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General Practitioners and Consultants.
GENERAL PRACTITIONERS AND CONSULTANTS. the continent of
Europe and in the United States, and it is rumoured that it is by no means unknown in this country. The essence of dichotomy is that the division of the fee is not known to the patient and this absence of knowledge on the part of the patient would suffice to bring the practice within the scope of the Secret
on
THE LANCET.
1353
Commissions Act. The influence of dichotomy has been very harmful; it appears to be certain that its tendency LONDON: SATURDAY, MAY 9, 1908. is to lead to the performance of unnecessary operations, however excusable it may have been in its origin. Dichotomy It is therefore satisfactory can in no wise be defended. General Practitioners and that dichotomy has been condemned in those countries Consultants. where it is especially rife and it is to be hoped that it will DURING the past few weeks a discussion has been going on not n spread here. We cannot but look upon dichotomy as in the columns of THE LANCET on the question of the vvery much on a level with the receiving of fees from underdivision of the operation fee between the operator and the t:takers or instrument makers who have been recommended. A method has been suggested by Dr. F. W. FORBESgeneral practitioner. It has been recognised widely that the fee of the general practitioner who takes a patient to a con- IRoss in the correspondence in our columns which is sultant for an operation is altogether out of proportion to thecertainly less objectionable than dichotomy, from which it c fee that the consultant charges for the operation which he cdiffers in several important respects. By this method the performs. Inasmuch as the functions performed by the two ffee for the operation is divided into three parts, the operator differ greatly in degree a great disparity is not unreasonable ;ttakes two-thirds and the general practitioner takes the but it is held by many medical men in general practice that rremaining third; and in return for this share of the the large amount of the fee charged for the operation may ffee he assists at the operation and undertakes a portion, the major portion, of the after-treatment. So far prove, and in fact often proves, a great strain on the financesperhaps 1 of the patient, with the result that the fees already owing to tthere is little to distinguish the method from dichotomy, the general practitioner cannot be paid. We venture to think Iexcept that certain assistance is rendered in return for the that there is a modicum of basis for this complaint and anyfee, i but, and this is most important, the patient is informed which could be made in the direc( the of satisfactory arrangement arrangement made, and this very fact of the knowthe amount received the of tion of equalising 1 the patient of the intended division of the fee by general practi- ledge tioner and by the consultant would be deserving of adoption, certainly < removes the arrangement from the category of but the arrangement must be in full accord with the ethicscdichotomy. There is a further point on which Dr. FORBESof the profession. ; Ross insists, and that is that if only a part of the fee can be There is a modern practice, happily little heard of in this paid at the time the consultant and the general practitioner i country, which is known by the name of dichotomy. Themust share in the same proportion as if the whole fee had word, indeed, is an old word and has several scientific been paid. There is, however, this to be said, as pointed applications, but so far as we are aware the recent special out by Mr. EDWARD DEANESLY, that this third of the fee medical meaning has not yet found its way into the should be paid directly to the general practitioner by the dictionaries. This special application of the word arose in patient and it should not be paid by the operator after he France where the practice to which it is applied also has received his fee. If the surgeon pays the third to appears to have originated. By dichotomy in its medical the general practitioner there is always the risk of the transsense is meant a division of the consultant’s fee between the action not being made clear to the mind of the patient and general practitioner and the consultant. The general then the practice falls into the same group as dichotomy. practitioner takes or sends a patient to a consultant who There is another method which is widely adopted and it advises the performance of an operation for which the is one which appears to us to have many points in its favour. operator charges, let us suppose, a hundred guineas. The The patient is often anxious to know what is the total patient agrees, undergoes the operation, and pays the amount of the expense to which he will be put, and the fee. Immediately on receipt of the fee the surgeon general practitioner, after consulting the operator, mentions sends
cheque for half the amount to the general a fee which is to include the operator’s fee, his own fee, practitioner who sent the case to him. Sometimes the fee is and the fee of the anassthetist. The general practitioner not divided equally but the exact proportions in which the receives the fee from the patient and hands to the operator division is made do not affect the matter. The patient, who the portion payable for the operation. This is often more pays the fee, knows nothing of this division; he imagines satisfactory for the patient and it appears to us to be perthat the whole of the operator’s fee is for the operator and fectly ethical. It has certainly nothing to do with dichotomy. the fact that the general practitioner who introduced him to Whatever arrangements are made it is essential, as we have the consultant gets a portion of the fee for the operation is already said, that the patient should be informed if any a
utterly unknown
to him.
The share of the fee given to the division of fees takes place. The general practitioner is given for assistance at the opera. generally in a position to know the amount of fee which tion or for after-treatment but wholly and solely for the will not be oppressive to the patient and yet which will be introduction of the case. This is dichotomy pure and simple, sufficient to remunerate those who perform and assist at the and if we may believe reports it is a practice very widespread operation and in the after-treatment.
general practitioner is
not
Europe and in the United States, and it is rumoured that it is by no means unknown in this country. The essence of dichotomy is that the division of the fee is not known to the patient and this absence of knowledge on the part of the patient would suffice to bring the practice within the scope of the Secret
on
THE LANCET.
