ABUSE OF MEDICAL CHARITY. A REMEDY APPLIED IN 3000 CASES OF OUT-DOOR PATIENTS: RESULTS. By FREDERICK F. DOGGETT, A.B., M.D. District Physician to the Boston Dispensary. Read at the Annual Meeting of the Massachusetts Medical Society June 8, 1886. ABUSE OF MEDICAL CHARITY.—A REMEDY APPLIED IN 3000 CASES OF OUT-DOOR PATIENTS : RESULTS. At the present time when "a little less than one-fourth” 1 of the inhabitants of Boston is receiving medical treatment free of charge, it is certainly of great moment to the phy- sicians of Boston to learn to what extent their charity is being abused, and if possible to find some remedy to correct such abuse. It is hardly necessary to say a word as to the mere exist- ence of such abuse, as it would be almost impossible to find a physician, who has had even a limited experience with charity cases, who would deny it. With such a phy- sician it is perhaps his weekly or even daily experience to treat gratuitously certain persons who live in comfortable homes, well furnished, are themselves well clad, not only able to procure all the necessities of life, but even many of the luxuries. Many persons in such circumstances, in considering their expenditures, seem to make no provision for sickness, but as a matter of course look upon medical treatment as a blessing as free to them as air or sunshine, and so appropriate what may be left over from the cost of necessities of life to an evening at the theatre or to some other gratification equally out of place under the circum- stances. To those who have not had experience with charity cases, does it seem probable that all the ninety thousand and more persons in Boston applying for free medical treatment are 1 C. D. Kellogg, N. Y. Medical Record, Nov. 28, 1885, p. 616. 4 ABUSE OF MEDICAL CHARITY. objects of medical charity? Luckily, we have a standard of numerical comparison whereby we can, reasoning from analogy, raise the question above probability. In New York City the experiment lias lately been tried of investi- gating the circumstances of each doubtful case, ad seriatim, as they applied at the New York Dispensary. The number of cases investigated1 was 845 ; of this number, 504 were deserving; 235 were not; 38 were doubtful, and 68 could not be found. Thus 59.G % were deserving. Dr. A. Siebert2 of the German Dispensary, reports that out of 434 cases investigated, 107 gave wrong addresses ; 187 were fully able to pay ; 42 were able to pay small fees ; 75 were unable to pay, while 23 gave no answer. In another series,3 investigated for the managers of this dispen- sary by the Charity Organization Society, from January to March, inclusive, 1884, out of 192 cases, 64 were able to pay, G5 not able, while G3 gave wrong addresses. In another New York charitable institution, in a series4 of 79 investigated, 24 were able to pay and 27 gave wrong addresses. And finally, in another series of 400 cases one- third were unworthy and one-third had given wrong ad- dresses. As a result of these investigations, it was found that something over 50% of the cases were unworthy of medical charity. In the light of these figures, is it not reasonable to suppose that at least a large minority of such cases are to be found in Boston? Further evidence on this point will be adduced from the writer’s figures as given later in this paper, which would go to prove that at least 23% of all cases applying in Boston are unworthy of medical charity. Much of the same results have been ob- tained in similar investigations in Philadelphia. 1 I)r. T. F. Gaunt, N. Y. Medical Record, Nov. 28, 1885, p. 616. 2 Loc. cit. 3 N. Y. Med. Record, June 13, 1885, p. 670. Vide Edit., loc. cit. Mav 30, 1885, p. 598. 4 Loc. cit. Nov. 28, 1885, p. 616. ABUSE OF MEDICAL CHARITY. 5 And when we consider that in London and New York, more than one-fourth of the inhabitants are treated free of charge ; in Philadelphia, one-fifth ; while in Liverpool 298,260 persons out of a population of 579,724,' or more than one-half, ai’e so treated,—one can realize the extent to which the abuse has gone. It is not proposed in this article to consider the causes which have produced this state of affairs, wherein so large a proportion of the inhabitants of large cities have got into the fashion of seeking medical charity. Nor is it necessary to consider in this place the motives which induce medical men to give so much of their services. However widely writers on the subject have differed on these two questions, there seems to be much unanimity in the opinion that promiscuous medical charity is alike demoralizing to the recipient, and detrimental at least to the income of practi- tioners taken as a body. Scarcely a month passes in which the London Lancet or British Medical Journal fails to contain some complaint of the absorption of private patients into Provident Associations or free hospitals and dispensaries. In an editorial in the London Lancet2 on a paper by Mr. C. J. Radley on "The best plan for establishing Provident Dispensaries in due relation to hospitals,” there will be found abundance of such complaint; also in another editorial3 on a proposition to disfranchise persons receiving medical charity. New York and Philadelphia Journals have of late mirrored much the same state of affairs in those cities, especially in the former. Dr. W. L. Carr4 has written on the impoverish- ment of the young physician through abuse of medical charity. While " Caritas Vera ” 5 complains that in going 1 British Med. Journ., Sept. 5, 1885, p. 471 et seq. 2 Jan. 31, 1885, p. 214. 