0The patient's dilemma
e have heard much of the doctor's
dilemma. We are likely to hear more of the patient's dilemma, as free play of the profession is impeded the unconsidered by legislation. It is by freedom that medicine has attained to its high place, because the physician, being a free man, has chosen to be the servant of all. He is his own master and yields a willing service such as no compulsion can secure. The practice of medicine is what it is, not by any fortuitous circumstance or conscious direction, but because it has grown up under the necessity which men experience for relief from pain,- from the dread of death, and for aid in the struggle for existence in an environment where other organisms also are rightly striving to live. And him we call the father of medicine who first rescued the practice of it from slaves and hirelings and made it worthy of free men. At various times medicine has become degraded again from a profession to the status of a trade. Those times we call the dark ages. The patient is free to ask:
the physician is free to serve; and the reward iis1S an afterthought. an
O
The profession of medicine seeks nothing for itself. It has no secrets. All it knows and all it can do is for the healing of the people. It has no existence apart from the public good, and the whole history of medicine teaches that the people are best served when the profession is at the high level whereat its founder placed it. The Chinese entertain a contrary opinion. To them a physician is a kind of scavenger and nothReprinted from the September 1911 (vol. 1, no. 9) issue of CMAJ, pages 885 to 888.
JULY 1, 1991
0
ing
more. He is paid by the piece, and his pay stops when his work is done badly; but it is not a fact that China is more free from disease than England is, or that its inhabitants are more comfortable and safe in sickness. The relation between physician and patient is not an affair of contract. It is based upon necessity on the one hand, and willingness to serve on the other. The patient is free to ask: the physician is free to serve; and the reward is an afterthought, an affair for future consideration. This is the system which humanity has evolved for itself, and where it is most completely employed humanity is best served. At this moment the profession in England is much disturbed over a piece of legislation, commonly called "The Insurance Bill," which aims to extend practice by contract to some nine million persons. We see no cause for alarm so far as the profession itself is concerned. No evil can come to it unless from within. Indeed, there are many reasons for the belief that the profession will be much relieved by this transference of the care of the sick from a small of men to the nation as a whole. The body proposal, in short, is that medical men shall
l
U
be paid for doing what they have hitherto
done for nothing. The higher ranks will be
freed from the burden of charitable work,
U
and the lower ranks will receive certain salaries instead of uncertain fees. Men of great ability have continued to work in the hospitals for a variety of reasons, which have been diminishing in force and will no longer hold good when patients can demand as a right what was formerly received as an act of charity. Physicians who could achieve fame in the hospitals alone, now shape their careers in the laboratory. The hospital bedside is no longer the only resort for clinical experience, and the wisest physician is not always the one who sees the most cases. A scientific training is now more important than ever before and
Y
fl
the routine of the hospital less alluring.
And if the
people
pay
by compulsion
CAN MED ASSOCJ 1991; 145(1)
43
for their treatment, charitable persons will be disposed to allow the support of hospitals to come from the public funds. There will then be fewer of these institutions, and the spirit of charity will be replaced by a cold, official atmosphere which is not congenial to a member of a free profession. When the higher lights disappear from the wards and operating rooms, students will vanish; and without the stimulus which the presence of students creates, institutions for the care of the sick will resemble a house of detention instead of a place of hope and cure.
In the treatment of the sick there is large room for those qualities of the heart which are too precious to be S appraised by an official
there willofficials soon be the will abeclearage, salaried forced intoand a sub-
Il
O
f s
Li
sion composed largely of civil servants,
superior.
S
rich will be the gainers and the last state of the poor will be worse than the first. And who will educate these officials? No medical student now pays for his own education. The fees which are exacted from him represent only a small part of his cost to the school. The balance is contributed by benefactors who are desirous that the people will be well served by good physicians. Professors teach because they are impelled to hand down the pure flame. They may quite reasonably determine that, if the officials whom they are educating are to be paid, they also shall be recompensed for their labour in carrying on a department of the government, since a government department is not commonly regarded as a suitable recipient of charity. In the freer profession of medicine, all are equal because all are free. In a profes-
A physician succeeds in virtue of a humane nature, because in the treatment of the sick there is large room for those qualities of the heart which are too precious to be appraised by an official superior. When physicians become civil servants, those who are peculiarly adapted for healing the sick be automaticatey forced out of the servwice wvice and into private practice, wout he eir gifts will be more highly appreciated. The
sidiary position, which is not favourable to an alert and open mind. If the government, or its agents, accept and distribute funds which have been levied for the care of the sick, they must appoint their own physicians and other officials. These can only be drawn from two classes, from those who have failed in free practice or from those:
|| y
II L
Who either fear their fate too much, Or whose desert is small, Who will not put it to the test, To win or lose it all.
