Notes When Taken
for Medical Services—How to Dispose of
“Paper” to Bankers Who Know the Financial
Responsibility of the Signers—Successful
Method of a Chicago Physician Who Handles
Considerable “Paper”—The Collection Agent
Evil
CHAPTER XIII.
PRESCRIBING OF REMEDIES. Why Physicians 179
Should Dispense Their Own
Prescriptions—Trouble With Present System
of Drug-store Dispensing—Number of Drugs
Actually Required in Practice
Limited—Duplication of Prescriptions by
Pharmacists an Injustice to
Doctors—Proprietary Medicine
Fakirs—Prescribing Secret Formula
Preparations—How Many Practitioners Are
Hoodwinked—Positive Injury in Prescribing
Remedies by Trade Names—Violation of Code
in Using Preparations With Unknown
Ingredients—Value of Mystery in the
Administration of Drugs—Unwise to Let
Patients Know Too Much About Their
Prescriptions—Why All Remedies Should Be
Designated in Latin—Views of Dr. Osler on
Drug Prescribing
CHAPTER XIV.
MEDICAL “STEERERS” AND THEIR WORK. Method by 187
Which Many Physicians Obtain Patients—Men
Who Make a Business of Directing Invalids
Where to Go for Treatment—Commercial
Diplomats—Their Style of Work—Large
Incomes—How Sufferers Are Approached—The
Kind of Talk That Wins the Confidence of
the Sufferer—Directing the Victim to a
Physician—Landing the Patient in the
Doctor’s Office—The Steerer’s
Commission—How He Protects Himself and
Insures Square Treatment by the
Doctor—Opportunities for Obtaining
Patients—Leading Hotels Favorite Places of
Operation—Old Brace Faro Game Worked in New
Form—Women Steerers and Their Methods
CHAPTER XV.
WHAT SHOULD THE PHYSICIAN DO? Various 195
Remedies Proposed for Existing
Conditions—Too Many Doctors in the Land—Not
Enough Patients to Go Around—What the
Medical Colleges Are Doing—Over 5,000
Doctors Made Every Year in the Strictly
Ethical Schools Alone—Temptations of Young
Physicians—What Men Like Dr. Evans and Dr.
King Have to Say—Prominent Practitioners
Endorse Division of Fees as an Act of
Justice—Prof. George Burman Foster on the
Profession as Allied to Business—No Reason
Why There Should Be Any Distinction Between
the Two
CHAPTER XVI.
CORPORATION DOCTORS. Evils of the Contract 207
Plan—How It Injures the Regular
Practitioner and the Contract Doctor
Himself—Miserly Economy by
Corporations—Disastrous Competition Among
Physicians—Life Insurance Examiners and
Their Lack of Business Sense—Moral as Well
as Medical Honesty Dwarfed by the
Corporation System—Contract Doctors
Expected to Hide the Truth to Retain Their
Jobs—Beggarly Salaries Paid by
Corporations—Practice Wrongfully Diverted
from Doctors Entitled to It—Collusion
Between Corporation Doctors and Claim
Agents—Sick and Injured Employees Often
Induced to Sign Away Their Rights by
Misrepresentation or Intimidation—The
Drawbacks of Promiscuous Fraternizing
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PREFACE
There are some methods explained in this book which the author does not
endorse. They are printed because they are necessary to a thorough
understanding of the subject. Newspapers publish reports of murders, but
this does not imply endorsement of the crimes.
Aside from these features there are many things which the practicing
physician may read and follow to his advantage. The introductory chapter
by Dr. Lydston will be found to be of special interest.
THE AUTHOR.
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CHAPTER I
=MEDICINE AS A BUSINESS=
By G. Frank Lydston, M.D.
As a general proposition it is safe to assert that the practice of
medicine from a business standpoint is a failure. The successful
exceptions merely prove the rule. It is also safe to assume that the
elements of financial non-success are cumulative in their action—a fact
that is easily proved by hospital and dispensary statistics.
The practitioner of medicine, like every man who relies on his own hand
and brain for a livelihood, is entitled to a bit of earth that he and
his may call their own, at least a modest competence, and a well-earned
rest when his sun begins to set and the twilight of his life approaches.
