The Why and the Wherefore of Doctors’ Bills

Edward J. Moore December 1 1912

The Why and the Wherefore of Doctors’ Bills

Edward J. Moore December 1 1912

The Why and the Wherefore of Doctors’ Bills

Edward J. Moore

In this article a question of the greatest importance and widest interest is discussed. Why is it that for the same service doctors charge different people different rates? There’s a reason. It is discussed here, both from the standpoint of the public and the profession. Should the members of the medical profession in Canada, particularly specialists and surgeons, have a tariff of fixed charges for their services? But do not attempt to answer the query before perusing the article.

You submit to the kneading and tapping over the sore spot in your vitals with as good grace—meaning as little grunting—as possible, and wait with anxiety for the verdict.

The specialist looks up at you over his eye-glasses, seemingly to see how you will take it.

“I’m afraid, Mr. Smith, it means an operation. If we had caught it a month ago we might have treated it, but now the surrounding tissue seems to be in such a condition that . . . .’’and

so on.

Your heart goes down with a jerk. Somehow there is a finality about the pronouncements of these specialists that strikes deep. Probably your family physician had led you to expect a similar decision, but now that the reality has come you feel a sinking in your stomach and your boots suddenly seem two sizes too large.

A good many of us have been through it and will remember. And for the comfort of those who have not yet had the experience, we can assure them that in all probability their opportunity ’s more or less closely at hand. In these days of manifold physical derangements and wonderful surgical me-

thods few there be that escape. If “that pain” hasn’t found you to-day, don’t worry, it will to-morrow. As Pompey or some one of similar calibre said a few centuries ago: “If you have not yet faced it, death or victory lies before you.”

A chaotic mass of thought rushes in at the moment wrhen one faces the real thing, but among these, two stand out prominently. First, “Will I come through it all right?” Second, “How much will it cost me?”

One finds out afterwards that the first question is really a negligible one. You always come through all right, of course. The second question is one well worth discussing.

It isn’t really a question one needs to worry over very seriously, for the reason that it is already answered. You have, unwittingly, made the answer yourself. Even though you haven’t yet a pain oían ache the whole matter is settled.

Are you a grocer’s clerk or a bank president? Do you rent fifty acres or own a peach farm and run a motor? Do you keep your surplus cash in the “Savings” or in “C. P. R.’s” and “Rio’s.” Tell us this, name the specialist whose tender mercies you would pre-

fer to submit to, and we’ll make out the bill without waiting for any further developments.

The nature of the operation? Oh, that makes little difference. Appendicitis or fleshy enlargement, cancer or whatever it may be, your bill will be the same, or so near it, it wouldn’t be worth inquiring about.

The writer put a question something like this to one of Toronto’s leading surgeon’s the other day:

“Is it true, doctor, that in making up your charges you specialists—like the railways and express companies—put on all you think the ‘trade’ will stand?”

“Well,” said the authority, smiling, “it does seem to work out a good deal like that. But why shouldn’t we?”

This latter side of the case will be dealt with later.

It will be seen, then, that our contention is true. Chats with half-a-dozen doctors, both greater and lesser lights’ “cub” physicians and those old in experience, bear out the facts. Members of the medical profession in Canada today, and this, of course, applies particularly to specialists and to surgical work, have no fixed charges for their services.

The surgeon mentioned above explained the matter this way:

“My regular fee for (naming a familiar abdominal operation) is $150. This is, of course, exclusive of hospital fees, which run from $15 to $75 a week, according to the fastidious ideas and desires of the patient. Last week I had a case of this kind and my bill was $50. The week before for a similar case I charged $300. I usually try to find out something about my patient’s circumstances before I render the account.”

A few examples picked up from and outside the doctors show the workingout of the system.

“Why, yes,” said a nurse from one of the hospitals, led innocently, perhaps, to make a small breach in her professional ethics, “I saw a good example of that the other day. A well-to-do patient, without any relatives, and who had an incurable disease, was being operated upon with a view to giving

him some measure of immediate cornfork In this case the doctor who administered the anæsthetic charged $100. The regular fee for this, by an ordinary doctor,” she went on, “is $10, but if they^ think you can stand it they charge

Rather an amusing story bearing on the point was told by a clergyman from one of the smaller towns.

“Some time ago,” he said, “I had an X-ray photo taken of my hand in one of the Toronto hospitals. I suppose they found out I was a minister, and concluded my salary was not too opulent, for my bill was $3. Here the other day, however, my son, who is at one of the preparatory schools in the city, and was injured in a football game, had to have his leg examined in a similar way. This time I suppose they argued that the parents of the boy must be at least fairly well-to-do to be able to keep him in college, for the bill was $10.”

Still another case bears out our contention. ^ Within the year an operation, decidedly delicate, though of a familiar type, was performed on a wellknown _ public man, whose interests mount into the millions. The surgeon’s fee in this case was said to be $5,000, while an attending physician of lesser reputation, who, it is whispered, “only looked on,” received $600. The anæsthetist’s fee was not mentioned.

“Of course,” commented the surgeon who told the story, “the five or six thousand was no more to that man than $5 would be to you.” With which the writer joyfully agreed.

It js perhaps worth mentioning that in this case the patient and both doctors are members of a somewhat exclusive patriotic fraternity. Presumably this had something to do with the second doctor’s interest in the case.

A firm of physicians, whose reputation is continental, located in one of the cities across the border, seems to have reduced the system to a fine art. Among other secretaries who look after the details of their business, there is said to be one bright young man whose sole duties are to ascertain the financial standing of the patients, so that so far as possible an equable levy may be made

for the expert work done. A somewhat interesting story is told which illustrates their methods.

