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DICHOTOMY OR FEE-SPLITTING.
DICHOTOMY OR FEE-SPLITTING.
129
a rule 15 or 20 years ago, although not nearly so prevalent now ; in Ohio a signed contribution states DICHOTOMY OR FEE-SPLITTING. that it is universal, while a Wilmington practitioner WE published last week a letter from a corre- understands, in a general way, that many of the spondent, who gave a very good reason for remaining general surgeons and specialists in Cincinnati split .anonymous, on what he described as an obnoxious fees with small-town doctors who refer them cases. practice which he had reason to believe is rapidly A Minnesota physician remarks that the practice .extending in certain parts of London. This practice is quite inevitable under present conditions, the consists in the diversion of part of a consultant’s large fees received by surgical specialists being its fee, without the knowledge of the patient, to the foundation. The ex-president of Iowa State Medical practitioner who has advised the consultation. The Society says, quite frankly, that 75 per cent. of the patient believes that his whole payment is made doctors of Iowa and Nebraska " want splits." These to the surgeon or physician who has been called in, examples may suffice to give some idea of the relative -whereas part of the fee has, in fact, been deducted prevalence of fee-splitting in the various United There are, States. The report does not cover Latin America, as a commission for the practitioner. we have been assured, a large number of consultants if only for the reason that division of the total fee in this country who have no cognisance of any such paid between the specialist and the family doctor is practice, and these may be inclined even to question apparently the accepted practice there. its occurrence, but it may be recalled that several Something has already been said, incidentally, years ago, in accordance with a widely felt desire, a regarding the circumstances which have brought meeting of consultants and specialists was called in about such a state of affairs. A New York correa provincial centre to discuss the practice, and two statement may be given as an example. resolutions were passed and circulated to all the spondent’s He writes : " The newcomer, or unknown specialist, practitioners in the neighbourhood. The resolutions in his desire to increase his clientele, offers part of were worded thus :his fee as an inducement to the family physician. 1. It is improper for a Consultant to transfer any portion Many young surgeons find it impossible to build of his consultation- or operation-fee to the Practitioner who , up a practice any other way. Some prominent has called him in. The Consultant who offers or agrees to with good followings take into consideration such payment, however innocently, is open to the suspicion specialists of the the plight referring physician and give him a of paying a commission for his own advantage. The Practitioner who accepts or asks for it cannot maintain the portion of the fee on the basis of good fellowship." position of a trusted and unbiased adviser as to the need For these reasons he regards the hope of eliminating for a consultation and the selection of a Consultant. fee-splitting completely from medical practice as 2. No Consultant or Specialist shall pay to the General rather meagre, and there is, in fact, throughout the Practitioner who is associated with him in a case any part symposium not only a wide admission of the practice of an operation-, consultation-, or so-called " inclusive and of its inevitability, but a good deal of justification fee, unless he informs the patient or his representatives of the for it. The legal profession, writes a Baltimore services for which the payment is made and the amount of splits fees and finds nothing wrong with it. physician, such payment. (The analogy would fail in this country if applied The situation is one which has been freely discussed to a busy barrister sharing his fee with another for some time past in the United States of America, barrister who has devilled a case for him, for there and at its April meeting the New York Medical is no element of agency.) A New York physician Society received a report on the subject from its feels that for the younger man fee-splitting should Committee of Economics. This report was, it appears, be legitimatised, for it cannot be eradicated. As a tabled without any vote being taken upon it. and remedial measure another suggests the sharing openly our contemporary, American Medicine, in expressing of the surgical fee between the surgeon and the its disapproval of the abortive result adds it would practitioner who refers the case, the surgeon receiving be interesting to have some patient sue a member of two-thirds or three-quarters of the fee, and the the profession for the return of money known to have medical man openly receiving one-third or onebeen paid to the doctor referring the case. The word quarter. An official of the Prudential Insurance known"is the crux, for in this country and, Company remarks that fee-splitting amounts to doing presumably, also in the United States, both the offer the right thing in the wrong way. From Denver and the acceptance of a secret commission are punish- comes the suggestion that the patient should be able at law, and evidence is therefore difficult to informed