How many doctors are in a position to enjoy or even render less awesome
their twilight days? As city doctors are all supposed to be rich—at
least by the public, that does all it can to prevent their becoming
so—it would be interesting to know what proportion of them, even in
metropolitan medical centers, own their own homes or have property
investments. A far smaller proportion than is just, I fancy.
The assertion has been made that the general poverty of the medical
profession is due to a lack of appreciation and a contempt for the
rights of the medical man on the part of the public at large. This,
however, is a secondary matter which, being self-evident, overshadows
the primary cause—the asinine stupidity of the profession itself. As a
broad, general proposition the reputable profession as a whole has about
as much sense as the dodo, and, unless signs fail, will, sooner or
later, meet the fate of that remarkable bird. How the profession can
expect the respect and appreciation of the public when it has no respect
or appreciation for itself is difficult to conjecture. The public cannot
be expected to keep clean the nest of the medical dodo. Furthermore, the
public quite rationally values the stupid thing according to its
self-appraisement.
Primarily, the practice of medicine is supposed to be founded on a
mawkish, blanket-like sentiment of philanthropy, which is expected to
cover both God’s and the devil’s patients—the pauper and the
dead-beat—the honest man and the rascal—the rich and poor alike. The
doctor is expected to wallow eye-deep in the milk of human kindness,
scattering it broadcast for the benefit of humanity, but he is in no
wise expected to even absorb a little of it, much less to swallow a gulp
or two occasionally for his own benefit. By way of piling Pelion upon
Ossa, the public, having discovered that the doctor sets little value on
his own services, proceeds to eye him with suspicion; the tradesman is
very careful how he trusts doctors. Of course the tradesman has his own
family physician “hung up” for a goodly sum, but—knowing doctors to be
poor business men—the tradesman often cheats them in both the quality
and price of goods.
It is a great and goodly game that plays from both ends and catches the
victim in the middle. The tradesman has one redeeming feature, however;
he does his best to teach his doctor patrons a lesson. He either sends
his goods C.O.D., or, if the doctor be one of the favored ones, he finds
the bill in his mail bright and early on the first of the month. I often
think my tradesmen must sit up all night in order to get their bills in
bright and early on the first. If not paid by the 15th, a collector is
usually at the doctor’s office to see about it.
Yet the professional dodo—my apologies to the shade of the “sure enough”
dodo—will not learn. He goes on and on, neglecting his accounts, mainly
because he is afraid of offending his patrons and driving them off to
some other doctor who isn’t so particular; and the worst of it is, there
are plenty of contemptible fellows who draw their own salaries promptly
when due, or present their bills for goods with frantic haste, who
consider a doctor’s bill a flagrant insult. Will nothing ever inspire
the doctor with courage enough to despise and ignore such contemptible
trash? Does he prefer the role of a lickspittle to that of an
independent and self-reliant man?
As illustrations of the value the profession sets on its skill and
learning, the amount of gratuitous work done is striking. Our pauper—or
pauperized—patrons are divided into several classes, viz.: 1. The free
hospital, clinic and dispensary class. This is on the increase.
According to Dr. Frederick Holme Wiggin, 51 per cent of all cases of
sickness in New York City are now classed medically as paupers, as
against 1.5 per cent twenty years ago! This is appalling. Of these
alleged paupers it is safe to say that 75 per cent are able to pay full
or at least fairly good fees. Why should pauperism be shown so
prominently in the matter of medical bills, as compared with other
necessities of life? And why should the profession carry a burden that
belongs to the public? 2. Free patients of the private class: (a) those
who can pay but will not, _i.e._, dead beats, and swindlers; (b) persons
whose circumstances are such that the doctor feels in duty bound to
render no bills; (c) persons who presume upon social acquaintance with
the doctor to “hold him up” for friendly, perhaps informal,
consultations.
It requires no great mental effort to see the terrible load the
profession is carrying—self-inflicted, and often for fallaciously
selfish motives, it is true, but none the less heavy. The college and
free hospital may be the professional “old man of the sea,” but so much
the worse for the medical Sinbad. Whatever the explanation, private
practice is on a par with dispensary practice with regard to the
impositions practiced on the doctor. It is safe to say that, of the sum
total of surgical and medical patients of all kinds and social
conditions under treatment in Chicago at the present time, over one-half
are paupers—honest or dishonest. Pay the doctor for the work involved in
this wasted and misapplied charity, and the medical profession would
plunge into a sea of prosperity that might swamp it. And it is not only
the rank and file of the profession that suffers. Ye celebrated
professor, reaching out for glory, yea, into infinite space, clutching
frantically at everything in sight, no matter how profitless—providing
the other fellow doesn’t get the case—often defeats his own ends. And
the great man dies, and is buried, and we take up a collection for his
widow, to meet his funeral expenses, and sell his library—six feet of
earth make all men of a size. _Sic transit gloria mundi._
And when, like dog, he’s had his day,
And his poor soul hath passed away,
Some friendly scribe in tearful mood
Will tell the world how very good
The dear departed doctor was—
And thus win for himself applause.
