But for the man who deliberately goes to work to undermine another; who takes advantage of some temporary absence of the regular physician to ingratiate himself; who, appreciating the fact that people worried nearly to death by the illness of a loved one, will forget every obligation and desert every old friend in the hope that the new one may offer some encouragement or extend some hope, is ready for these emergencies. He carries satchels full of hope for all cases and occasions. He prescribes it liberally, diluted, however, to the point of despair because he was called in an hour too late, or because the case had already been damaged beyond his power of repair. This gentleman advances not only by his own deceit, but uses the power of church, of politics, of family influence and social opportunity, to lift himself along. Verily he has his reward, but it is not in peace of mind, not in the honor and respect of his community, but the contempt of every honest man, be he of the profession or laity. Not the least of the perplexing questions which beset the man who is trying to lead an ethical life is his duty in his relation as consultant. Indeed, there is scarcely a situation in professional life that at times presents more embarrassing possibilities, or calls for the exercise of more tact. It is a pleasure to be able to bear witness to the ability of the man who has called you to his aid, to assure the family that everything has been done that care in diagnosis and skill in treatment could demand. But what of the cases where gross carelessness or blind ignorance have hastened what might easily have been delayed or averted? There is only one way here, only one duty. Treat the man as his carelessness or his ignorance deserves. Again, you are called in consultation with a thoroughly good man who has given ungrudgingly of the best that is in him. Perhaps your superior skill in certain lines, perhaps your superior opportunity to observe a certain line of cases, have taught you something that he has not had the chance to learn. As before it was your duty to expose the careless ignorance of one, now it is your place to so give your opinion and explain your position that no possible reflection can be cast upon the other. Don't approach a consultation with the manner of a priest of Delphi. Don't pose as the fountain of all wisdom and of all experience. Indeed, in this work you will be surprised how often you will learn from him you are called upon to assist. He has seen the case for days, where you can spend but minutes with it. It is his part to bear the blame, yours to share his fame should success crown your combined efforts.
Frequently you will be called upon when a resort to surgery is demanded--not so much to perform the operation as to give your opinion as to the advisability of a certain line of procedure. Having determined what is to be done, don't assume the place of prominence. You have little by way of reputation to gain by performing an operation that you were known to be competent to perform or you would never have been called. Let him do the work with your assistance and advice. In this way you will have gained a fast friend for future consultations, and you will have enshrined him in the esteem and confidence of his people. Therefore, help him and uplift and bear witness to his worth, and don't humiliate him by your airs and assumed superiority.
As a last word, don't consult with an unworthy man, for be assured that your reputation is worth more to you than any consultation fee, however badly you may think you need it.
The question of fees is one that must be considered. We hate to think of the combination of medicine and money, and our patients abhor it even more. The days once were when only the sons of the rich sought the liberal professions. It was thought unworthy in the days of the dim ages for a pupil of Esculapius to charge for his services. Any remuneration that came to him was an offering of gratitude--indeed an honorarium which might be tendered or withheld at the will of the patient. A truly noble conception this, that the good we offered was beyond a mere question of price. Equally comforting was the belief that the ill which resulted despite our best efforts was no reflection on our skill, but an evidence of the wrath of the Gods. Would that we were as near Olympus now as then, and that the Gods walked with men to reward the worthy and punish the unjust. Would also that the manners and costumes and climate of Ancient Greece were still with us, so that man need take little heed of raiment beyond a robe and sandals; that he required no expensive outlay for instruments, no intricate electric outfit, and no automobile. What a life ours would be if now as then our grateful patients sought us, and we passed our many hours of leisure in eloquent discussion or in lazy lounging amid the leafy groves or shaded porticos of the temples! But the times have changed, and we have changed with them, and abhor as we will the combination of medicine and money, we are forced to take thought of the morrow and to spend many, many anxious moments in this thought and in trying to evolve ways and means by which a balance can be maintained between the honoraria of patients, both grateful and ungrateful, and the claims of persistent creditors. Perhaps it is best thus, as the average man needs some incentive to good work beyond the acquisition of honor and glory. An axiom in the question of fees is this, that in order to be respected we must respect ourselves, and no one can respect himself unless he holds his calling above a trade and bases his charges upon this feeling of respect for himself and his profession. This axiom should be held in mind in arranging any fee table, and should be insisted upon in our settlements with those who think a doctor's bill should be discounted from one-quarter to one-half. I have often wondered how this right to a discount in a doctor's bill ever got such a firm hold in the public mind. Perhaps the city man cannot appreciate this fact like his country brother. The poor, honest old farmer, part of the bone and sinew of the land, expects the highest cash price for everything that he sells. If anybody has ever heard of one who when ten barrels of corn at $3.50 per barrel comes to $35, offering to take $25 for his bill, he should corral and cage this rara avis. But hundreds of us from the rural districts have been deemed mean and close-fisted and extortionate because we gently insist that $35 worth of professional services rendered are worth $35 and not $25.
