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By G. Frank Lydston, M.D.

As a general proposition it is safe to assert that the practice of medicine from a business standpoint is a failure. The successful exceptions merely prove the rule. It is also safe to assume that the elements of financial non-success are cumulative in their action—a fact that is easily proved by hospital and dispensary statistics.

The practitioner of medicine, like every man who relies on his own hand and brain for a livelihood, is entitled to a bit of earth that he and his may call their own, at least a modest competence, and a well-earned rest when his sun begins to set and the twilight of his life approaches. How many doctors are in a position to enjoy or even render less awesome their twilight days? As city doctors are all supposed to be rich—at least by the public, that does all it can to prevent their becoming so—it would be interesting to know what proportion of them, even in metropolitan medical centers, own their own homes or have property investments. A far smaller proportion than is just, I fancy.

The assertion has been made that the general poverty of the medical profession is due to a lack of appreciation and a contempt for the rights of the medical man on the part of the public at large. This, however, is a secondary matter which, being self-evident, overshadows the primary cause—the asinine stupidity of the profession itself. As a broad, general proposition the reputable profession as a whole has about as much sense as the dodo, and, unless signs fail, will, sooner or later, meet the fate of that remarkable bird. How the profession can expect the respect and appreciation of the public when it has no respect or appreciation for itself is difficult to conjecture. The public cannot be expected to keep clean the nest of the medical dodo. Furthermore, the public quite rationally values the stupid thing according to its self-appraisement.

Primarily, the practice of medicine is supposed to be founded on a mawkish, blanket-like sentiment of philanthropy, which is expected to cover both God’s and the devil’s patients—the pauper and the dead-beat—the honest man and the rascal—the rich and poor alike. The doctor is expected to wallow eye-deep in the milk of human kindness, scattering it broadcast for the benefit of humanity, but he is in no wise expected to even absorb a little of it, much less to swallow a gulp or two occasionally for his own benefit. By way of piling Pelion upon Ossa, the public, having discovered that the doctor sets little value on his own services, proceeds to eye him with suspicion; the tradesman is very careful how he trusts doctors. Of course the tradesman has his own family physician “hung up” for a goodly sum, but—knowing doctors to be poor business men—the tradesman often cheats them in both the quality and price of goods.

It is a great and goodly game that plays from both ends and catches the victim in the middle. The tradesman has one redeeming feature, however; he does his best to teach his doctor patrons a lesson. He either sends his goods C.O.D., or, if the doctor be one of the favored ones, he finds the bill in his mail bright and early on the first of the month. I often think my tradesmen must sit up all night in order to get their bills in bright and early on the first. If not paid by the 15th, a collector is usually at the doctor’s office to see about it.

Yet the professional dodo—my apologies to the shade of the “sure enough” dodo—will not learn. He goes on and on, neglecting his accounts, mainly because he is afraid of offending his patrons and driving them off to some other doctor who isn’t so particular; and the worst of it is, there are plenty of contemptible fellows who draw their own salaries promptly when due, or present their bills for goods with frantic haste, who consider a doctor’s bill a flagrant insult. Will nothing ever inspire the doctor with courage enough to despise and ignore such contemptible trash? Does he prefer the role of a lickspittle to that of an independent and self-reliant man?

As illustrations of the value the profession sets on its skill and learning, the amount of gratuitous work done is striking. Our pauper—or pauperized—patrons are divided into several classes, viz.: 1. The free hospital, clinic and dispensary class. This is on the increase. According to Dr. Frederick Holme Wiggin, 51 per cent of all cases of sickness in New York City are now classed medically as paupers, as against 1.5 per cent twenty years ago! This is appalling. Of these alleged paupers it is safe to say that 75 per cent are able to pay full or at least fairly good fees. Why should pauperism be shown so prominently in the matter of medical bills, as compared with other necessities of life? And why should the profession carry a burden that belongs to the public? 2. Free patients of the private class: (a) those who can pay but will not, i.e., dead beats, and swindlers; (b) persons whose circumstances are such that the doctor feels in duty bound to render no bills; (c) persons who presume upon social acquaintance with the doctor to “hold him up” for friendly, perhaps informal, consultations.

