The Doctor’s Dilemma/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.