The Future of Medicine 3 What the Patients Expect

It is worth while turning from the doctor to ask ourselves not only what the patient actually expects from his doctor but to consider what he might demand if he were aware of the full potentialities of modern medical practice. There are few people who really regard the doctor as a miracle-worker, although occasions occur when, because of the illness of a loved one, people sigh for a doctor who would produce a miraculous result. It may be the fact that doctors so seldom produce the truly miraculous, although they save many lives in the course of their career which makes some of the com­munity turn to other healing sources which do claim miracles as an every-day occurrence. That none of these is accepted by doctors generally is a natural result of their own experi­ences of the ways in which death has overtaken those who should have lived and has spared many whose chances seemed small indeed.

It is true to say, however, that the nearest approach to miracles comes from the hands of the surgeon and this has never been better exemplified than in the work of saving the lives of air raid casualties during this war.   Man has lost that faculty still shown by some more lowly creatures of being able to re-grow lost organs, but the tissues of the human body have remarkable powers of recovery and survival, and the really skilful surgeon handles these in ways which to those who have any imagination at all sometimes seem uncanny. The Surgeon who has started, say, an abdominal operation :in the expectation of finding a relatively simple condition but discovers a more complicated and dangerous one, needs all the coolness of which he is capable, and must be a complete master of any surgical technique which the new circumstances demand.   No less wonderful, however, is the work of those plastic surgeons who in a series of small and painstaking operations transplant tissues from one part of the body to another and reshape features or restore lost functions.

Such spectacular affairs are not for the general practitioner.   If he is not, then, a miracle-worker, is he any of the other grandiloquent things which sentimental writers have pictured him as? He is undoubtedly a very important member of the community and the more compact; and self-contained that community is, the more important is the part played by the best type of physician. This is best exemplified in the case of the country doctor who, either by settling there in a very early stage of his career and remaining in the one small town for the rest of his life, or, as is not uncommon, where the doctors’ son has taken over the practice of his father, has acquired a reputation with practically every member of the community, and who has also a very detailed knowledge of the lives of those families who have used his services over a long period of years. The practice of midwifery links him very closely with the lives of many individuals, and by the time he has assisted at the birth of children born to mothers and fathers whose own birth he attended he will, if he has certain humane qualities; have acquired an affectionate reputation which may be much higher than his professional skill and knowledge would warrant in another sphere.

He is assisted in this matter by the natural fact that childbirth, despite the emancipation of women, remains a rela­tively natural process, with successes far outnumbering the failures. Many a country doctor has gone through his whole career with hardly a case of that great danger to motherhood —puerperal fever. The proportion of such cases in a large midwifery practice need not be very high, and the doctor who practises among people with a fairly good standard of health has surprisingly few and is unlikely to damage a reputation based on hundreds of healthy babies. Yet even in the country districts the tendency today is to be less and less satisfied with the services of a man who has not special experience in this branch of Medicine. Natural as child­birth may be it is associated both during pregnancy and after­wards with a sufficiently large number of hazards for most people to feel that they would like the advice of the acknowledged expert.

The country-town doctor is responsible for the feeling among a certain section of the medical profession— most of the popular speakers and writers of which section are, of course, far removed from country practice and usually dwell in the “Harley Streets” of the country— that the doctor should be the “guide, philosopher, and friend ” of every patient that he sees. This, it is claimed, is an essential part of medical practice, a statement which probably was never very soundly based but which today has no relation to reality. Even if it were an essential part of the highest medical art, it is obvious that the qualities which lead to the reputation for philosophy ;or make the man the confidant of large numbers of his fellow citizens, are only to be found in a, few members of every community and do not require a background of medical knowledge but are innate in the individual. Some doctors are bound, by the law of averages, to possess such qualities and may acquire a particularly high reputation in their own community because of them. There have been doctors, however, who have acquired almost priceless reputations for far different qualities— for their straightforward speaking, for their refusal to stand any nonsense, and, although we do not say this in any term of reproach, for instincts and qualities which belong more to business than to the art of healing.

