_Read Before the University of Maryland Medical
Association, April 21, 1909._
Teaching specialties to undergraduates must be carefully separated from
the same teaching to post-graduate students. The latter may be supposed
to have given such thought to their future career as to have reached the
conclusion that they wish to devote themselves to a certain line of
work. It is not these men whom I propose to discuss, save to say, in
passing, that the average six weeks' or two months' course offered by
post-graduate schools is totally inadequate. As a rule such courses
attract a large number of men who do little more than follow the
clinical work of some well-known specialist and pick up what they can.
Either prolonged hospital experience, as interne or clinical assistant,
or a special _individual course_, with a competent teacher, is needed
for a decent foundation in special work.
It seems to me that with undergraduate work the first important step is
to secure the attention of the men, and convince them that there is
something in the special course worthy of notice. There is a state of
mind, not unnatural to the undergraduate, regarding specialties. Most of
them propose to begin professional life as general practitioners. They
think they will never have use for knowledge in the so-called
specialties, and that the little they will need in order to get a
passing mark can be easily crammed at the close of the session. As a
matter of fact, it is easy to frame questions so that this “crammed”
information is of little use, and the most liberal grading hardly ever
brings such men _up_ to a passing mark. The mental attitude of these men
is unjust to themselves, their teacher and the patients who, in the near
future, will entrust to them their physical welfare. The very term
“general practitioner” implies a general knowledge of medicine. If one
lives in a city, where the services of specialists are readily obtained,
he may, if he desires, refuse certain cases, and take only such as he
wants—say such as belong to internal medicine. But in so doing he
becomes a specialist himself, and if he has neglected a properly
prepared special course for undergraduates while a student he will miss
information of great use to him as an internist. Many men, however, do
not practice where specialists _are_ easily obtained, and, perforce,
_must_ take cases which would logically come under one or other of the
recognized specialties. Here is a professional responsibility which it
is the aim and duty of a special teacher to enable his student to meet.
May I illustrate by directing attention to two troubles which it is my
own privilege to explain to our students? Iritis, in eye, and acute
otitis media, in ear diseases, are very common troubles. Both are, as a
rule, readily diagnosed, and both offer good prognosis. Yet the
responsibility for eyesight in one, and may be life in the other, may
depend on the diagnostic ability and therapeutic resources of the man
who _first_ sees the case. Men are blind and children dead because a
general practitioner has not known enough of what was offered him when a
student to make a correct diagnosis. The red eye has been called
conjunctivitis and treated with nitrate of silver, in spite of the
absence of purulency, while the small, inactive pupil has escaped
notice. The ear pain has been called “earache” without an aural
examination, a hops bag and opium have been ordered, and the doctor has
gone home with that false sense of security which is so dangerous. Why?
If his teacher has known his business, it is not because he was not told
how to look for iritis and acute inflammation of the drum, but because
he had not given the subjects sufficient thought to get them drilled
into his thinking apparatus. Probably he could tell the diagnostic
points of iritis, if asked, or the signs of ear-drum inflammation; but
this was “crammed” information, not part of his real knowledge.
If it is the duty of the student, anticipating general practice, to
think about the specialties taught during his undergraduate course, it
is still more the duty of his teacher to present him only such things as
the general man needs. He will make a grievous blunder if he tries to
make specialists of his men. His selection of subjects should be limited
to the diseases which are of common occurrence, and stress should be
laid on _diagnosis_. If one knows, first, what to look for, and secondly
how to recognize signs and symptoms, he will generally find proper
treatment. Troubles which would lead the patient to go to the specialist
_primarily_, without consulting his family physician, should receive
little attention.
Two other classes of lesions in such organs as are usually handed over
to specialists should receive attention in the undergraduate
course—those which are apt to cause remote or reflex disturbances, and
those which are definitely symptomatic of central lesions. The first
should, in my judgment, be dwelt upon only to such an extent as to
enable the student to know causative relation and method of diagnosis.
Treatment, unless very simple and easily within the reach of the medical
man—i. e., the general practitioner—should be given little time. As to
the second class, every neurologist knows that Tabes Dorsalis would
often be diagnosed early, and proper treatment instituted, if the
physician had known the meaning of association of gastric crises with
Argyll-Robertson pupil, and had seen enough of these things to have them
in his every-day thoughts. One could present many other illustrations,
but this shows what is meant. With the student convinced of the
necessity of thinking about the specialty taught, the instructor careful
in selection of his subjects, a duty rests on those who fix the
curriculum.
It is unfair to students to use four years for work which can be done in
three. I believe that the object of the establishment of a four-year
course was to furnish a year in which students, freed from the
responsibility of examinations, might have time for guidance in clinical
observation. The ideal plan, in my judgment, is to get rid of didactic
lectures and examinations by the end of the third year, and to devote
the fourth to clinical observation. Genito-urinary work, gynaecology,
rhinology, neurology, ophthalmology, otology, cannot be learned from
text-books or lectures, at least in such a way as to become integral
parts of a man's daily thinking. And to my mind this is the only special
information which will help the general practitioner in his daily work.
A few hours spent in a large clinic brings more instruction than a whole
year of lectures. The personal contact of man to man, the exchange of
thoughts and impressions, are what sink in. A student is not to be
blamed if he fails to attend these opportunities when he knows that in a
few weeks he must face the ordeal of examinations on the didactic work,
and that the result of these will determine his graduation. To put into
a few words my idea of teaching specialties—it is the duty of the
student to realize that nothing is put into the undergraduate course
which is not important to _him_; it is the duty of the teacher to select
only what _is_ important to the general practitioner; it is the duty of
the school authorities to so arrange the curriculum as to give students
enough time to observe special practice personally, in small sections,
so that what is taught may be so impressed by observation as to become a
real factor in their medical thought.