found whose practice was entirely among immigrants of one race.

DIFFICULTIES OF IMMIGRANT PRACTICE

Statements such as the following, revealing the special difficulties that medical care of the foreign born entail, are typical of interviews with doctors of several races widely scattered throughout the country. A Hungarian doctor in Connecticut states:

There is no such thing as a family doctor among the Hungarians. In a case of pneumonia they might have any number of doctors even at the time of the crisis. A man will say to me, "We do not want you any more." "Why not? What is the trouble?" I would get the answer, "Oh, my wife she get worse. You no good. We get another doctor." At first this discouraged me, but I have gotten used to it now. I have seen six or seven doctors meet at a bed unexpectedly.

A Polish doctor from Chicago gives similar testimony:

Among the poorer people it is common for three or four doctors to be called in on the same case. One doctor is called, prescribes, and leaves the medicine. After the patient has taken two or three doses without noticing any benefit he calls another doctor without telling the first. A doctor who wishes to know how a patient is getting along and makes a call without being sent for must do this at his own expense.

An Italian doctor from New York said:

Italians almost always call an Italian doctor because of the mutual sympathy and common language. The Italians are very fond of their families and will spend every cent

to care for a member if ill. They are not satisfied with the American doctors because they make a short visit, prescribe, and leave. This leaves the family in much doubt and accounts somewhat for their calling in another doctor if there isn't a marked improvement in a few hours. The Italian doctors tell the family what the malady is, and explain to them all about it, and this is what they expect. But the Italians are very excitable and when a child gets sick they run off for the nearest doctor, regardless of nationality. They always pay cash and as a consequence they are inclined to call various doctors at different illnesses, just as they patronize different stores. Most of the Italians in this section are from the north of Italy and many of them knew one another in the old country. I was known in Europe by most of these people, and when I came to New York I had a big practice almost immediately.

From these instances it is evident that the problem is not merely to cure the patient. It is to make him and his family believe that he is cured or is going to be cured. Furthermore, the doctor has to compete with other resources for curing disease-the drug store, the quack, the wise woman, the hospital, and the dispensary. Often he needs to be a psychologist and a financier as well as a medical man, if he is to cure, convince, and make a living at the same time.

To make a financial success of practice among the foreign born a man must work hard. His fees are not large compared with those charged by physicians and surgeons among the well-to-do. He is a general practitioner and he can derive relatively little income from surgical operations. In order to attend enough cases to make a living he must hurry through them all. If he has not enough cases to keep him busy he must nevertheless act as if he were busy, lest his prestige be diminished.

Careful medical work generally calls for a thorough physical examination of each patient; some history of the patient's disease, previous illnesses, and family health; a stethoscope should certainly be used in examination; and some laboratory tests ought almost always to be made. As a matter of fact, such physical examinations, history-taking, and laboratory tests are almost unknown in this class of medical practice. If the doctor is trained to such procedures-which is not always the case he has not time, or he fears the patient will not understand, or would be unwilling to submit. Also, the doctor must work with poor equipment. Some of these physicians can afford a microscope, and a few appear to have one. They are called upon to treat all kinds of disease, but their equipment of instruments and appliances for diagnosis and for treatment is usually very limited compared to that provided in a well-equipped hospital or dispensary or in the private office of a physician in good circumstances.

These limitations are not, as a rule, the fault of the individual physician. In some cases they are due to inadequate training at the low-grade medical schools formerly tolerated in this country. In many instances, however, they simply result, first, from financial inability to provide more than a low minimum of professional equipment, and, second, from lack of time or opportunity to utilize fully the knowledge and facilities which the physician does possess. Laboratory tests (except those provided by health departments for contagious diseases) are practically beyond the reach of the average foreign-born patient. The fees charged by private laboratories are often

more than the fee the doctor himself would get for an ordinary visit.

The physician practicing among the foreign born rarely has a position in a hospital or dispensary. In New York City, where hospitals and dispensaries have been developed as fully or more fully than anywhere else in this country, an investigation made by Dr. E. H. Lewinski-Corwin showed that 51 per cent of the registered physicians had no connection with either. In communities where hospital and dispensary service are less developed than in New York the proportion is undoubtedly smaller. The 50 per cent or more of the medical profession who have no institutional connection includes most of the men in general practice in the poorer sections of the community, and so those who serve the foreign born.

Lack of time and lack of training on the doctor's part are more responsible for this deprivation than prejudice on the part of the hospitals and dispensaries, although the latter is not infrequently a factor. The private physician fears that he may lose his patients and he avoids the use of hospitals and more particularly of dispensaries, through which free consultation with a specialist might be had for his patient.

Let it not be thought that this review of medical practice among the foreign born has ignored the devoted, efficient, and unselfish service rendered by innumerable physicians, often when struggling under very difficult conditions. It would be easy to multiply such examples, and to illustrate the splendid ideals of the medical profession and their finely developed application by men of all races working

among both rich and poor. But our part has been to indicate some limitations and problems of medical practice among the foreign born in order to aid, if possible, the fuller realization of these ideals and their application on a more inclusive scale of community service.

More remote than the home and neighborhood resource, the midwife, and the doctor, legitimate or quack, is the distinctively American health agency. The nurse, the hospital, the dispensary, and other forms of organized health service are usually unfamiliar to the newly arrived immigrant. He is not accustomed to turn automatically to any of them. If they are to be successful in their work, ways must be worked out whereby they meet him more than halfway. How to achieve this will be discussed after we have taken up more fully some immigrant health customs which present special difficulties.