The Righteousness of Doctors’ Bills

George C. Lawrence, in Appleton's Magazine June 1 1908

The Righteousness of Doctors’ Bills

George C. Lawrence, in Appleton's Magazine June 1 1908

The Righteousness of Doctors’ Bills

George C. Lawrence, in Appleton's Magazine.

Professional Services Cannot be Measured by Ordinary Every-day Standards — Men May Yet Possess the Power to Cause Every Infectious Disease to Disappear Entirely From the Face of the Earth.

IF one were talking in fables this might be called the fable of the Physician, the Lawyer, and the Business Man. But as fables are more or less outof date and generally interpreted according to individual taste, it will serve better to recite the True Story of a Certain Mrs. Suburbs.

This particular Mrs. Suburbs wasn’t of the class to be commiserated, who want to live in the city but can’t afford it. She lived in the country from choice, in a big red brick house, surrounded by a wide green lawn, and her share of the world’s goods was very much more than most of us ever get. Among her other possessions were a husband and several children.

Now it so happened, which is not surprising, that one of the daughters fell ill and that it became necessary in order to save her life, to perform a very delicate and dangerous operation—the kind which a physician masters only after many years. So, because Mr. and Mrs. Suburbs didn’t want to take any unnecessary risks, a big man was brought from the city, a man by the way, more than fifty years old. He came. He operated and was successful. He returned many times to see his patient. The girl was made whole and Mrs. Suburbs was filled with undying gratitude—up to a certain point.

The certain point had come that morning in the shape of a bill for

$800. Mrs. Suburbs opened it with trepidation, viewed it with alarm which turned to resentment, and with the piece of news waited to hand it on to Mr. Suburbs.

Presently, subsequent to his naturally expected delays as a commuter, entered Mr. Suburbs. “JOHN,” exclaimed his wife, before he had even removed his coat, “what do you think !”

Experience had taught Mr. Suburbs that he was not at such a juncture expected to utilize his mental faculties. He merely waited.

“JOHN, Dr. Cutler’s bill came today and how much do you think it is?” Then rushing to a breathless climax: “E-I-G-H-T hundred dollars, what do you think of that?”

“Um,” was the noncommittal reply of John as he removed his coat. Being a professional man himself, though in a far less exacting calling, he perhaps remembered the early and empty years through which Dr. Cutler had struggled while acquiring the skill by which the daughter’s life had been saved. He even sighed a little as he thought of the difficulty of professional fees.

“I got a check from Rankin today,” John remarked.

“Oh !” cried Mrs. Suburbs, immediately interested. “The man you wouldn’t let the horrid judge send to jail for a year?” (Jail to her was a generic term including all places of involuntary incarceration.)

“He’s very well off, isn’t he? How much was it?”

“About as well as we are. Fifteen hundred dollars,” replied John, answering the questions in order. “He was very glad to pay it. Thought it ought to have been more. Said he would have paid ten times as much rather than go to jail. Said it would be worth that to him.

I wonder what a child’s life is worth ?”

Here the subject dropped, for Mrs. Suburbs had a premonition that Jfbhn was preaching at her. Dinner was hardly over before neighbor Business Man dropped in.

“Did a bully stroke of work today, Johnny, my boy.” he exclaimed, slapping him on the back. “Sold that property to the traction company for $96,000. Pretty good, wasn’t it?”

“Pretty good,” echoed John, and then: “Let’s see, what did it cost you? Sixteen thousand three years ago, wasn’t it?”

‘ Correct,” replied neighbor Business Man.

And then John, without any intention of being rude, fell into a brown study. He knew what the education of his brother, a struggling physician in a western town, had cost. He knew what his own had cost, too. It was more than $16,000 in each case. But even on that basis, what legitimate expectation had either of them of retiring at an age worth considering, with a net profit at the end, of $80,000? He put the thought from him with a sigh. And the years—here was Business Man at thirty-one cleaning up enough to last him the rest of his life if wisely invested. And here was he—Suburbs—at, well at quite a few years more than thirty-one— at which age he had been barely self-supporting on the meagerest basis, and not yet able to charge off on his mental books the cost of his education. He had much, to be sure, but he lived up to his income. To stop his work meant to stop that income. He had no investment in

land or bonds. His investment was in his education. And then again he thought of Cutler’s bill and grinned. “Well,” he remarked to himself, “we’re a whole lot better oft than the medicos.”

