DOCTORS, PATIENTS AND FEES

New Zealand Listener, Volume 11, Issue 281, 10 November 1944, Page 8

DOCTORS, PATIENTS AND FEES

A Naval Contribution to the Health Service Controversy

HE State Medical Service controversy is revived in an interesting way in a recent issue of *the "Lancet,’ which prints a contribution by the Medical

Director-General of the

Royal

Navy

Surgeon Vice-Admiral Sir Sheldon Dudley.

We have no space for the full text of the Admiral’s remarks, but reproduce these passages which bear on our domestic problem in New Zealand.

Admiral began, "it is strange that during all the discussions on the reorganisation of medical practice and education, which have culminated in the birth of the Government’s White Paper on a National Health Service, nobody as ‘far as I can find out has thought it worth while to discover if any permanent member of the medical branches of the fighting services could contribute anything useful ‘to the subject. The oldest and most comprehensive State medical services in existence are those of the Navy and Army, and the present Naval medical service at sea has evolved through over 400 years of trial and error, "Many. of the criticisms of a proposed National Health Service exhibit the common fallacy of arguing from the special case to the general case., For example, it may be claimed that choice of doctor is essential for a satisfactory doctor-patient relationship. This doubtless is true for some patients, but obviously not for all, The question to be answered is whether the proportion of patient-doctor associations for which the statement is true is large enough > to make the provision of an adequate se Ta me, a naval doctor," the choice of doctor for everybody essential, even if it can be arranged only at the expense of medical efficiency in other respects. A Matter of Statistics "Again, the general proposition is frequently made that fixed salaries cause careless work. This is true with ‘some men; but do the careless men outhumber those men who work all the ‘better for being freed from financial worries? "These are problems in group phenomena, which can only be solved by the use of -statistical methods. Here is a very simple example of the use of "Statistics in administration, It was premised at the beginning of the war that women hate being examined by male ‘doctors. This is probably true; but the meaning implied was-therefore women prefer being examined by female doctors, if they must be examined by anybody. This is obviously a non sequitur, as well as an example of the fallacy of argument from the special to the general. But, instead of arguing further about it, the hypothesis was submitted to statistical investigation. It was then discovered that only 242 per cent of a group of young women stated a preference for female doctors; 424% per cent preferred ‘male doctors and the remain"ing 55 per cent were indifferent. As only 1 in 40 women preferred to be examined

by their own sex, it would have been an uneconomical use of medical manpower to ensure that all the women were given the choice of male or female doctors. Fixed Salaries "Cynics are daily writing letters to the papers on the pernicious effect on doctors of working for a fixed salary. For example, one letter to the lay Press the other day stated: ‘He (the doctor) will be paid a set salary, and it: will matter little to him if his work is good, bad, or indifferent, so long as it will just pass.’ These critics do not realise how they are giving themselves away; because, if they think this attitude is common among salaried doctors, it follows that the profit motive must be the main incentive to their own work, and that in their own case a fixed salary would cause them to be negligent, discourteous or careless in their duties towards their patients. In all walks of life there are a certain number of people who dislike their work and live only to draw their pay. The practical question is to what extent do these people affect the total efficiency of a medical service. "In the Navy there are admittedly a few medical officers who do as little work as possible, I call them passengers. They-are parasites on their colleagues, who have to carry them, and bad: bargains to the Crown, Passengers are a worrying problem to the appointments division of a medical department, for nobody wants them, and they generally have to be sent somewhere where another medical officer can keep an eye on them. A _ civilian business firm would sack passengers without mercy; but in a government service, unless they commit some gross misdemeanour, they have to be retained. In a National Health Service the passenger problem may become a very real one. Passengers, however, must be as common in civil practice as in naval, and it is surely better to bring them to the surface in a State service than to leave them buried in the medical underworld. "A Stupid Libel" "These medical slackers damage the reputation of the Services, because anyone who wants to be sarcastic at the expense of the Services, or is looking for propaganda against a national salaried service, and has the common habit of arguing from the particular to the general, will point to one of these lazy or hard-drinking naval misfits, of whom he may have some knowledge, and leave his audience to infer that this rare specimen is more typical of the Service ‘than the civilian "doctor. I would not ‘have mentioned this stupid libel on a (continued on next page)

