The General Practitioner and the Specialist

Annual Oration 1906

John L. Hildreth, M.D.

Mr. President and Fellows of the Massachusetts Medical Society, The modern tendency toward subdivision and specialization is very strong. It is manifest in education, where the elective system which permits the selection of particular studies to suit a special training or individual caprice extends far back into the preparatory schools and reaches forward through the whole period of preparation for the active work of life. It appears in industry. The watchmaker no longer makes a complete watch or the shoemaker a complete shoe. Each is engaged upon some swift and deft machine which turns out parts of the complete product to be fitted to other parts by other hands. The student of science specializes. He no longer attempts a comprehensive understanding of the whole realm of knowledge, but early picks out his small chosen bit of the field and devotes his life to an assiduous cultivation of it. The successful merchant no longer tries to direct all the details of his business. These are subdivided and intrusted, this to that confidential representative, that to this head of a department. So through all domains of activity.

This tendency is nowhere more manifest than in the medical profession. So great are the changes which it has brought about that they are imperfectly realized even by the members of the profession. In general preparation for the profession there has been a remarkable advance during the last forty years. The difference in the amount of work required to graduate from the better medical schools now and forty years ago is very great indeed; and the character of the men entering the profession seems to me much stronger and better fitted for the scientific and successful practice of medicine now than then. Then bacteriology was unknown; medical chemistry and human physiology were inadequately taught; experience counted for everything with a doctor, and scientific attainments for very little. With this change in preparation for the profession there has come a change equally marked in the practice of it. Formerly, as I have said, it was experience that counted as the prime requirement in a doctor, and that was gained in large hospitals in the medical centers of our own and other countries.

There were then no specialists except those who devoted themselves to the eye and to the ear. There was, it is true, a recognized distinction between physicians and surgeons, but the innumerable classes of specialists that exist to-day were unknown and undreamed of.

A part of the present subdivision of work has come about, doubtless, through the adoption of German methods of study and instruction in medicine. The German mind is content to expend its energies upon detailed work, to pursue a subject to the farthest possible boundary, zealous rather in the search for ultimate causes than in the practical application of knowledge. But whether from the extension of the German influence or from other causes there has come about the existing state of things, with specialists for every organ of the body. Moreover, with this extension of specialism, there has come to pass a marked change in the position and possibilities of the general practitioner. The relations of the two—the general practitioner and the specialist—to each other and to the community furnish an interesting and, I hope, not unprofitable subject of study, to a hasty and inadequate discussion of which I venture to ask your consideration.

And in the first place, let us look for a moment at the advantages which each class of practitioners enjoys, and the disadvantages under which he labors. Neither path is wholly strewn with roses. Success may be won in either, and the rewards of success are great; but they come only as the fruit of labor and sacrifice.

The work of the general practitioner is harder to-day than it was a generation ago. He is much less independent, and he has less time to himself. The multiplication of telephones makes him more subject to interruptions by his patients, who find it so easy to call him by day or by night, to ask questions—some necessary, some unnecessary—that they leave him no time which he can call his own. He is on call at all times; and it is not surprising that, while he appreciates the uses of the telephone, he sometimes regards it as a device of the Evil One. He is a slave to the peremptory call of the instrument, and must constantly be ready to answer it, as in many cases no one can answer it for him. The telephone, and that later invention, the automobile, each of which, in its way, annihilates space and time, greatly affect the general practitioner in another way. They increase competition by making available for a patient, who for any reason has become impatient, the services of a physician from a distance. These new appliances and the constantly enlarging necessities of office outfit and supplies add greatly to the expenses of the general practitioner. Altogether, it would be fair to estimate the increase in the expenses of the regular practitioner during the last thirty-five years at least 25%. If he is to be, as his patients say, "up to date," he must attend medical meetings, read the medical journals and treatises, visit the hospitals or have a hospital service of his own, and from time to time must see what is being done in his profession in other countries.

