PROPERTY OF THE NATIONAL LIBRARY OF MEDICINE THE PROFESSION OF MEDICINE A COLLECTION OF LETTERS FROM GRADUATES OF THE HARVARD MEDICAL SCHOOL EDITED BY ARTHUR B. EMMONS, 2D, M.D. DIRECTOR OF THE APPOINTMENTS BUREAU OP THE HARVARD MEDICAL SCHOOL PUBLISHED FOR THE HARVARD MEDICAL ALUMNI ASSOCIATION BY THE HARVARD UNIVERSITY PRESS CAMBRIDGE, MASS. w 1115 PREFACE The Appointments Bureau was established at the Harvard Medical School, December, 1912, by the cooperation of the Medical School and the Harvard Medical Alumni Association. The director soon found that medical students and recent graduates asked many important questions concerning preparation and the practice of medicine. Recognizing his inability to answer intelligently and authoritatively these questions, the director decided to make a study in the hope of obtaining data which would help to guide the prospec- tive practitioner, and this pamphlet contains the results of such a study. . These results, it is believed, may be of considerable interest, not only to the young medical man, but to those already established, and particu- larly to those interested in the education and prepara- tion of medical students for their several callings in medicine. i CONTENTS PAGE Preface ....................... 3 Introduction..................... 9 The Practice of Medicine..............15 Medicine as a Career................15 The Strenuous Life...............". . 21 Relations of the Medical Profession with the Public ... 26 Specialism.....................37 Location .....................44 The Question of Money...............59 Medical Ethics...................64 Preparation for a Medical Career..........70 Hospital Training .................70 Scientific Medicine.................75 Business Training and a Medical Adviser.......76 Harvard Medical School Training..........81 Specific Lacks...................81 Satisfied Comments.................87 Therapeutics....................88 Constructive Comments...............93 Pre-medical Education.................99 Summary.......................102 5 THE PROFESSION OF MEDICINE PREPARATION, TRAINING, AND PRACTICE FROM A STUDY OF THE DOINGS AND OPINIONS OF TEN CLASSES OF THE HARVARD MEDICAL SCHOOL, 1901-1910 INTRODUCTION In making this inquiry it was decided to send a circular letter to the members of ten classes, approximately nine hundred men. These physicians had been out of the Medical School from three to thirteen years. Some therefore, were just beginning to practice after hospital work, while others were well established. Owing to the rapid changes in the school curriculum, and in the methods used in the practice of medicine throughout the community, the older classes were not brought into this inquiry, although it was recognized that many valuable facts might have been obtained from the older men. A copy of the circular letter follows: Dear Doctor: — This circular letter is being sent out to all graduates of the Harvard Medical School in the classes 1901 to 1910. The object is to gather such information as may be of helfLto medical students. You graduates know the present needs of the community; you know best how to prepare to meet them. We believe you will be glad of the opportunity to give that knowledge to guide the younger men. A few set questions are asked, but space is left for individual comment; perhaps the most valuable part. No name is desired so that there may be no hesitation in frankly answer- ing the questions. The location, such as " Boston " or " City of 10,000 inhabitants in Massachusetts " or " Town of 5,000 in California," is, however, desirable to make the information more valuable. 9 10 INTRODUCTION As such inquiries depend for their value largely on the proportion of answers received and not upon the degree of pro- fessional success of those answering, and, as we believe this value may be very great in " helping the other fellow " to make a wise decision in his life's work, you are urged to help out even though it may mean considerable effort of memory and a little time to answer the questions. Those especially earnest men who add individual comment, advice, or sugges- tions, will lay the future student under a double debt of gratitude. Very truly yours, Director. It will be noted that no name or identifying address was asked. This had the disadvantage of leaving the individual and his location unknown. Hence no follow- up letter could be sent. A sample of the blank sent to each man is shown on the opposite page. INTRODUCTION 11 Location: (a) City?.................................................................................... (b) State ?............Town ?............(Approximate Population) Year of Graduation from the Harvard Medical School ?.......... How much hospital work did you take after graduation ?........ Do you do general practice ?........................................................ or, What specialty ?.................................................................. or, Laboratory ?........................................................................ or, Teaching ?............................................................................ or, Public Health ?.................................................................... or, Special work ?...................................................................... How much money (approximately) did you make from medi- cal work each successive year since leaving the School ? 1901................, 1902................, 1903................, 1904.............., 1905................, 1906................, 1907................, 1908.............., 1909................,1910................, 1911................,1912.............., 1913................, What per cent (approximately) of your work is now paid in full ?..................In part ?..................Not at all ?...................... Is there a need in your community for general practitioners ? ....................Specialists ?....................Surgeons ?...................... Eye, Ear, Nose and Throat?........................Public Health Officers ?...................................................................................... In pre-medical preparation do you favor a predomination of 1. General culture, such as History, Philosophy, Economics, Literature, and Art ?.............................. 2. or, Natural Science, as Physics, Chemistry, and Biology?........................................................................ What do you consider was lacking (if anything) in your School course to fit for your particular work ?...................... Has the practice of medicine proved satisfactory to you ? If not, what is unsatisfactory ?................................................ Individual Comment: 12 INTRODUCTION Over one-third of the men answered, a proportion which is about the usual from such inquiries. The advantage of no identifying information proved very great, for the men who did reply felt free to speak frankly what they thought. These frank expressions form the most interesting and valuable part of this report. The form of the report, it was felt, should reflect as far as possible the thoughts and language of each writer. To accomplish this the history and en- vironment of each man is given briefly, for example: " H. M. S. '04. 2 years hospital. General practice in a city of 225,000 in New York. Income, 1913: $2,600. Favors: the sciences. Lack (in school work): " more of the little things." Practice: satisfactory. The comments which follow such a short biography are better understood when the reader knows the man's point of view. The editor hopes this novel scheme will give a more accurate picture and will enable the reader to draw his own conclusions from each " case." It was very difficult to edit this large number of remarks as many men cover a large field of medicine in their comments. Each opinion was, therefore, classi- fied according to the predominance of one of the sub- jects discussed. But remarks on other subjects were frequently of value or significance and were, for this reason, not often omitted. It seemed wise to limit this report to a reasonable length, so some remarks of lesser interest were omitted, and many were grouped and summarized to give due proportion to the general opinion. Owing to some vagueness in answering many of the questions the statistical tables must not be considered accurate. They do, however, reflect in a broad general INTRODUCTION 13 way the doings and opinions of these three hundred odd physicians who have answered. To prevent misunderstanding of conditions at Har- vard Medical School today it should be constantly borne in mind that criticisms of the way things were or were not taught in the day of these graduates may be far from fair criticisms of the School today. The School is constantly changing and these changes are not always followed by the graduates. The Department of Phar- macology, for instance, has had a new head for some time. New departments have been added. In short, to get an accurate idea of the School today, one would have to investigate each department. This present investigation aims only to reflect con- ditions in practice today, and as far as possible to glean hints of how best to prepare for, and what to expect to get from and give to this great profession. JP THE PRACTICE OF MEDICINE Medicine as a Caeeer A feeling of great satisfaction and love for the career of medicine is expressed by many men in the profession, both because of the amount of good they are enabled to do in the world, and because of the gripping interest of the work itself. Very few regret their choice of life- work, although there are many complaints against the overcrowded condition of the profession, the competi- tion with " quacks," and the small monetary reward to be gained from its pursuit. On the whole, the com- ments are typified by the remark of one man to the effect that the career of medicine " is a good game." To the question, " Has the practice of medicine proved satisfactory to you ? " 226 answered " Yes," 16 answered " No," and 18 others answered with a quali- fied "No"; 2 never practiced, and 10 did not reply. Total 317. A few of the general remarks read as fol- lows: H. M. S. '02. 