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diff --git a/78813-0.txt b/78813-0.txt new file mode 100644 index 0000000..19e3b32 --- /dev/null +++ b/78813-0.txt @@ -0,0 +1,1990 @@ +*** START OF THE PROJECT GUTENBERG EBOOK 78813 *** + + + + + Doctor and Patient + + _Papers on the Relationship of the Physician + to Men and Institutions_ + + + BY + FRANCIS WELD PEABODY, M.D. + + _Professor of Medicine, Harvard Medical School; + Director of the Thorndike Memorial Laboratory; + Visiting Physician and Chief of the Fourth + Medical Service, Boston City Hospital + 1921 to 1927_ + + + NEW YORK + THE MACMILLAN COMPANY + 1930 + + + + + Copyright, 1930, + By THE MACMILLAN COMPANY. + + All rights reserved--no part of this book + may be reproduced in any form without + permission in writing from the publisher. + + Set up and printed. Published June, 1930. + + + SET UP BY BROWN BROTHERS LINOTYPERS + PRINTED IN THE UNITED STATES OF AMERICA + BY THE FERRIS PRINTING COMPANY + + + + + Three of the papers in the collection have already appeared in + print; “The Care of the Patient” is reprinted by permission from + the Journal of the American Medical Association, Volume 88, pages + 877 to 882, and The Harvard University Press. “The Physician and + the Laboratory” is reprinted by permission from The Boston Medical + and Surgical Journal (now The New England Journal of Medicine), + Volume 187, Number 9. An expression of appreciation is also due + the Journal of the American Medical Association for permission to + reprint “The Soul of the Clinic,” which appeared in Volume 90. + + + + + CONTENTS + + + PAGE + Introduction by Hans Zinsser, M.D. ix + + The Public and the General Practitioner 1 + + The Care of the Patient 27 + + The Physician and the Laboratory 58 + + The Soul of the Clinic 72 + + + + + INTRODUCTION TO COLLECTED PAPERS OF FRANCIS W. PEABODY + + +The writer of these papers, composed at different times for specific +occasions, without thought at their writing, of eventual collective +publication, was beloved by his friends for qualities of heart and mind +that were not associated by them with his professional achievements. +Yet as one thinks of him in retrospect, appraising him as a physician, +one becomes more and more convinced that his great significance for +American medicine sprang from those very qualities which endeared +him in his personal relations, applied to and interwoven with his +professional life. Intellectual and emotional sanity and integrity, +from which wisdom, kindness and courtesy are derived, were the natural +endowments which brought him distinction as a human being and which +gave him an importance for American medicine possessed by very few of +his contemporaries. + +In the history of medicine there are many names associated with +the discovery of facts, with learned treatises and with technical +achievements of one kind or another; there are relatively few of whom +we think especially as physicians in the sense in which this word is +used in regard to Suydenham, for instance. It is a rare blending of +learning and humanity, incisiveness of intellect and sensitiveness +of the spirit, which occasionally come together in an individual who +chooses the calling of Medicine; and then we have the great physician. + +His professional life fell into a period of reorganization and +unparalleled expansion in the medical world in which public attention +quite naturally was focused on the material phases of these changes. +Fundamental to these, however, and far more permanently significant, +there was an intellectual reorganization and expansion which demanded +the development of new leaders who might accomplish for our generation +what men like Neusser, Nothnagel, McKenzie, Osler, Delafield, Shattuck +and James had accomplished for the one just past. Of these young +standard-bearers of the new Medicine he had become an affectionately +acknowledged leader. As he grew in maturity and authority his interests +were forced, almost in spite of himself, beyond his immediate work in +laboratory and wards, into the more general problem of the relations +of his profession to education, public health, sociology and, we may +call it, its moral and philosophical bearing upon community life. In +the educational phases of his work, the clinic which he headed at the +Boston City Hospital represents a contribution to the constructive +coördination of teaching, investigation and the care of the sick which +solved many difficult problems and has already exerted a profound and +lasting influence upon medical organization. This was his chief work at +the end of his life and here he was continuing the studies which had +already made him a noteworthy investigator and teacher. + +But the imagination and critical faculties which had given value to his +investigations were equally fertile in the more general aspects of his +interests. Sought as a member of the most important scientific bodies +of our country, he was capable of impersonal judgments and retained, +as he would have indefinitely, that combination of the young heart and +the old head in which the passage of time makes little difference and +which, together, are the essentials of true understanding. + +Of all his valuable contributions to the development of modern +medicine, these short papers are the ones which deal most directly with +the problems forced upon medicine by its own rapid development and by +the increased opportunities and responsibilities which involved it with +educational, social and economic changes. They deal with questions +many of which are still unsolved, and their publication will serve to +continue the influence of a voice that American medicine could ill +afford to lose--one of clear-headedness, unsentimental idealism and the +great wisdom of affectionate optimism. + + Hans Zinsser. + + + Francis Weld Peabody + + Born--November 24, 1881; died, October 13, 1927. + + _Degrees_--A.B., Harvard, 1903. + M.D., Harvard, 1907. + + _Positions_-- + + Intern, Massachusetts General Hospital, 1907-08. + + Assistant Resident Physician, Johns Hopkins Hospital, 1908-09. + + Fellow in Pathology, Johns Hopkins Hospital, 1909-10. + + Student of Chemistry, University of Berlin, 1910. + + Assistant Resident Physician, Hospital of the Rockefeller + Institute, 1911-12. + + Assistant of the Rockefeller Institute, 1911-12. + + Resident Physician, Peter Bent Brigham Hospital, 1913-1915. + + Member of Commission of Rockefeller Foundation to China, 1914. + + Member of China Medical Board of the Rockefeller Foundation. + + Member Red Cross Commission to Roumania, 1917. + + Major, U. S. Army Medical Corps, 1918. + + Assistant Professor of Medicine, Harvard Medical School, 1915-20. + + Physician, Peter Bent Brigham Hospital, 1915-21. + + Consulting Physician, The Collis P. Huntington Memorial Hospital, + 1915-21. + + Associate Professor of Medicine, Harvard Medical School, 1920-21. + + Professor of Medicine, Harvard Medical School, 1921-27. + + Visiting Professor of Medicine, Peking Union Medical College, + 1921-1922. + + Director of Thorndike Memorial Laboratory, Visiting Physician and + Chief of The Fourth Medical Service, Boston City Hospital, 1922-27. + + Consulting Physician, Peter Bent Brigham Hospital, 1922-27. + + Member Board of Scientific Directors of the Rockefeller Institute, + 1926-27. + + + + + THE PUBLIC AND THE GENERAL PRACTITIONER + + + Red Cross Meeting at the Tri-State Medical Association, + Seattle, June, 1923. + +“System and Efficiency,”--these watchwords of modern American business +life, are beginning to be adopted by what used to be called the +“learned professions”; and medicine, in particular, is entering a +period in which “organization” and “service” seem destined to play +a prominent and perhaps somewhat exaggerated rôle. The introduction +of business methods and business phraseology into a profession which +has hitherto been singularly free from a business atmosphere is to be +explained in part by the general trend of the times, and in part by +a praiseworthy attempt to give the public an opportunity to benefit +more systematically from the extensive, though often complicated, +advances of modern medicine. The function of the physician is no +longer regarded as being limited to the care of the sick. “Health +examinations” and “preventive medicine” for instance, are phrases as +well known to the layman as to the doctor, and the medical profession +is very properly preparing itself to offer to the public a new type of +“service,” aimed, at least, at limiting the occurrence of disease. In +making this broader program of usefulness available, there is every +reason to believe that more and better work will be accomplished if the +somewhat casual methods of many doctors are supplemented by those of +the business world; but it is also of the utmost importance to remember +that the experience of the centuries should neither be disregarded, +nor subjected to modifications which, because they are new, may be too +readily considered good. This conservative attitude applies chiefly, +of course, to the age-old function of the physician in his relation to +the sick. It may well be, though the question is debatable, that a new +field, covering the care of the well, involves or permits something new +in the relationship between doctor and patient. There may thus be some +justification for the use of methods generally referred to as “putting +the patient through the mill,” but there are already indications that +the same methods applied to the care of the sick often lead to the +patient’s confusion rather than to his peace of mind. And after all, +the patient does deserve some consideration! + +Any reorganization of the medical profession that threatens the +personal bond between doctor and patient is to be viewed with +suspicion, even if the object appears at first sight to be more +thorough and careful practice. With the exception of the relationship +that one may have with a member of one’s family, or with the priest, +there is no human bond that is closer than that between physician and +patient (or patient’s family), and attempts to substitute the methods +of machine or organization, be they ever so efficient, are bound to +fail. + +Even the most forward-looking medical man must admit that for a long +time to come, the main function of the medical profession will be +to heal, relieve and comfort those who are sick or in distress, and +plans which are devised to readjust the relationship between doctors +and laymen must be based primarily on this consideration. New needs +and opportunities are to be recognized and met as well as possible, +but the chief thing is to be certain that in the name of the newer +“Service” with its capital “S,” nothing of the old-fashioned, modest +but effective service of doctor to patient is lost. I do not intend to +suggest that relations between the layman and the medical profession +should remain in the future exactly as they have been in the past. +It is perfectly obvious that the manifold developments which have so +increased the complexity of the practice of medicine make certain +readjustments necessary, but it has become correspondingly clear that +we must “watch our steps.” The protests of patients and their families +or, to their credit, more often the muffled voice of their complaint, +that they are no longer happy or contented in their relations with +the medical profession are becoming more and more frequent. “I don’t +think my case was handled right” is a phrase very commonly heard +from patients who have had a long and varied medical experience, and +curiously enough one is quite apt to find that it does not refer to +the actual results of treatment. The modern layman of the educated, +and often of the comparatively uneducated, classes, seems to have +become surprisingly well aware of the fact that specific “cures” are +not available for every disease or every symptom, and he is usually +remarkably lenient in what he demands in the way of therapeutic +results. His dissatisfaction has to do more with the general management +of the case in which social and economic considerations are quite as +important as its scientific aspects. He has attempted to get the best +care, without regard to cost, and he finds that he has wasted his time +and money going from one physician to another without finding anyone +who can straighten out his troubles, or, what is more significant, is +deeply interested in them. + +One might be inclined to make little of such criticism, believing that +it is the natural lot of every difficult profession, but the truth is +that many of us who are in a position to hear of these experiences find +that they are becoming more numerous, that they are often serious, +and that the majority are quite avoidable. The difficulty seems +to arise from a failure of “liaison,” and at first sight it often +seems as though a more highly organized medical profession might be +better qualified to deal with the situation. The fact is, however, +that this type of trouble may arise in exactly those cases which +have been in contact with one or more of the most modern clinics, +and a careful study of the circumstances makes it perfectly clear +that the trouble arises, not from a lack of organization but from +lack of personal supervision and responsibility. For some reason or +other no one physician has seen the case through from beginning to +end, and the patient may be suffering from the very multitude of his +counsellors. Of course I do not mean to infer that lack of continual +personal responsibility on the part of an attending physician is the +sole explanation of the failure of the patient to establish a happy +relationship with the medical profession, but the observation of a +great many cases in which the patient or his family have felt that the +relationship was unsatisfactory, incomplete, remote and cold, makes +me feel certain that it is a very common explanation. Those of us who +value the high tradition which we have inherited in our profession find +much pleasure in the intimate bonds that have always existed between +ourselves and our patients, and if any break is threatened we must try +to discover and meet its causes as early as possible. + +There are unquestionably many explanations for the loosening of the +bonds between doctor and patient, but I shall dwell at present on only +one aspect of the situation, an aspect that involves the point of view +of the layman, and one in the correction of which the layman can play +almost, if not quite, as important a part as the medical profession +itself. + +The layman of the older generation, who has been disappointed in his +medical experience and who feels that something has been lacking in +the way of warmth, sympathy and understanding of his case as a whole, +is very apt to hark back to earlier days. “What we need,” he says, “is +a general practitioner! When I was a boy we went to see Dr. Brown if +we had anything the matter with us and he always fixed us up. Nowadays +there don’t seem to be any general practitioners, and we visit one +specialist after another, trying to find the one who happens to know +about our particular ailment.” Does this complaint merely represent +the normal senescent yearning for those old times which always seem +to have been so much better than anything that has come since, or +does it rest upon some firmer basis and suggest a possible way out +of our present difficulty? At any rate, the question raised is worth +serious consideration. Why is it that the general practitioner is being +supplemented by the specialist, and where does the responsibility for +this shift in emphasis lie? Is the further development of this trend +to be regarded as desirable, either from the point of view of the +public or the medical profession, and if not what can be done about it? + +The fundamental factor in the present increase in specialism is without +doubt the progress which has been made during the last two or three +decades in the various sciences which underlie the art of medical +practice. Researches in anatomy, embryology, physiology, physics, +chemistry, pathology, and bacteriology have so extended our knowledge +of disease processes in man that, in spite of a lengthening of the +period of study, it has become quite impossible for any individual to +acquire an intimate understanding of all the broad fields of modern +medicine. In the four years’ course of the medical school the student +can get little more than an introduction into the so-called premedical +sciences, and he learns of them only what is necessary to enable him +to grasp the basic facts on which medical practice rests. If he is +fortunate enough to be able to pursue his studies for a period of years +after graduation, he naturally devotes himself to some limited phase +of medicine in which he is particularly interested, and attempts to +develop himself as far as possible in this direction. Meanwhile it is +quite impracticable for him to keep in touch with the details of other +fields and he becomes, by force of circumstances if not by wish, a +specialist in what is often a comparatively narrow sphere. + +In an era which is so characterized by scientific progress in all +directions it would be strange and unfortunate indeed if medical men +should lack the instinct for intensive study or for scholarship. +Primarily, and in its highest expression, specialization represents +the attempt to fulfill an intellectual craving, and as such it is +most desirable, both for the tone of the profession itself and for +the public which depends on the profession. Such a view of the +situation is, however, far from complete, and other motives, of a less +disinterested nature it must be confessed explain a considerable part +of the tendency of medical men to prefer specialization to general +practice. Thus, for example, the life of the specialist sometimes +appears to be an easier one than that of the general practitioner, for +the latter has less regular hours of work and may be called to his +patients at most inconvenient times. If he is successful in his calling +it is true that his life can never be called his own. Many doctors +whose careers were interrupted by the war said, “I am not going back +to continue being at the beck and call of every one by day and night. +I’m going to specialize, and do an office practice.” On the other hand, +it must be remembered that the life of the specialist is not an easy +one. His hours of work can be to a considerable extent regulated, but +they are long and exacting, and, if he is worth his salt, he will run +up large bills for lighting, since most of his evenings must be devoted +to study in a struggle to keep abreast of the advances that are being +made in his field throughout the world. Again, the financial rewards of +the successful specialist are usually considerably greater than those +of the general practitioner, and to some this is unquestionably the +determining factor in the choice of a career. Many others, however, +are but slightly influenced by either of these considerations in +their preference for the limited fields of medicine, and are chiefly +affected, not by the new developments in the specialties, but by the +fundamentally altered circumstances which at present surround the life +of general practice. + +Let us approach this question by considering briefly the motives which +led men of high grade into the practice of medicine a generation ago +or before specialism with all its rewards was widely developed. The +motives were, in general, the earning of a livelihood, a specific +interest in medical science, and, in the great majority of instances, +a very real desire to be of service to one’s fellow men. The chief +reward was not the livelihood, which was often extremely meagre, or +the satisfaction of scientific interest, but the appreciation, the +love, the regard of a community. The physician was the friend and the +guide of his patients who turned to him in sickness and in trouble, +and he occupied a position among them which was almost unique. His was +a life into which any unselfish, high-minded young man might well be +drawn, and the reward was all that any man could ask for. Now there +is no reason to believe that the type of man who enters the medical +profession has altered. A few, of course, take it up purely as a +respectable means of getting a living, but the preparation is so long, +so expensive, and so laborious, the life itself is commonly known to +be so exacting and the financial rewards are usually so moderate in +all branches of the profession that the number of men who drift into +medicine with no more definite object in view is inconsiderable. A +somewhat larger group are drawn to medicine primarily because of a +love of science, much as they might be to zoölogy or to chemistry, but +this, too, accounts for only a small proportion of medical students. +Medical students have a crowded curriculum and work hard during +their course of study, but they are not noted for being particularly +studious as a class and only a very limited number enter research +or teaching, the obvious outlets for those imbued with profound +scientific interest. There is evidence for this in the fact that while +many excellent opportunities for scientific work have recently been +created in teaching and research-institutions the number of applicants +qualified for the positions remain seriously low. Interest in science +is thus not the compelling factor with most of the men who enter the +medical profession and another motive must be sought. To those who, +as teachers, watch successive classes of medical students progress +in their course of study it is always striking to see how each group +responds with enthusiasm when, after a year or two of laboratory study, +it reaches the stage where contact with patients begins. This is +what they have been working toward and waiting for. Dissecting room, +microscope, chemical experiment--these were but means to prepare them +for the great end which is the human relationship between the physician +and the patient. It is the desire for this human relationship, with +its opportunity for sympathetic intimacy and altruistic service, +that remains today, as it has been through all the generations, the +dominating impulse in drawing men to the study of medicine. The type +of man in medicine and his fundamental ideals have not altered. He +still retains the instincts that would lead him to general practice and +if he does not enter general practice the reason is that he does not +believe it is the most effective way to use his life. As he surveys +the world about him and the opportunities before him, he finds that +the specialist appears to occupy a position in the profession and in +the community at large which is more dignified and more respected +than that of the general practitioner. Professionally and socially +the specialist is often looked up to as on a higher plane, and it is +certainly neither unnatural nor discreditable for the young man to +desire the career which carries with it the sincere regard of his +fellows. It is this factor, rather than the wish for a life of ease +or for increased income that so often prompts him to say, “I do not +want to be merely a general practitioner.” It is the shift of emphasis +on the relative value of the general practitioner and the specialist. +Now it is probably true that the medical profession is to some extent +responsible for the development of a point of view which exalts the +specialist above the general practitioner. Certain trends in medical +practice have tended to accentuate it, and many medical teachers +and leaders, in their efforts to stimulate research and to promote +progress, have laid so much stress on the importance of intensive study +that students, often without any particular qualifications, have been +directed toward specialized practice. But, granted the truth of this, +the brunt of the responsibility for the present-day attitude toward the +general practitioner depends upon the general public. It is not the +manufacturer who eventually decides the value of his product, nor can +any profession determine its own worth to the community. In the last +analysis, the price of any article, or the significance of any calling, +must depend on its importance to the world at large, and by the same +token, the continued existence of the general practitioner will depend +on his value to the general public, or, more accurately perhaps, on +what the public _thinks_ the general practitioner is worth to it. The +supply will depend on the demand. + +It may be well, perhaps, to analyze a little more closely this +new attitude which the lay public has assumed toward the general +practitioner, and which is apparently so potent a factor in directing +young physicians away from the general practice of medicine. In +thousands of communities and in innumerable individual instances +there has been, of course, no change at all in the old relationship +between the doctor and his patient, and in the intimate and sympathetic +friendship with which the counsel and service of the one are met +by the gratitude and respect of the other. Throughout the country, +however, and particularly in large cities and the adjacent towns, the +bonds of this extremely personal relationship are rapidly breaking +down because the public is tending more and more to turn in the first +instance to the specialist instead of to the general practitioner. The +feeling seems to be that since the specialists know so much and are the +ultimate authorities it is foolish to waste time by going elsewhere. +Little effort is made to cultivate a relationship with a sound +general adviser. “What has happened to the general practitioner?” +someone asks, and without waiting for an answer, he runs off to visit +a specialist. Whenever there is “anything” the matter, or as soon +as one does not immediately recover from his disability, he seeks a +specialist, not on the advice of his general practitioner, who might +at least know what kind of specialist would be desirable, but on the +advice of John or Mary, who had a friend who was cured of what is +supposed to have been a similar complaint. In small communities the +“City Specialist” wears a particularly brilliant halo, and the country +physician must content himself with his lot while his patients seek +expensive advice in the metropolis. If this is the situation and if the +specialist is regarded with respect well-nigh akin to awe, while the +general practitioner is regarded as a useful convenience when one has +a cold or has overeaten, is it any wonder that so many of the better +medical students wish to prepare themselves for specialism? The public +does not seem to want them very seriously as general practitioners. + +These are the conditions, therefore, partly inherent in the progress +of medical science and partly depending on the attitude of the +public which are today determining the rapid increase of medical +specialism; and we may now pass on to consider whether this trend +toward specialism is really advantageous to the public itself. There +can be no question, I take it, that up to a certain point, the +development of specialists is not only desirable but necessary if +the medical profession is to be thoroughly equipped to prevent the +public from becoming sick and to restore them to health when they are +suffering. Thus, for instance, in the application of the results of +the most modern research in the basic sciences, both to the diagnosis +and treatment of disease, it is important that the physician should +be thoroughly trained in the principles of the underlying sciences if +the patient is to derive the maximum benefit that medicine can confer. +It is, therefore, well to have specialists in heart disease who, as +students of experimental physiology and pathology, have acquired a +knowledge of circulatory disturbances in animals which is subsequently +of assistance in treating disease in man; to have specialists in +diabetes who are at the same time competent chemists, since their +experience in the laboratory is of daily help in regulating the diets +of their patients; and to have specialists in infectious diseases who +have devoted years to bacteriology because their observations on the +course of infections in animals and the effect of sera and vaccines +on experimental infections are of practical value at the bedside. +There have also been many strictly clinical advances which are the +direct outcome of the intensive study of disease in man. Among these +may be mentioned the modern highly refined operative procedures. The +surgery of the eye, the ear, the nose and throat, or the brain, for +example, involves such intricate technical methods and such a high +degree of manual dexterity that it is done best by the surgeon with +constant experience and practice in the same general type of operation. +It is entirely reasonable that all of us prefer to have our tonsils +taken out by a laryngologist and not by a general surgeon, and such +specialists in medical practice must be available in every community. +In another quarter, moreover, and in one which is of vital, although +of less immediate concern to the layman, the need of specialists is +even greater. This is the field of medical research. Our knowledge of +disease has advanced so far that further progress will probably be +slow, and little is to be expected except as the result of prolonged +and concentrated labor. The nuggets lying on the surface have been +picked up and the hidden gold will be found only by him who digs deeply +and whose training has taught him where to dig. Here is needed not only +the specialist, but the specialist with that unusual gift of vision +which belongs to the pioneer and which urges him beyond our present +confines. + +In these two fields, therefore, in research and in the application to +practice of specialized knowledge or complex technical procedures, the +expert is absolutely necessary, but the number of men actually needed +to satisfy the demands is relatively small and, in the natural course +of events, there will always be enough doctors whose intellectual +interests direct them to intensive study. The lay public, therefore, +need have little anxiety about having sufficient specialists to serve +them. The important problem for the public is whether they still have +need of encouraging the development of general practitioners. Here is +the crux of the situation! Is an attitude which is bound to result +in a progressive increase in the number of specialists, at the cost +of a progressive decrease both in the number and quality of general +practitioners, one