One of the most potent causes of professional poverty is the mania of
the doctor for a pretense of well-doing. He exhibits this in many ways.
One of the most pernicious is an affectation of contempt for money. This
it is that often impels him to delay the rendering of his accounts.
Oftentimes his patient offers to pay all or part of his bill. With a
lordly and opulent wave of his marasmic hand the doctor says, “Oh,
that’s all right; any time’ll do.” And the triple-plated medical
imbecile goes on his way with a dignified strut that ill befits the
aching void in his epigastric region, and is decidedly out of harmony
with the befringed extremities of his trousers. And then the doctor
apologizes to himself on the ground of a philanthropy that is but the
rankest and most asinine egotism _en masque_.
When will the doctor understand that payment deferred maketh the patient
dishonest? When will he consider the necessities of his wife and
children as outweighing the feelings of the patient who owes him money?
When will he be a man, and not a time-server and truckler to
appearances? He would take the money did he not fear the patient might
suspect that his doctor was not prosperous. He wishes the patient to
think that the doctor and his family dine with the chameleons, or are
fed by ravens. Yet the medical Elijah waiteth in vain for the
manna-bearing birds—they know him for what he is, a counterfeit prophet
who vainly yearns for the flesh-pots of Egypt—who has a ponderous and
all-consuming desire for pabulum, and a microcephalic capacity for
finance.
Doctors are supposed to be keen judges of human nature. I often think
this is absolutely without foundation. Defective knowledge in this
direction is a very expensive luxury to the medical profession. The
confidence man and sharper cannot fool the average doctor into buying a
gold brick, perhaps, but they can come very near it. The oily-tongued
and plausible man with a scheme finds the doctor his easiest prey. The
doctor has often hard enough work to wring a few dollars out of his
field of labor, and it might be supposed that it would be difficult to
get those dollars away from him, but no, it’s only too easy. He bites at
everything that comes along—he often rises to a bare hook. Mining
stocks, irrigation and colonization schemes, expensive books that he
doesn’t want, will never need and couldn’t find time to read if he
would, histories of his town or state in which his biography and picture
will appear for $100—proprietary medicine schemes, stock in publications
of various kinds; he bites at everything going—he has _embonpoint
cerebrale_. Oh, but the doctor is easy! I have very painful memories.
The best investment I ever made was when I paid a fellow for painting a
sign for the door of my consultation room, reading: “Notice—Persons with
schemes will please keep out. I have some of my own to promote.”
It is rather a delicate matter, perhaps, for a college professor to
touch on the evils of medical colleges in their relation to the business
aspect of medicine, but I shall nevertheless speak plainly and to the
point. While theoretically the better class of medical colleges were
founded solely for the advancement of science, it is none the less true
that self-aggrandizement has been the pedestal on which most of our
disinterested giants in the teaching arena have stood and are standing.
Remove the personal selfish interest of college teachers and most of our
schools would be compelled to close for lack of instructors. Let us be
honest with ourselves, please. Not that self-interest is reprehensible—I
hold the contrary. One may teach for salary, reputation, the love of
teaching, or a desire for self-improvement, it matters not, for if he be
of the proper timber he is the right man in the right place.
Self-interest makes better teachers on the average than philanthropy,
providing the primal material is good.
Granting that self-interest is the mainspring of the college professor,
is he very “long-headed” from a business standpoint? I submit the
following propositions as proving that the average college professor
defeats his own ends.
1. He devotes to teaching, time and labor over and above the exigencies
of ordinary practice, which, if devoted to cultivating the good-will of
the laity, would be much more profitable.
2. While cultivating the acquaintance and friendship of the alumni of
his own school—a few each year—he alienates from himself the friendship
of every alumnus of every rival school, the instant he begins teaching.