of the fact that the diagnosis of the surgical A mass of information is, however, now condition by the attending physician is frequently come by. available owing to the action of the Medical Journal worth as much to the patient as the operation itself. and Record (of New York) in throwing open its columns The practitioner should therefore have courage to its readers in the form of an " open forum," enough to charge for his diagnosis and time ; and, if without editorially taking any sides in the matter. need be, the specialist should mention to the patient A questionaire was submitted to readers with the that he is cutting down his fee so that the patient remark : " We want you to have your say, and we can pay the family doctor. The hardship is specially want you to be indulgent enough, if indulgent it may well stated by a New York contributor, who writes : be called, to hear what the other man has to say, " The family physician who calls with his patient and so the matter stands. This is your department. to the consultant and spends from two to three hours Make use of it." The material result has been some or more, or visits the operating room, he is entitled 55 columns of print embodying the personal views to a reasonable fee. The patient should be told by "
"
"
"
of several hundreds of doctors. These views are extremely varied. Two groups, as no doubt was to be expected, predominate—namely, those who wish to deny, with more or less emphasis, the existence of the practice at all; and those who have utilised the opportunity for criticising the behaviour of their colleagues with an extreme, if not imaginative, freedom. It seems clear, from the mere number of the former group, that there are many members of the medical profession, especially in the Eastern States and their large towns, who have not come in contact with fee-splitting at all ; whereas it is equally evident that in the Middle West, and still more in the Southern States and in Texas, fee-splitting is by no means exceptional. A New Orleans correspondent states that in Louisiana it is a common practice ; in Alabama it seems to have been almost
the consultant or surgeon that his fee covers the fee for services of the family physician. Call it a collective fee or what you please. Patients will not pay the family physician any "additional conference fee." It is rather peculiar that it And another remarks : is perfectly ethical for the surgeon to pay his assistants out of his fee and yet not allow the family physician to assist and pay him." The situation is summed up in an article by Dr. A. L. Wolbarst, of New York, who after acknowledging that fee-splitting is a serious evil and one growing by leaps and bounds (not only in America but in Europe as well), describes it as the natural out-growth of the widespread specialisation in medicine, which Dr. Thayer deplored in his presidential address to the American Medical Association last month. Both the surgeon and the practitioner havecome to realise that prosperity
130
PNEUMONIA ON THE RAND.
lies in the close economic cooperation which is represented by the split-fee. Under existing practice, the amount of the specialist’s fee is paid to him, and he either retains it entirely, or returns part of it secretly to the "family doctor, in the form of" the The time has come," he says, for split-fee. illicit a revision of the code and for recognising the principle of open ethical fee-sharing as just and equitable." This modification of the code should provide that the specialist’s fee shall include the doctor’s fee. and it shall be deemed as much a violation of the code for the specialist to withhold the doctor’s rightful share as for the doctor to demand, or the specialist to offer, He does more than the duly established proportion. not regard the plan as perfect, but submits it as likely to improvethe position of all three parties to the bargain. The symposium may, as we have suggested, not represent very closely the average medical view in the United States, but it will have afforded an opportunity of utterance for extremists in both Nevertheless no one can read the directions. testimony brought forward in this " open forum " without gaining the impression that there is a situation which is not being met by ethical action alone, and may require some adjustment to the changing conditions of medical practice, especially in relation to the development of specialisation in America.
Annotations. "Ne quid nimis."
PNEUMONIA ON THE RAND.
following a visit to the Rand by Sir Almroth system was inaugurated of routine prophylactic inoculation of natives employed in the mines against pneumococcal infections. Since the independent discovery by Sir Spencer Lister, working at the South African Institute for Medical Research, and by American observers, that pneumococci can be separated into different serological groups, the vaccine IN 1912,
Wright,
a
used has been
a
mixed
one.
In 19191 we commented
the progressive fall in the incidence and mortalityrates of lobar pneumonia in the large population at on
The average annual death-rate for the years 1908 to 1911 was about 12 per 1000. After that it fell steadily. with the exception of a rise in 1915, which coincided with a reduced issue of vaccine ; by 1918 it was already less than 4 per 1000. The descent in the curve has been attributed in South Africa and elsewhere to the use of the vaccine. risk.
