The General Practitioner and the Specialist

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Address. medicine. The German mind is content to ex- pend its energies upon detailed work, to pursue a to the farthest zealous AND THE subject possible boundary, THE GENERAL PRACTITIONER rather in the search for ultimate causes than in SPECIALIST.* the practical application of knowledge. But BY JOHN L. HILDRETH, M.D., OF CAMBRIDGE. whether from the extension of the German influ- Mr. President and Fellows of the Massachusetts ence or from other causes there has come about Medical The modern toward the existing state of things, with specialists for Society, tendency of the Moreover, with this subdivision and specialization is very strong. every organ body. extension of specialism, there has come to pass It is manifest in education, where the elective in which the selection of a marked change the position and possibilities system permits particular of the The relations of the a or individual general practitioner. studies to suit special training the extends far back into the preparatory two —the general practitioner and specialist caprice to each other and to the community furnish an whole — schools and reaches forward through the I of for the active work of life. interesting and, hope, not unprofitable subject period preparation of to a and discussion of It in The watchmaker no study, hasty inadequate appears industry. which I venture to ask consideration. makes a watch or the shoe- your longer complete And in the first let us look for a moment maker a shoe. Each is place, complete engaged upon at the which each class of some swift and deft machine which turns out advantages practitioners to be to enjoys, and the disadvantages under which he parts of the complete product fitted is other other hands. The student of labors. Neither path wholly strewn with roses. parts by Success may be won in either, and the rewards of science specializes. He no longer attempts a comprehensive understanding of the whole realm success are great ; but they come only as the fruit of but out his small of labor and sacrifice. knowledge, early picks The work of the is harder chosen bit of the field and devotes his life to an general practitioner than it was a He is much cultivation of it. The successful mer- to-day generation ago. assiduous less and he has less time to himself. chant no tries to direct all the details of independent, longer The of makes him more business. These are subdivided and multiplication telephones his intrusted, to his who find this to that confidential representative, that to this subject interruptions by patients, it so easy to call him or to ask head of a department. So through all domains by day by night, questions some necessary, some unnecessary of activity. — — that leave him no time which he can call This is nowhere more manifest than they tendency his own. He is on call at all and it is not in So are the times; the medical profession. great he wnich it has about that they surprising that, while appreciates the uses of changes brought the he sometimes it as a device are realized even the members telephone, regards imperfectly by Evil is a slave to the of the In for of the One. He peremptory profession. general preparation call of the and must be the there has been a remarkable instrument, constantly profession to answer as in cases no one can advance during the last forty years. The dif- ready it, many in the amount of work to answer it for him. The telephone, and that later ference required gradu- invention, the each of in its ate from the better medical schools now and forty automobile, which, is indeed and the character way, annihilates space and time, greatly affect years ago very great ; in another of the men the seems to me the general practitioner way. They entering profession available for a much and better fitted for the scientific increase competition by making stronger who for reason has become im- and successful of medicine now than patient, any practice the services of a from a dis- then. Then was unknown; medical patient, physician bacteriology tance. These new and the and human were inade- appliances constantly chemistry physiology necessities of office outfit and experience counted for every- enlarging supplies quately taught; add to the expenses of the general practi- thing with a doctor, and scientific attainments for greatly little. With this in tioner. Altogether, it would be fair to estimate very change preparation the increase in the expenses of the for the there has come a change regular practi- profession equally tioner the last thirty-five years at least marked in the of it. as I have during " practice Formerly, If he is to as his to it was that counted as the 25%. be, patients say, up said, experience prime he must attend medical read the in and that was in date," meetings, requirement a doctor, gained medical and visit the in the medical centers of our own journals treatises, hospitals large hospitals or a service of his and from and other countries. have hospital own, time to time must see what is done in his were then no those who being There specialists except in other countries. devoted themselves to the and to the ear. profession eye All these make the There was, it is true, a distinction things general practitioner's recognized life much more laborious than it was a between physicians and surgeons, but the innu- generation merable classes of that exist ago. The simple life of the community has also specialists to-day and a strenuous and were unknown and undreamed of. disappeared, very complex A of the subdivision of work has life has taken its place. The practitioner has to part present himself to these conditions. He must be come about, doubtless, through the adoption of adapt German methods of study and instruction in alert and constantly on the watch to see that no one does better work than he, and whilst he does * Delivered before The Massachusetts Medical Society, June 13, 1906. not advertise or solicit patients, he must make