Now, this in all its essential points1 is a true story, and, as they say in story books, it teaches us—well,among other things, it teaches that the value of professional service can’t be measured by the same standard as the value of a house, or a pair of shoes, or a loaf of bread. And most of all this applies to the medical profession—the question of physicians’ fees—the returns of that service of which 2,500 years ago Hippocrates said, “Medicine of all arts is the most noble.”

To get as nearly as possible at the heart of this question of the righteousness of doctors’ fees, more than six thousand printed forms, containing questions pertinent or impertinent, as one may view them, have been sent to doctors of all classes in all parts of the country. They were questions frankly asked, questions as to figures and time and income and ethics of the profession. And they were as frankly answered. Much in the answers can be tabulated in an effort to analyze the doctor’s fee on a commercial basis. But much also, for the most part the human, cannot be tabulated. One must read between the lines.

It is a curious fact, almost startling in its significance, that while the value of all those physical things which enter into our lives may be and is determined on a purely commercial basis of cost of production, the value of that life itself cannot, except in comparative terms, ever be expressed. How much, for instance, is the value to you of the life of, say, a son ? More than all you possess. Judged on this basis, then, is the physician’s fee exorbitant, or is it, as a commercial service, immeasurably small?

Eternally, by the very nature of his calling, the physician is working for his own elimination. The

accomplishment of the prediction of Pasteur, that it is within the power of man to cause to disappear from the face of the earth every infectious disease, is not an idle dream. Already under the advance of medical, surgical, and sanitary science, the physician sees, rejoicing as he sees it, a diminution of that demand upon which he and his wife and children are dependent for their daily bread like any other mortals. On the authority of a physician in that city, the improvements in scientific sanitation in Chicago in the last twelve years coupled with the advances in medical science, have decreased the field of medical practice twenty per cent. Even as he works, whether in the laboratory, the field of experiment, the slums, the city, or the village, the physician is of necessity undermining his own livelihood, measuring his success by the increasing lack of need for his services.

“Into whatever house I enter, I will go for the benefit of the sick. With purity and with holiness I will pass my life and practice my art.” So ran the oath administered by Hippocrates to his students almost five centuries before Christ, and so still stands to-day the physician’s ideal. Medicine then partook of a character of holiness, for the student, too, swore “to reckon him who taught me this art equally dear to me as my parents, to look upon his offspring on the same footing as my own brothers, and to teach them this art if they shall wish it without fee or stipulation.”

Can anyone to-day with an inkling of the life of the disciple of medicine doubt that the spirit of this ancient oath is rigidly observed in its practice? Or that as Hippocrates dictated twenty-five hundred years ago, “Whatever in connection with my professional practice or not in connection with it I see or hear in the life of men which ought not to be spoken abroad, I will not divulge as reckoning all that should be kept secret.”

Investigation and knowledge, experience and association, can only make more apparent that commercialism and medical practice are as far apart as the poles. For the manufacturer, the shopkeeper, whom else you will, success may be measured—though happily it need not be—in dollars and cents. For the physician it is measured in the alleviation of pain and suffering, in appreciation and gratitude and friendships, but last of all in the number or size of his fees on vvliich he depends for his ability to carry on his work.

Says a physician writing from a small city in the West, into which he, after his years of study and training, has disappeared to carry on his work, “not all of medicine is bad. There are many pleasant things, gratitude, friendships, and the opportunity to be a force for good, for right living and right thinking.”

“My boys,” said an old doctor to his graduating class in a famous medical school (and his students were always in a sense to him boys, as were his patients’ children), “I want you always to believe in the human race and have hope. You will see the darkest side of life; you will learn what I have learned, and you will have pain and suffering for your bedside companions, and you will be poorly paid for what you are giving. But always remember the frailty of flesh, the holiness of your calling, and always have hope.”

While there are those who know the work of the physician in whatever field, there are those innumerably greater who do not, and who wonder with a commercial cynicism at the charge of the family physician, or specialist, or surgeon. To such, the experience, commercial if you will, collected from hundreds of doctors in all parts of the country may furnish a basis for belief in the primary importance of the Hippocratian oath, “Into whatever house I enter, I will go for the benefit of the sick.”

What seems to me the most significant statement echoed by many others was given me in the course of a casual conversation with one of New York’s greatest specialists.

“I doubt if there are to-day in this whole city ioo doctors who could retire and not starve to death within a year. Our expenses increase with our own income, and while the average business man can hope to retire some day, the average medical man retires when he dies.”

