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The American practitioner online

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which you will see has healed by granulation. He has regained his
usual good health, and says he now feels as well as he ever did in his

The paper of the evening, ** Where Are We At? " (a discussion of the
commission evil), was read by Ap Morgan Vance, M. D.

Discusston. Dr. Wm. Bailey : I do not feel that a paper like this
should be allowed to pass without some consideration. It is a question
of great importance, as it pertains to the honor of the profession. I
believe that honesty is the best policy, and certainly no man of hon-
esty will want or receive a fee for any service that he has not ren-
dered. I see no reason in the world why the general practitioner, when
a case comes under his charge, and he gives it the necessary attention
to determine first whether it is a case within his realm or that he can
successfully treat it, if he does it honestly and conscientiously, whether
he does the patient any good or not, I see no reason why he is not
entitled to a fee for the time and attention given. And any fee that any
man ought to receive he ought to be willing to make it in the regular
charge to the patient. I can not conceive how any honest man would
receive a fee from the specialist that he would not be willing for the
patient to know that it is coming to him, and that it is right by virtue
of the time and attention he has given to the case. It is a mistake
to have people think that the doctor is only entitled to pay for
service that does good. I think we would be deprived of a large source
or part of our revenue if we limited it to cases where we actually do
the patient much good. We even are entitled to a fee perhaps when
the service has been an injury, provided it was the best we knew how
to do. As long as a case is under my charge, and I am going to give
it attention, I am always willing to let it be known that a charge will
be made, and shall endeavor to collect a suitable fee according to that
service. I can not conceive of any circumstances under which I would
feel that I had any right to expect or to receive from the specialist any
part of a fee for service that he should render the case.

I do not believe it always necessary that a patient referred by the
general practitioner to the specialist should pass entirely out of the
hands of the general practitioner. I believe this would be a mistake.
We send our patients, for instance, to a distance to seek aid that we are
not able to give them. The specialist under such circumstances could
not continue the service that may be needed beyond what can be made

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by his operation ; and it would be perfectly proper, in my judgment^
for the general practitioner to continue the supervision.

So far as the operation itself is concerned, and the immediate super-
vision of the case at the time of the operation, I am satisfied that the
general practitioner should give way to the specialist, and not embar-
rass the surgeon in the immediate management of the case because of
any lien or interest he retains ; but when it passes beyond the field of
the specialist again, by right he ought to give the case back to the gen-
eral practitioner who has referred it.

These are my convictions, and I think if we would pursue such a
course we would not find any difficulty ; if we would do unto others as
we would have them do unto us we would have no trouble. A course
like this would remove much of this difficulty, and if the practices indi-
cated by Dr. Vance's paper are prevalent, it is an alarming state as to
the morale of the profession. I am sorry to hear it intimated that even
in this part of the country the evil exists to the degree suggested.
Personally I have known of no such thing.

Dr. H. H. Grant: It has so happened with me that I have had no
one ever to approach me, as the paper read by Dr. Vance indicates is
the habit among general practitioners, to ask for a division of the fee.
I think it is scarcely the expectation of any of my friends in the pro-
fession from out of the city to bring patients here with the expectation'
of a division of the fee. The greater part of what is contained in Dr.
Vance's paper must have been the result of an appeal to specialists who
do office practice, rather than to the general surgeon. I can scarcely
see how any self-respecting surgeon could entertain for a moment a
proposition to do an operation and regulate the charge for it with the
expectation of dividing his fee with the man who brings the patient.

I think in case a general practitioner has had under his care a
patient for a considerable time, who subsequently needs surgery, that
it is neither unwise nor improper for the general practitioner's bill and
the surgeon's bill to be presented together, with the definite under-
standing on the part of the patient that both bills are to be paid in one
— that the bill includes charge for the services of both ; then such divis-
ion may be made between the surgeon and general practitioner as they
may choose to make. I would be distinctly opposed to any conditions
of trade prior to the operation, or of paying anybody a commission upon
business, or of any intimation under such circumstances that special
concessions would be made; but after the patient comes directly to

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the hands of the surgeon through the aid of any general practitioner,,
and a good fee is paid for the operation, I can not see any reason why,
if it appears wise, that the bills may not be presented together, and that
such division should be made as may be indicated by the personal rela-
tions of the two physicians concerned. In the letter read Dr. Morris
says not infrequently where he has - collected a small fee he has
occasionally divided it with the general practitioner. It is a question
entirely of the personal relations between the two.