2\ years hospital. General practice and special work in Cleveland, Ohio. Income, 1,913: $3,800 (9 months). Favors sciences. Lack: nothing. Practice: very satisfactory. " My advice is, graduate as early as possible; complete at least two years of interneship in a hospital; do special work, Plan of if possible, life insurance examinations, medico- practice sociological work, and dispensary work from three to five years. Do general practice, including surgery, when you start in to practice; after ten years take a post-graduate course and limit your practice." 16 THE PROFESSION OF MEDICINE H. M. S. '07. 18 months hospital. General surgery in Boston. In- come, 1913: $5,300. Favors both arts and sciences. Lack: operative surgery. Practice: satisfactory. " Unless a man has professional backing when he leaves the hospital he will find practice in the city most discouraging. Getting I believe my success is due largely to the fact that started gQ £ar j naye £Qne j^ very \[^\e hospital Or teaching work, but have attended to getting as much practice as I could. Now that this foundation is laid I am branching into hospital work, and I hope soon to have a teaching posi- tion. Circumstances have forced me to play the game this way, as I have had to depend on my practice for my living." H. M. S. '09. 16 months hospital. General practice and surgery in Boston. Income, 1913: $1,186. Favors " chiefly arts with elementary courses in the sciences." Lack: "dietetics, and I wasted time watching operations, which was my own fault. The chief part of my income is Early derived from my position as assistant to two income general practitioners for whom I work from four to five hours a day, being paid $900 a year with the use of an office in town, besides contingent fees for seeing their patients when necessary." H, M. S. '02. 3 years hospital. General practice in a town of 9,000 in Massachusetts. Income, 1913: $8,500. Favors sciences. Lack: " I was not made to learn accurate physical examina- tion." Practice: satisfactory. " I am strongly in favor of Partnership the association of a good laboratory man with an or associate 0\^eT established physician. Even in the country this arrangement can be made to pay, and it makes work more accurate and makes an opportunity for freedom and study for both men." H. M. S. '02. No hospital. General practice and considerable surgery in a town of 2,800 in Massachusetts. Income, 1913: $4,000. Favors sciences. Practice: satisfactory. MEDICINE AS A CAREER 17 Lack: " Contact with patients outside of the hospital. The career of medicine should not be attempted with the expectation of becoming wealthy, or if one cannot feel him- self repaid by the results obtained by treatment. If possible, practice should be begun as the associate of an established man." H. M. S. '02. 6 months hospital. Bacteriologist for the Government. Salary, 1913: $1,800. " I am not engaged in practice because my natural bent is Tempera- toward laboratory work and research. My brief ment attempts in the latter part of 1905 and 1906 were not satisfactory because of my temperamental unfitness for practice." H. M. S. '09. 3 years hospital. General practice in a city of 40,000 in Massachusetts. Income, 1913: $1,600. Favors arts. Lack: " training in orthopedics. My practice has been un- satisfactory in having to wait for practice when one is young and best able to work. My advice is, get further training in specialties during the time of hospital work." H. M. S. '01. No hospital. General practice in a town of 3,000 in Massachusetts. Income, 1913: $4,000. Favors arts. Lack: "better knowledge of materia medica and thera- peutics." Practice: satisfactory. " Take a hospital service; lay more stress on medicine than on surgery; there are too many would-be surgeons." H. M. S. '07. 5 years hospital. Ear, nose, and throat in Boston. In- come, 1913: $1,000. Favors sciences. Lack: nothing. Practice: satisfactory " after the seven extra years of train- ing and discouragement. This is a poor business, but a Over- pleasant occupation if you can find the work. crowding Ttie profession needs improvement in the quality of trained and honest men, but it needs no more in numbers." 18 THE PROFESSION OF MEDICINE Some of the men who have taken up the career of Public Health Service say: H. M.S.'10. No hospital. U. S. Public Health Service. Salary, 1913: $2,880. Favors arts. Lack: nothing, " the course seemed almost perfect." Practice: satisfactory. " The United States Public Health Service is in need of men of the sort that Harvard produces. There are always vacan- cies for men of ability and refinement. Every opportunity is afforded the individual to progress as fast and as far as his natural ability will permit. I earnestly ask that the service be presented to every desirable student for careful considera- tion." H. M. S. '02. 3 years hospital. Pediatrics in New York City. Income, 1912: $2,400. Favors arts. Lack: individual teaching. Practice: " not wholly satisfactory because of unfair com- petition. I heartily commend special training for those who intend to enter the field of public health medicine, the field which offers the best opportunity for faithful work." H. M. S. '04. 1 year hospital. U. S. Public Health Service. Income and salary, $2,220. Favors sciences. Practice: satisfactory. " I advise no young man to go into the United States Public Health Service or into any government position. The salaries are very low, much lower in the profession than in the trades. The salaries, too, are fixed, and no matter how competent one is he well knows that the salary is not to be increased. " Of the three Government services I think that the Public Health Service should be entered only by those men who intend to stay in it. The work is more diverse, and there is less of ordinary medicine and surgery, on the average, than in the other two services. Promotion is at present somewhat more certain than it has been, and there is the advantage of one's immediate commander being a medical man." H. M. S. '06. 18 months hospital. Director of Hygienic Laboratory. Salary, 1913: $3,000. Favors sciences. MEDICINE AS A CAREER 19 " More emphasis should be put upon entomology and zoology." Lack: " course in bacteriology somewhat weak, not enough preventive medicine. As Director of the State Hygienic Laboratory my work is satisfactory to me. I pre- fer work of this sort with a small salary to practice with more money." The men who have entered the field of institutional work say in part: H. M. S. '08. 20 months hospital. General practice in a city of 40,000 in Massachusetts. Income, 1913: $2,250. Favors arts. Lack: "work in hospital wards." Practice: satisfactory. " I feel that the medical schools could do something toward preparing men for hospital administrative work just as they are doing for public health work. The field is large, and for the capable man, lucrative." H. M. S. '10. 18 months hospital. General practice in a city of 160,000 in Massachusetts. Income, 1913: $3,978. Favors arts. Practice: satisfactory. " My success has depended largely upon acquiring consider- able accident work and insurance examinations. The only commer- dissatisfaction I find arises from the intermediate position of practical medicine between a profes- sion and a business. Specialization and commercialization, as well as public charities, are transforming medicine from a profession into a business." H. M. S. '02. In hospital since graduation. " I lecture to nurses and assist visiting surgeons at a hospital." General practice in city in Massachusetts. Income, 1913: $2,300. Favors sciences. Lack: " A personal adviser." Practice generally satisfactory " except for so much work and responsibility and so little pay. I should advise a son of mine to prepare for ' State ' work where a known salary might be gotten." 20 THE PROFESSION OF MEDICINE One insurance man sets forth his case as follows: H. M. S. '06. No hospital. General practice in large city in Massachu- setts. Income, 1913, $1,000. Favors sciences. Lack: clinical work. " I advise less physiology and technique in laboratory (course changed now. — Ed.). I would suggest the repeal of the Industrial Accident Board Act, because the so-called big men control the insurance and thus degrade and decrease the reputation of the younger practitioner in the esteem of the working class. The younger men are despised by insurance companies and by the community." A Naval man says: H. M. S. '03. 