In the days of probation the student’s life may be lived by each one of you in its fullness and in its joys, but the difficulties arise in the break which follows departure from college and the entrance upon new duties. Much will now depend on the attitude of mind which has been encouraged. If the work has been for your degree, if the diploma has been its sole aim and object, you will rejoice in a freedom from exacting and possibly unpleasant studies, and with your books you will throw away all thoughts of further systematic work. On the other hand, with good habits of observation you may have got deep enough into the subject to feel that there is still much to be learned, and if you have had ground into you the lesson that the collegiate period is only the beginning of the student life, there is a hope that you may enter upon the useful career of the student-practitioner. Five years, at least, of trial await the man after parting from his teachers, and entering upon an independent courseyears upon which his future depends, and from which his horoscope may be cast with certainty. It is all the same whether he settles in a country village or goes on with hospital and laboratory work; whether he takes a prolonged trip abroad; or whether he settles down in practice with a father or a friendthese five waiting years fix his fate so far as the student life is concerned. Without any strong natural propensity to study, he may feel such a relief after graduation that the effort to take to books is beyond his mental strength, and a weekly journal with an occasional textbook furnish pabulum enough, at least to keep his mind hibernating. But ten years later he is dead mentally, past any possible hope of galvanizing into life as a student, fit to do a routine practice, often a capable, resourceful man, but without any deep convictions, and probably more interested in stocks or in horses than in diagnosis or therapeutics. But this is not always the fate of the student who finishes his work on Commencement Day. There are men full of zeal in practice who give good service to their fellow creatures, who have not the capacity or the energy to keep up with the times. While they have. lost interest in science, they are loyal members of the profession, and apreciate their responsibilities as such. That fateful first lustrum ruins some of our most likely material. Nothing is more trying to the soldier than inaction, to mark time while the battle is raging all about him; and waiting for practice is a serious strain under which many yield. In the cities it is not so hard to keep up: there is work in the dispensaries and colleges, and the stimulus of the medical societies; but in smaller towns and in the country it takes a strong man to live through the years of waiting without some deterioration. I wish the custom of taking junior men as partners and assistants would grow on this continent. It has become a necessity, and no man in large general practice can do his work efficiently without skilled help. How incalculably better for the seniors, how beneficial to the patients, how helpful in every way if each one of you, for the first five or ten years, was associated with an older practitioner, doing his night work, his laboratory work, his chores of all sorts. You would, in this way, escape the chilling and killing isolation of the early years, and amid congenial surroundings you could, in time, develop into that flower of our callingthe cultivated general practitioner. May this be the destiny of a large majority of you!
Have no higher ambition! You cannot reach any better position in a community; the family doctor is the man behind the gun, who does our effective work. That his life is hard and exacting; that he is underpaid and overworked; that he has but little time for study and less for recreation these are the blows that may give finer temper to his steel, and bring out the nobler elements in his character. What lot or portion has the general practitioner in the student life? Not, perhaps, the fruitful heritage of Judah or Benjamin but he may make of it the goodly portion of Ephraim. A man with powers of observation, well trained in the wards, and with the strong natural propensity to which I have so often referred, may live the ideal student life, and even reach the higher levels of scholarship. Adams, of Banchory (a little Aberdeenshire village), was not only a good practitioner and a skilful operator, but he was an excellent naturalist. This is by no means an unusual or remarkable combination, but Adams became, in addition, one of the great scholars of the profession. He had a perfect passion for the classics, and amid a very exacting practice found time to read “almost every Greek work which has come down to us from antiquity, except the ecclesiastical writers.” He translated the works of Paulus Aegineta, the works of Hippocrates, and the works of Aretaeus, all of which are in the Sydenham Society’s publications, monuments of the patient skill and erudition of a Scottish village doctor, an incentive to every one of us to make better use of our precious time.