It requires no great mental effort to see the terrible load the profession is carrying—self-inflicted, and often for fallaciously selfish motives, it is true, but none the less heavy. The college and free hospital may be the professional “old man of the sea,” but so much the worse for the medical Sinbad. Whatever the explanation, private practice is on a par with dispensary practice with regard to the impositions practiced on the doctor. It is safe to say that, of the sum total of surgical and medical patients of all kinds and social conditions under treatment in Chicago at the present time, over one-half are paupers—honest or dishonest. Pay the doctor for the work involved in this wasted and misapplied charity, and the medical profession would plunge into a sea of prosperity that might swamp it. And it is not only the rank and file of the profession that suffers. Ye celebrated professor, reaching out for glory, yea, into infinite space, clutching frantically at everything in sight, no matter how profitless—providing the other fellow doesn’t get the case—often defeats his own ends. And the great man dies, and is buried, and we take up a collection for his widow, to meet his funeral expenses, and sell his library—six feet of earth make all men of a size. Sic transit gloria mundi.

And when, like dog, he’s had his day,

And his poor soul hath passed away,

Some friendly scribe in tearful mood

Will tell the world how very good

The dear departed doctor was—

And thus win for himself applause.

One of the most potent causes of professional poverty is the mania of the doctor for a pretense of well-doing. He exhibits this in many ways. One of the most pernicious is an affectation of contempt for money. This it is that often impels him to delay the rendering of his accounts. Oftentimes his patient offers to pay all or part of his bill. With a lordly and opulent wave of his marasmic hand the doctor says, “Oh, that’s all right; any time’ll do.” And the triple-plated medical imbecile goes on his way with a dignified strut that ill befits the aching void in his epigastric region, and is decidedly out of harmony with the befringed extremities of his trousers. And then the doctor apologizes to himself on the ground of a philanthropy that is but the rankest and most asinine egotism en masque.

When will the doctor understand that payment deferred maketh the patient dishonest? When will he consider the necessities of his wife and children as outweighing the feelings of the patient who owes him money? When will he be a man, and not a time-server and truckler to appearances? He would take the money did he not fear the patient might suspect that his doctor was not prosperous. He wishes the patient to think that the doctor and his family dine with the chameleons, or are fed by ravens. Yet the medical Elijah waiteth in vain for the manna-bearing birds—they know him for what he is, a counterfeit prophet who vainly yearns for the flesh-pots of Egypt—who has a ponderous and all-consuming desire for pabulum, and a microcephalic capacity for finance.

Doctors are supposed to be keen judges of human nature. I often think this is absolutely without foundation. Defective knowledge in this direction is a very expensive luxury to the medical profession. The confidence man and sharper cannot fool the average doctor into buying a gold brick, perhaps, but they can come very near it. The oily-tongued and plausible man with a scheme finds the doctor his easiest prey. The doctor has often hard enough work to wring a few dollars out of his field of labor, and it might be supposed that it would be difficult to get those dollars away from him, but no, it’s only too easy. He bites at everything that comes along—he often rises to a bare hook. Mining stocks, irrigation and colonization schemes, expensive books that he doesn’t want, will never need and couldn’t find time to read if he would, histories of his town or state in which his biography and picture will appear for $100—proprietary medicine schemes, stock in publications of various kinds; he bites at everything going—he has embonpoint cerebrale. Oh, but the doctor is easy! I have very painful memories. The best investment I ever made was when I paid a fellow for painting a sign for the door of my consultation room, reading: “Notice—Persons with schemes will please keep out. I have some of my own to promote.”

It is rather a delicate matter, perhaps, for a college professor to touch on the evils of medical colleges in their relation to the business aspect of medicine, but I shall nevertheless speak plainly and to the point. While theoretically the better class of medical colleges were founded solely for the advancement of science, it is none the less true that self-aggrandizement has been the pedestal on which most of our disinterested giants in the teaching arena have stood and are standing. Remove the personal selfish interest of college teachers and most of our schools would be compelled to close for lack of instructors. Let us be honest with ourselves, please. Not that self-interest is reprehensible—I hold the contrary. One may teach for salary, reputation, the love of teaching, or a desire for self-improvement, it matters not, for if he be of the proper timber he is the right man in the right place. Self-interest makes better teachers on the average than philanthropy, providing the primal material is good.