This is largely our own fault, for so many of us present a bill in one hand and an apology in the other. We collect our bills not as if they were our just dues, but with a half-hearted insistence, inducing our debtor to believe that we have scruples ourselves as to the value of our services, and that a liberal discount from the face of the bill will about bring us to a fair settlement. It will be better for all--for patient as well as physician--to realize that the "science of human duty" implies a duty to oneself as well as a duty to the public, and that a small proportion of the charity of our profession should begin at home. To the young men I would especially give this advice: Having settled on a fair and honest fee for your services, do not depart from this fee. With us, as a rule, prosperity in the form of a numerous clientage comes sooner than to the other professions. You will not long have opened your office before you will be surprised at the number who demand your services. There will be no doubt of the demand, for those who pay the least invariably demand the most. Don't turn them away, for if you properly employ your time, you will gain in experience and occasionally a dollar or two. You will soon be enlightened as to your popularity, for the first pay day will send most of them to another and it is presumed easier man. Many of those who stick will tell you that Dr. ---- never charged but 50 cents a visit, when the regular fee is $1.00. Dr. ---- will vigorously deny this and produce his books to prove his truth. Here is everything plain before you. Every visit is listed at the established figure. You will rarely see his cash book, for then the whole transaction would be plain, and you would discover the simple manner by which in every community some supposedly ethical man is supplanting his truly ethical brother by charging full fees and settling for half.
Dr. ---- will cut 50 cents or a dollar from the established fees for out-of-town work, and immensely increase his practice by it. For be it understood the bone and sinew of the land dearly love the wholes and halves, and will flock to sell in the dearest and pay in the cheapest market. Don't envy this man his prosperity and, above all, don't follow in his footsteps. Bide your time with the assurance that the man who charges $1.00 for $2.00 worth of service rarely gives more than a dollar's value, and that when a real emergency arises and a capable, honest man is demanded, one who respects himself and his calling, if you have prepared yourself and are known to give the best that is in you, the cheap man will go to the wall and your merit will receive its reward. If by chance any of you have not seen Dr. McCormick's paper on this question of fees and collections, let him by all means find the proper A. M. A. Journal and read it. It is a classic worth any man's time and attention. In concluding this subject, let me endorse what he says about the cheap man, the price-cutter. Whatever his charge may be, he is usually getting full value for his services. Realizing his lack of education or ability or temperament, or whatever it is that puts him below his professional competitor, he cuts his fees in order to live. It is not our place to meet his competition, but to pity him, to extend to him the helping hand, to endeavor to elevate him to our standard, and never to lower ourselves to his.
I have only a few words to say on the subject of professional confidences. So sacred is the relation between the physician and patient regarded that the courts will not compel a physician, while on the witness stand and under oath, to tell the truth, and not only the truth, but the whole truth, to reveal what is imparted to him in confidence by his patient.
If in this exalted function of doing justice between man and man the courts will not compel the recital of some important piece of evidence, how carefully should we regard our professional relation, and see to it that neither in strict confidence or in idle gossip do we betray the secrets that suffering man has confided in us.