Given the sacred hunger and proper preliminary training. the student-practitioner requires at least three things with which to stimulate and maintain his education, a notebook, a library, and a quinquennial braindusting. I wish I had time to speak of the value of note-taking. You can do nothing as a student in practice without it. Carry a small notebook which will fit into your waistcoat pocket, and never ask a new patient a question without notebook and pencil in hand. After the examination of a pneumonia case two minutes will suffice to record the essentials in the daily progress. Routine and system when once made a habit, facilitate work, and the busier you are the more time you will have to make observations after examining a patient. Jot a comment at the end of the notes: “clear case,” “case illustrating obscurity of symptoms,” “error in diagnosis,” etc. The making of observations, may become the exercise of a jackdaw trick, like the craze which so many of us have to collect articles of all sorts. The study of the cases, the relation they bear to each other and to the cases in literaturehere comes in the difficulty. Begin early to make a threefold categoryclear cases, doubtful cases, mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch. You remember Lincoln’s famous mot about the impossibility of fooling all of the people all the time. It does not hold good for the individual who can fool himself to his heart’s content all of the time. If necessary, be cruel; use the knife and the cautery to cure the intumescence and moral necrosis which you will feel in the posterior parietal region, in Gall and Spurzheim’s centre of self-esteem, where you will find a sore spot after you have made a mistake in diagnosis. It is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience. It is a common error to think that the more a doctor sees the greater his experience and the more he knows. No one ever drew a more skilful distinction than Cowper in his oft-quoted lines, which I am never tired of repeating in a medical audience:
Knowledge and wisdom, far from being one, Have oft-times no connexion. Knowledge dwells In heads replete with thoughts of other men; Wisdom in minds attentive to their own. Knowledge is proud that he has learned so much; Wisdom is humble that he knows no more.
What we call sense or wisdom is knowledge, ready for use, made effective, and bears the same relation to knowledge itself that bread does to wheat. The full knowledge of the parts of a steam engine and the theory of its action may be possessed by a man who could not be trusted to pull the lever to its throttle. It is only by collecting data and using them that you can get sense. One of the most delightful sayings of antiquity is the remark of Heraclitus upon his predecessorsthat they had much knowledge but no sense -which indicates that the noble old Ephesian had a keen appreciation of their difference; and the distinction, too, is well drawn by Tennyson in the oft-quoted line:
Knowledge comes but wisdom lingers.
Of the three well-stocked rooms which it should be the ambition of every young doctor to have in his house, the library, the laboratory, and the nurserybooks, balances, and bairnsas he may not achieve all three, I would urge him to start at any rate with the books and the balances. A good weekly and a good monthly journal to begin with, and read them. Then, for a systematic course of study, supplement your college textbooks with the larger systems Allbutt or Nothnagela system of surgery, and, as your practice increases, make a habit of buying a few special monographs every year. Read with two objects: first, to acquaint yourself with the current knowledge on the subject and the steps by which it has been reached; and secondly, and more important, read to understand and analyse your cases. To this line of work we should direct the attention of the student before he leaves the medical school, pointing in specific cases just where the best articles are to be found, sending him to the Index Cataloguethat marvellous storehouse, every page of which is interesting and the very titles instructive. Early learn to appreciate the differences between the descriptions of disease and the manifestations of that disease in an individualthe difference between the composite portrait and one of the component pictures. By exercise of a little judgment you can collect at moderate cost a good working library. Try, in the waiting years, to get a clear idea of the history of medicine. Read Foster’s Lectures on the History of Physiology and Baas’s History of Medicine. Get the “Masters of Medicine” Series, and subscribe to the Library and Historical Journal.
Every day do some reading or work apart from your profession. I fully realize, no one more so, how absorbing is the profession of medicine; how applicable to it is what Michelangelo says: “There are sciences which demand the whole of a man, without leaving the least portion of his spirit free for other distractions”; but you will be a better man and not a worse practitioner for an avocation. I care not what it may be; gardening or farming, literature or history or bibliography, any one of which will bring you into contact with books. (I wish that time permitted me to speak of the other two rooms which are really of equal importance with the library, but which are more difficult to equip, though of coordinate value in the education of the head, the heart, and the hand.) The third essential for the practitioner as a student is the quinquennial brain-dusting, and this will often seem to him the hardest task to carry out. Every fifth year, back to the hospital, back to the laboratory, for renovation, rehabilitation, rejuvenation, reintegration, resuscitation, etc. Do not forget to take the notebooks with you, or the sheets, in three separate bundles, to work over. From the very start begin to save for the trip. Deny yourself all luxuries for it; shut up the room you meant for the nurseryhave the definite determination to get your education thoroughly well started; if you are successful you may, perhaps, have enough saved at the end of three years to spend six weeks in special study; or in five years you may be able to spend six months. Hearken not to the voice of old “Dr. Hay-seed,” who tells you it will ruin your prospects, and that he “never heard of such a thing” as a young man, not yet five years in practice, taking three months’ holiday. To him it seems preposterous. Watch him wince when you say it is a speculation in the only gold mine in which the physician should investGrey Cortex! What about the wife and babies, if you have them? Leave them! Heavy as are your responsibilities to those nearest and dearest, they are outweighed by the responsibilities to yourself, to the profession, and to the public. Like Isaphaena, the story of whose husbandardent, earnest soul, peace to his ashes!I have told in the little sketch of An Alabama Student, your wife will be glad to bear her share in the sacrifice you make.