Granting that self-interest is the mainspring of the college professor, is he very “long-headed” from a business standpoint? I submit the following propositions as proving that the average college professor defeats his own ends.

1. He devotes to teaching, time and labor over and above the exigencies of ordinary practice, which, if devoted to cultivating the good-will of the laity, would be much more profitable.

2. While cultivating the acquaintance and friendship of the alumni of his own school—a few each year—he alienates from himself the friendship of every alumnus of every rival school, the instant he begins teaching.

3. He assists in educating and starting in life young, active competitors to himself.

4. He is unreasonably expected to devote a large percentage of his time to the gratuitous relief of medical students and physicians. He may give his time cheerfully, but he yields up his nerve force just the same.

5. Most college professors are less successful in the long run than the more fortunate ones of the rank and file who have never aspired to teaching honors.

6. Greater demands are made on a professor’s purse than if he were in the non-teaching ranks of medicine. He, more than all others, is expected to put up a prosperous appearance.

The college clinic—especially of the surgical sort—is far-reaching in its detrimental effects on professional prosperity. Few or no questions are asked, and the millionaire is being operated on daily, side by side with the pauper, free. And the blame does not always lie with the professor who runs the clinic. General practitioners bring patients to the free clinics every day, with full cognizance of their ability to pay well. Why doctors will persist in thus cheapening surgical art is difficult to conjecture—but they do it just the same.

Of course, the college clinic is supposed to be a theater of instruction. Often, however, it is but a stage on which comedy-dramas are enacted. A brilliant operation that nobody six feet away can see, and an operator bellowing at his audience like the traditional bull of Basham—in medical terms that confuse but do not enlighten, terms that are Greek to most of the listeners—this is the little comedy-drama that is enacted for students who have eyes but see not; who have ears but hear not. Instruction? Bah! Take the theatric elements and the plays to the gallery out of some college clinics and there wouldn’t be a corporal’s guard in attendance.

Worse than the free clinics are the so-called charitable hospitals. Much has been said of dispensary abuses, but few have had the courage to say anything in adverse criticism of these institutions. While nominally founded to fill “a long-felt want”—and the number of long-felt wants, from the hospital standpoint, is legion—these hospitals are founded on strictly business principles, save in this respect—the people who found them feed on their innate capacity to get something for nothing. The first thing the founders do is to get a staff of doctors to pull the hospital chestnuts out of the fire. The members of the staff think that the hospital is performing the same duty for them, and everything is serene. And so the surgeon goes on operating on twenty patients—fifteen of whom are able to pay him a fee—in the hope that one among them all is willing to pay him a fee.

Exaggeration? Well, I cannot swear to the accuracy of the foregoing, but an eastern surgeon of world-wide fame once told me that for every patient who paid him a fee he operated on nineteen for nothing; and this man has no public clinic, either. Is it conceivable that the nineteen free patients are all paupers? Many of them go to my friend for operation from very long distances. Ought the railroads and hospitals to have all the profits? Have we not all had similar experiences in a lesser degree? With the development of charitable hospitals far in excess of any legitimate demand, it has come to pass that surgery is almost a thing unknown in general city practice. Even the minor operations have left the general practitioner—to return no more so long as there are free hospitals and dispensaries. Where is the emergency surgery, of which, in former days, every practitioner had his share? Railroaded off to the “charity” hospitals to be cared for gratis.

In a recent conversation with a practitioner of thirty years’ experience, I said, “Doctor, you used to do a great deal of general surgery throughout this section of the city. Have the hospitals affected your practice in that direction to any extent?” He replied, “Surgery with me is a thing of the past. Even emergency cases are carted off to the nearest hospital. If by chance one does fall into my hands, it is taken away from me as soon as I have done the ‘first-aid’ work.” Personally, I see very little use in teaching surgery to the majority of students who intend to practice in our large cities—they will have little use for surgical knowledge.

Here are three cases in illustration of the way our “charitable” hospitals antagonize the business interests of the profession:

1.—A very wealthy farmer engaged me to perform an exceedingly important operation. It was understood that $1,000 was to be the honorarium. He was afterwards advised to go to a certain “religious” hospital, where he was operated on by an eminent surgeon, who received nothing for his services. The patient paid $15 a week for hospital accommodation, and $25 a day to his family physician, who remained with him “for company.” What a harmonious understanding between the patient and his family doctor—and what a “soft mark” that surgeon was. I had the pleasure of telling the latter of the gold mine he didn’t find, some time later, and the shock to his system amply revenged the body surgical.