2 years hospital. General practice and surgery in U. S. Navy. Naval salary. Favors sciences. Practice: satisfactory. " The service offers many attractive features, such as a fairly good living, travel, and very pleasant associations. But at present promotion is slow, depending, as it does, on seniority, and there does not seem to be any immediate prospect of remedial legislation. On the whole, my ten years in the Naval Service have proven both valuable from the standpoint of experience, and pleasant from the stand- point of travel and friendly association, but if I had my career to begin over again I should consider very long and seriously before taking the same step." A man who entered the U. S. Army says: H. M. S. '06. No hospital. Medical officer in U. S. Army. Salary, 1913: $2,790. Favors "a judicious mixture of arts and sciences." Lack: " a proper valuation of the work done in other communities. There is too little known of the opportunities and work to be done in the Medical Corps of the United States Army." THE PRACTICE OF MEDICINE 21 The Strenuous Life To be engaged in general practice may mean worry, trials, and inconveniences. The financial rewards are small as compared with the strenuousness of the life, but the feeling of satisfaction is often great. H.M.S.'01. 2 years as interne and 2 years salaried in hospital. General practice in a city of 15,000 in Massachusetts. Income, 1913: $4,500. Favors arts. Lack: " The art of the practice of medicine. On the whole my practice has been satisfactory. I often become tired of the confinement and lack of opportunity to devote specific time to art, music, literature, etc. Irregular hours for meals and sleep are trying. I would advise no man to go into practice for the money that is in it. He should have the spirit of service uppermost in his mind if he is to get real enjoyment out of his work." H. M. S. '07. 2 years hospital. General practice in a town of 10,000 in Massachusetts. Income, 1913: $1,800. Favors arts. Lack: " too much theory and too little actual contact with patients. Practice: fairly satisfactory. The unsatisfactory part of this life is slow payments, night work, the unreason- ableness of patients in wanting you at a minute's notice day or night. " I should strongly advise a man against the study of medicine unless he has some income or some one to whom he could look for help during the first few years of his practice. I figured that I would not pay expenses for at least three years, having no one who would send or turn over cases to me, and I found I was right. " To my mind, a man just starting out should decide where he wants to live, go there and stick; if he is any good he will be successful anywhere. A man must not expect to make much more than a decent living in the practice of general medicine." 22 THE PROFESSION OF MEDICINE H. M. S. '07. 16 months hospital (surgical). General practice in small city in Massachusetts. Income, 1913: $10,000. Favors arts. Lack: " a good working knowledge of human nature." Prac- tice: not entirely satisfactory. "Some means or method should be found of obtaining time for relaxation, rest, and study. Night work in general practice, particularly in the winter, is very exhausting and disagreeable. Success is bought at a very high price, nothing less than constant and unremitting attention to business being required. " The idea of groups of physicians as suggested by Dr. Cabot appeals to me very strongly, and I believe that will be the ultimate solution and the means of making suburban practice desirable." H. M. S. '01. 5£ years hospital. General practice in a town of 1,000 in New York. Favors arts and sciences. Lack: "too large sections in medical school and too little individual instruction." Practice: fairly satisfactory. In- Professionai come, 1913: $4,500. "To practice medicine successfully a man must have a good education, general and medical, and means so that he can afford to sit down and wait and keep up appearances. He must be willing to go without a family until his practice is established on a solid foundation." H. M. S. '02. 1| years hospital. General practice in a town of 9,000 in Massachusetts. Income, 1913: $5,000. Favors sciences. Lack: "training in little things." Practice: satisfactory, except that " it is a dog's life and very confining. Competi- tion cheapens the physician in the eyes of the public. People call you at any hour of the day or night regardless of the nature of the case, and if you don't go some one else will." H. M. S. '02. 6 months hospital. General practice in Boston. Income, 1913: $4,000. Favors sciences. Lack: " surgical training and major work. My practice has been made unsatisfactory because of the lack of surgical THE STRENUOUS LIFE 23 training in medical school. The increase in expense in order to accomplish the work I have to do makes my income inade- quate. I am unable to save for a rainy day. " It is physically hard to be on duty every day in the year, day and night. It is also hard to be blamed undeservingly by people." H. M. S.'02. 18 months hospital. General practice in Boston. Income, 1913: $3,700. Favors sciences. Lack: elementary sciences. Practice: " satisfactory, except for the lack of freedom to control one's own time, and the unreasonableness of many patients in sending hurry calls when there is no real need for hurry." H. M. S. '09. No hospital training except active connection with a small private hospital. General practice in Blue Earth, Minn. Income, 1913: $3,500. Favors arts. Lack: " more personal responsibility in the care of dis- pensary patients." Practice: satisfactory. " The fact that Practice a man never has a moment he can call his own, confining ^^i he cannot leave business for any purpose without having that business stop while he is away naturally influences a man to tie himself down closely. This hinders him from Medicine............ 28 General practice only............................... 36 General practice with a specialty..................... 134 Specialty only (including laboratory).................. 142 Men not in practice................................. 4 Men in " hospital work only " (administrative)........ 1 Surgery, general........... 70 Genito-urinary............ 1 Gynecology............... 9 Orthopedic surgery........ 9 Anesthesia................ 1 Teaching.......................................... 36 Internal medicine.......... 21 Stomach and intestines..... 1 Lungs.................... 4 Heart.................... 1 Chest.................... lj Obstetrics......................................... 23 Laboratory work.......... 17 Pathology and bacteriology . 6 Ear, nose and throat....... 7 Eye...................... ■Ear...................... 3 Nose and throat........... 1 Pediatrics......................................... 14 Public Health...................................... 13 Special Work..................................... 11 Insurance......................................... 8 Nervous and mental diseases......................... 7 X-Ray............................................ 4 Skin diseases....................................... 2 Hospital management............................... 2 Syphilis......................................... 1 > Laboratories......... 23 Eye, ear, nose, and throatl9 At the present time when men in all branches of business are specializing it is interesting to note the difference in the comments of medical men upon this subject. Physicians have entered special fields, prob- ably more than men of any other profession, because they have found that in knowing one line of medicine or SPECIALISM 39 surgery thoroughly they have been able to accomplish more both for themselves and their patients than by trying to cover a field much too large to be mastered by one man. Many sides of the question are attacked in the comments that follow: H. M. S. '08. 