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THE FEES OF CONSULTANTS.
1051 THE FEES OF CONSULTANTS. To the Editors
of THE LANOBT. SIRS,—As general practitioner I write regarding the subject of consultants’ fees, for it seems to me that there is often much disproportion and that it would be much better for all concerned-consultant, general practitioner, and patient alike-if there were more frequently some attempt a
make "the punishment fit the crime." In my opinion it is the operating surgeon who stands most in need of reform. A lengthy operation requiring a highly skilful and experienced surgeon should certainly command a high fee, though here, too, the state of the patient’s pocket might more often be considered ; most of us can recall cases in which truly extortionate fees have been wrung from impecunious patients. But my point is that the minimum fee for short and simple operations is as a rule fixed at too high a figure. I will quote instances. The details have been to some extent altered, but the cases given are nevertheless quite typical of several that have occurred in my practice. A surgeon on the junior staff of one of our large hospitals operated on a patient of mine,a healthy woman of 40, with a small mammary tumour which was believed to be of a cystic and a nonmalignant character. It was not proposed to explore the axilla, and it was evident that the operation would be of a simple nature. The patient’s resources being quite limited, I asked the consultant if he would object to operating (at her house, which was situated in an easily accessible London suburb) for a fee of 10 guineas. He explained that he would have been very pleased to accept that fee, but that the fact of his having done so might " get about." He agreed, however, as a concession to take 15 guineas. This sum the patient paid, though with considerable inconvenience. The operation was quite simple; the surgeon was in the house less than an hour, and his total absence from his house in Harpole-street was under two hours and a half. Now, my contention is that a fee of 10 guineas would have met this case very well and (supposing no other fees to have been earned that day) this sum would have represented an annual income of over £ 3000. If it be said that even 10-guinea operations are not met with every day, I would, in reply, point out that numbers of patients whose cases are quite suitable for home treatment are under present conditions admitted for operation into hospitals, though they are able, and would prefer, to pay a reduced fee to a hospital surgeon and be operated on at home. This point is of importance to us general practitioners, for we lose a good deal through the admission to hospital of these cases which might properly have been treated at home. Turning to a consideration of medical as compared with surgical cases, there is food for reflection in such an instance as the following. A baby with a small raised nasvusof the back was taken to a consulting surgeon, who advised removal by operation. Here the diagnosis was easy and immediate and the treatment perfectly simple. The surgeon was paid 2 guineas for his opinion and subsequently received a substantial fee for the operation. On the same day another patient of mine consulted a well-known physician on account of an obscure group of symptoms. The physician made a very thorough investigation of the case, a difficult one, and was occupied for an hour in what was clearly highly skilled labour. For this he received the same consultation fee as the surgeon just mentioned-2 guineas. As a result of his diagnosis the physician recommended an operation ; this was performed by a surgeon, who received a large fee. The patient made a good recovery. Now, I maintain that in this instance the physician brought to bear on the case a degree of skill quite equal to that required of the surgeon. (The case was one of subdiaphragmatic abscess, with obscure symptoms. The surgeon was disinclined to operate, but did so on the strength of the physician’s opinion as to the probable condition existing.) It seems to me that a consultation fee of, say, 10 guineas, would have been none too large, considering the importance to the patient of a correct diagnosis, and I, for one, think that some attempt should be made to adapt the fees in both medical and surgical cases to the time involved and the nature of the case under investigation. I have myself made a start in this direction, for I have frequently wondered how medical consultants can live, considering the exiguous nature of their fees, and I have often been astonished that a physician will spend a long time over
to
difficult case, write a long letter to the general practitioner, and be content with a fee of 2 guineas for his work-work which, in a large number of cases, really involves the exercise of a higher degree of skill than is required in the performance of most surgical operations. I am in the habit, therefore, when sending such a case to a physician, of saying to the patient, "Dr. X will probably spend some time over your case, which is a a difficult one and one in which it is very important that a correct diagnosis be made ; he will probably write at length to me regarding your treatment and you must not be surprised if you are charged a fee of from 3 to 5 guineas." I have hardly ever found a patient object to paying such a fee when the matter had been mentioned to him before making his visit to the consultant. I shall be glad to know that these views as to the advisability of some readjustment of fees are shared by the profession at large, and I hope it is not too much to expect that consultants will put their views forward, even though at the expense of their ingrained modesty and reluctance to exhibit an interest in what may legitimately be termed the commercial aspect of their work. I am, Sirs, yours faithfully, SIGMA. London, Sept. 26th, 1907. a
FOURTEENTH INTERNATIONAL CONGRESS OF HYGIENE AND
DEMOGRAPHY. (FROM
OUR
SPECIAL SANITARY COMMISSIONER.) The Treatment
of Sewage.
