Our Anabasis*

Avan Greece, M.D.**

Vice-President, Rockefeller Foundation,
New York City

In addition to the liberty accorded
the speakers at these dinners, a gen-
erous measure of reflectiveness must
have been encouraged if one may
judge from the records. So, I shall
venture a theory or two, somewhat
fortified by the conviction that you
could supply a wealth of illustrative
examples if the general pattern of
my ideas makes sense. And I shall

have, at least in point of reflective-

ness, the benefit of your tradition,
and even an aegis from the Greeks.
For it was Plato who left us the wise
and widely applicable comment that

‘the “unexamined life is not worth
living.’ }

Jumping—and I use the word ad-
visedly—from. Plato to James Thur-
ber, I would quote the latter if only
to forestall critics or perhaps to gain
your clemency by pleading guilty.
‘Thurber observes that “Speculation
if confined to certainties is eased of
its wonder and its warmth.” Paren-
thetically I cannot but think that
the history of endocrinology might
have been more sober and sequential
if Thurber’s maxim had furnished
the core of editorial critique in that
field. . . - ‘‘Speculation if confined to
certainties is eased of its wonder and
its warmth.”

So let us start from the here and
now, confining ourselves at least fora
moment to the certainties of this
meeting and this association. Let us

* Address presented at the annual dinner of th

begin by asking what keeps men to-
gether in contented and effective
association? Curiously enough the
analysis of this question seems to
follow that strong sense of time
which the Indo-European languages
require their verbs to obey by means
of making sharp distinctions be-
tween past, present and future.
What keeps men together in happy
and effective association? Clearly
related to past, present and future,
three things mainly keep men to
gether: from the past it is shared ex-
periences; in the present, beliefs gen-
erally agreed upon; and for the fu-
ture, hopes and desires held in com-
mon. Of. these three sources of
gregarious reassurance and reward,
I would think that shared experience
is the most philosophical and pro-
found; that facts and opinions pres-
ently agreed upon are the clearest
and most manageable; and that
identical hopes and desires are the
least reliable and yet the, most allur-
ing. When someone speaks of the
past we can close our eyes or stare
in the fire. When he speaks of the
present we look at his graphs and his
evidence. But when he speaks of the
future we want to look at him.

Now this evening I suggest that
you close your eyes or stare in an ©
imaginary fire. For I have no graphs
for you to look at, no facts to prove,
no hopes to cultivate nor preferences

e Association of American Physicians,

Atlantic City, N.J., May 4, 1954. Reprinted from Transactions of American Physi-

cians, December 1954.
** Dr. G
chapter in 1951.

regg is an alumnus member of Alpha Omega Alpha, elected by Harvard

1 Plato, Apology of Socrates, Section 38. (Loeb Edition) H. N. Fowler’s translation-

14
February 1955

to exploit. It isin your own recollec-
tions that I shall find, or fail of
corroboration.

For my central theme concerns

the profound power of experience in
shaping us for the practice of medi-
cine, the power of experience as con-
trasted with the mere acquisition of
information. Surely we retain resi-
dues from the past more pervasive
and long-lived than memorized facts.
Edouard Herriot said that what the
French call “formation” is what re-
mains after one has forgotten every-
thing. We are only speaking of differ-
ent aspects of this same idea of
“formation”? when we refer to a
man’s turn of mind, his ways of
thinking, his approach, or his atti-
tude. I repeat then that out of the
three forces that bind men together
in effective and rewarding associa-
tionm—namely common experiences,
agreed upon facts and shared hopes
—I shall deliberately choose to ex-
amime the role of what may be
called shared experience. This I do
because I have reasons for thinking
it singularly neglected, ignored, per-
haps misunderstood and yet for all
that unquestionably interesting, de-
lightfully varied and _ potentially
valuable. Besides, you are presently
spending these days on the facts that
hold us together, and as for the
future I would not wish to spoil to-
night’s good dinner by evoking the
alarm reaction that follows most
attempts at rhetorical persuasion.

