DOCTORS' CHARGES.
WE are on the side of the Doctors, for once. They may be dying of dignity, and some of them certainly are, but. they are not dishonest. On the contrary, they are suffering in public opinion for their resolute adhesion to one of the wisest, most self-denying, and we fear, most disastrous reforms ever: introduced by any profession into the methods of collecting ita own revenue. They have incurred an unexpected amount of odium, revealed in the correspondence columns of the Times, by- preferring the health of their patients to their own receipts. Up to a very recent period, "general practitioners," who form five-. sixths of the whole profession, and who, except in hospitals, are- the only doctors whom the people ever see, were paid in a way which was, for such of them as had no reverence for science or for their patients' constitutions, a very pleasant way indeed: Except in the case of a serious operation, or after an aceouche.- ment, and sometimes even then, they were accustomed to send in their own medicines, and make half-yearly bills showing the quantity of mixtures, or pills, or plasters, or powders that the patient had consumed, or at least had, as they affirmed, received. This method of raising their incomes, though a little troublesome- to men who disliked accounts, suited them in many ways and for many reasons, and in every respect except one• it suited the patients too. It suited the latter because it was "business-like." They seemed to get something _for their money, something which they could touch, and taste, and count, and show to their friends,. and keep in cupboards, if they were very economical and very stupid, as a check upon the doctor's bill when it arrived. They believed in their hearts a good deal in. medicine, good nasty medicine, which " quackled " their throats and made them experi- ence some of the luxury of asceticism, and were proud, with a curious and sometimes pathetic pride, of the array of bottles and pill-boxes and powder-papers, as proofs evident to all visitors how really ill they had been. "I do not coddle myself," the patient would say. "I was really ill ; look at that mantel-piece, with all the doctor's stuff still on it. A nice bill he will send in ! " And the speaker felt a little uplifted at once with pity for himself and admiration for his constitution, and pride that he could pay even a vague bill still only in anticipation. There are him- dreds of houses still in English country districts where an inspector would find a shelf, sometimes in a bedroom, sometimes.in a cosy sitting-room, which appears unaccountably out of place, and as it were, self-developed, but which is the shelf just out of reach of the children and the eat, which was put up in a far-away day ta hold the medicine-bottles. On the other hand, the practice suited,the doctors, for two reasons, one professional or scientific, and one social or pos- sibly tradesmanlike. One of the difficulties of country doctors and doctors in low neighbourhoods was, and in some districts still is, the intolerable badness of the drugs supplied at inferior shops. Half the druggists were as ignorant as men who must know a little Latin could possibly be, and a good many of the remainder were compelled by poverty and overwork to trust assistants who knew nothing at all. Their drugs, originally brought to them by travellers who knew no medicine, and often selected for cheapness' sake, were adulterated to save money, kept till the virtue had gone out of them, or made up in the intervals of serv- ing the shop as rashly as if they had been groceries. The writer has seen—no doubt it was thirty years ago—a country druggist measure hydrocyanic acid by the eye, and laudanum in a broken wine-glass without a foot. Even now there are medicines which skilled London physicians recommend their patients to get only from four or five chemists' shops, and the retail prices of drugs vary to a degree intelligible only on the theory of gross adulteration. Whatever the reason, the doctors distrusted the druggists, and liked when medi- chie was seriously wanted to make it up for themselves. More- over, the method enabled them to vary their charges according to their patients' means, without offending those patients' amour propre or covetousness. Such variation is absolutely inevitable, in a profession so necessary that the practitioner has no moral right or indeed legal right to refuse attending, and the practice of supply-
ingmedicine enabled the doctor to fix a sliding-scale. Not one layman in a hundred can read a prescription, and not one in a thousand knows the price of any drug in small quantities, and if the squire was charged half-a-crown for the doses which the clergy- man's widow got for thirteenpence, nobody was either injured or the wiser. Then, no doubt, the system was profitable to the doctors. They could and did enlarge their pre- scriptioes according to the trouble the patient gave, they could and did get pay for time wasted in gossip or frivolous complaints, and they could and did insist -on being paid, if not for their skill, at least for the goods they had supplied. As long as they were not unconscionable, they had little fear of resistance in court, and none of any loss of prestige if they were resisted.
There were, however, two fatal objections to this method of payment. It was either not quite honest, or it was wretchedly unscientific. The doctor had to be paid, and paid according to his patient's means—a point we will touch on presently—and he had accordingly, in a multitude of cases, to choose between two alternatives. Either he was compelled to send in a quantity of medicine which would do the patient more harm than good, to administer strong drugs to men who perhaps were chiefly wanting starvation and exercise—over-eating has declined, but forty years ago over-eating was the commonest cause of ordinary ailments, and . -especially of an excruciating form of headache, lasting ordinarily , three days--or tomake up colourable imitations of medicine, liquids which had the proper degree of nastiness and stench, but were most , commonly valueless vegetable "tonics." The first alternative struck the doctors, as they gradually advanced in education and knowledge, or acquired a wide experience, as unscientific, and the second annoyed them as dishonest, or at all events, open to the charge of dishonesty. We do not exactly see why a doctor's skill should not sometimes be shown in giving a patient who will have drugs something that cannot hurt him, but still the practice was undoubtedly open to every grave abuse. Partly, therefore, from these ideas, partly because druggists were becoming educated, and partly from a sense of dignity, the old method of charging was abandoned, and the doctors commenced sending in hills charging for medical attendance without details.