All these things make the general practitioner's life much more laborious than it was a generation ago. The simple life of the community has also disappeared, and a very strenuous and complex life has taken its place. The practitioner has to adapt himself to these conditions. He must be alert and constantly on the watch to see that no one does better work than he, and whilst he does not advertise or solicit patients, he must make himself desirable enough to insure his being sought for. Very few general practitioners who have been away from schools and hospitals for fifteen years and are thoroughly established have a moment's time to themselves, from the time that their vacation ends in the summer or fall until it begins the next summer. From early morning to late at night they are in the harness; some one wants them, wants them in a hurry. If they want a half day off for leisure, some very sick patient prevents. If they plan for a day's recreation in the country, it is more than likely that some patient or expected patient will detain them. All these conditions are much changed from those of thirty or forty years ago.

Another important change affects the lot of the general practitioner. The medical profession has come to feel that everything that is brilliant, everything that makes an impression upon the laity, must be something that can be seen or that can be touched with the hands; in other words, must be something of a surgical nature. The man who gives advice concerning a difficult problem in medicine, who helps to complete a diagnosis when the symptoms are complicated and an accurate diagnosis extremely difficult, does very little to impress the laity by comparison with the man who performs a surgical operation. The conditions are wholly reversed from those of the time of the "barber surgeons" when the surgeon sat at the feet of the family physician. Now the surgeon is to be pacified only by the homage and admiration of the general practitioner.

The advantages and disadvantages of the specialist are obvious. He has regular hours for his office and regular hours for the hospital, and his day's work is done with the day. He can study to the farthest bounds of knowledge the causes and treatment of the diseases to which he has devoted himself. The field is not too large and the problems, although often intricate and sometimes unsolvable, are not too many. But he has to give more years to get a profitable following and he is less sure of success in the end. His time of life work is shorter. He becomes old-fashioned and some young man fresh from the large hospital fields of Europe becomes the public favorite in his stead. The field for the successful specialist is restricted to the large centers of population. A few are found in cities of from 50,000 to 100,000 inhabitants, but their opportunities for a large practice and remunerative fees are small. One thing which the specialist misses cannot be estimated by any pecuniary standard. He gains warm friends and admirers among his patients, but he does not know them as the family physician knows them; he is not their godfather, nor their elder counsellor and trusted friend as the family physician is. There is no experience in life which is quite like the peculiar and satisfying relationship which exists between the family physician and the family patients. The weary doctor derives a pleasure and comfort from this which no fee or words of praise can approach, in value.

Under existing conditions, the general practitioner cannot be expected to do original work. Everything of that nature, everything that promotes the progress of medicine in a scientific way, must be done by the specialist. But the general practitioner must be alert to follow all new discoveries and processes and to avail himself of them. It is a natural consequence of the changed conditions that young men entering the profession are drawn towards specialism rather than the general practice of medicine. My observation is that general practitioners who have sons in the profession encourage them, not to follow in their own footsteps, but to become specialists. I do not recall a single instance where the reverse is true, and where a father who is a specialist has a son who is a general practitioner. One of the older physicians of my acquaintance once said to me that it took a man of iron constitution to follow general practice, and he had on that account led his son to adopt a special form of surgery.

One strong reason which impels men to become specialists is not avoidance of night work and the other hardships of the general practitioner, but the increasing demand of the people for specialists. More and more it is coming to pass that any one who has or fears that he has some organic trouble asks his family physician, "Who is the best specialist in this or that? " or goes to a specialist without asking. It is in response to this tendency that we find that those doctors who advertise extensively, and who, while they may legally be practitioners, are not recognized by the profession, invariably advertise as specialists, with infallible cures for some particular malady. The story is told of a young lady who was asked to do something, and who, taking out her engagement book, said plaintively that she would have to be excused for that week, as on Monday she was to visit her oculist, on Tuesday her aurist, on Wednesday the orthopedic specialist regarding the arch of her foot; on Thursday she must go to a specialist in pelvic disorders, on Friday to a specialist in nervous disorders, and on Saturday to a specialist on the spleen.

It has always seemed to me that, when a general practitioner thinks that a patient should have the advice of a specialist, he should again, as he no doubt has done before, give his patient as thorough an examination as if he had never seen him, so that nothing may be overlooked and he may have as complete a knowledge of the case as possible, and be sure that his decision is correct. In this way some new light may be let in upon the diagnosis, and some help secured for the treatment before the decisive step is taken of recommending the patient to go to a specialist.