Is this thing we call shared experi-
ence so powerful? I think it is. What
is it, after all, that binds us not only
to the friends we still miss this eve-
ning, Bill Palmer and Francis Pea-
body and Warfield Longcope, but to
Osler and Frank Billings, J. B. Her-
rick, Fred Shattuck, Freidrich Mil-
ler, James McKenzie, Thomas Lewis
and Fernand Widal, and in another
chapter even to Sydenham, to Har-
vey and Maimonides and Galen. It

Alpha Omega Alpha

can hardly be the mere facts and
opinions we share with these men
that puts us in their brotherhood,
but rather the experiences we have
known as did they, simply because
we all became doctors. The bonds
of common experience require no
verification and no renewal. It is not
the areas of merely intellectual
agreement that bind us to our col-
leagues of the past but the frustra-
tions and predicaments both we and
they have lived through, of igno-
yance and powerlessness, or some-
times a happier circumstance,—the
kinship of lucky survivors. We have
thus something in common with the
doctors of every age and every
country, with the mediocre, obscure
and forgotten as well as the great
and distinguished and famous. It is
what our patients have made of us
quite as much as what we have made
of them, that forges for doctors a
common bond. We all have played
the same role to the rest of mankind.
We had to meet their expectations,
and had each our bit of that com-
munity of experience that all doc-
tors share—and only doctors. For
in the last analysis human societies
make their healers, and the healers
then make the doctrine. And eventu-
ally if the makers of doctrine happen
to espouse the scientific method a
feed-back phenomenon begins: the
doctrine because it is true begins to
make true healers of the healers,
and the healers, using the truth,
begin to remake the society that
made them. But until science has
provided us with the complete ex-
planation and control of every phe-
nomenon that confronts us as doc-
tors we shall have to accept, with a
degree of modesty to match our
ignorance, the traditional profes-
sional role that society has given us
—its pleasures, its frustrations, its
humor and its anguish, its rewards
and its burdens.

15
The Pharos

February 1955

 

Since what we all have lived
through simply as doctors seems to
be so important, I have been look-
ing during the past few years for
some account or listing of the generic
experiences of young men and wom-
en on their way into the profession
of medicine. Would there not be
food for thought in such a record?
I’ve searched steadily and in more
than one country for a doctor’s auto-
biography or biography that records
the events that impressed him in
his student days, together with a
thoughtful discussion of the inter-
pretations he placed upon those
events: something of the order of
“The Education of Henry Adams”
but relating to the nature of becom-
ing a doctor. I know such an account
would interest me. It might even be
useful to younger students for com-
parison, for reassurance or freeing
their thoughts about what they
could be and do—and when. But
thus far my search has been in vain
—neither biographies nor autobi-
ographies nor any considered essays
upon the generic experiences that
make a doctor out of a green begin-
ner—none of these have I found.

Perhaps I should be consoled by
reflecting that had I found a plenty
I would have had to look further for
a subject for this evening’s talk. For
tonight I should like to present to
you, with due apologies for being in
so speculative a mood, a rather
simple array, or first approxima-
tion, of the formative experiences
on the way to becoming a doctor.
These experiences may come before
the medical school or even after it,
and for this reason I call them
“formative” and “on the way to be-
coming a doctor.” The time at my
disposal precludes extended discus-
sion or the luxury of giving more
than one example of each meaning-
ful type of event. Obviously the way
you take an episode decides the

16

meaning it will have for you. And
that interpretation usually derives
from your own previous but some-
times only faintly analogous ex-
periences.

Rather than the first person of the
autobiographer or the third person
of the case history I have used the
second person singular as appropti-
ate for conveying the kind of
thoughts and feelings so many of us
have had, whether we began our
careers in Buenos Aires or Banga-
lore, Vancouver or Vizagapatam,
Helsinki or Hong Kong, Capetown
or Chicago, London or Los Angeles,
Bucharest or Boston, Keio or Ka-
rachi, Dunedin or Edinburgh, Utab
or Uppsala, Moscow or Melbourne.
For the sake of clarity I repeat that
I do not refer to the extensive body
of verifiable facts or presently shared
opinions in medicine throughout the
modern world. Nor am I competent
either to assert or to deny that the
followers of Aryuvedic medicine or
the healers of other cults with which
we are not really familiar, share all
or none of the pattern characteristic
of modern medicine throughout
much of the world. But one may be
sure of one thing, however—that the
events significant to beginners in
medicine do not always come in the
same order and still more important
that the meaning or significance of
a given event or even type of event
will vary and vary almost incredibly,
depending on the order and nature
of all that has preceded it.

