The Changing Physician

by DANA W. ATCHLEY, M.D.

AS THE spectacular progress in medicine of the past forty years is reviewed, one usually listens to a story of invention and discovery: the wonderful story of insulin, of vitamins, and of antibiotics; of advances in surgery of the brain, the lungs, and the heart; of X-ray diagnosis and treatment; of public sanitation. These are all practical and tangible aids in preventing disease, restoring health, and prolonging life.

Yet there are other advances which, though more subtle and less spectacular, are even more import ant than the practical gains. They concern the physician himself. If his own growth had not paced that of his science he would be unable to use all of these material advances safely and wisely. In contrasting the physicians of today and of forty years ago, I speak only of the best of the profession, comparing the fine clinicians who taught me at Johns Hopkins in 1915 with my colleagues of 1955. I shall first describe the nature of the change, and then note briefly some of the forces that have so successfully accomplished it. Although there are many doctors who have not changed with the progress of their discipline, yet the vigor and richness of a profession rest primarily on the quality of its leaders.

The physician of 1915 was an empiric follower of tradition, preoccupied with overelaborate techniques of physical examination. There was little understanding of disease; but worse, there was a somewhat complacent satisfaction with the existing status. The tide of science was still just lapping the clinical shores. True, isolated doctors with imagination and curiosity had made valuable discoveries, but a majority of even the best men were more interested in practicing than in perfecting their art. The aphorisms of the previous generation were revered and were easier to follow than the leadership of contemporary scientific research. One was categorically labeled as either a clinician or a laboratory man. Treatment was approached as an independent, highly codified field to be pursued without knowledge of the mechanisms involved. Diagnosis was usually mere cataloguing — applying a descriptive Latin phrase or attaching the name of the first observer, as Bright’s disease — and this classification was looked upon with satisfaction as an end, if not the end, to be achieved; the exceptions were those rare instances where the cause of the disease was known, as with diphtheria and typhoid fever.

Today’s physician combines the clinician and the laboratory man, for the rising tide of science has reached him at last and carried him to this new height. No longer happily content with restricted diagnostic pigeonholes, he is able and eager to understand the basic mechanisms that are involved. He is more preoccupied with the ideas of his predecessors than with their names. Instead of being satisfied merely to identify his patient’s condition with a large group of similar diseases, he tries to analyze all the various abnormal components in this one person and thus reach an appraisal rather than apply a label. When it is time for treatment, he thinks primarily in terms of the dynamics of the disturbed mechanisms and what procedures might influence their course, curbing them or diverting them to proper channels. He adapts his program to the specific individual. No longer is it a ritualized response to a symptom but a thoughtful consideration of the total problem. This is a scientist at work on a complex single human being, and concern with the whole person inevitably uncovers human facets that evoke the compassion which is so necessary for good medical care. Because of his scientific orientation, today’s physician is able to analyze his experience critically, rarely falling into the traps of coincidence and post hoc deductions; thus he is constantly growing, a lifetime student of disease and of man himself.

Copyright 1956, by The Atlantic Monthly Company, Boston 16, Mass. All rights reserved.

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WHAT are the forces that have produced this change? First and foremost is the participation of the physician in basic research, the clinician as chemist, bacteriologist, or physiologist, experimenter in person in the fundamental processes deranged by disease. The two outstanding factors in bringing the clinician into the laboratory and science into the hospital wards and private practice were the introduction of the full-time program into the clinical departments of the medical schools and the establishment of research hospitals such as the Rockefeller Hospital. Development of chemical and physical methods adaptable to the study of human physiology made the advance more rapid and extensive, but the most significant factor was the liberation of the clinical scholar from the anxieties and responsibilities of private practice.

In American medical schools prior to the twentieth century the entire faculty was, with few exceptions, recruited from the practicing physicians of the community. In order to carry on their class work, these busy men squeezed varying amounts of time and attention from their many patients. Johns Hopkins University broke away from this tradition when it was founded, and placed the faculty of the fundamental departments (anatomy, chemistry, physiology, etc.) on a true university basis, with the teachers of those subjects giving their entire time to the medical school; but the clinical departments (medicine, pediatrics, surgery, obstetrics, etc.) continued to be staffed by active practitioners. Some years later Johns Hopkins pioneered again, and in 1914 placed the clinical faculty on a university basis. There have been many modifications of the full-time program, varying all the way from complete rigidity to flexible combinations of men interested in teaching or in research or in practice, but the validity of the full-time principle is not questioned in educational circles. One of the most successful departments of medicine has a solid core of full-time men giving their whole time and exercising the dominant influence; another group confining their practice entirely to the Medical Center (known as “geographic full-time”), who are able to offer substantial contributions to the teaching program; and a group with offices outside the hospital, available for various degrees of responsibility. It should be noted that full-time men who are actively engaged in fundamental research have continual responsibility for patient care in the wards and the outpatient department.

