Is the Doctor a Shylock?
EDGAR ALLAN FORBES, IN THE WORLD’S WORK
Facts and figures about medical fees and incomes.
MENTION the subject of medical fees in the average group of men and you will learn that the American doctor is ”out of the money”—is a kind of licensed pirate, overhauling every disabled patient that enters the harbor of his office. Wherever an article on the subject appears outside of the medical press, which only physicians read, such is generally the point of view. Whenever a literary man is confronted with a doctor’s bill, railroad corporations and trust magnates dwindle into pygmies beside the medical “plunderbund,” and the editor or writer finds solace only in giving the doctor wide and scathing publicity. But it is a long search to find, in the protests against medical greed actual figures on which the man without a grievance may base his judgment.
It is a commonplace thing to hear men speak of the exorbitant fees of to-day as a new development in our civilization—but our fathers and our grandfathers and their grandfathers engaged in the same criticism. In a curious examination of the first collection of the laws of the Virginia Colony, I remember finding a statute aimed at “divers avaricious and griping practitioners in Physick and Surgery,’ a statute which permitted the patient to have his doctor arrested if he thought his bill too large. And this rebellious attitude is extended also to other bills in relation to sickness—the charges of the druggist, of the trained nurse, and of the undertaker—but the doctor is regarded as the archpirate.
It is a strange fact that although life and good health are priceless possessions, we begrudge all that it costs us to preserve them. The probable reason is that such payments seem a dead loss ; there is nothing to show for the expenditure. Another curious fact is that the size of the fee has little to do with the outcry. The Arkansas farmer, whose doctor charges $i a visit for a five-mile trip over a rough road, howls as loudly as the New York business man who yields up $10 for a visit that he himself made to the physician’s office.
It is too much to expect that the day will ever come when patient and doctor will be agreed on the subject of fees. Their points of view are too widely different. The physician,, it is, true, refuses to be considered in the same light as a business man or a lawyer, and insists that he is a public servant; but he looks at his income as a whole, not on any particular fee. He compares the number of his working hours and his responsibilities with those of men of equal standing in other lines; and then he contrasts his income with theirs. And what is his conclusion?
“One thing I am sure of,’ said one of the most skilful and most conscientious surgeons I ever knew—a man who has unquestionably dragged scores and scores back from the borderland of death—“is that physicians are the poorest paid of all the professions when you consider the kind of service they render. A doctor’s bill is the last to be paid,.
and they seldom do it with graeiousness.”
This veiw is practically universal among medical men—specialists, city doctors, country practitioners, and all. It is simply a case where the men who pay the bills think one way, and the men on the job think another way. The patient divides the number of dollars he pays, by the hours of service he individually has received ; the doctor divides his receipts for the day by the hours of medical service he has actually given.
The doctor makes no secret of the fact that he bases his charges partly on the service rendered and partly on the patient’s ability to pay. The well-to-do classes resent this as an injustice; the poorer classes ignore it and complain equally loud the doctor still insists that the burden of his ministry to the suffering poor should be shared by the well-to-do. If he were to be paid for all—or most —of the professional visits he makes, he could afford to cut his prices in two ; but the ethics of his calling demand that he respond to every ring of his bell, however hopeless the prospect of compensation. The reputable physician who would demand financial references before putting his finger on the pulse is as rare as the steamboat captain who deserts his passengers when the ship strikes— and shares the same odium. He would be forced out of the ranks of any reputable medical society in America. That he should not patent nor conceal any new formula whose merits he discovers ; that he should give to his profession the rights to all instruments he may invent, or improve; that he should leave his family or his bed at any hour at the call of any man ; that he should risk his own life and that of his children whenever an epidemic breaks out—all this and more is accepted by the public as a matter of course. His is a thankless task, for the doctor has no press agent. The only member of the community who realizes the extent of his public service and the smallness of his recompense is the doctor's wife.
I recall a certain medical student who in his senior year took charge of an obstetrical case “for practice." The patient was a poor Negro woman living in a tumble-down shanty on a disreputable street. The student careful to secure from his professor a promise that he would respond to his aid when needed. One night the call came unexpectedly and the student rushed for the telephone. The professor’s wife answered that the doctor was, out of the city. Beads of perspiration burst out on fhe young man’s brow and he worked his thinking apparatus quickly and hard. He could recall but one other, and for him he called with the haste of a man turning in a fire alarm. To his great joy the second doctor answered—but said that his wife had that hour returned from an absence of several weeks and would leave again the following morning. But when the student explained the situation, the doctor left his fireside and sat with the student in that poor woman's hovel until nearly daylight the following morning. But he did not do it “for practice !”
And if a physician be called from the bedside of a patient whom he has perhaps visited for weeks without the prospect of a single dollar, to attend a millionaire with an aching stomach, he regards it as only the capitalist’s duty to society that his check should balance the poor devil’s account also.
