Internal Medicine as a Vocation

IT was with the greatest pleasure that I accepted an invitation to address this section of the Academy on the importance of internal medicine as a vocation. I wish there were another term to designate the wide field of medical practice which remains after the separation of surgery, midwifery, and gynecology. Not itself a specialty (though it embraces at least half a dozen), its cultivators cannot be called specialists, but bear without reproach the good old name physician, in contradistinction to general practitioners, surgeons, obstetricians, and gynaecologists. I have heard the fear expressed that in this country the sphere of the physician proper is becoming more and more restricted, and perhaps this is true; but I maintain (and I hope to convince you) that the opportunities are still great, that the harvest truly is plenteous, and the labourers scarcely sufficient to meet the demand.

At the outset I would like to emphasize the fact that the student of internal medicine cannot be a specialist. The manifestations of almost any one of the important diseases in the course of a few years will “box the compass” of the specialties. Typhoid fever, for example, will not only go the rounds of those embraced in medicine proper, but will carry its student far afield in morbid psychology, and sometimes teach him, perhaps at the cost of the patient, a little surgery. So, too, with syphilis, which after the first few weeks I claim as a medical affection. I often tell my students that it is the only disease which they require to study thoroughly. Know syphilis in all its manifestations and relations, and all other things clinical will be added unto you.

Each generation has to grow its own consultants. Hossack, Samuel Mitchill, Swett, Alonzo Clark, Austin Flint, Fordyce Barker, and Alfred Loomis, served their day in this city, and then passed on into silence. Their works remain; but enough of a great physician’s experience dies with him to justify the saying “there is no wisdom in the grave.” The author of Rab and His Friends has a couple of paragraphs on this point which are worth quoting: “Much that made such a man what the community, to their highest profit, found him to be, dies with him. His inborn gifts, and much of what was most valuable in his experience, were necessarily incommunicable to others; this depending much on his forgetting the process by which, in particular cases, he made up his mind, and its minute successive steps, but mainly, we believe, because no man can explain directly to another man how he does any one practical thing, the doing of which he himself has accomplished not at once or by imitation, or by teaching, but by repeated personal trials, by missing much before ultimately hitting.”

Wherewithal shall a young man prepare himself, should the ambition arise in him to follow in the footsteps of such a teacher as, let us say, the late Austin Flint—the young man just starting, and who will from 1915 to 1940 stand in relation to the profession of this city and this country as did Dr. Flint between 1861 and the time of his death. We will assume that he starts with equivalent advantages, though this is taking a great deal for granted, since Austin Flint had a strong hereditary bias toward medicine, and early in life fell under the influence of remarkable men whose teachings moulded his thought to the very end. We must not forget that Dr. Flint was a New Englander, and of the same type of mind as his great teachers—James Jackson and Jacob Bigelow.

Our future consultant has just left the hospital, where, for the first time realizing the possibilities of his profession, he has had his ambition fired. Shall he go abroad? It is not necessary. The man whom we have chosen as his exemplar did not, but found his opportunities in country-practice, in Buffalo and Louisville, then frontier towns, and in New Orleans, and had a national reputation before he reached New York. But would it be useful to him? Undoubtedly. He will have a broader foundation on which to build, and a year or two in the laboratories and clinics of the great European cities will be most helpful. To walk the wards of Guy’s or St. Bartholomew’s, to see the work at the St. Louis and at the Salpêtrière, to spend a few quiet months of study at one of the German university towns will store the young man’s mind with priceless treasures. I assume that he has a mind. I am not heedless of the truth of the sharp taunt

How much the fool that hath been sent to Rome, Exceeds the fool that hath been kept at home.

At any rate, whether he goes abroad or not, let him early escape from the besetting sin of the young physician, Chauvinism, that intolerant attitude of mind, which brooks no regard for anything outside his own circle and his own school. If he cannot go abroad let him spend part of his short vacations in seeing how it fares with the brethern in his own country. Even a New Yorker could learn something in the Massachusetts General and the Boston City Hospitals. A trip to Philadelphia would be most helpful; there is much to stimulate the mind at the old Pennsylvania Hospital and at the University, and he would be none the worse for a few weeks spent still farther south on the banks of the Chesapeake. The all-important matter is to get breadth of view as early as possible, and this is difficult without travel.

