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third practitioner being called in and your further services dispensed with.

It is very bad taste to inform the patient later, when the consultant has left, that you disagree with his diagnosis or treatment. You will not increase your professional reputation in the eyes of your patient, and again will merely raise uncertainty as to the two conflicting opinions. We should invariably act honourably towards both our colleagues and our patients.

No reputable doctor having been called in as a consultant would ever think of taking over the patient and attending to him, though practising doctors acting as consultants are not infrequently invited, and even urged by the patient or his relatives to do so. It would be an unpardonable breach of medical ethics to do so.

It is by no means uncommon for a patient to call on a consultant or specialist without the knowledge of his own medical attendant. In such cases the consultant should point out to the patient that it is very irregular for him to see patients unless introduced to him by their own attendant and furnished by him with a letter of information. If he does elect to examine him, however (though this is also a breach of etiquette), he must tell the patient that he will write to his medical attendant and inform him that he had called for advice. In this letter he will explain the grounds of his diagnosis and outline the treatment to be followed. The consultant ought not to prescribe for the patient, he ought to let the private practitioner do so. It by no means furthers a brotherly feeling between medical men when

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consultants prescribe for and treat patients quite apart from their own medical attendants. Such consultants do not benefit in the long run, as medical men cease to recommend their patients to them. The term consultant" means one who consults with another medical man, hence, if he does not do so, then he becomes an ordinary medical adviser and loses that prestige which ought to go with the vocation.

Etiquette of the Consultation.-Having discussed the matter with the patient or his relatives, and having suggested the consultant or specialist whom you think would give the best opinion regarding the particular disease from which the patient is suffering, and having received permission to invite him, it is your duty to communicate with him. You arrange with him a day and hour suitable to you both for the consultation. You must then intimate to the patient the time when the meeting is to take place. You ought to arrive at the patient's house a little before the appointed time, as you must receive and introduce the consultant to the patient. It is very annoying for the consultant to arrive and find you not there, as he has to wait until you come before he can see the patient. It would neither be polite nor wise of him to see the patient before you came, as you might have wished to communicate some fact of importance which you wanted him to investigate.

Presuming that you have arrived in good time, you await his coming in one of the public rooms, drawing, dining-room or parlour, but not in the patient's room. On the arrival of the consultant

you receive him there and give him a short account of the patient's illness and your treatment of the case, as well as any fact of importance, e.g., family history, alcoholic excesses, etc. It is advisable that no relative be present at this interview.

You then precede the stranger into the sick chamber and introduce him to your patient and to his wife, or any immediate relative who may be present. It is your duty to remain in the room during the whole examination in order to give any further information which the consultant may require and to help him in any examination he may make. It is discourteous of you to indulge in conversation with his wife or other person while the interview is going on.

When the examination is finished both you and the consultant retire to another room in order to confer regarding the case. When you have both come to a decision as regards diagnosis and treatment, the consultant then returns to the patient and either tells him what his opinion is, or, if this is not desirable, talks to him in a guarded manner. Although desirable, it is not absolutely necessary that you be present during this interview. If the patient himself is not to be told of his actual condition, then his wife or other relative having charge of him is summoned to your conference room, and is informed by the consultant of the true nature of the illness, of its probable prognosis and the treatment to be carried out. If the latter is important, then the nurse or attendant should be given instructions apart from the patient.

On leaving, the consultant should shake hands

with the patient and with his nearest relative. You may accompany him to the door in case there is anything else he may wish to tell you. You should then return to the patient and explain to him, perhaps more fully, the result of the conference. You are entitled to charge an extra fee in cases of consultation, as it may have occupied much of your time. It is usual to charge four times the amount of an ordinary visit.

If a prescription has to be written, it is better that this should be done by the consultant or that, at least, he should dictate what drugs he wishes the patient to have as well as the dosage. If the medical attendant writes the prescription, then the patient or his friends may imagine that he prescribed his own drugs and not those recommended by the consultant.

It may be, however, that neither diagnosis nor treatment can be given on the occasion of the visit, as an analysis or further investigation may be required. In such a case it is the duty of the consultant to communicate with the medical attendant later on when he has obtained the results of the analysis or of the further investigation, as to what is his opinion of the patient's illness, and as to the prognosis and treatment.

The consultant's fee is paid to him at the end of his visit either by the patient or his relative, or by you on his behalf.

As regards the question of modifying this fee to suit the pocket of the patient, I have generally found consultants most willing to reduce the fee to your patient's ability to pay as known by you.

One has no right, however, to ask a leading consultant to see some poor patient who may hardly be able to pay any fee at all. The proper place for such advice is at the hospital or infirmary. In cases where the patient is confined to bed, a junior specialist is almost always willing to give his services at a reduced figure in cases of real necessity.

In cases where there is no urgency, you ought to allow the consultant to fix his own time, so that he may see your patient on some day and time when he is least busy, and in the case of a poor patient the modification of his fee will not cause him undue financial loss.

The consultation may be at the specialist's own house, and this is often much more satisfactory if the patient is able to go there. He may have appliances and methods of examination at his own consulting-room which cannot be carried about. A much more accurate diagnosis can thus be made, and it lies with you as the medical attendant to advise this manner of getting a second opinion when you think it necessary. You may accompany your patient to the consultant and give him all the information you can, or if not, then you must send a letter explaining the case either before the patient calls or, at any rate, along with the patient. In any case, the consultant will write to you or com municate with you by telephone, and tell you his diagnosis and advise as to further treatment.

Urgency Visits to Patients of a Brother Practitioner.—It is a common event to be called upon to make an emergency visit to the patient of a fellow practitioner who is not accessible. He may have

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