THE FEE-SPLITTING EVIL; THE SURGEON AND THE GENERAL PRACTITIONER; THE GENERAL PRACTITIONER AND THE SURGEON.* T David Ap. Myers, M. D., C. M., Lawton, Okla. O BEGIN with I wish to say that I shall call a spade, a spade. It was Shakespeare who said: "Oh, why rebuke you him that loves you so?" never received any of his work. His story was as follows: "Doctor, I have been sending my cases to a certain city for operation, and I thought I would drop in on you today to talk about a case I have that needs an operation. The expense of going to this city is somewhat greater and the danger of transporting cases is much increased by the distance, so if we can come to some agreement about fees I will be glad to send my surgery to you. He then proceeded to tell me that he often got as much as 60 per cent of the fee for bringing the case to the city. Now this doctor had driven thirty miles to find out how much he could get in the way of a It is evident that Bill Shakespeare had the present "fee splitting" evil in mind when he wrote those lines-for he knew that sooner or later there would be much "wailing and gnashing of teeth," and much rebuking. The surgeon berating the general practitioner for demanding and too often getting the required split-and the general man berating the surgeon for trying to keep it all after getting his business and allowing him a very generous slice of the first few fees. I know not whether the other states in the Medical Association of the Southwest are afflicted with the "fee splitting" parasite, but can vouch for Oklahoma. We have it in a most virulent form. And like all other parasitic life it lives and thrives where there is the most filth. I do not mean this to be construed that Oklahoma has all the bad ones in the practice of medicine and surgery, nor do I care to have this construed as a general reference to the profession in general. If there are those that differ from the statements made in this paper, I hope they will have the courage to stand up and let this association hear from them. Not that I mean that there may not be a much better solution of the matter than the one set forth, or that I am a criterion on the subject. The main object of this paper is to get the subject matter before this association and get the ideas and views of those who have had the parasite to deal with. It is an axiom among the physicians "out in the sticks" where I practice -that the closer you get to a certain city in the state of Oklahoma-and the longer you "shop" your case the larger grows the "split." Within the last thirty days I have had a physician in my office whom I had known for some time and often wondered why I had *Read before the Medical Association of the Southwest at Hot Springs, Ark, October 8, 1912. 'split" closer home. What do you suppose was the matter of the childan intussusception of the bowel. If there is any one condition in surgery that requires prompt attention, it would be my guess that the above case would be of such a variety. Still here was a doctor "shopping" for a "fee splitting" and his patient dying. I remarked to the doctor, among many other things that "fee spitting" was not the rule among the best menand he remarked right back that the 'general practitioners" would see to it that "fee splitting" would not be abolished. This type of "fee splitter" parasite is one that is entirely removed from the type that comes into existence because some surgeon splits a fee with him and thus gets him in the habit from thinking that it is the proper thing for him to demand it. The first type is a mercenary, dollars and cents doctor-pure and simplethe second type becomes such from being taught that it is right, and while they are both to blame one is to blame because he is naturally a parasite and the other because he has been taught to be one. The blame for both species lays with the surgeon and not with the general practitioner. If they were not given the first "fee split"there would be none of the second variety-if they were refused the first "fee split" there would be none of the first variety. You cannot blame the general man, it is easy money for him, and he will naturally take his patients to the man who will give the most money for them, provided always he is the kind of a doctor that cares not for the welfare of his patients, either physically or financially. I do not desire to have the general practitioner think that I consider him alone in the field of "fee splitting" parasites, the surgeon who gives a "split" is as much, and to my mind more of a parasite than the general man, for he is the one who can cure the disease if he will. Most crimes are committed at night-under the cover of darkness. So it is with the fee splitting evil, it goes on and sometimes by first-class operators. It is hard to catch up with them, but when you do publicity is the cure for such an evil. How do you think a prospective patient would think about a doctor who would deliberately sell him to the highest bidder, knowing that the extra money he was being charged was given to the doc. tor who had him in charge-not as a fee for services-but as a fee for the act