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Though medicine furnishes my illustration, the moral of this story applies to all the professions. They all more or less represent applied science. Without the continued progress of science, the modern professions cannot endure. But science cannot rest its future on magic. Nor can scientists eat science. The Chinese starved who undertook to support themselves by taking in one another's washing. Fundamentally and finally, science must depend on the common people for both its financial support and for its future personnel. To science, therefore, as well as to politics, applies the French maxim: "Walk from the people and you walk into the night.” If the maintenance and spread of great areas of joyous work moves us not, then self-preservation must move the professions to become educational agencies and enlist all men as comrades in a common intellectual venture.
It is certainly not knowledge that we professional men primarily lack today; we injure our professions far more by the lack of that democratic spirit that sees in every man a stimulus to share the best we have. Nothing could be more salutary for us in a democratic age than to remember that many of our professions arose in aristocratic times and have through tradition passed on to us ideals that are at war with our more human instincts. To strut down democratic lanes of hospital wards disporting the mannerisms of aristocratic Hippocrates can do nothing in the long run but belittle the profession that has made Hippocrates famous. In his day, indeed, knowledge was identified with virtue, and its possessors capitalized it for purposes of prestige. Later, men declared that knowledge was freedom, and those who had it celebrated their freedom by enslaving others. Since Bacon's time, we have called knowledge power, and many of its modern possessors have set themselves apart and exploited the weak. Knowledge is indeed both virtue and freedom and power; but wisdom consists in such generous sharing of our knowledge as will render power and freedom and virtue common property and thus professionalize the whole of life. This marks our larger professional service.
THE PHYSICIAN AMONG HIS FRIENDS
THEODORE DILLER, M.D.
The physician, in the minds of many, is set apart from other men; he occupies a peculiarly isolated position. He is held in reverence, respect and even adoration by some, and in scorn and contempt by others. His noble qualities, sacrifices, faults, failings and inconsistencies have been the subject of many writers from the earliest days down to the present moment. The physician himself can best understand himself, I believe, if he discounts both handsome and derogatory things that are said about him, and realizes that before he is a physician he is a man with the virtues, faults and failings of a man. While he follows this peculiar calling, his work in the life of the community has much in common with that of other men,he is a husband, a father, a school director; he is a churchman, a member of a lodge; he is a Democrat and a golfer; he is a historian, an automobilist, a member of the chess club or the literary society.
The physician receives the title of "Doctor," which in American life commonly denotes a member of the healing art, setting him aside from other men, constituting one of the greatest advertisements that any man can have. The title, at the same time is a drawback and a handicap, if the physician desires to mingle socially. People are self-centered and have deep feeling with regard to their health, so that when off duty, particularly at social gatherings of any sort, physicians are very apt to be subjected to some account of serious illness or operation of some sort, some opinion on things medical. And then he is subject to the jester who, with immense amusement, tells of the faults and failures of physicians, how they disagree, how disqualified they are, how they really know nothing at all, that
they only guess; and he may tell with guffaws of laughter how the physician buries his mistakes under 6 feet of ground, supposing no one ever heard this story before.
Well, what shall the physician do about this? The question regarding the recovery from a wonderful operation on the wife's sister and the wonderful skill of Dr. X. must be listened to with some appearance of attention. If the jokes, slants and squibs against physicians are old and well worn, if they are told with amiable humor, they must be smiled at. But all this is more or less of a strain on the physician, surely. Now and then some joker goes so far as to upset the equanimity of the most tolerant physician with his inveterate joking. He meets friends who are amiable and very fond of him, but who think it is highly amusing at the luncheon table to point out that physicians are barnacles and not producers; or that they never agree, never arrive at anything; that they have wonderful business sense in collecting fees disproportionate to their service, and that they love to devise operations of all sorts for the sake of operating. Surely this is a lame sort of wit, especially in view of the fact it is repeated over and over again. The physician must devise his own method of defense, whether to use the shaft of sarcasm or tolerance, or make some other sort of reply, must be left to the occasion. But one thing he had best not do is to show irritation.
Physicians oftentimes bring on themselves this sort of attack by talking of their profession to laymen. In mixed company it is best if the physician will say little or nothing as to the calling or profession to which he belongs, unless he is quite sure of the company and quite sure of an intelligent and sympathetic hearing. Many physicians talk of their work among laymen far too much. But when the physician has no business advantage in the title of “Doctor,” it would be better for him to omit it altogether. This is an excellent practice which has been observed by a colleague for a number of years in traveling to various parts of the world. He travels as plain Mr. X., not as Dr. X., and thus he meets his fellow passengers and is spared witticisms and conversations regarding operations and detailed accounts of the illnesses of his companions, his relatives and friends, but appears simply a man among men.
