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has, he can cheat him with colored water and pass his lancet through the
flame of a spirit lamp before scratching his arm. But he cannot make him
change his daily habits without knowing it.




THE REFORMS ALSO COME FROM THE LAITY

In the main, then, the doctor learns that if he gets ahead of the
superstitions of his patients he is a ruined man; and the result is that
he instinctively takes care not to get ahead of them. That is why all
the changes come from the laity. It was not until an agitation had been
conducted for many years by laymen, including quacks and faddists of all
kinds, that the public was sufficiently impressed to make it possible
for the doctors to open their minds and their mouths on the subject of
fresh air, cold water, temperance, and the rest of the new fashions in
hygiene. At present the tables have been turned on many old prejudices.
Plenty of our most popular elderly doctors believe that cold tubs in the
morning are unnatural, exhausting, and rheumatic; that fresh air is a
fad and that everybody is the better for a glass or two of port wine
every day; but they no longer dare say as much until they know exactly
where they are; for many very desirable patients in country houses have
lately been persuaded that their first duty is to get up at six in the
morning and begin the day by taking a walk barefoot through the dewy
grass. He who shows the least scepticism as to this practice is at once
suspected of being "an old-fashioned doctor," and dismissed to make room
for a younger man.

In short, private medical practice is governed not by science but by
supply and demand; and however scientific a treatment may be, it cannot
hold its place in the market if there is no demand for it; nor can the
grossest quackery be kept off the market if there is a demand for it.




FASHIONS AND EPIDEMICS

A demand, however, can be inculcated. This is thoroughly understood
by fashionable tradesmen, who find no difficulty in persuading their
customers to renew articles that are not worn out and to buy things they
do not want. By making doctors tradesmen, we compel them to learn the
tricks of trade; consequently we find that the fashions of the year
include treatments, operations, and particular drugs, as well as hats,
sleeves, ballads, and games. Tonsils, vermiform appendices, uvulas, even
ovaries are sacrificed because it is the fashion to get them cut out,
and because the operations are highly profitable. The psychology of
fashion becomes a pathology; for the cases have every air of being
genuine: fashions, after all, are only induced epidemics, proving that
epidemics can be induced by tradesmen, and therefore by doctors.




THE DOCTOR'S VIRTUES

It will be admitted that this is a pretty bad state of things. And the
melodramatic instinct of the public, always demanding; that every wrong
shall have, not its remedy, but its villain to be hissed, will blame,
not its own apathy, superstition, and ignorance, but the depravity of
the doctors. Nothing could be more unjust or mischievous. Doctors, if no
better than other men, are certainly no worse. I was reproached during
the performances of The Doctor's Dilemma at the Court Theatre in
1907 because I made the artist a rascal, the journalist an illiterate
incapable, and all the doctors "angels." But I did not go beyond the
warrant of my own experience. It has been my luck to have doctors
among my friends for nearly forty years past (all perfectly aware of
my freedom from the usual credulity as to the miraculous powers and
knowledge attributed to them); and though I know that there are medical
blackguards as well as military, legal, and clerical blackguards (one
soon finds that out when one is privileged to hear doctors talking shop
among themselves), the fact that I was no more at a loss for private
medical advice and attendance when I had not a penny in my pocket than I
was later on when I could afford fees on the highest scale, has made it
impossible for me to share that hostility to the doctor as a man which
exists and is growing as an inevitable result of the present condition
of medical practice. Not that the interest in disease and aberrations
which turns some men and women to medicine and surgery is not sometimes
as morbid as the interest in misery and vice which turns some others
to philanthropy and "rescue work." But the true doctor is inspired by
a hatred of ill-health, and a divine impatience of any waste of vital
forces. Unless a man is led to medicine or surgery through a very
exceptional technical aptitude, or because doctoring is a family
tradition, or because he regards it unintelligently as a lucrative and
gentlemanly profession, his motives in choosing the career of a healer
are clearly generous. However actual practice may disillusion and
corrupt him, his selection in the first instance is not a selection of a
base character.




