How much does a doctor earn? Is the GP dying out? Is the profession a closed shop? How widespread is fee splitting? Are unnecessary operations often done? Why is it hard to get a doctor in an emergency?
THE Canadian Medical Association publishes a blue vest-pocket-size booklet containing a code of ethics, binding on all practicing Canadian physicians. It reads, in part:
For the honorable physician the first consideration will always be the welfare of the sick... To each he gives his utmost in science and art and human helpfulness... He does not multiply costs without need, nor raise needless fears, nor allay fears without full consideration. Even when he cannot cure he will alleviate and be counsellor and friend . . .
In the opinion of a surprisingly large number of people I spoke to during my recent trips across Canada, the proportion of medical practitioners who live up to this code is declining year by year. As "a blond and stocky Montreal cab driver said to me with sharp cynicism, “Going to see a doctor is like taking your car into a garage. The mechanic will always find something wrong. Once you start with doctors you never finish.”
A more complete inventory of public complaints was recently drawn up by one doctor. It can be summarized as follows:
“Money-grabbing doctors are partly to blame for the high cost of illness. The medical profession’s prime interest is in acquiring worldly goods rather than the patient’s salvation.”
“Doctors don’t understand us. They treat the disease and neglect the patient. They forget we’re human and not merely pincushions for penicillin. What’s happened to the old doctor-patient relationship?”
“Doctors refuse to speak our language. They shrug off our legitimate questions and answer us in medical jabberwocky.”
“The doctor won’t come to us in an emergency; he won’t make house calls; and he keeps us waiting for appointments.”
“The medical profession has the tightest, strongest ‘closed shop’ in the country. They control the supply of doctors to the detriment of the public; they have too much false dignity; they think the public has no right to discuss medical mat ters; they sometimes protect the bunglers in their midst; they lack social consciousness and refuse to support legislation which extends the benefits and coverage of medical care.”
The doctors are becoming increasingly concerned about all this. They feel that such unfavorable criticism is caused by the misbehavior of only a few of our 13,873 doctors. They freely confess they’ve done a poor job of public relations. “Public relations consist of being right ninety percent of
the time and talking about it ten percent of the time,” says Dr. William Bramley-Moore, registrar of the Alberta College of Physicians and Surgeons. “We don’t do any talking at all.”
There’s no doubt about this. In every community I visited most people spoke in the warmest terms of individual physicians yet often harshly of the profession as a whole-—like the Ottawa man who remarked, “No other group has hoodwinked the public so successfully.”
To help rectify matters the Canadian Medical Association is now employing a public relations firm. But the cleverest public relations program cannot in itself restore the doctor to his former pedestal. Where there is public dissatisfaction there can usually be found honest and legitimate complaints. Only when these complaints are examined and discussed honestly and dispassionately will it be possible for doctors and their patients to demolish the barriers which seem to have arisen between them.
The doctor’s income is a case in point. Many people consider it excessive. “All the doctors are buying Cadillacs,” was a remark I heard frequently.
How well is the doctor really doing in terms of dollars and cents?
Most doctors’ incomes are at a high level. Tax figures show they are the third-highest-paid group in Canada, just behind “engineers and architects and lawyers.” The doctor’s average net income (before taxes) rose from $7,666 in 1947 to $9,009 in 1949. A comparable advance would put it at $10,352 in 1951.
It’s probable that the doctor’s yearly revenue is even higher than this estimate. The thirty-eight physicians working under the municipal-provincial prepaid medical-care plan in the Swift Current area of Saskatchewan last year drew an average of $12,500 from the fund set up to reimburse doctors for their services. Many have additional sources of income from such things as life-insurance examinations; it’s a good guess that a fair proportion earned $14,000 a year.
A man whose official position brings him in close contact with medical men in every part of Ontario told me that most general practitioners now make between $12,000 and $16,000. A Montreal doctor estimates that the average successful GP there earns an annual $17,000.
Yet, compared to the specialist, the general practitioner is the poor relation of the medical profession. The chief radiologist of one western
hospital receives a salary of $18,500. “You can’t get a man like that for a penny less,” a local medical authority told me. In Toronto the department of public health couldn’t get a psychiatrist for less than $12,000.
What do the doctors reply to the persistent charge that their fees are too high and their incomes too large?
