Physician and patient

by Worthington Hooker

Let me not be understood, that I would have the friends of a patient make no inquiries at all of the physician in relation to the case. His intercourse with them should be candid and free, and the intelligent and honorable physician wishes it to be so. All that I claim is, that the practitioner should not be harrassed with inquiries, and especially with such scrutiny, and such expressions of doubt as to the effect of remedies, as shall indicate their lack of confidence in the treatment, and therefore tend to destroy his own confidence in it. The physician knows, and for the most part should be left to judge, how much ought to be communicated to the friends of a patient in relation to his case.

Neither let me be understood to mean, that physicians are afraid to have their practice watched and scanned. Every honorable and intelligent practitioner is willing that his treatment of any case be scanned most thoroughly, but he would prefer that it should be done by skilful eyes. The friends of the patient should always remember, that they have not sufficient knowledge of the human system, and of the effects of agents upon it, to appreciate properly the workings of disease, and the operation of remedies; and they should therefore be careful not to put themselves in the attitude of clinical critics—a station for which none but a physician is really fitted. The physician himself is in constant danger of making wrong inferences, on account of the complicated character of the system, and the various circumstances which therefore modify the operation of agents brought to bear upon it—even he, prepared as he is by study and well-weighed experience to observe accurately, is obliged to sift well the evidence in regard to the effects of remedies, in order to avoid mistake in his conclusions. How much more then should they be cautious in the inferences which they draw, who have never studied the human frame, and who have had but little experience of the treatment of disease. And yet many make no scruple in forming the most decided opinions of the practice of physicians, in every case of which they have any knowledge, however limited, and in proclaiming those opinions with all the authority of an oracle. The practitioner is sometimes so much harrassed by these meddlers that he is in danger of mixing up with the measures of his practice expedients to satisfy or foil their officiousness—a compound which brings no benefit to the patient. The attention and the skill of the physician should be concentrated upon one object—the proper treatment of the case before him. And the expenditure of his ingenuity, in using feints and practising concealments, to avoid a collision with the whims and prejudices of by-standers, impairs this concentration to the injury of the patient, and that sometimes a fatal injury.

The influence of scrutiny in impairing the skilfulness of action is seen on other subjects, as well as in the practice of medicine. The eloquent clergyman, who would ordinarily carry his audience along with him, while he is aiming with clear mind and zealous heart to attain the one great object of his preaching, the impression of the truth upon the conscience would fail to produce the same effect upon an audience of critics. For, to say nothing of the embarrassment which the very idea of criticism occasions, his attention would be distracted by supposed criticisms, which would suggest themselves to his mind while he is speaking; and that concentration of mental and moral energies upon one object, which is essential to true eloquence, would be wanting. To be eloquent before such an audience, he must either disarm their criticism, or he must forget that they are critics, and look upon them only as men whose minds are to be impressed and whose feelings are to be moved by the truth.

Take another illustration of quite a different character. A noted juggler perceived, at the commencement of his performance, that he was very narrowly watched by a gentleman whom he knew at once to be a very acute observer. He was embarrassed, as I have seen a practicer of the juggleries of animal magnetism embarrassed by a similar cause, and he felt that he could not practice his deceptions with so free and easy a hand, as he could if he were not watched by so an intelligent an eye. The consciousness of being thus watched distracted his mind, and prevented him from concentrating its energies upon one object. The juggler immediately gave this gentleman a piece of money, telling him that he must look out or he would get it away from him in the course of the evening. At the conclusion of the exhibition the gentleman said to the juggler, ‘well, sir, here is your money—you see that I have kept it safely.’ ‘Yes,’ replied he, ‘and I meant that you should, for I chose that you should have something else to watch besides me.’

The case of the physician, whose practice is scrutinized by by-standers, is worse even than that of the criticized clergyman, or the watched juggler. For the criticism to which he is subjected is not skilful, and is therefore not capable of appreciating the merit of the measures which he employs. In the case of the clergyman, the analogy would be more correct if his audience were illiterate, and his subject were one of an abstruse and metaphysical character. Their criticism would then bear a strong resemblance to that to which the practice of the physician is often made to submit. If the physician investigate the case before him, thoroughly and scientifically, the reasonings upon which his treatment is based are often as much beyond the knowledge of those who have not been instructed in the science of medicine, as a strictly metaphysical argument is beyond the knowledge, and therefore the criticism, of a plain unlearned audience.

A similar defect can be pointed out in the analogy of the case of the juggler. However much he felt embarrassed by the keen eye which he was conscious was watching him, he knew that if the way in which his feats were performed was discovered, his skill would nevertheless be appreciated and admired. The physician, as you have seen, has no consolation of this kind. He knows that those who watch him have generally so little knowledge of disease, and of its treatment, that they cannot estimate with any correctness the skill with which he meets the various phases presented by disease, with its numerous and changing complications; and yet they are quite confident that they are exactly right in their judgment on such points. He is watched by ignorance, and ignorance, too, believing itself to be wise.

And farther, as the clergyman, if he be one, who, instead of possessing true eloquence, is skilled in the mere tricks of oratory, would prefer an ignorant and indiscriminating audience, and fears one of an opposite character; and as a bungling juggler had rather be watched by unskilful than skilful eyes; so the ignorant and dishonorable physician is more at home, when the eyes of the multitude are fixed upon him, than when he is under the scrutiny of his medical brethren. And as many, who are incapable of being real orators, study most faithfully the tricks of oratory, and so far succeed as to deceive the superficial and the ignorant, so there is many a physician, who, instead of bestowing all his energies upon the management of disease, wastes them in learning the tricks of the charlatan, which will enable him, like the mock orator, to make a show of skill and acquire the reputation of possessing it with the multitude. This he can do with more certainty than the pretender in oratory, because he deals with subjects on which most men are profoundly ignorant, and yet think themselves to be very wise. It is for this reason, that the quackish physician, in common with the open quack, addresses all his appeals to the multitude, and brings all his arts to bear upon the one point of making such false displays as will impress upon their minds the idea that he has uncommon knowledge and skill. He therefore loves their credulous gaze, while he hates the intelligent scrutiny of his brethren. There is no one thing, in which the difference between the empirical and dishonorable physician and the high-minded and truly skilful practitioner is more strongly marked than in this.

The practice, then, of interfering with physicians in the performance of their duties, which is so common in every community, impairs their usefulness, not only directly, by embarrassing them in their treatment of the sick, but also indirectly, by encouraging the intrigues and manœuvres of the dishonorable in our profession. We have no hope of persuading busy-bodies to abandon a practice of which they are so fond; but we have a right to expect, that the wise and good, who are so often betrayed into it by zeal for some favorite physician, or remedy, or by a generous kindness, or an urgent anxiety for the patient, will, upon seeing their error, renounce it, and pursue in future such a course as will secure to the sick the best efforts of the physician in their behalf.

FOOTNOTES:

[37] Though the plan of charging so much a visit, so universally adopted by the profession, is on the whole the best general plan of regulating the prices of the physician’s services, it is liable to some abuses. Some variations from it must of course be allowed; and in making these a door is opened for manœuvering on the part of dishonorable practitioners. It is a very common ‘trick of the trade’ to make more visits than are necessary, perhaps quite short ones, and then charge less per visit than is usually charged by medical men in the same neighborhood. In this way the credit of being both a very cheap and a very attentive physician is most unjustly obtained.