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THE DOCTOR'S DAY
1453
THE DOCTOR’S DAY " Come, tell me how "
you
live," I cried,
And what it is you do ! "
A a
glance at the corpse and its surroundings suggests peaceful and, probably, a natural end. But a glance
does not suffice. A careful examination may, and sometimes does, reveal signs of tragic, it may be of So policeman and doctor are THE metropolitan police surgeon is not a surgeon ; criminal, portent. cautious and systematic. They are the first portal a policeman. a medical is He is he not, strictly, nor or jurist; he is simply (and completely) a family doctor through which most deaths of unknown cause be whose family includes a number of individual types suspicious circumstance must pass. A slip may So the widely different from those met with in other branches fatal either to justice or to their reputation. of general practice. His status in the force is definitely case is reported to the coroner; and the doctor that of a doctor ; not less responsible on that account returns eventually to his other preoccupations. is his position which in some respects has improved BREAKING NEW GROUND of recent years. The care and treatment of the sick There is just time to see three patients and visit officer has become increasingly intimate and effective ; one other, to be seen "as soon as possible," before the examination of sick prisoners and others has at the local police-court to give evidence attending grown in importance, albeit the number requiring in a case colloquially known as a " drunk in charge " examination has, fortunately, diminished. A modern of a motor-car. Here is an example of work which critical (and sensitive) public opinion regarding police has grown in importance in recent years. Not of course administration requires qualities not only of clinical that " drunks " have increased in numbers ; they judgment but of tact and discrimination ; and these, have, in fact, greatly diminished. The days when a have all round to be exercised the clock. moreover, police surgeon might well see a dozen or more of Perhaps it is the continuity of his work which, Saturday night inebriates have passed, let us hope more than anything else, makes the divisional surgeon for ever. But the arrival of mechanical transport, something of an institution. Other officers come on apart from the birth of new standards of propriety and go off duty at early turn or late turn. They in the matter of alcoholic indulgence, has caused the appear, disappear, and reappear. Individually, they case of denied intoxication to become one for careful require the doctor’s services only occasionally for clinical examination. The case may- be disputed with themselves or their clients ; the doctor, on the other a vehemence and resource which in the past might hand, is available for all who may require his services have seemed disproportionate to the seriousness of throughout the day and night. In his r6le of medical the offence. The normally respectable citizen will man or medical witness, he is to be seen frequently often resort to every available aid to defend himself. not only at the local police station, but in the policeParticularly is this so in connexion with persons courts, in the courts of sessions, and the Old Bailey, charged with being under the influence of drink to and in the coroner’s court. Thus, he is necessarily such an extent as to be incapable of proper control ubiquitous, versatile and, however technically modest of a motor vehicle. Here is no simple question of and unobtrusive, well-nigh indispensable. Let us gross or incapable drunkenness. Criteria of behaviour review an occasional day in his life, noting well in or of ambulation do not directly arise ; but they have the first place that every day is new and none is a on an individual’s capacity for strong bearing " typical. proper control." The case will depend on evidence THE MORNING ROUND of incoordination, and of disorganisation by alcohol In the early morning he will see the " police sick." or drugs of essential mental faculties, such as attention, A sick policeman is a figure incongruous and unknown decision, and judgment. to the general public. He is much like other sick This is an aspect of the police surgeon’s work which people. He may be patient, confiding, and uncom- appears likely to develop further as the pace of life plaining. He may make light of his ailment, and even accelerates. Mechanisation and organisation of transapologise for being ill at all. On the other hand, he port spell nervous specialisation, and ask for efficiency may be alarmed and exigent. Invariably, however, on which the safety of drivers and pedestrians alike by virtue of his physique, his wordly wisdom, and depend. Fatigue, hunger, and exhaustion from illness his acquired discipline, he makes a " good " patient. render persons engaged upon occupations requiring Minor illnesses may be treated at home, especially superior and continuous concentration and efficiency if the officer be married. Injuries sustained usually liable to lapses which may be mistaken for intoxicaon the cricket or football field, or in the ring, or, tion. The examination of such cases demands of a occasionally, " in the execution of duty," are fairly doctor exceptional care, patience, and insight, frequent; and a good working rule is "the bigger qualities which are never uniform in anyone ; and he and stronger the policeman the greater the possibility must endeavour, in addition, to detach himself from of fracture." Serious or obscure illness can be any prejudice arising from the obvious circumstances transferred to the police nursing-home or to St. of a prisoner’s arrest. His opinions will often be Thomas’s Hospital. One of the advantages of the subject to close cross-examination, and sometimes, police medical service is the completeness of the in the view of justice, will be inacceptable. clinical facilities available. Also, in a service in Nevertheless, such work has its compensations. which discipline and regulation necessarily come first, The value of medical evidence is frequently recognised an officer’s relations with his official doctor will often by prosecution and defence alike. Indeed, the careful be as personal and confidential as in the case of a police surgeon can always