The High Cost of Babies
I
A PICTURESQUE fact connected with my arrival in the world is that it cost my parents, in doctor’s fees, exactly ten dollars. Nor did the bill ever vary for one of my mother’s six children born after me. No trained nurse assisted our doctor on these occasions, for there was none within a radius of seventy miles. But there was Aunt Lindsay, that intrepid woman with the huge spectacles and the shiny black bag, who always ‘stepped over’ from her plantation nine miles away to render my mother a bit of neighborly assistance in her hour of need.
So precisely did visits from Aunt Lindsay coincide with the arrival of a new baby at our house that we older children were thrown into a state of violent excitement whenever we saw her roan mare and ramshackle buggy appear over the top of the hill. During her stay she performed the duties which would have fallen to a trained nurse, mended up the stockings, planned the meals, made catnip tea for the baby, and took charge of the next youngest child. If we needed disciplining, she found time to do it, and before we started to school in the mornings she gave our necks and ears a critical inspection. No task was too trivial to enlist her interest, none was too big for her to tackle. My father always gave her five silver dollars for her services, and a basket of the choicest fruit and melons growing on the plantation. Once, when it seemed certain that a particular baby had started life handicapped by insomnia, and Aunt Lindsay’s biennial visit had been more than usually strenuous, he supplemented five dollars and a sack of apples with a fine young Jersey calf.
I do not say that things are not better to-day, but they are different. Statistics on infant mortality might be quoted indefinitely to show that the modern obstetrical nurse at forty-five or fifty dollars a week is a better investment than was the old-fashioned kind. But she is not nearly so comfortable to have around; for being, like nearly everyone else connected with the medical profession, a specialist, she does not concern herself with the other children of the household, or with those manifold small crises that spring up like mushrooms when the woman of a house temporarily relinquishes her authority.
The same doctor who presided at the birth of my mother’s seven children also saw us safely through the various children’s diseases. We teethed, whooped, and had chicken pox, measles, and pink eye under his benevolent supervision. Until our own children were born, we believed that our tonsils were an orthodox part of our anatomy, like our liver or our lungs, since he had never hinted the contrary. In point of time, this venerable family doctor is but one generation removed from the several men of the medical profession whose combined services have been required to keep our children, and my husband and myself, in a reasonable state of health. Spiritually, not to say financially, he is a type incalculably distant from the doctors we have known.
There is, for instance, the preoccupied and increasingly important obstetrician, who attended me at the birth of my first two children. He is successful now, and his fee is five hundred dollars for the delivery of a single child. There is the baby specialist, by whom, at the request of the obstetrician, my children were ‘gone over’ as soon as they arrived in the world, and whose word was as the law of the Medes and Persians to me until I came to wear the crown of my motherhood with something of the ease that arises from experience. There is, too, the at one time rising, but now risen, young throat-and-ear specialist who removed our superfluous tonsils and adenoids. In this list I do not include our excellent and modern dentist, one of whose office nurses calls me by telephone every three months to remind me that it is time for the oral hygienist of the staff to clean the children’s teeth, after which the dentist will fill them if they need it. That is another story. But I should like to mention the fact that my husband, poor wretch, occasionally sneaks off to a doctor of his own. Once, when I hinted that maybe it was a little extravagant of him to have a physician all to himself, he retorted that neither an obstetrician nor a baby specialist could do him any particular good. The subject has since been a closed one between us.
These physicians, and others called in by them, have seen us safely through the illnesses and minor operations which in this day no large family seems able to escape. As physicians, they have been skillful and tender. But their scale of prices has continued to soar, and our household accounts show that for every ninetyeight cents we have scraped together these past twelve years for what the family budget fancifully lists as ‘Education and the Higher Life,’ we have spent at least one hundred dollars for doctors’ fees. This in spite of the fact that we call ourselves a healthy family.