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org by JOSH ROSENFELD on April 25, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. himself desirable enough to insure his being Under existing conditions, the general practi- sought for. Very few general practitioners who tioner cannot be expected to do original work. have been away from schools and hospitals for Everything of that nature, everything that fifteen years and are thoroughly established have promotes the progress of medicine in a scientific a moment's time to themselves, from the time way, must be done by the specialist. But the that their vacation ends in the summer or fall general practitioner must be alert to follow all until it begins the next summer. From early new discoveries and processes and to avail him- morning to late at night they are in the harness; self of them. It is a natural consequence of the some one wants them, wants them in a hurry. changed conditions that young men entering the If they want a half day off for leisure, some very profession are drawn towards specialism rather sick patient prevents. If they plan for a day's than the general practice of medicine. My recreation in the country, it is more than likely observation is that general practitioners who that some patient or expected patient will detain have sons in the profession encourage them, not them. All these conditions are much changed to follow in their own footsteps, but to become from those of thirty or forty years ago. specialists. I do not recall a single instance where Another important change affects the lot of the reverse is true, and where a father who is a the general practitioner. The medical profession specialist has a son who is a general practitioner. has come to feel that everything that is brilliant, One of the older physicians of my acquaintance everything that makes an impression upon the once said to me that it took a man of iron consti- laity, must be something that can be seen or tution to follow general practice, and he had on that can be touched with the hands; in other that account led his son to adopt a special form of words, must be something of a surgical nature. surgery. The man who gives advice concerning a difficult One strong reason which impels men to become problem in medicine, who helps to complete a specialists is not avoidance of night work and the diagnosis when the symptoms are complicated other hardships of the general practitioner, but and an accurate diagnosis extremely difficult, the increasing demand of the people for specialists. does very little to impress the laity by comparison More and more it is coming to pass that any one with the man who performs a surgical operation. who has or fears that he has some organic trouble The conditions are wholly reversed from those asks his " Who is the best " " family physician, of the time of the barber surgeons when the specialist in this or that? " or goes to a specialist surgeon sat at the feet of the family physician. without asking. It is in response to this ten- Now the surgeon is to be pacified only by the dency that we find that those doctors who adver- homage and admiration of the general practi- tise extensively, and who, while they may legally tioner. be practitioners, are not recognized by the pro- The advantages and disadvantages of the fession, invariably advertise as specialists, with specialist are obvious. He has regular hours infallible cures for some particular malady. The for his office and regular hours for the hospital, story is told of a young lady who was asked to do and his day's work is done with the day. He can something, and who, taking out her engagement study to the farthest bounds of knowledge the book, said plaintively that she would have to be causes and treatment of the diseases to which he excused for that week, as on Monday she was to has devoted himself. The field is not too large visit her oculist, on Tuesday her aurist, on Wed- and the problems, although often intricate and nesday the orthopedic specialist regarding the sometimes unsolvable, are not too many. But arch of her foot ; on Thursday she must go to a he has to give more years to get a profitable specialist in pelvic disorders, on Friday to a following and he is less sure of success in the end. specialist in nervous disorders, and on Saturday His time of life work is shorter. He becomes old- to a specialist on the spleen. fashioned and some young man fresh from the It has always seemed to me that, when a large hospital fields of Europe becomes the public general practitioner thinks that a patient should favorite in his stead. The field for the successful have the advice of a specialist, he should again, specialist is restricted to the large centers of as he no doubt has done before, give his patient population. A few are found in cities of from as thorough an examination as if he had never 50,000 to 100,000 inhabitants, but their opportu- seen him, so that nothing may be overlooked and nities for a large practice and remunerative fees he may have as complete a knowledge of the case are small. One thing which the specialist misses as possible, and be sure that his decision is correct. cannot be estimated by any pecuniary standard. In this way some new light may be let in upon the He gains warm friends and admirers among his diagnosis, and some help secured for the treat- patients, but he does not know them as the ment before the decisive step is taken of recom- family physician knows them; he is not their god- mending the patient to go to a specialist. father, nor their elder counsellor and trusted It has not often fallen to my lot to be present friend as the family physician is. There is no when a specialist first saw his patient. It has experience in life which is quite like the peculiar not been my invariable custom, I regret to say, and satisfying relationship which exists between to send a detailed statement of the history of a the family physician and the family patients. case and its treatment to the specialist, so that The weary doctor derives a pleasure and comfort he might have the advantage of all my knowledge from this which no fee or words of praise can of the case at the time that the patient reaches approach, in value. him. I suppose that it does not matter what the