But still if a recognizable assort-
ment of experiences characterizes
the entrance to medicine whether or
not they follow any pattern of se-
quence, then I would say that in
sharp contrast to their apparent uni-
versality these typical experiences
have received astonishingly little at-
tention, deliberate or inadvertent.

Except for those examples of
young men going into medicine to
February 1965

please or to obey their parents, the
earliest event of major importance
on the way into Medicine relates to
the choice of medicine as a career.
An experienced schoolmaster of my
acquaintance told me that boys de-
cide in favor of medicine both earlier
and with fewer subsequent changes
of mind than they bring to the
choice of any other calling.

* FF RF Rk

You must have been about 11
years old when it happened. You
had a very sore throat and after a
night when the lamp never went out
and your mother was at your side
whenever yeu called for her, you
awakened to see her anxiously scan-
ning your face and heard her ask
your father to call Dr. Lawrence.
You used to see Dr. Lawrence go up
Cascade Avenue in his new horseless
carriage followed by his man driving
the other older horseless carriage in
case the new one broke down or blew
out a pneumatic tire. When Dr.
Lawrence came into your room he
put his lighted cigar very carefully
on the marble top of the dressing
table. Your mother didn’t seem to
mind that at all. He smelled awfully
strongly of tobacco when he leaned
down and put his ear right on your
bare chest. Then he asked your
mother to get a pitcher of fresh

_water, turned to you and said,
“Now watch!’’ He took a bottle out
of his medicine bag, uncorked it
deftly with one hand and shook
some shiny brown crystals into the
water which immediately turned a
wonderful purple. “Let him” (he
didn’t say ‘make him’) “let him
gargle with this every two hours,”
and then turning to you, ‘but don’t
swallow it! Two pounds of this
powder would turn all Prospect
Lake purple! By the way did you
hear the sicklebill curlews night be-
fore last? Asleep? Well I was com-

Alpha Omega Alpha

ing home from the Malones at 3
o’clock in the morning,” and turn-
ing to your mother he added, ‘84
pound boy . . . and the curlews’
eerie crying was beautiful.”’ Then
he turned to your Mother and said,
“Mrs. Bacon, you haven’t a thing
to worry about. I'll be back day
after tomorrow and sooner if you
want.” Your mother suddenly
looked very relieved and just after
Dr. Lawrence had left you heard
her say to your father, ‘Doctor
Lawrence is so faithful.” That was
her highest praise, as any one could
guess from her way of saying it.

Four days later sitting in the
swing in the bright September sun
an idea suddenly swept you through
and through—‘‘when I grow up I
want to be a doctor.” You rather
thought that with anything as big
as that you ought to tell God about
it immediately—and not just casu-
ally standing up, either. But if you
knelt down then and there some-
body might see you and ask why—
and you couldn’t tell. So you ran
upstairs to the only room in the
house that could be locked—the
bathroom—and there you knelt
down under three towels, an empty
hot water bottle and your father’s
back-scratcher, and took the Al-
mighty in on a decision that you
never doubted nor regretted from
that day to this.

After that day there came—some
years later—a wonderful experience
encouraging your hope or confirm-
ing your resolve to become a doctor.
One Saturday afternoon you were
down town shopping. You met your
English teacher right in front of
Eldon’s book store. He had always
seemed busy-—-too busy to talk to
any of his students with any ap-
pearance of leisure. So you were
surprised when he said with the air
of an equal rather than a teacher,
“Say, Raymond, have you a few

17
The Pharos

February 1956

 

minutes free?” Such a dignifying
form for the question! On promptly
saying yes, you were led the length
of the book store back to a browsing
room you had never seen before.
Your English teacher reached down
a volume of Wordsworth and read
you the Ode to Tintern Abbey. That
was all he did, but you walked home
on air. It wasn’t the beauty of the
Ode that stirred you: you were
moved beyond words and just be-
cause—for the first time in your life
—you were treated as a.grown-up
presumably possessing freedom and
tastes of your own. Then why not
go to the university of your dreams
instead of the nearby college? Right
there in that book store you turned
the corner.

