DUE MARCH 13,2021!Cyanna
The Elephants in the Doctor-Patient Relationship: Patients' Clinical Interactions and the Changing Surgical Landscape of the 1890s
The phrase 'doctor-patient relationship' obscures the profound differences between clinical interactions in hospital and in private practice. In the 1890s in private practice (whether in Britain, Australia or New Zealand) patients typically encountered doctors in their own homes, while accompanied by friends or relations. In hospital, solitary patients faced a multiplicity of nurses and doctors. At this time, surgery was already moving from homes to hospitals, thereby shifting the clinical encounter from the patient's to the doctor's territory, and the balance of power from the patient to the doctor. The fiction of one doctor interacting with one patient, ignoring the financial and administrative arrangements under which they met, served the interests of inter-doctor etiquette over 'ownership' of patients, and the emerging system of specialist referrals.
When something is very large, but for one reason or another people try to behave as if it is 1 not there, it is customary to draw attention to it by referring to the elephant in the room. The objective of this paper is to draw attention to the multiple elephants in the doctor-patient relationship. There are two major reasons for problematising the phrase 'doctor-patient relationship' in this way. First, focus on the dyad of a single doctor and a single patient is
deeply misleading, because it erases from the picture the many other people involved in the process of seeking and providing medical advice. Secondly, using these words obscures, and therefore supports, the false assumption that the content of the clinical encounter is constant, whatever the surrounding institutional and financial circumstances.
There is now a large body of literature that examines the history of the doctor-patient 2 relationship. Work in the 1960s and 1970s tended to focus on changes in the sites for the generation of new medical knowledge, famously encapsulated in Erwin Ackerknecht's tri-
partite progression from eighteenth-century bedside medicine to early–nineteenth-century hospital medicine and late–nineteenth-century laboratory medicine.1 This approach was associated with a great deal of discussion of changes in what doctors believed and how they behaved, and an emphasis on their shifting sources of information and ways of viewing the patient.2 During the nineteenth century, doctors began to examine patients using instruments such as stethoscopes and thermometers, and it has been argued that the role of patients
became increasingly passive, as the results of instrumental examinations were privileged over
patients' narratives.3 In a landmark article, N.D. Jewson argued that the transition from bedside medicine to hospital medicine was accompanied by a novel subordination of the patient to the doctor and further that, 'whereas under Hospital Medicine the direction of the power differential between the sick and medical personnel had been reversed, under Laboratory Medicine the patient was removed from the medical investigator's field of saliency altogether.'4 But more recent emphasis on the nature of medical practice, rather than on the ways in which new medical knowledge was produced, has substantially modi.ed this picture. In the 1980s, the work of Roy Porter and others moved the focus away from the doctor's perspective, and towards interest in the patient half of the dyad.5 There has also been significant work on the range of options available to patients in the medical marketplace, including alternative medical practitioners of many kinds.6 The work of Regina Morantz- Sanchez, Nancy Tomes and Judith Leavitt, among others, has extended a further challenge to the idea of passive and disempowered patients in the nineteenth century, by highlighting the patterns of negotiation and bargaining between doctors and patients in America.7 Nancy Theriot's work has broadened the focus to the relationships between doctors, patients and their families.8 She argues that female patients in particular cooperated with doctors in the late–nineteenth century, using them as allies in a bid for increased autonomy in relation to their families. Theriot's discussion of 'doctor-patient-family' interactions has broken through some of the limitations of an emphasis on the doctor-patient relationship by highlighting the importance of family and friends in nineteenth-century clinical encounters, but this approach still ignores the significance of the surrounding financial and institutional arrangements.
Figure 1: Punch's view of one patient's reaction to the new methods of diagnosis. (Illustration reproduced by permission of the Wellcome Trust.)
The examples of clinical encounters in the 1890s in Britain, Australia and New Zealand, are 3 used here to highlight some of the limitations of the phrase 'doctor-patient relationship' for conceptualising what went on when people sought the advice of medical practitioners. In
what follows, particular emphasis has been placed on the circumstances surrounding surgery. This is because the hospitalisation of surgery—that is to say, the shift from operating in
private homes to operating in purpose-built institutional spaces—was an important feature of medicine in the 1890s.9 The associated changes in the nature of clinical interactions demonstrate especially clearly the limitations of the concept of a 'doctor-patient relationship.' Whilst the rhetoric of surgery was about the achievements of skilled individuals, the reality was about work performed by teams.
This is an historical essay, but there are pronounced resonances in what follows for the 4 heterogeneity of the current 'doctor-patient relationship,' and the use of the phrase in current practice may well be just as misleading as its use by historians.
