It is probably fortunate that most systems of education are constantly
under the fire of general criticism, for if education were left solely
in the hands of teachers the chances are good that it would soon
deteriorate. Medical education, however, is less likely to suffer from
such stagnation, for whenever the lay public stops criticizing the type
of modern doctor, the medical profession itself may be counted on to
stir up the stagnant pool and cleanse it of its sedimentary deposit.
The most common criticism made at present by older practitioners is
that young graduates have been taught a great deal about the mechanism
of disease, but very little about the practice of medicine--or, to put
it more bluntly, they are too “scientific” and do not know how to take
care of patients.
One is, of course, somewhat tempted to question how completely fitted
for his life-work the practitioner of the older generation was when
he first entered on it, and how much the haze of time has led him to
confuse what he learned in the school of medicine with what he acquired
in the harder school of experience. But the indictment is a serious one
and it is concurred in by numerous recent graduates, who find that in
the actual practice of medicine they encounter many situations which
they had not been led to anticipate and which they are not prepared to
meet effectively. Where there is so much smoke there is undoubtedly a
good deal of fire, and the problem for teachers and for students is
to consider what they can do to extinguish whatever is left of this
smoldering distrust.
To begin with, the fact must be accepted that one cannot expect to
become a skilful practitioner of medicine in the four or five years
allotted to the medical curriculum. Medicine is not a trade to be
learned but a profession to be entered. It is an ever-widening field
that requires continued study and prolonged experience in close contact
with the sick. All that the medical school can hope to do is to supply
the foundations on which to build. When one considers the amazing
progress of science in its relation to medicine during the last thirty
years, and the enormous mass of scientific material which must be
made available to the modern physician, it is not surprising that the
schools have tended to concern themselves more and more with this
phase of the educational problem. And while they have been absorbed
in the difficult task of digesting and correlating new knowledge,
it has been easy to overlook the fact that the application of the
principles of science to the diagnosis and treatment of disease is
only one limited aspect of medical practice. The practice of medicine
in its broadest sense includes the whole relationship of the physician
with his patient. It is an art, based to an increasing extent on the
medical sciences, but comprising much that still remains outside the
realm of any science. The art of medicine and the science of medicine
are not antagonistic but supplementary to each other. There is no more
contradiction between the science of medicine and the art of medicine
than between the science of aeronautics and the art of flying. Good
practice presupposes an understanding of the sciences which contribute
to the structure of modern medicine, but it is obvious that sound
professional training should include a much broader equipment.
The problem that I wish to consider, therefore, is whether this
larger view of the profession cannot be approached even under the
conditions imposed by the present curriculum of a medical school. Can
the practitioner’s art be grafted on the main trunk of the fundamental
sciences in such a way that there may arise a symmetrical growth, like
an expanding tree, the leaves of which shall be for the “healing of the
nations”?
The physician who speaks of the care of patients is naturally thinking
about circumstances as they exist in the practice of medicine; but the
teacher who is attempting to train medical students is immediately
confronted by the fact that, even if he would, he cannot make the
conditions under which he has to teach clinical medicine exactly
similar to those of actual practice.
The primary difficulty is that instruction has to be carried out
largely in the wards and dispensaries of hospitals rather than in the
patient’s home and the physician’s office. Now the essence of the
practice of medicine is that it is an intensely personal matter, and
one of the chief differences between private practice and hospital
practice is that the latter always tends to become impersonal. At
first sight this may not appear to be a very vital point, but it is,
as a matter of fact, the crux of the whole situation. The treatment
of a disease may be entirely impersonal; the care of a patient must
be completely personal. The significance of the intimate personal
relationship between physician and patient cannot be too strongly
emphasized, for in an extraordinarily large number of cases both
diagnosis and treatment are directly dependent on it, and the failure
of the young physician to establish this relationship accounts for much
of his ineffectiveness in the care of patients.