The part that counts The real work of a doctor ... is not an affair ofhealth centres, or public clinics, or operating theatres, or laboratories, or hospital beds. These techniques have their place in medicine, but they are not medicine. The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice ofmedicine derives from it. -
44
CAN MED ASSOC J 1991; 145 (1)
Sir James Calvert Spence (1892-1954)
LE I
er jUILLET I1991I
e have heard much of the doctor's
dilemma. We are likely to hear more of the patient's dilemma, as free play of the profession is impeded the unconsidered by legislation. It is by freedom that medicine has attained to its high place, because the physician, being a free man, has chosen to be the servant of all. He is his own master and yields a willing service such as no compulsion can secure. The practice of medicine is what it is, not by any fortuitous circumstance or conscious direction, but because it has grown up under the necessity which men experience for relief from pain,- from the dread of death, and for aid in the struggle for existence in an environment where other organisms also are rightly striving to live. And him we call the father of medicine who first rescued the practice of it from slaves and hirelings and made it worthy of free men. At various times medicine has become degraded again from a profession to the status of a trade. Those times we call the dark ages. The patient is free to ask:
the physician is free to serve; and the reward iis1S an afterthought. an
O
The profession of medicine seeks nothing for itself. It has no secrets. All it knows and all it can do is for the healing of the people. It has no existence apart from the public good, and the whole history of medicine teaches that the people are best served when the profession is at the high level whereat its founder placed it. The Chinese entertain a contrary opinion. To them a physician is a kind of scavenger and nothReprinted from the September 1911 (vol. 1, no. 9) issue of CMAJ, pages 885 to 888.
JULY 1, 1991
0
ing
more. He is paid by the piece, and his pay stops when his work is done badly; but it is not a fact that China is more free from disease than England is, or that its inhabitants are more comfortable and safe in sickness. The relation between physician and patient is not an affair of contract. It is based upon necessity on the one hand, and willingness to serve on the other. The patient is free to ask: the physician is free to serve; and the reward is an afterthought, an affair for future consideration. This is the system which humanity has evolved for itself, and where it is most completely employed humanity is best served. At this moment the profession in England is much disturbed over a piece of legislation, commonly called "The Insurance Bill," which aims to extend practice by contract to some nine million persons. We see no cause for alarm so far as the profession itself is concerned. No evil can come to it unless from within. Indeed, there are many reasons for the belief that the profession will be much relieved by this transference of the care of the sick from a small of men to the nation as a whole. The body proposal, in short, is that medical men shall
l
U
be paid for doing what they have hitherto
done for nothing. The higher ranks will be
freed from the burden of charitable work,
U
and the lower ranks will receive certain salaries instead of uncertain fees. Men of great ability have continued to work in the hospitals for a variety of reasons, which have been diminishing in force and will no longer hold good when patients can demand as a right what was formerly received as an act of charity. Physicians who could achieve fame in the hospitals alone, now shape their careers in the laboratory. The hospital bedside is no longer the only resort for clinical experience, and the wisest physician is not always the one who sees the most cases. A scientific training is now more important than ever before and
Y
fl
the routine of the hospital less alluring.
And if the
people
pay
by compulsion
CAN MED ASSOCJ 1991; 145(1)
43
for their treatment, charitable persons will be disposed to allow the support of hospitals to come from the public funds. There will then be fewer of these institutions, and the spirit of charity will be replaced by a cold, official atmosphere which is not congenial to a member of a free profession. When the higher lights disappear from the wards and operating rooms, students will vanish; and without the stimulus which the presence of students creates, institutions for the care of the sick will resemble a house of detention instead of a place of hope and cure.
In the treatment of the sick there is large room for those qualities of the heart which are too precious to be S appraised by an official
there willofficials soon be the will abeclearage, salaried forced intoand a sub-
Il
O
f s
Li
sion composed largely of civil servants,
superior.
S
rich will be the gainers and the last state of the poor will be worse than the first. And who will educate these officials? No medical student now pays for his own education. The fees which are exacted from him represent only a small part of his cost to the school. The balance is contributed by benefactors who are desirous that the people will be well served by good physicians. Professors teach because they are impelled to hand down the pure flame. They may quite reasonably determine that, if the officials whom they are educating are to be paid, they also shall be recompensed for their labour in carrying on a department of the government, since a government department is not commonly regarded as a suitable recipient of charity. In the freer profession of medicine, all are equal because all are free. In a profes-
A physician succeeds in virtue of a humane nature, because in the treatment of the sick there is large room for those qualities of the heart which are too precious to be appraised by an official superior. When physicians become civil servants, those who are peculiarly adapted for healing the sick be automaticatey forced out of the servwice wvice and into private practice, wout he eir gifts will be more highly appreciated. The
sidiary position, which is not favourable to an alert and open mind. If the government, or its agents, accept and distribute funds which have been levied for the care of the sick, they must appoint their own physicians and other officials. These can only be drawn from two classes, from those who have failed in free practice or from those:
|| y
II L
Who either fear their fate too much, Or whose desert is small, Who will not put it to the test, To win or lose it all.
The part that counts The real work of a doctor ... is not an affair ofhealth centres, or public clinics, or operating theatres, or laboratories, or hospital beds. These techniques have their place in medicine, but they are not medicine. The essential unit of medical practice is the occasion when, in the intimacy of the consulting room or sick room, a person who is ill, or believes himself to be ill, seeks the advice of a doctor whom he trusts. This is a consultation and all else in the practice ofmedicine derives from it. -
44
CAN MED ASSOC J 1991; 145 (1)
Sir James Calvert Spence (1892-1954)
LE I
er jUILLET I1991I
