The day’s work of a doctor very often starts in the middle of the night. He may have had a tiring day with little or no respite, But no sooner has he gone to bed than the telephone or the front door bell may ring and he is called out on a case which may prove to be serious, keeping him out of bed for a long time, or may be a false alarm in the sense of some simple malady which might well have waited until morning. However short sleep he gets, his morning surgery will have its usual quota of patients as soon as he has finished his breakfast. Depending on the type of practice and the district in which it is situated, he will have a varying number of patients requiring visits which occupy him from the middle of the morning. He will have a list of those which are most urgent, and he will be lucky if he does not find among them one which keeps him so much longer than he has allowed that he must either leave over some visits to the afternoon or get back late for lunch. His afternoon is filled with further visits and consultations, and before he knows where he is, his evening surgery has filled up. If he is a successful practitioner he will measure his success by the number of patients that he sees, and if his practice is made additionally busy by reason of an epidemic, the greater part of his waking hours will be occupied with the ills and worries of his patients.
Doctors probably inspire a greater variety of deep feelings among the general public than any other class or profession. Those who have known the services of skilled practitioners, especially the surgeon, in saving a life which even to the lay eye was in urgent danger, probably regard the doctor himself —and through him all doctors— as the highest type of man kind. On the other hand, those who have lost a member of the family and have felt, justly or unjustly, that the doctor in attendance was inept, careless, or callous, may call that particular doctor a blackguard, and speak of the whole profession as being full of charlatans and fee-snatchers. There are in addition those who have as yet suffered little from the ravages of disease or have had little need of a doctor’s services, who regard medical men with a lenient and amused air as a class whose professional life provides the basis for nearly as many stories as do undertakers, mothers-in-law, and Scotsmen.
In any community however it would be found that this classification of the doctors was far from unanimous, and that the miracle-worker of one family might be the fee-snatcher of another. Doctors are not only as variable in their natures , and temperaments as the rest of mankind, but the results which they obtain depend on so many factors in the lives, constitutions, and environments of their patients that it is exceedingly difficult to generalise about their capabilities. The medical profession itself does divide doctors into different classes, but it does so according to the type of work which they are doing and the type of skill they possess. On the one hand there are those who have specialised in one branch of medicine or who have achieved renown for their knowledge of a particular disease or of one organ of the body; on the other hand there are those, constituting the bulk of the profession, who spend their lives in what someone has called the greatest specialty of all—general practice.
The general practitioner is today and appears likely to remain, the basis on which the machinery of medical care is built. Except in a few special types of service it is the general practitioner who first sees the individual whose health is causing concern to him or to his relatives.
An important principle is at once disclosed by this brief statement of the present position of the ordinary doctor. It takes as everyone knows five or six years at the university and some years in a hospital or assistantship of some, kind to give the doctor that knowledge, skill, and practice which will enable him to launch himself as a general practitioner. It is his job to detect at the earliest possible moment departures from normal health and to recognise what those departures mean interms of disease. Yet at the very outset the doctor has to wait in idleness until the degree of departure from normal has become so pronounced that the patient or those around him recognise that medical attention is needed.
A simple example from ordinary practice will make this clear. Everybody knows that in normal health it is necessary for the blood to be in perfect condition, that is to say, that it contains the proper number of those red cells which carry the oxygen from the lungs to the tissues, and that those red cells should themselves be of normal size and shape and contain a normal amount of iron. In the laboratory it is possible to detect quite small defects both in the number of cells and in their iron or (more scientifically) haemoglobin content. If blood examinations were made at regular intervals the laboratory would at once know if an alteration of anything over 5 per cent had taken place. If periodic physical examinations were carried out by a general practitioner he might recognise alterations of 15 per cent, and would certainly notice any drop so serious as 25 per cent that is 75 per cent of normal. As it is, it is not uncommon for patients to go to a doctor for the first time when the blood has dropped to 30 per cent, and cases of pernicious anaemia are quite often seen for the first time with only 20 per cent of normal blood
The general practitioner is therefore compelled, by the present system under which he is called into service only by those who are already sick, to spend his time either in treating those acute but so often trivial illnesses such as the common cold, or in diagnosing conditions which have already reached a stage where-the only thing to be done is to send the patient into hospital for surgical treatment or the opinion of specialists. This has important repercussions upon the doctor’s duty towards disease and towards his patients, and to be fully understood it must be examined in the light of the economics of medical practice. Its chief importance however, is that it restricts the work of the general practitioner to such an extent that it is only those who have particularly keen brains or who have opportunities for other types of medical work who succeed in maintaining a high professional standard.
A high professional standard is not used here in the sense of attention to medical ethics. The public is well aware that a code of medical ethics involving loyalty to professional colleagues and secrecy about the confidences of patients has long existed Indeed the medical graduate still swears by the same oath as did Hippocrates that he will observe these ethical rules with regard to his patients.
