Physician and patient

by Worthington Hooker

Again. It should not be among the objects of the friends of the sick, in calling a consultation, to obtain the opinion of the physician who is called in upon the course of treatment which has been pursued. He has nothing to do with the past, except so far as it will aid him in discovering the true nature of the case, and in fixing upon the course to be adopted at the present time. He steps out of his province altogether, if he says anything to the friends in regard to what has been done. This general rule applies not only to criticisms upon practice, but to all expressions of approbation also. The patronizing air, with which some physicians utter their commendations of the course, which has been pursued by the attending practitioner, is a most flagrant insult. It generally involves an unwarrantable and ridiculous assumption of superiority. It is a common trick resorted to by the dishonorable, to impress upon the by-standers an idea of their greatness.

The friends of the sick often put the consulting physician in an awkward position, by the inquiries which they make of him in regard to the measures which have been pursued. If he really approves of them all, of course there is no difficulty. But suppose that he does not—that he cannot say with truth, that if he had been called to the case at the first he should have adopted precisely the same course. What answer shall he make then to the inquiries put to him? Shall he reply to them fully and frankly? By no means. It would be cruel both to the friends of the patient and to the physician to do so. He has no right to take such a course, unless there be gross and palpable mal-practice, which the good of the patient and of the community requires should be exposed. This is the only case which can justify such a measure. Where there exists merely that difference of opinion, which results from the various individual notions and preferences and doctrines of physicians, all such inquiries of the friends of the sick should not be replied to.

There are also some exceptions to the rule in its application to expressions of approbation. If for example an older and well-established physician, on being called in to the patient of a junior member of the profession, sees that the propriety of the course, which has been pursued, has been called in question by some of the friends or by busy bodies, it is his duty to volunteer in the defence of that course if he can conscientiously do it. Older physicians often have such opportunities of doing essential service to meritorious young men.

It is only such cases as I have mentioned, which form the exceptions to the rule laid down. The general practice of remarking upon what has been done cannot be too severely reprobated, as opening a wide door for cunning intrigue and ungenerous insinuation. The honorable physician desires no such privilege, but the dishonorable prize it highly, as one of the means of inflicting their base wounds upon the reputation of their competitors. Such physicians are ever ready to answer the inquiries of friends and neighbors, about the previous treatment, in every case to which they are called. They commonly prefer to do this in a corner, rather than openly. Whenever they see that a stab can be given to the professional character of any competitor they do it, and often so stealthily, that it is not seen. A word, a look, a mere movement of the head may do it, and perhaps oftener does it than any tangible expression of opinion. An open show of the weapon that inflicts the wound the cunning and dishonorable physician most studiously avoids.

In this connexion I may remark, that the bandying about of the opinions of this and that physician, in regard to different cases, by their partizans, is one of the chief causes of the jealousies and quarrels among the members of our profession. If the friends of the sick would ask simply for the result of the consultation, instead of endeavoring to obtain the opinions of each physician in regard to the various points of the case, it would manifestly shut out all opportunity for intrigue at such times. And it is to this result alone that they have any right under ordinary circumstances. When a consultation is held, it is expected that some definite conclusion is to be arrived at, in relation to the nature of the case, and the treatment of it. It is the result of a deliberative body, no matter of how few, or how many it consists. The individual opinions expressed in the deliberations leading to this result are wholly confidential; and whoever reveals them without the consent of the parties is guilty of a breach of confidence. So long as the attending physician is alone in the case, he acts as an individual; but when a consultation is called individual action ceases, and he is now to act in obedience to the result of the consultation—his duty is simply to carry out that result. He is the executive of the acts of the deliberative body. He alone is to give the directions in the management of the case. If the consulting physician gives any directions either voluntarily, or in answer to the inquiries of the friends, he usurps authority which does not belong to him. His business is simply counsel, deliberation, and not action; unless, as in some surgical cases, he is called in for both purposes.

The chief object of consultation, which is to fix upon the best course to be pursued in the treatment of the patient, is to be secured by thorough and free investigation and discussion of the different points of the case. Anything which interferes with this mode of attaining the object has a tendency to defeat it. If, for example, jealousy exist—if one physician feels that the other is disposed to take advantage of anything that may occur, which can possibly be turned to his own benefit, there can be none of that frankness which is so essential to the accomplishment of the object proposed. A consultation between enemies is generally a failure, though the friends of the patient may not always know it. At the same time, let it be remembered, that the mere fact that physicians are competitors does not necessarily make them enemies. If the competition be an honorable one, and neither is disposed to treat the other in an ungentlemanly manner, there is nothing to hinder their consultation from being free and unembarrassed.

Physicians should always be alone in a consultation.

The presence of others would prevent that freedom of discussion, which in some cases is so necessary. For each physician, knowing that his individual opinions will be reported by those who are present, would be very cautious in expressing them, and there would therefore be none of that freeness of suggestion and discussion, which is so desirable in a consultation. And farther than this, while the honest and high-minded physician would be simply embarrassed under such circumstances, the selfish and unprincipled physician would, on the other hand, express his opinions with a view to their effect upon his own standing with those who are present, while the welfare of the patient would be altogether a secondary object. His main object would not be consultation based upon a rigid investigation of the case, but an exhibition of his skill and knowledge to the non-professional listeners.

The reasons which I have thus briefly given, are, I trust, sufficient to show the reader the reasonableness of the rule, which excludes the friends of the sick from the consultations of the physicians. But it is sometimes spoken of as unreasonable, and a strict adherence to it is considered by some as implying a want of frankness and candor. Tattlers and busy-bodies are ready to attribute some sinister design to this bar which is put upon their curiosity; and some physicians, especially in the country, where there is apt to be less regard to strict rules in medical intercourse, than in our cities, sometimes flatter this prejudice, and assuming an air of frankness in the expression of their opinions, adroitly throw the responsibility of the exclusion upon some of their brethren.

The intrigues, which are practised by the cunning and dishonorable in connexion with consultations, are very numerous. I will notice a few of them.