THE DOCTOR'S HARDSHIPS

A review of the counts in the indictment I have brought against private
medical practice will show that they arise out of the doctor's position
as a competitive private tradesman: that is, out of his poverty and
dependence. And it should be borne in mind that doctors are expected
to treat other people specially well whilst themselves submitting
to specially inconsiderate treatment. The butcher and baker are not
expected to feed the hungry unless the hungry can pay; but a doctor who
allows a fellow-creature to suffer or perish without aid is regarded as
a monster. Even if we must dismiss hospital service as really venal,
the fact remains that most doctors do a good deal of gratuitous work
in private practice all through their careers. And in his paid work the
doctor is on a different footing to the tradesman. Although the articles
he sells, advice and treatment, are the same for all classes, his fees
have to be graduated like the income tax. The successful fashionable
doctor may weed his poorer patients out from time to time, and finally
use the College of Physicians to place it out of his own power to accept
low fees; but the ordinary general practitioner never makes out his
bills without considering the taxable capacity of his patients.

Then there is the disregard of his own health and comfort which results
from the fact that he is, by the nature of his work, an emergency man.
We are polite and considerate to the doctor when there is nothing the
matter, and we meet him as a friend or entertain him as a guest; but
when the baby is suffering from croup, or its mother has a temperature
of 104 degrees, or its grandfather has broken his leg, nobody thinks
of the doctor except as a healer and saviour. He may be hungry,
weary, sleepy, run down by several successive nights disturbed by that
instrument of torture, the night bell; but who ever thinks of this
in the face of sudden sickness or accident? We think no more of the
condition of a doctor attending a case than of the condition of
a fireman at a fire. In other occupations night-work is specially
recognized and provided for. The worker sleeps all day; has his
breakfast in the evening; his lunch or dinner at midnight; his dinner or
supper before going to bed in the morning; and he changes to day-work
if he cannot stand night-work. But a doctor is expected to work day and
night. In practices which consist largely of workmen's clubs, and in
which the patients are therefore taken on wholesale terms and very
numerous, the unfortunate assistant, or the principal if he has no
assistant, often does not undress, knowing that he will be called up
before he has snatched an hour's sleep. To the strain of such inhuman
conditions must be added the constant risk of infection. One wonders
why the impatient doctors do not become savage and unmanageable, and the
patient ones imbecile. Perhaps they do, to some extent. And the pay is
wretched, and so uncertain that refusal to attend without payment in
advance becomes often a necessary measure of self-defence, whilst the
County Court has long ago put an end to the tradition that the doctor's
fee is an honorarium. Even the most eminent physicians, as such
biographies as those of Paget show, are sometimes miserably, inhumanly
poor until they are past their prime. In short, the doctor needs our
help for the moment much more than we often need his. The ridicule of
Moliere, the death of a well-informed and clever writer like the late
Harold Frederic in the hands of Christian Scientists (a sort of sealing
with his blood of the contemptuous disbelief in and dislike of doctors
he had bitterly expressed in his books), the scathing and quite
justifiable exposure of medical practice in the novel by Mr. Maarten
Maartens entitled The New Religion: all these trouble the doctor very
little, and are in any case well set off by the popularity of Sir Luke
Fildes' famous picture, and by the verdicts in which juries from time to
time express their conviction that the doctor can do no wrong. The
real woes of the doctor are the shabby coat, the wolf at the door,
the tyranny of ignorant patients, the work-day of 24 hours, and the
uselessness of honestly prescribing what most of the patients really
need: that is, not medicine, but money.




THE PUBLIC DOCTOR

What then is to be done?