THE treatment of sewage formed the subject of discussion in Section VI.A on Tuesday, Sept. 24th. Dr. G. J. FOWLER (Manchester) contributed a summary of results obtained in the study of the successful treatment of sewage under tropical conditions, dealing with the subject under the following heads-1. Differences between European and tropical conditions-temperature, water-supply per head, habits and diet of people. 2. Differences in composition between native sewage (vegetarian) and European sewage-typical analyses. 3. Preliminary anaerobic treatment, James’s experiments, utilisation of tank gas, Dr. Fowler’s experiments and observations with concentrated sewage, comparative results of varying rates of flow through tank, character of effluent, of sludge, and of evolved gas. 4. Principles of latrine tank construction for anaerobic treatment. 5. Filtration of effluent from anaerobic treatment, comparison of effluent obtained from percolating filters and contact beds. 6. Preliminary aerobic treatment, description of experimental installation, discussion of results, and applicability of method to special cases. 7. Sterilisation of effluents, effects of sunlight, &c. The general conclusions are that even with concentrated native sewage excellent purification can be obtained, but that the principles governing the process must be carefully adhered to. A paper by Councillor METZGER on the Utilisation and Removal of Sewage Sludge contained the chief conclusions : that the irrigation method isk superior to all other methods of purification with regard to realising the value of, and removing, the mud and the liquid and that it should be conducted over sufficiently large areas of land ; the collection of mud in the neighbourhood of settling works is to be avoided. Another paper of interest in the field of chemical hygiene was that on
The
Lf’gislation on Foodstuffs, by 1. KÒNIG. He is of opinion that the following legal provisions are wanting: 1. Exact legal definition of the various substances serving as food. 2. Uniform regulations for all foods with regard to their treatment or to additions made to them, especially in the shape of substances serving to keep them fresh ; regulations with regard to the kind, quality, and quantity of these latter substances. 3. Uniformity in regulations on the part of various Governments of the Requi’l’ements of
the
different Federal States or, at the least, on the part of the various departments of the same State. The German legislation on foodstuffs being enacted by the Reichstag there is a demand that all decrees and regulations in connexion with that legislation should be examined and made to agree with each other by a central imperial board. 4. Appointment a board of advice consisting of representatives of science,
of
of THE LANOBT. SIRS,—As general practitioner I write regarding the subject of consultants’ fees, for it seems to me that there is often much disproportion and that it would be much better for all concerned-consultant, general practitioner, and patient alike-if there were more frequently some attempt a
make "the punishment fit the crime." In my opinion it is the operating surgeon who stands most in need of reform. A lengthy operation requiring a highly skilful and experienced surgeon should certainly command a high fee, though here, too, the state of the patient’s pocket might more often be considered ; most of us can recall cases in which truly extortionate fees have been wrung from impecunious patients. But my point is that the minimum fee for short and simple operations is as a rule fixed at too high a figure. I will quote instances. The details have been to some extent altered, but the cases given are nevertheless quite typical of several that have occurred in my practice. A surgeon on the junior staff of one of our large hospitals operated on a patient of mine,a healthy woman of 40, with a small mammary tumour which was believed to be of a cystic and a nonmalignant character. It was not proposed to explore the axilla, and it was evident that the operation would be of a simple nature. The patient’s resources being quite limited, I asked the consultant if he would object to operating (at her house, which was situated in an easily accessible London suburb) for a fee of 10 guineas. He explained that he would have been very pleased to accept that fee, but that the fact of his having done so might " get about." He agreed, however, as a concession to take 15 guineas. This sum the patient paid, though with considerable inconvenience. The operation was quite simple; the surgeon was in the house less than an hour, and his total absence from his house in Harpole-street was under two hours and a half. Now, my contention is that a fee of 10 guineas would have met this case very well and (supposing no other fees to have been earned that day) this sum would have represented an annual income of over £ 3000. If it be said that even 10-guinea operations are not met with every day, I would, in reply, point out that numbers of patients whose cases are quite suitable for home treatment are under present conditions admitted for operation into hospitals, though they are able, and would prefer, to pay a reduced fee to a hospital surgeon and be operated on at home. This point is of importance to us general practitioners, for we lose a good deal through the admission to hospital of these cases which might properly have been treated at home. Turning to a consideration of medical as compared with surgical cases, there is food for reflection in such an instance as the following. A baby with a small raised nasvusof the back was taken to a consulting surgeon, who advised removal by operation. Here the diagnosis was easy and immediate and the