Perhaps one further event rein-
forced the nascent conviction that
you really were grown up and free
to choose your own career. In Junior
year in college you wanted to take
an advanced course in Psychology
without having taken the prelimi-
nary course. For this you had to get
special permission. You explained
that you were interested in Psy-
chology, had read a good deal, and
that your roommate who took the
preliminary course the year before
had mentioned nothing of it that
was unfamiliar to you. Almost
miraculously you were admitted to
advanced standing on the basis of
interest and independent reading
instead of the usual requirement of
“eredit hours’’: that was a bracing
and beautifully maturing thing to
have happened—even though it
came before the medical school.
What it really suggested to you—
though you may not have formu-
lated it at the time—was simply
that one can learn without having a
teacher—an axiom that only the
best teachers apparently can afford
to identify themselves with at all
generously.

18

These two types of experience are
characteristic for the years before
entering the medical school: the
choice of medicine as a career and
some form of reassurance that this
choice has been better than a bope—
responsible personal decision rather
than a dream. Nowadays in the
United States such reassurance must
frequently come only on the day the
college student gets the letter of ac-
ceptance from a medical school ad-
missions committee. Elsewhere in
the world it is the students who de-
cide whether or not they will enter
the medical faculties since the only
requirement is satisfactory gradua-
tion from secondary s¢hool.

* * * * * * * *

Have you ever wondered how long
in your dealings with patients it
took you to get over the fact that
your first patient was a cadaver? It
is commonly known that medical
students dissect the bodies of the
dead: it is less commonly realized
that these same dead do a good deal
of cutting, probing and pulling at
the minds of their youthful dis-
sectors—if we may call assumptions
and values by the name of ‘mind.’
What most of us sought that first
day among the naked, stark dead
in the dissecting room was detach-
ment—detachment enough to stand
and view the machinery devoid of
spirit, detachment and time enough
to compose life with stinking death.
You had never seen a dead person
nor a naked woman but your first
task was to bathe and shave her—
without her permission. She was the
recipient of your services—and noth-
ing more. The Patient as a Person—
the Cadaver as a Patient—the Per-
son as a Cadaver—take your choice.

More clearly than ever before
that first day, emotions involved
your olfactory sense and vice versa.
When you went to the wash room
February 1955

to get your hands clean enough to
light a cigarette you found two
classmates there vomiting. When
another student came in, he sniffed
conspicuously and turning upon the
nauseated neophytes exclaimed, “I
was getting along all right until you
did this; damn it, you’ve spoiled my
day!’ Yes, we sought detachment
desperately, by fair means or foul,
in the bravado of indecent jokes and
in deliberately exaggerated realism.
There was even some flavor of re-
lief, escape and detachment in con-
centrating our attention on the feats
of memory expected of us—the new
names of every bone and muscle,—
the power of being able to name
everything, the relief of a Latin
incantation. H. L. Mencken noted
once that love involves the inhibi-
tion of disgust. On this basis Anat-
omy as the gateway to medicine may
have some value as a test of the be-
ginner’s enthusiasm and sincerity.

* * * * * KK

Another memory recalls a dif-
ferent imprint from the anatomy
course. One day one of. your class-
mates found in his cadaver the
rather uncommon anomaly of an
accessory pectoral muscle. The emo-
tion this discovery produced in all
of your fellow students deserves at-
tention: it was one of relief—a sud-
den vacation, as it were, from the
rigid and tirmmg uniformity of the
human machine. Little did you real-
ize during that stern schooling in
uniformities that within three years
your clinical teachers would be snarl-
ing at you, “But don’t you know
that human beings are different?”
Nor did it occur to you that Em-
bryology with its bewilderingly swift
sequences of becoming, rather than
permanently fixed states of being,
offered a better paradigm of the life
sciences than its revered elder
brother Gross Anatomy.

19

Alpha Omega Alpha

Of human dissection as an experi-
ence many interpretations may be
made in private and many opinions
held in public. But few would deny
the power of its imprint on young
people, regardless of whether you
choose to accent its stark realism, or
its unending mystery, or its blunt
evidence of uniformity, or its power
in presenting that great leveller of
all manner of men, Death. No mod-
erm profession seems to require at
entrance an experience so close to
the initiatory rites of primitive
tribes in point of mystery and strain.
One begins medicine, as one begins
a prizefight, by shaking hands with
the Adversary: it is a good tradition
but not necessarily easy, so some
dodging and fast footwork is to be
excused in the first round.

x * * * * *# * *

I would record a query as to one
consequence of introducing the stu-
dent to the morphological sciences
first and foremost, when he is in his
most receptive phase. This query
may well take the form of the record
on an event which for the sake of
variety I'll put in its original form
of a personal record in quotation
marks. The story reveals the radical
change of ways of thinking that
come when narrative, time sequen-
ces, and history-taking suddenly ap-
pear to the student to have as much
importance as the sedulously culti-
vated skills of measurement and
description.

