Part 2

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.