Now we believe in the specialist. No one man can encompass the boundaries of modern medicine in a lifetime. But we have learned too what heavy burdens specialization can inflict on a family of average income. It is not what we pay one doctor — it is the sum total of what we pay two doctors, or three, and what we pay for X-rays, nursing-charges, and hospital accommodations that makes it possible for the savings of years to be wiped out by a single illness.
II
When our first child was born, twelve years ago, my husband was receiving the infinitesimal salary of a newspaper man, and earned extra money when he could by writing Sunday stories. We had not a penny beyond what he made, but we were blithe young people. We had married for love, hoping to have children, and expecting to be able to take care of them. As soon as we knew that we should need a physician, we looked about with great care, and found exactly what we wanted — a man young, ambitious, and making his own way like ourselves. He was specializing in obstetrics, and we believed in specialization with all the enthusiasm of our inexperience. Moreover, this young doctor had the one requisite that was necessary so far as we were concerned. He was establishing a practice, as we were establishing a family, and we were given to understand that, although his goal was the vast sum of one hundred dollars for attendance at childbirth, he now charged a beginner’s fees.
When our baby arrived, and his bill was presented, it put us at an unexpected disadvantage. We had thought that he would charge around forty dollars, perhaps as much as fifty. But he sent us a receipted bill for one hundred dollars, with a friendly note telling us that this was his fee, and that he would be pleased to accept what we felt we could pay. We disliked to accept his services at a price less than that at which he valued them, but we could not make our slender budget cover the full amount of the bill. My hospital expenses for two weeks were sixty dollars. I had no special nurse, but was looked after, as are many mothers, by the ward nurse. One other item I must not forget; it has become an almost inevitable part of a young mother’s expenses. When our baby was a few hours old, the baby specialist appeared upon the scene. He had been summoned with my consent by our doctor, who said: ‘I don’t know anything about babies. I advise you to let Doctor Blank look the youngster over.’
The child was brought from the nursery, undressed, examined, and pronounced healthy by the specialist, to the accompaniment of its lusty yells. From that moment Doctor Blank dominated my life for a number of years. My children were weighed, weaned, fed, and exercised under his direction, and I would sooner have broken the Ten Commandments than one of his rules. The other specialists who flitted in and out of our home during the early part of our married life were called in by him, and under his régime I unquestioningly accepted all the latest wrinkles in the upbringing of the very young. I faithfully gave the baby tomato juice to drink, and I kept her on the sleeping-porch at temperatures that would have caused the women of my mother’s day to have me up for lunacy.
My parents’ first child had cost them, for doctor and nurse, fifteen dollars. This was twenty-five years before I had children of my own, and these were country prices. My husband and I lived in a city, and the birth of our first child cost us, including the baby specialist’s visit, one hundred and thirty-five dollars.
III
Things were different when the second baby came. My husband’s salary had increased considerably. So had our expenses. He had been sent to Mexico by his paper to write special articles for six months. I managed thriftily while he was away, and when he returned we gave up our tiny city apartment and made our first payment on a little house in the suburbs. This time our young doctor sent us his bill for one hundred dollars, without qualification. We managed to pay it, and gladly.
My room at the hospital was larger than the one I had taken the first time, and it had, as the doctor recommended, a sunny exposure. Of course we paid for the sunshine, but it was worth it. Another luxury which the doctor advised for me was a special nurse for two or three days, longer if we could afford it.
At the birth of our second child, our bills went up to little more than two hundred dollars. When our third was born, war prices had set in. My own doctor being overseas, I placed myself under the care of an elderly physician who, while he did not cater to rich and fashionable patients, was a man of established reputation. His fee was one hundred and fifty dollars. The price of hospital accommodations and nursing-service had increased enormously, so that, though my husband was earning four thousand dollars a year, the bills inflicted genuine hardship upon us; especially as they were coincident with two of considerable size from the child specialist and the ear specialist whom he had called in when one of the older children was sick with an attack of grippe and inflamed ears. These men insisted that the child’s tonsils and adenoids be removed, and as soon as spring came we had it done. We paid fifty dollars for the operation, and more than half as much again for the hospital charges.