To begin with, the doctor points out that a sizeable chunk of the bill you pay goes for taxes and operating costs. An Edmonton doctor showed me his monthly bills. His car, office rent and expenses, including nurses’ wages, came to almost five thousand dollars a year.
Again, the training of a doctor is long and costly. It has been estimated that the specialist, who has to put in an additional five years after leaving medical school, has invested about forty thousand dollars in his education before he earns a penny. A Saskatoon specialist told me he was thirty-six before he earned his first fee. In training hospitals everywhere in Canada I met young doctors in their thirties, many of them married, who were completing their training only by going heavily in debt. Little wonder that the qualified doctor expects to do well as soon as he hangs up his shingle. As a
young Winnipeg doctor told me, “Somebody’s got to pay for the last fifteen years.”
A late starter, the doctor is also an early finisher. Surgeons scrubbing up for an operation will sometimes ask each other jokingly, “Have you had your coronary yet?” Heart disease is the occupational hazard of the physician. A study by the Metropolitan Life Insurance Company shows that the recorded death rate from disease of the coronary arteries among male physicians is one and fourfifths times that, of white males of the same age in the general population.
A high proportion of doctors feel insecure about money. A Halifax practitioner told me, “We’re completely on our own. We have no unemployment insurance, no retirement pension plan. If we get sick and can’t work our entire income ceases and our families are unprotected. It’s not like having a business that can carry on without you.” Not long ago a young Saskatchewan specialist, after three years of practice, contracted tuberculosis. His wife was forced to go to work, leaving the children to t he care of others.
Many a doctor, remembering the hungry Thirties, feels he has a right to enjoy the prosperous Fifties. A Montreal specialist told me that during
the depression ninety percent of the doctors that had office space in the downtown building where he practiced, couldn’t meet their monthly rent; of one hundred and thirty-nine Saskatchewan doctors who died between 1930 and 1946 forty-eight percent left behind f en thousand dollars or less.
Another complaint I found charged against doctors is that a sizeable proportion avoid paying their full share of income tax. This suspicion—voiced to me in Toronto, Vancouver, Ottawa and Montreal
was based on the fact that some doctors demand cash payment and are reluctant to give receipts. In a group of five Montrealers, for example, two of them had an experience of this sort. One man called a pediatrician to his home to see his child. Before leaving the doctor demanded ten dollars in cash and refused a receipt. "If you insist on a receipt I won’t treat your child anymore,” he said.
Doctors themselves don’t completely agree on what constitutes “a balanced and fair fee schedule.” At a recent meeting of the Ontario Medical Association a group of younger doctors wanted to raise the fees for hospital visits. Older practitioners successfully opposed this. “It’s not fair,” they said. “Most hospital calls are only courtesy calls. A doctor can easily make twenty or thirty before
going back to his office.” There is a strong impression in Ontario that certain specialists, radiologists, surgeons and pediatricians in particular are cornering too large a slice of the medical dollar. One widely known doctor told me that some pediatricians had boasted to him of how (hey can rush t hrough twelve appointments an hour by the skilful use of receptionists and nurses. “They smile at the mother, tell her what a wonderful child she has and ask her to come back next month,” the doctor told me. “It’s a profitable routine.”
In any discussion of doctors’ charges, sooner or later the subject of fee-splitting comes up. The commonest form of fee-splitting is the arrangement made between a general practitioner and a surgeon, whereby the former hands over all his surgical cases to the latter. In return the GP receives a prearranged commission, usually forty percent of the cash collected by the specialist.
All medical associations have condemned this and certified surgeons must swear they won’t split fees. Dr. Edward W. Gallie, professor emeritus of surgery, University of Toronto School of Medicine, says, “In effect fee-splitting means that one doctor is selling his patient to another doctor. There’s a chance that he’ll sell him not to t he most
competent man, but to the man paying him the highest commission. That’s criminal.” It can also lead to a lot of unnecessary surgery.
Yet I found evidence of a considerable amount of fee-splitting activity going on among doctors, particularly in Ontario and Quebec. A doctor, whose official position brings him in intimate contact with physicians all over Ontario, estimated three quarters of Ontario surgeons split fees. A Hamilton surgeon recently observed, “It’s the custom here. I’m regarded as queer because I won’t fall in line. There have been weeks where I have had practically no work to do because doctors won’t make referrals.”
