The General Practitioner and the Public Health—Responsibility of
the Private Practitioner in Tuberculosis—Impossibility of
Fulfilling this Obligation—Failure because of the Nature of
Tuberculosis—Failure through the Personal Equation.
=The General Practitioner and the Public Health.= Roughly speaking, we
may say that the medical profession is divided into three or four
branches—private practice, hospital or laboratory work, and public
health service. A man who takes up one of these branches is not
necessarily interested in or equipped for another. While all physicians
are supposed to have approximately the same medical education, and
therefore to be interested in those measures which tend to raise and
improve the standard of public health, it is only those who are most
keenly interested in this work who have made it a special study. For it
must be remembered that public health work is as much a specialty and
calls for as much training and ability along certain lines as laboratory
work, or the administration of an institution. This being so, a man who
goes in for it does so because he is more interested in it than in
private practice, or in research work. And the converse of this is also
true. The selection of one field rather than another is a matter of
individual taste or inclination. Yet curiously enough, the State does
not take note of this fact. It places certain obligations upon all
members of the medical profession, and expects them all to live up to
the responsibilities thus arbitrarily imposed.
=Responsibility of the Private Practitioner in Tuberculosis.= In the
pursuit of his calling, the private practitioner comes into contact with
certain diseases which by their nature are a matter of public as well as
private concern. In so far, therefore, he is expected to interest
himself in the general welfare of the community, but there is no way of
compelling him to do this. The State grants him a licence to practice
medicine, and in exchange for this licence or permission, he is expected
to serve the State more or less gratuitously. At best, it is volunteer
service, and therefore intermittent and unsatisfactory. That the State
expects this service is shown by laws referring to transmissible
diseases, the notification of births and deaths, and other matters which
in one sense belong to his private business, but which in another sense
are part of his public responsibility.
Physicians who have no taste for research work are not forced to
undertake it, nor are they coerced into any other line of service. Yet
the State obliges those who are least inclined, as well as the others,
to assume a graver responsibility; care of the public health. It takes
no account of the many reasons which may prevent their doing this, or
prevent their willingness to assume any part of this responsibility. It
is thrust upon them just the same, but the expected results are not
forthcoming. The State, therefore, is in the position of making an
unfair demand upon the private practitioner, and at the same time
relying upon an unfulfilled requirement for the security of the public
health. In regard to tuberculosis, there are certain regulations which
all physicians are supposed to comply with, no matter how little
interested they may be in public welfare, or how unwilling to consider
any other than their personal interests. These laws require, first, that
all cases of tuberculosis be registered with the local or state health
department, since in dealing with a transmissible disease it is
necessary to learn its distribution and prevalence. Second, the
physician in charge of a tuberculous patient must give this patient full
prophylactic supplies, and teach him how to use and dispose of them.
These supplies are furnished free of charge by the Health Department, so
that the physician is under no expense in distributing them. Third, all
houses vacated by a consumptive, either through death or removal, must
be reported to the Health Department for fumigation. If these
regulations could have been thoroughly complied with, they would
doubtless have insured a system of complete and satisfactory supervision
of tuberculosis. As it is, most of our large cities have found it
necessary to place special workers in the field, to give exactly the
same supervision and control which these regulations were designed to
secure. The private practitioner, endowed with special education,
special opportunity, and special authority, has not used these
endowments, or else has used them to so slight an extent that the
community has received no benefit.
If the physicians of a community have been able to diagnose
tuberculosis, and have been required by law to report it, why has it
become necessary to establish municipal dispensaries for this purpose?
Can the dispensary physician make a better diagnosis? Or is he more
willing to fill in a blank and report the case?