3 Loc. cit., June 9, 1885. 4 N. Y. Med.Ilec.. Mar. 7. 1885, p. 278. 5 Idem, Feb. 7, 1885, p. 168. 6 ABUSE OF MEDICAL CIIAlilTY. a not very long distance to visit a certain patient, lie must pass by no less than four free dispensaries. He suggests that if patients were questioned more thoroughly by dis- pensary physicians there would be less abuse. T1 le abuse of medical charity having for some time been admitted, and the wide spread evils therefrom noted, attempts have naturally been made to remedy the trouble. The two principal schemes which have been tried are the Provident Societies, principally in Europe, and the Charity Organization Society in America. In the London Provi- dent Society—the earliest type of them all—the person seeking medical aid may be elevated from the position of a charity patient to the dignity of a pay patient, by paying the sum of six-pence per month ; of ten-pence for husband and wife, and two-pence for children under 14 years of age. The scheme does not seem to thrive on American soil, ful- some reason. In England, one would judge from editorials and communications in the British Journals, that on the one hand the scheme diminished the receipts of the physician while adding to his labors ; while many apparently respec- table persons who would scorn to accept charity as such, have satisfied their scruples and avoided the physician’s bill by joining a Provident Dispensary. In this way the abuse of medical charity has not been corrected but has taken a more respectable form, in which guise the abuse is more difficult to meet. In case of the Charity Organization Society, it is pro- posed that the various charities of the city, instead of work- ing at cross-purposes,—as for example, by assisting a family previously found unworthy of assistance by a neigh- boring charity,—shall have a system of intercommunication, and shall assist only those cases which are found worthy after examination of their circumstances. Thus the register of the New York Charity Organization Society contains the names of 98,000 families who have applied for medical ABUSE OF MEDICAL CHARITY. 7 relief, together with their standard of worthiness or the opposite. Of late many such alliances have been established in European cities as well as in no less than forty cities and towns in this country. It is hardly necessary to say that the investigation bears on general relief as well as medical. In the writer’s opinion, this scheme is calculated to do great good. For instance, if all the charitable institutions in Boston should agree to treat no case that did not bring a card from the Associated Charities, say, endorsing the person’s worthiness after investigation, how completely would the abuse of medical charity be stopped ! But that ideal time has not yet arrived. If it were possible for each dispensary and hospital to contain a register of the thousands of families in Boston unworthy of medical charity, it would apparently not be difficult, nor would it take too much of the physician’s time, to decide which cases to reject. In the absence of such information, at pi'esent it is possible to learn through a card of the Associated Charities the charity status of any family, where it is possible to look it up. This might work reasonably well in cases of no urgency, as with most of those coming to the consulting rooms of hos- pitals and dispensaries. Of course, treatment would usually have to be deferred for twenty-four hours. But in regard to cases sick in bed such as the district physician attends, prompt treatment is demanded by the nature of the case, and time could not be allowed for investigation. In the light of these suggestions, it must be admitted that the scheme would be cumbrous as applied to the district phy- sician’s work. During the early months of his district dispensary practice, —October to December, 1882—it became evident to the writer, judging from the surroundings of many of the patients,—as from the rents paid, the furnishing of their 8 ABUSE OF MEDICAL CHARITY. houses, and the amount of their wages when discoverable,— that many were able to pay their physician’s bill. The position of affairs cannot be better illustrated than by relating two or three of the more glaring cases. He was called to treat a sick child in a family occupying a well furnished suite of rooms. On inquiring as to