We all appreciate the facts as Dr. Bailey has related them. Our
first duty is to the patient ; this applies with equal force to the surgeon,.
specialist, or general practitioner. I do not believe there is a doctor
in the city of Louisville, or a reputable man anywhere, certainly no
member of this Society, who does not first consider the welfare of his
patient, and many of us work earnestly and faithfully for the alleviation
of suflFering without the expectation of any reward. When it comes
to the point of actual division of the fee obtained from any patient, in
my judgment the only way in which it can be done is as I have out-
lined. That this can be wrong in any way I do not see ; but any thing^
that tends to interfere with either the benefits accruing to the surgeon
or the general practitioner, or any thing that interferes with the wel-
fare of the patient, needs condemnation.

Dr. J. A. Ouchterlony : I wish to say first, in answer to Dr. Grant,,
that I do not see any propriety in the bills being sent in conjointly
unless the two medical men are in partnership. The mere fact that
they have been in the case together seems to me no reason why they
should send in a joint bill. The physician should send in a bill for his
services, and the surgeon should send in a bill for his services. Each
should be paid for the service he has rendered and no more. I can not
conceive why the physician should receive part of the fee paid the
surgeon for services rendered by him simply because the case has been
referred to him. But the main point in the paper seems to be that
there is a practice prevalent of physicians being paid by specialists to
whom they have referred cases. I am very sure that this practice is
somewhat prevalent in this part of the country as well as elsewhere. A
number of years ago a physician who has now passed away said to me,.
"What do you get from surgeons when you send them cases?" I
asked what he meant, and he said : ** Why, don't you make them
pay you when you send cases to them?" I replied that I most
assuredly did not. He then remarked, ** They ought to be made to

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pay ; they get much bigger fees than we do." Well, I said, that is their
^ood fortune ; if we want to get equally large fees we must practice
surgery. That was the first time the subject had ever been brought
before me in that bold way. That country physicians hawk their
patients about after bringing them to the city to be operated upon I
am well aware. How often it is^ done I can not say, but I have known
of instances where the country doctor would bring a patient to a friend
of mine, then all of a sudden the doctor and his patient would disap-
pear and turn up in the office of some other surgeon. The first question
of the country doctor is, ** What are you going to charge ? " When the
fee was mentioned the rural physician would say, ** How much is there
in that for me?" The surgeon referred to was not a very good finan-
■cier, though a very honest medical man, and said " Nothing." The end
was just what I have mentioned. Now, it is common for the country
-doctors to try and make the consultant, whether he be physician
or surgeon, cut his fee down as far as possible, and then to say, " I
will pay it." That has happened to me. The doctor paid me the fee.
What is charged the patient afterward in such cases I do not know.
Of course I take it for granted the doctor did not charge the patient
any more, but there was a possibility that he might have done so. It
is very deplorable that such a thing should happen, but I do not see
how we could legislate such a state of things out of existence. The
only way is to elevate the morale of the profession by seeing to it that
those who are already in it and occupy high places should set a
good example, and as far as possible exclude men who are applicants
for degrees from entering the profession unless we are satisfied that
they are men of good moral character. Poverty is very demoralizing,
and often men will do things under the distress of poverty that they
would not do otherwise. Still we can not make them honest by legis-
lating any more than we can make them virtuous, and I must say that
I do not see where the remedy is to be found except in that rather
remote, indefinite way that I have mentioned.

Dr. J. G. Sherrill: There are three things to be considered in this
-connection, namely : the surgeon or specialist, the physician, and the
patient. The physician is many times the patient's adviser and friend,
and whenever you commence to introduce the commercial spirit in
matters of this kind the relations between the patient and physician
are materially changed, and you are bound to lower the plane of the
profession. If the physician turns his patient over to a surgeon or

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The American Practitioner and News. 269

specialist, then if the surgeon operates upon or otherwise treats this
patient, he is in his turn worthy of a fee.

If the surgeon includes in his bill sufficient to cover the amount
due the practitioner without notifying the patient, it places him in a
very unfavorable position; the patient goes away with the idea that
the surgeon has overcharged him ; that he is demanding more than he
really ought to receive for his services, while the surgeon is not getting
any more than he should, if as much, and the physician gets a fee
without the knowledge of the patient, the physician being paid for his
attendance upon the case out of the amount collected by the surgeon.
In this way the surgeon would often either rob himself or be compelled
to rob the patient to present the practitioner with a commission. If
this practice should extend and become general, you can readily see
how it would be looked upon by the patient ; he would have no respect
either for the surgeon or the practitioner. If the patient were to know
that his physician was guilty of such a practice he would certainly send
for another doctor, and if any surgical work were needed, if the surgeon
previously employed were known to be guilty, he would certainly send
for another surgeon ; and this is exactly what he should do. If this
practice becomes at all general the people are certain to know it, and
great harm will be done, not only to the individual, but also to the pro-
fession. I see only one way to remedy the evil, and that is for every
honest professional man to frown upon the practice, and when they
have proof of the existence of such a state of aflfairs, I believe it to be
their duty to report it in open meeting.

