Popular Science Monthly/Volume 84/June 1914/The Need for a Salaried Medical Profession


By Professor PAUL L. VOGT


THE state, in the interest of its own preservation and progress, has assumed control of certain activities closely affecting the life of every citizen. Among these are the care of the public roads, the distribution of the mails and the education of the youth. Still other activities now in private control should be supported by the state for the benefit of the whole people. One of the most important of these and the one perhaps receiving most public attention at the present time is the care of the health of the people, a function now delegated largely to physicians, men who receive their reward for community service in the form of fees from private individuals.

Attention to the public health presents two aspects, the one preventive, intended to preserve health by removing the causes of disease; the other curative, and intended to restore to health those who have fallen ill. The medical profession, through a large part of its history, has been almost exclusively concerned with problems of curing disease. The physician has had no direct financial interest in warding off disease from those who were well, but has dealt only with individuals who were ill. Until recently nothing was done to remove the cause of disease, the attention of the physicians being directed toward the problem of finding means of curing or relieving the pain of the one who had already contracted disease.

This was the logical course for physicians to pursue because it was from the sick individual and not from a well public that he received his pay. Under the present system the physician is prosperous in inverse ratio to the health of the community. The doctor is busiest during those seasons when illness prevails most. Were there no disease there would be no need of physicians. This would be an ideal condition for which the people would be glad, not because of hatred of physicians, but because of love for their own welfare. Since the physician to-day receives his reward from the curative side of medical practise he is not professionally interested in the prevention of disease. The public need is for a medical fraternity paid by the public whose interests will be as much in the prevention of disease as in the cure of it. Were physicians paid by the state, they would not fear the loss of income through working for the interests of the well, while at the same time attending to the ill, because the lessening of illness would not necessarily interfere with their incomes. Further, the greater their success in the prevention of disease the less the labor that would be required in the cure of it.

Under the present system much dissatisfaction exists over the charges made by physicians. The poor patient will get together $200 or $300 for an operation or will be treated by novices free of charge, while the rich man will pay $1,000 for the same service. The physician is bound by the ethics of his profession to heed the call of every individual without any preliminary inquiries as to ability to pay, and must give both prescriptions and medicine to many without hope of reward. He must depend for his livelihood upon the honesty and liberality of those who are able to pay for his services. It also places the burden of caring for the sick poor upon the sick well-to-do, because the physician must make his charges according to the net income desired. The system further tends to develop a class in the community that is looked upon as a pauper group requiring care according to special methods. Out of this condition has risen the system of free dispensaries to which physicians volunteer their services, and to which the poor may go for treatment. The physician prefers to volunteer his services to an institution of this kind rather than have the poor come to his office to interfere with his private practise. Their presence in the office is desired about as much as is the presence of the colored person in the office among white patients. The poor are made to feel the disgrace of their poverty and the well-to-do who frequent the dispensaries are induced to falsify as to their real ability to pay.

The present system is unfair to both the physician and the public. The young practitioner, eager to gain experience, is perhaps rewarded for the voluntary service rendered, but the experienced physician who must devote a certain portion of his time to unremunerative practise is unjustly treated. In certain cases he may derive benefit from the voluntary service in that it may bring him into touch with diseases not usually met with in regular practise. But the general dissatisfaction with the growth of free dispensaries, hospitals, etc., is proof that the medical profession is opposed to both an excessive volunteer service and to a diminished practise. On the other hand, it is unfair to the public because it places upon the poor the stigma of asking for assistance for relief from illness for which he is perhaps not responsible. Prevailing materialistic standards permit the erection of buildings that pure air and bright sunlight never penetrate and that in time become veritable breeding grounds of disease. The poor man, because he is too poor to afford anything better, is forced to live in these dens with every chance that both he and his family will contract serious illness. He goes to the free dispensary and is liable to have his home pried into by some charity visitor or to become known as the recipient of alms. The individual receives the burden that a neglectful society has placed upon him and is stigmatized because he must shift it—too heavy to bear—to the shoulders of other individuals who operate a free dispensary.

The present system prevents adequate and timely aid to those who need it. Many people, even within reach of dispensaries, dread the thought of patronizing them and often waste their earnings in buying nostrums from the neighboring drug store because they are cheap and because they seem to fit their case. Ofttimes they injure themselves more than they help. The pauper, who has lost all sense of deference to public opinion, goes at once to the dispensary and is adequately treated. But the vast multitude, too proud to patronize a dispensary and too poor to patronize a physician, run continual risk of neglecting serious illness.

The preservation of the public health is a matter of too great importance to be entrusted to the care of the person who is ill and who feels too poor to go to the doctor. The sick person becomes a non-producer and a care to his family and friends. If the father becomes ill the family becomes a public charge. If the children contract disease they suffer and die because the poverty of the parent prevents proper medical attendance. The masses of the people are too poor to avoid the risk of letting disease run into the danger period. Conditions demand nothing less than the removal of the stigma attached to dispensary patronage so that any person, be he rich or poor, can go to be treated. Medical attendance should be as free as the public schools. The healthy and well-developed body is as important as the healthy and well-developed mind. The two go together and the one can not be perfect without the other.

If, instead of lessening the amount of free medical attendance it were made universal the present fee system would be limited to the very wealthy and the physician for the common citizen would be placed on a salary basis. This would entail a large increase in public expenditures. Such an increase, however, would be a blessing in disguise in that it would fix public attention on the prevention of disease, thus lessening the amount of suffering in the community by eliminating the causes of it. It would open the way for a great number of people who are now deprived of proper medical oversight to consult a physician before real danger is present. It would eliminate the volunteer work and the charging of the rich to make possible the medical attendance of the poor. The emphasis in medical practise would be shifted from the curing to the prevention of disease. The physicians paid for by the state would become agents in removing the causes of disease. Instead of devoting exclusive attention to the cure of the consumptive or the one afflicted with other ills, contagious or otherwise, they would be concerned with the removal of the causes of the spread of the disease. The public physician would also become the agent for the dissemination of popular information on subjects of hygienic interest. In other words, it would bring the medical profession into line with the highest interests of the social group which they serve and would make the physician in relation to the preservation of public health what he now is in relation to the cure of illness, a leader in the fight for the extermination of disease.

The transition from a fee to a salary system of payment for medical service would not necessarily eliminate private practise. Those wishing the services of a private physician could secure the same at a rate based on value of services actually rendered. The existence of public schools has not eliminated private schools from the educational system. Neither has the public school system resulted in less consecrated service to the public welfare than was rendered by the private school. Neither should a salaried medical profession be less consecrated to its work than one rewarded by fees.

The transition from a private to a public medical practise is gradually coming. The appearance and persistence of free dispensaries and hospitals is not the least evidence of the change. The establishment of departments of health in city and state, the magnificent work of the medical service of the United States government; the system of engaging a company physician adopted by many of the large corporations; the movement toward medical inspection of school children with its accompanying treatment at public charge of children unable to pay for treatment; and the movement toward the public treatment of certain types of disease, such as tuberculosis, all indicate that a new order is coming wherein prevention of disease by trained and paid public servants will be considered as important a matter as the cure of disease already contracted. The economic interests of the medical profession will be brought into line with those of the general public and this is the end which should be sought.