Fee-splitting is not confined to Hamilton. A professor of surgery told me that some of his brightest graduates have come to him discouraged and depressed: members of the local medical profession made it perfectly clear to them that they couldn’t expect to succeed unless they shared their fees.
At present, money is the most frequent cause of disagreement between doctors and patients. Medical associations deplore this because they feel that most of these disputes stem from a misunderstanding, rather than a deliberate breach of
professional ethics. To promote better doctorpatient relationships your doctor is being coached by his professional associations on how to conduct his financial transactions. The gist of these instructions, summarized below, can also be read with profit by patients:
1. In a long or complicated medical case the matter of costs should first be discussed with the patient. A Toronto surgeon told me, “The real trouble starts when a patient innocently expects a job to cost seventy-five dollars and then gets a bill for four hundred and seventy-five.”
2. Before sending out a bill doctors should consider three things—the skill and time required to render the service and the ability of the patient to pay.
3. Bills should be itemized in detail.
4. The doctor should explain the extra cost if he plans to call in other practitioners. Many a patient after an operation is both angered and mystified to receive bills from anaesthetists, radiologists and pathologists. “But I’ve never seen any of those guys around,” he’ll complain.
Part of the story is the rise of specialist and the fall of the general practitioner. By a recent estimate, only forty-nine percent of our doctors now regard themselves as GPs. Specialists now
outnumber GPs in Halifax, Saint John, London, Ottawa, Regina, Edmonton, Vancouver and Victoria. There are now thirty specialties, as well as specialties within specialties: radiologist« for example, can concentrate on either diagnostic or therapeutic work. Dr. N. W. Philpott, of the Royal Victoria Hospital, Montreal, says “The family doctor, like the North American Indian, is disappearing.”
The trend will continue. The status of the GP has hit an all-time low. In many centres they are even kept out of hospitals. “A family doctor nowadays has about as much prestige with both the public and the profession as a ditchdigger,” an Ottawa physician complains. The dean of a medical school told me, “My son was a GP for two years and then gave it up to enter a specialty. That’s where the money is. All of his friends were getting ten dollars a call while he was getting two. Can you blame him?”
It goes without saying that the specialist fills an essential role in modern medical practice. Medical knowledge has so expanded that no single man can become expert in all fields. According to most medical authorities, the GP can handle eighty-five percent of all illnesses
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brought to him. In Europe the specialist’s role is to care for the fifteen percent of cases that are referred to him by the GP because of his expert knowledge. But in Canada things have gone haywire. Patients diagnose their own illness and then choose what they think to be the appropriate specialist. And specialists tend to cluster in larger communities where they soon outnumber the GPs. The local inhabi-
tants are in constant danger of being overcharged and overserviced, and overservice doesn’t always mean good service.
For example, a Toronto woman went to a specialist in blood diseases explaining that she was run-down. The physician found her anaemic and prescribed liver extract. Her real trouble was later discovered by a GP: cancer of the cervix. He referred her to the specialist she should have seen in the first place.
Scores of such cases can he cited. The patient gets a pain and goes to
specialists of his own choosing—often t he wrong one. The specialist often fails to see the patient as a whole person.
Specialization has created an even greater danger. With ten doctora taking the place of one, the intimate doctor-patient relationship is fast disappearing. In Regina 1 visited a clinic run by forty physicians which has treated as many as twelve hundred patients in a single day. One specialist told me that he had not entered the home of more than one sixth of the patients he had seen in the clinic. Yet
it is often impossible for a doctor to give good medical care unless he understands the patient as a whole person.
It is now generally believed that anywhere from one third to one half of the people going to doctors have symptoms of a neurotic origin. For, there is such a thing as “organ language.” By means of a backache, headache or chest pain our bodies can react to an unpleasant situation, even though, physically, we are sound. That is why an English writer, in discussing diagnosis, wrote, “What is spoken of as a clinical picture is not just a photograph of a man in bed. It is an impressionistic painting of the patient surrounded by his home, his work, relatives, his friends, joys, sorrows, hopes and fears.” What chance has the average busy specialist got, with his casual contact, of penetrating into this private world of the patient?
Take the Vancouver woman suffering intermittent stomach pains. A specialist she consulted gave her a number of tests, could report no findings, and hilled her thirty-five dollars. At the time this woman was going through a domestic crisis; when she and her husband were reconciled a few weeks later the pains disappeared.
