CHAPTER III It is really the fault of the profession if people do not (Part 2)

of attempting to adopt a system of fees for physicians or surgeons, any more than there is need for fixing the prices for the paintings of artists. The fee of the physician is determined largely by the finances of the com- mimity in which he practises. In one case I charged a thou- lod dollars for an operation for which several times that mount would have been proper. The one who was to pay TO-MORROW'S TOPICS 115 the bill was a woman, and women are habitually thrifty in relation to any sort of marketing. She sent me a check for six hundred dollars and asked me to accept that as full payment. I was interested in her point of view, as she was perfectly able to pay freely without deprivation, and an extremely clever woman besides. All of our correspondence was sent to three surgeons, with the name of the woman erased, so that it could hot be traced, and my colleagues' opinions were asked for publication. The correspondence on both sides was published in the New York Medical Record about ten years ago. The debtor finally paid the balance of the fee, and when enclosing the last check, wrote, ''My discussion with you has been a friendly one, and so you will not, I am sure, suspect me of acrimony when I say that my feeling about the present excessive charge of surgeons is a general one, and the reflection of a sentiment that is everywhere one of surprise and dissatis- faction. We do not question your ability, but we feel you make us pay dear for it." The case was one in which her son had acute appendicitis with gangrene of the inner coats rapidly on the way to general sloughing. The complete operation was done in ten or twelve minutes through a short incision. I did not see the patient again, and the whole procedure no doubt seemed like a small matter to the mother. If we had argued about the case for a day until peritonitis was well under way, and if I had employed a great incision necessitating daily calls to the country house for a long time, finally bringing the patient through by a narrow margin, leaving him with a hernia for subsequent operation, the mother would undoubtedly have paid me ten thousand dollars without any question. She could in that case have seen that a good deal had to be done. The avoidance of all such complications, and the saving of a life easily and quickly, called out this letter on the part of the mother. She wrote under a genuine conviction that she had TO-MORROW'S TOPICS been overcharged, and felt that I had used my reputation as a lever with which to pry money from her purse. The surgeon's fee is not based upon the way in which he uses the knife. It is based upon some point in technic which he thought about when awakening at five o'clock in the morning seven years previously in connection with some similar case. The legal fee is graded according to the value of property, liberty, or life which is in jeopardy. The same thing should belong to medicine in principle. At one time one of the most famous of the older physicians in Chicago charged one dollar per visit in his office. Another physician a short distance away on the same street charged twenty dollars per visit in his office. Patients would go from one office to the other, paying the respective fees to both physicians without any question, in order to obtain their opinions. I know of sur- geons who insist upon the payment of their fee in advance before performing an operation, but this cannot be done fairly to all parties as a rule. One may find that he has quite another sort of case to care for after he gets to work. The case may require the exercise of very little skill or of a very high degree of skill. From a plain business point of view, as one would buy calico by the yard, this sort of thing no doubt would be acceptable to a few surgeons, and to a few patients. As a L matter of fact, I really would like to talk over the question of I fee in advance in a general way, but most of the time when we l^are considering the features of a case, we dislike to consider I the fee part of it at all. and only have in mind the thought of f what we can do for our patient. I have many personal friends among lawyers who feel precisely the same way toward their clients, although the public at large has a very different opinion of the lawyers. That at least is my personal experi- ice, Horace Greeley to the contrary notwithstanding. Why should the Mayos not make charges like lawyers for TO-MORROW'S TOPICS 117 their services? The profession ought not to object to their making a couple of million of dollars a year, for that is no more than is made by men engaged in some other occupations every year, with no greater marshalling of talents, and we should feel proud as a whole profession that men in our midst are capable of setting that sort of an example. They now have to divide up most of their work among assistants, but the cases cared for by the principals might be made to con- sist largely of those who could pay for master strokes. The Mayos have always given as good personal service to the poor as to the well-to-do up to the limit of their capacity, but that limit was reached years ago, and personal attention must now be given chiefly to cases in which special experience is wanted, — ^and generously to colleagues who require their ser- vices. An additional selection of cases might be made from among patients who could without deprivation pay doctors what they now at times pay lawyers or engineers. If