“A team of five students was to
watch by means of the fluoroscope
the effect of fright on peristalsis in
the cat. We were the last group in
the class to perform this experiment:
we had heard of the vivid results
obtained by other groups. It hap-
pened by chance that in our team I
assigned the task of recording the
experiment. When I suggested that
we record the sex of our cat and
The Pharos

where it had come from—was it an
alley cat, or a hapless domestic pet?
—the suggestion was busily ignored
as a piece of sentimentality. The in-
structor observed dryly that we were
‘doing an experiment, not writing
a novel.” The cat was therefore
weighed and its weight recorded.
But on exposure to a barking fox
terrier our kindly tabby seemed but
little disturbed nor was her peristal-
sis appreciably affected, though the
recorded consensus of our team was
that there was ‘some inhibition of
normal peristalsis.’ But off the rec-
ord we ruefully admitted that our
experiment had ‘failed.’ I was de-
lighted at the experimental result
but outraged at the interpretations
put upon it. Not until long after-
. wards did I Jearn that the cats in
which Walter Cannon first observed
the effect of fright on peristalsis were
wild alley cats but that when he
first undertook to demonstrate the
phenomenon to his chief Professor
Henry P. Bowditch, Cannon had
the misfortune to use an even-
tempered domestic tabby who had
led a hitherto placid and amiable life
with dogs and children, so no in-
hibition of peristalsis was observable
in that animal. Experiments don’t
fail: the failures are in narrating,
observing, recording and interpret-
ing. I think it was an important ex-
perience to have my blind conviction
of the importance of narrative vin-
dicated. The time factor is so im-
portant. Time alone can change
many an apparently static pattern.
Time provides the ultimate terminus
to many an otherwise apparent
finality.”

Doubtless the discovery of the
importance of the time factor in
medicine may be so gradual as
hardly to be called an “experience.”
But a well developed sense of time,
narrative and sequence adds as much
and as new a form of understanding

20

Perec aaa

living tissue as a moving pi
projector brings to a series of sepge
rate frames. This narrative sense in-
forms and infuses Sir James Mag.
Kenzie’s wonderful example and
later Sir Thomas Lewis’ insistence
on studying the natural history of
disease. It makes possible the idea
of process and dynamics in the inter-
pretation of disease. Consequently
when the novice on his way into
medicine has an experience that dis.
covers to him the importance of
narrative, it is a cardinal event even
though its full meaning may not be
felt at the time.

* oe & Ok Kk ok ok &

As you got well into the medical
school there came slowly or perhaps
in some sudden revelation an almost
overwhelming sense of how much
you ought to know to practice medi-
cine. As an alternative to the cheap
cynicism or truculent self-assurance
so often summoned to meet such
worries I venture to record what
Soma Weiss told me was. his ex-
perience.

“I was inscribed as a first year
student at the University of Buda-
pest. We counted ourselves very
fortunate to have the great Professor
EKétvés as our Professor in Physics.
He did not appear on time at his
first lecture. This seemed to increase
our interest in what he would prove
to be like. Suddenly the side door
to the platform swung open and a
huge white-bearded man strode in
carrying two large books. He must
have been six feet. two or three and
in every way he met or surpassed
my expectations. He slammed the
two books on the lectern and then
looked out over some three hundred
of us students and in a deep booming
voice he cried, ‘I know nothing!
We students were dumbfounded at
such a fantastic statement. With
some reason we could have said that
February 1955

—but not Professor Eétvés. He re-
peated it—‘I know nothing!’—and
then dramatically pointing to the
books he shouted with a peculiar
precision and emphasis, ‘But gentle-
men, I have learned how to find out
anything I want to know!’ He
stopped, and looked out over the
class as though to let that idea
sink in.

