Even as American attitudes towards doctors began to shift in the nineteenth century, there was one factor which placed severe limits on a doctor’s ability to establish a practice: the cost of providing his service. Primarily this was because the doctor had to travel from patient to patient in order to do his work, and travel was difficult and expensive even over short distances; a common fee schedule was 50 cents for the visit, plus one dollar for each mile the doctor had to travel. It was also expensive to let the doctor know that he was needed, usually requiring a trip to find him on the part of a family member or neighbor. Rural people were reluctant to go to town to see the doctor, knowing that they would probably lose a day’s work on the farm and not knowing if they would find the doctor once they got there, since he might very well be out on call. As a result, the indirect costs incurred when seeing a doctor far outweighed the direct cost of his service, and folks were either unable or unwilling to pay those costs.
Hard roads were the first innovation that made a doctor’s travel quicker and more efficient. Railroads also helped doctors who focused on consultation; they were able to cover wide areas, and even to barter medical care to railroad workers in exchange for their fare. And when the car came along doctors were able to increase their home visits four- and fivefold.
Meanwhile, the telephone made it possible to establish an appointment system. Initially almost all office visits were done on a drop-in basis, with no guarantee that patients would find the doctor there or that a doctor would have patients on a given day. But as patients were able to call ahead they became amenable to scheduling a time for their visit.