The part to be played by the doctor in his community is one that has often been discussed, and in general it is felt that the profession itself claims so much of a man’s time and energy that he can have little left for pursuits which the lawyer and other professional men may indulge in, such as membership of public and official bodies.   It is quite obvious that the very qualities of observation and deduction and quick decision which make a good doctor are qualities which may be valuable in the conduct of our public affairs. Yet there has been a tendency in some quarters to regard the doctor who plays his part in these as utilising his public position to improve his professional connection.   In other words, they consider that patients are apt to be persuaded of a doctor’s ability by his public conduct rather than by his results. This is in conflict with the view, often held paradoxically by the same people, that patients must have the inalienable right to choose their own personal medical attendant. An inquiry into the method of selection reveals a bewildering, variety of means, from those who study the medical register of qualifications to those who assess ability by the worldly signs of Success— car house, and clothes.

Whatever relations the doctor has established between himself and his patients, and generally with the public in the area in which he lives and works, the greatest barrier to perfect human relations is that sooner or later the question of fees will arise. Medicine remains a service that is sold by the doctor and must be purchased by the patient, since the doctor operates in a competitive system. To earn his living and to pay the cost of his practice he is bound to make a charge every time his services are utilised. For the patient this is the great drawback, which in some cases amounts to an insurmountable difficulty, for the more ill he is the more medical care he will require and, theoretically at least, the more he will be called upon to pay. Where sickness means complete loss of income, the illness becomes not merely something that jeopardises life but part of that nightmare which is the lot of those whose economic stability is balanced precariously.

The fee question produces many conflicts in the mind of the sensitive physician. He cannot avoid being aware of the necessity for charging a fee, yet the only person who can judge what an appropriate fee may be in a particular case is him­self, and the only person who has a right to say how much medical service a particular patient requires is also the doctor himself. In purchasing other commodities no one would agree to a basis on which a grocer or milkman, the gas company or electricity supplier, or any other private individual or public body dealing in the necessities of life, should not only fix the price of the commodity but decide how much of it each household must take. For the patient there is a difficulty that while it is essential that he should feel able to trust his doctor in medical matters, that trust when translated into economics may involve payment of very large accounts.

The attitude of patients to this question is exceedingly variable. Doctors have built up practices by offering their services and a bottle of medicine at fees below those charged in the neighbourhood, attracting to themselves those patients for whom a saving of a few shillings is of importance. An equally large number of doctors have added to, their reputa­tion and increased their practices by charging slightly higher fees, thus implying that they are more highly qualified or skilled than their colleagues. Doctors also use their right to vary their fee as a means of getting rid of individuals or sections of their practice which they do not consider remunerative or otherwise attractive. “Night fees” fall into this category and the doctor who has grown tired of going out in the middle of the night and who has a practice which is paying him a good income, may see the end of all but the most urgent night calls by charging a sufficiently high additional fee for this service.

A sensitive doctor who is called out to a working-class family in the middle of the night and who appreciates the problem which the usual night fee in his district of, say, 10s. 6d. presents to this particular family, may have a difficulty in deciding what he is going to do about it. If he hardens his heart and justifies himself by saying that the patient might very well have called him in daylight, he will charge the maximum fee, even if he has but a poor chance of collecting it, or if he loses the patient thereby. If he recognises that this family have an income which leaves no margin for sickness, and that an anxious mother for example, had hoped all day that her child or the other sick member of the family would improve as the day wore on and so save any; doctor’s visit, and that it is only an obvious worsening of the patient’s condition that led to the urgent message at midnight, he may feel that he can charge only a nominal fee such as 3s.6d. If he does, one of two things will probably happen;  either the news spreads that there is a doctor who charges only a small fee even for night visits, and who then finds he is called out time and time again to see people who in daylight would have gone to another doctor whose repu­tation is that he does not like night work, or the conclusion is reached by his potential patients that if he cannot get a higher fee by going out in the middle of the night he cannot be much of a doctor. Whether in the end he will go on doing night work and charging a similar fee or decide to do it only when he is assured that the higher fee will be paid, depends on his temperament.