3. He assists in educating and starting in life young, active
competitors to himself.
4. He is unreasonably expected to devote a large percentage of his time
to the gratuitous relief of medical students and physicians. He may give
his time cheerfully, but he yields up his nerve force just the same.
5. Most college professors are less successful in the long run than the
more fortunate ones of the rank and file who have never aspired to
teaching honors.
6. Greater demands are made on a professor’s purse than if he were in
the non-teaching ranks of medicine. He, more than all others, is
expected to put up a prosperous appearance.
The college clinic—especially of the surgical sort—is far-reaching in
its detrimental effects on professional prosperity. Few or no questions
are asked, and the millionaire is being operated on daily, side by side
with the pauper, free. And the blame does not always lie with the
professor who runs the clinic. General practitioners bring patients to
the free clinics every day, with full cognizance of their ability to pay
well. Why doctors will persist in thus cheapening surgical art is
difficult to conjecture—but they do it just the same.
Of course, the college clinic is supposed to be a theater of
instruction. Often, however, it is but a stage on which comedy-dramas
are enacted. A brilliant operation that nobody six feet away can see,
and an operator bellowing at his audience like the traditional bull of
Basham—in medical terms that confuse but do not enlighten, terms that
are Greek to most of the listeners—this is the little comedy-drama that
is enacted for students who have eyes but see not; who have ears but
hear not. Instruction? Bah! Take the theatric elements and the plays to
the gallery out of some college clinics and there wouldn’t be a
corporal’s guard in attendance.
Worse than the free clinics are the so-called charitable hospitals. Much
has been said of dispensary abuses, but few have had the courage to say
anything in adverse criticism of these institutions. While nominally
founded to fill “a long-felt want”—and the number of long-felt wants,
from the hospital standpoint, is legion—these hospitals are founded on
strictly business principles, save in this respect—the people who found
them feed on their innate capacity to get something for nothing. The
first thing the founders do is to get a staff of doctors to pull the
hospital chestnuts out of the fire. The members of the staff think that
the hospital is performing the same duty for them, and everything is
serene. And so the surgeon goes on operating on twenty patients—fifteen
of whom are able to pay him a fee—in the hope that one among them all is
_willing_ to pay him a fee.
Exaggeration? Well, I cannot swear to the accuracy of the foregoing, but
an eastern surgeon of world-wide fame once told me that for every
patient who paid him a fee he operated on nineteen for nothing; and this
man has no public clinic, either. Is it conceivable that the nineteen
free patients are all paupers? Many of them go to my friend for
operation from very long distances. Ought the railroads and hospitals to
have all the profits? Have we not all had similar experiences in a
lesser degree? With the development of charitable hospitals far in
excess of any legitimate demand, it has come to pass that surgery is
almost a thing unknown in general city practice. Even the minor
operations have left the general practitioner—to return no more so long
as there are free hospitals and dispensaries. Where is the emergency
surgery, of which, in former days, every practitioner had his share?
Railroaded off to the “charity” hospitals to be cared for gratis.
In a recent conversation with a practitioner of thirty years’
experience, I said, “Doctor, you used to do a great deal of general
surgery throughout this section of the city. Have the hospitals affected
your practice in that direction to any extent?” He replied, “Surgery
with me is a thing of the past. Even emergency cases are carted off to
the nearest hospital. If by chance one does fall into my hands, it is
taken away from me as soon as I have done the ‘first-aid’ work.”
Personally, I see very little use in teaching surgery to the majority of
students who intend to practice in our large cities—they will have
little use for surgical knowledge.
Here are three cases in illustration of the way our “charitable”
hospitals antagonize the business interests of the profession:
1.—A very wealthy farmer engaged me to perform an exceedingly important
operation. It was understood that $1,000 was to be the honorarium. He
was afterwards advised to go to a certain “religious” hospital, where he
was operated on by an eminent surgeon, who received nothing for his
services. The patient paid $15 a week for hospital accommodation, and
$25 a day to his family physician, who remained with him “for company.”
What a harmonious understanding between the patient and his family
doctor—and what a “soft mark” that surgeon was. I had the pleasure of
telling the latter of the gold mine he didn’t find, some time later, and
the shock to his system amply revenged the body surgical.