Fortunately we have not to begin absolutely from the beginning: we
already have, in the Medical Officer of Health, a sort of doctor who is
free from the worst hardships, and consequently from the worst vices,
of the private practitioner. His position depends, not on the number
of people who are ill, and whom he can keep ill, but on the number of
people who are well. He is judged, as all doctors and treatments should
be judged, by the vital statistics of his district. When the death rate
goes up his credit goes down. As every increase in his salary depends on
the issue of a public debate as to the health of the constituency under
his charge, he has every inducement to strive towards the ideal of a
clean bill of health. He has a safe, dignified, responsible, independent
position based wholly on the public health; whereas the private
practitioner has a precarious, shabby-genteel, irresponsible, servile
position, based wholly on the prevalence of illness.

It is true, there are grave scandals in the public medical service. The
public doctor may be also a private practitioner eking out his earnings
by giving a little time to public work for a mean payment. There are
cases in which the position is one which no successful practitioner will
accept, and where, therefore, incapables or drunkards get automatically
selected for the post, faute de mieux; but even in these cases the
doctor is less disastrous in his public capacity than in his private
one: besides, the conditions which produce these bad cases are doomed,
as the evil is now recognized and understood. A popular but unstable
remedy is to enable local authorities, when they are too small to
require the undivided time of such men as the Medical Officers of our
great municipalities, to combine for public health purposes so that each
may share the services of a highly paid official of the best class; but
the right remedy is a larger area as the sanitary unit.




MEDICAL ORGANIZATION

Another advantage of public medical work is that it admits of
organization, and consequently of the distribution of the work in such
a manner as to avoid wasting the time of highly qualified experts
on trivial jobs. The individualism of private practice leads to an
appalling waste of time on trifles. Men whose dexterity as operators or
almost divinatory skill in diagnosis are constantly needed for difficult
cases, are poulticing whitlows, vaccinating, changing unimportant
dressings, prescribing ether drams for ladies with timid leanings
towards dipsomania, and generally wasting their time in the pursuit of
private fees. In no other profession is the practitioner expected to
do all the work involved in it from the first day of his professional
career to the last as the doctor is. The judge passes sentence of death;
but he is not expected to hang the criminal with his own hands, as he
would be if the legal profession were as unorganized as the medical. The
bishop is not expected to blow the organ or wash the baby he baptizes.
The general is not asked to plan a campaign or conduct a battle at
half-past twelve and to play the drum at half-past two. Even if they
were, things would still not be as bad as in the medical profession; for
in it not only is the first-class man set to do third-class work, but,
what is much more terrifying, the third-class man is expected to do
first-class work. Every general practitioner is supposed to be capable
of the whole range of medical and surgical work at a moment's notice;
and the country doctor, who has not a specialist nor a crack consultant
at the end of his telephone, often has to tackle without hesitation
cases which no sane practitioner in a town would take in hand without
assistance. No doubt this develops the resourcefulness of the country
doctor, and makes him a more capable man than his suburban colleague;
but it cannot develop the second-class man into a first-class one. If
the practice of law not only led to a judge having to hang, but the
hangman to judge, or if in the army matters were so arranged that it
would be possible for the drummer boy to be in command at Waterloo
whilst the Duke of Wellington was playing the drum in Brussels, we
should not be consoled by the reflection that our hangmen were thereby
made a little more judicial-minded, and our drummers more responsible,
than in foreign countries where the legal and military professions
recognized the advantages of division of labor.

Under such conditions no statistics as to the graduation of professional
ability among doctors are available. Assuming that doctors are normal
men and not magicians (and it is unfortunately very hard to persuade
people to admit so much and thereby destroy the romance of doctoring)
we may guess that the medical profession, like the other professions,
consists of a small percentage of highly gifted persons at one end,
and a small percentage of altogether disastrous duffers at the other.
Between these extremes comes the main body of doctors (also, of
course, with a weak and a strong end) who can be trusted to work under
regulations with more or less aid from above according to the gravity
of the case. Or, to put it in terms of the cases, there are cases that
present no difficulties, and can be dealt with by a nurse or student at
one end of the scale, and cases that require watching and handling by
the very highest existing skill at the other; whilst between come
the great mass of cases which need visits from the doctor of ordinary
ability and from the chiefs of the profession in the proportion of, say,
seven to none, seven to one, three to one, one to one, or, for a day
or two, none to one. Such a service is organized at present only
in hospitals; though in large towns the practice of calling in the
consultant acts, to some extent, as a substitute for it. But in the
latter case it is quite unregulated except by professional etiquet,
which, as we have seen, has for its object, not the health of the
patient or of the community at large, but the protection of the doctor's
livelihood and the concealment of his errors. And as the consultant is
an expensive luxury, he is a last resource rather, as he should be, than
a matter of course, in all cases where the general practitioner is not
equal to the occasion: a predicament in which a very capable man may
find himself at any time through the cropping up of a case of which he
has had no clinical experience.