The neurotic patient is a great menace to himself. He may try one doctor after another until he convinces one of them that his illness is organic. The result may he an unnecessary and often dangerous operation. An Omaha psychiatrist, Dr. A. E. Bennett, shocked the American Medical Association a few years ago with a study he had made of one hundred such patients. The record showed seventy-two were sent to the operating table, some more than once, for a total of one hundred and seventy-two operations—at least half of them without an adequate medical reason.
Fortunately the GP still survives in many parts of Canada. The value of his work is reaffirmed by doctors like Carleton Lamont MacMillan, who for the past twenty years has practiced in the town of Baddeck, N.S. (pop. 800), located two hundred miles northwest of Halifax. To reach the six thousand people in his bailiwick he averages sixteen hours a day by car, tractor, sleigh, canoe, motorboat, plane or foot.
MacMillan’s time is completely at the disposal of his patients. They often rouse him before dawn and seldom can he eat a meal without an interruption. He keeps open house, and out-oftown patients often stay for dinner. His nurse calls him “Dorothy Dix” because people bring him their most intimate problems. He has backed loans so that some of his fishermen patients could buy boats. He has given cash to patients who owe him money so that they could pay off hospital hills. A new nurse was surprised to find that for years the doctor had been dispensing drugs at only a fraction of their actual cost price. He willingly treats dogs, cats, and on one occasion tended a sick cow by hospitalizing it in a straw bed near a warm furnace and administering penicillin injections. He’s invited to every wedding in town and always accepts.
The people love him. Old ladies send him hand-knitted sweaters. Housewives make him jams and jellies. Hunters share their fish and game with him. A few years ago he was nominated as a candidate for the provincial government without his knowledge and elected without campaigning. After the first few weeks at parliament in Halifax, MacMillan grows restless and wants to return to Baddeck, which he has left in the hands of a substitute physician.
In every province there are country
doctors like Carleton MacMillan. They are a devoted hard-working group of met. And they also have their counternans in the crowded city, where they woik undramatically.
Vfhat can he done to restore the family doctor to his rightful place?
The medical profession is giving the problem a lot of hard thought. One of tie current suggestions is to modernize .he G P’s medical training. It has been proposed to extend his interneship for mother twro years, allowing him to spend several months specializing in the sort of thing he will spend most of his time doing when out in practice— gynaecology '&T*à 'Obstetrics, paediatrics, internal medicine (the diagnosis and treatment of disease) and emergency surgery. Such a course would end with a six-month apprenticeship to a qualified GP. The latter idea has already been tried by the Dalhousie University Medical School. Everyone was pleased with the experiment.
Are Specialists Unfair to GPs?
Another suggestion is that GPs should be helped “to keep up with medicine.” I saw many hopeful signs that steps are being taken in this direction. For example, the Montreal Jewish General Hospital ran a series of twenty lectures for GPs. Refresher courses at hospitals in Vancouver, Edmonton. Toronto and other cities, lasting from three to five days, are being attended by as many as four hundred doctors per course. The University of Toronto School of Medicine is now sending out teams of specialists to smaller centres like Kirkland Lake, Port Colborne and holding conferences in local hospitals.
A drive is also under way to get the GP back into hospitals. A doctor can’t adequately practice medicine today without hospital facilities. In the better hospitals in cities like Toronto and Montreal GPs are never given important staff appointments; at the very most they are allowed to make limited use of hospital facilities. Dr.
E. C. McCoy, a Vancouver family doctor who is actively interested in raising the status of the GP, claims this is unfair. He suggests that doctors who are performing a high quality of work and who keep abreast of the times in medicine should be admitted. As a possible later development McCoy suggests an “Academy of General Practice” which would grant certificates to those who can pass rigid examinations. Members of such a group would, in effect, be specialists— specialists in general practice. Such a body already exists in the LInited States.
A frequent complaint made by laymen in Canada is that people aren’t receiving proper medical care because of a serious shortage of doctors. And furthermore, it is charged, the doctors
themselves are responsible for maintaining this artificial shortage. To what extent are these charges true?
The latest figures show that we ; have 13.S73 physicians in active pracj tice—one doctor to every 977 persons. ! This is surpassed only by the United j States and Switzerland. It has been pointed out, critically, that our position j now is slightly worse than in 1911 forty-one years ago—when we had one ! doctor for 970 persons.