With good health and good habits the end of the second lustrum should find you thoroughly establishedall three rooms well furnished, a good stable, a good garden, no mining stock, but a life insurance, and, perhaps, a mortgage or two on neighbouring farms. Year by year you have dealt honestly with yourself; you have put faithfully the notes of each case into their proper places, and you will be gratified to find that, though the doubtful cases and mistakes still make a rather formidable pile, it has grown relatively smaller. You literally “own” the country-side, as the expression is. All the serious and dubious cases come to you, and you have been so honest in the frank acknowledgment of your own mistakes, and so charitable in the contemplation of theirs, that neighbouring doctors, old and young, are glad to seek your advice. The work, which has been very heavy, is now lightened by a good assistant, one of your own students, who becomes in a year or so your partner. This is not an overdrawn picture, and it is one which may be seen in many places except, I am sorry to say, in the particular as to the partner. This is the type of man we need in the country districts and the smaller towns. He is not a whit too good to look after the sick, not a whit too highly educatedimpossible! And with an optimistic temperament and a good digestion he is the very best product of our profession, and may do more to stop quackery and humbuggery, inside and outside of the ranks, than could a dozen prosecuting county attorneys. Nay, more! such a doctor may be a daily benediction in the communitya strong, sensible, whole-souled man, often living a life of great self-denial, and always of tender sympathy, worried neither by the vagaries of the well nor by the testy waywardness of the sick, and to him, if to any, may come (even when he knows it not) the true spiritual blessingthat “blessing which maketh rich and addeth no sorrow.”
The danger in such a man’s life comes with prosperity. He is safe in the hard-working day, when he is climbing the hill, but once success is reached, with it come the temptations to which many succumb. Politics has been the ruin of many country doctors, and often of the very best, of just such a good fellow as he of whom I have been speaking. He is popular; he has a little money; and he, if anybody, can save the seat for the party! When the committee leaves you, take the offer under consideration, and if in the ten or twelve years you have kept on intimate terms with those friends of your student days, Montaigne and Plutarch, you will know what answer to return. If you live in a large town, resist the temptation to open a sanatorium. It is not the work for a general practitioner, and there are risks that you may sacrifice your independence and much else besides. And, thirdly, resist the temptation to move into a larger place. In a good agricultural district, or in a small town, if you handle your resources aright, taking good care of your education, of your habits, and of your money, and devoting part of your energies to the support of the societies, etc., you may reach a position in the community of which any man may be proud. There are country practitioners among my friends with whom I would rather change places than with any in our ranks, men whose stability of character and devotion to duty make one proud of the profession.
Curiously enough, the student-practitioner may find studiousness to be a stumbling-block in his career. A bookish man may never succeed; deep-versed in books, he may not be able to use his knowledge to practical effect; or, more likely, his failure is not because he has studied books much, but because he has not studied men more. He has never got over that shyness, that diffidence, against which I have warned you. I have known instances in which this malady was incurable; in others I have known a cure effected not by the public, but by the man’s professional brethren, who, appreciating his work, have insisted upon utilizing his mental treasures. It is very hard to carry student habits into a large city practice; only zeal, a fiery passion, keeps the flame alive, smothered as it is so apt to be by the dust and ashes of the daily routine. A man may be a good student who reads only the book of nature. Such a one’ I remember in the early days of my residence in Montreala man whose devotion to patients and whose kindness and skill quickly brought him an enormous practice. Reading in his carriage and by lamplight at Lucina’s bedside, he was able to keep well informed; but he had an insatiable desire to know the true inwardness of a disease, and it was in this way I came into contact with him. Hard pushed day and night, yet he was never too busy to spend a couple of hours with me searching for data which had not been forthcoming during life, or helping to unravel the mysteries of a new disease, such as pernicious anaemia.