Prof Pierce A Grace, explores the thorny question that has exercised many minds, including in Ireland, down the centuries of how much to pay doctors

As he walked into the Baltimore and Potomac Railroad Station in Washington on that July day in 1881, he was in very good form thinking of the trip to New England where he would meet up with his wife, Lucretia, who had gone there to recuperate from a recent illness. He had just entered the building when something hard hit him in the back making him cry out, “My God! What is this?” It was a bullet.

James Garfield, 20th President of the United States, crumpled to the ground. The wound was not immediately fatal and he would not die for another 80 days. What he died from was sepsis, mostly introduced by the unsterile instruments and dirty fingers of his doctors who, in the absence of x-rays, kept poking about in his wound (euphemistically called ‘probing’) to find the bullet. They never did.

When Garfield died, his self-­appointed chief-physician, D. Willard Bliss, presented Congress with a bill for US $25,000 — equivalent to $600,000 (€532,200) in today’s money. They said they would pay him $6,500, which he refused, complaining that it was “notoriously inadequate as a just compensation”.

Secret yacht operation

Dr William W. Keen was involved with two American presidents. In 1893, Dr Keen assisted Dr Joseph D. Bryant in performing an operation to remove a tumour from the upper left hard palate of Grover Cleveland who was president for two terms, 1885-1889 and 1893-1897. The operation was performed in secret on the yacht, Oneida, owned by the president’s friend Commodore Elias C. Benedict. It is not recorded how much any of the six medics present were paid, but they obviously did a good job as Cleveland recovered, finished his term as president and lived for another 15 years without recurrence.

Keen had become a very famous physician when he was asked to see Franklin Delano Roosevelt in 1921 when the latter suddenly became paralysed from the waist down. Keen first thought Roosevelt’s condition was spinal thrombosis, but later changed his diagnosis to an inflammation of the spinal cord. He ordered massages to be performed and sent a bill for $600. Later, Dr Robert W. Lovett, Professor of Orthopaedics at Harvard Medical School, and an expert in infantile paralysis, diagnosed poliomyelitis.

Thorny issue of payment

How doctors should be compensated for their efforts is a thorny question that has exercised greater and lesser minds for centuries. There appear to be two main ways that doctors get paid: either they charge the patient directly for their services or they are paid by a third party to look after the patient. In Ireland, we have a combination of these two, with some patients paying general practitioners (GPs) or consultants directly and others being paid for by the State or insurance companies.

In ancient Greece, there was some debate as to whether doctors should be paid at all. If medicine was deemed to be a craft like carpentry, then physicians should be paid for their work — but if it was a liberal art like philosophy then the doctor would practise without fees for virtue and the love of humanity.

In the Islamic world, there was a view that the physician’s financial needs should be met by society so that he would not have to do other work to support himself. While the Talmud text states that “a physician for nothing is worth nothing”, European Jewish communities of the 17th and 18th centuries often employed a physician on a salary to attend the poor gratis. However, the rich were expected to pay.

Under the Brehon Law in Ireland, the fees paid to a physician were considerable. The physician’s fee was estimated as a percentage of the éric, which was a fine imposed on an individual for injuring another person. For many injuries, the doctor received a staggering 50 per cent of the éric, while for lesser injuries, a third or a quarter of the éric was paid as the fee. Status was also very important and the same injury to diff–erent ranks carried different penalties and fees.

In later medieval Ireland and Scotland, Gaelic physicians held hereditary tenure of lands (lucht tighe) in return for providing medical care to their aristocratic patrons, the usual amount being about 300 to 400 acres. The identity of some of the medical families is still preserved in townland names such as Ballysheil in Offaly or Farrancassidy in Fermanagh; both O’Cassidy and O’Sheil were prominent medieval medical kindreds.

When the Gaelic world fell apart at the beginning of the 17th Century, the Gaelic doctors lost some of their status, but individual physicians were still able to follow their profession. In 1590, a Nicholas Hickie, doctor of physic, was appointed by Dublin Corporation as a physician to the poor at a salary of £10 per annum. He was required to charge patients 6d each for ‘taking the view’ and looking at their urine if they came to him and a shilling each if he visited them.

Quacks or the real deal?

Dermot O’Meara (fl. 1610–46), who was born in Tipperary but obtained a medical degree at Oxford, railed against the number of quacks practising in Dublin in the early 17th Century. Patients had to pay their medical attendants, quacks or legitimate, and one of the most remarkable documents to survive from that time is the fee book kept by Dr Thomas Arthur (1593-1675) from Limerick.

