Medicine and the Middle Class
I
FOR a long time it has been open season the year round for doctors, especially those in private practice. No other class of public servants, not even the farmer, has had such a deluge of advice as to how to manage its affairs. The omniscient Arthur Brisbane is never so wise as when dispensing advice to the medical profession; as, for example, telling the best medical minds of Britain how to cure their sick ruler. In magazines so widely divergent in scope as the Atlantic Monthly, the Ladies’ Home Journal, and Liberty, articles more or less critical of the profession have appeared. Most of these articles are written by non-medical men, perhaps for the same reason that old maids and childless couples are proverbially generous with advice upon the rearing of children. The doctors who contribute are apt to be biased by their connection with some governmental health agency, some medical organization more or less frankly commercialized, or some private charitable institution. These men bear about the same relation to the rank and file of the profession that the registrar of an agricultural college does to a real dirt farmer.
The excuses for attacking the medical profession are many; but the one used oftenest, and, indeed, linked with most of the others, is the alleged high cost of medical care to the middle class. It is recognized that the wealthy arc able to pay for any medical service they want, and that the poor can get it for nothing, either at the expense of the state or from private charity; but, for the middle class, public sentiment is expressed by a recent writer in the Ladies’ Home Journal: ‘The cost of medical care is unconscionably high.’ It is hard to say just why, with so many other high costs all classes — upper, middle, and lower — have to face, their medical bill should be singled out.
Compare the cost of medical care with some other expenditures of the average American family, which pays its doctors each year $24; for drugs and patent medicines (chiefly the latter), $25; for non-governmental hospitals, $15; and for nurses, $8. For passenger automobiles, this same hypothetical family spends annually $150; for tobacco, $67; for candy, $37; for gasoline, $37; for theatres and similar entertainment, $35; for soft drinks, ice cream, and chewing gum, $34.
In the light of the above figures, why should not those writers who wax emotional over the high cost, of doctors plead with their Congressmen to lower the tobacco tax, or with candy manufacturers to make better and cheaper candy, or with a paternal government to supply its subjects with free gasoline for Sunday and holiday outings?
Undoubtedly, however, the cost of medical care has risen, though not out of proportion to the cost of living generally. There are many reasons which justify some increase in doctors’ fees, of which perhaps the chief is the greater length and expense of medical education. The time has passed when the only requisite for beginning the practice of medicine was the ambition to do so, fortified by a few months’ apprenticeship to an older preceptor. Now a medical education represents the end of a long and expensive journey. Thanks to the commendable work of the American Medical Association, within this century the number of medical schools has been reduced by half, and only the fittest have survived. The public may be assured that a recent medical graduate is a picked man, with a thorough grounding in his profession. Furthermore, the education of the right sort of doctor has just begun when he is given his diploma. From one to five years more are spent in a hospital to gain practical experience. After this the man who aspires to keep up to date must subscribe to a number of medical journals, buy new books from time to time, attend medical meetings, take postgraduate courses, and spend considerable sums in new equipment.
Many a country doctor fifty years ago never owned a thermometer. One whose name was a household word in my boyhood would often say, ‘If I had a thermometer and a hypodermic syringe, I should be as well equipped for practising medicine as any doctor could want to be.’ Contrast this equipment with the array now required even as a minimum for any man who aspires to be up to date. And books and instruments alike are subject to rapid obsolescence.
The great increase in the cost of living generally applies to physicians as well as to laymen. Indeed, the great majority of doctors belong to the middle class themselves. Only a few are wealthy, and these have either married or inherited their fortune.
II
The chief reasons for the high medical bill of the middle class are usually ignored or touched upon very lightly. Being myself a member of the great middle class, I am vitally interested in its problems. Furthermore, as a physician in active practice since 1908, I have had the opportunity to make some observations which I hope are worth as much as are those of the laymen and non-practising doctors who write most of the articles under discussion.
After long and careful pondering of the question, I am convinced that the people of the middle class have themselves to blame for the ‘unconscionably high’ cost of their medical care. By accepting as axiomatic that the value of medical service is in direct proportion to its cost, they have certainly not discouraged medical men from charging all the traffic will bear. The multitude of people newly enriched by the prosperity following the war helped to strengthen this idea. By failing to discriminate between luxury and comfort, the cost of hospitalization is needlessly increased. By accepting without question the creed of the specialist, that the field of medicine is so vast that no one mind can hope to keep up with its progress, they have encouraged specialism and its offspring, group practice.