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org by JOSH ROSENFELD on April 25, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. case is, whether of the eye, or ear, or brain, or his regard. Also, he may feel that the specialist abdomen,— or skin, or whatever else, it must be is prompted by pecuniary considerations and that all thorough specialists make —all inquiries thinks chiefly of his fee. Some general practi- for themselves at the first visit, just as though tioners, for these and similar reasons, hesitate to the patient had not been seen by any other person send patients to specialists, perhaps delaying to and just as though they had no information the detriment of the patient. This is all wrong. regarding the case from the practitioner sending For professional, humanitarian and scientific the case to them. reasons, there should be accord between the two. But I am quite sure that some of the specialists Each should recognize and respect the other as are not thorough in their examination of cases, doing good work in his line and should co-operate but simply accept the patient's statements, and with him in every way possible. These rivalries examine him for the trouble for which he has and misunderstandings are more likely to develop been sent to them. I have seen some very in the smaller cities and towns than in larger sorrowful mista ces made in this way by specialists. medical centers; but wherever they exist, and On the other hand, I have seen some remarkably to whatever causes they may be due, all who have good work done by specialists who have given the the highest interests of the profession at heart patient a thorough looking-over, have gotten a should allay and relieve them. If the general complete history of the sickness, and have taken practitioner is annoyed by the greater prosperity sufficient time to master all the details of the case of a specialist, he should recollect that the increas- up to the time when it presented itself for their ing demand for specialists is in line with the treatment. tendency toward specialization in the other Some specialists have the excellent custom of professions and in business; and also that in a writing out their opinion of what the diagnosis is, considerable number of cases, the people who and what they believe to be the proper method of seek specialists do not have family physicians, but treatment, and of sending this statement, very are led by what they hear about a specialist or read soon after they have seen the patient, to the about him in the newspapers, to seek him when practitioner who sent him to them. This is they have or think they have an ailment which helpful to the general practitioner; it brings the comes within his special field. The specialist specialist nearer to him; it makes the treatment nowadays does not receive his patients from the of the case more satisfactory if the work of the family physician in anything like the proportion specialist seems to go along as a continuation of in which he formerly did. that of the general practitioner. I have been The general practitioner, who spends all his greatly helped by such letters, and I believe that time in looking after $3.00 dollar ailments, thinks if this were a more general practice it would be of the specialist as sitting in his office gathering of advantage to patient, general practitioner and in $5.00 or $10.00 fees; or as engaged in surgical specialist alike. operations for which he receives large compensa- And I believe also that it would be helpful if tion. But he forgets that, while the specialist the specialist, when he is through with a patient, may spend his afternoon hours in this profitable should send him back with a note to the general and pleasant fashion, he has devoted his morning practitioner, so that he might see what the result to hospital work without remuneration. Though, of the treatment was, the specialist practically to be sure, his afternoon may bring him larger turning the patient back to the general practi- returns than the entire day of the general practitioner, so that conditions should be restored which tioner brings to him. From this view point of existed before the family physician sent the the general practitioner, the work of the specialist patient to the specialist. Perhaps this is done may well seem to be more on a commercial basis oftener than I suspect, but I am sure that a than his own, not only because of his larger fees, general observance of this custom would break but because often he sees his patient but once, down the barrier which now often exists between and there is an entire absence of the personal tie the general practitioner and the specialist. The which is so strong between the family physician general practitioner would not be afraid of losing and his patients. his patient for good if this practice were followed, As commercialism has taken so strong a hold and he would be the gainer by knowledge which upon other callings and is sometimes not alto- might be of help to him if a similar case should gether absent from the movements of the clergy, present itself. These may seem trivial points of it would not be strange if its influence were felt etiquette and of very little consequence to a busy among specialists. They are in a way of know- man; but if the work of the profession is to be ing as much as any one of the rapid accumulation thoroughly and carefully done, such co-operation of large fortunes in other vocations. The papers between the general practitioner and the specialist are full of facts regarding these fortunes and the is very desirable, especially in difficult and baf- processes by which they are heaped up. Doctors fling cases. are quite pardonable if they are not exempt from There has come, I am sure sometimes, to be some aspirations in this direction. The change some sense of rivalry between the general practi- in habits and expense of living which has taken tioner and the specialist. The general practitioner place among the people with whom the doctor is sometimes inclined to feel that, if he sends his associates makes it extremely difficult for him patient to a specialist, the latter will treat lightly to maintain his proper social level. The cost of what he has done for the patient, and will alienate educating his children and establishing them in