Dr Arthur appears to have been a good doctor and businessman. Between 1619 and 1666, he kept a meticulous record (in Latin) of the payments he received from his patients and also records of his income from rents and property in Limerick. Most of his fees were 5s to 10s, but his first patient, Charolus Bourk, gave him £2 for treating ‘gonorrhaea simplici’. In May 1620, he treated George Sexton in Dublin for ‘gonorrhaea laborantem’, who ‘being thoroughly cured, gave me a horse to the value of £8 and £5 in gold’. Although a Catholic and of Old English stock, Dr Arthur was much in demand by patients across the sectarian divide; his most famous patient was Archbishop James Ussher, Protestant Archbishop of Armagh, whose ailment the royal physicians had failed to cure. It is not known what the problem was, but Dr Arthur cured him and received £51 for his troubles.

He also treated the Lord Deputy, Charles Fleetwood and his successor Henry Cromwell (Oliver’s brother) for migraine and tonsillitis, respectively. Dr Arthur’s income almost quadrupled between 1619 and 1633, when he earned £283.

In Scotland in 1650, the Thane of Cawdor had the Gaelic physician ‘Donal O’Conochar phisitiane’ attend his son ‘qhen he was diseasit before his deceas’. In spite of the poor outcome, O’Connor’s fee was £66 13s 8d; two years later he received £80 for attending the Thane himself.

This may not have been as outrageous as it first appears as the rate of exchange between the Scots pound and the pound sterling in 1707 was 12 to one. In the 17th Century, surgery’s reputation got a boost when Louis XIV developed an anal fistula that was cured by an operation performed by his chief surgeon, Charles-François Félix (junior) (1635-1703) in 1686.

His reward for resolving the King’s little problem was 300,000 livres and an estate. Royal patronage under Louis XV would ultimately lead to the foundation of l’Academie Royale de Chirurgie in 1731, which significantly increased the status of surgery in France.

Professions competition

After 1704, the surgeons and physicians in Britain and Ireland had competition from the apothecaries. William Rose, a London apothecary, was prosecuted at the behest of the physicians for practising physic. Apparently, he treated John Seale, a butcher with various medicines that he had compounded. Seale was angered, not so much because he felt worse after the treatment, but because Rose presented him with a bill for £50.

He complained and Rose was tried before the Court of the Queen’s Bench in February 1701. Judgment was given in favour of the physicians, but later overturned by the House of Lords on appeal by the Society of Apothecaries. Henceforth, apothecaries were legally entitled to give medical advice so long as they only charged for their medicines. This judgment is seen as the beginning of general practice in these islands.

Voluntary hospitals

The 18th Century saw the development of several hospitals in Ireland.

Voluntary hospitals, so-called because the medical staff gave their services gratis to the hospital and patients were treated without charge, were established as medical charities by philanthropic patrons in Dublin, Cork and Limerick. Elsewhere the country was bereft of medical institutions.

From 1766, county infirmaries were established around the country with every county ultimately having its own infirmary. The funding came from local philanthropy, the Irish Parliament and the Grand Juries which were the precursors of the county councils. The Infirmaries Act stipulated that surgeons appointed to the infirmaries “shall each of them be paid by the year a sum… not exceeding £100 to be paid out of the publick money”.

Edward Foster, who was a physician and author of a book about how the hospitals should be organised, thought that surgeons should only receive £60, “very sufficient in proportion of £100 to a physician”. However, in general the surgeons received their salary of £100 but in Cashel, it was only £80 and in Kilkenny “two medical gentlemen were paid £40 each”.

Some hospitals, such as those in Wicklow and Down also employed apothecaries at £25 per annum while others arranged to buy their drugs more cheaply in Dublin.

Sometimes the governors of the hospitals failed to pay the surgeon his stipend. In 1788, Surgeon Spence in Lifford complained that the hospital suffered “great distress from the treasurer’s neglect to supply money… and he had not received any satisfactory payment of his salary for two years past”. Dr Lamy, who was the treasurer with more than 2,000 guineas in hand, pocketed £450 “no part of which… is ever likely to be recovered”.

The enhanced reputation gained from an appointment to a voluntary hospital or county infirmary led to lucrative private practice and income from medical students.

For example, Surgeon General Philip Crampton was able to give his wife, Selina, a huge £1,750 7s 0d for their household expenses in 1817 (including “a very good dinner and large evening party” for Sir Robert Peel and others in August at No. 14 Merrion Square).

Dispensary doctors

While dispensaries existed before 1851, in that year that the government uniquely established a complete network of dispensaries across Ireland based on the Poor Law unions that had been set up in 1838. The guardians (‘the lowest forms of life’) of each dispensary district had to employ and pay for a dispensary doctor; there were 810 doctors in 1891.