of bringing him to that particular surgeon. He will figure that if the surgeon can afford to give the doctor $75 for bringing the case to him, that the surgeon can afford to do the work for $75 less than he is being charged. When a doctor comes to your office seeking a split in fees, and does not get it, and proceeds to take that patient on, and continue to shop with them, then I would deem it the province of the surgeon consulted to tell the people concerned that the reason the case was not left in his care was not from any inability to properly perform the work, but because the physician in charge did not think that he was getting a sufficient fee for bringing the case, and that the one evil that surgeons had to contend with was the fee splitting evil. If you cannot educate the doctors you can educate the laity, and I assure you they will educate very readily in cases of this kind, for the education touches them in a spot that is very vital, namely, their pocket books. If you cannot get to the patient or their friends you are of course powerless, except talk to the doctor who is asking the split. More and more papers on this subject should be written; in this way good will be done and men converted from both sides of the controversy. I venture to say that if I were to ask every surgeon in this association to stand up, who was in the habit of splitting fees, that there would not be a single response. If I were to ask the same question of the general man, there would not be a response. Yet I am morally certain that there are men somewhere in these five southwestern states who do these things, and do them as a matter of business. Something that you are ashamed to acknowledge you do, is usually not the right and proper thing for you to have done. Therefore, I say "publicity" is the cure for the evil. It will not stand the light of the patient's scrutiny. After all is said and done it is the person who is the patient, who is the vitally concerned, therefore he should know what is being done for him in all cases. The man who does not split fees will say, the other fellow gets the cases. It is true he does in many instances. He will also tell you that the patient does not know who is or who is not a capable surgeon, nor does he know that he is being "peddled," and his ilfe endangered for the sake of a few paltry dollars. Education will cure that evil. When the laity begin to undersatd that a certain surgeon splits fees and are educated to know why he splits them, just so soon will the sun of that man's popularity begin to set. The laity have been educated along other lines by the judicious use of printer's ink and the application of a few good common sense arguments by word of mouth, why could they not be educated along this line. In the practice of law attorney have a word by which they designate a certain class of lawyers. If there were a word in the English language that would as appropriately fill the bill in reference to a certain class of surgeons, who willfully offer and give a split in their fees for the sake of get ting a case I would be more than pleased to apply the term and properly label all such. That word is 'shyster." The laity avoid a shyster lawyer; they can be taught to avoid the same class in the practice of medicine and surgery. I remarked early in this paper that I would be glad to have this paper discussed freely. If there is one present who will arise and defend the fee splitting evil I shall be glad of it and will do my level best to answer all his arguments; if I cannot do so I am sure there are men in this association who have had the parasite pester them so many times that they would be glad of an opportunity to find a champion of their cause and get a chance to relieve a much over-burdened bosom of an accumulation of words and thoughts on the subject. If you do not believe that last statement of fact, please arise at the proper time and champion the cause. Not a truth has to art or science been given, And many have striven, and many have failed, There are two sides to every controversy and the general practitioner has been very much abused in times past as well as present in regard to the way he has been treated regarding his surgical cases. Here is the story of the general run of cases as they are brought to the shrine of the great and mighty surgeon. After due delay in waiting at the outer door of the sanctum sanctorium, or the holy of holies, you are ushered in the presence of the great surgeon. Good morning, doctor. Ah, let me see, I cannot recall you name. I am the doctor that brought you that case of surgery last month from Podunk. Oh, yes. I remember you now, that was the case in which I made that great diagnosis for you after you had been puzzled so long over it, so much easier you know when you see those rare and interesting cases every day as I do. Have you a patient with you this time? Yes, Doctor. Well bring him in and I will tell you what is the matter and what he needs. Patient comes in. Dr. Big I this is my (notice the accent on the MY) patient Mr. Promptpay. Glad to know you, sir. Just remove your clothing and get up on the