CHAPTER III It is really the fault of the profession if people do not (Part 5)

TOPICS 141 would find in the same part of the country. It is these straight men in a community who can be depended upon to furnish leaven, and to set standards, and who are revered by young men of high ideals who are looking for heroes. Thank God there is plenty of the romantic among men in our pro- fession, and they are always looking for heroes. Question (i) requires no comment, excepting to call atten- tion to the joker word "demand." Question (2) — Leaves "appropriate circumstances" to the conscience of a man who wants money. Question (3) — Is very proper. Question (4) — Is proper with the exception of the intro- duction of the word "usually." Question (5) — Is the most important one of the series, and contains the courtesy which vice pays to virtue, in the negative statement of no attempt being made to conceal the transaction from the patient. Question (6) — Makes it the duty of the operator to ascer- tain if the regular attending physician is to be paid sufficiently by the patient. In my opinion it is not at all the duty of the operator to do this. It is the business of a dignified attendant to look after this matter properly himself. The only duty on the part of the operator is to use his judgment in determining whether an operation is really desirable or not, and to decide upon the best thing for the patient. He has been selected for that purpose alone, and for no other. He has not been selected by the patient for the purpose of using judgment about the fees of somebody else. That is a very nice duty belonging to the family physician himself. Question (7) — The physician's responsibility ends with getting his patient into the best hands, and the specialist's responsibility ends with giving the best service to the patient. I am imwilling to believe that such a large proportion of men TO-MORROW'S TOPICS Wkk really crooked as the ones favoring division of the fee in his list. It is my impression that thoughtlessness and lack of proper education will account for the large number of men who did not express opinions in accordance with high stand- ards. The system of cheap medical education, and the turning I out of large numbers of men from proprietary medical colleges which has prevailed in the past, will account in large degree I for the points of view which are developed in the course of t competition. A prominent surgeon on the Pacific Coast told me that fee splitting was practically universal along that coast, arid the only way he could see out of it was for certain men to group themselves together and allow it to be known that under no circumstances would they split fees. The ones who are shrewd enough to see the advantage of being honorable will find very quickly the direction of paths chosen by the people. When speaking with men of whom I had heard as splitting fees, they sometimes replied that it was not a feature of their work at all. They had not done it half a dozen times in their lives, but circumstances sometimes occurred in which it seemed to be proper. They were undoubtedly honest men, and did not realize the moral effect of splitting fees, upon some un- usual occasion. The mere fact that the instance had come to my ears indicated its wide and far-reaching effect — more marked perhaps when it is not expected of a man. A physician who recently came to the office with a patient from the South, told me that he had been strongly advised to consult a certain L.specialist, but would not do so because he had been informed of la case of fee splitting on the part of this specialist. I happen ■ to know that the latter is not the sort of man to engage in any Questionable procedure at all, professionally, but the mere fact of his having split a small fee on one "proper occasion" led to Ids losing a large fee to my definite knowledge, on this later TO-MORROW'S TOPICS 143 occasion. Aside from the money loss, he suffered a loss of prestige, because the matter was commented upon — how widely I do not know. One of the compensations for graft in the medical pro- fession, aside from the digging up of a lot of neglected sur- gical cases, has been the raising of legitimate fees. In former times the specialist was the prey of the general practitioner in quite another way than in having to divide fees. He was forced to contribute to the physician's reputation for gener- osity, but at his own expense. It was customary for a physi- cian to say to his patient of good circumstances : "Now I know the specialist whom we want to employ in your case, per- sonally, and will see to it that you get off easily. He will do what I ask." This customary procedure gained the gratitude of the patient, which was set down to the credit account of the physician. Preparations may be made to have some surgical operation done when physicians in charge of the case are all convinced of the necessity for an operation. The surgeon who is per- fectly free may find that the case is not one for operation at that time, or for operation at any time. If there were to be any commercial warp to his judgment, one may readily see where the temptation would appear. Then again, if the expert specialist were to offer a commission for cases, any poorly qualified specialist who offered a larger commission would get more cases in a locality in which the moral sense of the profession was not of high character. Competition would soon be on the usual commercial basis instead of on the high plane of usefulness to the patient. There is no objection to a division of the fee in cases in which several physicians par- ticipate, provided that