which will ultimately be of general benefit? +In the light of the development of modern medicine, is the general +practitioner an essential factor in preserving and promoting health +or is he a makeshift necessary only in communities too small or too +poor to support a competent corps of specialists? Can the public get +along without the general practitioner? To those who are in a position +to see the helpless flounderings of the unfortunates who pass from +specialist to specialist the answer is very clear. Never was the +sound general practitioner more important than he is today. Never +was the public in need of wise, broadly trained advisers so much as +it needs them today to guide them through the complicated maze of +modern medicine. The extraordinary development of medical science, +with its consequent diversity of medical specialism and the increasing +limitations in the extent of special fields--the very factors, indeed, +which are creating specialists, in themselves create a new demand, not +for men who are experts along narrow lines, but for men who are in +touch with many lines. The advantages to be derived from advice and +treatment by specialists are entirely obvious, but the disadvantages +are by no means always so clearly understood. They are inherent in +the training, however, for depth is not often combined with breadth, +and the enthusiasm which makes one an expert in a limited field is +frequently the very factor which prevents him from viewing a situation +as a whole. The training of the specialist is in its essence intensive, +and he can detect the slightest abnormality in the organ or system +which constitutes his field, but man is not merely an aggregation of +organs or of systems--he is first of all a human being whose proper +care involves an appreciation of his body as a whole, together with +the circumstances of his life. Many a sick person, after visiting a +series of experts, and being treated for the abnormalities which each +discovered in his own sphere, remains an invalid because none of his +doctors was accustomed to look at a case as a whole. Many a patient, +after going the rounds of the specialists, has found relief in mental +healing or New Thought or Christian Science, because he lacked the +guidance of a sound general practitioner who understood his physical +condition, his nervous temperament and knew the details of his daily +life. And many a patient, who on his own initiative has sought out +specialists, has had minor defects accentuated so that they assumed a +needless importance, and has even undergone operations that might well +have been avoided. Those who are particularly blessed with this world’s +goods, who want the best regardless of the cost and imagine that they +are getting it because they can afford to consult as many renowned +specialists as they wish, are often pathetically tragic figures as they +veer from one course of treatment to another. Like ships that lack a +guiding hand upon the helm, they swing from tack to tack with each new +gust of wind, but get no nearer to the Port of Health because there is +no pilot to set the general direction of their course. + +The latest substitute for the breadth of vision of the general +practitioner is that offspring of the American God of Efficiency, the +Diagnostic Clinic. What a strong appeal it makes, this apparently +ideal combination of a group of specialists so closely affiliated +as to afford all the advantages of expert knowledge and at the same +time maintain the desirable general supervision! Practically the +method seems to work out about like most substitutes--sometimes well +and sometimes badly. It all depends upon the men who constitute the +group. At its best the patient finds himself in the hands of a wise, +broadly trained physician who handles his case personally and refers +as occasion demands to intimate and trusted associates who are skilled +in special fields. One man has personal supervision over the case +and devotes enough time to it to grasp all of its ramifications, so +that he can estimate the relative importance of the findings of the +specialists on the production of the symptoms in the individual. At its +worst, however, the Diagnostic Clinic is a machine, and the patient is +automatically passed from one specialist to another and submitted to a +series of examinations, so detailed in their nature that it would seem +that nothing could be overlooked. The result is a list of so-called +“diagnoses”--in reality a list of deviations from the normal, some of +which may, and others of which certainly do not have any bearing on the +patient’s trouble. The unfortunate thing is that only too often the +patient undergoes treatment for some of these unimportant conditions +and at the same time, because of the lack of some one man who +understands the situation as a whole, the real underlying difficulty is +entirely overlooked. + +The truth of the matter is that the practice of medicine is intensely +personal and no system or machine can be substituted for the personal +relationship. The proper interpretation of symptoms involves not only a +comprehension of the causes of symptoms but also of the person in whom +the symptoms arise. Every experienced physician knows that when one of +his patients complains of a pain in the stomach it is probably a very +trivial matter and when another makes apparently the same complaint +it is probably a very serious matter. It all depends on the type of +patient, and the better the physician knows his patient the better +will he be able to decide on the proper treatment. Skilled physicians, +gifted with peculiar insight into human nature, can often estimate a +personality with remarkable accuracy in a few minutes or even seconds, +but in general the more a doctor knows of his patient’s background +the greater advantage he has in handling the case. That is the great +advantage which the general practitioner has always possessed and still +possesses. He knows the patient from childhood up--his physical health, +the nervous and mental strain to which he has been subjected, the +conditions of his social, business and domestic life, and, more even +than this, he may have the same detailed knowledge of the patient’s +parents and of the circumstances of their lives. Now all this kind of +information, which is difficult to obtain except as the result of years +of intimacy, has an infinitely important bearing on the question of +health and disease. Not to have it is an enormous loss, and the loss +falls, of course, primarily on the patient. He is the one who suffers. +The only person who can really gather together this fundamental +knowledge of his patients is the general practitioner. + +In the trend toward specialism the pendulum is swinging too far, and +it is the duty of medical educators and leaders to indicate to their +students the importance of general practice and the high professional +attainments that are necessary for success in it. But this alone will +not suffice. In the last analysis it is the attitude of the public +which will determine the careers of many of our future medical men. If +the public will but realize that it can have no greater asset than a +close and continued personal relationship with a wise, sound, general +adviser, it may rest assured that there will always be an adequate +response to the call for service. In order to get the best type of +medical men to turn to general practice, however, it is necessary for +the public to understand that the qualifications for general practice +are at least as high as those which are requisite for specialism, and +to appreciate that the general practitioner is worthy of its respect +and confidence. + + + + + THE CARE OF THE PATIENT + + +It is probably fortunate that most systems of education are constantly +under the fire of general criticism, for if education were left solely +in the hands of teachers the chances are good that it would soon +deteriorate. Medical education, however, is less likely to suffer from +such stagnation, for whenever the lay public stops criticizing the type +of modern doctor, the medical profession itself may be counted on to +stir up the stagnant pool and cleanse it of its sedimentary deposit. +The most common criticism made at present by older practitioners is +that young graduates have been taught a great deal about the mechanism +of disease, but very little about the practice of medicine--or, to put +it more bluntly, they are too “scientific” and do not know how to take +care of patients. + +One is, of course, somewhat tempted to question how completely fitted +for his life-work the practitioner of the older generation was when +he first entered on it, and how much the haze of time has led him to +confuse what he learned in the school of medicine with what he acquired +in the harder school of experience. But the indictment is a serious one +and it is concurred in by numerous recent graduates, who find that in +the actual practice of medicine they encounter many situations which +they had not been led to anticipate and which they are not prepared to +meet effectively. Where there is so much smoke there is undoubtedly a +good deal of fire, and the problem for teachers and for students is +to consider what they can do to extinguish whatever is left of this +smoldering distrust. + +To begin with, the fact must be accepted that one cannot expect to +become a skilful practitioner of medicine in the four or five years +allotted to the medical curriculum. Medicine is not a trade to be +learned but a profession to be entered. It is an ever-widening field +that requires continued study and prolonged experience in close contact +with the sick. All that the medical school can hope to do is to supply +the foundations on which to build. When one considers the amazing +progress of science in its relation to medicine during the last thirty +years, and the enormous mass of scientific material which must be +made available to the modern physician, it is not surprising that the +schools have tended to concern themselves more and more with this +phase of the educational problem. And while they have been absorbed +in the difficult task of digesting and correlating new knowledge, +it has been easy to overlook the fact that the application of the +principles of science to the diagnosis and treatment of disease is +only one limited aspect of medical practice. The practice of medicine +in its broadest sense includes the whole relationship of the physician +with his patient. It is an art, based to an increasing extent on the +medical sciences, but comprising much that still remains outside the +realm of any science. The art of medicine and the science of medicine +are not antagonistic but supplementary to each other. There is no more +contradiction between the science of medicine and the art of medicine +than between the science of aeronautics and the art of flying. Good +practice presupposes an understanding of the sciences which contribute +to the structure of modern medicine, but it is obvious that sound +professional training should include a much broader equipment. + +The problem that I wish to consider, therefore, is whether this +larger view of the profession cannot be approached even under the +conditions imposed by the present curriculum of a medical school. Can +the practitioner’s art be grafted on the main trunk of the fundamental +sciences in such a way that there may arise a symmetrical growth, like +an expanding tree, the leaves of which shall be for the “healing of the +nations”? + +The physician who speaks of the care of patients is naturally thinking +about circumstances as they exist in the practice of medicine; but the +teacher who is attempting to train medical students is immediately +confronted by the fact that, even if he would, he cannot make the +conditions under which he has to teach clinical medicine exactly +similar to those of actual practice. + +The primary difficulty is that instruction has to be carried out +largely in the wards and dispensaries of hospitals rather than in the +patient’s home and the physician’s office. Now the essence of the +practice of medicine is that it is an intensely personal matter, and +one of the chief differences between private practice and hospital +practice is that the latter always tends to become impersonal. At +first sight this may not appear to be a very vital point, but it is, +as a matter of fact, the crux of the whole situation. The treatment +of a disease may be entirely impersonal; the care of a patient must +be completely personal. The significance of the intimate personal +relationship between physician and patient cannot be too strongly +emphasized, for in an extraordinarily large number of cases both +diagnosis and treatment are directly dependent on it, and the failure +of the young physician to establish this relationship accounts for much +of his ineffectiveness in the care of patients. + +Hospitals--like other institutions founded with the highest human +ideals--are apt to deteriorate into dehumanized machines, and even +the physician who has the patient’s welfare most at heart finds +that pressure of work forces him to give most of his attention to +the critically sick and to those whose diseases are a menace to the +public health. In such cases he must first treat the specific disease, +and there then remains little time in which to cultivate more than +a superficial personal contact with the patients. Moreover, the +circumstances under which the physician sees the patient are not wholly +favorable to the establishment of the intimate personal relationship +that exists in private practice, for one of the outstanding features +of hospitalization is that it completely removes the patient from his +accustomed environment. This may, of course be entirely desirable, +and one of the main reasons for sending a person into the hospital is +to get him away from home surroundings, which, be he rich or poor, +are often unfavorable to recovery; but at the same time it is equally +important for the physician to know the exact character of those +surroundings. + +Everybody, sick or well, is affected in one way or another, consciously +or subconsciously, by the material and spiritual forces that bear on +his life, and especially to the sick such forces may act as powerful +stimulants or depressants. When the general practitioner goes into +the home of a patient, he may know the whole background of the family +life from past experience; but even when he comes as a stranger he +has every opportunity to find out what manner of man his patient +is, and what kind of circumstances makes his life. He gets a hint +of financial anxiety or of domestic incompatibility; he may find +himself confronted by a querulous, exacting, self-centered patient, +or by a gentle invalid overawed by a dominating family; and as he +appreciates how these circumstances are reacting on the patient he +dispenses sympathy, encouragement, or discipline. What is spoken of as +a “clinical picture” is not just a photograph of a man sick in bed; it +is an impressionistic painting of the patient surrounded by his home, +his work, his relations, his friends, his joys, sorrows, hopes, and +fears. Now, all of this background of sickness which bears so strongly +on the symptomatology is liable to be lost sight of