CHAPTER XI

=GETTING ADDITIONAL FEES=

It is a well-understood fact among physicians that the average man of 50 or over takes more interest and pride in his sexual virility than in any other phase of his physical system. It is equally well known that in almost every instance where a man has reached the age of 50 there is a very perceptible flagging or falling off in sexual power. In many instances it is entirely lost when the half-century mark is reached, or soon afterward. There are few men who care to admit this even to their family physicians, and, in consequence of this shyness, they fall ready victims to quacks of the “Be A Man” stripe.

When a man well past middle age comes into your office never broach the subject of sexual trouble to him at first, no matter how strongly you suspect it. If you do he will take treatment for that first, and that is the end of it. Secure him on some other line of treatment first. Humor his ideas in this respect—he has whatever ailment he may fancy he has. If you are satisfied that he is in position to pay well, but is hard to deal with in a financial way, it will pay you to name a modest fee for the initial treatment, but don’t let him get away. He will afford fat, liberal picking later on.

Where men of ordinary means will haggle over a $250 fee for being successfully treated for some annoying, really dangerous ailment, they will pay $1,000 or more cheerfully on anything that seems like a reasonable assurance of having their sexual power restored to its pristine vigor. There is not a physician in the land with any considerable practice who doesn’t know this.

Having secured your fee from a patient of this kind for the regular treatment of the trouble concerning which he came to consult you, and at the time when the treatment is beginning to show favorable results, spring the trap. As before stated there is generally a time when nearly every patient responds to greater or less extent to a new treatment. This response may be only temporary; it generally is. When the indications of this response are seen then is the time to act. It is the proper psychological moment.

Direct the conversation to the marked improvement in his condition, tell how much you are encouraged by the very noticeable change, and suggest another thorough physical examination so that you may make the proper record of his case. When the patient has disrobed give him the same thorough, searching examination you did when he first came to the office. Pay no attention to the sexual organs at first, but, when nearing the end of the examination say casually:

“How long have you been in that condition, Mr. ——?”

This is a random shot, but it will strike home ninety-nine times out of a hundred. There is very little chance of its going astray. Almost invariably the patient will ask:

“What condition do you refer to, Doctor?”

“Why your sexual organs are not exactly normal, are they?”

“Well, to tell the truth, Doctor, I am not as strong as I was a few years ago, but suppose it’s the natural result of advancing years.”

“You’re not an old man yet, Mr. ——. You are only 55, I think you told me. You ought to be good for at least ten years yet, and perhaps longer.”

“Do you really think so, Doctor. Is there any hope in that direction?”

“Most certainly. There is little question about the result. Modern science has given us an entirely new method of treatment in cases of this kind the effects of which are little short of miraculous. The one trouble, however, is that it is expensive, so much so that I hesitate to speak of it as a rule.”

No power on earth can prevent that man from having that treatment regardless of the expense. He has by this time an enlarged idea as to the doctor’s ability. He is pleased with the results of the treatment administered for the original ailment. He is impressed by the evident professional skill of the doctor in “discovering” a sexual condition which he fancied was known only to himself. He does not know that the physician has simply made a shrewd guess; one that he is in the habit of making several times a week, and generally with the same result. He is in the seventh heaven of delight. The doctor has adroitly dangled before his eyes a certainty which he had been vainly praying for. His next question is:

“What will it cost?”

Direct answer to this depends upon what the doctor has learned about the patient’s financial rating and willingness to pay. Few cases of this kind are taken under $1,000. Allowing that the physician has decided upon this amount as the extreme limit, he will reply:

“It is hard to say exactly, Mr. ——. Somewhere between $1,000 and $1,500. It depends upon what I have to expend for the remedies and permission to use them. They come from abroad and can only be obtained with the consent of the scientist who introduced them. That kind of men, as you doubtless know, are not always easy to deal with.”

“Well, the price is pretty steep, but if you are satisfied the treatment will do the work I want it.”

“There’s no doubt about the merits of the treatment, Mr. ——. The only thing, as I said before, that holds me back from recommending it generally, is its high cost. Besides I don’t, as a usual thing, care to handle cases of that nature.”

