There are other physicians, however, who have received an inferior medical education; they are neither sure of themselves, nor able to diagnose tuberculosis until it is in an advanced state. These object to the nurse on the ground, implied rather than expressed, that she is supervising and criticizing their work, and this self-consciousness often takes the form of a violent antagonism. It is always the badly trained physician who fears the well-trained nurse.
Furthermore, there are certain practitioners who frankly exploit their patients. They may be competent enough but they are in medicine to make a living, and are often brutally unethical as to how this is done. If through self-interest it seem best to them to withhold from the patient the nature of his disease, they do not hesitate to do so, regardless of the danger to which others may be exposed. By a strange paradox, the same profession which gives us the noblest, the most unselfish workers in the interests of public health, also gives us its most implacable enemies.
However, the new nurse must call upon all the physicians of the community, and endeavour to obtain their assistance and support. But, for the reasons mentioned, she must not be discouraged if she is not always cordially received by them. There will always be among them many who are enlightened and progressive, and who will assist generously in the anti-tuberculosis campaign. If a community can boast of only one or two such men, even, success is assured. And later on, as the nurse progresses quietly in her work, she will come into contact with other doctors, who promise her aid, but ignore their promises because they think she is trying to steal away their patients. As it gradually dawns on them that this is not the case, their opposition will wear off. To conquer this prejudice as soon as possible is part of the nurse’s work.
Furthermore, the community itself should not be daunted if the physicians as a body do not endorse the prospect of a tuberculosis nurse. This prejudice against public health nursing is the common experience in all cities where visiting work has been established, but it gradually wears off as the nurse is able to demonstrate her value. Little by little the doctors are won over, as they begin to realize that she is not a rival but an assistant. In Baltimore, our experience has been that those physicians who were at first our worst opponents have now become our staunchest and warmest friends.
CHAPTER VII
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?