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THE ETHICAL RELATIONS OF THE RAILWAY SURGEON.*
under the direction of a former railway employe, who was then "above" railroading. The company was willing to do the fair thing.
BY HENRY B. HEMENWAY, A. M., M. D., Why be too severe? EVANSTON, ILL.
Railroad companies are popularly considered soulless entities, whose every effort is directed toward "beating" all those with whom they come in contact. The result of this idea is the attempt of people to "beat" the roads. Men who would scorn to take unjustly from a private citizen, do not hesitate to attempt
to take a ride at the expense of the railway company, and if perchance they can be so fortunate as to be caught in a wreck, they find themselves hopeless invalids until the case is settled.
The best of men sometimes err, and railroad employes are but human. According to my observation, in cases of injury especially, railroad companies are much more liberal than the average private citizen. We have all known of cases in which the company was not in the least to be blamed, and yet the doctor's bill and other expenses have been met by the company.
I stood by the side of an operator one day while he wrote an order for the waiting passenger train to meet a freight at the next station. When upon a curve between the stations the two conductors compared orders, they found that each was obeying his own orders. It later developed that the error was made by the operator who wrote the order for the freight. Fortunately no one was killed. The operator made an inexcusable blunder, but that did not excuse the malingering that was practiced by one of the injured to get a fat sum from the company. What surprised me was that the malingering was practiced
*Read at the fourth annual meeting of the C., M. & St. P. Ry. Surgeons' Association, held in Chicago, November 12-13, 1896.
A railway surgeon is not a mere dispenser of physic and sawer of bones. His object is not only the saving of human life and the relieving of suffering. His work is broader. In his work he is brought into contact with (a) the corporation; (b) the injured and his friends; (c) other doctors, and (d) the clergy. The railway surgeon's first duty is to the company by which he is employed. The prime object in his employment is the securement of justice. Other doctors might be found who could perhaps treat the injury equally well. The appointment of a surgeon, however, insures good care, and it makes it possible for the railway company to secure definite information relative to the patient's condition. Justice is never hindered by truth. Where exact information is denied the company, injustice is being plotted.
I am fully aware that the attempt has been made to have it declared unethical for a surgeon to make a contract with a railway or other corporation. I cannot see, however, the essential difference between an engagement to look after the interests of a corporation and agreeing to attend in a confinement. In the legal profession retainers are customary. As previously remarked, the duties of the railway surgeon are partly legal.
The honest interests of the company and of the patient are not really antagonistic. In one case of interference the claim was made that I, being in the employ of the company, would be looking out for the company's interests, and the following conversation occurred with a representative of the family:
I asked: "Do you not want the patient to recover?"
"Do you not want him to get well as quickly as possible?"
"Don't you want a perfect recovery?" "Of course."
"Is it not for the interest of the company that he get well, and that he recover as quickly and perfectly as possible?"
"I think that's so."
"Well, wherein are his interests not the same as those of the company?"
"I don't know."
I kept control of the case.
It is expected that the surgeon will assist in collecting evidence. He should keep memoranda of important physical conditions and dates, for use in case of trial. He should give the statement of the patient as given, if possible; but if the surgeon should see disagreement between statement and facts, he should call attention thereto. He should be careful, however, not to raise a doubt where none existed. For example, a trainman had a head injury. He was able to walk and talk, though he was a little flighty. His breath smelled strongly of whisky, though he declared that he had not touched a drop. The friends who were with him at the time said they had given him none. I therefore concluded he was a little full before the accident, and that might have accounted for it. I am glad to say that before I sent in a report to that effect I accidentally ran across another trainman who was present at the accident, and in telling me about it he said that he, the narrator, had given the injured man some liquor as soon as possible, before he was taken home.
When the evidence is clear that the company is not to be blamed for the accident, if the company's surgeon takes charge of the injured, it should be understood that he does so as a private citizen, not as representing the company.
For that reason I have sometimes taken another surgeon with me, letting him reach the patient first, that by the common code it might be considered his patient, and I an assistant.