It has not often fallen to my lot to be present when a specialist first saw his patient. It has not been my invariable custom, I regret to say, to send a detailed statement of the history of a case and its treatment to the specialist, so that he might have the advantage of all my knowledge of the case at the time that the patient reaches him. I suppose that it does not matter what the case is,—whether of the eye, or ear, or brain, or abdomen, or skin, or whatever else,—it must be that all thorough specialists make all inquiries for themselves at the first visit, just as though the patient had not been seen by any other person and just as though they had no information regarding the case from the practitioner sending the case to them.

But I am quite sure that some of the specialists are not thorough in their examination of cases, but simply accept the patient's statements, and examine him for the trouble for which he has been sent to them. I have seen some very sorrowful mistakes made in this way by specialists. On the other hand, I have seen some remarkably good work done by specialists who have given the patient a thorough looking-over, have gotten a complete history of the sickness, and have taken sufficient time to master all the details of the case up to the time when it presented itself for their treatment.

Some specialists have the excellent custom of writing out their opinion of what the diagnosis is, and what they believe to be the proper method of treatment, and of sending this statement, very soon after they have seen the patient, to the practitioner who sent him to them. This is helpful to the general practitioner; it brings the specialist nearer to him; it makes the treatment of the case more satisfactory if the work of the specialist seems to go along as a continuation of that of the general practitioner. I have been greatly helped by such letters, and I believe that if this were a more general practice it would be of advantage to patient, general practitioner and specialist alike.

And I believe also that it would be helpful if the specialist, when he is through with a patient, should send him back with a note to the general practitioner, so that he might see what the result of the treatment was, the specialist practically turning the patient back to the general practitioner, so that conditions should be restored which existed before the family physician sent the patient to the specialist. Perhaps this is done oftener than I suspect, but I am sure that a general observance of this custom would break down the barrier which now often exists between the general practitioner and the specialist. The general practitioner would not be afraid of losing his patient for good if this practice were followed, and he would be the gainer by knowledge which might be of help to him if a similar case should present itself. These may seem trivial points of etiquette and of very little consequence to a busy man; but if the work of the profession is to be thoroughly and carefully done, such co-operation between the general practitioner and the specialist is very desirable, especially in difficult and baffling cases.

There has come, I am sure sometimes, to be some sense of rivalry between the general practitioner and the specialist. The general practitioner is sometimes inclined to feel that, if he sends his patient to a specialist, the latter will treat lightly what he has done for the patient, and will alienate his regard. Also, he may feel that the specialist is prompted by pecuniary considerations and thinks chiefly of his fee. Some general practitioners, for these and similar reasons, hesitate to send patients to specialists, perhaps delaying to the detriment of the patient. This is all wrong. For professional, humanitarian and scientific reasons, there should be accord between the two. Each should recognize and respect the other as doing good work in his line and should co-operate with him in every way possible. These rivalries and misunderstandings are more likely to develop in the smaller cities and towns than in larger medical centers; but wherever they exist, and to whatever causes they may be due, all who have the highest interests of the profession at heart should allay and relieve them. If the general practitioner is annoyed by the greater prosperity of a specialist, he should recollect that the increasing demand for specialists is in line with the tendency toward specialization in the other professions and in business; and also that in a considerable number of cases, the people who seek specialists do not have family physicians, but are led by what they hear about a specialist or read about him in the newspapers, to seek him when they have or think they have an ailment which comes within his special field. The specialist nowadays does not receive his patients from the family physician in anything like the proportion in which he formerly did.

The general practitioner, who spends all his time in looking after $3.00 dollar ailments, thinks of the specialist as sitting in his office gathering in $5.00 or $10.00 fees; or as engaged in surgical operations for which he receives large compensation. But he forgets that, while the specialist may spend his afternoon hours in this profitable and pleasant fashion, he has devoted his morning to hospital work without remuneration. Though, to be sure, his afternoon may bring him larger returns than the entire day of the general practitioner brings to him. From this view point of the general practitioner, the work of the specialist may well seem to be more on a commercial basis than his own, not only because of his larger fees, but because often he sees his patient but once, and there is an entire absence of the personal tie which is so strong between the family physician and his patients.