rely on fair play by all concerned whenever he is called upon to assist the private patient. The treatment and disposal of the sick does not processes of the law. Other occasions on which his take long, but there are two men to visit; they will evidence is required include cases of alleged assault, be seen during the morning round. Meantime the murder, rape, indecency, and so forth. Cases of doctor is about to apply himself to his other affairs so-called loss of memory, ranging from severe mental when the telephone bell rings. Now the telephone illness to hysteria or malingering, constitute a feature is a big factor here, as in other doctors’ lives. It is of intensive civilisation with which the modern policethe herald of work, much of which is welcome, of man and the police surgeon are familiar. Attempts good news and of happy diversion, but also, as we at suicide suggest some thorny problems. Is the all know, of disconcerting intrusions and interruptions prisoner legally responsible ? If not, is he definitely to plan and routine. So now. The call is urgent : certifiable ? If not certifiable, is his illness such as " P.-c. 2XYO speaking. Will the doctor come at once to require institutional treatment ? Psychiatrists to No. 276, Top Flat, Cato-street. A man apparently believe such attempts to be often a sign, if not proof, dead." ... A sergeant is awaiting the arrival of the of early mental illness ; but they are made, perhaps doctor. The man is dead ; there is no doubt of that.I impulsively, by persons free from any other sign of VIII.-THE POLICEMAN’S DOCTOR
1454 Home to bed, at midnight. But just as we begin to shut eye the telephone rings out another peremptory call. Quite an ordinary case : a woman denies drunkenness. With a certain amount of conscious exasperation and self-pity, the doctor once more wends his way to the station, and examines his patient. This time, fortunately for him, no problem exists. The lady is drunk, and generously so. He writes a certificate to that effect in the book, and returns home to bed. One little fact of some importance has evaded mention. The police surgeon, as a rule, has a private practice, the demands of which also are exigent and continuous. Fortunately, it is a fact of experience that in medical work everything comes at once, and there are gaps which provide opportunity for relaxation. The wise doctor is one who can sense such subsequently. opportunity and enjoy it, returning to work soothed END OF THE DAY and refreshed. To the doctor who combines the two To-day has already provided its quota of variety. spheres of practice, the experience gained is at least To-night the doctor has been invited to act as medical worth the strain and inconvenience, for, if he loses officer at a police boxing tournament, and we reach his illusions, he gains variety, understanding, and a point at which duty can be combined with pleasure. resource. mental disorder.
one such case other occasional call will arrive. About 6 P.M. it does. Some small boys playing on the riverside have fished out a sack of dubious content. Here we have the problem of the dead newly born baby. The sack and its contents are carefully inspected before its removal to the nearest mortuary. It may be that the coroner will order the police surgeon himself to perform the post-mortem examinations of this and of the tragedy of the morning. If so, these will be arranged for to-morrow morning, early ; such tasks are best discharged as soon as possible, and the early hours of the day are least likely to interfere with routine. An inquest may be necessary; here the police surgeon will give evidence of his findings at the riverside and
nervous or will occur
to-day; if not,
Perhaps
some
PANEL AND CONTRACT PRACTICE The retiring doctor is required to surrender to the get off the Panel insurance committee all record cards, certificates, ANY qualified medical practitioner is entitled to and prescription forms. The notice from the doctor join the National Health Insurance service, provided to the insurance committee to cease practice gives How to
his name has not already been removed from that service by the decision, after full inquiry, of the Minister of Health. It is of importance for those who are already practising under the Act to know how to give up that work if they desire to do so. The regulations are designed to protect the insured person from being left without medical attention. An insurance doctor cannot, therefore, be in practice one day and gone the next without saying anything to anybody; he is required to give three months’ notice to the insurance committee of a desire to terminate his contract. The insurance committee may allow him to retire before this period is up, provided that adequate arrangements had been made for the treatment of his insured persons after the date of his
suggested retirement-e.g., by a partner carrying or a purchaser of the practice taking over.
on
The first modification -of the rule arises if the insurance committee have given notice of an alteration of terms of service, when the doctor receiving it has one month in which to decide whether he will work under the new conditions ; as the committee is usually required to give three months’ notice of any such alteration, the doctor can then give two months’ notice to cease insurance practice, so that he need not work under the new terms. A second modification arises if the doctor has been found guilty of breach of the regulations warranting representation to the Ministry that he is not a proper person to be in the service ; he will not be allowed to resign whilst an inquiry is pending, or until the decision has been given, except with the consent of the Minister. Lastly, the insurance committee may come to the conclusion that a particular practitioner is old and infirm and past his work, or that he has left the practice and cannot be traced. The committee must then consult with the panel committee, and if they agree the insurance committee may then (with the consent of the Minister) notify all his insured persons that as this doctor is not in a position to carry out his obligations they must choose another doctor. Payment to the outgoing doctor is made to the date of his cessation of practice, and if this is in the middle of a quarter the proportional amount is paid.