This was the first and last time we ever had the privilege of paying fifty dollars for this particular operation. In the city to which we moved later, it had gone up to seventy-five. The favorite specialist of most of my neighbors now charges for it the round sum of one hundred dollars.
When we had been married seven years, we had three perfect children. Though we had never had a case of prolonged or serious illness in the house, our savings still fell far below what we had expended for doctors’ fees. Yet we reasoned that an ounce of prevention was worth a pound of cure; and we counted on getting ahead when the children were older. Our fortunes increased sooner than we expected. My husband received a business offer from a distant city at a salary almost twice as large as any he had received before. To us it seemed very big indeed, for we unconsciously measured it in pre-war terms. We sold our little house at a fair profit, had a good savings-account for the first time, and felt happy and secure in the move we were making.
But during our first year in our new home we learned what hardships extreme illness may inflict upon the average middle-class family of to-day, if it avails itself of the best that modern medical skill can offer. Our two eldest children had no sooner recovered from a neighborhood epidemic of measles than they were seized by a malignant illness; our attending child-specialist was not absolutely certain of its nature. He called in consultation another specialist, and they gave the disease a Latin name that sounded as if it might have come out of a seed catalogue. They informed us that it was one which in the history of medicine has been known to follow measles only about once in five hundred cases, and that our children were critically ill. We secured a night nurse at forty dollars a week, and I took charge by day. The child specialist was often at the house twice a day. An eye, ear, and throat specialist came three times, bringing his assistant once. The children recovered after several weeks, and we asked nothing more. I was happy when the doctors assured me that their illness could in no wise be attributed to lack of good care on my part, or on the part of the child specialist at home under whose supervision they had been since their birth. It was merely that lightning must strike somewhere. No family, however high its health standards, could be sure of immunity from disaster. The bills of the three men were considerate in the extreme. Added to the nurse’s salary, however, they made what was for us a staggering total. Yet we felt only gratitude for the skill of those who had served us to such good purpose, and we cheerfully drew upon our now diminishing savings.
IV
Our fourth child was born soon after this. My husband had accepted the advice of several acquaintances, all of whom named the same man, and had placed me under the care of Dr. X.
‘He may be a trifle more expensive,’we were told, ‘but you want the best.’ Yes, after the dreadful fright of our children’s first serious illness, we wanted the best as never before. Of course Dr. X specialized in obstetrics. His fee was two hundred dollars, and he had me go to a private hospital, explaining that all his patients went there and that I would not find it more expensive than any other. In this he was mistaken. My room for two weeks cost eighty dollars, and the other hospital charges were proportionately more expensive than any we had paid before.
It was at this time that we decided to change our policy very definitely.
‘No more specialists for us, ‘ we said, and meant it. ‘ We have taken an eightyear course under them in the care and feeding of infants. Now we shall apply the knowledge we have gained from the specialist, but we shall apply it under the tutelage of a good, old-fashioned, all-round family doctor. We shall find such a man, and under his precepts live and die. ‘
It was a decision that nearly cost us the life of our fourth child, and incidentally a great deal of money. Because the country is a healthy place for children, we looked about until we found a house we could afford within commuting-distance of my husband’s office. Within stone’s throw was the home of the family doctor, a man of long experience and excellent reputation.
No family ever had a better friend than we during the four years that we lived near him. He was a good doctor, too. But I have always felt that he did not have the highly specialized knowledge of which we stood in need when our youngest child developed serious digestive disturbances that went from bad to worse. We had determined to try out the family-doctor idea, and we clung doggedly to our resolve until it was almost too late. When the child specialist we had had in the city was finally called in consultation, he gave us to understand there was no time to lose. Within two hours after he entered our house the baby was in a tiny quiet room in the hospital in town, with a trained baby-nurse in charge.