Now, as to the matter in more detail. The average physician graduates from his medical school four years after the college man who elects a commercial career has begun to earn a living wage or even to lay by money, and from ten to twelve years after the class from which our wealthiest and most prominent men come, begins to be productive, and in the sense of not being a financial burden on some one else, independent. His preliminary college education up to that time, including the acquirement of a degree of A.B. now demanded by the best medical school, has cost the physician on an average $4,429.63. (These and subsequent figures are averaged from all replies received.) This figure is not the cost of the best medical education calculated to best fit the physician at some remote day to be self-supporting or even—vague hope—to marry. Nor does it take into account the loss through unproductive years when the man who elects to ‘■go into business” is earning.

A conservative estimate, taking these factors into consideration, places the amount which the graduating physician, the proud possessor of an M.D. has been called upon to spend, at $11,000. And then he has only begun. He cannot immediately begin to practice, for the moral obligation, so binding yet so little understood by the laity, demands that he shall spend from one to two years in a hospital. Indeed, figures from the largest and most prominent

medical school in the country show

that more than four-fifths of the graduating class enter hospitals, where more often than not in deep debt, they receive board and lodging, but, of course, no fees. It is a conservative estimate which places the age of the young physician, ready and equipped to take the plunge for himself (and incidentally encumbered with an appalling debt, as more than forty per cent, are) at twentynine or thirty—an age in the present commercial race already comparatively old.

Standing on the threshold of financial and far greater moral responsibility, what does the young doctor see before him? He is the belated producer, looking to benefit society and yet with no means of livelihood. Shall he go to the country town with its lessened chances for progress and achievement? Even there the time before he begins to pay current expenses is, if he is fairly fortunate, something like two years, and the expense during that lean period something like $1,000 annually. Shall he stay in the large city where his chances of service and prominence—in bald terms his prospects for a last quiet few years, if he ever attain to them—are bigger, and so a more hazardous problem? For in the big city his expenses are proportionately greater, and his term of unremunerative service proportionately longer, so that from five to eight years and from $7,500 to $15,000 more may be required before he sees where his bread and butter are coming from.

And here I should like to quote, though in abbreviated form, the figures compiled by an able and rising young physician (not yet thirty-six) in New York, partly because of long acquaintance, but chiefly because of a personal knowledge of the conscientiousness with which they were prepared and the struggle which, to those who know him, their size only emphasizes.

The value in time and money spent in acquiring a medical education during ten years he places at

$29,400, the time value being figured on a statistical earning table of men in commercial pursuits. “The average doctor may expect to be selfsupporting,” says he, “after the end of the third year. (That is, selfsupporting at thirty-two or thirtythree, but with his investment still unpaid.) The figure at which he places the cost of the first year of independent practice is $3,500; for the succeeding two years a little less because of the large initial investment necessary.

These figures may seem large, yet when I have referred to other physicians concerning them they do not find them so. Of course had this man gone to a country village his expenses would have been much less, just as would his hopes for ultimate income. But the average young doctor still retaining his ideals wants to locate where opportunities for study, for advancement, and for hospital work are greatest —that is, in a big city.

And here, perhaps, may best be answered a rather vulgar criticism made of doctors, “Oh, yes, he’s rich ; he comes around in an automobile,” for to certain persons an automobile stands as the chief indication of wealth. Well, this particular doctor from whom I obtained the foregoing figures keeps an automobile. He is nearly thirty-six and can’t afford to marry, thougn he wants to.

‘T can’t afford an auto either,” he said, “but I have to have it. With it I can make twice as many calls, and although it postpones my time of independence I hope it may pay financially in the long run. Medically, it is my duty to have it, as it is my duty to get to places where I am needed and get there quickly.”

There, briefly, is the dollars and cents side, in itself terrifying. But far above that there is the sense of service, the moral obligation which binds even the novitiate during his period of service. From the begining of his medical course the student comes in contact with condi-

tions calculated to make men weep. To him is to be opened the problem of life and death, of physical frailty and moral degeneracy. And if lie shirks he is lost.

And after this: the debts, the work, the suffering and the struggle to maintain ideals; the youth, no longer a youth, stands on the threshold of financial responsibility at an age at which other men are already successful and fathers.

It is not to be wondered therefore that the writer himself, acquainted with men in whose future he was interested, should query, “How do you expect to make money’ from a company of men about to receive their medical degrees. Nor to those who judge by any but a commercial standard is the reply any more wonderful, “We have not studied medicine to make money, it is something more than that.” Of the twenty-four men present at the time, twenty-one were already in debt and would be still more so before they could begin to pay current expenses. And yet money was farthest from their thought.