in the hospital: I +say “liable to” because it is not by any means always lost sight of, +and because I believe that by making a constant and conscious effort +one can almost always bring it out into its proper perspective. The +difficulty is that in the hospital one gets into the habit of using the +oil immersion lens instead of the low power, and focuses too intently +on the center of the field. + +When a patient enters a hospital, the first thing that commonly happens +to him is that he loses his personal identity. He is generally referred +to, not as Henry Jones, but as “that case of mitral stenosis in the +second bed on the left.” There are plenty of reasons why this is so, +and the point is, in itself, relatively unimportant; but the trouble +is that it leads, more or less directly, to the patient being treated +as a case of mitral stenosis, and not as a sick man. The disease is +treated, but Henry Jones, lying awake nights while he worries about his +wife and children, represents a problem that is much more complex than +the pathologic physiology of mitral stenosis, and he is apt to improve +very slowly unless a discerning intern discovers why it is that even +large doses of digitalis fail to slow his heart rate. Henry happens to +have heart disease, but he is not disturbed so much by dyspnea as he is +by anxiety for the future, and a talk with an understanding physician +who tries to make the situation clear to him, and then gets the social +service worker to find a suitable occupation, does more to straighten +him out than a book full of drugs and diets. Henry has an excellent +example of a certain type of heart disease, and he is glad that all the +staff find him interesting, for it makes him feel that they will do +the best they can to cure him; but just because he is an interesting +case he does not cease to be a human being with very human hopes and +fears. Sickness produces an abnormally sensitive emotional state in +almost every one, and in many cases the emotional state repercusses, +as it were, on the organic disease. The pneumonia would probably run +its course in a week, regardless of treatment, but the experienced +physician knows that by quieting the cough, getting the patient to +sleep, and giving a bit of encouragement, he can save his patient’s +strength and lift him through many distressing hours. The institutional +eye tends to become focused on the lung, and it forgets that the lung +is only one member of the body. + +But if teachers and students are inclined to take a limited point +of view even toward interesting cases of organic disease, they +fall into much more serious error in their attitude toward a large +group of patients who do not show objective, organic, pathologic, +conditions, and who are generally spoken of as having “nothing the +matter with them.” Up to a certain point, as long as they are regarded +as diagnostic problems, they command attention; but as soon as the +physician has assured himself that they do not have organic disease, he +passes them over lightly. + +Take the case of a young woman, for instance, who entered the hospital +with a history of nausea and discomfort in the upper part of the +abdomen after eating. Mrs. Brown had “suffered many things of many +physicians.” Each of them gave her a tonic and limited her diet. She +stopped eating everything that any of her physicians advised her to +omit, and is now living on a little milk with a few crackers; but her +symptoms persist. The history suggests a possible gastric ulcer or +gall-stones, and with a proper desire to study the case thoroughly, she +is given a test meal, gastric analysis, and duodenal intubation, and +roentgen-ray examinations are made of the gastro-intestinal tract and +gall-bladder. All of these diagnostic methods give negative results; +that is, they do not show evidence of any structural change. The case +immediately becomes much less interesting than if it had turned out to +be a gastric ulcer with atypical symptoms. The visiting physician walks +by and says, “Well there’s nothing the matter with her.” The clinical +clerk says, “I did an awful lot of work on that case and it turned out +to be nothing at all.” The intern, who wants to clear out the ward to +make room for some interesting cases, says, “Mrs. Brown, you can send +for your clothes and go home to-morrow. There really is nothing the +matter with you, and fortunately you have not got any of the serious +troubles we suspected. We have used all the most modern and scientific +methods and we find that there is no reason why you should not eat +anything you want to. I’ll give you a tonic to take when you go home.” +Same story, same colored medicine! Mrs. Brown goes home, somewhat +better for her rest in new surroundings, thinking that nurses are kind +and physicians are pleasant, but that they do not seem to know much +about the sort of medicine that will touch her trouble. She takes up +her life and the symptoms return--and then she tries chiropractic, or +perhaps Christian Science. + +It is rather fashionable to say that the modern physician has become +“too scientific.” Now, was it too scientific, with all the stomach +tubes and blood counts and roentgen-ray examinations? Not at all. +Mrs. Brown’s symptoms might have been due to a gastric ulcer or to +gall-stones, and after such a long course it was only proper to use +every method that might help to clear the diagnosis. Was it, perhaps, +not scientific enough? The popular conception of a scientist as a man +who works in a laboratory and who uses instruments of precision is as +inaccurate as it is superficial, for a scientist is known, not by his +technical processes, but by his intellectual processes; and the essence +of the scientific method of thought is that it proceeds in an orderly +manner toward the establishment of a truth. Now the chief criticism to +be made of the way Mrs. Brown’s case was handled is that the staff +was contented with a half-truth. The investigation of the patient was +decidedly unscientific in that it stopped short of even an attempt to +determine the real cause of the symptoms. As soon as organic disease +could be excluded the whole problem was given up, but the symptoms +persisted. Speaking candidly, the case was a medical failure in spite +of the fact that the patient went home with the assurance that there +was “nothing the matter” with her. + +A good many “Mrs. Browns,” male and female, come to hospitals, and a +great many more go to private physicians. They are all characterized +by the presence of symptoms that cannot be accounted for by organic +disease, and they are all liable to be told that they have “nothing +the matter” with them. Now my own experience as a hospital physician +has been rather long and varied, and I have always found that, from +my point of view, hospitals are particularly interesting and cheerful +places; but I am fairly certain that, except for a few low-grade morons +and some poor wretches who want to get in out of the cold, there are +not many people who become hospital patients unless there is something +the matter with them. And, by the same token, I doubt whether there +are many people, except those stupid creatures who would rather go to +the physician than go to the theater, who spend their money on visiting +private physicians unless there is something the matter with them. In +hospital and in private practice, however, one finds this same type of +patient, and many physicians whom I have questioned agree in saying +that, excluding cases of acute infection, approximately half of their +patients complained of symptoms for which an adequate organic cause +could not be discovered. Numerically, then, these patients constitute +a large group, and their fees go a long way toward spreading butter +on the doctor’s bread. Medically speaking, they are not serious cases +as regards prospective death, but they are often extremely serious as +regards prospective life. Their symptoms will rarely prove fatal, but +their lives will be long and miserable, and they may end by nearly +exhausting their families and friends. Death is not the worst thing in +the world, and to help a man to a happy and useful career may be more +of a service than the saving of life. + +What is the matter with all these patients? Technically, most of them +come under the broad heading of the “psychoneuroses”; but for practical +purposes many of them may be regarded as patients whose subjective +symptoms are due to disturbances of the physiologic activity of one or +more organs or systems. These symptoms may depend on an increase or a +decrease of a normal function, on an abnormality of function, or merely +on the subjects becoming conscious of a wholly normal function that +normally goes on unnoticed; and this last conception indicates that +there is a close relation between the appearance of the symptoms and +the threshold of the patient’s nervous reactions. The ultimate causes +of these disturbances are to be found, not in any gross structural +changes of the organs involved, but rather in nervous influences +emanating from the emotional or intellectual life, which, directly or +indirectly, affect in one way or another organs that are under either +voluntary or involuntary control. + +All of you have had experiences that have brought home the way in +which emotional reactions affect organic functions. Some of you have +been nauseated while anxiously waiting for an important examination +to begin, and a few may even have vomited; others have been seized by +an attack of diarrhea under the same circumstances. Some of you have +had polyuria before making a speech, and others have felt thumping +extrasystoles or a pounding tachycardia before a football game. Some +of you have noticed rapid shallow breathing when listening to a piece +of bad news, and others know the type of occipital headache, with pain +down the muscles of the back of the neck, that comes from nervous +anxiety and fatigue. + +These are all simple examples of the way that emotional reactions may +upset the normal functioning of an organ. Vomiting and diarrhea are +due to abnormalities of the motor function of the gastro-intestinal +tract--one to the production of an active reversed peristalsis of +the stomach and a relaxation of the cardiac sphincter, the other to +hyperperistalsis of the large intestine. The polyuria is caused by +vasomotor changes in renal circulation, similar in character to the +vasomotor changes that take place in the peripheral vessels in blushing +and blanching of the skin, and in addition there are quite possibly +associated changes in the rate of blood flow and in blood pressure. +Tachycardia and extrasystoles indicate that not only the rate but +also the rhythm of the heart is under a nervous control that can be +demonstrated in the intact human being as well as in the experimental +animal. The ventilatory function of the respiration is extraordinarily +subject to nervous influences; so much so, in fact, that the study of +the respiration in man is associated with peculiar difficulties. Rate, +depth, and rhythm of breathing are easily upset by even minor stimuli, +and in extreme cases the disturbance in total ventilation is sometimes +so great that gaseous exchange becomes affected. Thus, I remember +an emotional young woman who developed a respiratory neurosis with +deep and rapid breathing, and expired so much carbon dioxide that the +symptoms of tetany ensued. The explanation of the occipital headaches +and of so many pains in the muscles of the back is not entirely clear, +but they appear to be associated with changes in muscular tone or with +prolonged states of contraction. There is certainly a very intimate +correlation between mental tenseness and muscular tenseness, and +whatever methods are used to produce mental relaxation will usually +cause muscular relaxation, together with relief of this type of pain. +A similar condition is found in so-called writers’ cramp, in which the +painful muscles of the hand result, not from manual work, but from +mental work. + +One might go much further, but these few illustrations will suffice +to recall the infinite number of ways in which physiologic functions +may be upset by emotional stimuli, and the manner in which the +resulting disturbances of function manifest themselves as symptoms. +These symptoms, although obviously not due to anatomic changes, +may, nevertheless, be very disturbing and distressing, and there is +nothing imaginary about them. Emotional vomiting is just as real +as the vomiting due to pyloric obstruction, and so-called “nervous +headaches” may be as painful as if they were due to a brain tumor. +Moreover, it must be remembered that symptoms based on functional +disturbances may be present in a patient who has, at the same time, +organic disease, and in such cases the determination of the causes of +the different symptoms may be an extremely difficult matter. Every +one accepts the relationship between the common functional symptoms +and nervous reactions, for convincing evidence is to be found in the +fact that under ordinary circumstances the symptoms disappear just +as soon as the emotional cause has passed. But what happens if the +cause does not pass away? What if, instead of having to face a single +three-hour examination, one has to face a life of being constantly on +the rack? The emotional stimulus persists, and continues to produce +the disturbances of function. As with all nervous reactions the longer +the process goes on, or the more frequently it goes on, the easier it +is for it to go on. The unusual nervous track becomes an established +path. After a time, the symptom and the subjective discomfort that it +produces come to occupy the center of the picture, and the causative +factors recede into a hazy background. The patient no longer thinks, +“I cannot stand this life,” but he says out loud, “I cannot stand this +nausea and vomiting. I must go to see a stomach specialist.” + +Quite possibly your comment on this will be that the symptoms of +such “neurotic” patients are well known, and they ought to go to a +neurologist or a psychiatrist and not to an internist or a general +practitioner. In an era of internal medicine, however, which takes +pride in the fact that it concerns itself with the functional capacity +of organs rather than with mere structural changes, and which has +developed so many “functional tests” of kidneys, heart, and liver, +is it not rather narrow-minded to limit one’s interest to those +disturbances of function which are based on anatomic abnormalities? +There are other reasons, too, why most of these “functional” cases +belong to the field of general medicine. In the first place, the +differential diagnosis between organic disease and pure functional +disturbance is often extremely difficult, and it needs the broad +training in the use of general clinical and laboratory methods which +forms the equipment of the internist. Diagnosis is the first step in +treatment. In the second place, the patients themselves frequently +prefer to go to a medical practitioner rather than to a psychiatrist, +and in the long run it is probably better for them to get straightened +out without having what they often consider the stigma of having been +“nervous” cases. A limited number, it is true, are so refractory or +so complex that the aid of the psychiatrist must be sought, but the +majority can be helped by the internist without highly specialized +psychologic technic, if he will appreciate the significance of +functional disturbances and interest himself in their treatment. +The physician who does take these cases seriously--one might say +scientifically--has the great satisfaction of seeing some of his +patients get well, not as the result of drugs or as the result of the +disease having run its course, but as the result of his own individual +efforts. + +Here, then, is a great group of patients in which it is not the +disease but the man or the woman who needs to be treated. In general +hospital practice physicians are so busy with the critically sick, and +in clinical teaching they are so concerned with training students in +physical diagnosis and attempting to show them all types of organic +disease, that they do not pay as much attention as they should to the +functional disorders. Many a student enters upon his career having +hardly heard of them except in his course in psychiatry, and without +the faintest conception of how large a part they will play in his +future practice. At best, his method of treatment is apt to be a +cheerful reassurance combined with a placebo. The successful diagnosis +and treatment of these patients, however, depends almost wholly on the +establishment of that intimate personal contact between physician and +patient which forms the basis of private practice. Without this, it is +quite impossible for the physician to get an idea of the problems and +troubles that lie behind so many functional disorders. If students are +to obtain any insight into this field of medicine, they must also be +given opportunities to build up the same type of personal relationship +with their patients. + +Is there, then, anything inherent in the conditions of clinical +teaching in a general hospital that makes this impossible? Can you +form a personal relationship in an impersonal institution? Can you +accept the fact that your patient is entirely removed from his natural +environment and then reconstruct the background of environment from +the history, from the family, from a visit to the home or workshop, +and from the information obtained by the social-service worker? And +while you are building up this environmental background, can you enter +into the same personal relationship that you ought to have in private +practice? If you can do all this, and I know from experience that you +can, then the study of medicine in the hospital actually becomes the +practice of medicine, and the treatment of disease immediately takes +its proper place in the larger problem of the care of the patient. + +When a patient goes to a physician he usually has confidence that +the physician is the best, or at least the best available, person to +help him in what is, for the time being, his most important trouble. +He relies on him as on a sympathetic adviser and a wise professional +counsellor. When a patient goes to a hospital he has confidence in +the reputation of the institution, but it is hardly necessary to +add that he also hopes to come into contact with some individual who +personifies the institution and will also take a human interest in +him. It is obvious that the first physician to see the patient is in +this strategic position--and in hospitals all students can have the +satisfaction of being regarded as physicians. + +Here, for instance, is a poor fellow who has just been jolted to the +hospital in an ambulance. A string of questions about himself and his +family has been fired at him, his valuables and even his clothes have +been taken away from him, and he is wheeled into the ward on a truck, +miserable, scared, defenseless, and, in his nakedness, unable to run +away. He is lifted into a bed, becomes conscious of the fact that he +is the center of interest in the ward, wishes that he had stayed at +home among friends, and, just as he is beginning to take stock of +his surroundings, finds that a thermometer is being stuck under his +tongue. It is all strange and new, and he wonders what is going to +happen next. The next thing that does happen is that a man in a long +white coat sits down by his bedside, and starts to talk to him. Now +it happens that according to our system of clinical instruction that +man is usually a medical student. Do you see what an opportunity you +have? The foundation of your whole relation with that patient is laid +in those first few minutes of contact, just as happens in private, +practice. Here is a worried, lonely, suffering man, and if you begin +by approaching him with sympathy, tact, and consideration, you get +his confidence and he becomes _your_ patient. Interns and visiting +physicians may come and go, and the hierarchy gives them a precedence; +but if you make the most of your opportunities he will regard you +as his personal physician, and all the rest as mere consultants. Of +course, you must not drop him after you have taken the history and made +your physical examination. Once your relationship with him has been +established, you must foster it by every means. Watch his condition +closely and he will see that you are alert professionally. Make time to +have little talks with him--and these talks need not always be about +his symptoms. Remember that you want to know him as a man, and this +means you must know about his family and friends, his work and his +play. What kind of person is he--cheerful, depressed, introspective, +careless, conscientious, mentally keen or dull? Look out for all the +little incidental things that you can do for his comfort. These, +too, are a part of “the care of the patient.” Some of them will fall +technically into the field of “nursing,” but you will always be +profoundly grateful for any nursing technique that you have acquired. +It is worth your while to get the nurse to teach you the right way to +feed a patient, change the bed, or give a bed pan. Do you know the +practical tricks that make a dyspneic patient comfortable? Assume some +responsibility for these apparently minor points and you will find +that it is when you are doing some such friendly service, rather than +when you are a formal questioner, that the patient suddenly starts to +unburden himself, and a flood of light is thrown on the situation. + +Meantime, of course, you will have been active along strictly medical +lines, and by the time your clinical and laboratory examinations are +completed you will be surprised to see how intimately you know your +patient, not only as an interesting case but also as a sick human +being. And everything you have picked up about him will be of value in +the subsequent handling of the situation. Suppose, for instance, you +find conclusive evidence that his symptoms are due to organic disease: +say, to a gastric ulcer. As soon as you face the problem of laying +out his regimen you find that it is one thing to write an examination +paper on the treatment of gastric ulcer and quite another thing to +treat John Smith, who happens to have a gastric ulcer. You want to +begin by giving him rest in bed and a special diet for eight weeks. +Rest means both nervous and physical rest. Can he get it best at home +or in the hospital? What are the conditions at home? If you keep him +in the hospital, it is probably good for him to see certain people, +and bad for him to see others. He has business problems that must be +considered. What kind of compromise can you make on them? How about the +financial implications of eight weeks in bed followed by a period of +convalescence? Is it, on the whole, wiser to try a strict regimen for +a shorter period, and, if he does not improve, take up the question of +operation sooner than is in general advisable? These and many similar +problems arise in the course of the treatment of almost every patient, +and they have to be looked at, not from the abstract point of view of +the treatment of the disease, but from the concrete point of view of +the care of the individual. + +Suppose, on the other hand, that all your clinical and laboratory +examinations turn out entirely negative as far as revealing any +evidence of organic disease is concerned. Then you are in the difficult +position of not having discovered the explanation of the patient’s +symptoms. You have merely assured yourself that certain conditions +are not present. Of course, the first thing you have to consider is +whether these symptoms are the result of organic disease in such an +early stage that you cannot definitely recognize it. This problem is +often extremely perplexing, requiring great clinical experience for its +solution, and often you will be forced to fall back on time in which +to watch developments. If, however, you finally exclude recognizable +organic disease, and the probability of early or very slight organic +disease, it becomes necessary to consider whether the symptomatology +may be due to a functional disorder which is caused by nervous or +emotional influences. You know a good deal about the personal life of +your patient by this time, but perhaps there is nothing that stands out +as an obvious etiologic factor, and it becomes necessary to sit down +for a long, intimate talk with him to discover what has remained hidden. + +Sometimes it is well to explain to the patient, by obvious examples, +how it is that emotional states may bring about symptoms similar +to his own, so that he will understand what you are driving at and +will coöperate with you. Often the best way is to go back to the very +beginning and try to find out the circumstances of the patient’s life +at the time the symptoms first began. The association between symptoms +and cause may have been simpler and more direct at the onset, at least +in the patient’s mind, for as time goes on, and the symptoms become +more pronounced and distressing, there is a natural tendency for the +symptoms to occupy so much of the foreground of the picture that the +background is completely obliterated. Sorrow, disappointment, anxiety, +self-distrust, thwarted ideals or ambitions in social, business, or +personal life, and particularly what are called maladaptations to these +conditions--these are among the commonest and simplest factors that +initiate and perpetuate the functional disturbances. Perhaps you will +find that the digestive disturbances began at the time the patient was +in serious financial difficulties, and that they have recurred whenever +he is worried about money matters. Or you may find that ten years ago +a physician told the patient he had heart disease, cautioning him “not +to worry about it.” For ten years the patient has never mentioned the +subject, but he has avoided every exertion, and has lived with the idea +that sudden death was in store for him. You will find that physicians, +by wrong diagnoses and ill-considered statements, are responsible for +many a wrecked life, and you will discover that it is much easier to +make a wrong diagnosis than it is to unmake it. Or, again, you may +find that the pain in this woman’s back made its appearance when she +first felt her domestic unhappiness, and that this man’s headaches +have been associated, not with long hours of work, but with a constant +depression due to unfulfilled ambitions. The causes are manifold and +the manifestations Protean. Sometimes the mechanism of cause and effect +is obvious; sometimes it becomes apparent only after a very tangled +skein has been unraveled. + +If the establishment of an intimate personal relationship is necessary +in the diagnosis of functional disturbances, it becomes doubly +necessary in their treatment. Unless there is complete confidence +in the sympathetic understanding of the physician as well as in his +professional skill, very little can be accomplished; but granted that +you have been able to get close enough to the patient to discover the +cause of the trouble, you will find that a general hospital is not at +all an impossible place for the treatment of functional disturbances. +The hospital has, indeed, the advantage that the entire reputation of +the institution, and all that it represents in the way of facilities +for diagnosis and treatment, go to enhance the confidence which the +patient has in the individual physician who represents it. This gives +the very young physician a hold on his patients that he could scarcely +hope to have without its support. Another advantage is that hospital +patients are removed from their usual environment, for the treatment +of functional disturbances is often easier when patients are away +from friends, relatives, home, work, and, indeed, everything that is +associated with their daily life. It is true that in a public ward one +cannot obtain complete isolation in the sense that this is a part of +the Weir Mitchell treatment, but the main object is accomplished if one +has obtained the psychologic effect of isolation which comes with an +entirely new and unaccustomed atmosphere. The conditions, therefore, +under which you, as students, come into contact with patients with +functional disturbances are not wholly unfavorable, and with very +little effort they can be made to simulate closely the conditions in +private practice. + +It is not my purpose, however, to go into a discussion of the methods +of treating functional disturbances, and I have dwelt on the subject +only because these cases illustrate so clearly the vital importance of +the personal relationship between physician and patient in the practice +of medicine. In all your patients whose symptoms are of functional +origin, the whole problem of diagnosis and treatment depends on your +insight into the patient’s character and personal life, and in every +case of organic disease there are complex interactions between the +pathologic processes and the intellectual processes which you must +appreciate and consider if you would be a wise clinician. There are +moments, of course, in cases of serious illness when you will think +solely of the disease and its treatment; but when the corner is turned +and the immediate crisis is passed, you must give your attention to +the patient. Disease in man is never exactly the same as disease in +an experimental animal, for in man the disease at once affects and +is affected by what we call the emotional life. Thus, the physician +who attempts to take care of a patient while he neglects this factor +is as unscientific as the investigator who neglects to control all +the conditions that may affect his experiment. The good physician +knows his patients through and through, and his knowledge is bought +dearly. Time, sympathy, and understanding must be lavishly dispensed, +but the reward is to be found in that personal bond which forms the +greatest satisfaction of the practice of medicine. One of the essential +qualities of the clinician is interest in humanity, for the secret of +the care of the patient is in caring for the patient. + + + + + THE PHYSICIAN AND THE LABORATORY + + +The important part which the laboratory has come to play in medical +science is generally accepted and appreciated, but the relation which +it should bear to clinical practice remains to be satisfactorily +defined. It is obvious to all clinicians of experience that the +laboratory never can become, and never should