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.