For that first week our hospital, nursing, and X-ray expenses totaled eighty dollars, exclusive of the attendance of the family doctor and the specialist. And this was only the beginning. A wet nurse must be had. Here again the specialist’s methods meant securing the best, securing it immediately, and at whatever price one had to pay. We brought the baby home, and from an agency which sends out only those nurses who have undergone certain tests to determine that they have no diseases that may be transmitted to a nursing infant there came to us Alice, with her nameless baby. Dear Alice! I know that the Recording Angel wrote her name among the saints when she sat silently weeping because my child was too weak to draw from those lifegiving breasts of hers, and when she shared with me the watches of the night, and yet again when she so willingly and joyfully nourished my baby before her own, whom she loved as only mothers love.
Our child’s illness lasted five months. The services of the specialist were not needed continuously throughout this period; our family doctor conducted the case under his direction. All the visits that the specialist did make to our house were at a fee of ten dollars each. Nor was this exorbitant. We lived in the country, the winter was at its worst, and the physician’s services were greatly in demand. The family doctor charged the usual three dollars for a day call, and five dollars for a night summons, but I never felt that he made a superfluous visit. Alice and her baby stayed five months, and at the end of each week during that time I mailed a check to the nurses’ agency.
Except for the first week at the hospital we did not have a trained nurse, though there were times when I felt a bitter need of one. As it was, our savings had been wiped out entirely by the illnesses of a twelvemonth, and we were in debt for the first time. That our recent tribulations were outside the range of our ordinary experience was small comfort. They had happened once, and they might happen again. On the other hand, our child was saved. After all, nothing else mattered.
Like many a young mother, I probably went to extremes in my dependence upon the specialist when my children were in their babyhood. They are older now, and I have gained the confidence that comes with having learned their symptoms by heart. Also, experience has taught me the efficacy of castor oil and common-sense. I no longer cling to the coat-tails of the specialist, but I believe in him heartily. Even so, I want to put a certain question to him. In my daydreams I hear myself saying boldly: ‘Where, please, is this business of specialization going to end? Isn’t it already a little overdeveloped? ‘
V
Recently, when the subject of medical fees was discussed by a group of my friends, we agreed vaguely that one of the causes contributing to the size of present-day doctors’ bills is the overhead expense. I sometimes wonder if the doctor does n’t overdo this matter of overhead. A year ago my husband and our family doctor induced me to go to a certain diagnostician for examination. I appeared at his office at the appointed time. Did I say office? It was a suite which only the threadbare adjective ‘palatial’ can describe. There was no need for me to ring; at the door stood a smiling attendant to anticipate my coming.
I found myself in a happy glow of appreciation — until I cast an appraising eye at the appointments of the room. Then an uneasy feeling seized me. These Oriental rugs — they looked frightfully expensive. Those fine prints on the walls — they represented for me the patient economies of years. The two vases on the mantel — had the diagnostician paid for them, or would he put them on my bill? The thought terrified me. I should have tried to make my escape, no doubt, if at that moment my name had not been called by the most correct of graduate nurses. She conducted me to what, in all its appointments, might have been the dressing-room of a woman of fashion, and there she hovered over me while I changed my clothing for the coarse garment of unbleached ‘domestic.’
Then she led me tenderly into the adjoining apartment, which had the antiseptic smell, and much of the equipment, of a big operating-room. There we found a second young woman awaiting us, the diagnostician’s stenographer. When the trained nurse requested me to give in full my name, age, and place of birth, out came the other’s pad and pencil. It was all very professionally and efficiently done, but it gave me the depressed feeling I have frequently experienced just before going under an anæsthetic.