examining table, and I will tell you what is the matter, and what should be done in the matter. Several minutes of percussion and questioning, and then several more minutes of deep silence, accompanied by many contractions of the learned brow and an expression of deep study. This is followed by a long discourse on what "I saw the last time I was in Vienna," and what Professor This and Professor That has to say on the subject of such ailments as your patients. Finally you hear this: please be at the X.Y.Z. Hospital at 7:30 promptly tomorrow morning, and we will operate; fees in such cases are $350. Would you like to witness the operation doctor, if so, you will be allowed to be in the operating-room. I shall have several other cases on hand and I should be glad to have you witness them. That may sound a little doubtful, it is true nevertheless. I know because I am a general practitioner, and have had the experience. Morning comes, and you and your patient enter the hospital and are received very curtly. In due time you are hustled into a gown, stood up in corner near a red hot radiator, and told to stand hitched. You do. If you have never seen the inside of the "holy of holies" before, you are duly impressed and return home in awe and reverence, very much subdued in spirit and very much dissatisfied with your lot in life. If the awe and reverence last long enough you will bring your next case to Dr. Big I. If you let a little common sense sink into your system you will take your next case to Dr. Consideration, who will endeavor to treat you like a human being, and as a fellow doctor. You realize before you go to Dr. Big I, that you don't know as much as he does, but then you don't want everybody else to know it also. What you do want them to know is that you are not a surgeon, but a general practitioner, and that you want to be treated as such. Now Dr. Consideration is a good fellow and he gets all your work in the future. One day you find him out and you take a case to Dr. Needs Biz across the hall. He I is also a good fellow and treats you just as well as Dr. Consideration and when he collects his fee comes and hands you $75. By a proper and de cent treatment of the general man in the first case, the profession would have been saved another case of "fee splitting." In addition to doing some general work I do a little surgery. have been confronted with the fee splitting evil. I have conquered it, at least to my own satisfaction and in entire accord with my surgical and ordinary conscience. If I am wrong I shall be glad to be put right. But until I shall find a plan that will work better than the one I am now following. I shall be hard to convince. First of all I try to make a friend out of the doctor who brings me a case. I try to place myself in his position, and that is not very hard work, for I often refer cases to other men, and I know the attitude I have toward them, and realize the way I should like to be treated. Acting accordingly I pro ceed to treat my doctor friends as I I would wish to be treated. I do not say, lets find out what is the matter, I ask him what is the matter. If he says, I don't know; then I tell him that together we will attempt to find out. In other words, until I am proven wrong I assume that his diagnostic ability is as good as my own. I try in every way to give that patient to understand that his doctor's attention is as essential to the proper welfare and care of the case, except as to actual operation, as is my own. I ask the doctor and the patient whether or not he (the doctor) came with the patient at their request, and find out if they have been under treatment before coming. I then proceed to tell the patient, or friends, that the family doctor is entitled to a fee for his absence from his business, on account of being in attendance on this case, that the fee I have established is $25 and expenses per diem. That I shall see that the doctor is paid that fee, and that will be guided by the wishes of the doctor in charge of the case as to whether I charge that fee in with my own, or whether he chooses to settle with them direct. In case the doctor expressly requests that I shall make no charge for him, that he desires to collect his own fees for attendance on the case and time and money spent in coming with them and in the proper spirit and proper way seeing that they get the proper surgical attention; then I proceed to tell the patient that I am not including a fee for the family physician, but that whatever agreement they make with him is foreign to any fee they may pay me. If a doctor calls me over the phone, or sends me a patient I take advantage of the first opportunity I have to thank him for his kindness, and in the meantime I try to do the best work I know how to do for his patient, and send them home to the family doctor for after-care and attention. I consider that I owe no man a cent for the reference of a case, unless he spends time and takes the trouble to come with the patient at their request. If I am called to do a piece of surgery in the home and away from the hospital I use the doctor in charge of the work, unless