the apparent prosperity of the family, the mother declared that they had seen better days, but that her husbahd was then sick in the hospital with an incurable disease, and that the rest of the family was living on money loaned on the furni- ture. Some time after, it was learned accidentally through another family living in the same block, that in reality the husband was well and attending to his business ; he being the junior partner in a liquor firm which owns two establish- ments, not far from the lower end of Broadway, South Boston. In another case where the writer’s suspicions were aroused, the mother declared that her husband earned but six dollars a week as a barber working on short time, and with several children they were very poor. The husband was afterwards discovered to be the proprietor of a barber’s shop on Broad- way, and there was business enough to compel him to hire two assistants. lie was amply able to pay his physician’s bill. In still another case, after having treated a woman on several occasions, it was accidentally learned that her hus- band owned the house in which lived another family besides their own; that he further owned two horses and carts and was doing a retail coal business. It is perhaps hardly worth while mentioning the family who explained that the reason they could pay no physician’s bill, for the time being, was, that they had to set apart a certain sum each month, to meet a bill on a comparatively expensive set of furniture they had lately purchased on the instalment plan. ABUSE OF MEDICAL CHARITY. 9 And finally, may be noted the case of the lady—previ- ously a private patient of the writer’s—who clad in her third- best dress, probably for the occasion, unwittingly stepped into his presence for treatment at the woman’s room at the Dispensary. It is only fair to say, that aggravated cases like the above were only encountered while the writer was yet new to the district, and before he began to question as to the circum- stances of the patients. It is proposed to devote the remainder of this paper to the statement, working and results of a simple plan for pre- venting abuse of medical charity, adopted by the writer early in 1883, and continued since then in district dispensary practice. The plan was briefly as follows :—-in doubtful cases to ask—1st, the number of persons in the family; 2d, the united wages or total source of income; 3d, as to the permanency of it, and as to any debts due from previous lack of work ; 4th, as to the rent paid. Afterwards, as a supplement to this, to confirm the answers by statements of neighbors. Next, to note the unworthy families. If in the writer’s judgment, on pressing; the above questions, the family was unworthy, free treatment was refused except in urgent cases. A family of seven or eight persons, with an income of $30 to $40 per month, was al- ways treated. Not so a family of three persons with an income of $60 to $70. All the circumstances were con- sidered, such as the permanency of income, previous lack of work, or sickness. In cases of refusal to answer questions like the above, the case was judged unworthy. This state of affairs was not infrequent. It must be admitted that that is a lenient judgment which rests on the statements of the defendant, and that in a plan of this kind there is small chance of injustice in the distribution of medical charity at least, so far as the receiver is concerned. 10 ABUSE OF MEDICAL CHARITY. The above questions, in the experience of the writer, could be asked and answered in less than a minute, which is not an unreasonable time to take when it is remembered that it was only at first that many such cases were met with ; for apparently, when it was learned that they were likely to be subject to an investigation, such cases became scarce. In this way, the writer believes that there Was in the end a saving of time and trouble. This is also borne out by re- ferring to the table, No. I., where we can see that in Oc- tober, November and December, 1882, the number of cases from the pay-district was much in excess of those coming in the corresponding months of the next year. The part of Boston in question is that part of South Bpston, bounded by portions of Dorchester Av., Broadway, and Dorchester St., and the water of Boston Harbor. (See map.) The shaded portion represents the part of this territory occupied by comparatively well-to-do people, such as me- chanics, clerks, shopkeepers, etc. For the most part, these ABUSE OF MEDICAL CHARITY 11 people pay their physicians’ bills, and are able to do so, with some manifest exceptions. Bents range from $10 per month and upwards. Many own the houses they live in. The rest of the territory—the unshaded part—is bounded by portions o.f Second St., B St., Athens St. (including both sides), Dorchester Av., the water, and a part of Dor- chester St. It is occupied by people of small means,—for the most part day laborers, with a few fishermen, junkmen, etc. Bents range from $4 a month to $10 or $12, and as this is the region of large families there is more or less crowding. It is seldom that families will be found in this district able to pay a full physician’s bill. For convenience, the former territory will be spoken of as the " pay-districtthe latter as the " charity-district.” The time covered in the calculations of Table I. and Chart I. was from October 1, 1882, to October 1, 1885. The number of cases treated in these three years was 2,92(5; of this number, 2,224 resided in the charity-district; 702 in the pay-district. Table I. Time of Experiment. Total Cases. I’ay-Dist. Cases. Ch’y-Dist Cases. % 1*. D. Cases. % C. D. Cases. Oct.