become, the predominating +factor in the practice of medicine, but it is equally evident that +sound medicine cannot be carried on without the support of the +laboratory, and that in the future the dependence of the clinic on the +laboratory will probably increase rather than decrease. Among the men +engaged in active medical practice, however, only a small minority +can ever hope to undertake extensive laboratory work in connection +with their patients, and the great majority of physicians are and will +continue to be confronted by the difficult problem of their relation +to this growing influence in medicine. To the teacher of medicine, +whose foremost duty is to prepare his students for the practice of +the future, the same problem presents itself, for the students must be +thoroughly trained in the laboratory methods that will be of practical +service, but not burdened with those that are highly specialized or of +questionable value. + +The leading exponents of clinical laboratory work are the large +hospitals--especially the hospitals associated with teaching +institutions--and these exert a profound effect on private medical +practice, but the conditions existing in them are such as to demand a +separate consideration. In such hospitals, laboratory investigations +fall into one of three categories. The first includes those which +belong to the field of pure research, their object being to advance +the limits of our knowledge of disease. With this we have, at present, +no concern. The second consists of those laboratory methods that are +applied in order to obtain direct aid in the diagnosis or treatment +of individual cases of disease. This often means the use of standard +methods of proved and known value--methods which have received general +professional acceptance--but in addition it means the use of many +methods of possible value, the significance of which needs to be +thoroughly tested under conditions favorable for critical control. The +trying out of newly advocated measures for the diagnosis and treatment +of disease must always be an important function of the larger and +better equipped hospitals. Many--indeed the majority--of such methods +are found to be unreliable or of little practical value, and after +their status becomes established they are discarded. Very rarely a new +method withstands the test of prolonged observation and proves to be +of such practical significance that it can be properly advocated for +general adoption. This type of hospital thus serves as the court before +which all such new ideas must stand trial and it is astonishing, if +not depressing, to compare the enormous amount of time and labor that +is spent in gathering evidence with the comparatively meager results +that pass the tests. The burden added to the hospital laboratories by +such work is very great, but the importance of the function cannot +be overestimated, for it filters out what is useful and protects the +profession from much that is worthless. + +The third category under which hospital laboratory work is carried +on depends on the fact that every hospital is, or should be, an +educational institution, and one of its primary duties is the +instruction of all the members of the staff in the nature of disease. +Many of the laboratory data, therefore, that fill the pages of +carefully compiled hospital records do not have a direct diagnostic +or therapeutic bearing on the individual case, but they contribute +information which throws light on the pathological physiology and +clarifies the disease process. In so far as the accumulation of such +accessory laboratory observations is instructive to those who are +studying the patients, the work is more than justified, but if, as +sometimes happens, particularly with the younger members of the staff, +it leads to the idea that all these observations are necessary for +the proper diagnosis and treatment of any given case, the result may +be most unfortunate. Properly used, such laboratory observations are +enlightening and broadening; improperly used, they are blinding and +narrowing. The real reason for taking an electrocardiogram on every +patient with a cardiac arrhythmia is so that after one has studied the +records of a large series of cases, he may understand the clinical +manifestations of cardiac irregularities so well that he is able +to recognize the type of arrhythmia without the electrocardiogram. +His increased knowledge should, on the one hand, emancipate him +from the need of the complicated apparatus in most cases, and, on +the other hand, help him to appreciate the occasional case in which +careful instrumental study is desirable. From this point of view, +therefore, much hospital laboratory work may be regarded as of indirect +significance for the individual patient, but aimed at the training +of better clinicians. When, as sometimes happens, it results in the +production of poor clinicians, unable to interpret disease except +through the eyes of the laboratory, its purpose has failed, and failed +seriously. + +The physician engaged in the actual practice of medicine is directly +concerned, therefore, with only a small part of the laboratory work +which is carried on in the larger hospitals, for his attention must +necessarily be focussed entirely on those methods which contribute +immediately to the better care of his patients. The methods of the +teaching clinic cannot and should not be carried into extramural +practice. In the hospital all manner of tests can readily be performed +in obscure or doubtful cases, but in private practice the economic +factor usually restricts one to the tests which most obviously offer +practical assistance. Fortunately, however--and this is apparently +contrary to much present-day opinion--good medicine does not consist +in the indiscriminate application of laboratory examinations to +a patient, but rather in having so clear a comprehension of the +probabilities and possibilities of a case as to know what tests may +be expected to give information of value. Even so-called thoroughness +should be tempered by reason, and the reason that must dictate the part +which laboratory tests shall play in any given case must be the result +of a combination of clinical experience with an understanding of the +physiological significance of the available tests. + +For the physician in private practice laboratory tests fall into two +main classes. The first consists of those which every educated doctor +should be able to carry out, and the second consists of tests which are +more difficult in technique and which should be attempted only by a +limited number of men who have been able to devote the time necessary +to acquire specialized training. Fortunately, the first class is by far +the more important of the two. + +The laboratory tests which should be at the command of every +practitioner of medicine are those which deal with the more important +and practically useful examinations of the blood, urine, feces, gastric +contents, spinal fluids, pleural and ascitic fluids. These are the +tests that are customarily taught in the medical schools in the course +in clinical pathology, and the instruction is usually designed to +take up the laboratory methods that are absolutely necessary for good +practice and those only. An experience in teaching this subject during +the last seven years has emphasized the striking fact that in spite +of the great contributions which the laboratory has made to clinical +medicine there has been surprisingly little change in the character or +number of the technical methods which are essential for good practice. +In many instances the progress of medical science has resulted in a +clearer, broader, and more helpful interpretation of the tests, but +the actual technical procedures have not been greatly altered and they +are still available to the trained man who has a minimum of laboratory +apparatus. It has, indeed, been interesting to find how little new +material in the way of technical procedure could justifiably be added +to the course from year to year, even though the literature and the +practices of various clinics were carefully followed in the attempt +to keep the course up to date. The methods for the examination of the +urine, for instance, are taught much as they were two decades and more +ago. Certain tests, such as urea determinations, have been discarded +and others are regarded as having a different significance, but the +records still show the color, specific gravity, reaction, albumin and +sugar content, and the microscopic examination of the sediment. These +simple observations, correctly used and interpreted, are practically +all that is necessary in cases of nephritis. The modern “two hour renal +test” requires nothing more than determinations of volume and specific +gravity, and if it is combined with the phenolsulphonephthalein +test--the technique of which is entirely simple--the field is open for +the study of renal function. It is far more important to understand +the significance of these easy tests than it is to worry about the +quantitation of blood urea or blood uric acid. The situation is much +the same with regard to hematology. The technical procedures of primary +value are now as they have been for years, the counting of white cells +and red cells, the estimating of hemoglobin, and the preparation of +stained specimens of blood. Quite recently the students at the Harvard +Medical School have also been instructed in the methods of counting +platelets and of staining reticulated cells, but neither of these +procedures involves any essentially new technique. With these, and one +or two other tests, such as coagulation time and bleeding time, the +field of hematology is open. Again, the technique has been altered but +little, and little has been added to it, but modern investigations +have brought to it a greater significance. In the examination of the +spinal fluid the cell count, which is the most important point, is +merely an adaptation of the method of counting blood leucocytes, and +not a new technical process. With regard to the examination of the +gastric contents, body fluids, and feces, the same argument holds +true; none of them involves difficult or prolonged examinations or +expensive apparatus, and all of them yield information of the highest +value to the man trained in their use and interpretation. Here, +however, is the crux of the situation. All of these so-called routine +tests are easy and consume little time in the hands of a trained man, +but they are difficult, time-consuming, and of little value in the +hands of an untrained man. What is really needed in the application +of laboratory methods to the practice of medicine is not a knowledge +of more technical procedures, but a much more exact knowledge of a +few. Experience has shown that a proper degree of technical skill can +rarely be obtained during the medical school course, and it should be +the duty of every hospital to see that no house officer receives his +diploma unless he has demonstrated an ability to perform satisfactorily +all the simpler laboratory examinations and has shown a knowledge of +how to use the results in the study of his patient. If every physician +was so much at home with the technique of the simpler tests that it was +quicker for him to apply them than to wonder whether they were worth +while applying, and if he understood how to interpret these tests and +gain the maximum information from them, the problem of the relation of +the physician to the laboratory would be largely settled. + +The second group of laboratory methods having a direct bearing on +the practice of medicine consists of those which involve highly +specialized technique and complicated apparatus. Electrocardiography, +basal metabolism determinations, the Wassermann reaction, clinical +bacteriology, and the various types of chemical analysis of the blood +fall into this category. The information to be elicited from these +and other analogous methods is often extremely valuable, but their +application is necessary only in a comparatively limited number +of cases. As a whole, these methods do not have the broad general +significance and importance that characterize the simpler tests just +referred to. It is, of course, highly desirable that they should +be available to practicing physicians, so that they may be used in +the cases in which they are particularly indicated, but fortunately +there is no necessity for the great majority of physicians to bother +themselves about the details of technique. This should be relegated to +a small number of men who are devoting their attention to specialized +fields. Simplified technical procedures, supposed to be adapted to +the use of practicing physicians, are continually being advocated as +substitutes for the recognized standard methods employed in performing +some of these tests, but they are frequently unreliable, or reliable +only in the hands of one who has a thorough knowledge of all the +sources of error, so that it is far wiser to avoid them and to obtain +the dependable observations of experts. The clinician may, therefore, +neglect the technical side of these more elaborate tests with a clear +conscience, but in so doing he should not feel that he may drop the +matter entirely. If he is ever to make use of them--and this the +welfare of his patients may demand--he must have an understanding +of their significance and of the physiology underlying them. He +must know when they are indicated and when they cannot be expected +to give important evidence. A little insight into the fundamental +principles of metabolism, for instance, and a recognition of the common +relationship between increased heat production, pulse rate, and certain +other symptoms are of the greatest help in deciding in what cases an +observation of the basal metabolism may be of diagnostic significance, +and in what cases it is entirely superfluous. It is much more important +to know in what particular case a determination of the basal metabolism +may be of value than it is to know the details of the performance of +the test. Then again, the physician should be able to interpret the +results of the test in the light of his individual patient. A basal +metabolism which is reported as 15 per cent above normal may or may not +be significant, and an electrocardiogram showing a prolonged conduction +time may be due to one of several factors, but in either case the +physician should not be forced to depend for the interpretation on the +man who does the laboratory work and who presumably has a less intimate +knowledge of the clinical condition of the patient. The clinician +himself should be able to appraise the laboratory findings if the +patient is to derive the greatest benefit. + +It is frequently alleged that many of our medical schools and teaching +hospitals are producing “laboratory men” instead of clinicians. If it +is true that the graduates of these institutions enter the practice +of medicine handicapped by their dependence on the laboratory, then +the system of training is wrong or--what seems more probable--it is +imperfectly carried out. When schools and hospitals do their full +duty their graduates will have had an opportunity to study disease +intensively, checking and controlling their bedside observations by a +variety of exact laboratory investigations. Such an experience will +enable them to correlate the clinical manifestations of disease with +the underlying physiological processes, so that they can subsequently +understand and interpret disease without recourse to all the laboratory +procedures which were necessary in their student days. They will +enter practice trained so thoroughly in a limited number of simple +technical methods that they will not hesitate to use them, and they +will understand all of their significance. They will also know when +more complicated tests are indicated and how to interpret the results. +In spite of the extraordinary influence which the laboratory has had on +the development of medical science there is as yet no cause for the +physician to feel that he cannot keep up with the requirements of the +best modern practice. All of the more important elements are easily +within his grasp. The need in clinical medicine continues to be, not +for men trained in many laboratory methods but for men well grounded in +a few methods--not for better technicians, but for better clinicians. + + + + + THE SOUL OF THE CLINIC + + + [Note.