a man's whole estate is in jeopardy and a lawyer saves it after much work and trouble, his fee is perhaps twenty-five thousand dollars, in a case in which the man will gladly pay that amount. A man's whole estate is in jeopardy again, a strangulated hernia indicates that the man is soon to be de- prived of the use of his estate, but a doctor saves the estate for him after a few minutes of work which cost as many years of time and trouble as the lawyer expended in preparing himself for saving the estate. Here the man does not pay a fee of twenty-five thousand dollars willingly, however. This is all wrong, and the fault of a profession the weakness of which lies in its strength. A physician of large needs requires to be paid dignified fees. His responsibilities are great, and in order to maintain a position in accordance with his responsibilities and to operate the machinery essential for a high degree of usefulness, he TO-MORROW'S TOPICS must be able to command all of the expensive resources or profession. A physician or surgeon with an income of iioo.ooo per year could employ it all very well in his profes- sional work and not require much of it for his personal needs. The best doctors require little money for themselves. Commenting upon my suggestion that a fee of fifty thou- sand dollars would be proper for a certain operation, the editor of one of our popular lay periodicals says that on this basis a switchman at a railroad ought to get a similar salary for letting so many thousands of people pass the switch safely, because the switchman also has to be trained like the surgeon for his work. Taking this editor seriously as some people will, the fallacy is seen to lie in failure to make proper com- parison between the degree and kind of training required for the switchman and for the surgeon respectively. Almost any intelligent man of good mentality may be trained to make a successful switchman, but for every one who becomes remark- ably adept in surgery, hundreds of well educated doctors fait after expensive trial to become master surgeons. These hun- dreds have tried conscientiously but have found themselves to be unadapted for the work. The public seems unable to comprehend this part of the subject. Here are two points of view expressing two sides of a question : DECEMBER 2. 1912. $20,000 FEE JUSTIFIED Many Cases of Appendicitis Demand High Technical Skill To THE Editor of the New York Times: Under "Topics of the Times" the other day quotation is made of the New Orleans case of Danna vs. Williams, in which suit is being brought for a $20,000 fee in a case of appendicitis. The statement is made that "the operation for I appendicitis is of no special difficulty. Any surgeon properly called good can do it," Last Saturday a surgeon at one of the New York hospitals, in the presence of visitors, removed an appendix by a difficult operation in a case in which two good surgeons had previously made the attempt and had failed. The patient loses practically a year of time and can never be robust, but there was no fauh on the part of any of the three surgeons. A famous Chicago surgeon who recently died published a report upon fourteen consecutive appendicitis cases of his, complicated by peritonitis, with fourteen consecutive deaths. He advised against the performance of the operation in the presence of this complication. Another Chicago surgeon at the same time published a report upon a similar class of cases in which he had reduced the death rate to about 20 per cent., and since that time he has reduced it to a point below 5 per cent. Both men had about the same professional standing. Surgeons are considered to be progressively expert if they can reduce their death rate in complicated appendicitis cases I per cent, per year for fifteen consecutive years. Many a fine surgeon in a small town where things are "talked over" has had his entire reputation blasted by the results in his appendicitis work. Aside from the death rate, we have to consider the morbidity rate. One surgeon develops a degree of skill which allows almost all of his appendicitis patients to escape the later com- plication of post-operative hernia. This cannot always be avoided by the most skilled surgeons, but the hernia rate is such an important matter that surgeons expend a great deal of time and thought in perfecting their technique in relation to this point. Any surgeon properly called good can operate successfully in the average case of appendicitis. In every series of 100 cases there are many which require the last degree of technical skill on the part of the surgeon, and there are some in which he would like very much to have the privilege of "trying over again just once." In the Williams case a fee of $1,000 would have been L. I20 TO-MORROW'S TOPICS proper if the case was uncompiicated. It may have presented complications in which a fee of $20,000 is not only justified, but the payment should be accompanied by an expression of gratitude on the part of the patient. „ ^ ^ ^ VISITOR. New York, Nov. 30, 1912. MEDICAL "ROBBERY" To THE Editor of the New York Times: The most sel f -assuring and complacent confession of rob- bery is the proud acknowledgment of a surgeon who says in The Times that his charge for a special operation is $50,000. That is his price for a few hours work in cutting a patient up and severing his vitals! Where in the world did this surgeon acquire his great art? Did he learn nothing of it from the thousands of great surgeons who have lived before him and whose