The Title of Doctor or Mister?
A proposal to abandon the tradition of addressing surgeons as “Mr” instead of “Dr” met with a frosty reception, it was reported in Hospital Doctor early in 1992.287 The current tradition, which has never held for otolaryngologists in Edinburgh who proudly display the title Doctor, was defended by the Royal College of Surgeons which claimed that the custom dated back 800 years, had served the profession well, and that there was no reason for change. The controversy is nothing new, as anyone familiar with the British Medical Journal of Victorian times will be only too well aware. For those of our readers for whom clinical responsibilities bear too heavy to allow more than the minimum familiarity with this (and it is for those of our colleagues that this book is primarily intended) we will choose just one example, written anonymously under the title, A Doctor, But Not M.D. in 1876. He proclaims that “despite of any bylaw, I shall continue to call myself doctor, for the Royal College of Physicians were trying to restrict this to holders of the degree of Doctor of Medicine”. The worthy correspondent goes on to write that: to attempt to confine the title of “doctor” to M.D.s of Universities is an attempt to create a medical monopoly on the part of a limited number of bodies who do not respond to all necessities of practice. If this be upheld, there can be no “doctors” made in London, the greatest medical centre in the world, except by that very exclusive and high-flying body the University of London, which reserves that title for bookworms of the highest and most exhaustive (not to say exhausted) order.288
This is quite different from the position today. In fact an attacker to the 1992 article claimed that Mister was an inverted form of snobbery, singling out the highly qualified doctor from his peers. In more recent times (historically speaking) it has been the custom to restrict the use of this title to those who have passed their Fellowship examination. The librarian of the Royal College of Surgeons was even quoted in the Hospital Doctor article as saying that “he would be rather sad to see “Mr” go because it doesn’t harm anyone and these nice little idiosyncrasies in a sense make life worthwhile”. Your authors do not have such strong feelings as to consider that the worthwhileness of life depends on the subject, despite the flurry of correspondence which flooded the medical journals. One penned a reply but forgot to post it. The other held that were dentists to start using calling themselves doctor – an argument that was running parallel, then the title would be so devalued that everybody might as well be Dr – or Mr. This didn’t do him any good as his brother, a dentist, simply stopped lending him his sportscar.
The late, great Kenneth Harrison once asked a disciple “Why do you think I always use a post-aural incision rather than an endaural one?” A flood of answers ensued:
Because it is better cosmetically and follows Langer’s lines,
Because it never gives a fistula,
It is easier to stitch up,
It doesn ’t cause neuralgia,
There is less tension in the wound,
There is less post-operative pain”
All these answers were met with a dismissive negative. When at last the registrars gave up and asked for the real reason, the Master smiled and slowly replied:
Well, I suppose really it’s because I’ve always used it.
(b) Remuneration.
Fees have always been a thorny subject, not least when one considers what professionals in other fields might be making in considerably less time (though with perhaps more effort). We are told the story of a Lancashire man who consulted a colleague privately after going with a prostitute and who was worried he might have caught something. He sought the opinion of an Ear, Nose & Throat surgeon because that is where the action had taken place. After the requisite tests he was assured that he need have no worries, but as he had been seen privately there would be a bill to pay. Taking pity on the man, the kindly and benevolent otolaryngologist charged him his minimum rate, to be met with a gasp of disbelief. His fears that even this was beyond his pocket were put to rest when the man cheerfully announced that it was cheaper than the prostitute. One has not only to compare the fees which might be obtainable in the practice of otolaryngology with other professions, but also in looking over a period of time, with other costs. For example in 1902 an Urban Council unanimously passed a resolution that:
In cases notified as diphtheria in which swabbings taken by the medical attendant are confirmed by the bacteriologist to the Council a fee of 10s 6d shall be paid to the medical attendant.289
To put this in some sort of historical context this was a third to a half of many a worker’s weekly wage. However, in comparison to this, the announcement, admittedly thirty years before from the Committee of Westminster Hospital that registrars
who have hitherto done the duties of these appointments gratuitously will be remunerated; the sum of eighty pounds has accordingly been voted for the purpose, but only for the ensuing year.290
Tony Bull and Ian Mackay are the two smoothy London surgeons who run the excellent Rhinoplasty course at Gray’s Inn Road every year. Rhinoplasty, of course, is a bit of a money spinner,xx and expertise in the art can almost be “the potentiality of growing rich beyond the dreams of avarice.,yy Ian tells a lovely story about Tony Bull when he was about to go on one of his many continental trips and decided to apply for an American Express Gold Card. Evidently the agent was a young girl who was unaware that Tony was a wealthy Harley Street surgeon, and told him that before anyone could be given a gold card they must answer a few personal questions. He said that he quite understood and so she started to ask him about his income, starting rather tentatively at wondering whether he earned in excess of £20,000.
“Oh yes”, he replied without hesitation.
“Well then”, she said with a little less diffidence, “Do you earn more than £50,000?”
“Yes”, he replied.
Feeling more confident now she ventured: “Alright then Sir, would you say that you made more than £100,000?”