I carry an assistant with me. For this I allow him the same fee I would pay my assistant, namely, $25 for major work and in proportion for minor work. In all cases I see to it that all financial transactions are open and above board and with the full knowledge of the patient. In all my work I have yet the first case to meet whereby this method I have not sent the patient home in full confidence with his family doctor, and have the first dissatisfied doctor to deal with. I have one man that I do work for who insisted the first time I operated for him that I collect a fee for him. I refused and told him that I would, however, tell the people that he was entitled to a fee, that he choose to collect it from them direct and that any charge he might make for his services was entirely a matter between themselves. That my fee for the operation would be so much if I did not have to pay the doctor for assisting me; that if they desired I would make them a fee, which would include what I would pay for his assistance in the case and for the operation only. They chose to settle direct with the doctor. Ever since I have had that arrangement with him, and I do not neglect to tell the patient that they are to pay him for his services, that I am not including it in my fee. You who still believe in ''fee splitting" listen to the words of French: In gall and wormwood, tinctured with a curse, In this hell-brew let's spill libation, With wish that swift and sure damnation DISCUSSION. DR. S. S. GLASSCOCK, Kansas City, Mo.: This is not a theory that confronts the medical profession; it is a condition, one of the most serious that the American physician has ever had to deal with, and in some form is here to stay. Any idea that a discussion of this kind will in a short time eliminate fee-splitling is a mistake. It will not do it. I am opposed to fee-splitting. I am glad to defend the country physician, because the country practitioner in ability, in morals and from every point of view is the equal, if not the superior, of the city physician. The country practitioner should be paid for his services in referring a case to a surgeon, and I think the surgeon should insist on and have an understanding with the patient or the patient's friends that the physician should be given a respectable fee aside from the fee of the surgeon for doing the operation. That is the best solution of the problem. DR. JABEZ N. JACKSON, Kansas City, Mo.: The time has come when the profession should take some action if it would keep its skirts clear. This subject is not simply a matter of secret conversation among physicians; the people are already becoming conversant with the fee-splitting evil. A great many of you have doubtless read the O The articles which have been published in Pear- DR. JOHN F. BINNIE, Kansas City, Mo.: The family practitioner ought to receive a dignified fee for his services, such as for making the diagnosis and for his time an judgment. But there is another point of view. The family physician attended Mr. Brown when he had typhoid. He was in charge of this case for two or three weeks, charging perhaps $2 or $3 per visit, making two or three visits per day. In this way a considerable bill is obtaining. Again, Mrs. Brown becomes pregnant, the doctor attends her and receives a good fee for it. Little Johnnie has diphtheria and another child the measles, so that year in and year out the family physician is receiving a considerable income from this family. It is his duty to give the best advive he can. Should he receive a big fee for referring a case in this family to a surgeon for operation? I do not think so. He owes it to the family and to the confidence that the family reposes in him to refer the case to the best surgeon that can be had. DOLLARS VS. MEDICAL JOURNALS. NE of the truest things ever said was, "You can't make money without spend- We hear much about the increasing difficulty of making a living at the practice of medicine. This increasing difficulty, however, is not confined to the practice of medicine It is general in every profession and occupation. There is one way, Doctor, in which you can escape this increasing difficulty-by being a keener physician than the other fellow-by legitimately going after practice harder and giving better services when you get it. This is no easy problem, you say. Indeed, it is not an easy problem. Do you make your medical journals help you in this problem? Do you use medical journals with the definite idea-" How can I legitimately get more money out of my practice?" The keen physician is doing just that. Doctor, you shouldn't confine yourself simply to the few favorite journals that you read from cover to cover. Take a large and varied list of medical journals-one that will give you a broad and liberal viewpoint. Run over the tables of contents as they come in and mark what has particular value for you. Suppose it is only one article in an issue-and you don't even look at the rest of that issue-if that article has one good practical idea that you can make use of, isn't it worth while? Would you want that idea to get away from you?-Medical Council. |