On occasions the difficulty is a totally different one; The patient is able to pay the doctor’s ordinary fee for a short illness but unable to face the kind of bill that would mount up if daily visits proved necessary over a long period. In other cases the patient may be able to pay the doctor’s maximum charge but unable to face bills for extras,  food delicacies, expensive drugs, nursing assistance, and so on.

It is this kind of intervention of economic considerations between the doctor and patient which forces the sick arid their relatives to criticise the individual doctor and to discuss the possibility of obtaining medical care in other ways. It need not surprise us if among methods of obtaining medical advice and treatment there are many by  which the patient attempts to side-track all doctors, or at least the general practitioner.

In these side-tracking devices the primary object of: the patient is very often the purely economic one of trying to obtain results in a cheaper fashion, but the unorthodox method of treatment almost invariably proves to be more costly than that given by the general practitioner and rarely if ever is as beneficial.   That this is no overstatement is proven by the very briefest consideration of the medical preparations which are: advertised to and can be purchased by the general public.   In the earlier history of Medicine the pharmacist acted as the servant of the doctor, preparing medicines under his instruction.   It is clear that if the patient felt he could make his own diagnosis and could obtain the appropriate drugs directly from the pharmacist, he could do so at less cost than through the doctor.   From this it is an easy stage to the ready acceptance of pharmaceutical products already prepared and offered for sale in a form which can be advertised and for which panacea-like claims can be made. The industry has not been slow tp see in this exploitation of man’s ignorance of his own bodily functions and passionate desire for the maintenance of health an easy way of selling large quantities of relatively harmless but probably inefficient medicines.   To the patient this may appear a cheaper form of medicine than that provided by the doctor.  A study of the preparation cost in contrast to the selling price of many of our most advertised remedies is very revealing, but here we are concerned only with the question of whether the patient receives in this way any assistance which can be classified as medical, and whether it is superior or inferior to that pro­vided by the family doctor.

Even if we assume that these preparations are propounded as the manufacturers claim, and even if we were to grant — which is highly improbable— that these preparations would have the actions described by the writers of the advertise­ments, they still cannot be considered any substitute for proper medical attention, because the primary necessity of all medical treatment is absent.   That primary necessity is that the disease from which the patient is suffering should be diagnosed correctly and that its relation to the patient’s general condition and powers of resistance to disease should be taken into consideration.   It would be universally accepted by medical men and patients alike that diagnosis must always come before treatment and that when the condition is one of great rarity or obscurity the patient should have a right to the highest medical opinion obtainable.   That the patient should be prepared to accept the wording of newspaper advertisements ;as a basis for self-diagnosis arises largely from the relative ignorance of the general public about medical subjects, and this ignorance must in part be laid at the door of the medical profession itself. It has, however, not only produced the danger that the authority of the doctor in medical questions should be lowered by the pseudo-medical information given in the advertisements of these popular remedies, but has produced dangers of which the public is not sufficiently aware.

It is worth while noting that the position with regard to proprietary medical preparations varies very widely in different civilised communities. In one or two, strong legislative steps have greatly decreased the volume of this trade, and in others, notably the United States of America, the medical profession itself has exposed this trade, in scientific fashion. The methods available for this exposure in the United States are many, and include Government regulations which re­strict the claims that may be made for a remedy, and an insistence on the publication in clear terms of the ingredients used. In the case of substances proven to be harmful, public exposures by health organisations have been made and cam­paigns launched to educate the public in; the danger.