_
all the insured persons who had chosen him as their medical attendant the right to change to another doctor. This has always been so, but the administration of this right has had an interesting history. In the early days of the Act, insured persons were given notice they would be transferred from Dr. A to Dr. B, who had succeeded to Dr. A’s practice, unless within quite a short period (about 14 days) they wrote to say they wished to choose some other doctor. The effect of this was that the sale of insurance practices became very common, and at times quite lucrative. Dr. A would put up his plate in some sparsely medically populated industrial area, quickly pick up a large panel, and sell the lot to Dr. B ; then he would go and do likewise somewhere else. In order to stop this, a regulation was framed by which, on a practitioner ceasing to practise as an insurance doctor, the patients were sent a new medical blank card, and were informed that Dr. B was willing to accept them as he had agreed to carry on Dr. A’s practice. This procedure involved much work for the insurance committee as well as much work for Dr. B, who had to sign all the new cards brought up; it also left a large number of cards which the owners were too indifferent or too lazy to take to any doctor. These cases had then to come before the allocation subcommittee which, out of fairness to Dr. B, could not do otherwise than allocate them to him as he was generally the nearest doctor, and probably was practising in the same house as his predecessor. This allocation was made at the end of 18 months, and until that time had elapsed these voiceless patients were, in the.absence of a statement to the contrary, assumed to belong to Dr. B, and he was paid for them. It did not take long to discover that this new system, so expensive in time and postage, ended in practically the same result, namely, that well over 90 per cent. of the insured persons transferred to Dr. B from Dr. A; hence it was decided to revert to the old system, no new medical card being issued, but a notice being sent by the insurance committee to each insured person, informing him of his freedom to choose any other insurance doctor. At the request of the
outgoing doctor,
or
his
representatives,
the
name
and
THE DOCTOR’S DAY " Come, tell me how "
you
live," I cried,
And what it is you do ! "
A a
glance at the corpse and its surroundings suggests peaceful and, probably, a natural end. But a glance
does not suffice. A careful examination may, and sometimes does, reveal signs of tragic, it may be of So policeman and doctor are THE metropolitan police surgeon is not a surgeon ; criminal, portent. cautious and systematic. They are the first portal a policeman. a medical is He is he not, strictly, nor or jurist; he is simply (and completely) a family doctor through which most deaths of unknown cause be whose family includes a number of individual types suspicious circumstance must pass. A slip may So the widely different from those met with in other branches fatal either to justice or to their reputation. of general practice. His status in the force is definitely case is reported to the coroner; and the doctor that of a doctor ; not less responsible on that account returns eventually to his other preoccupations. is his position which in some respects has improved BREAKING NEW GROUND of recent years. The care and treatment of the sick There is just time to see three patients and visit officer has become increasingly intimate and effective ; one other, to be seen "as soon as possible," before the examination of sick prisoners and others has at the local police-court to give evidence attending grown in importance, albeit the number requiring in a case colloquially known as a " drunk in charge " examination has, fortunately, diminished. A modern of a motor-car. Here is an example of work which critical (and sensitive) public opinion regarding police has grown in importance in recent years. Not of course administration requires qualities not only of clinical that " drunks " have increased in numbers ; they judgment but of tact and discrimination ; and these, have, in fact, greatly diminished. The days when a have all round to be exercised the clock. moreover, police surgeon might well see a dozen or more of Perhaps it is the continuity of his work which, Saturday night inebriates have passed, let us hope more than anything else, makes the divisional surgeon for ever. But the arrival of mechanical transport, something of an institution. Other officers come on apart from the birth of new standards of propriety and go off duty at early turn or late turn. They in the matter of alcoholic indulgence, has caused the appear, disappear, and reappear. Individually, they case of denied intoxication to become one for careful require the doctor’s services only occasionally for clinical examination. The case may- be disputed with themselves or their clients ; the doctor, on the other a vehemence and resource which in the past might hand, is available for all who may require his services have seemed disproportionate to the seriousness of throughout the day and night. In his r6le of medical the offence. The normally respectable citizen will man or medical witness, he is to be seen frequently often resort to every available aid to defend himself. not only at the local police station, but in the policeParticularly is this so in connexion with persons courts, in the courts of sessions, and the Old Bailey, charged with being under the influence of drink to and in the coroner’s court. Thus, he is necessarily such an extent as to be incapable of proper control ubiquitous, versatile and, however technically modest of a motor vehicle. Here is no