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most efficient and abstemious group of medical men, taken as a whole, but that, astonishing as it may seem, certain influential medical men have not hesitated to advance it as an argument against a salaried service. It would be just as sensible to describe one of our outstanding physicians or surgeons as typical of a ship’s doctor., "It is surprising that the passenger class of naval medical officers is so rare. It is certainly not more than two or three per cent, as estimated from a study of hundreds of confidential reports and of those officers with whom I am acquainted. On the whole, self-respect, the desire to do well in the eyes of their herd, the natural sympathy with sick people, which must have influenced most men who choose medicine ‘aS a career, together with the more selfish but praiseworthy desire for promotion and good appointments, outweigh the alleged stultifying effect of a fixed salary, just as they keep in check the possible abuse of an unfixed fee system of payment. Choice of Doctor "The chief desire of the profession is that the choice of doctor by patient must remain sacrosanct. This is accepted in the recent White Paper as the first of the two principles which ‘a national service must observe’ (p. 26). "A Study of naval conditions of practice in which there is generally no choice of doctor, and incidentally, no choice of patient, does not lead one to attach the paramount importance to this principle which is generally given to it by the profession ashore. As regards the average quality of the treatment which an individual gets for his body, choice of doctor by patient makes no difference. Although he can pick a tall or a short doctor, or a serious or a cheerful doctor, as well as any other man, it is a lottery whether a patient picks an ignorant or a skilful clinician. A layman has no means of judging a doctor’s professional ability. Higher qualifications do not count for much, though ee

they do indicate that a man has taken the trouble to try to learn his job. On the other hand, psychological rapport between doctor and patient is such an important element in the treatment of many conditions that every effort should be made to obtain it. "The present system, in those places where choice of doctor is possible, is psychologically correct. The larger number of a_ general practitioner’s patients, whom he is able to see through their illnesses himself, are as much benefited by the personality and sympathy of a trusted doctor as they are by the therapeutic measures he employs. When the patient requires major surgical or special treatment, which his family doctor cannot provide, he goes to hospital, where it is equally right that the doctor should be chosen for him. The Doctor.of a-Ship "In the Royal Navy, especially in destroyers and the smaller ships, a relationship similar to the old familydoctor tradition often exists between the doctor and ship’s company. Before this war I was frankly sceptical of the advisability of wasting a doctor in the smaller ships. The amount of lifesaving, or prevention of ill-health, which a qualified man could accomplish among a ship’s company of 200-300 men seemed out of all proportion to the waste of medical. manpower involved in keeping a medical officer in a small ship, in which he was practically unemployed in clinical -work in the long intervals between actions and other emergencies. But since I have read the numerous eulogies in the captains’ ->onfidential Teports on their medical officers, and interviewed many of these young doctors and the senior executive and medical officers who know them, I have completely dropped my cynicism. Many of these youngsters have become as the ‘mother’ of their ship’s company. The doctor of a ship, provided he remains a doctor in the best sense of the word, has a privileged position. The doctor can ‘speak out of his turn’ more freely than anyone else to his captain, to whom he may become confidential adviser and friend; he may also do the welfare work of the ship and all sorts of odd nonmedical jobs. The wardroom and lower

deck consult him on their private and financial troubles, Specialism On the subject of specialism the Director-General was equally outspoken, , "The specialist is essential for the advance of knowledge and to give advice on, and treat, difficult, rare or obscure cases. In scientific research the © specialist of to-day must confine himself to the narrowest of subjects. But specialism cannot but have a narrowing effect on a man’s general outlook, however naturally broad-minded he is. A keen specialist’s specialism is the main complex which sways, consciously or unconsciously, all his thoughts and actions. However often a wise specialist pulls himself together, and reviews his subject in its relation to the rest of the world, he can never hope to see it in its proper proportions. For instance, it is impossible in the Navy to get some orthopaedic surgeons to realise that venereal diseases and tuberculosis are more important problems than fractures, when judged by their effect on the fighting efficiency of. the Fleet, the maintenance of which is the chief if not only duty of the Naval Medical Service in war. "But perhaps the besetting sin of the medical super-specialist is a reluctance to allow that any but themselves can deal effectively with even the easy and common cases within their subject. For example, in a recent letter to the British Medical Journal, a V.D, specialist, after describing two cases of malpractice in his specialty, argues from them that nobody should be allowed to treat V.D. but a recognised -V.D. specialist. Yet I stippose there are no diseases easier to recognise and great than early syphilis and gonorrhoea, and, if medical students wete taught something about them in the medical schools, the need for a consultant venereologist should seldom arise. "In my opinion it should be the duty of the ordinary doctor to know how to treat and ‘diagnose all the easy, common and emergency cases that are within each specialty, and leave the rare, obscure and difficult conditions to the specialist or to an expert surgical craftsman."