Specialists, to the lay mind, are notoriously high-priced. Yet here is the record of one of New York’s best known men of this class. When he started in to practice after several years of vicissitude which hardly left soul and body together, he was, for his education, still $5,000 in debt. And he was then thirty years old. The marriage for which he had hoped for years, was still as vaguely distant as ever. He had for less than a living wage been working seventeen hours a day for five years, and then, taking the bull by the horns, he started for himself. During three of those five years he had slept on an operating table with no mattress, and because of his indebtedness had eaten only two meals in his long day.

1 íe started in a poor locality where a large majority of his patients were charity patients. Now it is a peculiarity that while charity

patients will go anv distance to be treated by a good man, “pay” patients will go none at all. Year after year he found himself treating more people for nothing, and running farther and farther behind financially.

So at last he decided to take the plunge, lie moved to a good locality. still many thousands in debt, though getting on toward thirtyfive, and took an office, the cheapest he could find, which cost him $1,500 a year. Immediately, because of his location, he began to make money", until to-day he has what is for a doctor a large income, though for a man of his ability" extremely small.

He showed me his book running through months, and more than twothirds of his patients were those to whom he charged nothing. To talk with him, a man who had struggled alway"S and married late in life, was a revelation. One day" ty-pical of all will do. He showed me his ledger, calling oft the names and explaining, almost apologizing, for his charity.

There was a school teacher: “Well, y-ou know how school teachers are paid in New York—she would have died without an operation. So I operated. But” (apologetically), “I couldn’t send her a bill.” There was a seamstress—and so on and so on, and out of the nineteen patients he had spent his dayon, he had charged but six, and of them to two a reduced bill. And yet he called it a “good day,” at .nearly" fifty" y-ears of age.

I cannot resist one more story" of this man, both because of his prominence as a so-called “high-charging physician,” and the inner side I have come to see.

“A few yrears ago,” said he, “when I was still in debt for my education” (he was then almost forty and charged what he does to-day) “a man came to me to arrange for an operation to be performed on his wife. It was a long and difficult operation, necessitating many weeks 54

of frequent calls and when she was well I sent a bill for $500. Shortly after I received a note from her husband asking if he could see me, and when I talked to him I discovered that he was a poor man. He would not accept charity, so I sent him a bill for $100 which he is paying off at the rate of $25 a year. Yet the time and services expended were worth to me more than $2,000.” ■

And here in itself is a curious and interesting point. Suppose you were going to buy" a house, or a ring, or a set of books. Would you not naturally" inquire the price? Yet the average person calling upon a physician for his services, in the great majority of cases, never makes any inquiry at all. And then when the bill comes in, ignorant of the struggle and the sacrifices which made the service possible, it is regarded, let us say mildly, as exorbitant. Yet no doctor, worthy of the name, ever refused his services because of the inability on the part of the patient to pay the full fee.

“How does the doctor reconcile his fees?” Flatly, he does not. There is no need of reconciliation. The doctor of whatever class first goes “for the benefit of the sick.” Subsequently he has a living to make in order that he may still continue to benefit the sick, and so, naturally enough, rises the question of charges. For the same operation which for a poor person costs nothing the wealthy person may be charged $1,000.

To those who would put the matter of a physician’s fee on a commercial basis, it can only be said, “What is health worth?” Were any physician to charge in keeping with y"our own valuation of this “commodity,” would y"our valuation of his services be greater or less?

In the end, having had even a small insight into the physician’s life, one naturally returns to this question, “Well, how about big fees charged to wealthy patients?” It is an involved question this, difficult of answer after much investigation.

There is no commercial basis for the answer, for the service is something apart. If you are paying for any of the commodities which come within commercial limits there is a practical basis for figuring, whether that commodity be beef, or clothes, or stocks.

But let us suppose that your child lies dying. Let us suppose that all that is dearest in the world is menaced with the final obligation of life—what would you be willing to pay to escape that obligation—to have saved the life of the child, the wife, or the mother? And is it wide of the mark to say that the life in jeopardy is dearer to you than all else that you possess? Yet what physician ever made such a charge —even though it might be worth on a commercial basis of value received, all that be asked? But if one still persist in the idea that the doctor’s bill should be measured in dollars and cents of worth received, and forgets, with the price of that same doctor’s livelihood staring him in the face, the time and the labor and the sacrifices and the pain (for no man can rub shoulders with Old Mortality as does the physician and not suffer pain) which he gives freely and gladly, why then let us see, so far as the uncommercial standpoint applies, how this all works out.