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org by JOSH ROSENFELD on April 25, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. life has increased greatly; and, both by reason considerable personal observation in the Missis- of these heavier burdens and of the lower rates sippi Valley and in the far West, and on the other of interest on investments, the money which it is side of the Rocky Mountains, that this spirit of necessary for him to lay by to provide for them commercialism has gotten a pretty strong hold and for his own old age is much larger than was upon the profession. Medical and surgical ser- required a generation ago. vice is considered and estimated according to its There is, I am sure, a feeling among some of money value to the giver of the service. So far the older men in the profession that the spirit of has this gone in some of the western cities that commercialism is taking a very strong hold of the the fee tablet has in some instances of which I whole profession; and that, even in conservative have a personal knowledge contained nearly two Böston, where the highest professional standards hundred items where the price was fixed for have been maintained, there is danger that the certain services, and where the whole method in central idea of relieving human suffering and which the price was varied and fixed to the ser- making the lives of our fellow beings more pleas- vice rendered seemed to be based on the principle urable and more peaceful may give place, to some of exacting from the patient as much as he could extent, to consideration of the size of the fee possibly pay. which the doctor may exact from his patient. There are considerations on the other side of In too many instances this fee seems to be based, this question of fees to which it is too much to as the railway magnate said of the freight expect the laity to give much heed. As has been charges, upon " what the traffic will bear." truly remarked in the discussion of this question, When the Prince of Battenberg visited this all eminent surgeons have undergone a rigid and country some months ago in command of a severe technical training after their graduation, British squadron, and as the guest of our govern- and it is this training which makes their hand ment, he carried away, as a souvenir of his visit, sure while operating. The patient pays them, the receipted bill of a New York dentist for $1,000 not for the brief time spent in an operation, but as the price of filling four teeth. The distin- for the skill and training which have been guished guest was not in a position to remonstrate; acquired by years of strenuous effort, and upon he paid the bill like a gentleman, and it was only which he bases the assurance with which he gives by an accident that its extortionate character himself to the surgeon's knife, certain that every- was made public. But when the facts were thing which science can do to relieve his suffering made known, they aroused just indignation in and save his life will be done. That sense of the public mind, and more than one rich and assurance is worth so much to the patient that he patriotic American would rather have paid the should not begrudge paying for it, provided the fee bill from his own pocket, had that been possible, of the operating surgeon is not beyond reason. than to have had the distinguished guest carry There is another consideration also which the laity away such a reminder of American rapacity. overlook. Every surgeon and every physician But the charge of this New York dentist is devotes much time to hospital cases or to cases paralleled by many charges for surgical work. among the poor, where only nominal fees can be Recent correspondence in one of our medical asked at the most, and where often it is impossible journals contains an instance of this sort. that even these should be paid. In no other A New York surgeon asked $1,000 for an profession is a man expected cheerfully to take operation for removing an appendix. The mother such risks and undergo such hardships at the of the patient offered $600, but the surgeon dictates of humanity, without expectation of protested, cited testimony of brother physicians reward. If a physician or surgeon charges a to prove that the fee was not excessive, and wealthy patient a large fee, it may be in order finally received the balance. The letter which that he may thereby be the better able to render enclosed the last check was as follows: gratuitous service in the name of humanity. " My discussion with you has been a friendly No one will deny that the doctor who gives one, and so you will not, I feel sure, suspect me many years to study, who deprives himself of of any acrimony, when I say that my feeling many of the pleasures of life that he may minister about the present excessive charge of surgeons is to suffering humanity, should be properly re- a very general one, and the reflection of a senti- munerated so that he may have the ordinary ment that is everywhere one of surprise and dis- comforts of life. He should be able to make all satisfaction. We do not question your ability, the usual provisions against sickness and distress, but we feel you make us pay too dear for it." whether to himself or his family, to educate his This fee was not exceptional. Higher fees have children and to enjoy an old age free from worry been charged for similar services; and one case and care. But he is not like the man engaged in is on record where a surgeon charged his patient, business who studies every transaction to know a very rich man, $15,000 for an appendix just how much profit it is to yield him financially. — operation,— the case being one of no special diffi- He should study every case, not from the stand- culty, and the charge, evidently, being assessed point of dollars and cents, with a veiw to making with reference to the patient's wealth rather than the utmost possible by multiplying his visits or the service rendered him. Possibly the surgeon playing upon the fears of his patient, but with a may have been a bit of a Socialist in his way, view to doing everything in his power to relieve and may have taken this method to assist in the and save his patient without the slightest regard redistribution of wealth. I am quite sure from for the compensation he may receive.