4 years in hospital. General practice in large city in Rhode Island. Income, 1913: $2,500. Favors a combination of arts and sciences. Lack: therapeutics. Practice: satisfactory " to a cer- tain extent." " I should like to make the statement that a man should never go into the practice of medicine with the idea of mak- ing money. He will make the better physician who has plenty of money to start with and who does not depend upon his practice for his entire income, particularly if he contem- plates going into a specialty." H. M. S. '04. Out-patient work all the time. Special practice in ear, nose, and throat in Boston. Income, 1913: $4,200. Favors arts. Lack: " the opportunity to do the hospital work I desired to do. Hospital appointments should not only be required, they should also be supplied. My practice has been satis- factory, except that my services have to be measured in money. " I spent four years in practice and then went abroad for a year. Since my return I have been in special practice. "As to the question of location I will say that all large cities are alike, there being enough general practitioners and state specialists in each community, in fact, more than supervision are necessary. A large number of these are poorly trained and are serving a large part of the community. Friendships, business methods, practicability, and personality are probably the real cause of this condition rather than faulty training in medical schools. The time is coming when physicians will be part of the State organization, chosen for fitness, endowed with a fitting salary, and given only a 40 THE PROFESSION OF MEDICINE certain part of the community to care for, and encouraged to do something for the progress of medicine. " As it is today, the school leaves the beginner unfinished. His practical training is incomplete. He is advised to take a hospital appointment, but because the other students have a so-called ' pull' in the hospitals that are worth while, he may not get an appointment. Unless he has more than the usual ambition he will not succeed in learning more after he leaves school, for he will be forced to compete in some com- munity with inferior men. That does not encourage him to keep up-to-date. " Pre-medical education cannot be too broad. The tend- ency is to specialize too closely. The young physician acquires a sufficient amount of chemistry and general science in a general medical education for his purpose, and unless he desires to follow up the non-clinical side of medicine, his time is better spent in a broad, general pre-medical education in history, philosophy, art, literature, etc. Chemistry and sciences can be acquired later if more are needed. General culture is better obtained first so that the student may enter the study of medicine broad enough to realize its responsi- bilities apart from its money-value returns. " The practice of medicine with all its shortcomings can- not help but be satisfactory to the one who enters it with a broad outlook on life. It is unsatisfactory to the man who discovers that it is easier to make more money sooner any other way than in medicine. For me the pleasure of doing in life the work that I prefer above all others is sufficient." H. M. S. '02. 16 months in hospital. General practice in a city of 100,000 in Massachusetts. Some life-insurance work. Income, 1913: $2,500. Favors sciences. Lack: " nothing but more effort on my own part." Practice: fairly satisfactory. " My advice is, make a decision in the first year of medical school as to some special line of work." SPECIALISM 41 H. M. S. '10. 2\ years in hospital. General practice, surgery, gyne- cology, and obstetrics in Providence, R. I. Income, for 5 months of 1913: $576. Favors arts. Lack: " teaching in pharmacology and 4th- year anatomy in respect to surgical anatomy " (changes since '10). Practice: satisfactory " except that in Providence most of the surgeons do medical work. The so-called gynecologists t^«, ,., do medical work, and the medical men do obstet- Difficulties . ' rics and minor surgery. Everybody is afraid he will miss something. Hence it is hard for a younger man to limit himself to the work he has trained himself for, without starving." H. M. S. '08. 3 years in hospital. Income, 1913: $3,200. Favors sciences. Obstetrics in city in Ohio. Practice: satisfactory. " The greatest need of the community seems to be for men who will do general work along the line of internal medicine. The city is overcrowded with self-styled specialists." H. M. S.'05. 1 year in hospital. General practice in Boston. Income, 1913: $1,800. Favors arts. Lack: " rudiments of practical physiology " (many changes since '05). Practice: satisfactory. " Beware of immature specialism. For years to come the family physician will be needed. Treatment of a pathological state must fall short unless it takes into account the patient as a whole and his surroundings and family. The ' family doctor ' can be and should be the best friend to the family." H. M. S. '09. 2 years hospital. General practice in a city of 100,000 in Massachusetts. Income, 1913: $3,400. Favors arts. Lack: pharma- cology and therapeutics. Practice: fairly satisfactory. " I do not make enough money for the amount of work done. In my district fees are too small — $1.00 for office calls and $1.50 for house calls; $15.00 for a confinement. I find I cannot do surgery as a general practitioner in this place, partly because the people have not got the money. If I had it to do over again, I would specialize and open an office in the Back Bay and take a chance on waiting 42 THE PROFESSION OF MEDICINE for practice. Here I did not have to wait, but I find now that my maximum is nearly reached." H. M. S. '09. 45 months in hospital. General practice in small town in Massachusetts. Income, 1913: $1,000. Favors sciences. Lack: " training in psychiatry " (great changes since '09). " Also more definite training in therapeutics, although this lack was made up in the hospital training. My practice is Compulsion satisfactory, although the study of medicine has vs. freedom Deen so expensive to me, and it is so difficult for one without means to get started, that I doubt if I would attempt it again. " I am not in favor of holding before students the doctrine of specialism. The great majority of men in each class should not and cannot plan to become specialists, and each man should be made to learn as much as possible of each line as instruction is given in it in the medical school. " There seems to be a certain number of men in each class who do not know what is best for themselves. There should be some way of holding such men strictly to account for their attendance at all practical exercises for their own good as well as for the good of the school." H. M. S. '07. 1 year hospital. Nervous diseases in Boston. Income, 1913: $500. Favors arts. Lack: "nothing but time to think." Prac- tice : partly satisfactory. " I have no way of reaching people whom I can cure. My relation to medicine is a somewhat peculiar one. I entered Lure of Truth it; Primarily for the opportunity to do research work; secondarily, for medical practice. I think I have reaped as I have sown. That is, I have obtained that which I wanted. To the money-seeking man I am an abso- lute failure. I could have earned more had I played for it. But I do not want much money. " On the other hand, the research work I set out to do has cost me $2,000 a year for twenty years in training for it, and SPECIALISM 43 I do not regret it. The best of opportunities have been opened and I have spent most of my time in this field. I do not regret any of the time or money in fitting for this work, for I can often bring to a problem many sidelights. Thus I find new truths. I shall be satisfied with the outlay of my life in medicine if finally I may be able to add new truths to the science, and show that new fields are open to a wider program of investigation." H. M. S. '04. 1 year hospital. General practice in city in Washington. Income, 1913: $8,400. Favors sciences. Lack: required hospital year. Practice: unsatisfactory. " A few years in general practice is good, but later one should specialize. With contracts, lodges, etc., it is very difficult to $8,400 make anything for a rainy day. Although I made unsatisfactory ^4QQ ^ year j j^ t() gpend mogt Qf [t Qn hQme and the outfit which enabled me to earn the $8,400." H. M. S. '06. No hospital. Laboratory and teaching in city in New York. Salary, 1913: $2,500. Favors sciences. Lack: third-year electives. " The laboratory branches, including physiology, are in need of men here. Practice here as elsewhere is overcrowded. I feel that our school should strive constantly to impress the need that exists throughout the country for trained workers and teachers in medical sciences. This need should be im- pressed particularly upon such men as can afford to enter an underpaid, but exceptionally useful field, the chief satis- faction in which is not counted in dollars and cents." H. M. S. '07. 2 years hospital. Orthopedic surgery in Boston. Income, 1913: $3,500. Favors arts. Lack: "did not take enough general medicine." Practice: satisfactory. " A man who intends to take up a specialty should have a thorough ground work in general practice. For a surgical specialty a surgical and medical hospital course would be advisable, in fact should be compulsory." 44 THE PROFESSION OF MEDICINE H. M. S. '04. 3 years hospital. Dermatology in Boston. Income, 1913: $2,200. Favors sciences. Lack: " too little clinical work in all the course where it comes in." Practice: fairly satisfactory. " I should not advise any man to specialize in dermatology. The specialty is too apt to be looked down upon and mis- understood by those who should know better." H. M. S. '08. In special hospitals ever since graduation. 18 months in pathology. Psychiatry in Philadelphia. Income, 1913: $4,000. Favors arts. Practice: satisfactory. " There is a large field, with ample opportunity for research a need and moderate pay, in psychiatrical work." H. M. S. '05. Ear, nose, and throat in a city of 100,000. Income, 1913: $6,500. 