What are the real facts about medical incomes of to-day? In the effort to reach an honest answer, we must differentiate between the New York specialist, the average American specialist, the average successful practitioner, and the country doctor, at least.
The New York specialist receives the largest fees in the country and the most of them, for two reasons. Here are found a few physicians of exceptional reputation and hitherto gravitate the country’s wealthiest patients. Those who have not come to New York to live, come now and then for consultation. While figures that can be relied upon are not easily
obtained, there are doubtless a number of specialists on Manhattan Island whose incomes run above $100,000 a year. It is easy to imagine tjhat those who attend New York’s great magnates receive large fees and that their prestige attracts many other wealthy patients. These belong in a class to themselves and are representative neither of the American specialist nor of the average specialist of New York City.
The largest fees, quite naturally, are charged for surgical work ; the operation for appendicitis is a familiar example. The customary New York charge was brought out some months ago in the published letters that passed between the surgeon and the mother of a wealthy patient. The case was one of gangrenous appendicitis, “with impending disaster” ; the surgeon went twenty miles from the city to operate, and saved the patient. He sent a bill for $1,080; the mother sent a check for $600 and a friendly letter saying that she had found $500 to be the customary fee in the city. The surgeon replied that it was pretty well known that he never undertook the responsibilities of an abdominal operation for less than $1,000, that in some such cases his fee had been several times that amount, but that he would submit the correspondence to three other surgeons. All of them endorsed the charge as reasonable and one specifically stated that in all abdominal operations he also charged $1,000 or more. These charges, it seems, are made for services to families well able to pay. Some patients doubtless pay more ; most undoubtedly pay less—all the way down to nothing.
These figures, standing alone, will appear large to some. Their proper proportion will appear only when they are viewed in comparison with what other professions receive for an equal amount of skill, labor, and responsibility. The average fee for the hazardous task of opening the abdomen and subsequent attention will look trivial when compared with what a corporation or criminal lawyer would charge in a suit of equal grav-
ity. And beside the $100,000 income for a year’s work among the wealthy, place the statement recently made by Senator Depew with reference to Senator Spooner :
“Had he resumed the law when he desired to, he would have been employed as counsel in nearly all the big railroad reorganizations, in some of which legal fees of $1,000,000 were paid.“
In considering the average American specialist and the average general practitioner, let us take a city in the central part of the Union, with a population between 2oo,ooo and 300,000. I have before me the figures relating to such a city and have the advantage of an intimate knowledge of the physicians themselves, which is a check on accuracy. Of the many physicians—and the proportion of men with far-reaching reputations is usually large—about 20 per cent, do the bulk of the medical and surgical practice.
Of the surgeons, there are about a dozen whom their colleagues call “successful.” In round numbers, their yearly incomes are about as follows :
1 makes from $18,000 to $20,000 1 makes from 15,000 to 1)6,060 6 make from 10,000 to 12,000 4 make from 5,000 to 6,000
Among those whose annual incomes are less than $5,000, are the dozens of surgeons who have never risen above mediocrity and the younger men whose reputations are yet to be made.
So much for the yearly incomes of the surgeons. What about individual fees? I happen to know the most important facts so far as three of the leading surgeons are concerned. Dr. A. is a specialist in operations within the abdominal cavity—next to brain surgery the most perilious of all. His standing in the profession is such that every medical society is glad to have him as a member. He is also a professor of surgery in an important college. He is therefore entitled to receive as much as, or more than, any surgeon in his city. This specialist has never received a fee larger than
$1,000, and that amount has been paid him but a few times. A number of times he has received $400 and $500, but the majority of his fees range around $200. To the laity, the average of these fees looks like “easy money,” but the actual operation is the smallest part of the surgeon’s work, as the following typical case will show :
The operation is to take place at eleven o’clock. There have been at least three careful examinations of the patient beforehand, one of which included microscopic for chemical work. No less than two assistant physicians are required—one to give the anæethetic, another to pick up blood vessels as soon as severed, to avoid hemorrhage. The preparation of doctors, patient, instruments, and bandages has consumed most of the forenoon. The patient is back in bed within an hour, but the surgeon lingers until consciousness is fully restored. He sees the patient again late in the afternoon, and probably again at bedtime. He counts himself fortunate if he gets no telephone call at midnight and if he escapes a hurried call before daylight to check hemorrhage or allay pain. This average patient will require regular attention for two weeks. Such intangible cares as nervous strain, weight of responsibility, liability for mishaps, and loss of prestige through unavoidable failure cannot be reduced to figures. And if this average patient were rich—unfortunately, he is not— the surgeon would not feel overpaid if a grateful family should send him a check for $500 or even $1,000. The patient’s earning power, perhaps his life, has been saved.