Enter now the great man, the diagnostician himself. Where his assistants had been all solicitude for my comfort and well-being, his own manner was as impersonal as if I had been a dummy stuffed with straw. He placed a hand on each of my temples, tilted my head back, squinted his eyes, and began to dictate rapidly. When he thumped me, shook me, raised my eyelids with his thumbs, turned and twisted me unmercifully, I was as putty in his hands; there was something hypnotic in that muttered stream of strange terms which his stenographer continued to transmit to paper. During these proceedings the graduate nurse anticipated, with exquisite deftness, the physician’s every move. It was teamwork developed to the nth degree. Did he have need of an instrument, it was in his hands. Did he require stronger light, the room glowed. If he wanted more heat, it burned within arm’s length — all without spoken word from him.
And when, finally, he had done with me, was this all? It was not. It was just about half.
’One of my assistants will make an appointment for you with my partner, Dr. A. He will give you the pelvic examination. You know he specializes along that line.’
Ten days later I received by mail a document which I at first mistook for somebody’s last will and testament, mailed to me by mistake. It turned out to be my medical history as compiled in the offices of these two physicians. I should frame it if it were not twelve pages long, and if I could understand so much as a paragraph without referring to my Latin dictionary. As it is, I have laid it away to hand down to the children with other distinguished family records.
The result of these sessions with the diagnostician and his partner was that they pronounced me a sound woman, suffering only from overwork. I have often wondered, however, just what proportion of the bill that I received from them could be charged to overhead expense in the running of their offices.
VI
Not long ago I had an opportunity to ask a well-known member of the New York Health Department, himself a practising physician in that city for many years, what, in his opinion, was the remedy for the financial burden which specialization in medicine imposes upon the average family, and I told him some of the personal experiences recounted above. He regarded me with the tolerant look which a wise man sometimes bestows on a foolish woman, and said: —
‘There are thousands of women like yourself bringing up families of children on average incomes, and who, like you, feel that they have a right to those highly specialized services which doctors can give only at prices that none but the rich can afford. You do not realize that you are reaching for something beyond your grasp. It is just as if you were riding down Fifth Avenue in a Ford, and suddenly decided that you were entitled to a Rolls-Royce. Or as if you became dissatisfied with your string of beads when you saw a woman in a box at the opera wearing pearls. It is the middle-class woman reaching out for what only the rich woman can have. What all of you need is to utilize more of the knowledge of hygiene and preventive methods which the publichealth services, and other educational agencies, place at your disposal. Then, with the aid of a good general practitioner, or family doctor, keep your families up to such high health-standards that the services of the specialist will not be needed to any great extent.’
This was common-sense, of course, but it left me unconvinced. I talked back to him, eminent man that he is. The best medical attention when they need it, for the people whom I love, is a vital thing to me, like good schools, or pure water, or clean milk. My child, no less than the child of the woman with the limousine or the string of pearls, is heir to and flower of the ages. I demand the best for him as passionately as she demands the best for her own. Why should the splendid and thrilling results of specialization in modern medicine be employed for the benefit of two minority groups — those who are rich enough to pay enormous prices, and those who are poor enough to go to the clinic? What about the great middle class to which I belong?
To-day we still live in the country. Less than a mile from our house is the office of an excellent physician whom we fondly but fictitiously call our family doctor. But he is not a family doctor in the sense in which my parents knew the term. He does not attempt to cover the whole field of medicine. He too believes in the specialist, for he has us consult one whenever a situation arises that calls for a highly differentiated medical knowledge.
I believe that this family doctor of ours, in common with other general practitioners, is partly responsible for overspecialization in medicine. Because of the squeamish ethics for which the medical profession is noted, or because he feels that his patient has confidence in and desires specialized attention, the family doctor is too prone to recommend that a nervous woman or a fearful man go to the specialist for all sorts of simple operations, like throatspraying, for instance, which could perfectly well be attended to by himself. The specialist, without fanfare of trumpets, or blare of advertising, has sold himself with complete success to the public. He is rapidly obscuring, as well as subjecting to unbearable economic pressure, the general practitioner, whose lieutenant he should be, and with whose services we of the middle class cannot afford to dispense.