Hospitals--like other institutions founded with the highest human
ideals--are apt to deteriorate into dehumanized machines, and even
the physician who has the patient’s welfare most at heart finds
that pressure of work forces him to give most of his attention to
the critically sick and to those whose diseases are a menace to the
public health. In such cases he must first treat the specific disease,
and there then remains little time in which to cultivate more than
a superficial personal contact with the patients. Moreover, the
circumstances under which the physician sees the patient are not wholly
favorable to the establishment of the intimate personal relationship
that exists in private practice, for one of the outstanding features
of hospitalization is that it completely removes the patient from his
accustomed environment. This may, of course be entirely desirable,
and one of the main reasons for sending a person into the hospital is
to get him away from home surroundings, which, be he rich or poor,
are often unfavorable to recovery; but at the same time it is equally
important for the physician to know the exact character of those
surroundings.
Everybody, sick or well, is affected in one way or another, consciously
or subconsciously, by the material and spiritual forces that bear on
his life, and especially to the sick such forces may act as powerful
stimulants or depressants. When the general practitioner goes into
the home of a patient, he may know the whole background of the family
life from past experience; but even when he comes as a stranger he
has every opportunity to find out what manner of man his patient
is, and what kind of circumstances makes his life. He gets a hint
of financial anxiety or of domestic incompatibility; he may find
himself confronted by a querulous, exacting, self-centered patient,
or by a gentle invalid overawed by a dominating family; and as he
appreciates how these circumstances are reacting on the patient he
dispenses sympathy, encouragement, or discipline. What is spoken of as
a “clinical picture” is not just a photograph of a man sick in bed; it
is an impressionistic painting of the patient surrounded by his home,
his work, his relations, his friends, his joys, sorrows, hopes, and
fears. Now, all of this background of sickness which bears so strongly
on the symptomatology is liable to be lost sight of in the hospital: I
say “liable to” because it is not by any means always lost sight of,
and because I believe that by making a constant and conscious effort
one can almost always bring it out into its proper perspective. The
difficulty is that in the hospital one gets into the habit of using the
oil immersion lens instead of the low power, and focuses too intently
on the center of the field.
When a patient enters a hospital, the first thing that commonly happens
to him is that he loses his personal identity. He is generally referred
to, not as Henry Jones, but as “that case of mitral stenosis in the
second bed on the left.” There are plenty of reasons why this is so,
and the point is, in itself, relatively unimportant; but the trouble
is that it leads, more or less directly, to the patient being treated
as a case of mitral stenosis, and not as a sick man. The disease is
treated, but Henry Jones, lying awake nights while he worries about his
wife and children, represents a problem that is much more complex than
the pathologic physiology of mitral stenosis, and he is apt to improve
very slowly unless a discerning intern discovers why it is that even
large doses of digitalis fail to slow his heart rate. Henry happens to
have heart disease, but he is not disturbed so much by dyspnea as he is
by anxiety for the future, and a talk with an understanding physician
who tries to make the situation clear to him, and then gets the social
service worker to find a suitable occupation, does more to straighten
him out than a book full of drugs and diets. Henry has an excellent
example of a certain type of heart disease, and he is glad that all the
staff find him interesting, for it makes him feel that they will do
the best they can to cure him; but just because he is an interesting
case he does not cease to be a human being with very human hopes and
fears. Sickness produces an abnormally sensitive emotional state in
almost every one, and in many cases the emotional state repercusses,
as it were, on the organic disease. The pneumonia would probably run
its course in a week, regardless of treatment, but the experienced
physician knows that by quieting the cough, getting the patient to
sleep, and giving a bit of encouragement, he can save his patient’s
strength and lift him through many distressing hours. The institutional
eye tends to become focused on the lung, and it forgets that the lung
is only one member of the body.
But if teachers and students are inclined to take a limited point
of view even toward interesting cases of organic disease, they
fall into much more serious error in their attitude toward a large
group of patients who do not show objective, organic, pathologic,
conditions, and who are generally spoken of as having “nothing the
matter with them.” Up to a certain point, as long as they are regarded
as diagnostic problems, they command attention; but as soon as the
physician has assured himself that they do not have organic disease, he
passes them over lightly.