Dr. L. S. McMurtry: Certainly the subject was presented by Dr.
Vance in such a manner as to place all sides of it before the Society.
I am satisfied that the evil of paying commissions for the referring of
cases is more common in Eastern cities than it is with us. I have had
a rather extensive experience in special practice, and a considerable
proportion of the cases I have are referred to me by other physicians.
Individual experiences may give some light as to the condition of
affairs in our own bailiwick, and I have pleasure in stating that I have
never had but one proposition to pay a commission. I had the physi-
cian in the case write me a letter, stating that he had a case of a certain
character that he was contemplating referring to a specialist, and asking^
point blank how much I would allow him of the fee if he would refer
the patient to me.

Two years ago I met in Europe a distinguished surgeon of one of

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our Eastern cities. We were conversing upon various phases of pro-
fessional life, and he told me that this matter of paying commissions
for the referring of cases was very common in his city ; that whatever
I might think of it, he said the surgeon was compelled to do so, and he
-said that he did it. He is a man of distinction in the profession. I
was very much surprised, and it led me to believe that the practice is
very much more common in the large cities of the East than it is with
us here. I believe that the practice is exceptional here, though I have
^ood reason to know, from certain methods of observation suggested
by Dr. Ouchterlony, that such instances do occur here, but I think
they are rare.

There are other phases touched upon by Dr. Vance that are great
^vils, and they should receive consideration from gentlemen engaged
in special lines of practice, and I know that what I am going to allude
to now is familiar to the Fellows ; that is, that the practitioner who
refers the case to the specialist is directly interested in serving his
friends, among whom he practices, in having charged the lowest fee
for the specialist's services. With a desire to befriend his patient, be
is led to make statements which are not exactly correct. This is done
with the idea that the specialists get larger fees than they really do.
Many practitioners think that specialists in every department get
larger fees than they do. They have an idea that we charge according
to some standard that makes no discrimination, consequently they begin
to prepare for it as a service which they imagine they should render to
the people who are under their care. This is likely to work a great
injustice, because a man in excellent circumstances, one who is able to
pay a regular fee, such a fee as would be fair and just to the specialist,
may be pictured by the practitioner as unable to pay a reasonable fee,
-and in this way the pay is not compensatory for skilled work.

In regard to the paying of commissions downright — simply having
it understood with certain physicians that if they will bring their sur-
gical cases to certain surgeons they will be paid so much for each one
— I do not believe that occurs with us here except in rare instances.
In regard to the charges of the physician and those of the consulting
surgeon or specialist, I agree with Dr. Bailey that each one should
charge his own fee and collect it. This is the better policy ; it is better
for both the physician, specialist, and patient ; it makes a better impres-
sion, and every thing that is in the way of perfectly open, frank, and
.straightforward dealing with the patient is the best policy. Naturally

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every patient, and almost every physician who has a patient to refer,
wants to know beforehand what the surgeon's charges are going to be.
It is puzzling to know what to say to them. You do not know what the
case is, and the physician himself, perhaps, has only a general idea as
to whether any operative treatment will be required, yet he wants to
know before the patient is referred to you what will be your charge.
One single visit may be required, or the case may require a protracted
course of treatment; it may be an operable or an inoperable case; no
one can say before the patient is examined. Whenever it is possible
after seeing the patient, and the course of treatment has been deter-
mined upon, it is best to state just what the charges will be.

If the surgeon or specialist cultivates the commission business, it
will become known, not only to his colleagues but to patients. The
practice is indefensible, and is certain to injure the reputation of those
who engage in it. When the physician and surgeon, the physician and
consulting physician, or the physician and the specialist are working
jointly, each should be paid for his services in proportion to the means
of the patient, and their bills should be rendered separately ; every thing
in connection with the transaction should be open and above-board,
and it will be better for the reputation of the profession and the indi-
viduals connected with it.

As to the remedy for the evils which are said to exist, I do not know
that any thing can be said more than has been stated by Dr. Ouchter-
lony. The cultivation of a professional spirit and opposing com-
mercialism and insisting upon honest business methods is the only way
to do this. The cultivation of a high order of professional sentiment
and the hearty co-operation of physicians, surgeons, and specialists
will do more toward correcting the evils that exist than any thing else.
The interchange of views upon this subject is certain to do much good.
It will have a tendency to elevate the medical profession in all its
business aspects.

Dr. James B. Bullitt: The evil presented by the essayist is so prev-
alent that I can only believe that those who have not been made aware
of it are such as live so far above the clouds that they have not come
in contact with the ordinary things of earth. The whole thing hinges
upon honesty, and I believe that Dr. Vance in his blunt honesty has
struck a very hard blow which should make a dent, but whether the
reverse side of the shield will be any better for the dent which he has
made I am unable to say.