Let me elaborate the above statements somewhat. As an example of the first statement, a friend of mine who served his interneship in a New York hospital told me of a chorus girl who went to one of the best throat specialists in the city and asked his fee for removing her tonsils. Taking pity on her condition, he named the — for him — nominal sum of fifty dollars. She left his office without completing the arrangements for the operation, and a few days later was operated upon by a far less able man who charged her a thousand dollars.
One of the most successful pediatricians in a large city told me that he was often called in consultation by a general practitioner in a neighboring suburb, who always insisted that he make his fee at least a hundred dollars. When he offered to reduce it in the case of an obviously poor family, he was reminded that unless he charged that much his advice would not carry any weight.
Not long ago I had under my care a man who came to our hospital for a diagnostic survey. He had suffered a severe financial reverse, and in his late fifties, with a large family to support, was forced to take an uncongenial job at a small salary. Under the strain his nerves gave way. A thorough going over failed to show any physical defects except some arteriosclerosis, with an elevated blood pressure. I had a long talk with him; explained that he needed very little medicine, but that he did need to adjust himself to a changed method of living, and to learn to make the best of it. He seemed to be entirely satisfied with my advice, until he asked for my bill. Knowing his straitened circumstances, I told him there would be no charge. He thanked me, and then valued my services at their cost; for a few days later I learned that he had gone to another city to consult a practitioner of the notorious Abrams school — who possibly charged enough to make an impression.
How often in admitting a patient to a hospital is the expression heard, T want the very best, regardless of the cost.’ The true significance of ‘regardless’ appears on pay day. One true story will illustrate. A minister who was hurt in an automobile wreck was carried to a hospital, where it was found that he had two broken ribs. He spent ten days in the hospital, with two special nurses for three days, and one for the remaining week. When he left the hospital to go home, he insisted that the nurse accompany him. Many a doctor has continued to practise with a few fractured ribs, yet this ablebodied man spent enough money in this experience to have carried him through a long and serious illness. And very likely he is now regaling his congregation with the high cost of medical care. Incidentally, his physician neither expected nor received pay for his services.
III
The main reason, however, for the plight of the middle class is their unthinking acceptance of that shibboleth of the specialist, ‘The practice of medicine has become so complex that no one mind can attempt to keep up with its progress.’ At first thought this sounds plausible, and it has certainly had its effect upon the attitude of the public toward its medical advisers. More than anything else, the universal appeal of this idea has encouraged the overgrowth of specialism. In turn, the cost of medical care to the middle class has advanced in almost direct proportion to the increase of specialists.
The World War did much to accelerate the rise of specialism; but it had already begun its forward march before then. Other factors in its vogue have been the external pressure brought to bear by the increased prestige of specialization in business and industry, and by the restlessness and discontent of the general public, always anxious to try something new and different. Huge gifts from philanthropists, usually with knotty strings tied to them, have done much to encourage it. Even organizations within the profession have frankly encouraged men to specialize. Finally, the financial incentive to forsake the ranks of general practice for the easier and more lucrative life of a specialist tempts many.
Let me hasten to say that I have no quarrel with the real specialist. Our profession needs a balanced proportion of specialists of all sorts as well as of general practitioners. My personal debt to them is too great to be forgotten. From the crown of my head, which, thanks to a skin specialist, still has enough hair to comb, to the sole of my foot, which was rescued by another dermatologist from the ravages of ringworm, I have cause to be thankful to men trained to do special work. My tonsils have been removed — twice; my appendix once; a broken collar bone and four ribs were reunited so skillfully that I cannot tell the difference. Even the dread of old age has been greatly lessened by an oculist whose glasses have made reading once more a pleasure instead of an ordeal. The professional obligation I feel to the specialists is just as great. Times innumerable I have been helped in the diagnosis and treatment of patients by their greater skill. Indeed, I was once a specialist myself, for nearly a year, but could not be satisfied to travel such a narrow path after having been for ten years on the broad highway of general practice. It is true that my work is now virtually limited to pediatrics and internal medicine, but I still prefer to be recognized as a family doctor.
The admission might as well be made, also, that when specialism first began its meteoric rise a majority of the men who limited their work were of superior intelligence; but this has not remained the case. The desertion from the ranks of general practice by so many of the best minds of medicine has caused the need to be felt for able men to fill the gaps thus made. Many others besides myself have tried the life of a specialist and found that it failed to satisfy their professional souls.