Take the case of a young woman, for instance, who entered the hospital
with a history of nausea and discomfort in the upper part of the
abdomen after eating. Mrs. Brown had “suffered many things of many
physicians.” Each of them gave her a tonic and limited her diet. She
stopped eating everything that any of her physicians advised her to
omit, and is now living on a little milk with a few crackers; but her
symptoms persist. The history suggests a possible gastric ulcer or
gall-stones, and with a proper desire to study the case thoroughly, she
is given a test meal, gastric analysis, and duodenal intubation, and
roentgen-ray examinations are made of the gastro-intestinal tract and
gall-bladder. All of these diagnostic methods give negative results;
that is, they do not show evidence of any structural change. The case
immediately becomes much less interesting than if it had turned out to
be a gastric ulcer with atypical symptoms. The visiting physician walks
by and says, “Well there’s nothing the matter with her.” The clinical
clerk says, “I did an awful lot of work on that case and it turned out
to be nothing at all.” The intern, who wants to clear out the ward to
make room for some interesting cases, says, “Mrs. Brown, you can send
for your clothes and go home to-morrow. There really is nothing the
matter with you, and fortunately you have not got any of the serious
troubles we suspected. We have used all the most modern and scientific
methods and we find that there is no reason why you should not eat
anything you want to. I’ll give you a tonic to take when you go home.”
Same story, same colored medicine! Mrs. Brown goes home, somewhat
better for her rest in new surroundings, thinking that nurses are kind
and physicians are pleasant, but that they do not seem to know much
about the sort of medicine that will touch her trouble. She takes up
her life and the symptoms return--and then she tries chiropractic, or
perhaps Christian Science.
It is rather fashionable to say that the modern physician has become
“too scientific.” Now, was it too scientific, with all the stomach
tubes and blood counts and roentgen-ray examinations? Not at all.
Mrs. Brown’s symptoms might have been due to a gastric ulcer or to
gall-stones, and after such a long course it was only proper to use
every method that might help to clear the diagnosis. Was it, perhaps,
not scientific enough? The popular conception of a scientist as a man
who works in a laboratory and who uses instruments of precision is as
inaccurate as it is superficial, for a scientist is known, not by his
technical processes, but by his intellectual processes; and the essence
of the scientific method of thought is that it proceeds in an orderly
manner toward the establishment of a truth. Now the chief criticism to
be made of the way Mrs. Brown’s case was handled is that the staff
was contented with a half-truth. The investigation of the patient was
decidedly unscientific in that it stopped short of even an attempt to
determine the real cause of the symptoms. As soon as organic disease
could be excluded the whole problem was given up, but the symptoms
persisted. Speaking candidly, the case was a medical failure in spite
of the fact that the patient went home with the assurance that there
was “nothing the matter” with her.
A good many “Mrs. Browns,” male and female, come to hospitals, and a
great many more go to private physicians. They are all characterized
by the presence of symptoms that cannot be accounted for by organic
disease, and they are all liable to be told that they have “nothing
the matter” with them. Now my own experience as a hospital physician
has been rather long and varied, and I have always found that, from
my point of view, hospitals are particularly interesting and cheerful
places; but I am fairly certain that, except for a few low-grade morons
and some poor wretches who want to get in out of the cold, there are
not many people who become hospital patients unless there is something
the matter with them. And, by the same token, I doubt whether there
are many people, except those stupid creatures who would rather go to
the physician than go to the theater, who spend their money on visiting
private physicians unless there is something the matter with them. In
hospital and in private practice, however, one finds this same type of
patient, and many physicians whom I have questioned agree in saying
that, excluding cases of acute infection, approximately half of their
patients complained of symptoms for which an adequate organic cause
could not be discovered. Numerically, then, these patients constitute
a large group, and their fees go a long way toward spreading butter
on the doctor’s bread. Medically speaking, they are not serious cases
as regards prospective death, but they are often extremely serious as
regards prospective life. Their symptoms will rarely prove fatal, but
their lives will be long and miserable, and they may end by nearly
exhausting their families and friends. Death is not the worst thing in
the world, and to help a man to a happy and useful career may be more
of a service than the saving of life.