Unfortunately, though prophylactic inoculation being zealously carried out and the efforts to improvethe hygiene of, life in compounds have certainly not been relaxed, during the last few years the incidence- and mortality-rates have shown a tendency to rise. In the important group of mines controlled by the Rand Mines, Ltd., for example, the mortality-rate, which was under 1-5 per 1000 in 1920, is still
has since risen again irregularly, until in 1927 it was only just under 5. An attempt to ascertain the factors responsible for this disappointing rise has recently been made by the Transvaal Mine Medical Officers Association. In August, 1927, following on a communication from the Gold Producers’ Committee, the Association appointed a subcommittee, consisting of Dr. A. J. Orenstein (convener), Dr. H. Butt, Dr. A. Frew, and Dr. C. Scholtz, to report on the ser ous increase in mortality from disease among For this natives in the earlier months of 1927. increase the pneumonias were found to be mainly responsible. The subcommittee issued a questionaire to all mine medical officers in September last, and a critical summary of the information received is’ the substance of their report, which has now been printed in the Proceedings of 1 THE
LANCET, 1919, ii., 984.
the
Transvaal
Mine
Medical
Officers
Association
(April, 1928). The data under review concern the natives employed in 30 mines during the periods from Jan. lst to August 31st in 1926 (168,000 boys), and in 1927 (166,000 boys). Of these, approximately 94,500in each year were South African natives, the rest being from the East Coast. Both lobar and bronchoand influenzal pneumonias were studied and the.
tables and statistics on which the conclusions are based are set out in full. Some interesting results have emerged. For example, in both years approximately half the cases of lobar and of bronchopneumonia occurred in the first three months of employment ; no definite correlation was observed between recruiting ratios and incidence and mortality from any form of pneumonia. The case mortality varied only slightly, showing that the severity of the attacks was not markedly different in the two years. The chief conclusions reached are that the physiqu& of the native recruits plays a considerable r6le in both attack-rate and mortality-rate from the pneumonias ; that natives sleeping singly in partitioned-off concrete bunks are less prone to attacks of pneumonia ; that there is probably a periodicity in the incidence of pneumonias, and that the Witwatersrand mines are now going through a period of rise in the curve of incidence. A graph giving the incidence of pneumonias in Chicago between the, years 1867 and 1925 lends support to this suggestion. No ground was found for any suspicion that slackness in vaccination might be responsible for the increased incidence and mortality. Some of the statistics on lobar pneumonia among underground workers seemed to indicate that pneumococcal vaccine gives better prophylactic results in one 2 c.cm. dose than in three c.cm. given in divided doses. which is the more usual method. On one mine only one inoculation of 1 c.cm. of pneumococcal vaccine was used, and except in the incidence of lobar pneumonia among East Coast natives, this mine had a smaller incidence than the average for all the mines. The recommendations made are that the physical standard of recruits should be correlated with that recommended by the Association, that all compound rooms should, as soon as possible, be fitted with partitioned-off concrete bunks, and that the whole matter of prophylactic vaccination should be exhaustively examined at an early date. At the meeting of the Transvaal Mine Medical Officers Association, to which this report was presented,2 some of the medical officers spoke in favour of discontinuing inoculation. A better plan, and one which is likely to be adopted, is the suggestion that the natives on each mine should be divided into equal batches, of which one only should be inoculated. If administrative difficulties prevent this simple differentiation of employees, a certain number of mining areas could be set apart and used as controls. The opportunity for a clear test seems to have arrived. While the incidence- and mortality-rates were decreasing, it might not have been justifiable to withhold prophylactic treatment. But when these rates are rising, in spite of vaccination, there can be no ethical reason why a large-scale experiment should not be tried. It would be difficult to believe that the dramatic fall of the curve of lobar pneumonia in the years following 1912 was an epidemiological phenomenon independent of prophylactic vaccination ; but should a controlled test on a rising curve show that vaccines have but little effect, the whole question will have to be reopened, since the expense involved must be considerable. The stumbling-block against the acceptance of the efficacy of vaccination has always been the fact that an attack of pneumonia confers no immunity, but the apparent success of inoculation in South Africa has been an argument difficult to controvert. The Transvaal mine medical officers have now an opportunity to devise a series of crucial tests which should provide definite evidence for or against the value of prophylactic inoculation against
pneumonia. Journal
of
the
Medical
(B.M.A.), June 9th, p. 309.
