There is another class of practitioners, who, while willing enough, are nevertheless unable to contribute much towards the anti-tuberculosis campaign. These are the men whose education is limited, who are unable to recognize tuberculosis until it is advanced, and even then hesitate to commit themselves. The patient under these circumstances has ample opportunity to infect others, to say nothing of losing his own life into the bargain. No amount of conscientiousness, of integrity, and of honest intention can compensate for lack of skill. Indeed, many men of this sort come perilously near the border-line of quackery. Yet the State has granted them a licence, though thereby it entrusts them with obligations which they cannot fulfil.
We have spoken before of the unethical practitioner, who, while competent enough, feels himself under no obligation to protect the community from an infectious disease. There is sometimes a reason for this indifference, this failure to tell the patient he has tuberculosis, and to inform those who surround him of their danger. This reason is because many a patient is afraid to know the truth about his condition. If the physician tells him he has tuberculosis, he at once changes his doctor and seeks another who will give a more comforting diagnosis. Thus, the struggling physician, to whom this may mean the loss of livelihood and prestige, is forced to a decision between self-interest and the interest of a community which he learns to despise, because it has forced him to dishonesty. We grow cynical about the welfare of those who force us to trim our ideals.
We have tried thus briefly to review the main reasons why tuberculosis is emphatically a disease which should be removed from private practice and placed under municipal control. On the one hand, this is necessary because of the nature of the disease, since ambulatory patients cannot be followed except by those able to devote their whole time to it. On the other hand, it is necessary because of the wide diversity within the ranks of the medical profession. The greater number of private practitioners are either too busy, too intent on earning a living, too indifferent, or too poorly educated to assume effective supervision of an infectious disease which requires masterful handling. And since they themselves have not been able to deal with this great issue, they should not object to placing it in the hands of those qualified to do so. The greatest contribution that the private physician can make to the anti-tuberculosis campaign, is to do what he can to hasten the advent of full municipal controls.
CHAPTER VIII
The Nurse in Relation to the Physician—Municipal Control of Infectious Diseases—The Nurse’s Difficulties—A Waiting Policy—Undiagnosed Cases—The Nurse’s Responsibility to the Conscientious Physician Only.
The Nurse in Relation to the Physician. In the foregoing chapter, we have seen that the task of preserving and improving the public health is one which rests, theoretically, on the medical profession as a whole. As a matter of fact, however, this task is assumed only by certain members of the profession. We have pointed out the reasons for this—that physicians vary greatly as to personal character, ability, and ideals. In the field of public health, the nurse finds herself in contact with physicians of all classes. Some are able, high-minded, and skilful, and whether working as public officials or private practitioners, have nevertheless the same end; improvement of the public health. Others have standards quite the reverse. This brings us to the question: When the nurse’s duties bring her in contact with men of the latter class, how is she to meet the situation? In what relation does she stand to these men? What shall be her attitude to them, as regards her work? They are not numerous fortunately, but there are enough to constitute a serious problem, and one which sooner or later the nurse must face. This question will also have to be faced by those who are responsible for the nurse, and for her work.
In our opinion, the answer is simple enough—or, rather it will be, twenty years hence. For at present, public opinion is in a transition state and needs moulding. The nurse should work under the direction of, and in co-operation with, all those physicians who, whether as public officials or private practitioners, are working for a higher standard of public welfare. To all such, without discrimination, the public health nurse is the faithful, efficient, and tireless ally. But to all those other physicians who have no such aims or desires, the nurse stands in but remote and casual relation. The old teaching that she is the handmaiden of the doctor is gone. Both are now co-workers in the field of public health. The nurse still carries out the doctor’s orders, but there is this difference—she discriminates as to doctors. As a public servant, she obeys the orders of the municipal authorities, or of the private practitioner when the object of both is the same, that is, the welfare of the community. But she is not responsible to those physicians who try to defeat this object.
For this reason, the nurse can do more effective work if she is connected with the Health Department, since it is the Health Department of a city which must formulate standards of efficiency, and clothe its employees with authority to carry them out. The authority of the Health Department physicians should be superior to that of any private physician, should there be any conflict of opinion between them.
If the nurse cannot be established in connexion with the local Health Department, she will yet be responsible to a group of public-spirited citizens, which group will undoubtedly include many advanced and enlightened physicians. This group of people will represent advanced public opinion on the subject of tuberculosis, and the authority which the nurse gets from them will be of almost equal value to that which she would get from the municipality. Municipal authority, or the authority of enlightened public opinion, is a dangerous thing to oppose.
Municipal Control of Infectious Diseases. In the case of smallpox, diphtheria, or scarlet fever, the private practitioner attends the patient under the immediate supervision of the Health Department. Thus, in diphtheria and scarlet fever, he notifies the Department of each case that comes under his notice. A municipal physician is at once sent to take cultures from the patient’s throat, as well as from all the other members of the household. He placards the house, and instructs the family in such preventive measures as shall insure their safety and that of the community. The patient is then left in the charge of the original physician, who notifies the Health Department when, in his opinion, the infection is over. His opinion, however, is verified by the municipal physician, who takes another series of throat cultures, and ascertains, quite independently, whether or no the danger is past. If it is, he orders the placard taken down, and arranges for the fumigation of the house.