Some years ago a famous doctor from abroad came to this country, and for a famous fee treated successfully the child of very wealthy parents. That fee in its size became a subject of much discussion —abstractly. But practically no one seemed to remember that the famous surgeon had passed far beyond the age where many men can retire before he became successful, and even fewer remember now that for that one fee he left his practice—that is, his means of living—and while in this country gave without price and freely to the poor and afflicted the same service for which in the case in question he had received a large fee.

A famous operator recently recited to me the history of a certain case. Said he, “I was called upon by a physician in a certain city to operate on a case where success meant escape from blindness. The patient came to New York and all arrangements were made. On the day appointed she came to the hospital. She came in her own automobile, and the furs which she wore could not have been worth less than $10,000. She had with her two maids and two private nurses. I operated. It was a delicate and a dangerous operation. It was successful, although for weeks afterwards she demanded and received one quarter of my time. At the end she was cured, her eyesight was saved.

“When I sent in my bill (and it was for $2,700) I received a curt note saying that she would pay $700 and no more. During the time in which I attended her I had given, based on a minimum fee, more than $6,000 of service to persons from whom I shall never ask a cent. You can think what you please. I have to live. I wrote to her that if she considered my services worth only $700 I should be glad to consider the matter closed. I almost wonder how doctors live and hope and believe. I am almost sixty. My best days are gone. It is my duty to give way to younger men. Yet I charge no more to-day than twenty years ago, and if I should stop I would starve. I must die in harness. We all must. All that I have to give—when giving is called for— and yet at sixty-two I cannot see a few quiet years free from financial worry. I have never known a physician yet worthy of the name who considered money. You laymen don’t know.”

The big fee charged to the rich person—there is the crux of the question. But the matter appears in a very different light when one stops to consider that it is big not in proportion to the service rendered, but only in comparison to the fee

of nothing at all for which the p’nv-

sician renders the same service to those unable to pay, but usually infinitely more thankful.

A certain famous surgeon, whom I know, wore for three winters, to the wonderment of his friends and until they were nothing but tatters, a pair of knitted mittens. They were the Christmas gift of a poor woman whose son's life he had saved through a long siege of gladly rendered attendance free of cost. They came to him with a note on Christmas Day when I happened to be with him, and I doubt if in his long life of service he was ever more deeply touched.

“Dear Doctor—’’ ran the penciled note, “I know you have to go out much in winter in the cold. I hope that these mittens may keep your hands warm. It is all I have to give.”

Well as I knew him, I think he was never more moved. lie tossed me the note while he held the mittens and said, “There are compensations. These mittens mean more to that mother than an automobile to you or me.” And almost in the same hour he showed me with an entirely different sort of a smile a letter from a multi-millionaire protesting against the charge for saving his son's leg.

“Let him keep the fee," he cried, almost savagely, as he looked at the mittens. “If he thinks I reckon life on the same basis that he reckons beef, let him keep it.”

Incidentally it is interesting to note, in this effort to commercialize a noncommercial spirit, that the multi-millionaire, graced perhaps by the light of understanding, sent to the physician a check for ten times the amount of the original bill, and that the physician as promptly turned it over to the hospital.

The fee of the rich man is undoubtedly larger than that of the poor man—and why? Barring the ministry, medicine is the only trade which takes into consideration the purchaser's need. Let the poor man—even though he be starving—try to purchase a loaf of bread and he finds that the price to him poor is just what it would be to him wealthy. And the same is true of everything that goes

to make up his physical life, with one exception, the service which keeps that life going. If the patient has means to let him pay, or if he has not, the same service is given without price. Were we all wealthy there would be an easily determinable value for the doctor’s service, based on his cost of education, the worth of the service which he performs, the lateness at which he begins to earn and the quickness with which he is forced to retire.

The greatest railroad in the country sets seventy years as the age at which a man must quit. Its employes, on that basis, have fifty earning years ahead of them when they start at the average age of twenty. But the doctor starts at thirty, and if he be fortunate has twenty-five years of productive practice ahead of him. Many with whom I have talked or corresponded place the limit of the physician's, and, particularly, the surgeon’s remunerative life, at twenty years.