-Dec., 1882 195 86 109 44.1 55.9 Jan. -Mar., 1883 281 101 180 37.3 62.7 April-June, 1883 229 62 167 27.6 72.4 July-Sept., 1883 208 47 161 22.6 77.4 Oct.-Dec., 1883 224 43 181 19 2 80.8 Jan.-Mar., 1884 258 55 203 21.8 78.2 April-June, 1884 196 42 154 18.9 81.1 July-Sept., 1884 249 52 197 20.1 79.9 Oct.-Dee., 1884 224 61 163 27.2 72.8 Jan. -Mar., 1885 290 52 238 18. 82. April-June, 1885 319 43 276 13.5 86.5 July-Sept., 1885 253 58 195 23. 77. In order that the working of the scheme may be shown with its results, the three-years’ time has been divided into quarterly intervals. The number of cases treated in each quarter has been reckoned. Further, the cases coming from 12 ABUSE OF MEDICAL CHARITY. the pay-district and charity-district, respectively, as above described, have been estimated, and the per cent, in each to the total number. (See Table I.) The principal fact that Table I. illustrates—namely, the rapid falling off in the number of cases from the pay-district after March 1, 1883, the beginning of active application of Chart I. the scheme—can be shown still plainer in the chart form. (See Chart I.) The three-months’ intervals, beginning 13 ABUSE OF MEDICAL CHARITY. October 1, 1882, are represented by the spaces between the vertical lines, while the horizontal spaces represent units of tens of the number of cases coming during the respective intervals. The upper curve shows the tri-monthly variation in the total number of cases ; the middle curve, the same variation in the number of cases from the charity- district ; the lower dotted curve, the same for the cases from the pay-districts. Besides the falling off in the pay-district curve after March 1, 1883, it will be noticed that it continues at a low level thereafter, showing how few unworthy cases came after investigation began. On the other hand, the charity- district curve attains and keeps a higher elevation ; the high point attained by this curve in the 10th and 11th quarters, is due to the fact that there was prevalent an epidemic of measles in the poorer part of the district during the winter and spring of 1884 and 1885. Otherwise, this curve would have been more uniform in character. The rise of all the curves during the first six months of the author’s service may, perhaps, be due in part to the fact that he at that time came a new man into the district, and on that account was more likely to be imposed upon. It is further explained by the fact that it was no doubt influenced by the usual rise coming at the advance of winter, as witness also the rises at the winter periods of the 6th and 10th quarters. To throw further light on the scheme and its results, a comparison has been made between the number of cases coming from the above mentioned pay-district, during the six months ending December 1, 1882, and the correspond- ing six months in the following year,—that is, after the scheme had been in use for several months. By the table (Table II.) it will be seen that some twenty fewer cases in every hundred of total cases were in the habit of applying for medical charity (also including those cases refused treat- ment) during the interval from June to November, 1883, 14 ABUSE OF MEDICAL CHARITY. than in the same interval in 1882. While in the former interval, 164 persons, in some measure able to pay, got Table II. Months Before Total I’ay-Dist. Ch’y-Dist % P. D. % C. D. Experiment. Cases. Cases. Cases. Cases. Cases. June, 1882 51 25 26 49.1 50.9 July, 1882 82 35 47 42.7 57.3 August, 1882 47 23 24 48.1 51.9 September, 1882 70 33 37 47.2 52.8 October, 1882 55 26 29 47.2 52.7 November, 1882 73 22 51 30.2 69.8 Months During Total, Total, Total, Total, Total, Experiment. “ 378 164 214 43.4 56.6 June, 1883 62 14 48 22.6 77.4 July, 1883 66 14 52 21.2 78.8 August, 1883 71 17 54 24. 76. September, 1883 67 16 51 23.9 76.1 October, 1883 85 20 65 23.6 76.4 November, 1883 62 14 48 22.6 77.4 Total, Total, Total, Total, Total, 413 95 318 22.9 77.1 medical charity ; in the later interval, under working of the plan, only 95 such persons got such aid. Yet, in the latter interval, instead of there being a smaller number of ABUSE OF MEDICAL CHARITY. 