Smart doctor! He has got his human fly stuck on a gummed trap from which he couldn’t extricate himself if he would, and he doesn’t want to. If this wonderful treatment will restore his lost sexual power, and the doctor, in whom he has strong confidence, has told him it would, he’s going to have it. There is a little more conversation of an innocuous sort, and then the doctor says:

“I’ll tell you what I will do, Mr. ——. While I am not certain that the cost of the treatment may not run as high as $1,500, you may pay me $1,000 and I will endeavor to get the case closed for that amount. Should it be necessary to pay the other $500 I’ll leave it to your honor, but I am reasonably confident that I can make the necessary arrangements for $1,000.”

This looks good to the man who has rosy visions of a restoration to the fire and vigor of youth, and he generally draws a check on the spot. If his bank account will not admit of this he gives a “memorandum,” at least that is what the doctor calls it, and the deal is closed.

There are similar ways of getting additional fees from patients who have already paid well for the original treatment. One man (or woman) needs the eyes looked after and fitted with proper glasses, another should have the teeth fixed up, another requires a special surgical appliance, while still another should have a special prescription compounded.

The doctor always has a list of experts to whom he directs patients on the fee-sharing plan, and these fees are never over-modest. To the doctor’s credit be it said that he invariably warns such patients that if they want the best they must expect to pay well for it. It will undoubtedly cost considerable money, but the results will justify the expenditure.

“Your eyes certainly need attention, Mrs. ——, and it would be a good plan to have it done while you are here in Chicago. The longer you put it off, the more serious the complication will become. But, whatever you do, don’t go to one of these cheap occulist fakirs. They are liable to ruin your eyesight.”

“Who is a good man, Doctor?” is the natural inquiry.

“There are a number of able, competent oculists here. Dr. Seestraight stands at the head of his profession, and is probably the most satisfactory of the lot. I’ll give you a card to him, if you wish. He has always attended to my eyes, and has given satisfaction.”

This proffer is gladly accepted and when the patient leaves the doctor’s office she carries a note of introduction to Dr. Seestraight. It is an innocent looking note, but it contains a hidden cipher which gives the oculist a tip as to the fee which he may safely name. This cipher is generally made in flourishes, under the doctor’s signature, unintelligible to the patient, mere flourishes as it were, but perfectly plain to Dr. Seestraight. When the latter collects his fee he sends half of it to the physician who recommended the patient, and the incident is closed.

The same arrangements are made with certain pharmacists, dentists, and surgical instrument makers. There was one physician in Chicago who made it a practice to say to certain of his patients:

“You are getting along very nicely, but recovery would be much more rapid if you could take a little extra special treatment. But I hesitate to suggest it on account of the expense and the difficulty of procuring the proper ingredients.”

“Darn the expense, Doctor, if the stuff will do me good. What is it, and where can I get it.”

“There are several ingredients, and the only place in Chicago where there is any prospect of finding them is at Doem & Doem’s. But they don’t always have a supply. They are foreign preparations, very expensive, and there is such little demand for them that pharmacists dislike to carry them in stock. I’ll write the prescription, but I can’t vouch for your getting it compounded. At any rate if you can’t get it filled at Doem & Doem’s, there’s no use trying any other drug store.”

“You dwell so on the expense, Doctor, that I’m curious. What will it cost?”

“The expense varies somewhat. The last patient I supplied with the prescription had to pay $23.25.”

“That’s nothing.”

The prescription is written and Doem & Doem find on it a cipher telling them that the patient will stand for $25. As a member of the firm glances it over he says to the customer:

“This is a very rare and expensive preparation. It happens that we have just about enough material on hand to fill it, but I feel that I should warn you first that it will be very expensive.”

“I expected that. Dr. —— told me that it would probably cost $23 or $24.”

“That would have been a fair price a few weeks ago, but since then there has been an advance in the cost of the materials and I shall have to charge you $25.”

“All right. Go ahead and fill it. A dollar or so won’t stop me.”

The customer gets an ordinary preparation which any druggist would be glad to sell at 50 or 60 cents, while Messrs. Doem & Doem pocket $12.50, and send a like amount to the enterprising doctor.