2 years hospital. Favors sciences. Lack: " special course in a specialty." Practice: satisfactory. " My field of specialty is overcrowded in this city, there No need being nearly twenty too many for a place of this size. Some physicians are barely making a living." H. M. S. '08. 4| years hospital. Surgery in Boston. Income, 1913: $2,500. Favors arts. Lack: specialization. Practice: satisfactory. " Every man should take up one branch of the profession early and do nothing else. Be perfect in one branch and success is certain anywhere." H. M. S. '04. 1 year hospital. General practice and some surgery in a town of 6,000 in Massachusetts. Income, 1913: $4,800. Favors arts. Practice: satisfactory. " In my opinion it is an advantage for a man to make up his mind while in school to follow some specialty, and get his training with that in mind." Location The old adage, " Pick a place you like to live in and stick there " works well if the' place needs you and you fit in it. On the other hand, such a rule tends to in- LOCATION 45 fluence men to neglect the question of " need in the community," and it also influences the majority of men to start in large cities. With the conviction that no longer can a real success be made in general practice in Boston as one reason, this Appointments Bureau was started to discover, if possi- ble, and to point out to individuals the real needs of the community for young medical graduates. It also tries to help each man in deciding where he fits. Question 7 which asked the need of doctors in each community was answered as follows: General practitioner needed ?........Answered Specialists needed ?. " no " 221 " yes " 43 " no " 185 " yes " 59 " yes " 19 " yes " 21 " yes " 72 Surgeons needed ?.................. Eye, ear, nose, and throat men needed ? Public Health Officers needed ?....... A few of the comments on city practice are: H. M. S. '05. 2 years hospital. General practice in city in Rhode Island. Income, 1913: $2,100. Favors "a judicious mixture of arts and sciences for general practice." Lack: " practical treatment, pre- scription writing, and knowledge of drugs" (many changes since '05). Practice: satisfactory. " The advice given to me on starting was to find a place I wanted to live in and to go there and stick, and success Along would eventually come. It took practically six "stick» years to get on my feet, and only an unusually favorable opportunity was the cause of my leaving my first location." H. M. S. '04. 2 years hospital. General practice in a town of 5,000 in Massachusetts. Income 1913: $6,002. Favors arts and sciences. Practice: satisfactory, "except for getting up nights and living on the end of a telephone wire." Lack: " a medical 46 THE PROFESSION OF MEDICINE student needs a lot of hospital work, actual practice. He should have surgical training, for those who have it take everything. They feel competent to treat cardiac or other serious medical diseases, but they do not want a medical man to touch diseases for surgery. Hence, if not grounded in surgery, one's income is cut down. " One should locate where there is a good hospital, prefer- ably a private one, or he will often wish that one were near Hospital a by. Get a good hospital training and you can good neighbor \0CSiie an(j £o well in almost any community, but if you locate in a town of 25,000 or more your ultimate income will probably be greater than it would be in a small town. I think that students need more guidance than they get as to where to locate, so that they will not do it blindly and afterward be sorry that they did not settle elsewhere. The older men seem to be afraid to give advice on this point, and the young " doc " does not know just where to go. For instance, had I appreciated the advantage of having a good hospital in the community I should never have located in a town without one, nor in a town quite so small. I am close to my limit now, while some of my friends in larger places are going to pass way beyond my limit in business because they have a larger field to draw from, and, having had good training, are bound to be very successful in a very few years." H. M. S. '08. 27 months hospital. Ophthalmology and Otology in New York City. Income, 1913: $1,700. Favors both arts and sciences. Lack: "Absolutely no instruction in refraction, which is medical as well as optical work and should be taught in the medical schools " (now required). " If one is well trained in special work one can make a fairly good income in a small city, but the hospital opportunities The gist of it are not so great" If located in a large city, the income is slow in proportion to the expenses, but the goal is greater and the opportunities are inexhaustible. LOCATION 47 For instance, in New York City my rent alone is $115 a month, and I give one-half of my time to clinical work. But the advantages are in associating with older men as an assis- tant, which lessens the expense of an office and supplies more or less material for practice. But, on the other hand, there is greater individual and professional progress in building up one's own practice and being the head of one's own office. " It is a good plan to join and attend the meetings of all the medical societies possible in order to become acquainted with the men there and to be known by them. But the greater part of work does not come to the young practitioner from other medical men, so much as from friends and satis- fied patients. If you intend to follow a specialty, take it up and drop all else, let other medical men know what line you have chosen, even if a few dollars in some other field have to be refused by so doing. In this way the confidence of other physicians as to honest relations intended by you is estab- lished. There are also, in the long run, bigger fees to be gained in sticking to a specialty. " Infinite patience is required to build up a practice, to give and to demand honest work, and to keep going, by Pride vs. being willing and having the nerve to borrow, modesty until your income exceeds your expenses. Not intending to boast for the school or for myself, wherever I have gone the men from Harvard Medical School are either on top or on the way to the top." Some of the men who have located in Boston have summed up their experiences: H. M. S. '10. 1 year in hospital. Surgery in Boston. Income, 1913: $3,600. Favors arts. Lack: " I think no special thing was lacking. I thought the training very good." Practice: satisfactory, " except for the long time in getting started. Nearly three-quarters of my income has come 48 THE PROFESSION OF MEDICINE from assisting older men. I could not begin to support myself on my own practice. I don't see how a man can starting in start in practice in a place like Boston, or in any aclty large city, unless he has either money or older friends in the profession, although he could, of course, if he had a salaried position of some sort." H. M. S. '08. 6 years in hospital. Orthopedic surgery in Boston. In- come, 1913: $500. Favors arts. Lack: anatomy. Practice: satisfactory. " Too many men in my city in medicine who have inde- pendent incomes, so do charity work, which, properly, should be paid for and not done free in clinics." H. M. S. '05. Massachusetts General Hospital (medical). Internal medicine in Boston. Income, 1913: $1,148. Favors arts. Lack: chem- istry. Practice: not entirely satisfactory. " I am not yet self-supporting. I think that two factors have Not self- tended to keep down my practice; one, I do not eight years need the money to live; two, I am not married. I think well-trained men who are willing to stick to general medical practice are needed here." H. M. S. '07. 3 years in hospital. General practice in Boston. Income, 1913: $2,500. Favors sciences. Lack: " not instructed sufficiently in treatment." Practice: satisfactory. " Much of my success has been due to luck and influential success, friends. I think that most of my friends who $2500- have remained in Boston have had a harder time of it than I have had." There seems to be a more general feeling of satisfac- tion among those men who have located in rural dis- tricts. The advantages and disadvantages are con- tained in some of these comments. H. M. S. '03. General practice in a town of 1,000 in Massachusetts. Income, 1913: $3,000. Favors arts. LOCATION 49 Lack: " general culture. I specialized in college in courses in science. I wish I hadn't. My practice has been unsat- isfactory because of its uncertainty; a day's work is never done; and its poor remuneration in money. My territory comprises four or five towns with a total population of some five or six thousand who are served by five or six doctors. I live in one town and maintain an office in another town, keeping daily office hours two miles away. " Country practice is not monotonous, there is plenty of variety in it, and the advent of the automobile has taken some of the drudgery out of it. You will notice that my collections jumped from $1,800 in 1910 to $2,700 in 1911. There are two reasons for this. One was the death of a man who had practiced here for thirty years, and the other reason was the raising of my fee table one-third. " I would advise no student to study medicine unless he felt he had a very deep love for the work. The fact that not a minute of time is actually your own, that you cannot make the simplest plan with any certainty of carrying out the same is a very disagreeable aspect of the profession. "The advantages are these: usually there is a fair living to be gained in the country districts (though this is not so common as it once was), and the assured social position in Conditions and the respect of the community. The general changing practitioner today in the country is getting to be a sorter or sifter for the specialists. Specialists are becoming more common. Means of transportation are becoming more convenient, hence there is easier access to the specialists. Moreover people are not sick as they used to be as they have learned some of the fundamental rules of prophylaxis (venti- lation, quarantine, diet, etc.), and thanks to many of the popular magazine articles are learning that nature is the great physician and that most diseases tend to cure them- selves." 