The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org by JOSH ROSENFELD on April 25, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. Before dismissing this subject of commercialism It is the work of the physician to relieve_suf- in medicine, I want to add a word concerning a fering; to calm apprehension; to make easy and certain class of practitioners, constituting a con- secure the entrance into life; and to attend siderable percentage of the brotherhood, who are humanity every step of the way from the cradle at the farthest possible remove from any reproach to the grave. His it is to study and aid the on this score. processes of nature in restoring health; to pro- Most of those whom I have in mind live in the vide a just ground of confidence in time of acci- country towns, where business methods do not dent or sudden fear; to be a friend, counsellor prevail as in the larger centers of population. In and helper in every physical emergency of life these communities, long credits are almost invari- for which human skill is of any avail; to do all ably given, accounts between neighbors and this gladly, enthusiastically, unselfishly. The friends sometimes run indefinitely without being annals of the profession are full of the records of brought to a settlement, and bills for groceries, men who have faced every contagion and every provisions, dry goods and other articles for form of peril without a thought for their own family use are not paid every month, or every personal safety. In every great epidemic many three months, and sometimes not every year. doctors have given up their lives who might have Naturally enough, the doctors fall sometimes into saved themselves by flight, but who would not the same habits that the farmers and mechanics leave those who needed them. On every battle- and laboring men among whom they live have field, in the track of advancing armies surgeons acquired. Assuredly these men do not need a have cared for the wounded while bullets were warning against carrying on the practice of medi- still flying. This very year, doctors have been cine for the purpose of accumulating a fortune. murdered by the side of their patients in Russia, Their life is hard, their hours of labor long. The because they would not forego their work of ready money in their communities is limited, and mercy at the demand either of Cossacks or of they have to adapt themselves to the conditions the mob. around them. They suffer more than any other This is a noble profession to which we belong. class from these conditions, because in these Richer than any heritage of birth is that which rural communities the doctor's bill often is the falls to us as successors of the courageous and self- last to be paid. If they have children growing forgetful practitioners of the past. The nobility up and to be educated, they find it extremely of this heritage imposes upon us a corresponding hard to do for them what they would like to do. obligation. We cannot be, we ought not to be, I believe that, as a class, these men are the most like men without such a heritage. If the mer- self-sacrificing, honest, conscientious workers for cenary were to be substituted for the humane the relief of human suffering in the whole range motive in the practice of medicine, the most of the medical profession. But I wish that they ennobling and beautiful qualities of the profession might adopt new methods, especially in the would be lost. management of financial matters. It would be It is a serious misfortune that such a profession better for them, and better for the profession, and as ours should even become subject to the suspi- better for their patients, if they were to send their cion of commercialism. But, if it should yield bills promptly once a month or once in three to that influence, if it should be overwhelmed by months. Their fault is a fault which leans to it, that would be a calamity indeed. — 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 Original Articles. faithful servants of the public might do better for themselves. If they would do even half as well THE TREATMENT OF TUBERCULOSIS OF THE as for for themselves and their families they do BONES AND JOINTS.* those to whom minister, their outlook would they BT JOEL E. GOLDTHWAIT, be much brighter than it now sometimes is when M.D., BOSTON. some accident or sudden sickness curtails their In presenting a subject of such magnitude as activities. And, although they do not realize it, the title of my paper implies it is impossible, in the time to do more to a change in their methods would be of advantage allotted, than mention the to the profession by dignifying its proper com- essential features which are the basis of all treat- pensations and preventing the spread of the ment, giving due emphasis to the prevention of destructive notion that a doctor's bill is the disease, that which represents the special something of that can be attended to at any time, or not at work this association. all, if it is not convenient — It should be remembered, in the first place, that " Noblesse oblige " is a familiar French phrase. the disease under consideration is tuberculosis, When the French say this, they mean that and that while the structures involved may differ of birth imposes a upon histologically from those in which the condition nobility special obligation is whoever boasts of it. The man nobly born can- more frequently seen, the essential charac- not be, or at least not to be, like common teristics, nevertheless, are the same. ought is of than men. The very circumstance which increases Bone naturally greater density the soft his privilege increases in the same ratio his respon- tissues, and, consequently, the time required for sibilities. But, if this is true of noble birth, how * Read at the meeting of the National Association for the Study and Prevention of Tuberculosis, held at Washington, May 17 and 18, much more is it true of a noble profession. 1906.