Nor is this practice confined to what might be called the tradesmen in medicine, the druggists, the surgical instrument dealers, and so on. It is followed by what are known as high-class surgeons, men of eminence in the profession, and even finds favor among the physicians themselves. It is no uncommon thing for the doctors to exchange patients and divide the fees.

“Really, Mr. ——, you ought to consult Dr. Flubdub about that feature of your case,” a doctor will say to a patient when he has about exhausted him on the fee proposition. “That particular feature is a little out of my line. It needs the attention of an expert specialist in that line, and Dr. Flubdub has made a close study of just such cases.”

So the patient goes to see Dr. Flubdub and the latter is ready for him. He has been advised by phone as to what is coming about as follows:

“Hello, is this Dr. Flubdub? Yes. This is Dr. Grab. I have just advised a patient—Mr. ——, to see you. He seems to have a little ear trouble that needs attention. He’ll stand for about $250.”

Thanks to the tip given by Dr. Grab the ear specialist is able to speedily locate and describe the trouble with which Mr. —— is afflicted. Dr. Flubdub names his fee at $250, collects it, and sends $125 to his worthy brother, Dr. Grab. It’s a case of two pluck one.

When opportunity offers Dr. Flubdub returns the favor by sending patients to Dr. Grab who, in turn divides the fee, and thus the medical mill is kept busy.

Some physicians are very bold in demanding a division of fees as if it were right, rather than a honorarium. There is a letter in a certain office in Chicago, preserved as an evidence of gall, in which the writer says, when suggesting that he can send the recipient a patient:

“The woman will do just about what I tell her. She is business-like, and so am I. I think she will stand for $200. Now, if you can see any money in that after giving me $100, I’ll send her to you; if not, why I know plenty of others who will take the case on those terms. She is my meat, and will go where I say. I am not charging $100 for my time, but for steering the case to you. This is my game and I can steer the case where I please,” etc.

Nothing modest or backward, no hesitancy about this. The writer comes bluntly to the point, without false delicacy or reserve. Well, to give the devil his due, the fellow was honest in his straightforwardness. He knew what he wanted, and didn’t hesitate to ask for it. And the doctor who received the letter? Well, to tell the truth, he had conscientious scruples against that sort of thing, so he lost the case. Another physician of equal prominence got the patient, presumably on the terms named by the writer of the letter.

Speaking of deals between physicians and undertakers, Dr. G. Frank Lydston says:

“Over on the great West Side lives an undertaker friend of mine, who, in deference to his ancient and honorable vocation, we will call Mr. Watery Weeps. My friend Weeps has an eye to business; in faith, he has two eyes to business—both of ‘em red; some say from ‘red eye’ homeopathically applied. I do not believe this theory regarding Mr. Weeps’ headlights. Their peculiar bicycle lamp glow, like their excessive humidity, is due to his faithful, sorrowful ‘proxifying.’ In the course of my practice it did befall that a certain pulmonopathic vassal of mine—we will designate him as Mr. One-Lung, insomuch as he had no other lung—did feloniously, with malice prepense and aforethought and intent to deceive, up and die. Having a corpse on my hands, I naturally bethought me of my post-medical friend, Weeps, who undertaketh much in that vicinity. Weeps was prompt, and my late friend of the pulmonary solitaire was soon duly boxed and crated, ready for shipment to his ancestral home in ‘Injianny,’ whereupon quoth Weeps, lachrymosing his prettiest the while:

“‘Ahem, Doctor, I am very much obliged to you for the favor you have shown me. I hope to do a large share of your business in the future. I expect a check for this job to-morrow, and will then extend to you the _usual courtesies_ to the medical profession.’

“‘Ah,’ I replied, ‘and what might that be?’

“‘Why, 25 per cent. I call that pretty good, too, considering the hard times, don’t you Doctor?’

“And my friend Weeps still thinks I was bluffing when I declined the ‘usual courtesies.’ Truth is strange, passing strange—stranger than fiction.”