What is the matter with all these patients? Technically, most of them
come under the broad heading of the “psychoneuroses”; but for practical
purposes many of them may be regarded as patients whose subjective
symptoms are due to disturbances of the physiologic activity of one or
more organs or systems. These symptoms may depend on an increase or a
decrease of a normal function, on an abnormality of function, or merely
on the subjects becoming conscious of a wholly normal function that
normally goes on unnoticed; and this last conception indicates that
there is a close relation between the appearance of the symptoms and
the threshold of the patient’s nervous reactions. The ultimate causes
of these disturbances are to be found, not in any gross structural
changes of the organs involved, but rather in nervous influences
emanating from the emotional or intellectual life, which, directly or
indirectly, affect in one way or another organs that are under either
voluntary or involuntary control.
All of you have had experiences that have brought home the way in
which emotional reactions affect organic functions. Some of you have
been nauseated while anxiously waiting for an important examination
to begin, and a few may even have vomited; others have been seized by
an attack of diarrhea under the same circumstances. Some of you have
had polyuria before making a speech, and others have felt thumping
extrasystoles or a pounding tachycardia before a football game. Some
of you have noticed rapid shallow breathing when listening to a piece
of bad news, and others know the type of occipital headache, with pain
down the muscles of the back of the neck, that comes from nervous
anxiety and fatigue.
These are all simple examples of the way that emotional reactions may
upset the normal functioning of an organ. Vomiting and diarrhea are
due to abnormalities of the motor function of the gastro-intestinal
tract--one to the production of an active reversed peristalsis of
the stomach and a relaxation of the cardiac sphincter, the other to
hyperperistalsis of the large intestine. The polyuria is caused by
vasomotor changes in renal circulation, similar in character to the
vasomotor changes that take place in the peripheral vessels in blushing
and blanching of the skin, and in addition there are quite possibly
associated changes in the rate of blood flow and in blood pressure.
Tachycardia and extrasystoles indicate that not only the rate but
also the rhythm of the heart is under a nervous control that can be
demonstrated in the intact human being as well as in the experimental
animal. The ventilatory function of the respiration is extraordinarily
subject to nervous influences; so much so, in fact, that the study of
the respiration in man is associated with peculiar difficulties. Rate,
depth, and rhythm of breathing are easily upset by even minor stimuli,
and in extreme cases the disturbance in total ventilation is sometimes
so great that gaseous exchange becomes affected. Thus, I remember
an emotional young woman who developed a respiratory neurosis with
deep and rapid breathing, and expired so much carbon dioxide that the
symptoms of tetany ensued. The explanation of the occipital headaches
and of so many pains in the muscles of the back is not entirely clear,
but they appear to be associated with changes in muscular tone or with
prolonged states of contraction. There is certainly a very intimate
correlation between mental tenseness and muscular tenseness, and
whatever methods are used to produce mental relaxation will usually
cause muscular relaxation, together with relief of this type of pain.
A similar condition is found in so-called writers’ cramp, in which the
painful muscles of the hand result, not from manual work, but from
mental work.
One might go much further, but these few illustrations will suffice
to recall the infinite number of ways in which physiologic functions
may be upset by emotional stimuli, and the manner in which the
resulting disturbances of function manifest themselves as symptoms.
These symptoms, although obviously not due to anatomic changes,
may, nevertheless, be very disturbing and distressing, and there is
nothing imaginary about them. Emotional vomiting is just as real
as the vomiting due to pyloric obstruction, and so-called “nervous
headaches” may be as painful as if they were due to a brain tumor.
Moreover, it must be remembered that symptoms based on functional
disturbances may be present in a patient who has, at the same time,
organic disease, and in such cases the determination of the causes of
the different symptoms may be an extremely difficult matter. Every
one accepts the relationship between the common functional symptoms
and nervous reactions, for convincing evidence is to be found in the
fact that under ordinary circumstances the symptoms disappear just
as soon as the emotional cause has passed. But what happens if the
cause does not pass away? What if, instead of having to face a single
three-hour examination, one has to face a life of being constantly on
the rack? The emotional stimulus persists, and continues to produce
the disturbances of function. As with all nervous reactions the longer
the process goes on, or the more frequently it goes on, the easier it
is for it to go on. The unusual nervous track becomes an established
path. After a time, the symptom and the subjective discomfort that it
produces come to occupy the center of the picture, and the causative
factors recede into a hazy background. The patient no longer thinks,
“I cannot stand this life,” but he says out loud, “I cannot stand this
nausea and vomiting. I must go to see a stomach specialist.”