Ethical codes may prevent a doctor from doing something which the profession as a whole does not regard with favour, and may even attempt to dictate the moral life of doctors. They do not, however, involve any consideration of the doctor’s ability. In this country, certain ethical aspects of Medicine are controlled by the General Medical Council, a statutory body not to be confused with the British Medical Association, which is a voluntary professional organisation. The General Medical Council may prevent a really good doctor from practising because of some alleged moral or technical lapse, but has not the power to interfere with a very bad doctor so long as he observes the code.
But a high professional standard in Medicine means much more than this. It involves not merely the retention of knowledge acquires during studentship and the ability to carry out the recognised methods of detecting signs of disease, but the acquiring and putting into practice of a considerable volume of new knowledge and new methods.
Consider for a moment the history of a disease such as pneumonia. This condition has long been recognised as one very often fatal but from which a certain number of cases recover by a process so dramatic as to be given the name “crisis.” The cause of pneumonia remained unknown until various workers about 1883 showed that it was due to infection of the lung by a germ we now call the pneumococcus. Nearly fifty years had to elapse however, before research workers were able to develop a serum which, when injected into the pneumonia patient, neutralised the poisons of the pneumococcus and thus wrought a great saving of life. Doctors everywhere had to learn how to use this serum, what the correct dose was, and what dangers might attend its use. Research workers endeavoured to improve the quality and life-saving properties of the serum, and medical literature was flooded with articles assessing the results that were being obtained.
Suddenly it was announced that a new drug— soon to be known all over the world by the mystic symbol “M&B 693 ”—had been discovered, tested experimentally on animals tried out in hospitals on desperately ill pneumonia cases and proved to be the most potent weapon yet devised against this disease. At once every doctor had to learn not only what it was said this drug could do but something of its chemical composition and manner of working, so that he might be able fully to understand its operation in the body so as to apply the knowledge to his next cases of pneumonia. But he had also to remember that until even the safest drug has been used in tens of thousands of cases no one can be sure that it may not produce unexpected and unwanted results. He had also to learn that even with this drug there would still be cases that would have a better chance of survival if some of the serum which preceded it were also given, and eventually he had to learn that there would still be a few cases in which even these wonderful chemicals would not be able to destroy the pneumococcus before it had damaged the vital organs.
That is a particularly striking example of the way in which our. knowledge of one disease and its treatment changes in a few years and the general practitioner has many such advances, important if not so dramatic, to learn every year. He has to make his own arrangements for acquiring new information, for there is no official way in which it can be conveyed to him and no way in which he can obtain authoritative information upon such subjects. He is of course subjected to a barrage put up by manufacturers of medical preparations, and unless he has learned by experience how to assess the claims of these manufacturers he may be led as widely astray as are the general public by certain manufacturers of proprietary medicines.
The greatest difficulty with which the general practitioner has to contend is the number of patients that he may be expected to see in a day. The detection of the earliest signs of disease is a matter that requires not only skill and experience but time and patience. Contrast the surgery work of a general practitioner in an industrial area with that of a consulting physician or surgeon at a large hospital. The practitioner has had a very busy day with many visits in different parts of the town, driving his own car, climbing up and down stairs, and making one or two detours because of wrong addresses: of overlooked calls. He finds his evening surgery crowded with patients who have come to him at that time of night because they could not pay the slightly higher fee which he would have charged for a visit in their home, or because their illness has not been sufficiently severe to keep them from work, or because they could not afford to take time off. If he is to see all these people and finish his surgery by supper-time he cannot give to each patient more than a few minutes. A few rapid questions about the main symptoms, perhaps a stethoscope placed on a small area of the chest (for the patient is fully clothed) and a decision to give a bottle of medicine aimed at the alleviation of a troublesome cough or pain or other symptom, is all there is time for.
The public does not realise the almost infinite variety of symptoms, combination of signs, and even mixture of diseases that a doctor may see in one evening. Coughs make up a large proportion, and a cough is something that every patient thinks can be cured bya bottle of medicine. There is even, a much-advertised bottle which, it is claimed, ”cures every-thing with a cough in it.” But to the doctor that cough may be the first sign of tuberculosis; it may be the first indication of an incurable cancer; or it may be due to too much smoking. To confuse these diagnoses one which might be cured, one so often fatal, and one easily treated would not surprise anyone who knows the conditions under which so many doctors work in their surgeries. Yet a good doctor makes few mistakes, quickly noting which of these patients he must see in their own homes or must refer to hospital for another opinion. But he certainly has no chance of discovering anything but the most obvious signs of the most prominent disease. He has no time or opportunity of detecting small departures from normal, and very little scope for suggesting to the patient ways in which these could be prevented from developing in serious fashion. Often when he does discover a small defect, he is barred by his knowledge of his patient’s economic position from suggesting the cure if that would involve expense or absence from work.