THE SOCIAL SOLUTION OF THE MEDICAL PROBLEM

The social solution of the medical problem, then, depends on that large,
slowly advancing, pettishly resisted integration of society called
generally Socialism. Until the medical profession becomes a body of men
trained and paid by the country to keep the country in health it will
remain what it is at present: a conspiracy to exploit popular credulity
and human suffering. Already our M.O.H.s (Medical Officers of Health)
are in the new position: what is lacking is appreciation of the change,
not only by the public but by the private doctors. For, as we have seen,
when one of the first-rate posts becomes vacant in one of the great
cities, and all the leading M.O.H.s compete for it, they must appeal to
the good health of the cities of which they have been in charge, and not
to the size of the incomes the local private doctors are making out of
the ill-health of their patients. If a competitor can prove that he has
utterly ruined every sort of medical private practice in a large city
except obstetric practice and the surgery of accidents, his claims are
irresistible; and this is the ideal at which every M.O.H. should aim.
But the profession at large should none the less welcome him and set
its house in order for the social change which will finally be its own
salvation. For the M.O.H. as we know him is only the beginning of that
army of Public Hygiene which will presently take the place in general
interest and honor now occupied by our military and naval forces. It is
silly that an Englishman should be more afraid of a German soldier than
of a British disease germ, and should clamor for more barracks in the
same newspapers that protest against more school clinics, and cry out
that if the State fights disease for us it makes us paupers, though
they never say that if the State fights the Germans for us it makes us
cowards. Fortunately, when a habit of thought is silly it only needs
steady treatment by ridicule from sensible and witty people to be put
out of countenance and perish. Every year sees an increase in the number
of persons employed in the Public Health Service, who would formerly
have been mere adventurers in the Private Illness Service. To put it
another way, a host of men and women who have now a strong incentive
to be mischievous and even murderous rogues will have a much stronger,
because a much honester, incentive to be not only good citizens but
active benefactors to the community. And they will have no anxiety
whatever about their incomes.




THE FUTURE OF PRIVATE PRACTICE

It must not be hastily concluded that this involves the extinction of
the private practitioner. What it will really mean for him is release
from his present degrading and scientifically corrupting slavery to his
patients. As I have already shown the doctor who has to live by pleasing
his patients in competition with everybody who has walked the hospitals,
scraped through the examinations, and bought a brass plate, soon finds
himself prescribing water to teetotallers and brandy or champagne jelly
to drunkards; beefsteaks and stout in one house, and "uric acid free"
vegetarian diet over the way; shut windows, big fires, and heavy
overcoats to old Colonels, and open air and as much nakedness as is
compatible with decency to young faddists, never once daring to say
either "I don't know," or "I don't agree." For the strength of the
doctor's, as of every other man's position when the evolution of social
organization at last reaches his profession, will be that he will always
have open to him the alternative of public employment when the private
employer becomes too tyrannous. And let no one suppose that the words
doctor and patient can disguise from the parties the fact that they are
employer and employee. No doubt doctors who are in great demand can be
as high-handed and independent as employees are in all classes when a
dearth in their labor market makes them indispensable; but the average
doctor is not in this position: he is struggling for life in an
overcrowded profession, and knows well that "a good bedside manner"
will carry him to solvency through a morass of illness, whilst the
least attempt at plain dealing with people who are eating too much, or
drinking too much, or frowsting too much (to go no further in the list
of intemperances that make up so much of family life) would soon land
him in the Bankruptcy Court.