2.—A patient who was under my care for some weeks and paid me an excellent fee finally divulged the fact that he had meanwhile been living at a certain hospital as an “out patient,” at an expense of $8 a week. He had become dissatisfied with the hospital attention, he said, and, pretending great improvement, was permitted to get about out-of-doors.

3.—A man on whom I operated and who paid me my full fee without argument or question, came to me directly from one of our large hospitals, where he had been sojourning for several months.

That medical men in hospitals are imposed on is a trite observation. So long, however, as it appears to be the doctor’s advantage to be on a hospital staff, plenty of men will be found who will be glad of the chance. As for the injury which the system inflicts on the profession at large, that is no argument with the individual. Human nature operates here as elsewhere. Knowing that the system is bad, we are all anxious to become victims.

In recommending the payment of salaries to hospital men, the Cleveland Medical Journal claimed that such a plan will remedy all the evils incident to the professional side of hospital management. I do not agree in the opinion that the payment of salaries to the staffs of institutions for the care of the sick will alone correct the evils of such institutions. The writer of the aforesaid editorial is incorrect, also, when he says that an awakening is at hand. No, not at hand; it is coming, though; the handwriting is on the wall. When the revolution does come, this is what will happen:

1.—Hospital physicians and surgeons will be paid salaries.

2.—Hospitals will take as free patients or patients who pay the hospital alone only such persons as rigid investigation has shown to be indigent. All others will be compelled to pay their medical attendants, just as in private practice.

3.—Certificates of indigency will be required of every free patient, such certificate being signed by the patient’s attending physician—outside of the hospital—and at least two other persons in the community where he or she resides.

4.—General, and especially country, practitioners will cease to deceive hospital doctors as to the circumstances of their patients. One medical man should not impose on another.

Too much trouble, eh? Well, my friends of the hospital and dispensary—for the same charges should apply to the latter—you must either take your medicine or the revolution will go farther and this is what will happen: The profession at large will boycott every man who runs a college clinic, and every hospital and dispensary man. It will fight colleges and hospitals to the bitter end.

The day is perhaps not far distant when doctors outside of colleges and hospitals will run their private practices on the co-operative plan, thus dealing a death blow to the free clinic and dispensary. Every man of prominence will have his own private clinic and advertise it among his patients. What is fair for twenty or thirty men is fair and ethical for one. Each man can have his own hours for the poor; he can eliminate the unworthy ones, and, best of all, he can refer all his dead-beat patients to his clinic. Pride may bring fees from patients to whom honesty is a thing unknown. The private hospital will run most of the public hospitals off the earth. There will be no room for anything but municipal hospitals run squarely and fairly for charity, and reputable private hospitals run frankly for pecuniary profit, in which the operation and the attendance fees are the chief factors. Such hospitals will benefit, not hurt, the profession.

One of the most vital flaws in the business sense of the general practitioner is his penchant for hero worship. He hears of the medical tin god from afar, and burns incense on the altar of his greatness. The great man pats the humble doctor on the back, calls him a good boy, and tells him just where to take all his cases. Sometimes he offers to divide fees with him.

The medical tin god is truly a “self-made man in love with his maker.” He has “genius stamped upon his brow—writ there by himself.” His evolution is interesting. It is history repeating itself: Apsethus the Libyan wished to become a god. Despairing of doing so, he did the next best thing—he made people believe he was a god. He captured a large number of parrots in the Libyan forests and confined them in cages. Day after day he taught them to repeat, “Apsethus the Libyan is a god,” over and over again. The parrots’ lesson learned, Apsethus set them free. They flew far away, even into Greece. And people coming to view the strange birds, heard them say, “Apsethus the Libyan is a god; Apsethus the Libyan is a god.” And the people cried, “Apsethus the Libyan is a god; let us worship Apsethus the Libyan.” Thus was founded the first post-graduate school.