Poll the successful consulting physicians of this country today, and you will find they have been evolved either from general practice or from laboratory and clinical work; many of the most prominent having risen from the ranks of general practitioners. I once heard an eminent consultant rise in wrath because some one had made a remark reflecting upon this class. He declared that no single part of his professional experience had been of such value. But I wish to speak here of the training of men who start with the object of becoming pure physicians. From the vantage ground of more than forty years of hard work, Sir Andrew Clark told me that he had striven ten years for bread, ten years for bread and butter, and twenty years for cakes and ale; and this is really a very good partition of the life of the student of internal medicine, of some at least, since all do not reach the last stage.

It is high time we had our young Lydgate started. If he has shown any signs of nous during his student and hospital days a dispensary assistantship should be available; anything should be acceptable which brings him into contact with patients. By all means, if possible, let him be a pluralist, and—as he values his future life—let him not get early entangled in the meshes of specialism. Once established as a clinical assistant he can begin his education, and nowadays this is a very complicated matter. There are three lines of work which he may follow, all of the most intense interest, all of the greatest value to him—chemistry, physiology, and morbid anatomy. Professional chemists look askance at physiological chemistry, and physiological chemists criticize pretty sharply the work of some clinical chemists, but there can be no doubt of the value to the physician of a very thorough training in methods and ways of organic chemistry. We sorely want, in this country, men of this line of training, and the outlook for them has never before been so bright. If at the start he has not had a good chemical training, the other lines should be more closely followed.

Physiology, which for him will mean very largely experimental therapeutics and experimental pathology, will open a wider view and render possible a deeper grasp of the problems of disease. To Traube and men of his stamp, the physiological clinicians, this generation owes much more than to the chemical or post-mortem-room group. The training is more difficult to get, and nowadays, when physiology is cultivated as a specialty, few physicians will graduate into clinical medicine directly from the laboratory. On the other hand, the opportunities for work are now more numerous, and the training which a young fellow gets in a laboratory controlled by a pure physiologist will help to give that scientific impress, which is only enduring when early received. A thorough chemical training and a complete equipment in methods of experimental research are less often met with in the clinical physician than a good practical knowledge of morbid anatomy; and, if our prospective consultant has to limit his work, chemistry and physiology should yield to the claims of the dead-house. In this dry-bread period he should see autopsies daily, if possible. Successful knowledge of the infinite variations of disease can only be obtained by a prolonged study of morbid anatomy. While of special value in training the physician in diagnosis, it also enables him to correct his mistakes, and, if he reads its lessons aright, it may serve to keep him humble.

This is, of course, a very full programme, but in ten years a bright man, with what Sydenham calls “the ancient and serious diligence of Hippocrates,” will pick up a very fair education, and will be fit to pass from the dispensary to the wards. If he cannot go abroad after his hospital term, let it be an incentive to save money, and with the first $600 let him take a summer semester in Germany, working quietly at one of the smaller places. Another year let him spend three months or longer in Paris. When schemes are laid in advance, it is surprising how often the circumstances fit in with them. How shall he live meanwhile? On crumbs—on pickings obtained from men in the cakes-and ale stage (who always can put paying work into the hands of young men), and on fees from classes, journal work, private instruction, and from work in the schools. Any sort of medical practice should be taken, but with caution—too much of it early may prove a good man’s ruin. He can-not expect to do more than just eke out a living. He must put his emotions on ice; there must be no “Amaryllis in the shade,” and he must beware the tangles of “Neaera’s hair.” Success during the first ten years means endurance and perseverance; all things come to him who has learned to labour and wait, who bides his time “ohne Hast, aberohne Rast, whose talent develops “in der Stille,” in the quiet fruitful years of unselfish devoted work. A few words in addition about this dry-bread decade. He should stick closely to the dispensaries. A first-class reputation may be built up in them. Byrom Bramwell’s Atlas of Medicine largely represents his work while an assistant physician to the Royal Infirmary, Edinburgh. Many of the best-known men in London serve ten, fifteen, or even twenty years in the out-patient departments before getting wards. Lauder Brunton only obtained his full physician-ship at St. Bartholomew’s after a service of more than twenty years in the out-patient department. During this period let him not lose the substance of ultimate success in grasping at the shadow of present opportunity. Time is now his money, and he must not barter away too much of it in profitless work—profitless so far as his education is concerned, though it may mean ready cash. Too many “quiz” classes or too much journal work has ruined many a promising clinical physician. While the Pythagorean silence of nearly seven years, which the great Louis followed (and broke to burst into a full-blown reputation) cannot be enjoined, the young physician should be careful what and how he writes. Let him take heed to his education, and his reputation will take care of itself, and in a development under the guidance of seniors he will find plenty of material for papers before medical societies and for publication in scientific journals.