In another instance in which the company's responsibility was questionable, the family sent for their family physician. I told them that I represented the company, simply wishing to know the extent of the injuries, and giving temporary relief. In answer to their ques
tions I signified my willingness to assist their family physician, or, if they wished it, to take charge of the case, but in either case I would not represent the company, but be in the employ of the family.
The company's surgeon should be loyal to his company. He should not permit unjust criticism upon the company in his presence. He should aid in the settlement of claims, even in cases not under his care. It sometimes happens that the surgeon, riding as he does across the railroad in his buggy, rather than along the track, discovers points of danger previously overlooked. I think it is entirely proper to call attention to a dangerous crossing, and the reasons why it is so. A negligent flagman should be promptly reported. In one instance I found a man who had been in the employ of the company for over thirty years, in charge of a very important crossing close to a station on a trunk line in Michigan. He had asked to be given a less responsible position, but he was too trustworthy. By accident I discovered a serious heart lesion, which rendered him liable to sudden prostration. A report to the proper authorities caused his removal to another crossing. While I was in Michigan complaint had been made that the stagnant water in a certain pond was producing sickness. While looking for some means of draining the pond I found that the trouble was really not in the pond at all, but on railroad land close by, which was covered by a thick growth of bushes. This land was in a city, and it would be only a question of time, perhaps, before a suit for damages might be instituted against the company. A single trainload of dirt corrected the difficulty.
In regard to relations with the patients and friends, it must be remembered that the company surgeon has no right to assume the care of the case without the consent of the patient or the family. He has a moral right to know the exact condition of the patient, and to do so must make an examination. If the company surgeon is satisfied that the case is not receiving proper care he should make an immediate report to that effect in writing, and if time does not permit of delay, he should, if possible, bring another trustworthy surgeon to substantiate his report. For exam· ple, if an arm or a leg is about to be unnecessarily sacrificed.
It is never best to force one's way to the patient in spite of the family. Such a course will do no one any good, but rather complicate conditions.
According to the common code the first physician to a patient injured, takes the case; but if the family physician arrives the case should be surrendered to him. Generally speaking, in railroad cases the company surgeon takes the place of the family physician in the above rule. If, however, a preference is expressed by the family for another surgeon the company's representative is limited in his work to observation. A neglect of this rule has caused much misunderstanding among individuals, and it has produced attacks upon corporation surgeons generally. If, therefore, the company's representative arrives upon the scene after other surgeons, it is proper for him to announce his relation to the case, and ask if anyone else is there to represent the family. This he may first discover by inquiry from the family. If the family physician is already there the company surgeon should offer assistance, and not infrequently the case will be surrendered. If the company's surgeon arrives first he should invite the assistance of the family physician.
If the case is in the hands of an unworthy member of the profession, report should be at once made to the company, and his unworthiness pointed out to the family. The fact that he graduated from a homœopathic or eclectic school should not alone, however, be deemed sufficient cause for protest to the family, even if the surgeon would not ordinarily meet him in consultation. Nor should that be sufficient cause for refusing to assist in an operation.
If the treatment contemplated or practiced by the family physician is contrary to the judgment of the company's representative, he should make private protest to the doctor. If the treatment is persisted in, the fact should be at once reported to the company, with reasons for disagreement. If the question seems vital, permission should be asked from the doctor to make statement to the family in case a satisfactory consultant cannot be secured otherwise.
In all cases the company's surgeon must use the utmost care not to unjustly disturb the
ordinary relations between the family and their ordinary attendant.
In cases where there are no special instructions, and an operation has been begun, or dressings applied by another physician first upon the ground, it has been my custom not to claim the case. In not a few instances the other physician will at once insist on yielding the case, especially where the pay is doubtful. I have considered in such doubtful cases that it is better for the corporation for me to assume control in such doubtful cases.