Doctors take an optimistic view of j the “critical” shortage. True, they say, while the doctor-patient ratio hasn't improved the effectiveness of the individual doctor has. “One doctor today,” j says Dr. E. D. Kelly, deputy general ! secretary of the Canadian Medical Association, “can do as much work as : five or ten doctors thirty or forty years ago.” Miracle drugs have shortened many treatments. Inoculations almost eliminate many diseases. Furt hermore, i the doctor no longer works alone. A whole crew of technicians helps him. Hospitals are used more than ever before and this further conserves the doctor’s time and energy.
What is, beyond dispute, a serious situation is the inequitable manner in which our available doctors are distributed.
Theoretically there is one doctor to every 977 persons. But this is not t he real situation. In Ontario the ratio is actually 1 to 860. But in Saskatchewan a single doctor has to he shared by 1,430, in Newfoundland by 2,417.
Within each province there is a poor : distribution between rural and urban centres. Almost half Newfoundland’s doctors are clustered in St. John’s. Vancouver alone boasts of having more than sixty percent of B.G.’s total. This is working great hardships.
There is no doctor to serve several | thousand islanders off the New Brunsi wick coast who are periodically isolated ; from the mainland by had weather. A local resident observed fatalistically, ! “If you happen to get an acute appendicitis at the wrong time you just die.”
In Quebec, Dr. Albiny Paquette, the Minister of Health, has had to authorize one hundred and twenty-eight nurses I to act as physicians in areas otherwise I without medical care. In Manitoba, I where seventy percent of the doctors I ai-e located in Winnipeg, there are now twenty sizeable communities without j doctors. Sand Lake (pop. 2,000) is j typical. In the past year they’ve built j a four-bed nursing home containing a j doctor’s office and have posted a notice offering an annual eight-hundred-dollar subsidy. But they still have no doctor.
Fifteen hundred Gulf Islanders, less than one hundred miles off the B.G. coast, have been without a resident physician for more than a year.
In spite of the fact that provincial medical associations constantly keep requests from these areas on fileno doctor has yet been found who would he willing to settle in any of them. For one thing, the doctor won’t go anywhere unless lie’s assured of an adequate living, despite the desperate j need of any particular community. J Three or four physicians went out to ! look over the Gulf Islands as a place j to locate hut turned it down. The j reason? To quote an official of a B.C. | medical society: “Practically all the j islanders are old-age pensioners without much money.”
Lack of money isn’t the only deterrent. The modern doctor is reluctant to settle in some hinterland area where all he has to depend on is his own ingenuity and his little black hag. I spoke to one New Brunswick doctor, i who had just left his practice after ■ spending two years in a remote area. j He had great difficulty with transpor
tation. In a single year ruts had destroyed thirteen tires on his car. He could never leave for a week end or holiday because he was always needed. He felt professionally isolated; there were no other doctors nearby to talk to and the nearest medical society meetings were held a hundred miles away. He had to perform operations he wasn’t qualified for with inadequate equipment. Because the people were poor he ended up his two-year tenure with no savings.
There is also a poor distribution of specialists. There isn’t a single certified obstetrician or paediatrician in the whole of Cape Breton Island. In Quebec province there are 100-bed to 200-bed hospitals without a single pathologist, radiologist or anaesthetist. Of Quebec’s 886 specialists, 668 are in Montreal.
Could the shortage be relieved by licensing European immigrant doctors? It has been charged that this has been blocked by “organized medicine.” I found this only partially true.
At present, the licensing of physicians is controlled by the medical profession through the various provincial Colleges of Physicians and Surgeons. The immigrant doctor must satisfy the college as to his credentials and experience, serve a one-year rotating interneship in a hospital to learn our language and ways, and finally pass the examinations of the Canadian Medical Council —the same exams tried by our own medical graduates. During a recent four-year period fifty-one European doctors "have qualified in Ontario, two in Nova Scotia.
An elaborate screening process is necessary to protect the Canadian public against the unqualified doctor. After Hitler’s accession some European medical schools became factories, dedicated to turning out assembly-line doctors for the German medical corps. Again, some immigrants show up with other people’s credentials. One man, who claimed to have been an assistant professor of surgery, couldn’t perform simple surgical procedures, such as suturing.