There is another fact that must not be overlooked. Dr. A.’s average fee is about $200 for these operations— not his average for each operation performed. I have seen this surgeon operate in at least a dozen cases, each requiring as much attention as the case above, from whom he could not possibly have expected to receive enough to pay for the ether used during the operation. Yet his technique was as thorough and his attention as conscientious as any patient could have required.
Dr. B. ranks equally with Dr. A. in almost every respect. His largest fee, up to the present time, is $600 ; it was for an abdominal operation when the patient’s life was at stake. His smallest fee has been nothing— many times. I called him once to come in haste to a laboring man whose ankle had been badly crushed ; it was a protracted case and upon the surgeon’s skill depended the man's ability to support his fafnily. The charge for all services was $25.
Dr. C. is an older surgeon, and there is none in his city who outranks him. Before me lies the record of his first 100 operations for appendicitis, read to a small group of surgeons the evening afer the last operation. Every man in the room sat straight up when he began to read it, for it was well known that his operations had been the most desperate of all. “Forlorn hopes,” upon which other surgeons refused to operate sent for Dr. C. If there appeared one chance in ten to save life, the surgeon took reputation in his teeth and went in. His colleagues accused him of occasionally operating after death ! His remarkable success with these cases does not concern this article so much as his compensation. For no operation out of the hundred did he receive more than $1,000; the average was $100.
In this representative ctiy are eight “successful” specialists in diseases of the eye, ear, nose, and throat. Their annual incomes are about as follows :
2 make from $12,000 to $15,000
3 make from 10,000 to 12,000
3 make from 3,000 to 6,000
Besides the foregoing, there are probably not more than two or three specialists in other lines who receive as much as $10,000.
Of the general practitioners, there are probably fifteen in the upper ranks —men of excellent reputations, prominent in medical societies, most of them professors in medical colleges, A fair estimate of their yearly incomes is the following:
3 or 4 range above $10,000 a year 4 or 5 range from $8,000 to $10,000 G or 8 range from $4,000 to $8,000 General average of the fifteen: $8,000.
What do they .do to earn it? They are in their carriages so constantly that it is difficult to keep the office hours, rarely possible to leave the city for a few days, and impossible to take a vacation without serious loss. To gain an income of this size, they do much more than ordinary day-andnight medical work. Most of them are also insurance examiners and physicians to institutions ; many of them lecture to students more hours than the average college professor.
With regard to fees, I systematized the accounts of one of these general practitioners and kept his books for two years. His practice is large and wealthy, and his standing is such that when he rises in a medical society to discuss a case, all others sit down. His scale of prices, which rarely varied, was fixed in this way : Day visits, $2 or $3 ; night visits, $5 ; office consultation, $1 or $2; consultation with other physicians in serious cases, $5 or $10: special examinations, $5 to $25. His bills were rendered all the way from three months to a year after the service, according to the patient’s circumstances. The only instances I can recall when payment was insisted upon were cases where well-to-do patients were in flagrant default. At the end of every month, the number of calls I was instructed not to transfer to the ledger was surprisingly large ; they were profit and loss. Medical service to students and to institutions was not recorded, even on his daily memorandum. “At least half of our work is never paid for,” he said one day “—except in thanks or the reverse.”
Yet this man, like most of his colleagues through the country, is stamped as a Shylock by the easy writer who feels the sting of a recent bill for medical attention.
All these whose incomes are given fall within the 20 per cent, doing the bulk of the business. Of the remaining 80 per cent., one thoroughly competent to judge says that the young doctor probably makes from $500 to $1,000 a year during his first five years of practice. After his business is established, his average should be about $1,800, gross. Another places the average income for the entire country at $1,000; he thinks 80 per cent, collect less than $3,000 a year.
The income of the doctor in the small town, if his practice be established, will range from $750 to $1,250 a year. A western physician made the statement last year that careful inquiry made by him in nine different states had shown that the charges of physicians had not increased one cent in twenty-five years, though the incomes of the people had more than doubled. The schedule for four states was about as follows : Day visits in town, $1 ; office consultation, 50 cents ; country visits, 50 cents a mile, charged one way only ; obstetrical attendance, $10. I11 five states, the
charges for visits and office consultation were twice as much.
These figures are offered by way of protest against careless statements —growing out of exceptional experiences—that reflect on the medical profession at large, a profession that does more practical relief work, without credit, than any other class of men. For the figures seem to show that—
( i ) A very few physicians of preeminence have large incomes, but smaller than men pre-eminent in other lines.
(2) Something like 20 per cent, of the physicians in the larger cities have handsome incomes, in return for expert work and much of it.
(3) Eighty per cent, of city physicians and most of the country doctors make little more than a decent living —man)’’ not even that.
(4! The average of fees charged in city and in country is no larger than it was twenty-five years ago.
(5) The code of medical ethics (established by physicians themselves) is such that no class of the American people need suffer for medical attention because of inability to pay.
Is the doctor a Shylock?