Some little time ago an ordinarylooking farmer who sadly needed surgical treatment, asked as usual, after preliminary examination, what the expense would be.

“We do not accept any case under $100,” was the reply.

Somewhat regretfully, the patient agreed to the terms and a little time after the operation sent a check for the amount. In the meantime, however, the firm’s secretary had looked into the man’s circumstances, ascertained that while straightforward and hard-working, he had had a great deal of trouble and had in desperation borrowed the cash to pay for his operation. As a result, the check was returned with the receipted statement.

From the public’s standpoint the question as to the legitimacy of this “charge-according - to - circumstances” method is certainly a discussable one.

John Jones, laborer, who makes $2.50 per day, pays just as much for his bread and tea and water and coal as does W. J. H. Smith, of the legal firm of Smith, Chase, Casey & Wood, who draws $50,000 per year. If he buys a bicycle to carry him to and from work he pays exactly the same price Mr. Smith would pay if he bought the same wheel for the use of one of his sons; more perhaps, for Smith is likely to have a friend in the factory who will cut off a percentage of the sales commission for him.

Thus far the spirit of democracy prevails under the fortunate conditions of life in Canada. But go a step further.

John Jones falls down his front steps in the dark some evening and breaks his collarbone. Dr. Blank, who hapens to be passing in his motor, fixes im up and sends in a bill for $5. The next day Mr. Smith slips off the steps of his bank and sustains exactly the same injury, in this case “a fracture of the clavicle.” Dr. Blank, fortunately passes just at this moment, gives the same attention as he gave to Jones, but renders an account for $100.

The system certainly works out to

the inestimable advantage of Jones. But should it? Hasn’t Smith a real reason for complaint? Hasn’t the millionaire, whose operation, referred to above, cost him about $6,000 in surgeon’s fees alone, a really just cause for objection? Is the system, after all, an equable one?

Thus far we have been dealing more or less closely with the public’s side of the matter. Let us now turn to the professional side.

It is a quite well-understood fact, though one we do not always stop to remember, that the ethics of the medical profession require a physician to give treatment when and where called on, provided it is at all practicable for him to do so, no matter what station in life the prospective patient may occupy, nor what his chances of reward for the given service may be.

Thus, in considering the large amounts charged by the doctors under certain circumstances, we must also consider the fact that in numerous cases their services are given entirely gratis. This would not seem to apply so frequently to specialists who have climbed well up the ladder. When they reach the point where their reputation is widespread and they are constantly in demand, there is naturally a tendency on the part of less well-to-do patients to get along with less expert service. But the service without charge or at very moderate charge is given much more frequently than the public imagines. One hears about the large bills, but, since man’s cupidity is universal, little is said about the small ones.

The head surgeon of one of Toronto’s hospitals put the matter this way.

“I have just come,” he said, “from my morning round of the hospital. In the past three hours I have examined fifty patients. So far as I see now, I shall receive payment from only two of them. One of these is the wife of a man who makes probably $15,000 a year and is not overly generous with his'surplus cash. Have I not a moral as well as a legal right to ask for a fairly generous fee from him?”

The matter deserves consideration, as well, from another standpoint.

The medical profession is one to enter

which cost not only an abundance of long-sustained effort, but also an abundance of time and money. The medical course, with its laboratory fees, its necessary respectable little library and its five, to eight years of training, is the most expensive offered by the universities. There are cases, but they are few, where students have put themselves through the course financially by their own efforts. Again, many of the graduates of the Canadian colleges, to gain wider experience and thus make themselves more valuable to prospective patients, spend two or more years rather expensively in England or on the Continent before entering active professional service.

Yet another factor applies to those members of the profession who are able to command the highest fees. They achieve their reputation, either through an enormous amount of exacting mental and physical labor, by reason of years of experience, by reason, again, of a modicum of genius in some particular line, or, as in many cases, through an application of all these factors. Those who stand at the top of the medical profession, have not gotten there as have many of the heads in other lines of business, namely, by reason of a fortune or a well-established business being handed down to them, or, as in other cases, by a lucky dea1 in real estate or on the stock market. Their places have been achieved by reason of straight personal effort. No unearned increment attaches to them.

Since this is so, have they not a right to provide for the assurance of financial rewards which will place them on a par, so far as the possibilities of life are concerned, with men of similar ability in other professions.

There is still another side of the story, one which would surely not occur to the layman unless his attention were attracted to it.

“Most of these well-to-do men,” said

a young physician who has already gained considerable local repute, in discussing the matter, “are people of high standing in the community, men who are either large employers of labor or who direct large public interests. Even did he not wish to do so, the physician who attends them feels that he must give more than ordinary service because of their importance to the community. This class of people do not want ordinary service. They want the best. And to give it to them the physician takes extra precautions and extra time. Then again, the nervous strain of operating en a man of this type is terrific. It cannot be imagined by one who has not had the experience. The tension is bad enough when one is performing an operation on an unknown patient from the “free” wards, but to go through the same workvon a man of the type I refer to, when a slip of the knife may cause death or an infinitesimal amount of carelessness lead to serious infection and the ultimate removal of so useful a life—then is the time when one’s nerves suffer. That’s one reason,” he went on, “why I feel perfectly justified in charging one of these men what you might consider a large fee. The mental agony I undergo in treating him is worth it.” Without doubt there is a good deal in his contention.

The question possesses features of decided interest which, after all, cannot be settled on a general basis. Each case, like those diagnosed by the physician, must be judged on its own peculiar circumstances.

So then, ye prospective patients, prepare to meet the crisis with all possible fortitude. The only advice which can be offered with the assurance of being at once safe and timely is as follows:

Prepare for the worst, as regards the disturbance to the interiors of both yourself and your bank book. This avoids all possibility of disappointment.