Large Fees and How to Get Them: A book for the private use of physicians. Albert V. Harmon
“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