And if the physicians, required by law to instruct and keep careful
watch over their consumptive patients, had been able to do this, why has
it become necessary to place tuberculosis nurses in the field, designed
to give just such service? Is the special nurse better fitted to explain
the nature and danger of the disease? Is she a more efficient
distributor of prophylactic supplies? To all these questions there
should be but one answer—there is, or should be, no difference between
the two. The private practitioner should be as well able to make a sure
diagnosis as the municipal physician. He should be as ready to report
the case. The private practitioner should be as capable a teacher, as
careful a distributor of supplies, as alive to the danger of
tuberculosis as the municipal nurse. The only difference between these
two groups of people is that one acts and the other does not—or acts in
such intermittent and irregular manner as to be productive of no
results. And it is because of this lack of action on the part of the
physicians in private practice, their failure to recognize, report,
teach, and continually supervise consumptive patients, that our cities
are placing the care of tuberculosis under municipal control. The care
of tuberculosis is gradually being withdrawn from the man in private
practice, and placed in the hands of specialists, who devote their
entire time to the welfare of the community. And although now as always
the latter solicit the support of the private physician, if he withholds
his co-operation they can do without him, and reach their goal through
other means.
=Impossibility of Fulfilling this Obligation.= We may ask why the
private practitioner is being supplanted by municipal control.
Undoubtedly he once held the key of the tuberculosis situation, as he
holds it of many other problems involving the public health. He is being
supplanted for two reasons: because of the peculiar nature of
tuberculosis, and because of the failure of the medical profession to
act as a united whole.
=Failure because of the Nature of Tuberculosis.= Let us first consider
the nature of the disease. Tuberculosis is a prolonged, chronic disease,
which may be drawn out over a period of months or years. The patient has
many ups and downs, being sometimes so ill that he places himself under
the care of a physician, sometimes so much better that he does not see a
doctor for months. We have known patients who have not been to a
physician for years, yet during that time they were infectious cases, as
proved by sputum examination. During a hiatus of this kind, how can we
possibly hold the doctor responsible for the tuberculous patient? How
can we hold him responsible for the conduct, training, and surroundings
of a case he never sees? Undoubtedly a very large number of patients
pass completely from under the observation of their physicians, and are
utterly lost to them. With the best intentions in the world, the private
practitioner cannot follow and supervise a disease of this character,
not acute, but chronic and ambulatory in nature. If he attempted this,
it would leave him little time for anything else.
Nor can we assume that the patient who closes his account with one
doctor necessarily places himself in the hands of another. He frequently
drifts along without any medical advice whatsoever, and only seeks it
again when his symptoms become alarming. These facts alone, exclusive of
all other considerations, show the necessity for centralized control of
these ambulatory patients.
Tuberculosis is largely a disease of the poor, as we have remarked
before. A poor consumptive must consider the spending of every dollar,
and the doctor’s fee is a matter of grave importance. For this reason,
the patient will pay just as few visits to the physician as he possibly
can. A doctor who sees a case only once or twice may well hesitate to
pronounce it tuberculosis, and may wish to keep the patient under
observation for a time, but the poverty of the patient prevents this.
Again, patients of the poorer classes continually change their doctors.
Unlike people in more fortunate circumstances, they have no one
physician to whom they always turn when in trouble. To such as these,
the “family doctor” is unknown. Their fickle interest is attracted by
the newest shingle, and they pay a visit or two to its owner and they
depart. We knew one patient who visited five different doctors within
the week. Small wonder that the doctor forgets these patients—mere
transients—and that, even if he has time to diagnose them, he does not
consider himself their physician, or responsible for them in any way. It
is for just such cases, however—those patients who come into fleeting
and haphazard relation with their physician, that municipal control is
required. It is no reflection upon the private practitioner that he has
failed to make headway against tuberculosis. It simply proves that
people with this disease must be watched and cared for by those who are
able to devote their entire time to it.
So much for the disease itself, and for the sociological and
psychological conditions which complicate it, and make it a matter which
cannot be handled successfully by the man in private practice. For no
matter how conscientious he may be, or how willing to assume the full
responsibility imposed by the State, he cannot do this when the patients
refuse him the opportunity. He cannot follow them up at the expense of
his private obligations. While the State expects service from those whom
it licenses to practise, it does not expect the impossible.