On the other hand, to protect their interests, the medical profession in some provinces deliberately turns down all—or nearly all—requests for a license, whether the applicant is qualified or not. Some highly placed medical officials will admit this quite frankly. In Quebec the European doctor is required to take a bachelor’s degree at a Canadian university, acquire Canadian citizenship, then graduate from a medical school in Quebec. A man of thirty-five would be well into his fifties by the time he met all these requirements. When I observed to a spokesman for the Quebec College of Physicians and Surgeons that such regulations would virtually bar all foreign-born doctors from practicing in Quebec he replied, “That’s right. But remember—we have three hundred young men coming out of medical school each year.”
His counterpart in B. C. told me that strict regulations there were “a matter of self-preservation.” In the Maritimes I saw a batch of applications received that month. “We’ll sit down at our next meeting and turn the bunch of them dowm in less than an hour,” I was told.
There is little doubt that if our health services were to be reorganized and extended there would be an immediate demand for hundreds, perhaps thousands, of additional doctors. In the Swift Current Health Region (Sask.) there were nineteen doctors until 1946, when a prepaid medical-care plan covering all area residents was introduced. That number has now jumped to thirty-eight.
Our medical schools can and are turning out more graduates. In 1951, 857 new doctors graduated—an all-time peak. In the next few years there will be an additional one hundred and ten doctors graduating each year, thanks to the University of Saskatchewan and the University of British Columbia, which will shortly offer a complete medical course.
Allied to the dissatisfaction over the shortage of doctors is the public complaint that, even in cities, “you can’t get a doctor when you need him.” The layman is often aroused at the apparent way in which doctors remain indifferent to the frantic pleas from a person in distress.
A Hull, Que., electrical worker brushed against a high-voltage wire and fell senseless to the ground. It took firemen twenty-four minutes to get a doctor to agree to answer the call. One of them said, “I’m a specialist. I don’t want to get mixed up in that sort of thing.” Three others excused themselves. In Timmins, a northern Ontario mining centre, a seventy-yearold man collapsed outside his home. A call for help was put through to the police station, but a doctor who happened to be present refused to go; so did six other doctors. It took an hour before anyone could be coaxed to see the old man, who died next day, still unconscious.
The medical profession is aware that incidents such as these create a lot of ill-feeling. “This complaint,” says Dr. Kelly, of the Canadian Medical Association, “is the one most frequently made against the current practice of medicine.” To side-step such criticism in the future the CMA recently circularized every community, asking local doctors to set up an emergency call service. Some centres have already established such a service. Vancouver lists two numbers in the front page of the telephone directory, where a doctor can be reached night or day. The Toronto Academy of Medicine has done likew'ise: three hundred doctors, listed according to district, are available twenty-four hours a day. The one weakness in the Toronto service is that the emergency number is not given wide enough publicity, through fear that drunks and cranks would turn in unnecessary calls. These fears are groundless. The well-advertised emergency numbers in Vancouver and in hundreds of American cities have not led to very many frivolous calls.
Many doctors I spoke to feel that the public is often unfair with them in the matter of responding to emergencies. Practically every doctor I spoke to has carried on this sort of sleepy conversation at 3 o’clock in the morning:
Patient: Doctor, you've got to come right away. I have a terrible pain in my chest.
Doctor: How long have you had it?
Patient: On and off for the past two weeks.
Doctor: Why didn’t you come and see me sooner?
Patient: Well, I think it hurts a little more than it did and I’ve been lying here worrying about it.
Another bone the doctor has to pick is this: many families don’t have a regular family doctor and, when they are faced with an emergency situation, they pick a name out of the phone book and expect the doctor to come rushing to their side. Doctors have noted, with distaste, the growing public habit of switching from specialist to specialist, doctor to doctor. Such a lack of loyalty doesn’t inspire the medical practitioner to give you his best service.
What quality of service is the average Canadian receiving from his doctor?
It is a difficult question to answer
with complete fairness and accuracy. It’s the doctor’s blunders—which are few—and not his successes which attract the most attention. Again, in every community there exists a group of neurotic patients who spend much of their time railing about the alleged mistreatment they received at the hands of local physicians. But. keeping both these factors in mind, 1 was impressed by the number of complaints 1 received during my trip regarding t he standard of medical care from stable intelligent people whose health was not the constant object of their concern. For instance:
In a New Brunswick community I ¡ spoke to two people who visited the same doctor, each with different symptoms. Both patients were told that they had a sinus infection and were given a series of injections which cost thirty dollars. Neither of them obtained any relief from their symptoms and visited other doctors. Subsequently, their ailments—not remotely connected to sinus infection—were correctly diag, nosed and treated. One of the patients observed, “This doctor gives everyone sinus shots. He’s becoming well known for it.’’