It often becomes necessary for the surgeon to find a place in which to care for an injured person. Of course, in so doing, he must first consider the patient's interests. In so doing it will not infrequently become necessary to take him to a hospital having a regular staff. This complication arose in my own experience. A hospital rule required that private patients be treated in private rooms, and all patients in general wards should be treated by the staff then on duty. Though myself a member of the staff "off duty" I had not so understood the rule as mandatory. For good reasons the patient, injured in the night, could not be treated in a private room, and he was therefore put into a ward. When I next called I found my orders upset by a member of the staff then on duty, he having been informed that it was a case for him. I insisted that the railroad company expected me to look after their work, and the hospital management yielded. In this particular case I should not have insisted, except for precedent, as the member of the staff then on duty was thoroughly reliable.
Lastly, I am sorry to say that sometimes the surgeon comes in conflict with the clergy. I am aware that the medical profession is not ordinarily considered too religious. I venture the assertion, however, that no profession, not even excluding the clergy, as a profession, follows more closely the example of the Divine Healer the Great Physician. We may be sometimes rough in speech, but more selfsacrificing, kindly and sympathetic, more thoroughly filled with the real truths-not doctrinal arguments-of Christianity, there is no class of men. We should be on friendly and sympathetic terms with the clergy. It is best when we see death approaching to notify the
friends, and sometimes to send for a suitable clergyman. We should be particularly careful not to violate the religious beliefs of a patient. It may be that for himself the surgeon may scoff at "extreme unction." If the patient is a Romanist the surgeon has no right to force his ideas between the patient and his priest. The surgeon may believe that he is right, but he does not know.
When, therefore, a Romanist is seriously injured he should assist the priest to have access to the patient. I never have found them unreasonable. As a class Roman priests are anxious to help the physician, and they use good judgment. Two or three minutes may be spared without detriment to the patient's condition. I am sorry, to say, however, that I have several times known of Protestant surgeons absolutely preventing a priest from conferring with a member of his church.
DISCUSSION OF DR. HEMENWAY'S PAPER. Dr. A. I. Bouffleur: There are just two points that I wish to speak about in connection with this paper. One is with reference to taking care of a person or offering services in a case in which another physician has been called in. I think it is a good plan, and one which will meet with the approbation of the officials of the company, in a case of that sort to offer your services, and, if possible, offer them in the presence of a third party, someone not interested in the case. Also at the time, if they decide to have the family physician or someone else to care for them, you should inform them that the company you represent is willing to have the surgeon take care of the case without expense to them. Furthermore, in offering your services, also state to them that if they prefer their own physician they can have him, but they must not expect the company to pay him. By so doing you will decide the question in a few minutes. Some people get an idea that they can call their family physician and the company will pay the family physician for his services. If the company is liable, they will do this. You should make a note of all these points in your report of the circumstances to the claim agent, stating whether or not the doctor is to be paid by the company, so that whatever fee is to be received would be included in the bill of settlement.
As far as the employe is concerned, unless
the company is grossly liable, I would not entertain any view at the time of settlement in the case. Your report is looked upon as your side of the case. The patient will present his side of the case at the time of settlement, when perhaps you are not at hand. If your report does not state the facts in the case it is your fault, and if your interests are not conserved at the time the settlement is made to the extent of the other physician's position being recognized and a fee allowed him, it is in all probability because you have not stated the facts to the claim department. It is the desire of the company not only to protect the surgeon, so far as his immediate connection with the case is concerned, but also as far as the medical profession of the community is concerned. But they cannot do so unless they have the facts showing them who assumed charge of the case. I run across a case of this nature once or twice a month. Some employe goes down to the claim department and says that he could not get me at the time of the accident. You will have to meet these issues. The patient tells his story, and you are not there. They will have to give them weight. Subsequently some of you receive letters inquiring why you did not take care of John Jones at such and such a time, and you are told by the company that Dr. So-and-So took care of him and a large bill was incurred in consequence. I come across these cases quite often, and I take special pains to run them down. I am not called upon to do anything more than make a statement, and we find in nineteen out of twenty cases that the cases are stirred up for the purpose of getting the doctor's bill paid.