Association of
South Africa
129
a rule 15 or 20 years ago, although not nearly so prevalent now ; in Ohio a signed contribution states DICHOTOMY OR FEE-SPLITTING. that it is universal, while a Wilmington practitioner WE published last week a letter from a corre- understands, in a general way, that many of the spondent, who gave a very good reason for remaining general surgeons and specialists in Cincinnati split .anonymous, on what he described as an obnoxious fees with small-town doctors who refer them cases. practice which he had reason to believe is rapidly A Minnesota physician remarks that the practice .extending in certain parts of London. This practice is quite inevitable under present conditions, the consists in the diversion of part of a consultant’s large fees received by surgical specialists being its fee, without the knowledge of the patient, to the foundation. The ex-president of Iowa State Medical practitioner who has advised the consultation. The Society says, quite frankly, that 75 per cent. of the patient believes that his whole payment is made doctors of Iowa and Nebraska " want splits." These to the surgeon or physician who has been called in, examples may suffice to give some idea of the relative -whereas part of the fee has, in fact, been deducted prevalence of fee-splitting in the various United There are, States. The report does not cover Latin America, as a commission for the practitioner. we have been assured, a large number of consultants if only for the reason that division of the total fee in this country who have no cognisance of any such paid between the specialist and the family doctor is practice, and these may be inclined even to question apparently the accepted practice there. its occurrence, but it may be recalled that several Something has already been said, incidentally, years ago, in accordance with a widely felt desire, a regarding the circumstances which have brought meeting of consultants and specialists was called in about such a state of affairs. A New York correa provincial centre to discuss the practice, and two statement may be given as an example. resolutions were passed and circulated to all the spondent’s He writes : " The newcomer, or unknown specialist, practitioners in the neighbourhood. The resolutions in his desire to increase his clientele, offers part of were worded thus :his fee as an inducement to the family physician. 1. It is improper for a Consultant to transfer any portion Many young surgeons find it impossible to build of his consultation- or operation-fee to the Practitioner who , up a practice any other way. Some prominent has called him in. The Consultant who offers or agrees to with good followings take into consideration such payment, however innocently, is open to the suspicion specialists of the the plight referring physician and give him a of paying a commission for his own advantage. The Practitioner who accepts or asks for it cannot maintain the portion of the fee on the basis of good fellowship." position of a trusted and unbiased adviser as to the need For these reasons he regards the hope of eliminating for a consultation and the selection of a Consultant. fee-splitting completely from medical practice as 2. No Consultant or Specialist shall pay to the General rather meagre, and there is, in fact, throughout the Practitioner who is associated with him in a case any part symposium not only a wide admission of the practice of an operation-, consultation-, or so-called " inclusive and of its inevitability, but a good deal of justification fee, unless he informs the patient or his representatives of the for it. The legal profession, writes a Baltimore services for which the payment is made and the amount of splits fees and finds nothing wrong with it. physician, such payment. (The analogy would fail in this country if applied The situation is one which has been freely discussed to a busy barrister sharing his fee with another for some time past in the United States of America, barrister who has devilled a case for him, for there and at its April meeting the New York Medical is no element of agency.) A New York physician Society received a report on the subject from its feels that for the younger man fee-splitting should Committee of Economics. This report was, it appears, be legitimatised, for it cannot be eradicated. As a tabled without any vote being taken upon it. and remedial measure another suggests the sharing openly our contemporary, American Medicine, in expressing of the surgical fee between the surgeon and the its disapproval of the abortive result adds it would practitioner who refers the case, the surgeon receiving be interesting to have some patient sue a member of two-thirds or three-quarters of the fee, and the the profession for the return of money known to have medical man openly receiving one-third or onebeen paid to the doctor referring the case. The word quarter. An official of the Prudential Insurance known"is the crux, for in this country and, Company remarks that fee-splitting amounts to doing presumably, also in the United States, both the offer the right thing in the wrong way. From Denver and the acceptance of a secret commission are punish- comes the suggestion that the patient should be able at law, and evidence is therefore difficult to informed of the fact that the diagnosis of the