THE DOCTOR'S BUSLNESS EYE
By OUR MEDICAL CORRESPONDENT
IT is not an uncommonly heard remark, especially when doctors of the older generation are talking together, that the younger doctors and surgeons of today are of a different and much more detached type. The tradition that the doctor should also be the counsellor, friend and guide of his patients is said to be visibly waning. The days when the doctor, in addition to acting in his strictly professional capacity, was the composer of family quarrels, the adviser upon education, wills, and a dozen other non- professional matters, are alleged to have disappeared or to be fast disappearing. The younger doctors, trained in a more strictly scientific school, are charged with regarding their patients rather as cases than as persons, and themselves as impersonal sellers of scientific knowledge and services.
To some extent the increased—and on the whole admittedly beneficent—range of specialism is one of the suggested reasons for this. -No one doctor, it is recognised, can be an expert radiologist, bio-chemist, bacteriologist, and laboratory expert ; and to obtain as correct a picture as may be of the possible causes of many indispositions, the modern young doctor, and often rightly, insists upon reference to all these specialists. He regards it as not only in the interests of his patient or client but requires it for his own peace of mind, intellectual satisfaction, and possibly legal protection. This makes, it is said, for a team-work diagnosis and treatment—even more pronounced in some other countries than in these islands—that must in itself modify the attitude of the doctor of today towards his patients in the direction of a less personal and intimate relationship. And that being so, a more strictly commercial attitude is—or so it is argued—coming to take the place of this. Evidence can be found for this, say the old school, even in professional terminology. Partner- ships of doctors all over the country are increasingly becoming known as " firms."
Charges of an increasing commercialism in Medicine have also been made upon other grounds. The habit of fee- splitting, as between general practitioners and consultants, though probably less common in this country than in some others, is said to have increased rather considerably during the last few years and indeed, in comparison with the preceding two or three generations at any rate, to be a new and sinister phenomenon. The charge, in other words, is that some general practitioners demand what is in fact a commission from the consulting surgeons or physicians whom they advise their patients to employ, and usually a commission that the patient knows nothing about ; and if the particular surgeon or physician is not complacent to such an arrangement, he is given to understand—or such is the charge—that his services in future will probably not be suggested.
Another charge of commercialism is the alleged exploita- tion by certain specialists, or pseudo-specialists, of long and expensive courses of vaccines, injections or other forms of treatment, the efficacy of which has not been established to the impartial satisfaction of trained and authoritative observers, or which has even been shown by these, as the result of large- scale and adequately controlled trials, to be ineffective.
Such are the charges, and it would be idle to pretend that there was not a certain amount of truth in them, although the accused, even if they were to plead guilty, would doubtless advance pleas in extenuation. Thus the fee-splitters, probably an extremely small minority of the whole profession, could point to the great disparity between the usual consulting or operation fee charged by a specialist and that of the general practitioner, who has to meet and brief him, often with a long and complicated history ; and the general practitioner could also urge that he has to bear the chief burden of the after-treatment. The consultant could plead that he did not grudge the general practitioner an associate fee ; and if the patient were fully informed of the arrangement, later to be properly set out in the respective professional accounts, the ethical objections would no doubt be lessened.
As regards the vaguer charges of exploitation in respect of expensive courses of non-proven treatment, such exploita- tion complained of is usually in the class of disease for which there is as yet no single recognised or established specific treatment, and it tends perhaps to be alleged by patients who have mistrusted or neglected the guidance of their general practitioners. The accused here could also argue that, by such empiricism as theirs, many of the great discoveries of Medicine have been made—although, as a matter of fact, this is scarcely historically true, nor would theirs, as a rule, be the stuff of which the great discoverers have consisted.
But here again it may be confidently stated that such exploiters as may exist are in a very small minority of the whole profession, of which the ethical code in respect of sef-advertisement and the moral obligation to place indi- vidual researches and results at the disposal—for discussion, criticism, and re-trial—of their professional brethren, for the public good, remains extraordinarily strong. Imagine, for example, the millions that could have been made out of insulin if this had remained a proprietary or secret remedy ; and many similar instances could be quoted.
Finally, as regards the younger generation, there are probably far more young doctors today than there were yesterday who would welcome some form of Socialised Medicine, under which they would receive a salary for their clinical work and be free to pursue it for its own sake, untram- melled by the necessity of sending in bills and the dependence on extraneous and, as they would argue, non-medical circum- stances for their living. There are of course many and weighty considerations that could be urged against such a course, but at least its advocates could not fairly be accused of commercialism.
As regards the others, Medicine, being a large profession, must almost inevitably embrace, as it always has done, a certain number to whom success is largely synonymous with income. But the long medical training is such that even these can hardly have emerged from it without some tem- pering, as the result of the human contacts forced upon them, of their acquisitive instincts. They would probably, that is to say, have seemed even more commercially minded if encountered in some other profession. And although it may be true that the younger generation of doctors is more scientific, less sentimental, perhaps a trifle more sceptical; a reasonably wide experience of them at their work up and down the country suggests that their capacity for making friends of their patients is not less than that of their fore- fathers ; and that, by and large, though their language may disguise the fact, they are no less faithful to the Hippocratic ideals.
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