Quite possibly your comment on this will be that the symptoms of
such “neurotic” patients are well known, and they ought to go to a
neurologist or a psychiatrist and not to an internist or a general
practitioner. In an era of internal medicine, however, which takes
pride in the fact that it concerns itself with the functional capacity
of organs rather than with mere structural changes, and which has
developed so many “functional tests” of kidneys, heart, and liver,
is it not rather narrow-minded to limit one’s interest to those
disturbances of function which are based on anatomic abnormalities?
There are other reasons, too, why most of these “functional” cases
belong to the field of general medicine. In the first place, the
differential diagnosis between organic disease and pure functional
disturbance is often extremely difficult, and it needs the broad
training in the use of general clinical and laboratory methods which
forms the equipment of the internist. Diagnosis is the first step in
treatment. In the second place, the patients themselves frequently
prefer to go to a medical practitioner rather than to a psychiatrist,
and in the long run it is probably better for them to get straightened
out without having what they often consider the stigma of having been
“nervous” cases. A limited number, it is true, are so refractory or
so complex that the aid of the psychiatrist must be sought, but the
majority can be helped by the internist without highly specialized
psychologic technic, if he will appreciate the significance of
functional disturbances and interest himself in their treatment.
The physician who does take these cases seriously--one might say
scientifically--has the great satisfaction of seeing some of his
patients get well, not as the result of drugs or as the result of the
disease having run its course, but as the result of his own individual
efforts.
Here, then, is a great group of patients in which it is not the
disease but the man or the woman who needs to be treated. In general
hospital practice physicians are so busy with the critically sick, and
in clinical teaching they are so concerned with training students in
physical diagnosis and attempting to show them all types of organic
disease, that they do not pay as much attention as they should to the
functional disorders. Many a student enters upon his career having
hardly heard of them except in his course in psychiatry, and without
the faintest conception of how large a part they will play in his
future practice. At best, his method of treatment is apt to be a
cheerful reassurance combined with a placebo. The successful diagnosis
and treatment of these patients, however, depends almost wholly on the
establishment of that intimate personal contact between physician and
patient which forms the basis of private practice. Without this, it is
quite impossible for the physician to get an idea of the problems and
troubles that lie behind so many functional disorders. If students are
to obtain any insight into this field of medicine, they must also be
given opportunities to build up the same type of personal relationship
with their patients.
Is there, then, anything inherent in the conditions of clinical
teaching in a general hospital that makes this impossible? Can you
form a personal relationship in an impersonal institution? Can you
accept the fact that your patient is entirely removed from his natural
environment and then reconstruct the background of environment from
the history, from the family, from a visit to the home or workshop,
and from the information obtained by the social-service worker? And
while you are building up this environmental background, can you enter
into the same personal relationship that you ought to have in private
practice? If you can do all this, and I know from experience that you
can, then the study of medicine in the hospital actually becomes the
practice of medicine, and the treatment of disease immediately takes
its proper place in the larger problem of the care of the patient.
When a patient goes to a physician he usually has confidence that
the physician is the best, or at least the best available, person to
help him in what is, for the time being, his most important trouble.
He relies on him as on a sympathetic adviser and a wise professional
counsellor. When a patient goes to a hospital he has confidence in
the reputation of the institution, but it is hardly necessary to
add that he also hopes to come into contact with some individual who
personifies the institution and will also take a human interest in
him. It is obvious that the first physician to see the patient is in
this strategic position--and in hospitals all students can have the
satisfaction of being regarded as physicians.