A Montreal physician told me of three flagrant cases of sloppy diagnosis and treatment in that city which had come to his personal attention recently: ■ A girl of twenty-three was treated for ' bronchitis for a year; a post-mortem j study of her medical records indicated, j beyond reasonable doubt, that she was tubercular during all that period. A woman with pneumonia, running a temperature of 104, was treated for a gall-bladder complaint—an error that might have cost her her life had it not j been fdr the intervention of another physician. A man of twenty-nine who complained of pains in his stomach and had lost a lot of weight was treated for a duodenal ulcer for six months. A radiologist, who took an X-ray, immediately spotted a well-developed stomach ulcer. The original doctor had taken X-rays only a month earlier which had cost the patient fifty dollars.
Dr. Dean MacDonald, St. Catharines, Ont., recently analyzed in the Canadian Medical Journal the diagnostic and 1 therapeutic mistakes which occurred in two hundred consecutive patients who went to their doctor complaining of severe abdominal pain. The author stated that “a conservative estimate would seem to be that one patient in five was not correctly diagnosed.” In sixteen cases no diagnosis was made; j in nineteen the wrong diagnosis was made. Twelve patients were given the wrong therapy, including five who were correctly diagnosed. The author felt that ninety-five percent of the diagnostic mistakes were theoretically preventable. He cited the case of a seventy-three-year-old man who died after a complicated operation—a simpler surgical procedure could have been substituted which carried with it practically no mortality. “This is a good example of (the doctor) being physically present but mentally absent at the operating table.”
MacDonald lists the reasons for the high percentage of error: incomplete investigation, ignorance, errors in judgment, obsessions, failure to think anatomically, failure to think at all. Concludes the article: “There’s no
comment upon the fact that approximately fifty percent of the deaths could have been prevented . . . the implication is obvious and serious.”
Special reference must be made to surgery.
Never before have we had so many top-flight surgeons in Canada. In all the larger and better hospitals major surgery is now performed only by “certified surgeons,” men who have
had four or five years of intensive postgraduate surgical training and have passed special examinations set by the medical profession. In the better hospitals the patient is also protected by constant supervision by senior physicians, a pathological examination of all tissue removed from the body and by a periodical review by the hospital staff of all surgical results.
But this excellent protection is only afforded to some Canadians. In all parts of the country, particularly the smaller centres, difficult surgical procedures are being undertaken by noncertified surgeons, some of whom are not qualified either by training or experience. One of our leading surgical authorities told me that ninety percent of all surgical operations in Canada were being performed by non-certified surgeons. The implications are frightening.
One of the most frequent misdeeds of the incompetent surgeon is an overzealousness to perform operations.
An outside doctor was inspecting a hospital in eastern Canada on behalf of a medical association with a special interest in surgery. The local chairman of the board of directors boasted to him about the skill of their local obstetrician. “Wedelivered one hundred babies last year, and thirty of them were Caesarean!” The physician could only conclude that the obstetrician was a very ignorant man, or a dangerously mercenary one. (Caesarean deliveries, performed by cutting through the walls of the abdomen and uterus, in good hospitals generally constitute four percent or less of all deliveries. The fee for an ordinary delivery: $60; for a Caesarean: $160.)
Many CPs remark on the readiness of certain surgeons to remove a patient’s appendix. Typical was one surgeon’s lighthearted axiom, “You never know what’s inside the box until you’ve opened the lid.”
The hysterectomy operation (removal of the womb) has become increasingly popular in recent years. At some hospitals scores of such operations are performed annually. American gynaecologist Dr. Norman F. Miller, after studying two hundred and fifty such operations, found that at least one third of them were absolutely unnecessary, since the tissue removed was in a healthy condition. He also brought to light errors in diagnosis as stupid as they were tragic: pregnancies were mistaken for tumors.
Part of the blame for such abuses lies in our method of licensing physicians. At present the young doctor is granted a license which legally entitles him to perform even the most complicated surgery. Yet the average medical graduate gets little practical experience
during his single year of interneship. He may have taken out a few pairs of tonsils, delivered a half dozen babies and assisted at an appendectomy. The more complicated surgical procedures are far beyond him. In the smaller centres only the doctor’s conscience prevents him from performing operations he is incapable of doing. Sometimes such conscience is lacking, as in the case of a British Columbia practitioner who boasted, “I’ll take on anything—even brain surgery.”
