by faithgibson on September 22, 2012

Burden on the State to Compensate Physicians for Charity Cases

Our present system of caring for the so-called “charity cases” is entirely wrong, and this does not apply to midwifery cases only. Our charities are, for the most part, but poorly investigated and supervised and are inefficiently administered. Much of it is not legitimate, and the cost is unjustly distributed. Physicians have been called upon to do much more than their share. There is not the slightest reason why the physician should give his professional services without pay, as it is no more his business to administer without compensation to the dependent and sick poor than that of any other citizen. The fact that he is especially fitted to so serve them does not in any wise alter the situation.

The poor when ill are the State’s charges, just as much as when they must be fed, clothed and sheltered, and the State should administer to the needs in one case just as much as in the other. Until physicians are justly compensated for their services to the poor they will not receive adequate medical attention. In the long run individuals receive just about the service to which they are entitled by the compensation provided. This is just as true in medicine as in any other field of endeavor, and so far as I can see there is not the slightest reason why it should not be. Public charities of all kinds should be placed upon a strictly business basis, should be well organized, thoroughly supervised, and all the workers should be justly compensated.

The placing of the burden of medical service to the poor upon physicians, without compensation, has led them to seek in return excessive fees from those who can pay, with the result that much harm has been done to the cause of medicine. The practice of medicine has been thereby converted into a trade, and commercialism has destroyed much of its higher and finer side, and has done untold harm in the attitude which the public should have toward the physician and the schools which educate him. And for this the leaders of the profession, the teachers of medicine, have been largely responsible. They have frequently used their professorial appointments for their personal profit, prostituting the ideals of medicine to their greed for gold, and “exploiting their patients at the expense of the entire profession.”

This does not apply to the so-called laboratory men, who have worked upon modest salaries, and yet have shown an unselfish devotion and enthusiasm which have astonished the whole world, and who have contributed practically the only knowledge in medicine which has been worth the while. Such men as Pasteur, Koch, Behring, Ehrlich, Flexner and a score of others are striking examples of medical men who have done a lasting service to humanity without levying a tribute upon it, and stand out in striking contrast, for example, to an equal number of American surgeons whose very work has been made possible only through that of the laboratory workers, but who, unlike them, have demanded from their patients unreasonable and dishonest fees for no other reason than that they have had the opportunity of doing so.

No one questions the justice of the man of means paying in accordance with his ability toward the medical care of the dependent poor, and that on this basis the burden should be equitably distributed, but it is the business of the State to collect such moneys for the purpose, and not the business of private persons to levy tribute upon individuals of means on the plea that they are serving the poor without pay. The State should pay the physician adequately for all his services to the poor and should collect by taxes from all the people their just share of the money necessary to care for its charges.

In medical charities economy and efficiency are all important and can best be secured when such charities are utilized for teaching purposes. Medical education and medical service to the poor should go hand in hand, since patients in teaching institutions receive the best possible attention and at the least possible cost to the State. Both are matters for the State rather than for private individuals and the State should, therefore, see that each contributes to the other all that is possible. It is not generally appreciated that medical schools should be first of all educational institutions rather than medical institutions; that they should be, moreover, public service organizations and exist for the public good, as do other educational institutions, and that the teacher of medicine should be an educator in the highest sense of the term and should stand in the closest relationship to all the problems of medical education, medical practice, eugenics and social service. He should spend his life, therefore, as a public servant, and should use his calling and the innumerable possibilities and opportunities which go with it, not to enrich himself at the expense of the profession, but to serve his generation in all that pertains to the public good.

For all these reasons medical schools should be liberally supported by the State as in Germany, where medical education and medical service have reached their greatest development. The number of medical schools should be limited to the actual needs of the country, and medical teachers should be put upon liberal salaries and should be required to devote their entire time to teaching, research and the care of hospital and dispensary patients. Until this is done it will not be possible to prevent many medical teachers from seeking and obtaining professorial appointments for the purpose of advancing their own personal interests.

But you may ask what has all this to do with the subject of my paper. This much, that men and women of influence and of means will never contribute all that is necessary in money and in legislation to medical education and medical charities until they have more confidence in the ideals and motives of those who administer them. And this brings up a very important matter which cannot be neglected in such a discussion as this, namely: the administration of medical charities— hospitals and dispensaries. Each supplements the work of the other and if properly co-ordinated they cover, without conflict, the entire field of medical service to the poor. Each is, therefore, indispensable, and each has its legitimate field. In so far as they care for the State’s charges, they should be supported by the State, the one just as much as the other. All patients applying for care through either should be rigidly investigated and required to pay to the extent of their ability.

To this class belong all patients who are unable to pay adequate physicians’ fees, whether they can pay all, a part or none of the cost to the hospital or dispensary of caring for them. And in this investigation all the facts should be taken into consideration—the size of the family, the income and cost of living, the actual legitimate earning capacity of the family; while the physical health and mental equipment must not be overlooked. If the income, whatever it be, is entirely needed for the necessities of life, it ought not to be used to pay physicians’ fees. Such individuals cannot, therefore, be looked upon as of any legitimate financial value to the physician to whom their care by hospitals and dispensaries should give no cause for offense.

The manifest and professed purpose of the science and art of medicine is the prevention and cure of disease. The physician exists, therefore, for the benefit of the patient, and not the patient for the benefit of the physician; and the solution of this matter will not be reached until this fact is fully appreciated, and until it governs our attitude toward providing medical service for the dependent poor. Any system, therefore, which does not provide the most economical service consistent with essential efficiency is wrong. On the other hand, physicians should not be criticized for not giving medical service to such patients, but, on the contrary, should be paid for it, and this applies with equal force to nurses and social workers.

In Pennsylvania the hospitals and dispensaries are paid by the State to the extent of the difference between what it costs to care for their patients and the receipts secured from them and from private gifts, and this is as it should be.

Part 3 ~ Criticism of hospital monopoly of ‘clinical material” and recommendations for improving clinical training