methods have come down in history ? Did he learn nothing from the great institutions of surgery supported largely by the rich ? Counting the sacrifice of life in wars and the interminable struggles of the poor for a living, no life is worth such a fee in this world, though the law says it is. It is well he hides his name under the guise of "Visitor." HENRY F. K . Cranford, N. J., Nov. 22, 1912. My answer to the letter of H, F. K. would be this : (i) The price is not for a few hours of work, but for a IfcAv minutes of work only, those minutes, however, repre- nting years of eflfort which have finally led to successful tilts. (2) His art was not acquired from a single one of the ■ surgeons who have gone before. His knowledge was 'Quired through their aid. to be sure, but his art must be P®**nguished as quite as personal a matter as the art of TO-MORROW'S TOPICS 121 Millais, compared with the art of some unknown contemporary of Millais, both of whom obtained their knowledge but not their art from precisely the same source. (3) He obtained his knowledge from the great institutions which arc supported by the rich, but these institutions did not give him wisdom or master strokes. (4) "No life is worth such a fee in the world." The prin- ciples in this question, it seems to me, relate to the laws of salvage, and I would like to have the matter adjudicated in an admiralty court. There are two notable elements opposed to the obtaining of fair fees by the physician. Wealthy men are accustomed to being preyed upon, and they become over-suspicious. I know all about it, because in some badly informed localities I am held to be a wealthy man myself, and am subjected to all of the attitudes of mind which are customarily aimed at such men. It has made me uncomfortably suspicious at times, because of an abundance of justification for at least exercising caution when dealing with men. In my attempt at raising the fee standard for doctors, a rather curious effect has been noted. Many colleagues have quoted my position in order to turn it to their own advantage, when conferring with patients or their physicians. My at- tempt to give service to the whole profession in this regard has been very injurious personally, although there has been much satisfaction in knowing that little by little I have been useful to the profession. A prominent surgeon is per- haps wrongly quoted as saying he did not believe that any surgeon should charge fees which would give him an income of more than fifty thousand dollars for a whole year's work. I wonder what he is going to do for science (taking the report at face value). It seems to me that he might much better play the game without limit and find in his own personal hands TO-MORROW'S TOPICS the means for doing for his profession and for the people things that he cannot possibly do on fifty thousand dollars a year. One would feel almost ashamed of a surgeon who did not perceive urgent need for an expenditure of several hun- dred thousand dollars per year. He may live on two thousand dollars per year for personal expenses if he chooses. No objection to that ! When attempting to raise standards of various kinds a doctor is apt to meet opposition in the ranks in his own profes- sion. One can usually "make twice as much by charging half as much." The doctor who does this, however, leaves his profession in the lurch and the worse for his having been in it when the time comes for his epitaph. Whatever defeat I have met on this point has been at the hands of colleagues who might much better have said to the patient that their charge would be twice as much as mine and they would render service worth the difference in cost. I have no objection whatsoever to a brother surgeon telling the patient that he will charge twice as much as I would, and will render better service. That sort of thing would stimulate me to efforts at rendering service of still better quality, — a competition in excellence of service. The statement that one will do the work just as well for less money introduces a commercial competition feature, inhibits progress, and leaves the doctor complaining of conditions that he himself has brought about. Either one of the two forms of statement rests with the spirit and character of the individual making it. Doctors are regu- larly underpaid. They must either stop complaining about it, or else must lend a hand when I try to give them aid at my own personal expense and sacrifice, — which has been pretty large in degree. It is not unusual for physicians, especially in the smaller towns, to feel that a small charge should be made for service, TO-MORROW'S TOPICS 123 in the fear that someone else may get a certain case. This is fallacious on the whole. Patients naturally estimate the value of service by the charge that is made. The tendency to charge small fees on a selfish basis is bad in its results, for the reason that the physician who is working for a low fee unconsciously adapts the value of his services in a most human way to the size of the fee. He is very sure to become neglectful and to do inferior work, when not encouraged by stimulating beverages for human nature. If a physician makes a larger charge than is customary among his confreres in a town, and if he at the same time gives more attention to his cases, he will eventually be surrounded by a clientele of the kind of people who are appreciative of that sort of thing. These people, furthermore, with enlarged views, will then be ready to go on with the support of hospital