How is the public to be protected against the unskilled wielder of the knife?
One suggestion is to grant the young doctora “limited license,” which would restrict him to doing those things he is capable of doing. As his skill increases the terms of the license can be broadened. This idea was met with considerable approval when it was discussed at a meeting of the deans of Canadian medical schools, at Kingston. Ont., last summer.
There are a number of other safeguards which should be instituted. Some are already in practice in our better hospitals.
For example, major operations should only be performed after the doctor has consulted with one or two of his colleagues. Surgical results should be carefully reviewed and analyzed at regular hospital staff conferences. Medical associations should redouble their efforts to stamp out fee-splitting, since it can lead to unnecessary surgery. Smaller hospitals should receive closer supervision. Finally some consideration should be given to the suggestion that no doctor in private practice should engage in surgery. Distinguished and experienced surgeons like Dr. Leon M. Davidofif, professor of clinical neurological surgery, Columbia University, and Dr. Bertram M. Bernheim, of the Johns Hopkins Hospital, feel that surgeons should be employed on a salary as staff' members of a hospital. Too often, these doctors claim, does money influence the final decision as to whether or not a patient should undergo a surgical operation.
After seven weeks and ten thousand miles of travel I returned home with the impression that much of the public’s dissatisfaction with doctors stems from a feeling of frustration. The patient believes there’s no place he can conveniently take his complaint and come away with the feeling that he’s going to get fair play. As a Calgary bank clerk put it, “All doctors are in cahoots with each other.”
In no province did I find an effectively operated grievance committee at the disposal of the public. To be sure, the College of Physicians and Surgeons
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in each province will act on any written complaint made to them The Ontario Medical Association has even gone a step further by asking each of their fifty-two local societies to establish grievance committees But the weakness of all these arrangements is that they are kept more or less secret As an Ontario Medical Association spokesman explained it, “We don’t want to advertise our grievance committees. If we did, the public would get the impression that there’s a problem. And, besides, we’d attract all kinds of crackpot complaints.”
But a problem does exist and it can’t be wished out of existence by turning the other way
Doctors sometimes forget that the average person stands in awe of the medical profession. The patient is reluctant about complaining to the man in whose hands he places his very life. For that reason the patient needs every encouragement to air the real sources of his dissatisfaction.
Canadian doctors might do well to study the example of the Colorado Medical Society, which organized a twelve-man board of supervisors to which citizens could directly take their complaints and gave it the widest possible publicity. This step was taken because Colorado’s physicians were alarmed at the way in which they had fallen in the public’s esteem. Attempts are first made to settle doctor-patient conflicts by telephone or correspondence. If that fails the board of supervisors convenes to hear the doctor’s and patient’s version of the story from their own lips. No doctor is required to sit in on judgment when a complaint is being made against a neighbor or a local competitor or a close personal friend. Early in its career the board clearly showed that it had no intention of whitewashing the doctor. It vigorously swept aside the antiquated doctrine that only a medical society member can initiate a charge against a fellow member. When a doctor refused to appear before the board to defend himself against a patient’s complaint he was astonished when he was unceremoniously tossed out of the medical society.
Some interesting lessons have been learned in Colorado. One is that after the first few months the number of frivolous complaints from crackpots, psychopaths and dead-beats are negligible. Another is that most complaints are due to misunderstandings which can be settled amicably if there is good will and honesty on both sides. Even doctors who were skeptical about the value of the board of supervisors are now sold on it. One observer stated, “The board is a shield as well as a sword. As well as protecting the patient from bad doctors, it protects the doctor from ill-founded complaints.”
The doctor is neither a devil, a saint, or a superman — only an ordinary human being engaged in what is perhaps the most difficult of all professions. But because we entrust our comfort, our health and our very lives to his hands, we have given him an exalted place in the community. In return we ask a great deal of him. Besides being an expert technician we expect him to be a man of sterling character and broad understanding. We want him to be a wise friend, guide and counselor.
It is a rugged challenge—and, fortunately, one that is being successfully met by many doctors in every hamlet, town and city across this broad country. For such doctors no problem in public relations exists. For, as one wise physician prescribed, “The best public relations is to do good and be good.” ★