Clinical encounters in the 1890s (as in all times and places) did not just involve doctors 5 and patients.10 Patients might search for medical help alone, or in various combinations of husbands and wives, parents and children, and friends and relations. In their travels across the
medical landscape in search of advice, they might encounter multiple doctors, alternative health care practitioners, nurses, hospital administrators and friendly society officials, not to mention well-meaning friends with just the right remedy for their condition. However, despite the variety and complexity of these encounters, each of the financial arrangements under which patients received medical advice was associated with a distinct pattern of interaction. Financial arrangements in medicine mattered, as the following quote demonstrates:
Mrs. P ... is a patient of mine ... she had a uterine polypus and unbeknown to me she was admitted into your hospital and operated upon. Now, I consider this most unfair treatment, as the above is in good circumstances and was quite willing to pay the fee which I told her I should charge for the operation.11
This is an extract from a letter in the complaints files of the Middlesex Hospital, written in
1900 by a Suffolk doctor.12 Mrs. P's case highlights a number of features of patients' clinical encounters in the 1890s, and the complex ways in which patients made their choices among the various health care options that were then available. Mrs. P's husband also wrote to the Middlesex Hospital about her case, and his letter allows a glimpse of 'doctor-patient relationships' in the 1890s from the viewpoint of someone who was neither the doctor nor the patient. The Suffolk doctor, noted Mr. P, examined his wife and proposed an operation
which he was extremely anxious to perform at once. Having no confidence in him for such a matter I considered it desirable to consult the doctor who had attended my wife in another town for some years and in whom we had implicit confidence. He advised me to obtain her admission to a London Hospital. To this I readily consented for two reasons, first my cottage is unsuitable for the performance of any intricate operation, secondly I desired that my wife should be in the hands of Gentlemen with the utmost experience of similar cases and not in those of a man in whom I had not a particle of confidence and who possibly had not attended a like case before.13
Mrs. P's husband appears to have made decisions on her behalf: 'I considered it desirable ...'; 'I readily consented ...'; 'I had not a particle of confidence ....' Mr. P may, of course, have consulted his wife and certainly implies a joint view ('we had implicit confidence'), at least once. But the overall impression is that Mr. P was more involved in making decisions about his wife's treatment than she was. Clearly, Mrs. P and her doctor were not the only people involved in this case. Mr. and Mrs. P consulted the Suffolk doctor and at least one other practitioner privately, in addition to those they saw at the Middlesex Hospital, so that in this series of medical interactions there was a patient, her husband and a multiplicity of doctors. Further, none of the doctors dominated the patient. Mr, and perhaps also Mrs, P were making choices, not only about doctor, but also about diagnosis and treatment and the place where that treatment should take place.
As Irvine Loudon, Anne Digby, Christopher Crenner and others have highlighted, in both 6 Britain and America many patients continued to exercise considerable autonomy until well
into the early–twentieth century.14 In private practice, as Mrs. P's case illustrates, patients and their friends had the freedom to choose their doctor and their treatment. Indeed, M. Jeanne Peterson has argued that nineteenth-century doctors were victims of 'medical powerlessness.
At every turn men in medical practice found themselves ruled by their patients, by the governors of hospitals, by the workingmen who ran medical clubs ...'15 This is an extreme view, but without going that far, it is clear that the Suffolk doctor did not enjoy anything even remotely resembling the 'medical dominance' attributed to doctors two or three generations later by scholars such as David Rothman, Eliot Freidson and Evan Willis.16 Despite this doctor's wish to perform surgery at once, Mr. P had 'no confidence in him for such a matter' and took his wife elsewhere.
So how common was it for patients and their 'friends' to make conscious choices of this 7
kind as they sought diagnosis and treatment for the causes of their pain?17 Was it always possible for patients to find 'gentlemen' in whom they had 'confidence'? Or did some patients have more choices than others? In what follows, published case reports have been examined in a search for answers to these questions.18 There are striking similarities in the style of case reports between Britain, Australia and New Zealand, at least partly because a very large proportion of Australasian doctors in this era had trained in Britain.19 Published case reports were not representative of practice as a whole.20 They were selected, firstly by the doctors concerned, and secondly by the journal editors, as reports of cases they considered interesting in some way. Almost by definition they omit the mundane 'bronchitis in winter and diarrhoea in summer' of general practice.21 Published case reports were essentially advertising by doctors to an audience of their peers, and the general tone is of slightly self-deprecating boasting In this era doctors did not just publish their successes, and deaths were often recorded in case reports, possibly because this was an opportunity to publicly explain (make excuses for?) any failures. Despite these limitations, 1890s published case reports are a valuable source of information This is particularly so for private practice, for which very few unpublished case note series have survived. These reports demonstrate that clinical interactions varied enormously according to the circumstances of the various parties, and that they often involved multiple people, not all of whom were either doctors or patients. There were, however, distinct patterns to clinical interactions, and each pattern was associated with a particular kind of financial basis for the consultation between patients and their 'medical advisers.' Members of friendly society clubs, recipients of Poor Law services and users of charitable dispensaries, for example, each had distinctive ways of interacting with those who provided them with medical advice. From the patient's perspective, the overall experience of a clinical encounter under any of these arrangements was influenced quite as much by issues such as poverty, ideas about their rights, and the problems of negotiating access to means tested services, as by the content of their interaction with a doctor, if and when they eventually got to see one. Two of the most common frameworks within which patients encountered doctors will be examined in some detail in what follows, to demonstrate just how misleading the phrase 'doctor-patient relationship' can be.