The average medical practitioner must be entirely absolved of the charge of commercialism. Stop and think when next you receive your doctor's bill, at which you may feel some surprise, that the doctor, when 'he is ready to practice, has' spent some twenty-five thousand dollars at a conservative estimate in time and money in acquiring the education which may mean the saving of your life ; that at thirty years of age, when the majority of his friends have married'and are laying by a competence, he stands on the threshold of a financial struggle which he knows will probably never be largely remunerative ; that when he starts he is more often than not heavily in debt ; that during his early years he has had long hours and has been inevitably brought in his.daily life into close touch with suffering, and pain, and debt, and want, and vice, and sorrow, and need, to an extent which would lead you or me to doubt the very purpose of life; that for far more than half of his services he can never expect more than thanks, and that at the age when the average business man is at his zenith he loses those delicate senses and powers on

which his practice rests, and, finally, that his work is first and always a service of humanity and secondarily a service for return.

After all, the physician is not a commercial proposition. He gives what is asked, receives what he may, and, in the end, having seen many births, much suffering, and many deaths, he joins the innumerable caravan—leaving what? Under ordinary conditions a dependent family and a few friends who truly understood him ; under abnormal conditions a name, a long-delayed appreciation of services rendered, and a dependent family. Come, let us reason together. Can anyone of you point to a physician wealthy, that is, wealthy in proportion to his services, or wealthy in proportion to his ability had it been applied in any other field? Judged on an honest basis—not one in ten thousand.

Says one man (and it should be understood that all these comments were obtained under the assurance of confidence, since, like all lovers of good, the physician is little inclined to talk of his work), “no physician is ever paid proportionately to the work he is called upon to perform. Practically no physician (except the most fortunate, an extremely small proportion of the whole body) leaves anything but life insurance and uncollectable bills to his family.”

And another physician, writing from a western city in answer to the query as to the advisability of postgraduate work, “the work is necessary, but ninety-nine per cent, are financially unable to afford it.”

Fifty per cent of a doctor’s working life, at least, he gives to charity, and here is a note of sadness for those who wonder at their charges. In the words of a Western physician who writes in to what he gives in time and money annually, “half of my time,” and then as to money, “I have never had any to give.” Half his time, the earnings time of his life, and this physician, noted for his sincerity, has “never had money to give.” Commercialism or non-commercialism?

And the doctor, aside from an earning standpoint, is short-lived. One, indeed, when asked how long they lived, replied with a note of cynicism, remarkable for its uncommonness, “about twice as long as they ought to.”

But seriously considered in the light of their irregular hours, their exposure to contagion and the mental strain which the constant grappling and compromise with inevitable if ultimate death produces on the physician, he is as a class short-lived. The men who do the work are, as a rule, not more than middle-aged.

Always the physician feels in his heart the absolute uncommerciality of his profession which can be summed up in no better manner than in the answer of a well-known physician of Boston in answer to the question, “How much does a doctor contribute in charitable works in time?” The answer was: “He never refuses.” It

is an answer that smacks of nobility even though it be nameless. And when that bill, by which, after all, we are prone to judge the physician, greets you at the breakfast table or the office, it is worth while, as it is honorable, to consider it, remembering that the service for which he charges you or me “he never refuses” to those who need and lack, even while the bill is not so large as it would be on a commercial basis.

There is, after all, for those who question the righteousness of the physician’s fee, a final test. The cost of living of late years has advanced at an almost prohibitive rate. Naturally this might be expected to increase the cost of any commercial service. Yet more than six thousand inquiries sent to physicians throughout the country asking what effect this same increased cost of living had on doctor s fees brought the practically unanimous answer—almost pathetic in its noncommerciality, “none.” Just three physicians made any other answer, and their replies were that fees had advanced during their practice only in small proportion to the cost of life’s necessities.

Long years of study. Tort years of usefulness, long hours of association with pain and suffering and death, poor pay. one-half his working life given and given gladly to charity, old age or rather comparatively old age without a competence (“we must all die in harness or starve”), facing him, always a depressing knowledge of human frailty, and with death always for an opponent—that is the part of the average physician.

Let us pay the tribute long overdue, not in money, but in appreciation. \Yc who ring the telephone at two o’clock on a snowy morning to summon the doctor, who, for aught we know, has been working since day-

light, let us remember the words of that old doctor who gave to his departing disciples the message, “Always remember the frailty of flesh, the holiness of your calling, and always have hope.” And if we stop to think, there is a holiness and an absolute freedom from commerciality in the calling of him who has for his opponent not a rival manufacturer, not a rival financier, but the inevitably victorious Death. Consider the sacrifices, the needs, and the gifts of the physician, measure to yourself the value of even a day more of life, and then judge, so far as it is given to us to judge, the righteousness of the physician’s fee.