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It takes two parties to perpetuate an evil of this kind, and if the
surgeon or specialist is unwilling to accept a case and in return pay
commission therefor, such a practice of course could not exist ; but this
certainly has not been the case. Perhaps we would as well not speak
of where such a practice does or does not exist, but speak of the sec-
tion in which we live; it is a matter quite patent to all who have
knowledge of such dealings that there are men who will not only
divide fees, pay commissions, etc., but who will make direct overtures
for the reception of such fees on the ground that if the patient were
sent to others, a division of the proceeds would not be allowed.

Division of the fee as spoken of by Dr. Grant might be regarded as
proper under some circumstances, although, as indicated by the
remarks of several of the gentlemen, I believe it would be an impolitic
arrangement ; it would be an arrangement which would allow a man
to indulge in this practice which we are trying to avoid. In much
that has been said to-night and in the papers quoted by Dr. Vance we
are led to believe that the fault lies not so much with the surgeon or
specialist as with the general practitioner. This is perhaps not true.
While the practice may be encouraged on the one hand it is also per-
mitted on the other, and therefore I believe it would be wise to cast the
beam out of our own eye before attempting to cast the mote out of
the eye of the general practitioner. As regards the ultimate remedy
for such an evil, of course, as suggested by Dr. Ouchterlony, it does
not exist. Medical legislation as proposed by Dr. Morris would be
absolutely inadequate; it would simply direct attention to the evil, and
might be productive of good in this way. Such a paper as Dr. Vance
has read is calculated to do the same thing; attention should be called
to these practices, the searchlight should be turned upon them, with
the hope that the evils will be discontinued.

If a division of the fee is made, it always results in detriment to
the surgeon and to the financial gain of the physician rather than
always to the detriment of the patient. I mean by that, it is a very
much easier matter for the surgeon to take a certain amount out of his
pocket and give to the practitioner in a case of this kind than it is to
make the patient pay a larger fee. We know it is a difficult matter to
get patients in this section of the country at least to pay large fees, fees
which we believe our ser\ ices are justly entitled to, and if we are to
further divide this fee with the general practitioner, it works to the
detriment of the surgeon always.

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Dr. William Cheatham : In twenty-two and a half years of practice
in the city of Louisville, I have never had the commission proposition
made to me but once. In this instance a gentleman from a distance
wrote me regarding a certain case, asking what his commission would
be. In reply to my letter refusing to consider the matter, he gave a
very satisfactory explanation, and I believe he was sincere in it. He
has been a good friend of mine since. I know such practices exist, but
this is the only experience I have had.

Dr. H. A. Cottell: It seems to me that the evil can not be very prev-
alent or more of us would know something about it. In all my
experience with specialists — and I am a sort of half specialist myself —
I have had such a proposition made to me but once. A medical gentle-
man sent a patient to me to be treated for some nervous afiFection, and
suggested in return that a percentage of the fee collected would not be
refused. I believe much of this sort of thing is going on among a
certain class of doctors. They are, however, men who could not gain
entrance to this Society ; men who would be black-balled if they should
apply for membership.

That the evil exists there can be no question ; but I do not believe
it exists in high circles; there ought to be a remedy, and the plan
suggested by one of the writers of having the American Medical Asso-
ciation frown down upon it is a most excellent one. It has always
seemed to me that we ought to have in Louisville a strong represent-
ative medical society that would fix the ethical aspects of matters of
this kind, that could discipline its members if they broke over the
rules, a society to which every reputable doctor of the city might belong
and to which he would wish to belong. Such an organization as that
could do a great deal in the way of correcting abuses such as those to
which attention has been called. The spirit of commercialism is bound
to enter our profession ; we may hold ourselves above it^ which we
ought to do as far as possible, but it is in every line of business, and so
long as medicine is considered as a business men will be found who
would be willing to prostitute it for business purposes.

Dr. T. C. Evans: I am thoroughly in accord with what Dr. Bullitt
has said, that the fault lies more with the surgeon and specialist than
with the general practitioner. So far as the local condition is con-
cerned, my experience is that the general practitioners who have a good
business of their own are not engaged in dividing fees. The practice
is almost entirely with what might be called shysters, who stand in


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with some of the surgeons who stand high in the profession ; these
surgeons say to those on the outside : on all the cases you bring to me
for operation I will give you a certain percentage of the fees collected.
I have reason to believe that such things exist here as well as in the

Online LibraryUniversidad de Buenos Aires. Facultad de Derecho yThe American practitioner → online text (page 31 of 109)