2.—A patient who was under my care for some weeks and paid me an
excellent fee finally divulged the fact that he had meanwhile been
living at a certain hospital as an “out patient,” at an expense of $8 a
week. He had become dissatisfied with the hospital attention, he said,
and, pretending great improvement, was permitted to get about
out-of-doors.
3.—A man on whom I operated and who paid me my full fee without argument
or question, came to me directly from one of our large hospitals, where
he had been sojourning for several months.
That medical men in hospitals are imposed on is a trite observation. So
long, however, as it appears to be the doctor’s advantage to be on a
hospital staff, plenty of men will be found who will be glad of the
chance. As for the injury which the system inflicts on the profession at
large, that is no argument with the individual. Human nature operates
here as elsewhere. Knowing that the system is bad, we are all anxious to
become victims.
In recommending the payment of salaries to hospital men, the Cleveland
_Medical Journal_ claimed that such a plan will remedy all the evils
incident to the professional side of hospital management. I do not agree
in the opinion that the payment of salaries to the staffs of
institutions for the care of the sick will alone correct the evils of
such institutions. The writer of the aforesaid editorial is incorrect,
also, when he says that an awakening is at hand. No, not at hand; it is
coming, though; the handwriting is on the wall. When the revolution does
come, this is what will happen:
1.—Hospital physicians and surgeons will be paid salaries.
2.—Hospitals will take as free patients or patients who pay the hospital
alone only such persons as rigid investigation has shown to be indigent.
All others will be compelled to pay their medical attendants, just as in
private practice.
3.—Certificates of indigency will be required of every free patient,
such certificate being signed by the patient’s attending
physician—outside of the hospital—and at least two other persons in the
community where he or she resides.
4.—General, and especially country, practitioners will cease to deceive
hospital doctors as to the circumstances of their patients. One medical
man should not impose on another.
Too much trouble, eh? Well, my friends of the hospital and
dispensary—for the same charges should apply to the latter—you must
either take your medicine or the revolution will go farther and this is
what will happen: The profession at large will boycott every man who
runs a college clinic, and every hospital and dispensary man. It will
fight colleges and hospitals to the bitter end.
The day is perhaps not far distant when doctors outside of colleges and
hospitals will run their private practices on the co-operative plan,
thus dealing a death blow to the free clinic and dispensary. Every man
of prominence will have his own private clinic and advertise it among
his patients. What is fair for twenty or thirty men is fair and ethical
for one. Each man can have his own hours for the poor; he can eliminate
the unworthy ones, and, best of all, he can refer all his dead-beat
patients to his clinic. Pride may bring fees from patients to whom
honesty is a thing unknown. The private hospital will run most of the
public hospitals off the earth. There will be no room for anything but
municipal hospitals run squarely and fairly for charity, and reputable
private hospitals run frankly for pecuniary profit, in which the
operation and the attendance fees are the chief factors. Such hospitals
will benefit, not hurt, the profession.
One of the most vital flaws in the business sense of the general
practitioner is his penchant for hero worship. He hears of the medical
tin god from afar, and burns incense on the altar of his greatness. The
great man pats the humble doctor on the back, calls him a good boy, and
tells him just where to take all his cases. Sometimes he offers to
divide fees with him.
The medical tin god is truly a “self-made man in love with his maker.”
He has “genius stamped upon his brow—writ there by himself.” His
evolution is interesting. It is history repeating itself: Apsethus the
Libyan wished to become a god. Despairing of doing so, he did the next
best thing—he made people believe he was a god. He captured a large
number of parrots in the Libyan forests and confined them in cages. Day
after day he taught them to repeat, “Apsethus the Libyan is a god,” over
and over again. The parrots’ lesson learned, Apsethus set them free.
They flew far away, even into Greece. And people coming to view the
strange birds, heard them say, “Apsethus the Libyan is a god; Apsethus
the Libyan is a god.” And the people cried, “Apsethus the Libyan is a
god; let us worship Apsethus the Libyan.” Thus was founded the first
post-graduate school.
The medical Apsethus and the deluded parrots of the medical rank and
file are here, and here to stay, until both are starved out. And the
modest general practitioner looks up to the medical tin god and wonders
“upon what meat does this our Cæsar feed that he hath grown so great?”