I would like to add here a few words on the question of clinical instruction, as with the great prospective increase of it in our schools there will be many chances of employment for young physicians who wish to follow medicine proper as a vocation. To-day this serious problem con-fronts the professors in many of our schools—how to teach practical medicine to the large classes; how to give them protracted and systematic ward instruction? I know of no teacher in the country who controls enough clinical material for the instruction of classes say of 200 men during the third and fourth years. It seems to me that there are two plans open to the schools: The first is to utilize dispensaries for clinical instruction much more than is at present the rule. For this purpose a teaching-room for a class of twenty-five or thirty students immediately adjoining the dispensary is essential. For instruction in physical diagnosis, for the objective teaching of disease, and for the instruction of students in the use of their senses, such an arrangement is invaluable. There are hundreds of dispensaries in which this plan is feasible, and in which the material now is not properly worked up because of the lack of this very stimulus. In the second place, I feel sure that ultimately we shall develop a system of extra-mural teaching similar to that which has been so successful in Edinburgh; and this will give employment to a large number of the younger men. At any large university school of medicine there might be four or five extra-mural teachers of medicine, selected from men who could show that they were fully qualified to teach and that they had a sufficient number of beds at their command, with proper equipment for clinical work. At Edinburgh there are eight extra-mural teachers of internal medicine whose courses qualify the student to present himself for examination either before the Royal Colleges or the University. If we ever are to give our third and fourth year students protracted and complete courses in physical diagnosis and clinical medicine, extending throughout the session, and not in classes of a brief period of six weeks’ duration, I am confident that the number of men engaged in teaching must be greatly increased.

Ten years’ hard work tells with colleagues and friends in the profession, and with enlarged clinical facilities the physician enters upon the second, or bread-and-butter period. This, to most men, is the great trial, since the risks are greater, and many now drop out of the race, wearied at the length of the way and drift into specialism or general practice. The physician develops more slowly than the surgeon, and success comes later. There are surgeons at forty years in full practice and at the very top of the wave, a time at which the physician is only preparing to reap the harvest of years of patient toil. The surgeon must have hands, and better, young hands. He should have a head, too, but this does not seem so essential to success, and he cannot have an old head with young hands. At the end of twenty years, when about forty-five, our Lydgate should have a first-class reputation in the profession, and a large circle of friends and students. He will probably have precious little capital in the bank, but a very large accumulation of interest-bearing funds in his brain-pan. He has gathered a stock of special knowledge which his friends in the profession appreciate, and they begin to seek his counsel in doubtful cases, and gradually learn to lean upon him in times of trial. He may awake some day, perhaps, quite suddenly, to find that twenty years of quiet work, done for the love of it, has a very solid value.

The environment of a large city is not essential to the growth of a good clinical physician. Even in small towns a man can, if he has it in him, become well versed in methods of work, and with the assistance of an occasional visit to some medical centre he can become an expert diagnostician and reach a position of dignity and worth in the community in which he lives. I wish to plead particularly for the wasted opportunities in the smaller hospitals of our large cities, and in those of more moderate size. There are in this State a score or more of hospitals with from thirty to fifty medical beds, offering splendid material for good men on which to build reputations. Take, for example, the town of Thelema, which I know well, to which young Rondibilis, a recent interne at the Hotel Dieu, has just gone. He wrote asking me for a letter of advice, from which I take the liberty of extracting one or two paragraphs:

