The Doctor’s Dilemma/The Successful Doctor

The doctor whose success blinds public opinion to medical poverty is almost as completely demoralized. His promotion means that his practice becomes more and more confined to the idle rich. The proper advice for most of their ailments is typified in Abernethy's "Live on sixpence a day and earn it." But here, as at the other end of the scale, the right advice is neither agreeable nor practicable. And every hypochondriacal rich lady or gentleman who can be persuaded that he or she is a lifelong invalid means anything from fifty to five hundred pounds a year for the doctor. Operations enable a surgeon to earn similar sums in a couple of hours; and if the surgeon also keeps a nursing home, he may make considerable profits at the same time by running what is the most expensive kind of hotel. These gains are so great that they undo much of the moral advantage which the absence of grinding pecuniary anxiety gives the rich doctor over the poor one. It is true that the temptation to prescribe a sham treatment because the real treatment is too dear for either patient or doctor does not exist for the rich doctor. He always has plenty of genuine cases which can afford genuine treatment; and these provide him with enough sincere scientific professional work to save him from the ignorance, obsolescence, and atrophy of scientific conscience into which his poorer colleagues sink. But on the other hand his expenses are enormous. Even as a bachelor, he must, at London west end rates, make over a thousand a year before he can afford even to insure his life. His house, his servants, and his equipage (or autopage) must be on the scale to which his patients are accustomed, though a couple of rooms with a camp bed in one of them might satisfy his own requirements. Above all, the income which provides for these outgoings stops the moment he himself stops working. Unlike the man of business, whose managers, clerks, warehousemen and laborers keep his business going whilst he is in bed or in his club, the doctor cannot earn a farthing by deputy. Though he is exceptionally exposed to infection, and has to face all weathers at all hours of the night and day, often not enjoying a complete night's rest for a week, the money stops coming in the moment he stops going out; and therefore illness has special terrors for him, and success no certain permanence. He dare not stop making hay while the sun shines; for it may set at any time. Men do not resist pressure of this intensity. When they come under it as doctors they pay unnecessary visits; they write prescriptions that are as absurd as the rub of chalk with which an Irish tailor once charmed away a wart from my father's finger; they conspire with surgeons to promote operations; they nurse the delusions of the malade imaginaire (who is always really ill because, as there is no such thing as perfect health, nobody is ever really well); they exploit human folly, vanity, and fear of death as ruthlessly as their own health, strength, and patience are exploited by selfish hypochondriacs. They must do all these things or else run pecuniary risks that no man can fairly be asked to run. And the healthier the world becomes, the more they are compelled to live by imposture and the less by that really helpful activity of which all doctors get enough to preserve them from utter corruption. For even the most hardened humbug who ever prescribed ether tonics to ladies whose need for tonics is of precisely the same character as the need of poorer women for a glass of gin, has to help a mother through child-bearing often enough to feel that he is not living wholly in vain.