50 THE PROFESSION OF MEDICINE H. M. S. '09. 2 years in hospital. General practice in town in Vermont. Income, 1913: $1,800. Favors: " It seems to me that if a man has funds arts add to his attitude toward life in a way that science does not." Lack: "I do not think that I can blame my school, college, or professional training for any deficiencies I may show. The assignment and collection of fees will always be unsatisfactory. The problem of work in the country is made difficult by the need of assigning some fee. After observing the work in out-patient departments, and the class of people who have access to them, it makes me feel that something ought to be done for our country people along the same lines, but the working out of such a scheme is going to take wise heads." H. M. S. '02. 1 year in hospital. General practice in town in Massa- chusetts. Income, 1913: $2,000. Favors arts. a town "Practice satisfactory except that my field is too small to keep me busy." H. M. S. '08. 2 years in hospital. General practice, including obstet- rics, in a city of 15,000 in Massachusetts. Income, 1913: $1,200. Favors arts. " Practice has been satisfactory to me in every way, except the financial. This work, it seems to me, is underpaid consid- ering the preliminary training and the labor. I Small cities . ° ^ J. te picked out a small city forty miles from Boston partly for family reasons, but chiefly because the place appealed to me more than a large city. I believe there is more work for the young graduate in such a place, but there is less pay in proportion than in a large city. The expenses are not so great, so matters are equalized somewhat. There is decidedly more danger of getting into a rut and stagnating in such a city, but should this happen it is one's own fault." H. M. S. '04. 2| years hospital. General practice in a town of 7,000 in Massachusetts^ Income, 1913: $3,862. Favors arts. Lack: modern languages. Practice: satisfactory. LOCATION 51 " The men of average ability, and many of the men of marked ability, will find a greater field of usefulness outside rather than inside the large cities. The pleasures of living and working in suburban or rural communities are greater than those of the cities." H. M. S. '01. 2\ years hospital. Orthopedic surgery in St. Louis, Mo. Income, 1913: $6,300. Favors arts. Practice: satisfactory. " In all cities and large towns in the Middle West there is need of men with the training given at the Harvard Medical „„ ,„ „, School and its associated hospitals. Much good Middle West . . . is done the School by these representatives, and they are most welcome in any good medical community." H. M. S. '01. 4 years hospital. General practice and insurance in Lynn. Income, 1913: $7,000. Favors arts. Practice: satisfactory. " I think any earnest doctor can find a place to make a good living, especially in the West. There is also plenty of opportu- nity for Public Health Officers and executives in institutions." A few men have accurately described the places they have chosen for their field. The descriptions of con- ditions, whether favorable or otherwise, undoubtedly give the prospective physician a fair idea of certain specified places. H. M. S. '06. 3 years hospital. General practice in Hartford, Conn. Income, 1913: $4,000. Favors arts. Lack: "a more practical and specific course in therapeutics." Practice: very satisfactory. "Hartford is a very desirable location. The feeling among the medical men is fine, collections are good, and the city has a large hospital and a growing population. I should say that the average Harvard Medical School man would do about $700 to $800 the first year, and increase $300 or $400 each year. The city is conservative and progress is slow, perhaps, but sure." 52 THE PROFESSION OF MEDICINE H. M. S. '10. Massachusetts General Hospital (medical), and Children's Hospital of Boston (medical). Internal medicine in St. Paul, Minn. Income, 1913: $800. Favors sciences. " With the exception of the financial side my practice has been very satisfactory. The situation in St. Paul is peculiar. Three There is very little referred work — for instance, medium-sized cities only three or four men confine themselves to sur- gery, two to children's diseases, and three to internal medicine. A large number of men do eye, ear, nose, and throat, and apparently do well. The men doing nerve work, with one or two exceptions, have large practices without enjoying much confidence among the other doctors. The average man here does everything from skin diseases to major surgery. The fact that all hospitals are open to any doctor to do surgery helps this condition. " The only free hospital is the City and County Hospital with a large staff of men of very varied ability, so the prestige of staff positions as found in Boston is decidedly lacking. The clinical opportunities are not of the best, as the city services are short, being limited to three months, and the house and nursing staff small. There is practically no out- patient work done. " The work at the University provides splendid equipment for experimental work, but the school is eight miles from the center of the town. All offices are down town, chiefly in a single building, and this, with the fact that there are two telephone companies, makes a considerable difference in the expense of maintaining an office. Usually the up-keep of such an office costs $40 a month. The logical result, of course, is that practice is widely scattered over the city, necessitating great waste of time or an automobile early in the game. " Practically speaking, there is nothing to the idea that St. Paul and Minneapolis are, or will be, essentially one city. Except that the doctors meet at the University, they have LOCATION 53 little or nothing to do with each other. Fee splitting is common among men with extremely good practices, but it is not at all universal." H. M. S. '05. About 2| years in the hospital. Internal medicine in Cleveland, Ohio. Salary, $5,000. Favors both arts and sciences in equal degree. Lack: neurology and physical diagnosis. Practice: satis- factory. " The drop in income from $700 to $300 noted between 1908 and 1909 was because I left Boston and took a resident appointment at the Lakeside Hospital in Cleveland. My salary of $300 was the earning of 1909. Young men and good men are needed here, but there are many physicians, and it is not an El Dorado. It is, however, an excellent place for young men to settle." H. M. S. '06. 3 years in hospital. General practice in Northampton, Mass. Income, $2,300. Favors sciences. Practice: satisfactory. " In Northampton there is an opportunity for a good surgeon; a small but one going there must stand on his own feet city and not get mixed in the medico-political intrigues that exist in many of the smaller cities." H. M. S. '04. 3 months hospital and If years abroad in Vienna and Berlin. Internal medicine in Chicago, 111. Income, 1913: $100. Favors: "some of both arts and sciences. For general practice I prefer general culture. I lacked definite bedside training such as is given at Johns Hopkins." " My practice is satisfactory as I practice it. It is hardly fair to take my earnings as a criterion as I started by limiting myself to internal medicine, spending most of my time in dispensaries and hospitals and not trying for a remunerative practice. Of course I am not sure that I could have made a living in practice. I find dispensary work much more con- genial than practice, and I have stuck to that. There is plenty of chance for a Harvard man to get the work that he wants here. I think that the man who graduates from the reputable local medical school stands much more chance of 54 THE PROFESSION OF MEDICINE rapid advancement. I also think that there is plenty of room in Chicago for good, or even fair, laboratory men and pathologists." H. M. S. '07. 