What is the remedy for such a state of affairs? Does it lie in limiting the number of specialists? Will it be found, as some medical journals and several recent books ask uneasily, in the supplanting of the present system of individual medical practice by a system of state medicine, in which an efficiently administered public-health service shall be the physician of the people? Is the solution in group practice? Or in educating the public away from the specialist and back to the general practitioner? Or in a scale of medical fees based upon incomes?
The most gifted and successful young specialist whom I know has an interesting plan, not yet worked out as to detail, for relieving the pressure which the high medical costs impose upon certain classes. He would establish clinics, at which the man of small income would pay according to his ability to pay. Such clinics, my friend believes, would solve the problem for those of quite limited income as free clinics have solved it for the very poor. This young specialist honestly means to work out this plan of salvation. But when I consider the enormous overhead expense which he incurs in the practice of his specialty, and the increasing number of wealthy and important patients who wait in his reception rooms, I wonder if he will not, as years go by, be too busy and too prominent to think about it at all.
VII
This question of specialism in medicine, and the resulting high costs of medical service, are problematic to doctors no less than to a restive public. The forward-looking physician sees in the numerous subdivisions of medical practice that exist to-day an economic menace to the whole of his profession. Obviously the system must topple if it becomes more complicated. He realizes that the practice of medicine must be reorganized, but so far as I am aware he has not as yet come forward with a programme looking toward a solution. If any doctor or layman thinks it impertinent of a plain, everyday woman to make the suggestions that follow, let him come forward with better.
First, there should be fewer and better specialists. In saying this I do not mean to detract from the contributions made by the specialist to surgery, bacteriology, and other branches of modern medicine. But it is a fact acknowledged by members of the medical profession that many specialists embark upon their careers with inadequate preparation. Let the national and state medical organizations require of a man three years at least of general practice before he becomes a specialist. Five years would be better.
Second, we need not fewer, but more and better general practitioners, with better equipment at their command. These practitioners must deserve and must have our confidence.
Third, there should be some method whereby specialists’ fees may be fixed, not according to the supposed, but according to the actual income of the patient. The doctor has every right to ask and to learn the patient’s income.
I would go further. There are circumstances under which I believe the patient has the right to inquire as to the doctor’s, and to receive a truthful answer.
Fourth, all doctors must find some way in which to cut down on the present senseless and unnecessary overhead expense, if the cost of medical attention is to be lowered. This might be done by a common use of reception rooms, a practice which I understand is gaining in certain Western cities; by the substitution of a common laboratory for expensive individual equipment, and by combining on the services of bookkeepers, attendants, and office nurses.
The responsibility by no means rests wholly with the doctor. The layman can do much to help the situation. He should demand the best general practitioners, and he should depend more upon them and less upon the specialist. Also he should realize that the health of the community is the health of the individual. He should insist that our boards of public health be in the hands of professionally competent physicians.
Finally, one important point rests with us women. We are both unwilling and unable to nurse the children that we bear; we are bringing up a bottlefed generation. Despite our enlightened knowledge of hygiene and sanitation, such a generation is but too likely to stand in need of all the doctors and dentists that the times can supply.
The cost of hospital accommodations is another menace to the pocketbooks of the middle class. Recently a neighbor of mine hurried her boy to the Children’s Hospital in the city near us, where a gland in his neck was opened by the ear specialist whom her doctor had called in. She arrived at the hospital at eight o’clock in the evening, the operation was performed at ten that night, and she carried the boy home at eight next morning. She had no special nurse, but took care of him through the night herself, with the aid of the ward nurse. The hospital bill for the night was thirty-one dollars, itemized as follows: ‘Room, eight dollars; use of operating-room, ten dollars; anæsthetist’s fee, ten dollars; laboratory examination, three dollars.’
These suggestions are made in the humble spirit of a layman who acknowledges a large debt of affection and thankfulness to many men of the medical profession.