The medical Apsethus and the deluded parrots of the medical rank and file are here, and here to stay, until both are starved out. And the modest general practitioner looks up to the medical tin god and wonders “upon what meat does this our Cæsar feed that he hath grown so great?” The meat of industry? Perhaps. The meat of prodigious cerebral development? Seldom. The meat of opportunity? Yea, yea, my struggling brother, “and the devil take the hindmost.” But, more than all, he hath fed on the meat that the parrots have brought him—Elijah’s ravens were not a circumstance to those parrots. “In the kingdom of the blind the one-eyed man is king.”

How long will the general practitioner continue to play parrot to the medical tin god of the charitable hospital the very existence of which is a menace to the best interests of the profession—the profession for which the institution has no charity? In that happy time to be there will be no tin gods. There will be a more equable division of work and every prosperous community will have its up-to-date private hospitals with up-to-date men at the head of them.

As for the post-graduate teacher—good or bad—he is already defeating his own ends—he is exciting ambitions in the breasts of his pupils. Here and there among them is an embryo McDowell, a Sims, or a Battey. The backwoods country produces good, rich blood and virile brains. And the Sims, and McDowells, and Batteys of the future will be found in relatively small places, doing good work, and then—good-bye to the tin god and his horn, “for whosoever bloweth not his own horn, the same shall not be blown.” And in that day the parrot shall evolve into an eagle, and the hawk had better have an eye to windward. Meanwhile, hurrah for the post-graduate school and its pupils, and more power to the tin gods.

This business handicap is so self-evident that it is hardly necessary to touch on it. We raise the standard of medical education year by year, yet the mushroom colleges do not go—they are here to stay. If one-half the colleges were wiped out of existence there would still be more than enough to supply the demand for physicians. We have done the best we could to breed competition by manufacturing doctors, and we are doing all we can to make that competition first class—a queer business proposition in force of the oversupply of doctors. We are unjust, too, to the men we educate, by offering them inducements to enter an already overcrowded profession—but so long as human nature is as it is I see no way out of the dilemma.

There was once a time when it appeared a goodly thing for the chosen few to get together like the “three tailors of Tooley street,” and, after establishing to their own satisfaction the fact that they were indeed “the people,” formulated rules for the guidance of the many. These rules were called “ethics.” And the profession has been wrestling with its ethics ever since, trying to determine what it was all about anyhow. The ethical garment of half a century ago no longer fits—it is frayed and fringed, and baggy at the knees; full many a patch has been sewed on it, in individual attempts to make it fit from year to year, until it is now, like the Irishman’s hat, respectable by age and sentimental association only. And the public, the ever practical and heartless public, has also wondered what ’twas all about, and exhibits little sympathy for a profession which, while driveling of ethics, has “strained at gnats and swallowed camels.”

Who does not remember when all the wiseacres with number eighteen collars and number five hats seriously discussed the relative propriety of “Specialty” vs. “Practice Limited,” on professional cards? How times have changed. And then came the discussion by a learned society, of the ethical relations of “Oculist and Aurist” to “Practice Limited to Diseases of the Eye and Ear.” And it was decided that men who had the former on their cards were not ethical and could not enter that society. Ye Gods! Is the fool-killer always on a vacation? Must we always see those long ears waving over the top of the ethical fence, built by the fat hogs to keep all the little pigs out of the clover patch? What is the public to think of a profession that winks its other eye at the man who prints on his cards, “Diseases of Women Only,” but rolls up it eyes like a dying rabbit at the sight of a card reading, “Diseases of Men Only?” What has raised the woman with leucorrhea to a more exalted plane than that occupied by a man with prostatorrhea, does not appear. Why so many inconsistencies, and why such hypocrisy!

Sir Astley Cooper had his own private “hours for the poor.” Our European brethren print their college and hospital positions and all their titles on their cards. Are they less ethical than we? Homeopathy is a dead duck over there, and quackery has a hard row to hoe in Europe—queer, isn’t it?

Our system of ethics has not only been hypocritic, but somewhat confusing. The young man on the threshold of medicine doesn’t know “where he is at.” He is confronted by the unwritten law that only celebrated men and quacks may advertise. Small fry, who haven’t the ear of the newspapers nor a chance for a college position, are tacitly ordered to keep their hands off. And the young fellow watches the career of the big man, who hides every other man’s light under his own bushel, and marvels much. Especially does he marvel at the accurate photographs, life histories and clinical reports of his more fortunate confrères that appear in the newspapers without their knowledge.