As commercialism has taken so strong a hold upon other callings and is sometimes not altogether absent from the movements of the clergy, it would not be strange if its influence were felt among specialists. They are in a way of knowing as much as any one of the rapid accumulation of large fortunes in other vocations. The papers are full of facts regarding these fortunes and the processes by which they are heaped up. Doctors are quite pardonable if they are not exempt from some aspirations in this direction. The change in habits and expense of living which has taken place among the people with whom the doctor associates makes it extremely difficult for him to maintain his proper social level. The cost of educating his children and establishing them in life has increased greatly; and, both by reason of these heavier burdens and of the lower rates of interest on investments, the money which it is necessary for him to lay by to provide for them and for his own old age is much larger than was required a generation ago.

There is, I am sure, a feeling among some of the older men in the profession that the spirit of commercialism is taking a very strong hold of the whole profession; and that, even in conservative Boston, where the highest professional standards have been maintained, there is danger that the central idea of relieving human suffering and making the lives of our fellow beings more pleasurable and more peaceful may give place, to some extent, to consideration of the size of the fee which the doctor may exact from his patient. In too many instances this fee seems to be based, as the railway magnate said of the freight charges, upon "what the traffic will bear.”

When the Prince of Battenberg visited this country some months ago in command of a British squadron, and as the guest of our government, he carried away, as a souvenir of his visit, the receipted bill of a New York dentist for $1,000 as the price of filling four teeth. The distinguished guest was not in a position to remonstrate; he paid the bill like a gentleman, and it was only by an accident that its extortionate character was made public. But when the facts were made known, they aroused just indignation in the public mind, and more than one rich and patriotic American would rather have paid the bill from his own pocket, had that been possible, than to have had the distinguished guest carry away such a reminder of American rapacity.

But the charge of this New York dentist is paralleled by many charges for surgical work. Recent correspondence in one of our medical journals contains an instance of this sort.

A New York surgeon asked $1,000 for an operation for removing an appendix. The mother of the patient offered $600, but the surgeon protested, cited testimony of brother physicians to prove that the fee was not excessive, and finally received the balance. The letter which enclosed the last check was as follows:

"My discussion with you has been a friendly one, and so you will not, I feel sure, suspect me of any acrimony, when I say that my feeling about the present excessive charge of surgeons is a very general one, and the reflection of a sentiment that is everywhere one of surprise and dissatisfaction. We do not question your ability, but we feel you make us pay too dear for it."

This fee was not exceptional. Higher fees have been charged for similar services; and one case is on record where a surgeon charged his patient,—a very rich man,—$15,000 for an appendix operation, the case being one of no special difficulty, and the charge, evidently, being assessed with reference to the patient's wealth rather than the service rendered him. Possibly the surgeon may have been a bit of a Socialist in his way, and may have taken this method to assist in the redistribution of wealth. I am quite sure from considerable personal observation in the Mississippi Valley and in the far West, and on the other side of the Rocky Mountains, that this spirit of commercialism has gotten a pretty strong hold upon the profession. Medical and surgical service is considered and estimated according to its money value to the giver of the service. So far has this gone in some of the western cities that the fee tablet has in some instances of which I have a personal knowledge contained nearly two hundred items where the price was fixed for certain services, and where the whole method in which the price was varied and fixed to the service rendered seemed to be based on the principle of exacting from the patient as much as he could possibly pay.

There are considerations on the other side of this question of fees to which it is too much to expect the laity to give much heed. As has been truly remarked in the discussion of this question, all eminent surgeons have undergone a rigid and severe technical training after their graduation, and it is this training which makes their hand sure while operating. The patient pays them, not for the brief time spent in an operation, but for the skill and training which have been acquired by years of strenuous effort, and upon which he bases the assurance with which he gives himself to the surgeon's knife, certain that everything which science can do to relieve his suffering and save his life will be done. That sense of assurance is worth so much to the patient that he should not begrudge paying for it, provided the fee of the operating surgeon is not beyond reason. There is another consideration also which the laity overlook. Every surgeon and every physician devotes much time to hospital cases or to cases among the poor, where only nominal fees can be asked at the most, and where often it is impossible that even these should be paid. In no other profession is a man expected cheerfully to take such risks and undergo such hardships at the dictates of humanity, without expectation of reward. If a physician or surgeon charges a wealthy patient a large fee, it may be in order that he may thereby be the better able to render gratuitous service in the name of humanity.