In Britain almost the only way in which drugs and chemicals offered to the public under proprietary names can be restricted is by use of the Dangerous Drugs Act.   Substances which have been placed on the schedules of that Act can only be sold by qualified chemists on the prescription of a doctor. Today, however, the chemical industry makes discoveries with such rapidity that drugs may be offered to the public , and used by many before their dangerous nature is fully understood.    A notorious case which illustrates this oc­curred in America and is often quoted.   A chemist discovered that a substance having important uses in the preparation of paint and varnishes tasted exactly like ginger and therefore could be used as a substitute for flavouring beverages sup­posed to be made from real ginger.   These could, by this method,, be made very much more easily and very much more cheaply.   What the chemist neglected to do was to test his new flavouring material for its effects on the nervous system.   His product was widely consumed and was not at first suspected as the cause of a mysterious outbreak of nerve disease, later to be known as “Ginger Jake Paralysis.” Before this ghastly error could be traced and the sale of the product stopped, nearly 20,000 people were made seriously ill and many died.    Usually the way in which this substance was taken was as a drink made up from the “ginger” extract at a soda fountain, and it was calculated that a single drink containing only two parts per hundred was enough to bring on an attack.   This began with paralysis of the hands and feet and often spread to the whole body.   In those cases which recovered, many months of careful attention were re­quired before the affected limbs could be restored.

A similar case of the marketing of a dangerous drug has occurred in this country but fortunately without .such: wide­spread tragedy.    Mankind is afflicted with many pains and aches, and it is therefore not surprising that pain-killers constitute a very large proportion of the substances advertised and sold to the public.   Indeed, the manufacturing chemist has realised that, no matter what complaint the purchaser of his goods imagines himself to have, it will probably be bene­ficial to include a certain proportion of substances which have a sedative effect on the nervous system.   Among these is one, amidopyrine, which for a time was much prescribed  by doctors and because of its rapid effect in alleviating pain was used in many proprietary preparations.   Unfortunately this substance has, in a certain proportion of people who are abnormally sensitive to its effects a very destructive power on the white cells of the blood, so essential in the body’s fight against germs.   In this and other countries cases began to appear of patients who were seriously ill and whose blood on examination proved to be almost completely lacking in white cells.   Quite a number of deaths occurred before it had been clearly shown that amidopyrine was the cause, and adequate evidence was obtained that some of these deaths were due to the self-medication of the patients with pills and powders sold under a variety of names for a variety of complaints but all depending to some extent on this substance for whatever effect they produced.

In this instance the recognition that this hitherto easily obtained drug had these dangerous properties led to its with­drawal from use except under the control of a doctor, and the proprietary remedies which had previously contained it quietly withdrew it— and went on with their selling campaigns with the same advertising material and the same stories of wonderful results.

No one will deny that there are a considerable number of medical preparations which the average intelligent house­holder can use and will probably always wish to have without in any way interfering with the proper function of the doctor. But even with these substances it may still be true that the price paid for them will be higher than their cost warrants, and if added to the amounts paid for medical attention represent a very considerable increase  in the cost of medical care. It can be stated quite emphatically that there is no evidence that were all these remedies taken from the market tomorrow, as has, from time to time been suggested in Bills placed before the House of Commons the medical position in any class of society would be worse than it is at present. That money would be better spent on real medical care. Those who indulge in this form of spending might ask them­selves whether in fact they would not prefer to see it spent on providing a type of service more in line with the needs of the patient.

The need of the patient might be stated as the constant services of an efficient medical practitioner. We have, however, already shown that the medical care of a patient does not depend entirely on the efficiency of one doctor. Indeed most practitioners would claim, and their friends would sup­port them, that their training was designed and has resulted in developing their efficiency, and if for the moment we overlook the wide variation in the temperaments and professional attainments of general practitioners and accept the idea implicit in our system of medical registration that all who have qualified in Medicine are capable of acting as general practitioners, are there any difficulties which diminish the efficiency of the service they provide? In truth, difficulties abound, many of them arising from the varying circumstances of the patients, from the differences of reaction to the same disease in one case and another, and from faults in other branches of Medicine. We may contrast the problem which faces a doctor when he finds a straightforward case of a relatively mild illness in a patient living in a house with adequate space and enough attention and assistance to avoid the unpleasantness of confinement with a difficult case in a house where there is no possibility of privacy for the patient and adequate help for the patient or other members of his family is unobtainable.