surgical A mass of information is, however, now condition by the attending physician is frequently come by. available owing to the action of the Medical Journal worth as much to the patient as the operation itself. and Record (of New York) in throwing open its columns The practitioner should therefore have courage to its readers in the form of an " open forum," enough to charge for his diagnosis and time ; and, if without editorially taking any sides in the matter. need be, the specialist should mention to the patient A questionaire was submitted to readers with the that he is cutting down his fee so that the patient remark : " We want you to have your say, and we can pay the family doctor. The hardship is specially want you to be indulgent enough, if indulgent it may well stated by a New York contributor, who writes : be called, to hear what the other man has to say, " The family physician who calls with his patient and so the matter stands. This is your department. to the consultant and spends from two to three hours Make use of it." The material result has been some or more, or visits the operating room, he is entitled 55 columns of print embodying the personal views to a reasonable fee. The patient should be told by "
"
"
"
of several hundreds of doctors. These views are extremely varied. Two groups, as no doubt was to be expected, predominate—namely, those who wish to deny, with more or less emphasis, the existence of the practice at all; and those who have utilised the opportunity for criticising the behaviour of their colleagues with an extreme, if not imaginative, freedom. It seems clear, from the mere number of the former group, that there are many members of the medical profession, especially in the Eastern States and their large towns, who have not come in contact with fee-splitting at all ; whereas it is equally evident that in the Middle West, and still more in the Southern States and in Texas, fee-splitting is by no means exceptional. A New Orleans correspondent states that in Louisiana it is a common practice ; in Alabama it seems to have been almost
the consultant or surgeon that his fee covers the fee for services of the family physician. Call it a collective fee or what you please. Patients will not pay the family physician any "additional conference fee." It is rather peculiar that it And another remarks : is perfectly ethical for the surgeon to pay his assistants out of his fee and yet not allow the family physician to assist and pay him." The situation is summed up in an article by Dr. A. L. Wolbarst, of New York, who after acknowledging that fee-splitting is a serious evil and one growing by leaps and bounds (not only in America but in Europe as well), describes it as the natural out-growth of the widespread specialisation in medicine, which Dr. Thayer deplored in his presidential address to the American Medical Association last month. Both the surgeon and the practitioner havecome to realise that prosperity
130
PNEUMONIA ON THE RAND.
lies in the close economic cooperation which is represented by the split-fee. Under existing practice, the amount of the specialist’s fee is paid to him, and he either retains it entirely, or returns part of it secretly to the "family doctor, in the form of" the The time has come," he says, for split-fee. illicit a revision of the code and for recognising the principle of open ethical fee-sharing as just and equitable." This modification of the code should provide that the specialist’s fee shall include the doctor’s fee. and it shall be deemed as much a violation of the code for the specialist to withhold the doctor’s rightful share as for the doctor to demand, or the specialist to offer, He does more than the duly established proportion. not regard the plan as perfect, but submits it as likely to improvethe position of all three parties to the bargain. The symposium may, as we have suggested, not represent very closely the average medical view in the United States, but it will have afforded an opportunity of utterance for extremists in both Nevertheless no one can read the directions. testimony brought forward in this " open forum " without gaining the impression that there is a situation which is not being met by ethical action alone, and may require some adjustment to the changing conditions of medical practice, especially in relation to the development of specialisation in America.
Annotations. "Ne quid nimis."
PNEUMONIA ON THE RAND.
following a visit to the Rand by Sir Almroth system was inaugurated of routine prophylactic inoculation of natives employed in the mines against pneumococcal infections. Since the independent discovery by Sir Spencer Lister, working at the South African Institute for Medical Research, and by American observers, that pneumococci can be separated into different serological groups, the vaccine IN 1912,
Wright,
a
used has been
a
mixed
one.
In 19191 we commented
the progressive fall in the incidence and mortalityrates of lobar pneumonia in the large population at on
The average annual death-rate for the years 1908 to 1911 was about 12 per 1000. After that it fell steadily. with the exception of a rise in 1915, which coincided with a reduced issue of vaccine ; by 1918 it was already less than 4 per 1000. The descent in the curve has been attributed in South Africa and elsewhere to the use of the vaccine. risk.