Clinical encounters in private practice
In the 1890s, the private practice of most doctors involved a mix of house calls—where they 8 visited their patients—and consultations in their surgeries—where the patients visited them. Published case notes from the early 1890s describe many instances where the 'private' consultation did not involve a solitary doctor and a solitary patient, especially where the encounter took place in the patient's home. Indeed, the idea of a doctor interacting with a
group rather than an individual is implicit in the idealised concept of the family doctor, which was already well established by the 1890s.22 Jukes De Styrap, in his 1890 guide book for young doctors setting up in practice, takes it for granted that the usual relationship was between a doctor and a family, rather than between a doctor and a patient as an uncontextualised individual. 'Many a young practitioner,' he wrote, 'secures a good family permanently by simple kindness and assiduous attention in cases of accident, convulsions, colic and the like...'23
Figure 2: Punch's view of a doctor-family interaction: Doctor: "Well, you got those leeches I sent for your husband, Mrs. Giles!" Mrs. Giles: "Yes, Zur; but what on earth be the good o' sending they little things vur a girt big chap like he! I jes' took an' clapped a ferret on 'un!" (Illustration reproduced by permission of the Wellcome Trust.)
As might be expected, children seldom saw a doctor without the presence of a parent or 9 some other responsible adult, and several people might be present during a medical consultation.24 For instance, in reporting a case of acute intussusception in an infant, Dr. Newmarch of Sydney noted the following: 'Operation was advised, and whilst the parents
were hesitating, an old lady who happened to be present remarked that she had seen Dr. Fiaschi invert a patient suffering from a similar complaint with success.' Dr. Newmarch duly shook the child by its feet, which seemed to rectify the problem.25 In this instance, someone who was not the doctor, the patient or a parent suggested the successful treatment. But it is not just children who did not always have a one-to-one relationship with their medical advisers. There were also cases of adults where, for various reasons, someone else spoke and acted on their behalf.26 In the case of a 'poor old maid, living alone in a little house in the neighbourhood of Dunedin,' for instance, the local clergyman's wife and the neighbours were involved, as well as at least two doctors.27 Quite commonly, husbands were involved in decisions about the medical care of their wives and it appears that fathers were sometimes involved in consultations over the health of what we would now consider to be adult daughters.28 With older people, sons and daughters sometimes became involved in consultations over the health of their parents. In the case of a seventy-three-year-old farmer's
widow in Lancashire, for instance, a servant, a son, a doctor and a daughter all appear to have been involved in discussions about her hernia.29 It should also be appreciated that treatment very often began before any doctor appeared on the scene. The following example of a case of snakebite in outback New South Wales in the summer of 1892 gives a hint of some of the complexities that might be involved in the interactions affecting the treatment of a patient:
Mr. and Mrs. [Robert] Simson and master John Simson, aged 15 years, son of Mr. Colin Simson of Carmyle, Toorak, were sitting on the lawn at the homestead when the lad was bitten by a young deaf-adder on the forefinger of the right hand. A ligature was promptly placed round the finger, and Mr. Robert Simson injected some drops of the strychnine antidote prepared by Dr. Mueller, of Yackandandah. A messenger was immediately sent to Quirindi for a doctor, and pending his arrival, which did not take place until 9 o'clock next morning, Mr. Simson and one of the station hands kept the patient awake by walking him briskly about the house.30
Was John Simson's primary medical relationship with his uncle, who administered the strychnine, with Dr. Mueller, who devised the treatment that was marketed by L. Bruck of Castlereagh Street, Sydney, or with the local doctor who arrived the morning after Simson was bitten? Or is it more useful to understand this as one of many medical episodes involving interactions between the patient and a range of people?