--During the latter days of his life Dr. Peabody set down on + paper in a letter to Dr. Warfield T. Longscope[1] his conception + of the relationship and responsibility of the Medical Chief to his + Clinic. Though he felt that it was not entirely complete in certain + details, he finished the first draft and wrote the last sentence + the day before his death. His friends felt that the letter was + too valuable to remain as a private possession, and it was made + available to the medical profession. The document was published, + as it was written, a letter to an intimate friend in answer to + sympathetic correspondence and discussion.--Ed.] + + [1] Professor of Medicine and Physician-in-Chief, the Johns Hopkins + Hospital. + + +Dear Warfield: + +Thank you so much for your good letter. Of course you are altogether +too kind in what you say about the clinic at the Boston City Hospital +and the part I have played in its development, but you set me up and +stimulate me to write you at some length about the problems that many +of us who are teaching clinical medicine have on our minds--Whither +are we tending and what ought our aim to be? I have tried recently, +without much success, to formulate a very brief statement as to the +type of clinic I wanted to develop at the Boston City Hospital and I +am glad to be encouraged to try my hand at the subject rather more in +detail. First of all, I do not think we can or should all aim at having +the same type of medical clinic. This must depend in part on local +conditions. Thus you, in a university hospital, completely under your +own control, have a very different problem and will produce something +quite different from what I, a cog in a great municipal hospital, can +produce. Each has its own advantages and its disadvantages. In part, +moreover, the type of clinic will reflect the personality and interests +of the chief, and the whole character of the clinic may alter when a +new chief is put in charge of it. + +One of the first problems to be considered is the kind of man who +ought to be selected as professor of medicine. I quite agree with +you that the requirements which are now generally put forward are so +impossible to fulfil that they become almost ludicrous. May we perhaps +take pride in the fact that we have been called to fill the shoes of +such supermen even if we do rattle around in them! When a professorship +falls open, the committee in charge of filling the position usually +says somewhat naïvely that it is looking for a man who has had +an intensive scientific training, has done important research, is +a good administrator, is a competent teacher, and finally has had +clinical experience. We have heard this string of specifications so +often that they are becoming rather hackneyed. Such a man is, of +course, almost impossible to find, and I have been wondering where +the ideal originated. I think it results from the fact that in recent +years--since what we may call the Reformation--the selection of +professors of clinical medicine has been more and more influenced +by laymen and by professors of nonclinical subjects. Both may be +excellent pedagogues and experts on education and yet fail to grasp +the difficulties and complexities which confront this particular type +of position. Thus the administration of the department of medicine, +with its large teaching and clinical staff, its responsibility for the +welfare of a considerable number of patients, its interrelations with +the hospital administration and its subdepartments (social service, +dietetics, physical therapy) is a very different thing from the +administration of a department of physiology or biologic chemistry. +It is all very well to say that the professor should delegate most of +his work to others, but you and I, who are practical laborers in the +vineyard, know that this does not work and that actually the chief +must do it himself if the department is to run smoothly. “Clinical +experience” is apt to be put last among the specifications. This is +because some of our friends think that clinical medicine can be “picked +up” very easily by the prospective professor, while others believe +that if a man is well trained in such sciences as chemistry, physics +and physiology he has only to learn the technical clinical methods +of percussion and auscultation. Clinical medicine is to them little +more than the application of these sciences to the sick patient, which +is, comparatively, easily acquired. As a matter of fact, however, we +know that clinical medicine is a subject which is to be mastered only +by years of long, hard experience, and if any of the members of the +committee to select a professor were taken sick and were to be under +his care, I am pretty certain they would rate “experience” higher. The +argument actually put forward, that the professor need not be much of +a clinician because some one else can tell the students how to take +care of patients, is weak and beside the point because it begins by +accepting as insignificant what is a very important function of the +department. + +I believe that the primary function of a department of medicine is +to teach students those things that will enable them to practice the +best contemporary medicine and will give them a foundation on which +to superimpose the advances that will come during their professional +life. They must be taught medicine as a vital and expanding subject, +and must be stimulated to keep abreast of its growth. If it be true +that preparation of students for a career in clinical medicine, and +more specifically for the practice of medicine, is the first duty of +a department of medicine, then it seems clear to me that the backbone +of the clinic is the general ward and the outpatient department, for +it is here that one finds or can readily create conditions which most +closely resemble those which are found in actual practice. In order to +preserve this backbone intact I have always hesitated to encourage the +development of wards and departments for special groups of patients. +This is, of course, necessary to some extent both for intensive +training and for research, but it should not be done at too great +expense to the general ward, lest the general ward come to contain +nothing but what are regarded as “uninteresting cases,” and the idea of +specialization be instilled in student and staff too soon. After all, +“intensive training” does not involve the study of many patients of a +group at one time, and the rest can be left in the general ward, which +should be as exciting in its variety and unexpected manifestations of +disease as is the actual practice of medicine. + +If the general ward is the backbone of the clinic, then the head +of the clinic must be close to it; indeed, it ought to be directly +under him. The importance of the general ward and what it stands for +as representing the general practice of medicine can be impressed +on the younger members of the staff and on the students only if the +relation of the chief to the ward is real and not fictitious. The whole +atmosphere of the general ward, and thus the attitude of the future +practitioners to the profession of medicine, is here set by the chief +of the clinic, for it must always be remembered that standards of +thought, as well as of action, are set from above. If the chief has +any conviction as to the relation of doctors to their patients, to +scientific research, or to any other aspect of his profession, this +is his opportunity to bring it out, and in so doing he will determine +the character of the clinic. The growing tendency for the chief to +delegate ward authority and responsibility to his assistants, and +to “spare himself” from making ward-rounds and doing ward-teaching, +seems to me extremely unfortunate. The wards may be run as well or +better, but the dignity of the general ward becomes impaired in the +eyes of staff and students just as soon as the chief separates himself +from it. This is one of the reasons that I have not adopted the usual +plan of having a resident staff over the intern staff in the general +wards. I want the interns to learn to assume responsibility for the +patients and then to come directly to the chief with their problems, +rather than feel that they can take things up only with subordinates. +This arrangement leads directly to a consideration of the status +of the interns. On this point I feel very strongly. They should be +regarded as advanced students, and as perhaps the most important group +of advanced students that we have. They come with minds, characters +and personalities in the most pliable and receptive states, and can +be affected in an extraordinary degree even by the atmosphere of the +clinic. Their very manner of dress and parting their hair changes. +Social ease, and manners that will play a large and legitimate part +in medical practice, develop. At the same time intellectual changes of +a far deeper character are going on, and the chief has an opportunity +to set his seal on them. Provided the chief has anything in himself to +offer, here is his chance to turn out every year a group of selected +men who shall represent his ideas and his clinic all over the country, +and it is to be hoped that they will gradually affect the type of +medicine in many remote communities. Again, this cannot be done as +successfully through subordinates as it is if the chief undertakes to +keep himself close to the interns. It takes time, but it seems to me +that the results are well worth striving for. + +This does not mean that all the subordinate members of the staff, +including (with rare exceptions) those whose time is largely devoted +to research, should not undertake direct responsibilities for the ward +routine. I believe, indeed, that such responsibilities form a very +valuable part of their training--so much so that the men must be made +to assume them even if they are reluctant and prefer to stick to their +research. This can usually be arranged for in the vacations and at +such times as their research is not at a critical point. It is very +easy for a man to get absorbed in his own little problem, or in the +somewhat larger field of which this is a corner, and to neglect the +opportunity to get a training in internal medicine. At the present time +there are many men who have been associated with American clinics for +several years and who have had only the narrowest contact with medicine +as a whole. Few of the men who become members of our departments of +medicine will become stimulating teachers and still fewer will ever do +important research work, but almost all can be made into first class +clinicians. This is in itself a very important contribution, for the +majority of the staff are eventually going to practice medicine, and +the chief should do his best to see to it that every one who has been +attached to his staff for three or four years has at least made a good +start at becoming a high grade internist, as well as being an expert in +some narrow field of medicine. The necessary training is, of course, +best attained by assuming actual responsibility in general wards, and +very often the men have to be driven, almost by force, from their own +laboratories to take up what is sometimes spoken of a little casually +or even cynically as “ward routine.” Here, again, the example of the +chief is vital. + +One further point with regard to the general ward. I have spoken +of it as the backbone of the clinic because it represents general +practice, which is the backbone of the medical profession. It is +proper, therefore, that it should be the meeting place of those +who devote themselves to different fields of medicine; and here +the active full-time practitioner should come in contact with the +man who is devoting most of his time to research and teaching. In +clinical teaching the active practitioner of internal medicine +plays a very important rôle, and he should receive positions and +titles corresponding in dignity to the contribution he makes. These +conventional details must not be neglected, for they help to make +clear to the staff that the work of the practitioner is going to +be completely recognized by the school. In my own mind there is no +question but that the man whose practice is largely outside the +hospital can bring something to students and staff that is difficult +for the man whose practice is largely inside the hospital to bring, +and several years of experience have confirmed this view. On the other +hand, the practitioner should also get a stimulus from contact with the +research which the hospital group is carrying on. In the Boston City +Hospital Clinic, representatives of the two types of men alternate in +making ward rounds during the school term and, as far as possible, +the same plan is continued by the younger men in the summer. Curiously +enough, it has seemed to me more difficult to find enthusiastic and +competent clinical teachers among the practitioners than in the +hospital group. + +Research should always be regarded as one of the activities of teaching +clinics. Such clinics are usually relatively well equipped in the way +of laboratories and endowment; and the very fact that the laboratories +are closely associated with the wards gives an exceptional opportunity +to the staff and thus places a responsibility on its members for the +investigation of disease. It is fair to assume that a large part of +the progress that will be made in our knowledge of the diagnosis and +treatment of disease will come through the medical clinics, even +if much of the fundamental work on which this practical advance is +based is the outcome of investigations which have been carried on in +the laboratories of so-called pure science. (As a matter of fact, +it has interested me recently to see how frequently the clinical +investigator, studying a problem in disease in man, is forced to +go back and tackle the most fundamental aspects of it--anatomic, +physical, chemical--because the necessary facts have not been made +available by workers who specialize in these various fields.) Research +should also play a part in the clinic because it is a type of training +which develops critical