The next point I wish to mention, and one which comes to the surface each time we meet, is a very delicate topic. I refer to the question of schools in medicine and the relation they have to railway surgeons, and especially to our meetings. There was a reference in the Doctor's paper which called the matter to my mind. The question of medical schools cuts absolutely no figure with the railway company. They do not recognize them. They do not know the difference between them, and personally I do not know the difference between them as far as the railway surgeon is concerned. I think when the list is run over and checked up we will find quite a number
of homoeopaths and a number of eclectics. I do not know whether there are any physiomedical men or not, but it matters not to the railway company. We are all doctors as far as they are concerned, and let us be broad enough to be doctors as far as we ourselves are concerned. The science of medicine is broad enough to include all the schools and "isms" in Christendom, and so far as your relations with me or my relations with you are concerned, they should be as doctors and not as members of this or that school. Sometimes the question comes up: "Shall I consult with such a doctor?" Some of you, perhaps, have scruples on the question of consulting with some homœopath or eclectic. There are no “isms" in the profession so far as the railway company is concerned, and you should be willing to consult with each other as freely as you would consult with members of the same church, or of any other church, in regard to any religious affair. When you come to a city election you do not figure all the time whether this individual is a Congregationalist, or a Methodist, or a Baptist, or a Catholic. They are all trying to get to heaven, and it is all right so far as good citizens are concerned. I am a cosmopolitan on the question of "isms," and while I am not very old, I am of the opinion that as we grow older we are becoming more and more liberal. I expect to live long enough to see all the "ism" business disposed of in the medical profession, so far as any distinct lines are concerned. So far as the railway is concerned, so far as your relations with the patients and their disease is concerned, these things are out of consideration, and I wish in our discussions here that it would be always so considered, and that in our dealings and relations with one another the same friendly spirit will at all times prevail.
Dr. McLean: I fully agree with what Dr. Bouffleur has said on this subject. I want to ask one or two questions as to our relations with local and state societies in regard to this matter. Those who are members of the reg. ular profession, who subscribe to the code of ethics of the American Medical Association, find themselves placed in a rather embarrassing situation. Are we not restricted in this matter of consultations with other physicians? Do we not make ourselves liable to charges
and expulsion from our local societies? How about this?
Dr. Bouffleur: The cause of humanity is superior to any other cause that we have to deal with, and if any society is so narrow or dogmatic as to expel me because I consult or have professional relations with a homoeopath, and especially if it be in a case of railway surgery for a company by which we are both employed, I want to be expelled, and the quicker the better.
Dr. Hemenway: I wish to call attention to one or two points brought out by Dr. Bouffleur, one in particular. That is our explaining why we are not called in certain cases. I sometimes wish the instructions sent out were a little more mandatory to those in charge, relative to injuries, that we might receive immediate notice. I know in one instance some three months ago, after an injury occured, I received a letter asking for a report of a certain case that occurred in my jurisdiction, and it was absolutely impossible to give it, as it was the first I had ever heard of the accident. This case occurred while I was in Michigan. I have had similar experiences with the Chicago Milwaukee & St. Paul. I remember one day I took a train and the conductor came to me and asked if I had been sent for to go and see a certain case. I replied, no; that I had heard nothing about it. He then told me about the case, and requested me to get off at the next station and go over there. I did so and found the family physician in charge. The fault was with the trainmen, as no instructions were given, and consequently nobody had notified me.
With reference to schools, the only reason why I put in a statement of two or three sentences with reference to schools of medicine, was because I have known men who drew the line on this point, even in railway surgery. I most emphatically believe that the time will come in the near future when physicians will be regarded as physicians, and that they will have their standing, not because of the particular school from which they have graduated, but as men, as honorable men. I think, furthermore, there is nothing in the code of ethics which can be construed by any right-minded person as prohibiting consultation with and ordinary homoeopathic practitioner. He is not limited to his own school.