‘Keeping abreast of medical progress’ is not so difficult as the specialist would have us believe. As Dr. Crookshank said in a recent Forum, ‘A vast, deal of rubbish has been written about the impossibility of any one man’s grasping all the recent advances in medical science. I say “rubbish,” because real science simplifies and does not confuse; it synthesizes and leads back to first principles, so that men of intelligence and judgment can with case keep themselves abreast of the best opinion.’ As Dr. Logan Clendening has shown, the most important discoveries in medicine have vastly simplified the treatment of disease. For example, the discovery of insulin has put the treatment of diabetes within the hands of any intelligent general practitioner. The treatment of pernicious anaemia has been reduced to the simple means of eating a half pound of liver daily, or of taking a concentrated liver extract. Vaccination against diphtheria, typhoid, and smallpox can be done by any nurse.
IV
Various suggestions have been made for reducing the cost of medical care for the middle class without retaining the family doctor. The most popular of these is group practice, in various forms, with some form of state medicine as second choice.
Group practice, as is well known, is the combination of a number of specialists into a medical firm or clinic. It might be defined as the departmentstore idea applied to the practice of medicine. Its advantages may be thus summarized: first, it assures, if properly conducted by competent men, a more thorough examination than can be given by one man alone; second, — an advantage which may be also a disadvantage, — a more impersonal view is taken of the patient; third, a doctor should certainly improve his technique by constant repetition of the same manœuvres; fourth, with a number of men using a common reception room, laboratory, telephone, and otherwise dividing expenses, it is possible to give medical service at wholesale rather than retail rates — though not many patients who have been ‘through the mill’ extol this feature!
The objections to group practice as a substitute for the individual doctor are: first, the average patient is subjected to an altogether needless expense, for only a small proportion of people who consult a doctor need an exhaustive examination to find out what is the matter with them; second, the impersonal view of the patient may lead to a lack of interest in his ailments; third, it is proverbial that a chain is no stronger than its weakest link, and the patient’s trouble may lie within the province of the weak member of the firm; fourth, the view of a specialist is inevitably narrow, no matter how clear, and no aggregation of piecemeal observations can make up for a broad view of the whole organism; fifth, the patient is usually seen by each man once or twice, in a hurried examination, whereas every doctor of experience knows that the key to many obscure ailments, especially in the psychic realm, is to be found only after long, patient, and repeated interviews. Finally, if the diagnosis lies between a functional disorder and an organic lesion, it is hard for even the most honest man not to yield to the subtle temptation to decide in favor of the organic trouble and advise operation, rather than launch upon the long and tedious course of psychotherapy necessary to uproot the more or less imaginary ailment. It is so spectacular to point an accusing finger at a curly appendix tip in an X-ray picture and tell an emaciated, overworked, high-strung little school-teacher that her trouble is there, and that its removal will cause her to become strong, rosy-cheeked, and placid. Even if there is a lingering doubt in the mind of the group diagnostician, two thoughts will help to dispel it: the first, that even if the appendix is not badly diseased, the psychic effect of its removal will do her good; the second, that he will not sec her after she goes home, anyhow.
On the other hand, in the hurried examination often given, real trouble may be overlooked. Only last week a doctor friend of mine told me that two months ago he went to an important medical clinic for a complete physical examination. His tonsils had been inflamed several times the winter before, and he knew they still harbored infection. In his own language: ‘I have a perforation in my right eardrum you can put your fist through; the septum of my nose is crooked as a rail fence; yet when I went through the nose and throat department both these were overlooked. They told me my tonsils were all right until I told them of several recent attacks and called their attention to enlarged glands on both sides of my neck. Then they decided they had better come out. ’ If a physician gets such short shrift as this, what can a mere layman expect?
The analogy is often forced between the individual doctor and the retail shopkeeper and small manufacturer. Because department stores are replacing retail shops, and mergers are absorbing small industries, it is assumed that medical firms or groups, or such huge medical mergers as the Mayo clinic, must drive out of business the individual doctor. The basic defect in this comparison is that doctors arc dealing with human beings instead of machines; and human beings simply refuse to be standardized. The parts of one Ford car will fit a million other Fords; but no two human beings are just alike. To overlook the human equation and to attempt to treat people as animated machines is to invite failure.
So-called part-pay clinics, in which medical service is to be obtained at reduced rates, have been suggested as a solution of the middle-class medical problem. Their expenses are to be borne cither by the state or by private charity. In passing it may be observed that if the philanthropists who arc given so much credit for their generosity in providing medical aid for the poor would raise their wage scale in keeping with their profits, there would be less need for such help. These clinics are open to the same objections as group practice in general, and, in addition, would have some of the objectionable features of state medicine.
V
State medicine may be defined as the assumption by the state or federal government of all responsibility for t he health of its subjects. A most plausible argument for it appeared in a recent Atlantic Monthly, in which Russia was cited as a worthy example. This gives point to what Will Rogers said not long ago: ‘Russia is starving her own people in order to feed propaganda to the rest of the world.’