The meat of industry? Perhaps. The meat of prodigious cerebral
development? Seldom. The meat of opportunity? Yea, yea, my struggling
brother, “and the devil take the hindmost.” But, more than all, he hath
fed on the meat that the parrots have brought him—Elijah’s ravens were
not a circumstance to those parrots. “In the kingdom of the blind the
one-eyed man is king.”
How long will the general practitioner continue to play parrot to the
medical tin god of the charitable hospital the very existence of which
is a menace to the best interests of the profession—the profession for
which the institution has no charity? In that happy time to be there
will be no tin gods. There will be a more equable division of work and
every prosperous community will have its up-to-date private hospitals
with up-to-date men at the head of them.
As for the post-graduate teacher—good or bad—he is already defeating his
own ends—he is exciting ambitions in the breasts of his pupils. Here and
there among them is an embryo McDowell, a Sims, or a Battey. The
backwoods country produces good, rich blood and virile brains. And the
Sims, and McDowells, and Batteys of the future will be found in
relatively small places, doing good work, and then—good-bye to the tin
god and his horn, “for whosoever bloweth not his own horn, the same
shall not be blown.” And in that day the parrot shall evolve into an
eagle, and the hawk had better have an eye to windward. Meanwhile,
hurrah for the post-graduate school and its pupils, and more power to
the tin gods.
This business handicap is so self-evident that it is hardly necessary to
touch on it. We raise the standard of medical education year by year,
yet the mushroom colleges do not go—they are here to stay. If one-half
the colleges were wiped out of existence there would still be more than
enough to supply the demand for physicians. We have done the best we
could to breed competition by manufacturing doctors, and we are doing
all we can to make that competition first class—a queer business
proposition in force of the oversupply of doctors. We are unjust, too,
to the men we educate, by offering them inducements to enter an already
overcrowded profession—but so long as human nature is as it is I see no
way out of the dilemma.
There was once a time when it appeared a goodly thing for the chosen few
to get together like the “three tailors of Tooley street,” and, after
establishing to their own satisfaction the fact that they were indeed
“the people,” formulated rules for the guidance of the many. These rules
were called “ethics.” And the profession has been wrestling with its
ethics ever since, trying to determine what it was all about anyhow. The
ethical garment of half a century ago no longer fits—it is frayed and
fringed, and baggy at the knees; full many a patch has been sewed on it,
in individual attempts to make it fit from year to year, until it is
now, like the Irishman’s hat, respectable by age and sentimental
association only. And the public, the ever practical and heartless
public, has also wondered what ’twas all about, and exhibits little
sympathy for a profession which, while driveling of ethics, has
“strained at gnats and swallowed camels.”
Who does not remember when all the wiseacres with number eighteen
collars and number five hats seriously discussed the relative propriety
of “Specialty” vs. “Practice Limited,” on professional cards? How times
have changed. And then came the discussion by a learned society, of the
ethical relations of “Oculist and Aurist” to “Practice Limited to
Diseases of the Eye and Ear.” And it was decided that men who had the
former on their cards were not ethical and could not enter that society.
Ye Gods! Is the fool-killer always on a vacation? Must we always see
those long ears waving over the top of the ethical fence, built by the
fat hogs to keep all the little pigs out of the clover patch? What is
the public to think of a profession that winks its other eye at the man
who prints on his cards, “Diseases of Women Only,” but rolls up it eyes
like a dying rabbit at the sight of a card reading, “Diseases of Men
Only?” What has raised the woman with leucorrhea to a more exalted plane
than that occupied by a man with prostatorrhea, does not appear. Why so
many inconsistencies, and why such hypocrisy!
Sir Astley Cooper had his own private “hours for the poor.” Our European
brethren print their college and hospital positions and all their titles
on their cards. Are they less ethical than we? Homeopathy is a dead duck
over there, and quackery has a hard row to hoe in Europe—queer, isn’t
it?
Our system of ethics has not only been hypocritic, but somewhat
confusing. The young man on the threshold of medicine doesn’t know
“where he is at.” He is confronted by the unwritten law that only
celebrated men and quacks may advertise. Small fry, who haven’t the ear
of the newspapers nor a chance for a college position, are tacitly
ordered to keep their hands off. And the young fellow watches the career
of the big man, who hides every other man’s light under his own bushel,
and marvels much. Especially does he marvel at the accurate photographs,
life histories and clinical reports of his more fortunate confrères that
appear in the newspapers without their knowledge.