=Failure through the Personal Equation.= We must now consider the second
reason for removing tuberculosis from private into public control. For
while the nature of the disease itself explains in large measure why it
cannot be dealt with by the private practitioner, that is not the entire
explanation. And here we must put the blame where it belongs—at the door
of the physician himself.
When we think of the medical profession, we unconsciously think of its
finest members—not only of the leaders in thought and achievement, but
the numbers of highly educated, advanced, efficient, and conscientious
men who form so large a part of it. In thinking of these, however, we
are apt to overlook men of another sort, who are less well equipped, or
who are imbued with commercialism, yet who are none the less members of
this great profession. Yet even the least of these is armed, and has the
sanction of the State in bearing these arms, which may be used either
against a common enemy, or in a guerilla warfare in behalf of his own
interests. The wide diversity among its individual members is the reason
why the medical profession has been unable to act as a united whole in
the warfare against tuberculosis.
In the first place, all physicians, no matter how well they may be
trained, are not necessarily good teachers. No matter how keenly aware
of the danger of tuberculosis, they are often unable to impress it upon
their patients. Again, the busy physician has usually too little time to
be a careful teacher. When conscious of a crowded waiting-room, or of
the urgency of his next call, he is unable to give any but the most
superficial and hurried instructions about the nature of tuberculosis,
or the use of the prophylactic supplies. He does not realize that that
which is obvious to him is frequently unintelligible to those less
enlightened. We have often found patients possessing bundles of
prophylactic supplies, given conscientiously enough, but without
sufficient instruction to enable them to fold the fillers or to dispose
of them afterwards. We recall one such case, where the doctor had given
his patient a package of supplies, but had hurried off without opening
the bundle or explaining its contents. A week later, we found the
package still unopened. The patient, however, had torn a small hole in
the wrapper, through which opening he had seen enough to convince
himself that the strange objects within were no concern of his. We do
not mean to say that no physicians are good teachers, but we do say that
even where they are, and are moreover highly conscientious men, that
they frequently give inadequate instruction to the patients under their
charge, because they are too busy.
There is another class of practitioners, who, while willing enough, are
nevertheless unable to contribute much towards the anti-tuberculosis
campaign. These are the men whose education is limited, who are unable
to recognize tuberculosis until it is advanced, and even then hesitate
to commit themselves. The patient under these circumstances has ample
opportunity to infect others, to say nothing of losing his own life into
the bargain. No amount of conscientiousness, of integrity, and of honest
intention can compensate for lack of skill. Indeed, many men of this
sort come perilously near the border-line of quackery. Yet the State has
granted them a licence, though thereby it entrusts them with obligations
which they cannot fulfil.
We have spoken before of the unethical practitioner, who, while
competent enough, feels himself under no obligation to protect the
community from an infectious disease. There is sometimes a reason for
this indifference, this failure to tell the patient he has tuberculosis,
and to inform those who surround him of their danger. This reason is
because many a patient is afraid to know the truth about his condition.
If the physician tells him he has tuberculosis, he at once changes his
doctor and seeks another who will give a more comforting diagnosis.
Thus, the struggling physician, to whom this may mean the loss of
livelihood and prestige, is forced to a decision between self-interest
and the interest of a community which he learns to despise, because it
has forced him to dishonesty. We grow cynical about the welfare of those
who force us to trim our ideals.
We have tried thus briefly to review the main reasons why tuberculosis
is emphatically a disease which should be removed from private practice
and placed under municipal control. On the one hand, this is necessary
because of the nature of the disease, since ambulatory patients cannot
be followed except by those able to devote their whole time to it. On
the other hand, it is necessary because of the wide diversity within the
ranks of the medical profession. The greater number of private
practitioners are either too busy, too intent on earning a living, too
indifferent, or too poorly educated to assume effective supervision of
an infectious disease which requires masterful handling. And since they
themselves have not been able to deal with this great issue, they should
not object to placing it in the hands of those qualified to do so. The
greatest contribution that the private physician can make to the
anti-tuberculosis campaign, is to do what he can to hasten the advent of
full municipal controls.