It may be somewhat out of place in a paper dealing with "The Ethics of the General Practitioner" to speak of the tendency, or perhaps better, the half-formed determination of the majority of every class to be specialists. I must confine myself to the predilection of the average medical student for surgery. It was so in my day, and I suppose it is so now, that almost 75 per cent. of the graduating classes are thoroughly satisfied that the end and aim of medicine is surgery; that practice and the less spectacular branches are parts of the profession essential to it as a whole, and fitted for those who intend to lead the plodding life, but too slow and too prosaic for the man bursting with the knowledge of his own brilliancy and his own special fitness. There is no question but that this tendency has done much to lower the average fitness of many classes. Men become listless and careless, neglecting everything but their hobby, and while the surgical amphitheatre is crowded, the medical clinics will be shunned, even deserted were it not that the sections are such that the absentees can be spotted and warned. There is no question also but that indifference to everything but surgery is responsible for many of the failures before the State Examining Boards. We must have surgeons, and they must begin their training in medical schools, and it is not my purpose to discourage earnest work and honest effort to this end. I wish, however, to say that every ethical specialist needs a thorough grounding in the general branches of medicine, and he should not in his student days neglect the other essentials to a well-rounded man. Most heartily do I wish to condemn the careless, happy-go-lucky manner in which so many men totally unprepared and totally unsuited by temperament for this branch "rush in where angels fear to tread." I wish especially to draw your attention to the fact that there is a vast difference between the operator and the surgeon. Almost any young man with a disregard of the sight of blood, with nerves unaffected by human suffering and a heart untouched by a knowledge of his power to do harm, can in six months' practice on the cadaver learn to cut, to sew and to ligate with neatness and despatch. Indeed, there may be many before me of the student body whose young and nimble fingers could teach dexterity to the best surgeons of the city. Very many with no pretense to this dexterity, and no equipment but a superabundance of assurance, graduate as surgeons and assume and aspire to a position of prominence that it has taken the true surgeon years of the hardest, closest, most untiring study, observation and work to reach. We are told as an excuse for this remarkable evolution from the student to the surgeon that the young man of today is taught so much more than the old men were; that the very manner of teaching, the equipment of the schools and the superior requirements for matriculation cannot but turn out better posted and more competent men. There is much truth in this. There is much truth also in the fact that while more is taught, more, infinitely more, is demanded of the student, and the knowledge that would have secured him a diploma fifty years ago will now scarcely carry him through his freshman year.
We also hear that "I want to be a surgeon, because surgery accomplished positive results." This is very true also, and it is evident that if you amputate a leg your patient will be minus a member. Don't lose sight of another fact, however, that if without being competent to meet any unforeseen emergency that may arise, you lightly open the abdominal cavity, you will have a positive result in the shape of your own little private graveyard. The newly graduated surgeon is not as dangerous as the man who left medical school years ago, before the students received one-third of the surgical training that they do now. Many of these men have not taken a post-graduate course, have never been associated with a hospital, nor have they had even an opportunity for moderate surgical observation; and yet they are attempting to do the work that only a skilled specialist should undertake. I am not speaking of emergency surgery for which any man should try to prepare himself, and be brave enough to undertake when human life is at stake. I am referring to operations of election when the services of a competent man can be secured. The point is just this, gentlemen, that medicine as a science is the result of evolution and not the creation of some brilliant brain; that what has been done in it has been accomplished not so much by inspiration as by close plodding work, exhaustive experiment and continual observation; that surgery as one of its branches cannot be mastered in the four years of student life, but that to be surgeons you must be workers and observers. It will not do to settle the matter by saying that a man must make a start. This truth is too self-evident to be smart, nor is it entirely convincing. An answer equally true will be that you will not allow the embryo surgeon to start on you, and before you put yourself or your wife or your mother in his hands you will demand that he possess some other qualification for his specialty besides his conceit, his gall and his need of the fee. There may be some exceptions where the man is born and not made, but I beg to assure you that the surgeon rarely springs full-fledged and fully fitted from the brain of Minerva.