the patient is fully aware of the entire transaction. That is the crucial point and the pivot upon which the moral side of the matter rotates. Even this may TO-MORROW'S TOPICS not often be done, for the reason that very few cases are so distinctly outlined that one can know in advance just what expense items may be introduced. I remember one case in which a physician intimated in my side room that he would like to be paid for his time in coming on with the patient. He had previously written asking if I would do a rather complicated hernia operation for a patient of his for two hundred and fifty dollars and I answered in the affirmative. When the patient and the doctor arrived, how- ever, it was evident that the patient was a man of the sort who did not need any charity. He was one of the blunt, out- spoken men of that comfortable sort to whom one could say almost anything and allow him to say anjthing in return. After making an examination and finding the case a proper one for operation I said to the patient, "Now, your doctor has not arranged about the fee quite right. The operation will be done for two hundred and fifty dollars, as agreed, if that is your wish, but I will state exacdy my feelings in the matter and you can tell me yours, and the final decision will be all satisfactory." I asked how much he was paying his doctor for coming on. Turning to the latter, he replied. "I am not paying him anything. He is a friend of mine who is willing to come here for the sake of seeing the operation." "Now," I said, "the proper thing is this: You should pay me one thousand dollars for the operation, and you ought to pay your doctor two hundred and fifty dollars for his time in coming down." "Why, that is all right," said the patient without a moment's hesitation, "I am glad to do it." The good doctor is constantly on the alert when guarding his patient's interest, even to the point of overdoing protec- tion and miscalculating on possibilities of injustice for the expert. The division of fee plan would destroy this kindly protection of the patient's interests. TOMORROW'S TOPICS 145 So long as the mention of division of fees in conversation brings a flushed cheek, the profession is safe. Our leaders do not wish to have their cheeks flush when referring to any part of their personal conduct. Burton J. Hendrick, in a capital article in McClure's for January, 1914, describes the area of fee-splitting. He states that in the South and in New England this abuse has not reached large proportions. The principal area reaches across New York to Ohio, Indiana, Illinois, Kansas and Nebraska, then shoots upward to the Dakotas and across to California, where the art has reached its highest development. It is probable that articles like that of Mr. Hendrick for the popular reader do good on the whole, even though the entire profes- sion is apparently smirched. The people when awakened will eventually use better discrimination in selection of physicians, and that is precisely what the better element in the profession has always implored the public to do. It is probable that Puritan conscience in New England, Dutch honor in New York and cavalier pride in the South have stood out fairly well against the shifty sands of "business expediency.*' A very' insidious circular has recently been sent out to physicians by members of a certain Western Hospital Asso- ciation. Doctors are informed that if they join this hospital association they will have such hospital connection that their charity cases will be cared for at cost. Their better class of patients will be cared for in the best manner at very reason- able rates. Members who join the association will receive forty per cent, of all fees exclusive of hospital charges received from their patients. From the share of fees received from first patients sent to the hospital the amount of a member's stock subscription will be taken. He then, without direct expense, becomes a stockholder in what the founders say is to be the best paying hospital in the Mississippi Valley. Such a TO-MORROW'S TOPICS circular will attract the attention and interest of the most undesirable element in our profession. Doctors who have not been enabled to obtain a remunerative position through pro- fessional capacity will now hurry to make forty per cent, of profit from all the patients whom they can send to so-called competent men at this hospital. Physicians subscribing to this stock become ordinary hounds engaged in hunting. They can inform patients about the professional capacity of the men who are connected with this hospital more successfully than they can tell about their own capabilities. Every member of the hospital association becomes a runner for the institu- tion, engaging in work with a greater degree of interest than if he were on a salary. If the barker persuades a sufferer that he should pay a very large fee, the barker's proportion makes him feel good no matter how the patient feels about it. In practically every sort of business the payment of percentage commissions instead of salary is stimulating to the highest degree of individuality on the part of agents. I happen to know that some of the staff members of this particular hos- pital association are really very skilful, and in that degree the more dangerous. Moral weakness is a menace of dimensions proportionate to the weight of a body which it subtends. If a patient were to be sent to this hospital for operation, with a diagnosis of appendicitis, or gall-stones, or ulcer of the stomach, but with symptoms really dependent upon arterio- sclerosis, I would not like to be that patient. Would you? He