Unfortunately, though prophylactic inoculation being zealously carried out and the efforts to improvethe hygiene of, life in compounds have certainly not been relaxed, during the last few years the incidence- and mortality-rates have shown a tendency to rise. In the important group of mines controlled by the Rand Mines, Ltd., for example, the mortality-rate, which was under 1-5 per 1000 in 1920, is still
has since risen again irregularly, until in 1927 it was only just under 5. An attempt to ascertain the factors responsible for this disappointing rise has recently been made by the Transvaal Mine Medical Officers Association. In August, 1927, following on a communication from the Gold Producers’ Committee, the Association appointed a subcommittee, consisting of Dr. A. J. Orenstein (convener), Dr. H. Butt, Dr. A. Frew, and Dr. C. Scholtz, to report on the ser ous increase in mortality from disease among For this natives in the earlier months of 1927. increase the pneumonias were found to be mainly responsible. The subcommittee issued a questionaire to all mine medical officers in September last, and a critical summary of the information received is’ the substance of their report, which has now been printed in the Proceedings of 1 THE
LANCET, 1919, ii., 984.
the
Transvaal
Mine
Medical
Officers
Association
(April, 1928). The data under review concern the natives employed in 30 mines during the periods from Jan. lst to August 31st in 1926 (168,000 boys), and in 1927 (166,000 boys). Of these, approximately 94,500in each year were South African natives, the rest being from the East Coast. Both lobar and bronchoand influenzal pneumonias were studied and the.
tables and statistics on which the conclusions are based are set out in full. Some interesting results have emerged. For example, in both years approximately half the cases of lobar and of bronchopneumonia occurred in the first three months of employment ; no definite correlation was observed between recruiting ratios and incidence and mortality from any form of pneumonia. The case mortality varied only slightly, showing that the severity of the attacks was not markedly different in the two years. The chief conclusions reached are that the physiqu& of the native recruits plays a considerable r6le in both attack-rate and mortality-rate from the pneumonias ; that natives sleeping singly in partitioned-off concrete bunks are less prone to attacks of pneumonia ; that there is probably a periodicity in the incidence of pneumonias, and that the Witwatersrand mines are now going through a period of rise in the curve of incidence. A graph giving the incidence of pneumonias in Chicago between the, years 1867 and 1925 lends support to this suggestion. No ground was found for any suspicion that slackness in vaccination might be responsible for the increased incidence and mortality. Some of the statistics on lobar pneumonia among underground workers seemed to indicate that pneumococcal vaccine gives better prophylactic results in one 2 c.cm. dose than in three c.cm. given in divided doses. which is the more usual method. On one mine only one inoculation of 1 c.cm. of pneumococcal vaccine was used, and except in the incidence of lobar pneumonia among East Coast natives, this mine had a smaller incidence than the average for all the mines. The recommendations made are that the physical standard of recruits should be correlated with that recommended by the Association, that all compound rooms should, as soon as possible, be fitted with partitioned-off concrete bunks, and that the whole matter of prophylactic vaccination should be exhaustively examined at an early date. At the meeting of the Transvaal Mine Medical Officers Association, to which this report was presented,2 some of the medical officers spoke in favour of discontinuing inoculation. A better plan, and one which is likely to be adopted, is the suggestion that the natives on each mine should be divided into equal batches, of which one only should be inoculated. If administrative difficulties prevent this simple differentiation of employees, a certain number of mining areas could be set apart and used as controls. The opportunity for a clear test seems to have arrived. While the incidence- and mortality-rates were decreasing, it might not have been justifiable to withhold prophylactic treatment. But when these rates are rising, in spite of vaccination, there can be no ethical reason why a large-scale experiment should not be tried. It would be difficult to believe that the dramatic fall of the curve of lobar pneumonia in the years following 1912 was an epidemiological phenomenon independent of prophylactic vaccination ; but should a controlled test on a rising curve show that vaccines have but little effect, the whole question will have to be reopened, since the expense involved must be considerable. The stumbling-block against the acceptance of the efficacy of vaccination has always been the fact that an attack of pneumonia confers no immunity, but the apparent success of inoculation in South Africa has been an argument difficult to controvert. The Transvaal mine medical officers have now an opportunity to devise a series of crucial tests which should provide definite evidence for or against the value of prophylactic inoculation against
pneumonia. Journal
of
the
Medical
(B.M.A.), June 9th, p. 309.
Association of
South Africa