Consider, for example, the difficulty that faces a doctor in a poor area when he finds someone ill with pneumonia. We have already suggested that the danger from this disease has to a large extent disappeared through its treatment with modern drugs, but even under these circumstances it is a disease which taxes the patient’s strength so severely that the assistance of fully qualified nurses is usually necessary. To leave, the patient in surroundings which all his training and experience tell a doctor involve their own dangers, may nevertheless cause less risk than occurs when a patient with pneumonia is moved to hospital.   It is impossible for the doctor to consider only the medical aspects of the case, and it is in such circumstances that the general practitioner is often compelled by the entreaties of the patient or his relatives to an action which he would otherwise refuse to carry out.

In the previous chapter we remarked on the special methods of diagnosis which are used in all hospitals and to an increasing extent by doctors in every branch of Medicine. It will therefore be evident that except in perfectly straight­forward cases of well-known diseases the general practitioner  may find it impossible to make a diagnosis at all or to confirm the ideas that he has formed from clinical observation alone, and it is equally obvious that he cannot follow the development of complications in certain diseases without the services of the radiologist and clinical pathologist.   Unless these services; are available in the home of every patient, the efficiency of the care given by the general practitioner is enormously decreased.

A common example is the case of influenza which in the presence of an epidemic the doctor has diagnosed from a relatively superficial examination but which has not settled down, so that the patient may be developing pleurisy or pneumonia, or through the weakness caused by the influenza is showing signs  of previously-latent tuberculosis.   To establish : the diagnosis with the greatest rapidity the general practitioner will certainly know that he should have the whole chest X-rayed and should have certain blood tests made.   The dis­covery of a very high content of a particular white cell in the blood would be strongly in favour of an ordinary pneumonia, whereas absence of this reaction would incline to the more serious diagnosis of consumption.   In either case the radiologist would be able to add his opinion; and diagnosis could be made at once and treatment instituted.   The doctor, as we have said, will know that this is what should be done, but he cannot obtain these special services except by the payment of specialist fees usually beyond the means of his patient, by arranging for these to: be done by the charity of specialist colleagues, or by sending the patient: to hospital.

It is quite evident that patients do feel that a doctor’s efficiency has been lowered by the conditions in which he works, for there has been a steadily increasing tendency to seek the services of the staffs of hospitals. This drift to­wards hospitals has caused much discussion among doctors for they see in it a threat to their own position. Among patients it may not have produced any clear understanding of the problem facing them and their doctor, but it has led to the formation of large voluntary organisations designed to ensure at least, a minimum of hospital treatment. It has also led in one year over two million patients to visit the out­ patient departments of our hospitals.

This very significant figure shows to what extent the patient has doubted the efficiency and quality of the service obtain­able by the panel and private fee systems, leading him to look for something; better at hospitals which have acquired a reputation for sound medical work. Whether these people went to the out-patient department through the agency of their own doctor or did so on their own initiative, the sig­nificant point is that they are exchanging the personal service of the isolated general practitioner for the organised and therefore possibly more efficient but strictly impersonal services of the doctors attached to the hospital.

We say “possibly more efficient,” as ,there are many aspects of hospitals which lead some people to have doubts on this point. One of these is a tendency in certain hospitals to keep on the outpatient list many people with chronic dis­ease who could be equally well or better treated by the general practitioner. Their hospital treatment too often consists of receiving a repeat supply for anything from one to four weeks, of a bottle of medicine which they feel has benefited them. This apparently ingrained desire for “a bottle” has led to much discussion among doctors and medical administrators, who, rightly refuse to consider the constant increase in the number of “bottles” prescribed a measure of medical progress.

Nevertheless it is significant that so many turn to the hospitals for a service they cannot obtain otherwise. This need not be regarded, as in some medical quarters a blow at the medical profession as whole, nor accepted with com­placency by those who control the hospitals as proof of their perfection; but rather as an indication of the patients de­mand for something more than they get today. That demand is not for a  “friend of the family” with a bedside manner, but for a service or chain of services; in which the general practitioner and the hospital should be mutually dependent links.