Here, for instance, is a poor fellow who has just been jolted to the
hospital in an ambulance. A string of questions about himself and his
family has been fired at him, his valuables and even his clothes have
been taken away from him, and he is wheeled into the ward on a truck,
miserable, scared, defenseless, and, in his nakedness, unable to run
away. He is lifted into a bed, becomes conscious of the fact that he
is the center of interest in the ward, wishes that he had stayed at
home among friends, and, just as he is beginning to take stock of
his surroundings, finds that a thermometer is being stuck under his
tongue. It is all strange and new, and he wonders what is going to
happen next. The next thing that does happen is that a man in a long
white coat sits down by his bedside, and starts to talk to him. Now
it happens that according to our system of clinical instruction that
man is usually a medical student. Do you see what an opportunity you
have? The foundation of your whole relation with that patient is laid
in those first few minutes of contact, just as happens in private,
practice. Here is a worried, lonely, suffering man, and if you begin
by approaching him with sympathy, tact, and consideration, you get
his confidence and he becomes _your_ patient. Interns and visiting
physicians may come and go, and the hierarchy gives them a precedence;
but if you make the most of your opportunities he will regard you
as his personal physician, and all the rest as mere consultants. Of
course, you must not drop him after you have taken the history and made
your physical examination. Once your relationship with him has been
established, you must foster it by every means. Watch his condition
closely and he will see that you are alert professionally. Make time to
have little talks with him--and these talks need not always be about
his symptoms. Remember that you want to know him as a man, and this
means you must know about his family and friends, his work and his
play. What kind of person is he--cheerful, depressed, introspective,
careless, conscientious, mentally keen or dull? Look out for all the
little incidental things that you can do for his comfort. These,
too, are a part of “the care of the patient.” Some of them will fall
technically into the field of “nursing,” but you will always be
profoundly grateful for any nursing technique that you have acquired.
It is worth your while to get the nurse to teach you the right way to
feed a patient, change the bed, or give a bed pan. Do you know the
practical tricks that make a dyspneic patient comfortable? Assume some
responsibility for these apparently minor points and you will find
that it is when you are doing some such friendly service, rather than
when you are a formal questioner, that the patient suddenly starts to
unburden himself, and a flood of light is thrown on the situation.
Meantime, of course, you will have been active along strictly medical
lines, and by the time your clinical and laboratory examinations are
completed you will be surprised to see how intimately you know your
patient, not only as an interesting case but also as a sick human
being. And everything you have picked up about him will be of value in
the subsequent handling of the situation. Suppose, for instance, you
find conclusive evidence that his symptoms are due to organic disease:
say, to a gastric ulcer. As soon as you face the problem of laying
out his regimen you find that it is one thing to write an examination
paper on the treatment of gastric ulcer and quite another thing to
treat John Smith, who happens to have a gastric ulcer. You want to
begin by giving him rest in bed and a special diet for eight weeks.
Rest means both nervous and physical rest. Can he get it best at home
or in the hospital? What are the conditions at home? If you keep him
in the hospital, it is probably good for him to see certain people,
and bad for him to see others. He has business problems that must be
considered. What kind of compromise can you make on them? How about the
financial implications of eight weeks in bed followed by a period of
convalescence? Is it, on the whole, wiser to try a strict regimen for
a shorter period, and, if he does not improve, take up the question of
operation sooner than is in general advisable? These and many similar
problems arise in the course of the treatment of almost every patient,
and they have to be looked at, not from the abstract point of view of
the treatment of the disease, but from the concrete point of view of
the care of the individual.
Suppose, on the other hand, that all your clinical and laboratory
examinations turn out entirely negative as far as revealing any
evidence of organic disease is concerned. Then you are in the difficult
position of not having discovered the explanation of the patient’s
symptoms. You have merely assured yourself that certain conditions
are not present. Of course, the first thing you have to consider is
whether these symptoms are the result of organic disease in such an
early stage that you cannot definitely recognize it. This problem is
often extremely perplexing, requiring great clinical experience for its
solution, and often you will be forced to fall back on time in which
to watch developments. If, however, you finally exclude recognizable
organic disease, and the probability of early or very slight organic
disease, it becomes necessary to consider whether the symptomatology
may be due to a functional disorder which is caused by nervous or
emotional influences. You know a good deal about the personal life of
your patient by this time, but perhaps there is nothing that stands out
as an obvious etiologic factor, and it becomes necessary to sit down
for a long, intimate talk with him to discover what has remained hidden.