Experiences differ. I haven’t yet got around to newspaper clinical
reports, but it has been my fortune to be “written up” on several
occasions. I do not recall that the newspapers drew on their
imaginations for my photograph. I wish I might think so, and that their
imaginations were distorted—the result was so uncomplimentary.
So far as I can learn, nobody protests against being legitimately
represented in the newspapers. Why not be honest about it? The hypocrisy
of some men is sickening. Paying clandestinely for newspaper write-ups
is despicable, yet some of the very men who protest that they “really
don’t see how that could have gotten into the papers,” have paid for the
advertising in good “coin of the realm.” It is queer that the newspapers
should write up the most minute details of the wonderful exploits of
some poor fellows, together with their family histories, and publish
their photographs, without their knowledge or consent—especially queer
when we read in conclusion that “Professor John Doe is the greatest
surgeon that ever lived.” Why not come out and acknowledge that these
are paid for? This would give an equal chance to all, and especially to
young fellows who have money enough to pay for similar things. He who
has not the price should not find fault with the fellow who has, for,
“business is business.” Meanwhile, my young friends, remember that “big
mountains may do what little mountains may not do.”
When Koch’s tuberculin was yet new, soon after it escaped, half-fledged
from the laboratory, only to be captured and made to perform like a
trick monkey for the benefit of the laity, there came a ring at the
phone of a prominent daily paper: “Hello, is this the _Daily Bazoo_?”
“Huh, huh, it are.” “Well, I’m Dr. Squirtem Galls. I wish you would send
a reporter over here at once. I want to be interviewed on Koch’s
tuberculin.” It is said that $25 changed hands, but I don’t believe it.
The gentleman would never advertise—at that rate—“no sir-ree.” My
informant was once the sporting editor of the _War Cry_, and hence
unworthy of credence.
And what wonderful contributions the newspaper-great-men are making to
science! The daily paper is the place to study appendicitis and things.
It is not long since I learned from a distinguished surgeon friend of
mine, via a daily paper, that evidence of a blow having been received on
the head is an imperative indication for craniectomy, whether symptoms
are present or not.
In preference to the clandestine methods now in vogue, would it not be
better for men in authority to write signed articles for the newspapers
and intelligently present medical matter to the public? But that
wouldn’t be ethical, would it? Such topics as “Advice to Young Men,”
“Letters to Young Wives” and “How to Keep Healthy,” must be left to the
quacks. We will confine ourselves to the surreptitious blowing of
surgical horns and never mind the false notes.
Meanwhile, let us stand back and watch the procession of modest men who
never advertise—oh, no! At the head, with haughty mien, comes Professor
Keene Carver, preceded by a herald in blood-red garb, blowing a large
brass horn. Then comes the “bearded lady,” whose blonde and breezy
whiskers so delight the heart of his swell society _clientele_. And here
comes Rip Van Winkle—a middle-of-the-road “eclectic,” gathering up his
long and weedy beard to keep it from getting tangled up in the
scientific barbed wire fence along the route. And here comes another
sure-enough “regular,” evidently a medicine man—so rare nowadays. He is
riding in a swell turnout and is on his way to his clinic. How do I know
that Professor Windy Bowels is a regular? Because the gentleman who is
riding beside him to his clinic is a reporter on the Chicago _Daily
Jib-boom_.
I presume that the suggestion that I have made of the advisability of
taking the public frankly into our confidence and giving it accurate
information so far as its comprehension goes, by signed articles, in
preference to clandestine advertising and the promulgation of fallacious
ideas of medicine and surgery, will meet with bitter opposition. I
nevertheless believe that a better education of the public is the only
way to down quackery. The opposition will come chiefly from the
surreptitious advertiser, who sees a prospect of other men getting the
advertisement that he believes to be his proprietary right.
Then there is the tribe of the Microcephali. The howl of protest will be
long and loud from the pews occupied by these far-famed champions of
medical orthodoxy. “We won’t put _our_ discoveries or contributions in
the newspapers—not ever.” And gazing at their lemur-like front
elevations, we can well believe that they would have no trouble in
establishing a “halibi.”
Apropos of “discoveries,” it may as well be understood that the public
is bound to get the details of them sooner or later, and, when the time
is ripe, the matter should be presented to it in a clear and
intelligible form—comprehensible to the layman.
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