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GRAINS AND SCRUPLES

Under this heading appear week by week the unfettered thoughts of doctors invarious occupations. Each contributor is responsible for the section for a month ;

his name can be seen later in the half-yearly index

FROM A BACTERIOLOGICAL BACK-NUMBER

IV

A DAY or two ago there appeared in the personalcolumn of a famous London daily the followingitem :-

S 0 S-Is there an AMERICAN SPECIALIST on BLOODDISEASES in London ? Pray answer this.One forbears to smile as one never knows whatanguish and misfortune may lie behind such anappeal; but one cannot help being curious as to thecircumstances under which it was made. One couldunderstand an application for a French chef or anItalian marble mason, but a skilled doctor it mightbe thought would have exercised the same skillthe whole world over. There seems no way ofgetting any nearer the matter unless one were oneselfan American specialist of the type required, and forlack of a better explanation we can only think thatthis entry in the agony column is one more illustrationof the curious, complex, and largely irrational groundsupon which the average patient chooses his doctor.The patient certainly chooses his doctor on differentprinciples from those which make him decide onhis garage mechanic or a gardener. It is not a mattermerely of choosing a knowledgeable and impartialexpert and telling him to get on with it. No doctoris allowed to be merely ordinary. Patients delightin forming their own opinion of their doctors, thoughthey might know that their judgment in the mattermust be almost worthless. If they like their doctorhe is everything that is perfect: if they don’t, then" the reason why I cannot tell, I do not love theeDr. Fell," and there’s the end to it. The patientlikes to talk of his doctor as a "clever" doctorthough it is hard to see how the estimate of clevernessis arrived at. The patient will sometimes refer

proudly to the " high qualifications " of his doctor,but he rarely seems to lay much stress on a merestring of degrees and diplomas. I have a goodstring myself-to be precise jE166 worth-but I havenever found myself accepted as a " clever " doctor ;in fact I usually find it difficult to get anyone tobelieve that I am qualified at all. Appearances gofor much and it is certainly important that a doctorshould look like a doctor ; but if we ask again whata doctor should look like it is not easy to reply.Perhaps the important thing is that he should notlook quite like other people ; there should be some-thing mysterious about him-some slight reminderof the primitive and the occult, something to linkhim with the ancient medicine man whose memorystill lies only superficially buried in the subconsciousfolk mind. That knowing young practitioner Mr. BobSawyer had got the idea when as he said " I put on ablack suit of clothes and a pair of spectacles, andcame here to look as solemn as I could." Even tothis day the doctor must adopt a priestly conservatismin his dress and we find him wearing a stiff collarwhen everybody else around is wearing a soft one,and after all it is not so long ago when even in remotecountry districts the top-hat and frock-coat wasstill his daily garb.

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When one considers the enormous temptations the’ ordinary practitioner has to adopt the methods of

the quack it is a remarkable evidence of the moraleand integrity of the profession that they resist thetemptation. Ordinary patients certainly like a touchof quackery about their doctor and if the doctor hasnot got. it naturally-and he usually has not-they insist upon investing him with it. We have allheard from patients the astonishing and mysteriousstatements alleged to have been made by brotherpractitioners. We have heard how the doctor has

solemnly diagnosed a " chill on the liver " though we

know perfectly well that our colleague has no such adiagnostic term in his vocabulary. We have a goodidea of how these statements come about: a patientis very partial to his own diagnosis and as a wisedoctor is chary and wary about it the patient takesthe matter in hand and puts the necessary words intohis mouth. The key is given in the old Punch joke-" I say it’s measles, doctor, what’s your humble,opinion ? "And patients seem sometimes to derive consider-

able satisfaction from running down their doctors.That is the natural reaction against the high andalmost heroic legend which normally surrounds thedoctor’s craft. Human beings when they tire of theirmumbo-jumbo are given to knocking him off hispedestal. In the old Greek plays the Gods were madeto look foolish at times and King Arthur, so gloriousin the romances, cuts some sorry capers in thefabliaux.

Patients will sometimes exult over their doctor’smistakes even when they are themselves the victims.A circular was recently left at the houses in theSt. John’s Wood neighbourhood. It was headed"Have You a Story" and it announced that a" Mr. H. V. Langley is completing a book on

manipulative surgery, and would be pleased to receivepersonal experiences for publication relating to

injuries or conditions treated by doctors prior toconsulting Mr. Langley." We feel that if Mr. Langleyis not going the right way to investigate the claims ofmanipulative surgery he certainly ought to be able topresent some interesting data on the psychologyof patients, and if as is stated the price of thepromised book " will not exceed 6s." a copy I amnot sure that I shan’t have six shillings’ worth.

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It is curious that laymen so readily charge medicalmen with avarice. Probably no other professionever does so many services for which it should bepaid and yet is not paid and certainly no otherprofession has to work so intensely and with so littleoff time. True, a doctor has a certain standard ofliving and is, speaking generally, fairly well off;but his training is long and difficult and his standardof life is to some extent dictated by the patientrather than by himself. He has to have a car whereinto visit his patients and maids to open his door tothem by day and night. A patient quite ready tocomplain of a very ordinary doctor’s bill wouldsnort if the doctor did his rounds on a push bikeor a motor-cycle combination. I know an old doctorwho dislikes cars and always goes his round on hisfeet and he tells me he only keeps the big Americancar which lies unused in his garage because " patientsexpect a doctor to keep a car even if he doesn’t

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use it." Chaucer’s doctor was allowed to be " a verreyparfit practisour " and the profession may well beproud of the character Chaucer gives to it ; but evenhe finishes up with the remark :-

For gold in phisik is a cordialTherefore he lovede gold in special."