Sometimes it is well to explain to the patient, by obvious examples,
how it is that emotional states may bring about symptoms similar
to his own, so that he will understand what you are driving at and
will coöperate with you. Often the best way is to go back to the very
beginning and try to find out the circumstances of the patient’s life
at the time the symptoms first began. The association between symptoms
and cause may have been simpler and more direct at the onset, at least
in the patient’s mind, for as time goes on, and the symptoms become
more pronounced and distressing, there is a natural tendency for the
symptoms to occupy so much of the foreground of the picture that the
background is completely obliterated. Sorrow, disappointment, anxiety,
self-distrust, thwarted ideals or ambitions in social, business, or
personal life, and particularly what are called maladaptations to these
conditions--these are among the commonest and simplest factors that
initiate and perpetuate the functional disturbances. Perhaps you will
find that the digestive disturbances began at the time the patient was
in serious financial difficulties, and that they have recurred whenever
he is worried about money matters. Or you may find that ten years ago
a physician told the patient he had heart disease, cautioning him “not
to worry about it.” For ten years the patient has never mentioned the
subject, but he has avoided every exertion, and has lived with the idea
that sudden death was in store for him. You will find that physicians,
by wrong diagnoses and ill-considered statements, are responsible for
many a wrecked life, and you will discover that it is much easier to
make a wrong diagnosis than it is to unmake it. Or, again, you may
find that the pain in this woman’s back made its appearance when she
first felt her domestic unhappiness, and that this man’s headaches
have been associated, not with long hours of work, but with a constant
depression due to unfulfilled ambitions. The causes are manifold and
the manifestations Protean. Sometimes the mechanism of cause and effect
is obvious; sometimes it becomes apparent only after a very tangled
skein has been unraveled.
If the establishment of an intimate personal relationship is necessary
in the diagnosis of functional disturbances, it becomes doubly
necessary in their treatment. Unless there is complete confidence
in the sympathetic understanding of the physician as well as in his
professional skill, very little can be accomplished; but granted that
you have been able to get close enough to the patient to discover the
cause of the trouble, you will find that a general hospital is not at
all an impossible place for the treatment of functional disturbances.
The hospital has, indeed, the advantage that the entire reputation of
the institution, and all that it represents in the way of facilities
for diagnosis and treatment, go to enhance the confidence which the
patient has in the individual physician who represents it. This gives
the very young physician a hold on his patients that he could scarcely
hope to have without its support. Another advantage is that hospital
patients are removed from their usual environment, for the treatment
of functional disturbances is often easier when patients are away
from friends, relatives, home, work, and, indeed, everything that is
associated with their daily life. It is true that in a public ward one
cannot obtain complete isolation in the sense that this is a part of
the Weir Mitchell treatment, but the main object is accomplished if one
has obtained the psychologic effect of isolation which comes with an
entirely new and unaccustomed atmosphere. The conditions, therefore,
under which you, as students, come into contact with patients with
functional disturbances are not wholly unfavorable, and with very
little effort they can be made to simulate closely the conditions in
private practice.
It is not my purpose, however, to go into a discussion of the methods
of treating functional disturbances, and I have dwelt on the subject
only because these cases illustrate so clearly the vital importance of
the personal relationship between physician and patient in the practice
of medicine. In all your patients whose symptoms are of functional
origin, the whole problem of diagnosis and treatment depends on your
insight into the patient’s character and personal life, and in every
case of organic disease there are complex interactions between the
pathologic processes and the intellectual processes which you must
appreciate and consider if you would be a wise clinician. There are
moments, of course, in cases of serious illness when you will think
solely of the disease and its treatment; but when the corner is turned
and the immediate crisis is passed, you must give your attention to
the patient. Disease in man is never exactly the same as disease in
an experimental animal, for in man the disease at once affects and
is affected by what we call the emotional life. Thus, the physician
who attempts to take care of a patient while he neglects this factor
is as unscientific as the investigator who neglects to control all
the conditions that may affect his experiment. The good physician
knows his patients through and through, and his knowledge is bought
dearly. Time, sympathy, and understanding must be lavishly dispensed,
but the reward is to be found in that personal bond which forms the
greatest satisfaction of the practice of medicine. One of the essential
qualities of the clinician is interest in humanity, for the secret of
the care of the patient is in caring for the patient.