Experiences differ. I haven’t yet got around to newspaper clinical reports, but it has been my fortune to be “written up” on several occasions. I do not recall that the newspapers drew on their imaginations for my photograph. I wish I might think so, and that their imaginations were distorted—the result was so uncomplimentary.

So far as I can learn, nobody protests against being legitimately represented in the newspapers. Why not be honest about it? The hypocrisy of some men is sickening. Paying clandestinely for newspaper write-ups is despicable, yet some of the very men who protest that they “really don’t see how that could have gotten into the papers,” have paid for the advertising in good “coin of the realm.” It is queer that the newspapers should write up the most minute details of the wonderful exploits of some poor fellows, together with their family histories, and publish their photographs, without their knowledge or consent—especially queer when we read in conclusion that “Professor John Doe is the greatest surgeon that ever lived.” Why not come out and acknowledge that these are paid for? This would give an equal chance to all, and especially to young fellows who have money enough to pay for similar things. He who has not the price should not find fault with the fellow who has, for, “business is business.” Meanwhile, my young friends, remember that “big mountains may do what little mountains may not do.”

When Koch’s tuberculin was yet new, soon after it escaped, half-fledged from the laboratory, only to be captured and made to perform like a trick monkey for the benefit of the laity, there came a ring at the phone of a prominent daily paper: “Hello, is this the Daily Bazoo?” “Huh, huh, it are.” “Well, I’m Dr. Squirtem Galls. I wish you would send a reporter over here at once. I want to be interviewed on Koch’s tuberculin.” It is said that $25 changed hands, but I don’t believe it. The gentleman would never advertise—at that rate—“no sir-ree.” My informant was once the sporting editor of the War Cry, and hence unworthy of credence.

And what wonderful contributions the newspaper-great-men are making to science! The daily paper is the place to study appendicitis and things. It is not long since I learned from a distinguished surgeon friend of mine, via a daily paper, that evidence of a blow having been received on the head is an imperative indication for craniectomy, whether symptoms are present or not.

In preference to the clandestine methods now in vogue, would it not be better for men in authority to write signed articles for the newspapers and intelligently present medical matter to the public? But that wouldn’t be ethical, would it? Such topics as “Advice to Young Men,” “Letters to Young Wives” and “How to Keep Healthy,” must be left to the quacks. We will confine ourselves to the surreptitious blowing of surgical horns and never mind the false notes.

Meanwhile, let us stand back and watch the procession of modest men who never advertise—oh, no! At the head, with haughty mien, comes Professor Keene Carver, preceded by a herald in blood-red garb, blowing a large brass horn. Then comes the “bearded lady,” whose blonde and breezy whiskers so delight the heart of his swell society clientele. And here comes Rip Van Winkle—a middle-of-the-road “eclectic,” gathering up his long and weedy beard to keep it from getting tangled up in the scientific barbed wire fence along the route. And here comes another sure-enough “regular,” evidently a medicine man—so rare nowadays. He is riding in a swell turnout and is on his way to his clinic. How do I know that Professor Windy Bowels is a regular? Because the gentleman who is riding beside him to his clinic is a reporter on the Chicago Daily Jib-boom.

I presume that the suggestion that I have made of the advisability of taking the public frankly into our confidence and giving it accurate information so far as its comprehension goes, by signed articles, in preference to clandestine advertising and the promulgation of fallacious ideas of medicine and surgery, will meet with bitter opposition. I nevertheless believe that a better education of the public is the only way to down quackery. The opposition will come chiefly from the surreptitious advertiser, who sees a prospect of other men getting the advertisement that he believes to be his proprietary right.

Then there is the tribe of the Microcephali. The howl of protest will be long and loud from the pews occupied by these far-famed champions of medical orthodoxy. “We won’t put our discoveries or contributions in the newspapers—not ever.” And gazing at their lemur-like front elevations, we can well believe that they would have no trouble in establishing a “halibi.”

Apropos of “discoveries,” it may as well be understood that the public is bound to get the details of them sooner or later, and, when the time is ripe, the matter should be presented to it in a clear and intelligible form—comprehensible to the layman.