Carried to its ultimate conclusion, there would be no physicians in private practice. All would be employed by the government and paid fixed salaries — probably varying according to their length of service. Various modifications have been suggested, such as compulsory health insurance, adopted years ago in England.
Theoretically much may be said for state medicine. Everybody would have the privilege of consulting the physician of his choice, without thought of the cost. On the other hand, every doctor would be assured of a fixed income. All the financial burden would be distributed in taxes and paid according to the ability of the taxpayers. This, in the language of the street, sounds good. But let us consider some of the objections.
First, look at the effect upon the people themselves. In England, where compulsory health insurance has been in eff ect for years, since unemployment has increased, the number of certificates of illness has almost doubled. The doctors arc placed in the embarrassing position of having to sign many certificates for faked illness or lose patients from their ‘panel’ to those who will be accommodating enough to help their ‘patients’ draw ‘.sick benefits’ from the government.
The right sort of doctor holds as his dearest possession his professional reputation. For many years after he begins practice his greatest ambition is to become known as an able and honorable physician; and the more firmly established his reputation becomes, the harder he strives to live up to it. One index of a doctor’s professional standing is the number and the character of patients who come to him, and the proportion who remain loyal through the years. This does not mean that the best doctor always has the largest practice, or the reverse; for many other factors enter into the problem. It is only too true that a quack may so prostitute his knowledge of human nature as to attract a large following; but his practice is seldom a stable one. Dr. Axel Munthe has said, ‘You cannot be a good doctor without pity,’and of pity the quack has none. Perhaps the best indication of a physician’s real worth is the proportion of his patients who stick to him for many years. It is true that the stress of competition in private practice sometimes — nay, often — has developed heartburning jealousy between its members; but it. has also brought forth their best efforts. And a much higher incentive than that of competition has been the trust imposed in the physician by his families. To merit their confidence, the right, sort of doctor will make almost any sort of sacrifice.
Under state medicine, inevitably the old relation between doctor and patient would be destroyed. If the hypothetical John Smith only knew it, he would be exchanging an excellent birthright for a mess of very questionable pottage, were he to be a party to the socialization of medical practice. Instead of the whole-hearted attention of a physician who is using every ounce of energy to give the highest medical skill possible, and who keeps his professional acumen at the keenest possible edge, he would most likely find the indifferent, devilmay-care attitude of the man whose reward is the same for much or for little effort; who has only to live long enough to attain the highest standing possible in his profession, and who cannot feel the pride in his work that the individualist can. Imagine a doctor’s being required to treat a certain number of patients per hour, regardless of what ails them, rather than to see how clever a diagnosis he can make in each individual case, whether simple enough to be dismissed in five minutes or complex enough to require his attention for an hour or more.
If the day ever does come when the state takes over the health of its subjects, individually as well as collectively — God pity the patient!
VI
The solution of the medical problem of the middle class is, after all, simple. It is for every family to select one physician for its medical adviser. This man should be selected with great care, then trusted as long as he is found worthy of confidence. If the right sort of man is chosen, and knows that he is the absolute guardian of the family health and that he is expected to call in the help of a specialist or a group of specialists when he deems it necessary, he will put forth his best efforts to merit this confidence. His professional pride, combined with a personal interest in his patient, will make him more anxious to get results than any specialist would be.
The modern family doctor is not necessarily a general practitioner, in the sense that he undertakes personally to practise all branches of medicine. Indeed, the modern family doctor is apt to limit his work somewhat; but he keeps so well informed along all medical lines that he is capable of wisely directing those who trust him. Undoubtedly many patients with obscure ailments will be directed to individual specialists or to clinics; but the family doctor is abundantly able to take care of the great majority of the ailments that arise in his patients. Such a high authority as the Committee on Medical Education of the American Medical Association has estimated that a capable general practitioner can care for from 80 to 90 per cent of the illness for which people consult doctors. The Committee on the Cost of Medical Care has found that the famous ‘ upper respiratory infections’ — colds, influenza, and their near relatives — alone constitute 62 per cent of the usual disabling illness, with the diseases of childhood and other common ailments to be added. Does this seem as though there were no more work for the family doctor?
The very conflict of opinions as to what is to be done to replace the family doctor argues for his continued existence. The very fact that no satisfactory way has been found to get along without him indicates that he is an essential part of the medical scheme. The medical man who is meant to be a family doctor can never be satisfied with any amount of success in another kind of work. In the present stage of medical evolution, this type of man is successfully adapting himself to his changing environment. While numerous lay and medical writers are penning more or less flattering obituaries of the old family doctor, the modern family doctor is busy making himself indispensable to as many families as he can serve.