I WAS deeply interested in Anne Miller Downes’s article in the Atlantic Monthly for October on ‘The Cost of Illness.’ I am sorry to say that her contentions are in great measure true, but there are good reasons for the high costs.
Medicine in its various branches has so developed that no one man can know it all. The X-ray is a good example. Only a few can be X-ray experts, and those who are such must devote all their time to the subject and be on the alert to learn and utilize every new advance. They must also make a decent living for themselves and their families.
Again, the auxiliary sciences which aid in the diagnosis and cure of disease are outside the knowledge of all but a few doctors. If the patient is to benefit by the most recent discoveries in chemistry, physics, biology, and physiology, in many cases an expert must be called in who will know technically the many varying conditions of the heart and the arteries, of the blood, the urine, the intestinal contents, the endocrine glands, and other organs. In the many brain cases I have cared for I invariably called in the X-ray specialist, the neurologist, the ophthalmologist, and sometimes the aurist, and, if the general condition of the patient required it, other competent physicians.
These statements indicate the many lines of progress which greatly promote the welfare and even may save the life of the patient. Other experts in other lines are also crowding upon us to aid in diagnosis and treatment. Were I in active practice I should want to have the knowledge of all these experts to aid me in every important, case involving danger to life. But, if such experts are to be had, they must be so paid that they can investigate and experiment with test tube, microscope, and the like, and, again, live in comfort.
How to reconcile the purse of the patient with the family purses of the chemist, the microscopist, the physiologist, and the other experts is a most difficult problem. All the doctors I know are glad to do their best to adjust their fees to the income of the patient.
In the November Harper’s Magazine Dr. Louis I. Dublin points out how that may be accomplished in part.
But there are also other considerations which must weigh heavily with the public in their appreciation of the generosity of the medical profession. I trust that I may not be deemed egotistical if here I draw on my own experience.
The active practitioner’s time is never his own. When duty calls, sleep and meals and social engagements always yield to the patient’s welfare. At one time, many years ago, I well remember that I was called out of bed, and usually for several hours, for thirteen nights in succession.
One of these nights, toward the end of the thirteen, I can never forget. As my tired head touched the pillow I said to myself, ‘ Well, anybody must be mighty sick to get me out of bed this night.’ At that very moment my night bell rang, and through my speaking tube the messenger on my doorstep — it was long before the telephone was invented — informed me of a great fire near St. Mary’s Hospital. Scores of people had been compelled to jump from windows to save their lives, and the hospital was full to overflowing with the desperately injured. I must go at once. Weary as I was, I responded immediately and spent the entire night there. For the first and only time I saw the thermometer mark one hundred and seven degrees, in a patient who had scarcely an unbroken bone in her body. She died in a short time.
About 7 A.M. I gathered up my instruments and took a Second Street horse car to my home, nearly three miles away. An Irish laborer, going to his work after a good night’s sleep, sat down beside me and noted my surgical instrument case. On his inquiring why I was out so early I told him of my night’s work. ‘Well,’ said he, ‘you’ll get a nice fat fee for all that work, sure.’ When I told him that most of the thousands of hospital physicians and surgeons received no pay, he was wholly incredulous, and exclaimed, ‘Why the divil do you do it, thin?’ and was only half convinced by my explanation.
On another memorable occasion when I was called out of bed, a severe storm had already piled the snow on the streets up to and sometimes beyond the level of my knees. All traffic was stopped; neither street, cars nor cabs were available, and I had to tramp nearly three miles from my home. En route I met not one single man or woman. I became so exhausted toward the end that I almost collapsed. But finally I did reach the patient’s house. I spent the entire night in ministering to a little child who was desperately ill, and had the satisfaction of rescuing her from impending death.
One Sunday, while I was at my dinner just after church, a man living in a small street less than a block away rushed at once into my dining room, when the maid opened the front door, crying, ‘For God’s sake come and see my boy! He is strangling to death from diphtheria!’ I lost no time, be sure, in answering that summons, for I had been a witness to the actual strangling to death from diphtheria of a playmate brother when I was but twelve years old, and of a little niece some years later, long before this Sunday call to duty.
I seized my instrument case, which was always ready for just such emergencies, and ran with the father to the bedside of the boy. He was gasping for breath and evidently would soon die if not instantly relieved. Diphtheria had its iron grip on his throat. I did a quick tracheotomy, and it saved his life. It was one of the small percentage of cases in which tracheotomy did save life in diphtheria. This case occurred years before the blessed antitoxin came in 1895 with healing in its wings. Since that date tracheotomy for diphtheria has practically disappeared.
After some time I removed the tube from his windpipe, and the wound quickly closed. I frequently met the little chap playing near my home. He always tipped his cap to me and gave me a cheery ‘Hello, Doctor Keen.’
Whenever I think of such experiences my nerves are set a-tingling to my very finger tips. What doctor all over this broad land has not had many like them!
Such cases brought me no money, be it observed, but they paid me better than in gold. The poor are the best paymasters of the doctor — not in coin of the realm, but in the gratitude they cherish for years and years, in prayers for the doctor’s welfare, and in the inward glow of satisfaction of duty done. Our names are household words in many a grateful home.
There are many thousands of physicians and surgeons all over the United States who give their services in hospitals absolutely free. These do not include, of course, the doctors who devote their entire time to hospital work, as superintendents and the like, who of necessity receive a salary.
The last Report of the Jefferson Medical College in Philadelphia gives the following figures on which I base the appended very moderate estimate of fees had they been private cases: —
193,124 visits @ $1 each. $193,124
10,664 surgical operations @ $25 each 266,600
Thus the medical staff of the Jefferson Hospital alone gives to the community the equivalent of about half a million dollars a year, and this figure is always increasing — and that is only one hospital in one city.
From a pecuniary standpoint, — a far lower level, which I mention only to complete the picture, — the doctors give freely of their time and skill without fee to every private patient who is not able to pay. I am sorry to add that the doctor’s bills in families able to pay are often the last to be paid, and not seldom arc never paid at all.
I never even entered in my ledger the names of patients who I thought were too poor to pay anything. They appeared only in my visiting book. When finally I closed my medical ledger in 1907, however, there were standing unpaid bills of many thousands of dollars which have never been liquidated. They cannot be charged to ‘cost of illness,’but to that hypothetical account, ‘the cost of being a doctor.’
But there is also a large additional cost of ‘becoming a doctor.’ The physician’s education is prolonged far beyond the college or the university, and he must have spent two years in premedical studies unless he has had these in a college or a university. Then come four years of the medical college itself, including, of course, his living expenses. Next he must spend one or two years in a hospital and learn the practical work of his profession. And often, as I know from my own experience, practice comes slowly. One of my old students, now a teacher of renown, whose writings are known all over the country, came to me years ago in great discouragement. He had the prestige of postgraduate study in Europe and was married, yet in the first seven months after he entered upon practice — that is, in two hundred and ten days — his total income from patients (if the plural is allowable) had been just two dollars and fifty cents, or a trifle over one cent a day.
I have obtained from a number of internes in hospitals a statement, of their actual expenses for their professional education as outlined above, and the average is practically $10,000. Of course in the state universities of the West the cost will be less; in some of the larger of the Eastern medical schools it will be considerably more. Not a few medical students have been obliged to borrow a part of the money, and this debt is a millstone around their necks in their earlier years of practice.
Next come the expenses of beginning to practise, — the rent of an office and a waiting room, the purchase of a desk and chairs, a bookcase, a card-catalogue outfit, medical books and journals, — all in anticipation of the lagging patients. As to marriage and children, he who assumes such responsibilities before his practice fully warrants them is a brave man.