Needless to say, a lot of skulduggery was involved in the appointment of the medical officer with medical qualifications being almost the least important factor in the decision.

In 1906 in South Tipperary, Dr J. Dowling was asked straight out for £20 by a guardian to secure his vote for the position. The guardian did not get the £20 and the high-minded Dr Dowling did not get the job.

However, the fact that the dispensary doctor would also be looking after the guardians and their families probably mitigated against the appointment of people who were completely incompetent no matter how well connected.

Entitlement to treatment by the dispensary doctor depended on a ticket, which could be issued by a guardian, a relieving officer, or a warden of an electoral division in the district.

Once the patient had the ticket they were entitled to see the doctor at the dispensary (black ticket) or as a domiciliary visit (red ticket – ‘the scarlet runner’) and be given medicine for free.

Getting tickets was relatively easy so that many people, who could well afford it, avoided paying the doctor. This was something the doctors complained about bitterly.

The salary of the doctor was not fixed so that different doctors got different salaries. In 1792 an apothecary in Belfast got £40 per annum while the Earl of Dunraven’s dispensary doctor in Limerick got £42.

By the 1890s, the average salary was £140 including vaccination and sanitary officer fees. Private income varied from £10 to £100 per annum depending on the district and the local guardians’ penchant for dishing out dispensary tickets to their relatives and friends. The doctor generally got around in a pony and trap which cost him £60 a year to maintain. The usual fees in the 1930s were 2s 6d to 5s for seeing patients privately and 10s to15s for house calls.

Dispensary doctors had no pension rights until 1919 and the concept of a locum was totally alien to the employers; one doctor in 1892 stated: “I am in attendance on my dispensary 51 years without ever asking or getting a penny for a substitute, sick or well”.

In 1911, an opportunity to improve the lot of the dispensary doctors came with Lloyd George’s National Insurance Bill which would have freed the dispensary doctors from the tyranny of the guardians.

For 4d per week the insured person would be entitled to a free GP service from a panel of doctors and free medication on prescription.

As Ireland was the only part of the United Kingdom with a dispensary system the new insurance scheme would have to be merged somehow with the existing service in Ireland.

While the (poor) dispensary doctors generally supported the Bill the (wealthy) hospital specialists and those in private practice (what Lloyd George called “the swell doctors”) saw it as a threat to their private incomes. In a prequel to the Mother and Child controversy of the 1950s, the scheme was opposed by the doctors and the bishops, and the status quo and low salaries for the dispensary doctors persisted. In Britain, the National Insurance Act greatly increased the income of GPs from an average of 4s to 9s per annum per patient.

Negotiation of fees

Consultant fees in the first half of the 20th Century were by negotiation, but it was a seller’s market as there were very few consultants. Some patients were charged very little, but others, with known means, quite a lot; 100 guineas for a hernia or 50 for a cataract was a lot of money in the 1950s, when the average weekly wage for industrial workers was £8. When asked one day how he was going to make any money as he seemed to have so many poor patients in his surgery, Oliver St Gogarty replied: “Oh I have a duchess coming from London and I will settle her snout for a century”.

Barry O’Donnell in his wonderful book Irish Surgeons and Surgery in the 20th Century recounted how another ENT surgeon P. J. Keogh went by train from Dublin to Kildare to drain a quinsy, charging £17 4s 10d for his services.

When asked how he had arrived at that peculiar fee he replied: ‘Simple, …it was all the money they had in the house’. After the VHI came into being in the 1950s, fees became more standardised, but for many years the insurer paid the patient directly with no guarantee that it would be passed on to the hospitals or the doctors.

The compensation question

At the beginning of the 21st Century. we still wonder how best to compensate our doctors for their efforts and most societies have some kind of system in place, even if none of them are ideal.

According to the Medscape Physician Compensation Report, 2019 physician salaries in the US range from $209,000 (€185,400) for public health and preventative medicine doctors to $471,000 (€417,800) for orthopedists with most, but not all, doctors feeling that they are fairly compensated.

But, as Dr Atul Gawande, CEO of the Amazon-JP Morgan-Berkshire Hathaway healthcare partnership asked: “What do you do when patients come who can’t pay?” You could refuse to see them, but Dr Gawande disagrees: “We are in medicine and that comes with certain moral obligations… part of my job is to see those who can’t pay — even if sometimes it hurts”. However, we do not want to go back to the old dispensary system where the doctors ended up seeing dozens of patients who, in collusion with the guardians, could, but wouldn’t pay.

Pierce A Grace, MA, MCh, FRCSI, FRCS. Adjunct Professor of Surgical Science. Graduate Entry Medical School & Honorary Fellow, Dept of History. University of Limerick.