At this point Mr Bull hesitated and there was a pregnant silence, broken eventually by him admitting that it was rather difficult to say; some weeks he did, some weeks he didn’t.
When considering the vexed question of filthy lucre, one should obviously bear in mind that there has always been a contrast between the high earnings of those at the top of the profession and those struggling their way up. Medicine differs in this in no way from the other professions where the bright young newcomer has to serve his time before reaching the remuneration of the seasoned campaigner. The profession of prostitution may well prove an exception, though the authors would not like to be too definite upon this, their application for a research grant having been turned downzz. What has changed nowadays is that formerly the difference between a well-established practitioner and his apprentice was in the cut and quality of clothes rather than the mode of dress and both were for the most part distinguishable from those they treated. Today neither is the case. Someone walking the wards in pre-War days would notice stiff erect formal figures soberly dressed (the doctors)aaa surrounded by bent, broken Lowry-like characters clutching dressings to various parts and oozing blood, pus etc (the patients). How different the scene is today! A bronzed, permed young Adonis bounds into the Sports Medicine Clinic and after being counselled by a variety of health care professionalsbbb (and no doubt receiving a few free condoms) asks the doctor for some embrocation (no doubt using a fancy word learnt at the health club) and a support bandage for his “sports injury”. The doctor, after a sleepless night in an uncleaned on-call room bereft of bed linen stares blankly ahead, a sheaf of job applications spilling out of a tattered white coat which, in the way that plumbers and electricians strap their tools onto belts, serves as a scaffolding for a panoply of medical instruments, trousers crumpled and unshaven. Some of the men are even worse.
Of course when speaking of remuneration one must consider the non-pecuniary rewards as well. Delightful unwitting testimony to the subtle use of influence to procure additional benefit is given by Sir Frederick Mott when relating the practice of a colleague, Sir William Broadbent. Describing him as “that great and experienced physician”, he relates how he had noticed that frequently in the houses of the wealthy it was difficult to obtain suitable food for patients, owing, he held to the failure of the chefs to understand, and the lack of authority of the nurse. He would, therefore, knowing the great importance attached to proper food being given to his patient, go into the kitchen and instruct the cook in the preparation of suitable food. Afterwards he would, when visiting, “ask for the food to be brought that he might taste it”.291 Neither author has adopted this for use in domiciliary visits, but would be interested to hear from any reader who can vouch for its efficacy.
Frank Stansfield of the anatomy cramming course fame, used to hold that the only function of Waldeyer’s ring was to provide custard-coloured Rolls-Royces for ENT surgeons. In this he was probably not strictly correct. A well-known Australian surgeon called his Rolls-Royce Grommets – because they had paid for it. Tonsillectomy might, in the view of some, fulfil a similar function. Whilst demonstrating a new instrument he had devised for tonsillectomy, Mr J F O’Malley told the audience that he was in the habit of operating on thirty cases in the morning at his hospital in two hours.292 Not all ENT surgeons are so conventional in their tastes and there is none better to illustrate this than Sir William Milligan (for even the eccentric Draffin possessed a couple of Rolls-Royces). The department in Manchester where he worked still treasures the picture of him directing the traffic in the centre of Manchester, and local children used to wait after school for him to pass by to laugh at him.293 One should be aware of the dangers of appearing too unconventional – in the words Alan Bennett puts into the mouth of a character seeing the doctor who is about to manage her case:
He had one of those zip-up cardigans, which didn’t inspire confidence.294
It has been customary for eminent surgeons to advertise their eminence and adroitness at the operating table by inviting colleagues (usually for a fee) to watch them operating. The dress of such spectators should be, it is advised by Shambaugh in his famous textbook, trussed like a mummy with the arms completely immobilised by the sides rather like a straight-jacket.295 This was presumably to prevent the surgical equivalent of a “back seat driver”. It may in earlier times have also served to protect the innocent bystander for it is reported that with a single cut, one of the nineteenth century’s greatest surgeons not only amputated the patient’s leg as intended but also managed to remove three fingers of the assistant and his own coat-tail.296 A case has also been reported where the surgeon cut so vigorously that he managed to perform inadvertent self-circumcision! Jacques Joseph took the practice a stage further when he dismissed his spectators during crucial parts of the operation so that they would not learn his “trade secrets”. The authors are as yet unaware as to whether his operating theatre nurses ever divulged this information and for what price. Cottle was so irritated at having to be one of an audience of twenty or so spectators for one of Joseph’s nasal operations that in desperation to obtain a good view he bought all twenty seats. Two seats at a fancy restaurant with the nurse might have yielded better results. Such behaviour has not been confined to the operating theatre. Thomas Braidwood who opened the first school for the deaf in this country kept his teaching methods a family secret although they were published after his death by his son as Instruction of the Deaf and Dumb (1809).297 Of course, sometimes education and the dissemination of information can have results which might not be received in the manner in which they were intended. The great Lord Baden-Powell wrote warning of:
the “rutting season“, when young men are attracted to women. This disagreeable phase troubles some fellows to an alarming amount of depression or excitement which often lasts for several months.298
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