No one will deny that the doctor who gives many years to study, who deprives himself of many of the pleasures of life that he may minister to suffering humanity, should be properly remunerated so that he may have the ordinary comforts of life. He should be able to make all the usual provisions against sickness and distress, whether to himself or his family, to educate his children and to enjoy an old age free from worry and care. But he is not like the man engaged in business who studies every transaction to know just how much profit it is to yield him financially. He should study every case, not from the standpoint of dollars and cents, with a view to making the utmost possible by multiplying his visits or playing upon the fears of his patient, but with a view to doing everything in his power to relieve and save his patient without the slightest regard for the compensation he may receive.

Before dismissing this subject of commercialism in medicine, I want to add a word concerning a certain class of practitioners, constituting a considerable percentage of the brotherhood, who are at the farthest possible remove from any reproach on this score.

Most of those whom I have in mind live in the country towns, where business methods do not prevail as in the larger centers of population. In these communities, long credits are almost invariably given, accounts between neighbors and friends sometimes run indefinitely without being brought to a settlement, and bills for groceries, provisions, dry goods and other articles for family use are not paid every month, or every three months, and sometimes not every year. Naturally enough, the doctors fall sometimes into the same habits that the farmers and mechanics and laboring men among whom they live have acquired. Assuredly these men do not need a warning against carrying on the practice of medicine for the purpose of accumulating a fortune. Their life is hard, their hours of labor long. The ready money in their communities is limited, and they have to adapt themselves to the conditions around them. They suffer more than any other class from these conditions, because in these rural communities the doctor's bill often is the last to be paid. If they have children growing up and to be educated, they find it extremely hard to do for them what they would like to do.

I believe that, as a class, these men are the most self-sacrificing, honest, conscientious workers for the relief of human suffering in the whole range of the medical profession. But I wish that they might adopt new methods, especially in the management of financial matters. It would be better for them, and better for the profession, and better for their patients, if they were to send their bills promptly once a month or once in three months. Their fault is a fault which leans to virtue's side, and it is a great deal more lovable than the fault of commercialism, which lies at the opposite extreme. But I wish that these faithful servants of the public might do better for themselves. If they would do even half as well for themselves and their families as they do for those to whom they minister, their outlook would be much brighter than it now sometimes is when some accident or sudden sickness curtails their activities. And, although they do not realize it, a change in their methods would be of advantage to the profession by dignifying its proper compensations and preventing the spread of the destructive notion that a doctor's bill is something that can be attended to at any time,—or not at all, if it is not convenient.

"Noblesse oblige" is a familiar French phrase. When the French say this, they mean that nobility of birth imposes a special obligation upon whoever boasts of it. The man nobly born cannot be, or at least ought not to be, like common men. The very circumstance which increases his privilege increases in the same ratio his responsibilities. But, if this is true of noble birth, how much more is it true of a noble profession.

It is the work of the physician to relieve suffering; to calm apprehension; to make easy and secure the entrance into life; and to attend humanity every step of the way from the cradle to the grave. His it is to study and aid the processes of nature in restoring health; to provide a just ground of confidence in time of accident or sudden fear; to be a friend, counsellor and helper in every physical emergency of life for which human skill is of any avail; to do all this gladly, enthusiastically, unselfishly. The annals of the profession are full of the records of men who have faced every contagion and every form of peril without a thought for their own personal safety. In every great epidemic many doctors have given up their lives who might have saved themselves by flight, but who would not leave those who needed them. On every battlefield, in the track of advancing armies surgeons have cared for the wounded while bullets were still flying. This very year, doctors have been murdered by the side of their patients in Russia, because they would not forego their work of mercy at the demand either of Cossacks or of the mob.

This is a noble profession to which we belong. Richer than any heritage of birth is that which falls to us as successors of the courageous and self-forgetful practitioners of the past. The nobility of this heritage imposes upon us a corresponding obligation. We cannot be, we ought not to be, like men without such a heritage. If the mercenary were to be substituted for the humane motive in the practice of medicine, the most ennobling and beautiful qualities of the profession would be lost.

It is a serious misfortune that such a profession as ours should even become subject to the suspicion of commercialism. But, if it should yield to that influence, if it should be overwhelmed by it,—that would be a calamity indeed.

_______________

Hildreth, John L. "The General Practitioner and the Specialist." The Boston Medical and Surgical Journal 155, no. 4 (1906): 79-83.


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