The involvement of parties other than just the doctor and the patient often becomes 10 evident when the question of consent for surgery is mentioned: 'On being called to see her, I found her pale and anxious-looking,' wrote one doctor. 'The patient and her friends readily consenting, abdominal section was performed without delay.'31 The outcome was a happy one
in this case, but the doctor concerned reports a less favourable outcome in another case in the same article. 'I urged operation without delay as the only chance of saving her, but the friends would not consent till the patient became moribund.'32 'Friends' might be involved in decisions over consent for surgery involving men as well as women:
Mr. Pat H ... had the misfortune of having his ankle terribly smashed by a tree falling on it ... two doctors—men of very high attainments—advised amputation; but as the patient and his friends objected to this, and said that he might as well be dead as to lose his leg, they asked me to try and save it for him.33
It should also be noted that the strictly commercial side of the clinical consultation—who
paid the bill—was by no means always a matter of a one-to-one relationship, with the patient paying the doctor. Parents, husbands and employers, for instance, all regularly paid doctor's bills on behalf of someone else, and sometimes they refused to pay, which might bring the matter to the attention of the medical journals. 34 In July 1890, for instance, the Lancet reported from Birmingham:
a successful action by Mr. Hallwright to recover from a gentleman £5 5s., chiefly for obstetric attendance on Mrs.—, which he had agreed to pay. Though neither the husband of the woman nor the father of the child, he had relations with her, and had clearly authorised her engaging Mr. Hallwright, and promised to pay him, undertakings he afterwards, on quarrelling with her, sought to escape from.35
Clinical encounters in hospital practice
The experience of patients in the hospital environment contrasted strongly to the clinical 11 encounter in private practice. However, it still seldom involved a one-to-one relationship between the patient and the doctor who was notionally responsible for their case. In crowded outpatient clinics, patients might see one or more members of the medical hierarchy. These hierarchies varied by hospital and by specialty. The pattern in Australia and New Zealand, especially in the larger hospitals, was modelled on that of the major charitable hospitals in London, such as St Bartholomew's and the Middlesex. At the Melbourne Hospital, for
instance, the hierarchy included surgical and medical clinical assistants, resident medical
officers (RMOs), registrars, a medical superintendent, and honorary physicians and surgeons to outpatients and to inpatients. In smaller hospitals, the medical hierarchy was less complex. In the Brisbane Hospital in 1900, for instance, it consisted of resident medical officers, a medical superintendent, honorary medical officers to the outpatient department, and honorary visiting surgeons and physicians.36
Whatever the details of the medical hierarchy, except in remote areas anyone going to an 12 outpatient clinic in this era would typically be seen initially by a junior doctor and then
passed up the hierarchy, depending on the complexity or interest of the case. Notionally,
patients were under the care of the most senior member of the hierarchy, yet they might quite possibly never see this august individual. Alexander Francis gives us a glimpse of this world
at St Bartholomew's Hospital in London, where he was appointed to a junior position in 1886. He describes how not only the patients but also the junior doctors seldom saw the senior honorary surgeon in charge of their cases, and the effective senior doctor on duty for most purposes was the House Surgeon, although even him 'we did not like to disturb ... more often than necessary.'37 At the Brisbane Hospital, it was the duty of the Medical Superintendent to: 'inform the member of the Visiting Staff, whose case it is, if it require attendance, and in the event of that officer being unable to attend he shall himself operate ...'38 Here, too, it seems, a member of the Visiting Staff might not actually have seen 'their' patient before an operation was performed.
Figure 3: The Hospital for Sick Children, Brisbane, c. 1899. (Photograph reproduced by permission of the State Library of Queensland, John Oxley neg. 22159.)
Those patients who were admitted to the wards would have had multiple clinical encounters 13 with nurses every day, but they would usually have seen doctors less often. The standard
pattern was for the RMOs to visit the ward at least once a day, but the honorary surgeon or physician in charge of the case might only put in an appearance once or twice a week. In teaching hospitals, the appearance of the honorary on the ward was famously a group affair, the great man (never a woman in this era, except in dedicated women's hospitals) accompanied by all the more junior members of his team, plus a varying number of medical students, nurses and possibly also student nurses. Questions were asked and answered at the foot of each bed and the case discussed by members of what could be quite a large group. Even at the Brisbane Hospital in 1900, which was not to become a teaching hospital for doctors until the 1930s, RMOs accompanied 'the Visiting Staff in their going round the wards, bringing under their notice any important particulars concerning the cases under their charge, and reporting to them anything that has been ordered as urgent.'39
Patients who were treated in private hospitals had a rather different experience. Besides 14 better food, more comfortable rooms and greater privacy, they would have had a direct relationship with the doctor that they (or their husband or father or employer) were paying for medical advice and treatment. But their care would still have been provided by teams rather
than by a single individual, and this is illustrated especially clearly by the experience of patients who went to hospital for surgical treatment.