1353
Commissions Act. The influence of dichotomy has been very harmful; it appears to be certain that its tendency LONDON: SATURDAY, MAY 9, 1908. is to lead to the performance of unnecessary operations, however excusable it may have been in its origin. Dichotomy It is therefore satisfactory can in no wise be defended. General Practitioners and that dichotomy has been condemned in those countries Consultants. where it is especially rife and it is to be hoped that it will DURING the past few weeks a discussion has been going on not n spread here. We cannot but look upon dichotomy as in the columns of THE LANCET on the question of the vvery much on a level with the receiving of fees from underdivision of the operation fee between the operator and the t:takers or instrument makers who have been recommended. A method has been suggested by Dr. F. W. FORBESgeneral practitioner. It has been recognised widely that the fee of the general practitioner who takes a patient to a con- IRoss in the correspondence in our columns which is sultant for an operation is altogether out of proportion to thecertainly less objectionable than dichotomy, from which it c fee that the consultant charges for the operation which he cdiffers in several important respects. By this method the performs. Inasmuch as the functions performed by the two ffee for the operation is divided into three parts, the operator differ greatly in degree a great disparity is not unreasonable ;ttakes two-thirds and the general practitioner takes the but it is held by many medical men in general practice that rremaining third; and in return for this share of the the large amount of the fee charged for the operation may ffee he assists at the operation and undertakes a portion, the major portion, of the after-treatment. So far prove, and in fact often proves, a great strain on the financesperhaps 1 of the patient, with the result that the fees already owing to tthere is little to distinguish the method from dichotomy, the general practitioner cannot be paid. We venture to think Iexcept that certain assistance is rendered in return for the that there is a modicum of basis for this complaint and anyfee, i but, and this is most important, the patient is informed which could be made in the direc( the of satisfactory arrangement arrangement made, and this very fact of the knowthe amount received the of tion of equalising 1 the patient of the intended division of the fee by general practi- ledge tioner and by the consultant would be deserving of adoption, certainly < removes the arrangement from the category of but the arrangement must be in full accord with the ethicscdichotomy. There is a further point on which Dr. FORBESof the profession. ; Ross insists, and that is that if only a part of the fee can be There is a modern practice, happily little heard of in this paid at the time the consultant and the general practitioner i country, which is known by the name of dichotomy. Themust share in the same proportion as if the whole fee had word, indeed, is an old word and has several scientific been paid. There is, however, this to be said, as pointed applications, but so far as we are aware the recent special out by Mr. EDWARD DEANESLY, that this third of the fee medical meaning has not yet found its way into the should be paid directly to the general practitioner by the dictionaries. This special application of the word arose in patient and it should not be paid by the operator after he France where the practice to which it is applied also has received his fee. If the surgeon pays the third to appears to have originated. By dichotomy in its medical the general practitioner there is always the risk of the transsense is meant a division of the consultant’s fee between the action not being made clear to the mind of the patient and general practitioner and the consultant. The general then the practice falls into the same group as dichotomy. practitioner takes or sends a patient to a consultant who There is another method which is widely adopted and it advises the performance of an operation for which the is one which appears to us to have many points in its favour. operator charges, let us suppose, a hundred guineas. The The patient is often anxious to know what is the total patient agrees, undergoes the operation, and pays the amount of the expense to which he will be put, and the fee. Immediately on receipt of the fee the surgeon general practitioner, after consulting the operator, mentions sends
cheque for half the amount to the general a fee which is to include the operator’s fee, his own fee, practitioner who sent the case to him. Sometimes the fee is and the fee of the anassthetist. The general practitioner not divided equally but the exact proportions in which the receives the fee from the patient and hands to the operator division is made do not affect the matter. The patient, who the portion payable for the operation. This is often more pays the fee, knows nothing of this division; he imagines satisfactory for the patient and it appears to us to be perthat the whole of the operator’s fee is for the operator and fectly ethical. It has certainly nothing to do with dichotomy. the fact that the general practitioner who introduced him to Whatever arrangements are made it is essential, as we have the consultant gets a portion of the fee for the operation is already said, that the patient should be informed if any a
utterly unknown
to him.
The share of the fee given to the division of fees takes place. The general practitioner is given for assistance at the opera. generally in a position to know the amount of fee which tion or for after-treatment but wholly and solely for the will not be oppressive to the patient and yet which will be introduction of the case. This is dichotomy pure and simple, sufficient to remunerate those who perform and assist at the and if we may believe reports it is a practice very widespread operation and in the after-treatment.
general practitioner is
not