“Now I do not believe I have ever
felt such a glorious sense of relief,
of spiritual freedom, elation, almost
ecstasy, in all my life before or since.
I see why now, but I didn’t then.
The swiftly increasing sense of how
much I would have to know in order
to practice medicine had up till that
moment all but overwhelmed me.
And here was no less an authority
than the great Professor Hétvés
saying that finding out how to learn
was what he relied on—not on know-
ing everything . . . or even anything.
To me such a simple incisive atti-
tude toward the vast accumulations
of medical knowledge came as an
astounding relief.”

x * Kk * * * *

Together with learning, as Soma
Weiss did, what attitude to take
toward the size of his task, you
wanted to know a dependable an-
swer to the perennial question
“How am I doing?’’ With your
conscience reinforcing the pressure
of the competition all around you,
solicitude as to the quality of your
performance must have tempted
you to leave all such decisions as to
your competence to the wisdom of
your teachers. From that imma-
turely evasive solution progress was
slow. Finally it came in this wise.

During your internship you had
as visiting men two physicians of
very different character, tastes and
interests. You had soon learned to
write two different styles of history
of a patient, one that Dr. A. would

21

Alpha Omega Alpha

find satisfactory and another for Dr.
B.; quite a different selection and
presentation of facts. But you could
not control the situation: Dr. A.
would find the histories written for
Dr. B. very poor—and vice versa.
And you got bored with such pica-
yune maneuvering. It seemed not
much better than intellectual prosti-
tution. So you got up courage to ask
the Resident if he could give you
any tips on writing good histories.
The Resident was Bill Palmer. He
gave you the perfect answer. He
said, “I don’t know any devices’—
and then after a pause he added, “I
think if you wrote a history that
satisfied you it would be a good
history.”

Now you had learned to take a
history for Dr. A. or Dr. B. in about
45 minutes and do the rewrite in a
half hour. But the next afternoon,
fired by the idea of having only
yourself to please, you spent two
hours and a quarter getting the his-
tory and an hour and half writing
it out. And then two miracles—or
near miracles—took place. First
you could hardly wait to get to the
library. On the other cases you’d
gone to the library from a sense of
duty. But this time it was from
spontaneous eagerness and interest.
The patient bad migraine—about
which much indeed had been writ-
ten, but you suddenly realized and
for the first time, that the time to
use the library is after you've begun
to work and not as a substitute for
work. The other miracle was that
both Dr. A. and Dr. B. took up that
case and both asked who had written
such a good history. Of course you
stepped manfully forward and took
the responsibility, thinking the while,
“You haven’t the faintest inkling
of what this means to me!”’ Nor had
they. For in realizing that you have
only yourself to please, in short, in
integrity, lies the answer to that
The Pharos

ever-returning question, “Quis cus-
todes ipsos custodiet?” Who is to
supervise the supervisors?

* k ek *€ * F *

Sooner or later—it may have been
an experience unuttered but borne
in shy loneliness—came your real-
ization that medicine is not omni-
potent. Consequently the question
posed itself whether some patients
were worth working so hard on—
frog babies for example, or aged,
defenseless, friendless derelicts with
pneumonia, or admirable persons
with inoperable cancer and in un-
remitting pain, or hemiplegics with
broken necks, and the long array of
‘“Sncurables” on the Island? Do you
remember that day you compared
notes with your brother? He was in
the third year of a civil engineering
course and you were interning at the
City Hospital. He told you he had
spent the whole afternoon writing
the specifications for a bridge to
carry up to 20 ton loads with a
specified factor of safety—three,
thirty foot spans. He said he could
specify anything he wanted in point
of material with known and prov-
able tensile strength, expansion co-
efficients, shear, etc. And the result
was to be a bridge not seriously short
of perfection. His afternoon had
been one of imaginary but un-
trammeled creation.

It came upon you like a tidal
wave that you had spent that same
afternoon working over an elderly
taxi driver who complained of head-
aches and spots before his eyes,
headaches of eight months’ duration
and neglect, who, at the best, would
return to a fifth-rate rooming house
with December weather for his con-
valescence. In short, that for the
bridge vou were building you had
the equivalent of rusty girders, old
timber of uncertain strength, doubt-
ful cement and used brick. Your job