The older satirists, who were certainly out to findout the weaknesses of all professions, are generallyhard on doctors and rarely fail to charge them withincompetence and greed. According to old JohnEarle the best cure his " Mere Dull Physician " hasdone " is done upon his own purse, which from alean sickness he has made lusty " and lest surgeonsshould smile at the discomfiture of the mere dull

physician let us add this item from his character of asurgeon : " The rareness of his custom makes himpitiless when it comes." Nicholas Breton gives uscharacters of both a worthy and an unworthy physician.-" An unlearned and so unworthy physician is a kindof horse-leech, whose cure is most in drawing blood,

and a desperate purge, either to cure or kill, as ithits " ; but there is surely also a slight sting even inhis remark on his worthy physician that " by thesecret of his skill out of others’ weakness he gathershis own strength."

Plato was more understanding and generous." Then is it not true," he asks, " that no physician,in so far as he is a physician, considers or enjoinshis own interest, but that all seek the good of theirpatients ? " Elsewhere he tells us that " the scienceof medicine, in a word, is a knowledge of the loveaffairs of the body-and he is the most skilfulphysician who can trace those operations of the goodand evil love, can make the one change places withthe other, and attract love into those parts from whichit is absent." By love in this sense Plato no doubtmeant the harmony and health of body and mind,and if we demand a short answer we can hardly geta more satisfactory one to the question " what is theskilful doctor ? "

PANEL AND CONTRACT PRACTICE

MessagesAN insured woman was taken ill late one evening

and next morning her mother attended at the practi-tioner’s surgery and obtained a prescription formedicine for the acute diarrhoea from which thedaughter was suffering. The daughter took the medi-cine as directed but as her condition became worseduring the day a message was sent to the doctor onthe following morning asking him to visit her imme-diately and also her mother (a private patient) whohad meanwhile had a seizure. The messenger called.at the surgery before 9 A,M., and was assured thatthe practitioner would be informed as soon as hearrived at the surgery. At about 2 P.M., as the doctorhad not then called, his surgery was rung up and the.assurance given that the doctor had been told andmight be calling any minute. An hour later the

patient’s condition having become worse anotherdoctor was summoned, who gave an injection to easethe pain, and the insurance practitioner was notifiedthat he need not now call. The second doctorremained in attendance for several days.When the medical service subcommittee inquired

into the circumstances the practitioner agreed hehad received the first request for a visit but noindication of any degree of urgency. He finished hissurgery work at about 12.30 P.M. and made sevenvisits before lunch at about 2.20 P.M. He did notreceive the two o’clock message ; this message reachedhis assistant who lived at the surgery, and as he andthe assistant had prepared the visiting list togetherand marked urgent cases the assistant assumed theprincipal would be visiting this patient. The threeo’clock message taken by his housekeeper and can-celling the request for a visit came just before hewent out again, and he interpreted it as meaningthat the insured person’s condition had improved.The committee was satisfied that the practitioner

received the first message but did not realise thathis services were urgently required ; that the secondmessage was received at his surgery but was not trans-mitted to him, and that he was negligent in notmaking proper arrangements for the transmissionto him of messages received during his absence fromthe surgery ; and that he failed to visit and treatthe patient whose condition so required. Theydecided to recover from the doctor the expense

incurred in calling in the services of the seconddoctor and to repay the amount to the person bywhom the expense was incurred ; and while in thisinstance they did not propose to ask the Ministerto withhold money they would be compelled to takea more serious view another time. The doctor isto be asked to make more satisfactory arrangementsfor the receipt and transmission of messages.

In a case such as this it is often difficult to dis-tinguish between the occasional miscarriage of thebest-laid plans and the failure to make reasonableprovision. No doubt the original messenger intendedto oonvey that a visit was urgently necessary, andclearly the doctor did not get the impression thatthis was so-in fact, he said he was told he waswanted for the patient’s mother " and while thereto see the insured person." Short of a machine ofthe dictaphone type to record the actual words ofthe messengers practitioners can hardly avoid therisk of failing some time or other to appreciate theurgency of a call which is really urgent. And eventhen the inflection of the voice may make all thedifference in the meaning of "Will doctor pleasecome as soon as he can."

The Drug TariffAt present insurance practitioners are supplied

with a copy of the drug tariff once a year. Repre-sentations have been made to the Minister by theInsurance Acts Committee that practitioners oughtto have a copy of each (quarterly) issue. The Ministerhas agreed to do this but has suggested that themost suitable course to pursue is to supply a copyof the tariff once a quarter to those practitionerswho wish to have it so often. The London panelcommittee has circularised all its constituents askinghow they feel about it.

Road Traffic Act

The London panel committee has been informedthat an insurance company refused to pay a fee toa doctor for emergency treatment under the RoadTraffic Act on the ground that the written applica-tion had not been sent by registered post. The Actprovides that written applications for fees are tobe delivered to the person who was using the vehicleor sent by registered post. This should be borne inmind.