“Your training warrants a high aim. To those who ask, say that you intend to practise medicine only, and will not take surgical or midwifery cases. X. has promised that you may help in the dispensary, and as you can count blood and percuss a chest you will be useful to him in the wards, which, by the way, he now rarely visits. Be careful with the house physicians, and if you teach them anything do it gently, and never crow when you are right. The crow of the young rooster before his spurs are on always jars and antagonizes. Get your own little clinical laboratory in order. Old Dr. Rolando will be sure to visit you, and bear with him as he tells you how he can tell casts from the ascending limb of the loop of Henle. Once he was as you are now, a modern, twenty years ago; but he crawled up the bank, and the stream has left him there, but he does not know it. He means to impress you; be civil and show him the new Nissl-stain preparations, and you will have him as a warm friend. His good heart has kept him with a large general practice, and he can put post-mortems in your way, and may send for you to sit up o’ nights with his rich patients. If Y. asks you to help in the teaching, jump at the chance. The school is not what you might wish, but the men are in earnest, and a clinical microscopy-class or a voluntary ward-class, with Y.’s cases, will put you on the first rung of the ladder. Yes, join both the city and the county society, and never miss a meeting. Keep your mouth shut too, for a few years, particularly in discussions.

Let the old men read new books; you read the journals and the old books. Study Laennec this winter; Forbes’s Translation can be cheaply obtained, but it will help to keep up your French to read it in the original. The old Sydenham Society editions of the Greek writers and of Sydenham are easily got and are really very helpful. As a teacher you can never get orientiert without a knowledge of the Fathers, ancient and modern. And do not forget, above all things, the famous advice to Blackmore, to whom, when he first began the study of physic, and asked what books he should read, Sydenham replied, Don Quixote, meaning thereby, as I take it, that the only book of physic suitable for permanent reading is the book of Nature.”

A young fellow with staying powers who avoids entanglements, may look forward in twenty years to a good consultation practice in any town of 40,000 to 50,000 inhabitants. Some such man, perhaps, in a town far distant, taking care of his education, and not of his bank book, may be the Austin Flint of New York in 1930.

“Many are called, but few are chosen,” and of the many who start out with high aims, few see the goal. Even when reached the final period of “cakes and ale” has serious drawbacks. There are two groups of consultants, the intra- and the extra-professional; the one gets work through his colleagues, the other, having outgrown the narrow limits of professional reputation, is at the mercy of the profanum vulgus. Then for him “farewell the tranquil mind, farewell content.” His life becomes an incessant struggle, and between the attempt to carry on an exhausting and irksome practice, and to keep abreast with young fellows still in the bread-and-butter stage, the consultant at this period is worthy of our sincerest sympathy.

One thing may save him. It was the wish of Walter Savage Landor always to walk with Epicurus on the right hand and Epictetus on the left, and I would urge the clinical physician, as he travels farther from the East, to look well to his companions—to see that they are not of his own age and generation. He must walk with the “boys,” else he is lost, irrevocably lost; not all at once, but by easy grades, and every one perceives his ruin before he, “good, easy man,” is aware of it. I would not have him a basil plant, to feed on the brains of the bright young fellows who follow the great wheel uphill, but to keep his mind receptive, plastic, and impressionable he must travel with the men who are doing the work of the world, the men between the ages of twenty-five and forty.

In the life of every successful physician there comes the temptation to toy with the Delilah of the press—daily and otherwise. There are times when she may be courted with satisfaction, but beware! sooner or later she is sure to play the harlot, and has left many a man shorn of his strength, viz., the confidence of his professional brethren. Not altogether with justice have some notable members of our profession laboured under the accusation of pandering too much to the public. When a man reaches the climacteric, and has long passed beyond the professional stage of his reputation, we who are still “in the ring” must exercise a good deal of charity, and discount largely the on dits which indiscreet friends circulate. It cannot be denied that in dealings with the public just a little touch of humbug is immensely effective, but it is not necessary. In a large city there were three eminent consultants of world-wide reputation; one was said to be a good physician but no humbug, the second was no physician but a great humbug, the third was a great physician and a great humbug. The first achieved the greatest success, professional and social, possibly not financial.

While living laborious days, happy in his work, happy in the growing recognition which he is receiving from his colleagues, no shadow of doubt haunts the mind of the young physician, other than the fear of failure; but I warn him to cherish the days of his freedom, the days when he can follow his bent, untrammeled, undisturbed, and not as yet in the coils of the octopus. In a play of Oscar Wilde’s one of the characters remarks, “there are only two great tragedies in life, not getting what you want—and getting it!” and I have known consultants whose treadmill life illustrated the bitterness of this mot, and whose great success at sixty did not bring the comfort they had anticipated at forty. The mournful echo of the words of the preacher rings in their ears, words which I not long ago heard quoted with deep feeling by a distinguished physician, “Better is an handful with quietness, than both the hands full with travail and vexation of spirit.”