[Note.--During the latter days of his life Dr. Peabody set down on
paper in a letter to Dr. Warfield T. Longscope[1] his conception
of the relationship and responsibility of the Medical Chief to his
Clinic. Though he felt that it was not entirely complete in certain
details, he finished the first draft and wrote the last sentence
the day before his death. His friends felt that the letter was
too valuable to remain as a private possession, and it was made
available to the medical profession. The document was published,
as it was written, a letter to an intimate friend in answer to
sympathetic correspondence and discussion.--Ed.]
[1] 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.
What is to be expected of the chief in the way of research? One
hears a great deal about research ability as a qualification for the
professor of medicine and about the necessity of his carrying on
research personally while he occupies the position. Capacity for high
grade research is so rare a quality in itself that it will always be
almost impossible to find it combined with the other qualifications
demanded of a professor of medicine. Ability to do good, conscientious,
independent work, interest in stimulating and assisting others to carry
on research, and an appreciation of the rôle that research plays in the
medical clinic are more important than great personal research genius.
The professor must keep in close touch with the work of his staff,
guiding where he can, suggesting and encouraging, and he should always
try to keep up some independent work if only for his own intellectual
satisfaction, so that he may set an example to the staff and may have
some little field in which he excels his assistants. Even if he had
great ability as an investigator he could not expect to accomplish
much, as the multifarious demands on his time make it almost impossible
to obtain the sense of leisure which thoughtful work requires. Indeed,
I feel that if a man really has this rare gift he ought not to be the
head of a department of medicine lest his talent be wasted.
One may reasonably question whether the large proportion of the budget
of the department of medicine that is devoted to research and the
great stress that has been laid on research ability in the selection
of teachers is entirely justified, when one considers that much of the
research output is of a routine nature and that really significant
research is unusual. My personal feeling is that it is justified,
although I think the pendulum has swung too far in the matter of
choice of professors. Here there is a very unfortunate tendency to pay
too little attention to broad clinical experience, something that
is acquired only by many years of hard work and too much attention
to research ability, or, what is worse, to the possible development
of research ability in some promising young man. The publication of
a number of good papers does not really indicate any marked capacity
for investigation, and such papers certainly offer limited evidence
of ability to run a department of medicine. Even in the preclinical
laboratories and research institutes the proportion of research that
is very noteworthy is not always particularly high, and, when one
considers all the other functions required of the men in the department
of medicine, I think that we may be rather proud of what they are
accomplishing.
There is a common tendency to attempt to select assistants in a
department of medicine whose training represents the different
preclinical sciences, physiology, organic chemistry, physical
chemistry, physics, bacteriology, so that one may have a well rounded
clinic. There is obviously much to be said in favor of such a plan
as it helps to bring together an experienced group of “scientists”;
but there is also an inherent practical danger which I am sure we all
have observed and to which more attention should be paid. These men,
thoroughly trained in one direction, quite naturally look for their
research problems in the fields in which they are trained. They seek
the problem to suit their particular tools. This must necessarily be
the attitude of workers in a fundamental science when they attempt
to study a clinical problem, and this may explain why they often are
not more successful in formulating and working out problems involving
a knowledge of disease in man. The approach of the internist to the
study of disease in man should be quite different. He is, first of
all, absorbed by an interest in the problem and then seeks the type
of tools necessary to solve it. This is the intellectual, rather than
the technical, method of approach. Once given an absorbing passion for
the solution of a clinical problem, the man who has a good, general
scientific training can usually acquire in a few months or in a year
or so enough of any of the fundamental sciences to enable him to
tackle it. The clinical investigator, with his knowledge of disease
in man, thus finds the problem first and determines the practical way
to study it, turning to his colleagues in the fundamental sciences
especially for technical experience. We often discuss what the
difference is between the function and opportunity of the man who is
primarily a “scientist” working on a clinical investigation, and the
man who is primarily an “internist” using methods of exactly the same
highly refined nature, and also working on the same general type of
investigation. The real difference is, I think, to be found in the
point of view. The medical clinic should encourage its staff to use
methods of any sort, no matter how difficult or specialized, that are
needed for the solution of their immediate problems; but their first
interest should center about the general subject of disease in man.
The first interest of the “scientist,” on the other hand, is in the
development of his own particular field. Each has his proper rôle, but
in the medical clinic it is better to have an inspired “internist” than
a skilled “chemist.”
The administration of a department of medicine, with its complicated
relationships and responsibilities toward a large group of various
types of men, to the students of three classes, to interns, to the
medical school administration with all its subdivisions (wards,
social service, outpatient department, dietetics and other clinical
departments), to patients and their families, and to laboratories,
represents a problem which is unapproached in any other department of
the medical school with the possible exception of that of surgery.
