Part 4

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

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.