This early detection of disease has two aspects. On the one hand it may enable treatment to be started so early that the patient is never really ill. On the other hand it may be the only chance of starting any form of treatment, even palliative.; This applies especially in the case of tumours and of these any doctor’s surgery would supply an astonishing variety. The human body produces a bewildering number of “growths;” both internal and external ,and among them are the cancers which can only be treated if diagnosed at a very early stage. There are many which even a full medical examination might not reveal early enough but the number that would be found while still small enough to be removed would justify many times over the regular examination of every citizen.
The importance of a periodical examination, apart that is, from a patient’s own realisation of the need to seek medical. advice, has been Shown time and again by the experience of army doctors’ dealing with enlistments The wide range of defects— some unsuspected by the would-be recruit— found in those apparently carrying on a normal and arduous life has been surprising. In one extreme case a man was found to be near-sighted, slightly deaf, had chronic indigestion, rupture, varicose veins: and flat feet He had been carrying on his duties as a warehouseman but not without discomfort, and though conscious that he ought to see a doctor, he could neither afford to take time off nor pay for a private doctor, nor to do anything that might suggest to his employers that he was unfit for the work he was engaged to do. A periodic examination would have brought aid and relief to him years before.
When a general practitioner does send a patient into hospital the examination there is a very different matter. Although the final decision would be the work of the physician or surgeon of senior rank, the examination is in fact the cooperative work of a large team. There is the preliminary examination and history-taking of the doctor who admits the patient to hospital, there is a second examination by one of the junior members of the staff who sets in motion machinery for X-ray and laboratory examinations, and there are the observations of temperature, pulse, and so on, made by nurses. If the case is a medical one, the senior physician may make his examination only when :the results of these additional examinations are ready. For him there is no question of that two inches of chest wall which patients very often present to the general practitioner. He sees the patient in bed and is able to make a complete examination of every organ, utilising a variety of apparatus and spending as long as may be necessary to discover and classify every sign of disease.
In making this contrast one does not imply a deficiency in the general practitioner. When the matter is discussed at professional gatherings the most common remark made by ordinary doctors is that they simply have not the time to examine the patients as they would like.
If. they did have time and their eyes, ears, fingers, and brain were sufficiently acute, would general practitioners be able to detect earlier signs of disease? The answer is that so long as they are dependent on patients coming to them for advice they would have no opportunity of detecting early signs of that disease on which the patient was seeking advice, although they might discover signs of one which the patient did not suspect. If however, the general practitioner—even if he had no other means but his own senses and skill—were given the opportunity of regularly examining in circumstances which would enable him to make full notes, or to study the notes of examinations .previously made by others, he would detect quite small departures from good health. If he had in addition the opportunity of sending every patient for other examinations which he considered necessary, the amount of early and curable disease which he would detect would be considerable. If, to carry the matter a stage farther, a certain series of routine periodical investigations were made of every individual these would enable the general practitioner to detect departures from normal so small as to be unnoticed by the patient and by the ordinary examinations of the doctor himself. Cure of disease at such an early stage is not only often a much simpler procedure but is of immense savingto the patient and to the community.;
Investigations have shown, for example, that a certain proportion of young people suffer from tuberculosis sufficiently well established to mean serious illness if their bodily resistance to it is lowered by overwork, under-nourishment, or the occurrence of some trivial malady; yet such cases can be cured before the patients actually become ill.
A few moments’ consideration of the life of the general practitioner would convince one that it cannot be by the wish of or through the negligence of the practitioners that they find themselves in this position— that with all the potentialities for the detection and treatment of disease they are nevertheless bound to that type of practice which earns for them the opprobrious title of “panel doctor.” Almost every practice has a varying number of those patients who pay the doctor a fee for services rendered, and also of National Health Insurance patients who are entitled to treatment because of their stamp payments. It is these latter patients, and those who as already noted cannot afford to pay for a home consultation, who fill the morning and evening surgeries of the general practitioner. It is their presence that leads to an otherwise good doctor getting the habit of dispensing bottles of medicine aimed at particular symptoms, and of sending to the nearest hospital those patients who cannot be “cured” by this method.
It is clear that the significance is not a medical but an economic one. The doctor is not only under the necessity of making a living, but, as we shall see, is often labouring under a huge financial debt incurred in buying his practice, and it is for these two reasons that he is compelled to crowd into his day and night as many consultations as he can possibly manage. We have here the twin economic factors of the doctor who must charge the highest fees he can obtain for whatever service satisfies the patient’s need, and of the patient who must obtain a maximum of medical care at the lowest possible cost.