2 years in hospital. General practice and surgery in Wabash, Minn. Income, 1913: $6,500. Favors arts. " I am pretty well satisfied with what Harvard did for me. My practice is satis- factory." " This community is typical of many such communities in the Middle West and Far West. We have a forty-bed hospital surgery in the and do surgery for a surrounding territory extend- MiddieWest ^ twenty-five to forty miles. We are only forty-four miles from Rochester, and yet are not interfered with at all by that wonderful clinic as far as cases going that way are concerned. Our surgery is almost entirely abdominal with such emergency as railroad work brings in. I do anything from an appendix to a Caesarean. The Middle West is dotted with small hospitals run by the sisters. This fact alone has made surgery possible in these small com- munities. " My general practice covers long ranges of territory in a prosperous farming community with calls at the rate of a dollar a mile, which are made very easy by automobile. My best recommendation to the young practitioner is to pull away from the city and do some real work in the country. Over three-quarters of my work is confined to the hospital." H. M. S. '08. 30 months in hospital. Pediatrics in Portland, Ore. Favors arts and sciences. Practice: satisfactory. " Best city in the United States to live in. The medical field Too healthy is overcrowded here as in other localities. It is a bad place for pediatrics, as babies never get sick in summer. There is no summer enteritis to amount to any- thing." H. M. S. '10. No hospital training. General practice and laboratory work in Colorado Springs. Income, 1913: $2,300. Favors sciences. LOCATION 55 Lack: therapeutics. Diagnosis had too much emphasis. Practice: satisfactory. " This being a health resort has too many men. This is largely due to the fact that men come here with tuberculosis, Health resort get better, and then practice here themselves. My lack of hospital work was not from choice, but from necessity." H. M. S. '09. 16 months in hospital. General practice and surgery in a city of 400,000 in New York. Income, 1913: $354. Favors sciences. Lack: " How to charge and keep books. My practice has not been satisfactory financially. " There is a good chance in this state for men who have had three years of practical public health work. The Civil Service offers a salary of $4,000 for men experienced in public health work with the understanding that any one undertaking such a position shall not engage in the practice of medicine, but give all his time to public health service. " There is a medical school in this city, and most of the men located here are its graduates so an outsider is not helped and has a hard time getting hospital work. As an example of the method of doing things, there is no good dispensary or out-patient department in this city. " This is a good place for a gynecologist, or a nose and throat man. It is also good for an obstetrician after he has been here about ten years, provided he is a good mixer. " There is a tendency here toward contract practice, in so far as large manufacturing concerns employ doctors to care for employees." The general tendency in the past has been to look to the West for opportunity and prosperity in all branches. Three Harvard Medical School men, who have settled in the West, warn the young physician who is about to start practice that the West is overcrowded. Their comments are suggestive: — 56 THE PROFESSION OF MEDICINE H. M. S. '05. 3 months in hospital. In school for Health Officers in California. Favors sciences, but sociology is important for physicians. Lack: practical training in therapeutics and surgery and hospital service. " My practice has not been satisfactory because the supply of doctors is not adjusted at all to the demand. Patients California pay badly. California is overstocked with doctors overcrowded and fml of oste0paths, Christian Scientists, and other ' quacks.' There are only 250 to 300 persons to each doctor in Southern California. I advise every eastern man to stay away. The State Board examinations are also very hard and are often unfairly given, eastern men being dis- criminated against." H. M. S. '06. 1 year in hospital. General practice in Mosier, Ore. Income, 1913: $1,397.50. Favors arts. Lack: Pharmacology. Prac- tice: satisfactory. " I settled in the western edge of the Cascade mountains in a pioneer country where there are no brilliant prospects for a career, but great necessity for my services among the mountains. There is ' vistu, vestitu, domque frui,' the grand scenery, the wild free life on horseback, health, vigor super- abundant, and the feeling that I am really needed." H. M. S. '05. 2 years in hospital. General practice in Portland, Ore. Income, 1913: $9,460. Favors arts and sciences, as much as can be obtained from both. Lack: general therapeutics and the use of appli- ances outside of materia medica. Practice: satisfactory. " Portland is, of course, filled with good, bad, and indifferent doctors, as are all western cities. There are a good many live towns in the State which need men with Harvard training." The question of location is so vital to the young man about to go into practice that it is important to hear what men have to say about it from their own exper- iences and upon all sides. A few general comments follow: LOCATION 57 H. M. S. '05. 3 years in hospital. Eye, ear, nose, and throat in a city of 12,000 in Maine. Income, 1913: $6,700 (2 months vacation). Favors sciences. " The medical school gave me a satisfactory training. I have no criticism to make." " My practice has been satisfactory, although I should take Overcrowding up some work, had I the opportunity to choose in the East again, that would fit the worker for his career five or six years earlier. " The figures given above are not a fair indication of the conditions here. Of the six physicians who have started during the time I have been here, three general practitioners are getting but an inadequate return, and three specialists have left town. As two of them are doing well elsewhere^ the location must have been at fault rather than the training." H. M. S. '07. 2 months at Massachusetts General Hospital. General practice in a town of 13,000 in Massachusetts. Income, 1913: $1,350. Favors arts. Lack: nothing. Practice: satisfactory. " One man has all the Catholic work. Two other men and one woman have two-thirds of the rest. Four or five more men are making a living; two or three are not. One man was starved out about six months ago." H. M. S. '07. 3 years in hospital. General practice in a town of 5,000 in Massachusetts. Income, 1913: $5,025. Favors arts. Lack: "a more thorough training in practical anatomy, ear, nose, throat, and skin. Practice: fairly satisfactory, but there are too many doctors." " Financial success is possible to only the few men of excep- tional ability (except the ' quacks ') who are slaves to their profession and who pay a personal price for it. The ideal medical life at the present time would be with an income sufficient to succeed independent of any money earned by practicing." H. M. S. '10. 27 months in hospital. General practice in city in Rhode Island. Income, 1913: $1,000. Favors arts. Lack: "methodical habits on my own part." "lam dissatisfied with the small extent of my private prac- tice. In this part of the country openings are scarce. If a 58 THE PROFESSION OF MEDICINE place has but few doctors it is because the place does not need doctors. So find the place you want to live. There will be competition, and you will be placed according to what you can deliver. Methodical habits and industry always make good. Marked ability will help them out." H. M. S. '01. Hospital 2 years and 8 months. Internal medicine in Boston and some teaching. Income, 1913: $2,666. Favors arts " which are a very valuable asset, and sciences which are essential." Lack: " I did not have sufficient acquaintance with my teachers. I made up for this in hospital work. Practice: very satisfactory." " The choice of location is a great factor in the question of happiness in the profession. To locate in a large city means Country seen strong competition, delayed marriage, lack of from city recognition for honest, competent work. To locate in a small town means hard work, long hours, happy home life, and an affectionate hold upon patients which can never be known by the city practitioner." H. M. S. '06. 27 months in hospital. Surgery in Springfield, Mass. Income, 1913: $3,000. Favors sciences. "It is very discouraging in getting the start in this pro- fession. There is a chance here for a man who will do obstet- rics exclusively. Other branches are well covered." H. M. S. '09. 22 months in hospital. Obstetrics and gynecology in Fall River, Mass. Income, 1913: $2,200. Favors sciences. Practice: satisfactory. " There is a big demand for an internist who will do that and nothing else, there is also a big amount of obstetrical work for which the fees are small." H. M. S. '08. 