One frequently hears it said that if the chief is a good administrator
he will divide all this work up and put it on the shoulders of his
assistants. To a certain extent this is possible and is, indeed,
absolutely necessary; but experience has shown me that beyond a
certain point it is unwise to do so and that the major part of the
administrative responsibility must be assumed by the chief. The
representatives of the medical school, the superintendent of the
hospital, the chief of the roentgen-ray department, the assistant in
charge of the chemical laboratory, all want to deal directly with the
chief; and the smooth running of the clinic demands that they shall.
But to my mind it is not only to these dignitaries that the chief must
leave his door ajar. How often one finds interns and students lurking
outside the office, waiting to catch the chief as he hurries by. “Can
I have five minutes with you, sir?” You let him in, sit down, and
find that what he has approached so modestly is the problem of his
whole career; and who can tell whether it may not be a career with
very significant possibilities? Is there, on the whole, anything more
important than giving advice about a man’s life? Of course, a first
class administrator might say, “Tell him to return next Tuesday at
2:30, at the time appointed for such conferences.” All right; but
usually the youth has worked himself up and is full of his problems
now, and it is _now_ that you can help him most. We hear a great deal
about the necessity of the professor “closing his door” and “protecting
himself.” I fear that some of this “protection” is made necessary by
the fact that our professors are apt to be rather inexperienced, and
they have to get their training after they get their job. The real
question is whether the professor ought to devote himself to looking
after his own career or whether he ought to regard as his first duty
that of stimulating, helping and advancing his assistants. Of course,
this is largely a question of personality; but there are so few men
whose research ability is extraordinarily valuable (and, as I have
said, they ought not to be professors of medicine) that I believe in
general in the “open door policy.” This is, at any rate, the policy
that best suits my temperament and capacity. I have always attempted to
keep some of my own work going, partly through assistants, and, so far
as I can, with my own hands (although this comes more and more to what
can be done in the summer vacation) for this is what keeps me alive
intellectually and is where I get my real fun. On the other hand, I
feel that probably I accomplish most in the long run, not by protecting
myself too closely, but by accepting as my major function that of
helping my students and assistants. Much greater contributions to the
advancement of medicine will come from the training of these men than
through my own individual efforts.
In all this lengthy letter I do not think I have once used the phrase
“full-time” as applied to a clinic or a teacher. This is partly because
I have become as tired of discussions of “full-time” teaching as I
am of discussions of the Eighteenth Amendment, and partly because
I do not think the issue is any longer of importance. There was a
time when discussion of the system had a distinctly healthy effect
on the teaching of medicine in America; but the whole situation is
altered. A complete “full-time” system is impossible from an economic
point of view, even if it were desirable medically, which I do not
think it is. Experience has made it perfectly clear that the men who
are in successful outside practice have something very definite and
important to contribute to the teaching, and, as already indicated,
they must be regarded as an integral part of the teaching service
and receive proper recognition in the way of titles, salaries and
clinical opportunities. I am, moreover, also convinced that it is not
desirable to have any hard and fast rule as to the members of the
hospital staff having private patients. For many, if not for all, it
is desirable that they should have a few patients of their own, with
whom they have the same relations that one does in outside practice.
Occasional consultations, even outside the hospital, office practice
and a few private patients in the hospital form the basis of a valuable
experience for the teacher and investigator; but, of course, his other
work will not allow him to assume the care of sick patients in their
homes. There is no question in my own mind that I am a much better
teacher for having had a limited number of such patients in recent
years. These are the patients to whom I talk at length personally, and
they are apt to be the cases that stick in my mind, so that I refer to
them continually in talking to students. One can always say that the
same thing may be done as well if the patients belong to the clinic
and if, for instance, their fees are paid to the clinic; but I fear I
do not agree to this. If they had been the patients of the clinic I
should have had most of the work done by my assistants and I should
have missed exactly that personal relationship with patients which many
people say cannot be obtained in a hospital. If, however, I have been
continually confronted with these personal relationships of practice,
even though it be with few individuals at a time, it is much easier
for me to keep accentuating their importance in the course of my work
in the ward. In all of this, moreover, I do not believe that I am very
different or more sordid in attitude than most men. It is not wholly
a question of to whom the fees are paid (often there are no fees),
although this certainly is a factor in establishing and maintaining the
personal bond. The main point is that the patient has sought you or me
personally and not the hospital.
In the last analysis, the whole problem resolves itself into what
kind of men you select for the hospital staff. If they do the type of
work they are expected to do, they can never see more than a very few
private patients--fewer, indeed, than come now to the private wards of
some “full-time” clinics. If they want to see more patients they must
be transferred to the clinical staff. Practically, the issue has seemed
to me to solve itself without presenting any great difficulties, and
without resorting to an overorganization that limits the freedom of
the individual. What we want is less of the system and law that kills
and more of the spirit that gives life.