There can be no doubt that in a social way a physician should aim to make himself acceptable as a companion without depending in the least degree on his medical knowledge or experience to float himself. If he cannot do this he is more or less a social failure—a bore.
ANNUAL CONFERENCE OF SECRETARIES OF CON
STITUENT STATE MEDICAL ASSOCIATIONS
HELD AT CHICAGO, NOV. 21-22, 1924
(Continued from December, 1924) ADDRESS OF THE PRESIDENT-ELECT
W. D. HAGGARD, M.D.
It has been a very great pleasure to be present at this conference. I am frank to say that I didn't conceive of the value and scope of useful suggestions that a group of this sort can take back to their component societies. I am familiar with the vast amount of good that the conferences we have had on medical education for so many years have accomplished. There is a man or more than one man from each of our forty-eight states, and they are bringing their problems here and carrying back the unanimous concept of a group of hand-picked men who mean to American medicine jointly what the highest ideals would seem to require. CLINICAL MEETINGS I have been a secretary, myself, of many organizations to which I have had the honor to belong, and I wondered if we all in building programs realize the great value of the present trend toward clinical meetings. You are familiar with certain societies that do practically nothing else, and I want briefly to commend to your consideration the wisdom of having the dry clinic in the state medical society. The so-called wet clinic (the surgical clinic) has certain advantages, but it has many disadvantages. Relatively few men can see; the patient's interests are not best conserved, and a great deal of unnecessary time is consumed in preliminary and technical details that of themselves are not of moment. The dry clinic is so easy to handle. Any town in your state (it doesn't even need to have a hospital) can present cases, the diagnosis and presentation of which will be most thoroughly studied and the discussion of which, by men of prominence, men of experience and ability to impart knowledge, is incalculably valuable.
I was particularly struck with that in attending certain societies that have men come from a distance. I don't want to raise the question as to whether or not it is wiser to have our programs of purely local men or whether it is not advisable to have men come from a distance. In behalf of the latter proposition I may say that it does have a certain drawing value that our local men cannot and do not have, so that a wise balancing of material would be very attractive. In the proper utilization of the dry clinic we will bring modern medicine to the doctor at home.
It is hardly necessary for me to say to you men who have to edit the papers that we have inflicted on each other for so many years and have survived so valiantly, that whenever a man writes a paper he feels it must be the last word and the first word, and that everything on that subject must be in it. That same man, if he discusses that same topic from the standpoint of a clinician, will only tell about that thing which he does know. You are perfectly familiar with the fact as teachers—many of you—that it is one thing to attempt to teach a man something that you are familiar with in a general way, and it is a totally different thing if you undertake to teach him something that you yourself know of your own knowledge. If you only teach what you know that isn't so, it would be doing a real service.
It is the case report, the living thing, that the practitioner wants. He doesn't want to hear about the first man that wrote on a certain topic. He wants to know what is the matter with his patient.
WORKMEN'S COMPENSATION There is another problem that confronts us, and those of you who are medical editors, mentors of our profession, must seriously consider it. In the Workmen's Compensation Act something has been introduced that is most unfortunate, and that is taking away from the patient the liberty of choice of his doctor. The Workmen's Compensation Act is splendid; it is all right; but in its framing we didn't have the foresight to see the actual workings of all of its provisions. The practical way that it works out is that one or two men in a community are permitted or perhaps almost compelled to treat a large number of injuries that take cases away from the individual practitioners. That is wrong. It was not the intent of the law, and it must be cured.
In my own state we were short-sighted or negligent. We have in the Tennessee law a provision whereby the employer of labor is only liable for $100, a lump sum, for the medical, surgical and hospital care of any case. That is all right so far as a minor injury is concerned, and the profession is not the loser provided the man could have the physician of his choice, because the majority of accidents, being minor, never amount to that much, but in a case where a man has a serious injury and long hospitalization, $100 is gone before the treatment is fairly
Another question that is of prime importance now, is the question of the periodic physical examination. We are so busy taking care of the sick that we give little thought to the care of the well and the prevention of individual sickness. We are alert in regard to the prevention of community illness, but we have neglected the detection of incipient disease. Other organizations have sprung up and commercialized in an unfortunate way the splendid thought that periodic health examinations are very important.
If you as state secretaries could bring that to the attention of your societies, through papers and editorials, you would annihilate this commercial effort that is being propagated throughout this country. The House of Delegates, as you know, took a decided stand against the broker or middle man who sells medical service to the public.