The new scheme seemed reasonable, patients were glad to be rid of potions, and all were satisfied, but there were three defects in the new practice. The patients disliked paying a great deal morethan they did before. They had nothing tangible to show for their money, and as for skill, the belief of the true Englishman in skill the result of which he cannot see with his eyes—in skill shown, for instance, in alleviating an inevitably fatal case—is exceedingly limited. Then neither doctor nor patient had any common ground on which to estimate charges, except visits, which may be few in a most serious case—as, for instance, typhoid—and endless in a chronic case, as, for instance, a neuralgic disorder ; and the bill, even when paid, was scrutinised like a lawyer's, and with the same disposition to believe that "attending you" had been overcharged, attendance to prevent • death and attendance to prevent toothache seeming to the patient the same thing. And finally, the power of proportioning doctors' charges to the patients' means was most seriously diminished. This power is absolutely essential to the very existence of a good class of general practitioners, and as it excites more odium than any other claimed by the doctors, it is as well to explain why this should be so. The doctor, unlike any other professional man, is not at liberty to fix a definite price for his work, and tell his customer either to pay his price or go without the article he wants. The positive laws of the profession, public opinion—which upon this subject is quite relentless—and that feeling of pity for suffering without which a doctor is comparatively useless, alike make it imperative to attend any pressing case, and to charge a low price where a heavy one cannot be paid. Unless, therefore, the charge is exceedingly low, uniformity cannot be secured ; and if it is exceedingly low, able young men will not • enter upon a profession so thankless as that of a general prac- titioner in the country. There is no such life led by educated men. A general practitioner in a country district, to make /500 a year by the time he is forty, must be out all day every day and half the night, in all weathers, upon all roads, in an open vehicle ; must abandon all notion of regularity and almost any notion of study, and must be at the beck and call of patients of whom one- half -at-least will never pay him for the cost of his horse's shoes. He must bear with the fractiousness of each new patient, be • pestered with a demand for gossip from each new household, and be an attendant, useful or useless, at every death-bed, and in the case of his richer patients, every funeral ceremony. He must be thoroughly educated to be efficient,—that is, must have spent from /600 to I800—must be decently charitable to keep his heart from hardening, and must have a good consti- tution merely to get through the most ordinary work. If the attendance-fee is to be fixed on one uniform, low level, no such man is to be obtained, and it comes to this,—that the well-to-do, if they want good doctors, must pay a small fine to secure cheap attendance to the badly-off and gratuitous attendance to the poor. There is no way out of it, but the difficulty of arranging a fair scale is endless, and is the main cause of the quarrels related in the recent columns of letters to the Times. The disputes about the number of visits are perfectly needless if the fee is paid at the time, and if it is made an etiquette for the patient and not the doctor to suggest the next call. In Manchester, we see, the profession has adopted a scale varying with the rental, the patients paying about a penny in the pound of rental for each visit up to 1100 a year ; but that scheme, though a sensible one, would not work in a village where rental has nothing to do with means, the most insolvent farmer often paying most, and is in principle radically unfair. Why should the over-housed professional pay so much more than the under-housed tradesman who lives away from his shop ? or why should Dr. Smith, who has the head of a Harvey, be paid the same fee as Dr. Brown, who has the head of a bad horse-doctor? The scale needs to be corrected by bargain, and we do not see, subject to certain professional rules, which, of course, prevent an arrangement on the "No cure, no pay" principle, why bargains should not be made ; why, for instance, it should not be settled in advance that a visit to such a family should be charged so much. The old Indian plan of paying by the year, irrespective of visits, is of course much better, being an easy application of the principle of insurance ; but Englishmen hate paying money for nothing, and in a crowded locality the annoyance of waiting for a salaried doctor would be keenly resented by the payer. The best practicable method is the Manchester one, corrected by bargain, and of course by payment either at the time, or when- ever the amount reaches a guinea, a compromise already not in- frequent. The "fee system," as practised in London, looks very silly, levelling, as it does, the great specialist and the great donkey, but it works, nevertheless, reasonably well. The public wants to be cured so much that it soon detects skill, the doctors correct the system for the poor educated, and the main evil perceptible is that the highly-skilled specialist whose reputation is made is under a strong temptation to reduce his advice, and con- sequently the time he expends, to the lowest point that his patients will bear, sometimes an immorally low one. There are only twenty-four hours in a day, and if a physician is reputed to make more than /8,000 a year in those hours, we should say, as a rule, that the very beat advice was to consult somebody who made a little less.
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