3§ years in hospital. General practice in a town of 8,000 in Oregon. Income, 1913: $1,200. " The more a man knows the better is he equipped. I think a reliable bureau of information for the man about to start in practice concerning the parts of the country where doctors are really needed may save a change in location, or may help him financially at the beginning. THE QUESTION OF MONEY 59 " Many places are overstocked with doctors. This is es- pecially true of the West. There are other places too healthy to need many. Often a town will have a dangerous boom after which the doctors who have flocked there are abandoned. These facts lead to the conclusion that a bureau of informa- tion from which could be obtained valuable data as to partner- ship, private work, country, city, and town practice, civic health positions, etc., would be of enormous help to the young man about to start practice. This, I judge, is what is about to be done. All success to this much-needed work." The Question of Money Many physicians consider the practice of medicine unsatisfactory from the standpoint of money-making. The expense of training, i. e., the amount of time and the living expenses far overbalance the actual amount received from patients in the early years of practice. Some men rather cynically express themselves to the effect that the only satisfactory way of entering upon this career is to regard it as a philanthropy. The few men who appear to have entered it solely to gain the reward of gold regret their choice of the career. The general opinion is that the consciousness of satisfaction comes not from the earnings in money, but from the amount of good accomplished in the world for which the medical profession gives the opportunity. A table of the average earnings is shown on the next page: 60 THE PROFESSION OF MEDICINE Average Earnings Classes Practice 1901 1902 1903 1904 1905 1906 1907 1908 1909 1910 1st ... . $866 $787 $541 $362 $625 $502 $350 $533 $425 $1237 2d .... 827 1089 790 995 773 826 588 1250 874 1083 3d .... 1181 1539 1412 1295 995 1262 1353 1025 1370 1578 4th.... 1505 1694 1720 1566 1559 1765 1963 1575 1632 1835 5th.... 2027 1556 1966 1981 1818 2359 2347 1847 2150 6th.... 2341 1837 2333 2277 2347 2997 3202 2360 7th.... 2527 2161 2654 2967 3043 3650 3545 8th.... 3003 2491 3155 3042 3337 4332 9th.... 3560 2900 3616 3604 4500 10th.... 3524 2963 4135 4535 11th.... 3885 3691 4604 12th.... 4422 4130 13th.... 4680 Max. no. of men.. 38 39 29 39 33 26 29 29 25 26 A few of the comments on this subject read as fol- lows: H. M. S. '06. 2 years hospital. General practice and surgery in Dor- chester, Mass. Income, 1913: $2,200. Favors arts. Lack: training in public health work and in medico-legal work (both now offered). Practice: " very well as a voca- saiaded t*on, kut not yet satisfactory financially. The assistantships lack of small salaried jobs to enable one to live while getting a start is really the great difficulty. It is almost necessary to have capital or a wealthy wife to get a start anywhere within twenty-five miles of Boston. If there could be a system of paid dispensary or contract work similar to the Jewish Lodge system, or the small salaried assistant's work as in Great Britain, it would be a tremendous help to THE QUESTION OF MONEY 61 the future graduates who have to earn their livings from the start. At present, and for some years past, the school has a comparatively great proportion of men who are entering medicine as an occupation, and not as a means of livelihood. This has made it very hard for those of us who have had to borrow to get through and get started. " I am a firm believer in the ten years of preparation. There should be from three to four years spent in college, from four to five in medical school, and at least two years in hospital work. But I think it ought to be possible for a considerable number of each graduating class to be placed at living wages from the beginning. " I have not a word of fault to find with the Medical School training. I feel better equipped than most of the men I have met. from other schools, not excepting Baltimore for a minute. But I wish I had had some notion of the various Board of Health requirements, and a little bit of advice to keep me from being made a fool of by the gentlemen of the legal profession. " The present customs in Boston make regular hospital work, which is the only way to keep up with the leaders in medicine, the amusement of the idle rich or the expensive luxury of the fairly busy practitioner. A system of district men and out-patient assistants at, say $1,000 a year instead of $200, would make better men and would also give pretty good service." H. M. S.'07. 2\ years hospital. Obstetrics in Boston. Income, 1913: $3,461.20. Favors arts. Lack: "No course in physiology, or rather, worse than none " (many changes since '07). " Practice absolutely satisfactory, but, on second thoughts, there is one drawback, and that is having to charge people who really cannot afford to pay, but who insist upon it." H. M. S. '05. 2 years hospital. Pediatrics in Boston. Income, 1913: $7,000. Favors sciences, " some of both with predominance of sciences." 62 THE PROFESSION OF MEDICINE Lack: German, French, and Italian. " Wanted more chemistry and a working knowledge of Russian." Practice: satisfactory. " Question No. 5 is rather hard to answer: it cost $4,000 to take in $7,000. This amount represents eight months' work, the other four months being taken out for sickness." H. M. S. '02. About 4 years hospital. General practice and surgery in city in Connecticut. Income, 1913: $2,700. Favors sciences. Practice: "unsatisfactory because of the fact that the full amount of time and money wasted in acquiring a medical education does not bring a return great enough to compare with the same investment in any other line of activity." H. M. S. '02. No hospital training. General practice in New York City. Income, 1913: $3,590. Favors sciences. Lack: " practical training in handling patients as a source of income." " My practice has been unsatisfactory for three reasons: low remuneration, too great a tendency to specialize, and too much charity work. I advise future physicians to, first, develop the business side of the profession; second, let each patient understand that medical work must be paid for; third, do as little charity work as possible; fourth, be more practical and less altruistic." H. M. S. '06. 18 months hospital. Lung diseases and insurance in city in Connecticut. Income, 1913: $2,304. Favors arts. Lack: teaching in applied therapeutics. Practice: satisfactory. " The services of a physician are on the whole poorly paid in comparison with other professions. Young men entering this profession in a city should have some independent in- come to help them over the first few years." H. M. S. '05. No hospital. General practice in town in Massachu- setts. Income, 1913: $500. Favors sciences. Lack: business training. Practice: unsatisfactory. " There is not enough real honest work for all of us to make a decent living. The dollar is still the measure of a man's Minus the success. With the majority it seems to be just a game of grab. It is a philanthropy for those who are independent." THE QUESTION OF MONEY 63 H. M. S. '02. 14 months as interne, 8 months out-patient department. General practice in Boston. Favors arts and sciences. 1913: not in practice. Lack: business training and personal advice. Practice: unsatisfactory. " You have to have a pull to succeed in medicine, lacking that you have to have capital and be willing to lose or win." H. M. S. '04. 6 months hospital. General practice in Lynn, Mass. Income, 1913: $3,000. Favors arts. Lack: operative surgery and materia medica. Practice: satisfactory. " Physicians should receive a salary from the government." H. M. S. '07. 3 years hospital. General surgery in small city in Minne- sota. Income, 1913: $4,500. Favors arts and sciences. Lack: physi- ology and chemistry. Practice: " satisfactory in most respects." " Most beginners are deficient in the art of practicing medi- cine. I venture to say that a large number of men practicing in the profession today, and indeed for many generations back, would or might have lent their voices to the very un- satisfactory relationship which frequently exists between the financial and professional aspects of their calling." H. M. S. '05. 2 years at a general hospital. General practice in Brock- ton, Mass. Income, 1913: $7,764. Favors arts. Lack: application to pre-medical preparation. " My practice has been satisfactory except for the lack of time for study, either at home or away in post- graduate work. I also lack the money for study as I have a large family to support." H. M. S. '06. 3| years in hospital. General practice in Providence, R.I. Income, 1913: $3,600. Favors sciences. Lack: " attention to psychology and psychotherapy." Practice: satisfactory. " Almost any man with a Harvard training and a hospital interneship will succeed, but if starting out in a large city he needs the help of a hospital appointment and friends, or else he needs to be so fixed financially that he can afford to wait from three to six years before making a really com- fortable living." 64 THE PROFESSION OF MEDICINE H. M. S. '05. 2 years hospital. General practice in Vancouver, B. C. Income, 1913: $6,000. Favors sciences. Lack: nothing. Practice: satisfactory. " Nothing doing. Times are harder than hell and collections are rotten." The following table shows the amount of paid work done from the year 1901-1910. Percentage of Paid Work Done Paid in Full (1st Class Private Practice) Paid in Part (Middle Class) Unpaid Work (Charity) "2 '3 1° eSo GQ.H 6? 0 0 1 0 OS 6? Os 00 A 00 OS A 6? OS to A to 6? OS •o 1 O 10 6? OS 6? OS A co 6? OS