I saw a practical application of periodic physical examination at the Kings County Medical Society of Brooklyn that I was privileged to visit recently. They first tried it out on themselves. They had all their doctors try it first. Which one of us doctors has been examined in the longest kind of time? None of us. We are examined all right when we are sick—that is, we are sometimes examined.
The nestor of our profession who sits in front of me once said something that ought to be emblazoned on the thought of every practitioner of medicine. Dr. Billings said that we have a pleasant conversation with the patient, but we don't always examine them.
We are so clever in making a shrewd diagnosis from the symptoms we are almost clairvoyant. A patient was brought 100 miles to the hospital for intestinal obstruction. When the bedclothes were pulled down a strangulated hernia was very prominent, but had never been observed. The diagnosis of intestinal obstruction was all right, but the physical examination was all wrong.
Every examination is not so easy. If we examine the patient thoroughly, we will be doing something that we should be doing regularly, uniformly and satisfactorily.
The best postgraduate course that the American medical profession could have at the present time would be to learn how to examine the well person. We should examine every case from head to foot, no matter what the complaint. If we had that sort of routine and uniformity of examination in our individual practices, what wonderful doctors we would be. What is our trouble? Lack of knowledge? No. We really don't see many obvious conditions because we don't examine systematically. What better preparation can you have for examining and diagnosing the pathologic conditions than to make it a custom among physicians to examine frequently every individual in their own clientele?
This is urgent, and we want to get at it right now. Let us begin by having ourselves examined. It will be a very valuable thing, a very illuminating thing, a very useful thing, and then we ought to so popularize it so that our patients will recognize the wisdom and the worth of it.
What happens now? People make long journeys to institutions and sanatoriums remote from their homes. They go with a sick relative, and when they get there they say, “Well, we went through and were examined, too.”
"What was the matter with you?” "Nothing."
But they come back with those reports and those urinalyses and are just as proud of them as if some one had conferred a diploma on them. Why don't we give them these thorough-going examinations at home?
The slogan is, "Have a complete physical examination on your birthday.” In order to make it a little bit more frequent and to popularize it in these days when marriage certificates come with divorce coupons, why not say, "Have an examination on the anniversary of your marriage.
But we must have the periodic health examination. It is the most far-reaching beneficient thing that has occurred in recent years for the benefit of the public in general and the profession in particular.
The trouble with us is that we have been so busy in the purely scientific side of our work that we have neglected the social side and the economic side. We have neglected the side of the propaganda, and we have thus neglected in this day to do our entire and complete duty by the patient.
In the splendid body that composes the American Medical Association, there is nothing that is worth while and far-reaching that will redound to the benefit of humanity that we must in any way ever neglect.
DIRECT VERSUS INDIRECT SERVICE
M. L. HARRIS, M.D.
It would seem from the very nature of things that the practice of medicine must be a personal or direct service, and that anything that interferes with this must do violence to the welfare of the individual. We will admit that human beings are in a sense machines, but each individual reacts to the conditions of life in a manner specific to himself. Therefore, generalizations must be quite broad and can never reach the particular reaction of a particular individual.
No person is able to describe the reactions of another so that a third person may have as clear an understanding and may render as sound an opinion concerning this individual as one who has come in personal contact and gotten his reaction through his own senses. We realize that in the medical profession, and always have realized it. It is perfectly absurd for one to attempt to consult over another at a distance. No intelligent, honest physician attempts today to diagnose and treat a patient whom he knows nothing about through personal contact. It is equally absurd on the part of the individual to seek consultation from some person at a distance, who has never had an opportunity of understanding him by personal contact.
SELLING INDIRECT SERVICE There is a great tendency today, which is growing very rapidly, for this personal or direct service to be interfered with by commercial organizations, to be taken away from the individual physician by a corporation rendering to the individual an indirect service. By indirect service I mean a service based on what information some one else may get from the person who is in actual contact with the individual. It is perfectly evident, it seems to me, that any such indirect service is to the detriment of the welfare of the individual, because it can never be as valuable to him as a like service rendered personally.
These organizations claim that they are not dealing with the sick but only with the well, and that their service is not the practice of medicine. In the very next breath, in order to show the necessity of their business, they claim that 97 per cent. of those whom they examine are not well, that they have some physical defect or some disease which has not been recognized by reason of the fact that the individual has never been examined, and it is their duty to be the intermediary between the individual and the medical profession. I never knew that the medical profession needed a go-between.
They not only have these individuals examined, but they say they amplify the knowledge which they get from the doctor, just like speaking through a megaphone, and that the description sent in by the doctor is mulled over by a number of individuals who have not seen the patient and know nothing about him except