treatment perfectly simple. The surgeon was paid 2 guineas for his opinion and subsequently received a substantial fee for the operation. On the same day another patient of mine consulted a well-known physician on account of an obscure group of symptoms. The physician made a very thorough investigation of the case, a difficult one, and was occupied for an hour in what was clearly highly skilled labour. For this he received the same consultation fee as the surgeon just mentioned-2 guineas. As a result of his diagnosis the physician recommended an operation ; this was performed by a surgeon, who received a large fee. The patient made a good recovery. Now, I maintain that in this instance the physician brought to bear on the case a degree of skill quite equal to that required of the surgeon. (The case was one of subdiaphragmatic abscess, with obscure symptoms. The surgeon was disinclined to operate, but did so on the strength of the physician’s opinion as to the probable condition existing.) It seems to me that a consultation fee of, say, 10 guineas, would have been none too large, considering the importance to the patient of a correct diagnosis, and I, for one, think that some attempt should be made to adapt the fees in both medical and surgical cases to the time involved and the nature of the case under investigation. I have myself made a start in this direction, for I have frequently wondered how medical consultants can live, considering the exiguous nature of their fees, and I have often been astonished that a physician will spend a long time over
to
difficult case, write a long letter to the general practitioner, and be content with a fee of 2 guineas for his work-work which, in a large number of cases, really involves the exercise of a higher degree of skill than is required in the performance of most surgical operations. I am in the habit, therefore, when sending such a case to a physician, of saying to the patient, "Dr. X will probably spend some time over your case, which is a a difficult one and one in which it is very important that a correct diagnosis be made ; he will probably write at length to me regarding your treatment and you must not be surprised if you are charged a fee of from 3 to 5 guineas." I have hardly ever found a patient object to paying such a fee when the matter had been mentioned to him before making his visit to the consultant. I shall be glad to know that these views as to the advisability of some readjustment of fees are shared by the profession at large, and I hope it is not too much to expect that consultants will put their views forward, even though at the expense of their ingrained modesty and reluctance to exhibit an interest in what may legitimately be termed the commercial aspect of their work. I am, Sirs, yours faithfully, SIGMA. London, Sept. 26th, 1907. a
FOURTEENTH INTERNATIONAL CONGRESS OF HYGIENE AND
DEMOGRAPHY. (FROM
OUR
SPECIAL SANITARY COMMISSIONER.) The Treatment
of Sewage.
THE treatment of sewage formed the subject of discussion in Section VI.A on Tuesday, Sept. 24th. Dr. G. J. FOWLER (Manchester) contributed a summary of results obtained in the study of the successful treatment of sewage under tropical conditions, dealing with the subject under the following heads-1. Differences between European and tropical conditions-temperature, water-supply per head, habits and diet of people. 2. Differences in composition between native sewage (vegetarian) and European sewage-typical analyses. 3. Preliminary anaerobic treatment, James’s experiments, utilisation of tank gas, Dr. Fowler’s experiments and observations with concentrated sewage, comparative results of varying rates of flow through tank, character of effluent, of sludge, and of evolved gas. 4. Principles of latrine tank construction for anaerobic treatment. 5. Filtration of effluent from anaerobic treatment, comparison of effluent obtained from percolating filters and contact beds. 6. Preliminary aerobic treatment, description of experimental installation, discussion of results, and applicability of method to special cases. 7. Sterilisation of effluents, effects of sunlight, &c. The general conclusions are that even with concentrated native sewage excellent purification can be obtained, but that the principles governing the process must be carefully adhered to. A paper by Councillor METZGER on the Utilisation and Removal of Sewage Sludge contained the chief conclusions : that the irrigation method isk superior to all other methods of purification with regard to realising the value of, and removing, the mud and the liquid and that it should be conducted over sufficiently large areas of land ; the collection of mud in the neighbourhood of settling works is to be avoided. Another paper of interest in the field of chemical hygiene was that on
The
Lf’gislation on Foodstuffs, by 1. KÒNIG. He is of opinion that the following legal provisions are wanting: 1. Exact legal definition of the various substances serving as food. 2. Uniform regulations for all foods with regard to their treatment or to additions made to them, especially in the shape of substances serving to keep them fresh ; regulations with regard to the kind, quality, and quantity of these latter substances. 3. Uniformity in regulations on the part of various Governments of the Requi’l’ements of
the
different Federal States or, at the least, on the part of the various departments of the same State. The German legislation on foodstuffs being enacted by the Reichstag there is a demand that all decrees and regulations in connexion with that legislation should be examined and made to agree with each other by a central imperial board. 4. Appointment a board of advice consisting of representatives of science,
of