Private practice, thus protected, would itself protect individuals, as
far as such protection is possible, against the errors and superstitions
of State medicine, which are at worst no worse than the errors and
superstitions of private practice, being, indeed, all derived from it.
Such monstrosities as vaccination are, as we have seen, founded, not on
science, but on half-crowns. If the Vaccination Acts, instead of being
wholly repealed as they are already half repealed, were strengthened by
compelling every parent to have his child vaccinated by a public officer
whose salary was completely independent of the number of vaccinations
performed by him, and for whom there was plenty of alternative public
health work waiting, vaccination would be dead in two years, as the
vaccinator would not only not gain by it, but would lose credit through
the depressing effects on the vital statistics of his district of the
illness and deaths it causes, whilst it would take from him all the
credit of that freedom from smallpox which is the result of good
sanitary administration and vigilant prevention of infection. Such
absurd panic scandals as that of the last London epidemic, where a fee
of half-a-crown per re-vaccination produced raids on houses during
the absence of parents, and the forcible seizure and re-vaccination of
children left to answer the door, can be prevented simply by abolishing
the half-crown and all similar follies, paying, not for this or that
ceremony of witchcraft, but for immunity from disease, and paying, too,
in a rational way. The officer with a fixed salary saves himself trouble
by doing his business with the least possible interference with the
private citizen. The man paid by the job loses money by not forcing his
job on the public as often as possible without reference to its results.




THE TECHNICAL PROBLEM

As to any technical medical problem specially involved, there is none.
If there were, I should not be competent to deal with it, as I am not a
technical expert in medicine: I deal with the subject as an economist, a
politician, and a citizen exercising my common sense. Everything that I
have said applies equally to all the medical techniques, and will hold
good whether public hygiene be based on the poetic fancies of Christian
Science, the tribal superstitions of the druggist and the vivisector, or
the best we can make of our real knowledge. But I may remind those
who confusedly imagine that the medical problem is also the scientific
problem, that all problems are finally scientific problems. The notion
that therapeutics or hygiene or surgery is any more or less scientific
than making or cleaning boots is entertained only by people to whom
a man of science is still a magician who can cure diseases, transmute
metals, and enable us to live for ever. It may still be necessary for
some time to come to practise on popular credulity, popular love and
dread of the marvellous, and popular idolatry, to induce the poor
to comply with the sanitary regulations they are too ignorant
to understand. As I have elsewhere confessed, I have myself been
responsible for ridiculous incantations with burning sulphur,
experimentally proved to be quite useless, because poor people are
convinced, by the mystical air of the burning and the horrible smell,
that it exorcises the demons of smallpox and scarlet fever and makes it
safe for them to return to their houses. To assure them that the real
secret is sunshine and soap is only to convince them that you do not
care whether they live or die, and wish to save money at their expense.
So you perform the incantation; and back they go to their houses,
satisfied. A religious ceremony - a poetic blessing of the threshold, for
instance - would be much better; but unfortunately our religion is weak
on the sanitary side. One of the worst misfortunes of Christendom was
that reaction against the voluptuous bathing of the imperial Romans
which made dirty habits a part of Christian piety, and in some unlucky
places (the Sandwich Islands for example) made the introduction of
Christianity also the introduction of disease, because the formulators
of the superseded native religion, like Mahomet, had been enlightened
enough to introduce as religious duties such sanitary measures as
ablution and the most careful and reverent treatment of everything
cast off by the human body, even to nail clippings and hairs; and our
missionaries thoughtlessly discredited this godly doctrine without
supplying its place, which was promptly taken by laziness and neglect.


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Online LibraryGeorge Bernard ShawThe Doctor's Dilemma: Preface on Doctors → online text (page 6 of 7)