simple question of and unobtrusive, well-nigh indispensable. Let us gross or incapable drunkenness. Criteria of behaviour review an occasional day in his life, noting well in or of ambulation do not directly arise ; but they have the first place that every day is new and none is a on an individual’s capacity for strong bearing " typical. proper control." The case will depend on evidence THE MORNING ROUND of incoordination, and of disorganisation by alcohol In the early morning he will see the " police sick." or drugs of essential mental faculties, such as attention, A sick policeman is a figure incongruous and unknown decision, and judgment. to the general public. He is much like other sick This is an aspect of the police surgeon’s work which people. He may be patient, confiding, and uncom- appears likely to develop further as the pace of life plaining. He may make light of his ailment, and even accelerates. Mechanisation and organisation of transapologise for being ill at all. On the other hand, he port spell nervous specialisation, and ask for efficiency may be alarmed and exigent. Invariably, however, on which the safety of drivers and pedestrians alike by virtue of his physique, his wordly wisdom, and depend. Fatigue, hunger, and exhaustion from illness his acquired discipline, he makes a " good " patient. render persons engaged upon occupations requiring Minor illnesses may be treated at home, especially superior and continuous concentration and efficiency if the officer be married. Injuries sustained usually liable to lapses which may be mistaken for intoxicaon the cricket or football field, or in the ring, or, tion. The examination of such cases demands of a occasionally, " in the execution of duty," are fairly doctor exceptional care, patience, and insight, frequent; and a good working rule is "the bigger qualities which are never uniform in anyone ; and he and stronger the policeman the greater the possibility must endeavour, in addition, to detach himself from of fracture." Serious or obscure illness can be any prejudice arising from the obvious circumstances transferred to the police nursing-home or to St. of a prisoner’s arrest. His opinions will often be Thomas’s Hospital. One of the advantages of the subject to close cross-examination, and sometimes, police medical service is the completeness of the in the view of justice, will be inacceptable. clinical facilities available. Also, in a service in Nevertheless, such work has its compensations. which discipline and regulation necessarily come first, The value of medical evidence is frequently recognised an officer’s relations with his official doctor will often by prosecution and defence alike. Indeed, the careful be as personal and confidential as in the case of a police surgeon can always rely on fair play by all concerned whenever he is called upon to assist the private patient. The treatment and disposal of the sick does not processes of the law. Other occasions on which his take long, but there are two men to visit; they will evidence is required include cases of alleged assault, be seen during the morning round. Meantime the murder, rape, indecency, and so forth. Cases of doctor is about to apply himself to his other affairs so-called loss of memory, ranging from severe mental when the telephone bell rings. Now the telephone illness to hysteria or malingering, constitute a feature is a big factor here, as in other doctors’ lives. It is of intensive civilisation with which the modern policethe herald of work, much of which is welcome, of man and the police surgeon are familiar. Attempts good news and of happy diversion, but also, as we at suicide suggest some thorny problems. Is the all know, of disconcerting intrusions and interruptions prisoner legally responsible ? If not, is he definitely to plan and routine. So now. The call is urgent : certifiable ? If not certifiable, is his illness such as " P.-c. 2XYO speaking. Will the doctor come at once to require institutional treatment ? Psychiatrists to No. 276, Top Flat, Cato-street. A man apparently believe such attempts to be often a sign, if not proof, dead." ... A sergeant is awaiting the arrival of the of early mental illness ; but they are made, perhaps doctor. The man is dead ; there is no doubt of that.I impulsively, by persons free from any other sign of VIII.-THE POLICEMAN’S DOCTOR
1454 Home to bed, at midnight. But just as we begin to shut eye the telephone rings out another peremptory call. Quite an ordinary case : a woman denies drunkenness. With a certain amount of conscious exasperation and self-pity, the doctor once more wends his way to the station, and examines his patient. This time, fortunately for him, no problem exists. The lady is drunk, and generously so. He writes a certificate to that effect in the book, and returns home to bed. One little fact of some importance has evaded mention. The police surgeon, as a rule, has a private practice, the demands of which also are exigent and continuous. Fortunately, it is a fact of experience that in medical work everything comes at once, and there are gaps which provide opportunity for relaxation. The wise doctor is one who can sense such subsequently. opportunity and enjoy it, returning to work soothed END OF THE DAY and refreshed. To the doctor who combines the two To-day has already provided its quota of variety. spheres of practice, the experience gained is at least To-night the doctor has been invited to act as medical worth the strain and inconvenience, for, if he loses officer at a police boxing tournament, and we reach his illusions, he gains variety, understanding, and a point at which duty can be combined with pleasure. resource. mental disorder.