The hospitalisation of surgery
Although she was not poor, Mrs. P went to hospital. We would almost certainly be right in 15 assuming that if her case had been categorised as 'medical' rather than 'surgical,' she would
have been treated at home. As Charles Rosenberg has noted, the late–nineteenth and early– twentieth centuries saw a revolutionary change in hospitals, which involved both the hospitalisation of surgery and the surgicalisation of hospitals.40 The pressures for the hospitalisation of surgery are often mentioned in 1890s case reports. For instance: 'it was
almost impossible to form a diagnosis in the small room and amid the inconvenient surroundings of the private residence,' and: 'The surroundings being non-hygienic in the extreme, the patient was brought in to the Sydney Hospital in an ambulance.'41 By 1900, the focus was often on poor light: 'as the hour was late, the light and the surroundings totally un.t for the performance of a serious operation ... we decided to ... defer operative procedures until the following morning,' wrote an Adelaide doctor.42 In 1897, Professor Archibald Watson noted in his diary another case with bad light that would have been better treated in hospital.43 The patient had multiple ovarian cysts and the operation took place in her kitchen. Despite putting blocks under the table legs, the patient was still not in the best position to provide the surgeons with good access. The room was small with 'terribly bad light,' so that it was difficult for them to see what they were doing. There was no electricity in the house and they were 'afraid to use a candle on acct. of ether.' In addition, the silk they were using for sutures kept breaking, and it was difficult to stop the patient bleeding. The overall result was a disaster, and the patient died three days later.44
By 1900, basic items of equipment such as rooms of an adequate size with adjustable 16 operating tables and good light were regularly available in hospitals, but were not regularly available in private homes. Photographs from the turn of the century begin to show operating theatre staff wearing gowns and caps, and sometimes even gloves and masks, and using
enamel bowls in well-lit, white-tiled spaces.45 Meanwhile, behind the scenes, steam sterilisers and laundries were also adding to the cost and complexity of the paraphernalia associated
with operations, tipping the balance even further in favour of hospitals as sites for providing 'safe' surgery. However, among the greatest advantages of hospitals were the pooled facilities that drew together teams of appropriately skilled people.
Figure 4: Medical students C. Farrow and R. Johnson, Resident T. Millar, surgeon V. Hurley and two unnamed nurses, Grice Operating Theatre, Melbourne Hospital, c. 1924. (Reproduced by permission of the Royal Melbourne Hospital Archives.)
Also by 1900, many kinds of medical therapy involved the work of multiple people, but this 17 was particularly clear in the case of surgery. Doctors found it very difficult to perform
surgery unaided. During the 1890s, considerable publicity was given to deaths under
anaesthesia, and they were regularly the subject of coroners' inquests in both Britain and Australia.46 Even before this publicity, many surgeons drew the conclusion that it was safer if someone else administered the anaesthetic, and by 1900 all major operations involved a
doctor and at least one assistant (often named in published case reports). In private practice, there are reports of a wide range of people providing anaesthesia, including family doctors, medical students and nurses, and in country areas doctors sometimes called on the help of vets, chemists and even 'laymen.'47 In hospitals, people experienced in the administration of anaesthetics were more readily available. The Middlesex Hospital, for instance, had both a junior and a senior 'chloroformist' by 1890, although this did not prevent deaths under anaesthesia and, following two embarrassing inquests, regulations for the administration of anaesthetics were tightened in 1892.48 However, the surgeon and the anaesthetist were just the core of the team. When operations were performed in hospitals, the procedure regularly involved other people, including one or more nurses and, particularly if the operation was difficult or complex, one or more surgical assistants. Importantly, hospitals also provided pre-
11 and postoperative nursing care, and practitioners trained to make provision for whichever mix
of antisepsis, asepsis and cleanliness was favoured by the surgeon.49
As a result, the trend toward having their operations in hospitals, which began with those 18 in moderate circumstances who lived in 'cottages,' was increasingly followed by people
higher up the social scale.
Private practice versus hospital practice
We have, then, two strongly contrasting pictures of encounters between 'medical advisers' and 19 patients. On the patients' ground— in their homes—doctors encountered patients in the
company of varying numbers of friends and relations. In the private practice setting, even
when the consultation took place in the doctor's surgery, the patient retained a degree of
control over the consultation.50 In the hospital, in contrast, the patient may have had various friends and relations with them in outpatients, but on the ward, visiting hours were strictly limited and they were far more likely to encounter nurses and doctors on their …