is entrusted to business mercies. Forty per cent, commission goes to a hound who has followed the trail of a sufferer and, having holed him, sits by with wistful eye and dripping jowl awaiting a share of the blood when the experts have finished with exercising judgment. Some people will say, "Oh. well, we know that the south- western part of that state was the last stronghold for train k. I I I TO-MORROWS TOPICS 147 robbers and horse thieves, but we do not believe that any doctors belong in that class." Wait a minute. Not many years ago the legislature of that state (not worse than many others) said, "Give everybody a chance. We will charter diploma mills and let anybody practise medicine if he wishes to do so," The result was that the state hatched out a brood of many thousand licensed incompetents, who now have families to support. They cannot hold practice very well because the element of finely equipped doctors in that same state has finally gained control. The men with increasing families and de- creasing incomes are still in the prime of life and they have gilt-edged licenses allowing them to practise. They were seldom taught principles of ethics to begin with, and principles of ethics would now stand in the way of their gaining a live- lihood for a hungry family. Ergo, making a living by sending patients to really skilled practitioners comes in handy for several thousand incompetent doctors in one state alone, we observe. Although reserving belief in the correctness of the report, I have been informed, perhaps wrongly, that in a large hos- pital in a certain city one member of the visiting staff gives the house doctor a percentage on all of the fees collected from private patients. (Bait!) This at first thought would repre- sent a generous attitude on his part, because good young men are perennially penniless. One direct effect of this procedure upon a young man would lead him to influence patients toward the donor. On that ground it would be a bait procedure on the part of a chief, and demoralizing for young men who are just getting their lessons in medical morals from men whom they naturally idealize. Were it a matter of simple and dis- ingenuous interest in young men, the chief would call together upon this question all of his colleagues on the visiting staff. After a conference they would all agree to give or not to give I J 148 TO-MORROWS TOPICS a commission to members of the house staff. The giving of such a commission secretly would indicate the insincere nature of the transaction. The selfish motive would cause unrest not only on the part of the staff of that particular hospital but also on the part of other hospitals. Incidentally the question of remtmeration for members of a house staff is one of considerable interest. The yoimg men on the staff are supposed to give their time in order to learn. It is such a valuable position for apprenticeship that the struggle for position on the house staff of large hospitals has resulted in the establishing of a very high order of entrance examinations, and there are more than enough yoimg men who are eager to work for the experience alone. If remuneration is to be added for the purpose of securing special attention from the house staff for patients in private rooms, patients in the wards would be apt to suffer from a certain degree of neglect, because there is much human nature still to be found among yoimg men. If at any hospital, for any reason, it should be decided that the best interest of patients is ser'ed by paying members of the house staff for special attention to patients in private rooms, it would have to be according to agreement of the entire visiting staff. Definite amounts of payment would be agreed upon ; otherwise the giving of com- missions to yoimg men on the house staff by any one of the visiting staff would be of bait character and based upon in- sincerity in relation to their real interests. The whole prin- ciple would be wrong. It would fix the attention of susceptible young men upon the financial feature of cases, and patients would be reckoned in terms of dollars rather than in terms of pity. Personally I would like to have the state or mimicipality give a salary to every member of the house staff, but if this were to be arranged in such a way as to purchase special privileges for private room patients, it would foster inhuman- TO-MORROW'S TOPICS 149 ity. Young men would start out in practice with flaws in their running gear. Dr. Tanne at a certain medical meeting recently asked how a doctor engaged iii lodge practice with an average fee of about five cents per visit could be expected to make a living. He explained that the only way is to call prominent doctors in consultation and split the fee with them, and that he had done it himself. He thinks we should have no nonsense about matters of this sort and says of the Golden Rule — ^"It is childish. We have gone beyond that. We must seek deeper for causes of bad conditions on the East side.'' He is evi- dently a socialist. As a matter of fact, he described immedi- ate, direct, and natural results of lack of regard for the Golden Rule. The "deeper down" cry I am getting to believe is a mystic obsession. In the course of progress there has recently been founded the American College of Surgeons, with 450 representative men as charter members. The intention is to give some sort of basis for judgment in relation to the capability of surgeons. This exerts a corrective influence upon the destructive features which accompanied the movement toward establishment of numerous small hospitals. Half of the members of a staff sometimes felt they must