Then there is another class of physicians who will not hesitate to take advantage of a brother practitioner if they can do so to their own benefit. This is done in several ways: One method is to misrepresent the financial status of the patient whom he takes to an expert for consultation. It is not long since a physician called up another by telephone and arranged for him to see a “poor patient” who could only pay a small fee for consultation. The doctor thus called upon discovered that the patient, who was a wealthy stock raiser from the West, had paid his doctor friend a good fee already, and had arranged to pay him $200 more for the prospective operation—which the second doctor was expected to tell his friend how to do.

It is frequently the case that general practitioners call a consultant without making arrangements for the fee beforehand. It is unpleasant to spend half a day or night in consultation and then have the doctor say:

“Now, doctor, these people haven’t got much money, so don’t charge them a large fee.”

The consultant thereupon cuts his fee in two.

“Well, doctor, I’ll see that you get it in a day or two,” is the reply. But the consultant never gets it. Should he protest, the family physician says, “Don’t be in such a hurry, doctor, I haven’t got anything out of the case myself, yet.”

How easy it would be for the physician who calls the consultation to see that the fee is ready when the consultant comes. Unless there is an understanding that the case is one of pure charity, the physician calling the consultation should be held responsible for the fee. The consultant himself cannot always do so, but where possible he should stipulate beforehand that a certain fee be in readiness. The family physician who does not know that such a plan is best for his own interests is stupid.

An intolerable nuisance to the consultant is the doctor who writes a friendly letter asking for “the diagnosis, prognosis and treatment” of some case under his care. Rarely does he inclose a stamp, never a fee. The consultant who answers such letters, save to inform the writer that office rent cannot be paid by such consultations, is frequently laughed at for his pains, but this should be the rule.

A more “pestiferous professional parasite,” if possible, than the foregoing, is the doctor who refers a patient from a distance, with a request to send the bill to him. Here again Dr. Lydston says: “I have sent many such bills first and last—accent on the ‘last’—but have never received a remittance, nor do I expect my reward in Heaven. In the first place, I am not so sure about getting there, and if I were, and knew that those doctor debtors were going to be there too, I—well, I’d ask for a change of venue. As for the patients who are accessories to such professional ‘hold-ups,’ a fellow wouldn’t want to chase around all over hades to collect his fees from them.”

No less an authority than Dr. John P. Lord, president of the Western Surgical Association, in an address delivered before the association, said:

“The practitioner,” he said, “will call a man of sufficient standing to enable him to name a fancy price as the consultant’s fee, which he collects, and then remits the consultant the minimum fee. The graft element is also going into medical politics and some county societies are controlled by it.”

It will be noticed that Dr. Lord does not find fault so much with the division of fees, as with the unfair manner of division. His plaint appears to be, not that division in itself is wrong, but that the man who handles the money does not treat his professional brother fairly. There’s a lot of truth in this, but the objectionable practice is mostly confined to a class of short-sighted practitioners who don’t take the future into consideration.

Another doctor, speaking on the same subject, said: “This is an age of commercialism in medicine and surgery. Graft rules the majority. There are a few old fogies, like myself, who don’t graft—but do you know why? Just because we’re too old to learn how. Oh, yes, we’d all do it if we had a chance, I presume. We’d be forced to. Those who do it claim that they have to. It may be the public’s fault, but it’s certainly hard on the public which has to do the paying and which doesn’t know whether it has stomach ache or appendicitis.

“In ancient Rome the doctors used to graft successfully. They’d place a finger on the severed end of an artery and say to the patient: ‘Now, old fellow, just come across with the fee, right away, or the finger will be removed and you’ll bleed to death.’

“We are coming to that. We may not work it in the same way, but the idea will be the same. Even now they—or we—want money before operations, and will endeavor to learn something of a patient’s standing in the community before his check will be accepted. Wouldn’t a business man do the same thing? And if surgery is becoming a business, why isn’t it proper? It is proper—from that standpoint. But, oh, the pity of the passing of old ideals!

“The whole matter seems to me a question of economics. The medical profession is a belated profession. We cannot collect a fee by statute under certain conditions—as when the call comes from a third party. We must have money. What is there left to do? Graft! Or ‘commercialize.’ That’s a nicer name for it. Let’s see now just what the public brings on its own head.