judgment; and even a limited experience in a +research problem, undertaken under skilled guidance, is a valuable +discipline for every one, including the man who subsequently goes into +practice, for among other things it teaches him to estimate the worth +of the publications of other men. Finally, it is generally true that +the investigator is a more stimulating teacher than the man who is not +actively laboring at the forefront of scientific advance. + +By what members of the staff should active research be carried on? +The strictly clinical group, engaged largely in outside practice, +should be encouraged, but, of course, one cannot expect that they +will produce much, as they do not have the time or the sense of +leisure that is necessary for research. If any of them produce an +occasional clinical study, they are to be congratulated. This must not +be considered to be their field. The younger members of the hospital +staff, residents and assistants, should all take part in some research +problem, but as they are apt to be almost wholly untrained they +can be regarded only as extra hands at the beginning. They receive +a training that is of utmost value to them personally, particularly +if they are, as they should be, under the personal supervision of an +experienced investigator; but one cannot anticipate that they will +make important contributions. Experience has made it clear to me that +one of our common errors is to expect too much of these men, in that +we allow them to work too independently both for the good of their +own training and for their productiveness. With rare exceptions few +men are qualified, either technically or intellectually, to carry on +clinical research of any great importance until they have had several +years of experience in laboratory work and in the study of disease +in the wards. This means that it is only the older members of the +medical staff who may be expected to undertake continuous problems +of any particular significance and it accentuates the importance of +providing adequate salaries for assistants who are five or ten years +out of school. These are the men who can plan for prolonged periods of +time devoted to one problem, and they will also be the men to guide +and train the recent graduates. Of course, even among the selected +groups of older members of the staff there will be few who will produce +research that is important in itself, for in any field high grade +investigators are unusual. In general, one can only expect good solid +research of a more or less routine character. Such work is, however, +not to be depreciated, as it plays an important part in keeping up the +tone of the clinic and in the long run advance in our knowledge of +disease probably depends as much on this type of conscientious, honest +investigation as on the gifted researches of brilliant geniuses. + +What is to be expected of the chief in the way of research? One +hears a great deal about research ability as a qualification for the +professor of medicine and about the necessity of his carrying on +research personally while he occupies the position. Capacity for high +grade research is so rare a quality in itself that it will always be +almost impossible to find it combined with the other qualifications +demanded of a professor of medicine. Ability to do good, conscientious, +independent work, interest in stimulating and assisting others to carry +on research, and an appreciation of the rôle that research plays in the +medical clinic are more important than great personal research genius. +The professor must keep in close touch with the work of his staff, +guiding where he can, suggesting and encouraging, and he should always +try to keep up some independent work if only for his own intellectual +satisfaction, so that he may set an example to the staff and may have +some little field in which he excels his assistants. Even if he had +great ability as an investigator he could not expect to accomplish +much, as the multifarious demands on his time make it almost impossible +to obtain the sense of leisure which thoughtful work requires. Indeed, +I feel that if a man really has this rare gift he ought not to be the +head of a department of medicine lest his talent be wasted. + +One may reasonably question whether the large proportion of the budget +of the department of medicine that is devoted to research and the +great stress that has been laid on research ability in the selection +of teachers is entirely justified, when one considers that much of the +research output is of a routine nature and that really significant +research is unusual. My personal feeling is that it is justified, +although I think the pendulum has swung too far in the matter of +choice of professors. Here there is a very unfortunate tendency to pay +too little attention to broad clinical experience, something that +is acquired only by many years of hard work and too much attention +to research ability, or, what is worse, to the possible development +of research ability in some promising young man. The publication of +a number of good papers does not really indicate any marked capacity +for investigation, and such papers certainly offer limited evidence +of ability to run a department of medicine. Even in the preclinical +laboratories and research institutes the proportion of research that +is very noteworthy is not always particularly high, and, when one +considers all the other functions required of the men in the department +of medicine, I think that we may be rather proud of what they are +accomplishing. + +There is a common tendency to attempt to select assistants in a +department of medicine whose training represents the different +preclinical sciences, physiology, organic chemistry, physical +chemistry, physics, bacteriology, so that one may have a well rounded +clinic. There is obviously much to be said in favor of such a plan +as it helps to bring together an experienced group of “scientists”; +but there is also an inherent practical danger which I am sure we all +have observed and to which more attention should be paid. These men, +thoroughly trained in one direction, quite naturally look for their +research problems in the fields in which they are trained. They seek +the problem to suit their particular tools. This must necessarily be +the attitude of workers in a fundamental science when they attempt +to study a clinical problem, and this may explain why they often are +not more successful in formulating and working out problems involving +a knowledge of disease in man. The approach of the internist to the +study of disease in man should be quite different. He is, first of +all, absorbed by an interest in the problem and then seeks the type +of tools necessary to solve it. This is the intellectual, rather than +the technical, method of approach. Once given an absorbing passion for +the solution of a clinical problem, the man who has a good, general +scientific training can usually acquire in a few months or in a year +or so enough of any of the fundamental sciences to enable him to +tackle it. The clinical investigator, with his knowledge of disease +in man, thus finds the problem first and determines the practical way +to study it, turning to his colleagues in the fundamental sciences +especially for technical experience. We often discuss what the +difference is between the function and opportunity of the man who is +primarily a “scientist” working on a clinical investigation, and the +man who is primarily an “internist” using methods of exactly the same +highly refined nature, and also working on the same general type of +investigation. The real difference is, I think, to be found in the +point of view. The medical clinic should encourage its staff to use +methods of any sort, no matter how difficult or specialized, that are +needed for the solution of their immediate problems; but their first +interest should center about the general subject of disease in man. +The first interest of the “scientist,” on the other hand, is in the +development of his own particular field. Each has his proper rôle, but +in the medical clinic it is better to have an inspired “internist” than +a skilled “chemist.” + +The administration of a department of medicine, with its complicated +relationships and responsibilities toward a large group of various +types of men, to the students of three classes, to interns, to the +medical school administration with all its subdivisions (wards, +social service, outpatient department, dietetics and other clinical +departments), to patients and their families, and to laboratories, +represents a problem which is unapproached in any other department of +the medical school with the possible exception of that of surgery. +One frequently hears it said that if the chief is a good administrator +he will divide all this work up and put it on the shoulders of his +assistants. To a certain extent this is possible and is, indeed, +absolutely necessary; but experience has shown me that beyond a +certain point it is unwise to do so and that the major part of the +administrative responsibility must be assumed by the chief. The +representatives of the medical school, the superintendent of the +hospital, the chief of the roentgen-ray department, the assistant in +charge of the chemical laboratory, all want to deal directly with the +chief; and the smooth running of the clinic demands that they shall. +But to my mind it is not only to these dignitaries that the chief must +leave his door ajar. How often one finds interns and students lurking +outside the office, waiting to catch the chief as he hurries by. “Can +I have five minutes with you, sir?” You let him in, sit down, and +find that what he has approached so modestly is the problem of his +whole career; and who can tell whether it may not be a career with +very significant possibilities? Is there, on the whole, anything more +important than giving advice about a man’s life? Of course, a first +class administrator might say, “Tell him to return next Tuesday at +2:30, at the time appointed for such conferences.” All right; but +usually the youth has worked himself up and is full of his problems +now, and it is _now_ that you can help him most. We hear a great deal +about the necessity of the professor “closing his door” and “protecting +himself.” I fear that some of this “protection” is made necessary by +the fact that our professors are apt to be rather inexperienced, and +they have to get their training after they get their job. The real +question is whether the professor ought to devote himself to looking +after his own career or whether he ought to regard as his first duty +that of stimulating, helping and advancing his assistants. Of course, +this is largely a question of personality; but there are so few men +whose research ability is extraordinarily valuable (and, as I have +said, they ought not to be professors of medicine) that I believe in +general in the “open door policy.” This is, at any rate, the policy +that best suits my temperament and capacity. I have always attempted to +keep some of my own work going, partly through assistants, and, so far +as I can, with my own hands (although this comes more and more to what +can be done in the summer vacation) for this is what keeps me alive +intellectually and is where I get my real fun. On the other hand, I +feel that probably I accomplish most in the long run, not by protecting +myself too closely, but by accepting as my major function that of +helping my students and assistants. Much greater contributions to the +advancement of medicine will come from the training of these men than +through my own individual efforts. + +In all this lengthy letter I do not think I have once used the phrase +“full-time” as applied to a clinic or a teacher. This is partly because +I have become as tired of discussions of “full-time” teaching as I +am of discussions of the Eighteenth Amendment, and partly because +I do not think the issue is any longer of importance. There was a +time when discussion of the system had a distinctly healthy effect +on the teaching of medicine in America; but the whole situation is +altered. A complete “full-time” system is impossible from an economic +point of view, even if it were desirable medically, which I do not +think it is. Experience has made it perfectly clear that the men who +are in successful outside practice have something very definite and +important to contribute to the teaching, and, as already indicated, +they must be regarded as an integral part of the teaching service +and receive proper recognition in the way of titles, salaries and +clinical opportunities. I am, moreover, also convinced that it is not +desirable to have any hard and fast rule as to the members of the +hospital staff having private patients. For many, if not for all, it +is desirable that they should have a few patients of their own, with +whom they have the same relations that one does in outside practice. +Occasional consultations, even outside the hospital, office practice +and a few private patients in the hospital form the basis of a valuable +experience for the teacher and investigator; but, of course, his other +work will not allow him to assume the care of sick patients in their +homes. There is no question in my own mind that I am a much better +teacher for having had a limited number of such patients in recent +years. These are the patients to whom I talk at length personally, and +they are apt to be the cases that stick in my mind, so that I refer to +them continually in talking to students. One can always say that the +same thing may be done as well if the patients belong to the clinic +and if, for instance, their fees are paid to the clinic; but I fear I +do not agree to this. If they had been the patients of the clinic I +should have had most of the work done by my assistants and I should +have missed exactly that personal relationship with patients which many +people say cannot be obtained in a hospital. If, however, I have been +continually confronted with these personal relationships of practice, +even though it be with few individuals at a time, it is much easier +for me to keep accentuating their importance in the course of my work +in the ward. In all of this, moreover, I do not believe that I am very +different or more sordid in attitude than most men. It is not wholly +a question of to whom the fees are paid (often there are no fees), +although this certainly is a factor in establishing and maintaining the +personal bond. The main point is that the patient has sought you or me +personally and not the hospital. + +In the last analysis, the whole problem resolves itself into what +kind of men you select for the hospital staff. If they do the type of +work they are expected to do, they can never see more than a very few +private patients--fewer, indeed, than come now to the private wards of +some “full-time” clinics. If they want to see more patients they must +be transferred to the clinical staff. Practically, the issue has seemed +to me to solve itself without presenting any great difficulties, and +without resorting to an overorganization that limits the freedom of +the individual. What we want is less of the system and law that kills +and more of the spirit that gives life. + +*** END OF THE PROJECT GUTENBERG EBOOK 78813 *** |