Since the full-time man is a teacher as well as clinician and investigator, the medical student working on the wards of a university hospital is exposed to men who are studying disease. The scientific point of view is inculcated as the student makes his first contact with patients, and he continues to feel it as interne and resident, usually participating himself to a certain degree before he enters practice. So the young physician moves into his life’s work with some understanding of the difficulties and joys involved in the advancement of knowledge, and if he is at all perceptive, he will have acquired a modest critical ability in the evaluation of scientific evidence, a priceless acquisition. He will not fall for every new vitamin or so-called “cancer cure,” yet he will be alert for the frequent valid advances in his field.

The physician of today has a self-confidence and humility that derive both from his understanding of the forces that cause sickness and from his capacity with modern methods to make an accurate study of each patient. The knowledge so obtained gives a remarkable awareness of anatomical and physiological details, yet this very accuracy serves to highlight the unexplored areas; thus comes humility. When many patients are observed with repeated crosssection studies, a concept of the longitudinal section - that is, the life history of the disease — emerges, and we are better able to recognize the basic processes, anticipate the complications, and predict the outcome.

The analytic approach may be briefly illustrated by the story of a man aged fifty-five who complained of shortness of breath on exertion. He is a highstrung, successful businessman, accustomed to dispel a great deal of his emotional tensions at golf. He can cope with the golf course if he walks slowly (he is ashamed to use a golfmobile), but he has been told that the exertion will damage his heart. Accurate techniques of laboratory study demonstrate a normal heart, but prove that his essential difficulty is due to prematurely aging lungs. This is a process uninfluenced by activity, and therefore his exercise need be limited only by his comfort. Management can thus be guided by an understanding of both his emotional needs and his deranged physiology. As he exercises without anxiety it becomes apparent that a portion of his breathing difficulty was psychosomatic, introducing therewith an additional component, a small one but one capable of reversal. While the net result is not championship playing, it represents adequate recreation, and the man’s happiness has been increased. This ultimate goal of medicine, the happiness of the individual, should not be overshadowed by the extraordinary advances in the cure of disease and the prolongation of the life span.

In his ignorance the medical man of previous generations often assumed a self-protective and rather arrogant remoteness that discouraged all questions; he knew too little to dare say, “I don’t know.” Treatment was smothered in secrecy, prescriptions were wholly in Latin, and no clue as to the whys or wherefores was offered. Of course, the warmhearted, sympathetic practitioner managed to evade this convention of unapproachability, but many patients still apologize before they make a thoroughly justified query as to the results of their examination. The modern physician takes pride in exposition. He avoids dogmatic authoritarianism. He feels that his prime responsibility is to teach the patient all that he can comprehend about his illness; exposition, not dictation, is his concern. If the physician has some skill as a teacher, or even merely patience, he will have little difficulty in translating essential technical details for an individual whose attention should be well focused. And this participation of the sick person is not confined to the management of his treatment; it is often very important in the analysis of his case, as well. Certain types of asthma, for example, are stimulated by factors external to the patient: exposure to animals, birds, pollens, molds, dust, and so forth. If the asthmatic is properly instructed, he will observe his reactions and return with data invaluable for his appraisal. The scientifically oriented physician can sift these data, discarding the coincidental and retaining the causal. Then carefully controlled experiments in treatment may be set up in a parinership of doctor and patient; if cure be possible under present knowledge, such an approach will surely find it.

Although the wise and perceptive physician has always recognized the etiological influences of the environment, economic and emotional, as well as the role of the patient’s own temperament, this recognition was often on an almost unconscious level. It guided his management more by intuition than by deliberate analysis. The medical student of today is taught to take a history that is not only comprehensive but consciously analytical of the forces other than organic disease that are projected onto the patient by his family, his work, and his own character. A case presentation in the wards of a modern university hospital describes first of all a person, a special person, as thoroughly as the limitations of tact will permit; then follows a delineation of the symptoms and the objective abnormalities existing in this well-defined personality. Attention to the personality competes in no way with a systematic study of the physical status, for the two aspects are wholly complementary. The increasing body of knowledge concerning man’s emotions and their effect on his health often makes it possible to substitute scientific integration for pure intuition, thus freeing the intuitive approach for other areas. No one attempting to solve human problems can dismiss the valuable aid that intuition, the mobilization of unanalyzed experience, can provide at crucial moments.

As the physician has been able to give up the magic that was once the chief stock in trade of the most honest practitioners and to assume the role of scientific adviser to his patient, a new quality of integrity has entered the relationship. The atmosphere is that of an honest and candid interchange, the patient responding to the penetrating interest that is implicit in a modern diagnostic study and the physician reacting with the confidence and humility that comes from scientific insight. Such honesty is the firmest foundation for rich human relationships.

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