“There’s a man who thinks it is necessary that his leg comes off. He has nerved himself for the operation and has announced his willingness to pay, say $250. A conscientious surgeon examines the leg and saves it without the use of a knife and the man recovers the use of it. In a few days he is able to sit up and dispute the bill for $100, claiming it is exorbitant. What do you think his argument is? This:

“‘You didn’t have to operate. Why should it cost so much?’”

“That may not be logic, but it’s what happens right along. That is the grateful reply we get from many patients for saving them from mutilation. And it is things like that which have largely influenced surgeons, I believe, to operate when it is unnecessary. It is not right, of course. A surgeon should be as a father and mother to a helpless, sick soul. Still he is human and he must live. Like Robin Hood, there is a better class of surgical robber who takes only from the rich.

“You know, the rich are always in a precarious condition. It’s a mighty conscientious doctor who will tell a rich man that his trouble is only imaginary. The average physician or surgeon will fly around briskly, ‘dope’ the man up and then probably remove a perfectly good appendix—bill $2,000.

“I attended the son of a rich man who really had appendicitis at one time. The operation was successful and the boy pulled through, although I never saw a more serious case. I sent in a bill for $2,000 and received no reply. I tried again and received no reply. Shortly afterward I met this man on the street—you’d know his name if I were to mention it—and he said, ‘I have no intention of paying your exorbitant bill.’

“I wouldn’t sue. Never do. Bad practice. So I compromised for $500, although he could have paid $10,000 without missing it—and the operation was worth it.

“There are rogues in every profession. There are brutes in the medical profession who will demand money from a woman before she is out of the anæsthetic—who will haggle with a dying man as to terms. And there are many of them. I could mention names of men in Chicago that would make you open your eyes. The really first-class doctor of the old school who retains the old ideas of the profession should have a halo. He deserves it. Of course he can’t live by pursuing such antiquated methods as those of a gentleman, but then—says the rest of the world—who needs to live, anyway?”

The surgeon was asked about the number of cases where lives had been lost through carelessness or stupidity on the part of surgeons.

“Caveat emptor!” was his reply. “You know the old gag? Let the purchaser beware. He doesn’t have to go to a poor doctor. Even some of the biggest grafters are eminent surgeons and at the top of their profession. I do not underestimate their ability. But heaven only knows there are ever so many cases of recklessness or carelessness or foolishness which have taken lives. Patients keep right on dying, you know, in spite of doctors or because of them.

“A good example of graft which came to my notice is this: A young Swedish farmer called in a doctor in a small town. He had pains and other things and looked generally shot to pieces. The young doctor speedily discovered that the real trouble was lack of air—unsanitary conditions in the home.

“‘You haven’t typhoid fever, you goat,’ he told the fellow. ‘I’ll fix you in a few days.’

“He opened the bedroom window first. Some one had told the farmer he ought not to raise his window nights, and there he was sleeping in that foul atmosphere. No wonder he felt badly. Well, anyway, in the course of a few days my friend had him feeling better. One day he called up and said he ‘wouldn’t be around that day. It wouldn’t be necessary—patient better,’ and so forth.

“Then the quack hove in sight. Some one had heard of him and he was sent for. He gave the convalescent Swede one look and said: ‘My God, man! You’ve got typhoid! Back into bed with you immediately or you’ll die.’ The terrified farmer crawled back into bed and began to feel worse immediately. Then the quack ‘doped’ him religiously for a few days and ‘completely cured him.’ My friend had been let go in the meantime.

“The idea of the younger generation of doctors, I find, is just opposed to the old ideal. The young man wants money and as a rule he isn’t particular how he gets it. He hustles through school, gorges his mind for the ‘quiz’—a ridiculous thing—and gets his diploma. No really good man could pass a ‘quiz.’

“Some schools, of course, are good, and I will say that the material we have in this country of which to make doctors cannot be improved on; but, on the other hand, some of the schools—many of them—are so bad that no school at all would be better.

“I must say that I do not entirely agree with everything you have said in your book, but I must confess there is much truth in your statements. As for Dr. Lord’s contentions—anent grafting, fee splitting and that sort of thing—well, almost everybody’s doing it. I know that. The number of physicians and surgeons in Chicago who would not do it is so small that it would be like looking for a needle in a haystack to find them.”