one such case other occasional call will arrive. About 6 P.M. it does. Some small boys playing on the riverside have fished out a sack of dubious content. Here we have the problem of the dead newly born baby. The sack and its contents are carefully inspected before its removal to the nearest mortuary. It may be that the coroner will order the police surgeon himself to perform the post-mortem examinations of this and of the tragedy of the morning. If so, these will be arranged for to-morrow morning, early ; such tasks are best discharged as soon as possible, and the early hours of the day are least likely to interfere with routine. An inquest may be necessary; here the police surgeon will give evidence of his findings at the riverside and
nervous or will occur
to-day; if not,
Perhaps
some
PANEL AND CONTRACT PRACTICE The retiring doctor is required to surrender to the get off the Panel insurance committee all record cards, certificates, ANY qualified medical practitioner is entitled to and prescription forms. The notice from the doctor join the National Health Insurance service, provided to the insurance committee to cease practice gives How to
his name has not already been removed from that service by the decision, after full inquiry, of the Minister of Health. It is of importance for those who are already practising under the Act to know how to give up that work if they desire to do so. The regulations are designed to protect the insured person from being left without medical attention. An insurance doctor cannot, therefore, be in practice one day and gone the next without saying anything to anybody; he is required to give three months’ notice to the insurance committee of a desire to terminate his contract. The insurance committee may allow him to retire before this period is up, provided that adequate arrangements had been made for the treatment of his insured persons after the date of his
suggested retirement-e.g., by a partner carrying or a purchaser of the practice taking over.
on
The first modification -of the rule arises if the insurance committee have given notice of an alteration of terms of service, when the doctor receiving it has one month in which to decide whether he will work under the new conditions ; as the committee is usually required to give three months’ notice of any such alteration, the doctor can then give two months’ notice to cease insurance practice, so that he need not work under the new terms. A second modification arises if the doctor has been found guilty of breach of the regulations warranting representation to the Ministry that he is not a proper person to be in the service ; he will not be allowed to resign whilst an inquiry is pending, or until the decision has been given, except with the consent of the Minister. Lastly, the insurance committee may come to the conclusion that a particular practitioner is old and infirm and past his work, or that he has left the practice and cannot be traced. The committee must then consult with the panel committee, and if they agree the insurance committee may then (with the consent of the Minister) notify all his insured persons that as this doctor is not in a position to carry out his obligations they must choose another doctor. Payment to the outgoing doctor is made to the date of his cessation of practice, and if this is in the middle of a quarter the proportional amount is paid.
_
all the insured persons who had chosen him as their medical attendant the right to change to another doctor. This has always been so, but the administration of this right has had an interesting history. In the early days of the Act, insured persons were given notice they would be transferred from Dr. A to Dr. B, who had succeeded to Dr. A’s practice, unless within quite a short period (about 14 days) they wrote to say they wished to choose some other doctor. The effect of this was that the sale of insurance practices became very common, and at times quite lucrative. Dr. A would put up his plate in some sparsely medically populated industrial area, quickly pick up a large panel, and sell the lot to Dr. B ; then he would go and do likewise somewhere else. In order to stop this, a regulation was framed by which, on a practitioner ceasing to practise as an insurance doctor, the patients were sent a new medical blank card, and were informed that Dr. B was willing to accept them as he had agreed to carry on Dr. A’s practice. This procedure involved much work for the insurance committee as well as much work for Dr. B, who had to sign all the new cards brought up; it also left a large number of cards which the owners were too indifferent or too lazy to take to any doctor. These cases had then to come before the allocation subcommittee which, out of fairness to Dr. B, could not do otherwise than allocate them to him as he was generally the nearest doctor, and probably was practising in the same house as his predecessor. This allocation was made at the end of 18 months, and until that time had elapsed these voiceless patients were, in the.absence of a statement to the contrary, assumed to belong to Dr. B, and he was paid for them. It did not take long to discover that this new system, so expensive in time and postage, ended in practically the same result, namely, that well over 90 per cent. of the insured persons transferred to Dr. B from Dr. A; hence it was decided to revert to the old system, no new medical card being issued, but a notice being sent by the insurance committee to each insured person, informing him of his freedom to choose any other insurance doctor. At the request of the
outgoing doctor,
or
his
representatives,
the
name
and