15 total cases treated, there was in reality an increase of 35 cases. Further, it is to be noted that in the first interval there were 214 cases in a great degree deserving of medical help, while in the latter this number had increased to 318. As the writer understands it, the great object of medical charity is best attained when such persons as in general make up the first mentioned class can be to some extent excluded, while the physician’s time and attention can be given the better, by such exclusion, to the really deserving class. One of the reasons why 104 more cases were treated in the latter inter- val, comprising the poorer patients, was, that they probably observed that more of the physician’s time and attention was Chart III. being given to them than formerly. However, it was no doubt further due to the fact that times got harder in 1883, and there was less work; this reason, of course, would apply equally to the pay-district, and yet fewer cases came from this district than in 1882. Chart II. is supplementary to Table II. In it the hori- zontal spaces represent units of ten cases, while the vertical columns represent the periods of time. It well illustrates the low pay-district curve in 1883 as compared with that of 1882—before inquiries were made. It further shows that contemporaneously with this lowering the total number of cases had increased, as can be seen by comparing the total curve for 1883 with that of 1882. 16 ABUSE OF MEDICAL CIIABITV To show in the simplest manner the working of the plan, Chart III. has been constructed ; six, three monthly inter- vals, are formed by the time between July, 1882, and December, 1883—a period of eighteen months. The number of cases treated, residing in the pay-district, in the respective quarters, as marked at the tops of the columns in the chart, were—81, 86, 101, 62, 47, 43. The horizontal spaces in the columns represent blocks of tens in the num- ber of cases treated. Here at a glance one sees the decided effect of the working of the plan when applied in the spring of 1883. The argument has often been advanced that any attempt to reform abuse of medical charity would lead to scarcity of clinical material for instruction. The writer’s figures refute this in a marked manner ; for while this scheme was in action, the number of cases coming to the Dispensary increased from 381 in the six-months interval in 1882, to 413 in the like interval in 1883. The number of cases in- creased in the whole district from 510 in a six-months inter- val in 1882 and 1883, to 618 in a like interval in 1885. Dr. S. Hall,1 of New York, says that the Northern Dis- pensary of that city, at present, treats only two-thirds of the number that it did ten years ago, when indiscriminate charity was given, yet it does more real good in the cause of charity ; and that the good done by a dispensary should be measured, not by the number of patients treated, but by their quality as regards their worthiness to receive medical charity. After completing this paper—the most of which was written some months ago—a thoughtful paper of Dr. Hasket Derby2 came under the notice of the writer. He seems to have hit upon much the same plan as above detailed, although no results are given as to the working of it, which 1 N. Y. Med. Record, Nov. 28, 1885, p. 616. 2 Boston Med. andSurg. Journal, Nov. 12, 1885. ABUSE OF MEDICAL CHARITY. 17 would be much more difficult in such a field, namely, in an in-patient service made up of patients living over a wide territory. The plan is to combine the duties of an amateur detective with those of the physician, in suitable cases. Dr. Derby says—"passing over other plans, the solution of the whole matter seems to me so simple that I mention it with diffidence. It is but to accept the principle that the out- patient department is for the benefit of those whose lack of means would prevent their obtaining relief elsewhere and to leave the application of this principle to the physician in attendance.” He further points out that "police work ” of this description, though distasteful, is not as onerous as would at first sight appear, as in regard to most of the cases there is little or no doubt. Pie further continues,—"and when anything in the dress, manner or statement of the individual causes hesitancy to be felt, a few questions, put with tact and kindness, will readily resolve the matter ; or if any doubt should still be felt, the applicant for aid should certainly receive its benefit. It is not pretended that the medical examiner will be infallible, but we claim that fewer mistakes will be made by him than by any other to whom this task may be delegated.” In taking leave of the subject, I wish here to record my opinion, that by practice of the above detailed plan, abuse of medical charity in the dispensary district of which the writer has charge has been almost completely stopped. Let the above mentioned experience and figures bear me out. How far the scheme is applicable to similar practice in other sections is for others to judge.