*

22

February 1955

was not to create perfection. It was
to do the best under the circum.
stances. You could not ask for, o
expect, the ideal in material to work
with, nor perfection in the finished
product. You used to think doctors
cured people. Not any more! You;
job was to make do with what con.
fronted you. Make Do. M.D. Quaint
idea! M.D. stands for Make Do
Work for the handicapped . . . who
is handicapped, your patients or
you? Both. Helping the survival of
the unfit . . . with more to come
What in the world was the solution?
Where to find a formula for head
and heart too? Hold on! How wag
it that you had found it so natural
to compare treating a chronic ne.
phritic with building a bridge? Were
you thinking of a patient as a piece
of machinery comparable to a struc-
ture like a bridge because your first
patient had been a cadaver and your
entrance to medicine by way of
chemistry and physics? What of
compassion? Doesn’t the mere fact
that there is such a thing as compas-
sion make it seem shallow to com-
pare treating patients with building
bridges, ideal specifications, perfect
materials, etc. ete. Had you planned
to live from the practice of medicine,
or to live in the practice of medicine?

* * * * * k &

Despite the readjustment that
began to take place between the
detachment of the nascent scientist
and the none too mature compassion
of the beginner in therapy, by the
time you got to work on the district
in obstetrics you were getting a bit
discouraged with the patchwork—
as it seemed—the patchwork and
inadequacy of the acute hospital
with its re-entrant cases coming
back again from the stews and sties
that had made a mockery of con-
valescence. And the places actually
denominated “Homes for Incur-

*
February 1956

ables.” Then at last with your first
three obstetric cases, the path turned
and you saw the practice of medicine
as you had wanted it to be. Your
first patient was a girl of 17 and
from Monday night at 9 till 5 o’clock
Wednesday morning you stayed by
—her first baby and professionally
speaking your first too. Everything,
according to your report, had been
“normal.” At long last a husky
baby, faint smiles and the long sleep
of carefree exhaustion. The next was
a perfectly charming negress who
like so many of her race possessed
the ultimate in tact, good manners
and warm kindliness. There too it
was the first baby and the husband
as beautifully grateful to his wife
and as laughingly delighted by his
young son as anyone you could have
imagined. And the third a stout
Irishwoman of huge frame and
hearty manner, mildly disgusted
with her husband’s complete alco-
holic eclipse, but with more of the
evidences of angry resentment at her
pain than dismay or feeling deserted.
Her brisk performance and perfect
delight at learning it was a boy—a
fact you celebrated together with
a bit of whiskey she’d hidden from
her husband expressly for celebrat-
ing in case it was a boy. These ex-
periences were sound, refreshing and
what you had hoped the practice of
medicine would be like: life-giving,
based on knowledge of the machin-
ery but transcending it and giving
a sense of completed accomplish-
ment leading somewhere, even if
you got a deal more credit than you
deserved.

* Ox t+ * ok * *

You had been dismayed and out-
raged when a youthful classmate on
his obstetric service renewed his
Crede’s silver nitrate solution care-
lessly ordering 25% instead of one-
tenth that strength . . . and so

*

Alpha Omega Alpha

blinded a baby for life. But your
exasperation was short lived. At
Charity Hospital outpatient there
seemed to collect all the sick steve-
dores in the city. One day when you
were in charge of the male out
patient a gaunt negro of fifty came
in saying he couldn’t swallow ‘so
good.”’ You sometimes used to think
the negroes never complained of any-
thing and it would have been well

‘had you been on guard that day

23

against underestimating his distress.
His story and emaciation suggested
a possible carcinoma of the stomach.
So you arranged for a test meal the
next morning. When you were pass-
ing the stomach tube, in his con-
vulsive retching his aneurysm burst
and he died as only such patients
die. How do we reconcile ourselves
to those deaths for which in our
innermost beings we must take the
full and bitter blame? It is in such
situations that caution and com-
petence, humility, intellectual hon-
esty and integrity prove their worth.
It is in such circumstances that the
avoidance of blame, the evasion of
responsibility or just plain inade-
quacy of education and training in-
crease the already intolerable trag-
edy by denying it, or failing even to
recognize it. And they say that
medical education is so expensive!
It is unsatisfactory medical educa-
tion that is expensive—and so ex-
pensive.

* x * * KF * *

One kind of experience may per-
haps best be mentioned without an
example drawn from life. It is not
an inevitable experience but it may
occur and when it does the effect is
hard to forget. By so much as one’s
relations with his chief have been
intimate and admiring, the day of
utter disillusionment, if it ever
comes, is a lonely sort of date, de-
serving no anniversary—a day hard

*
The Pharos

to get through without either anger
or self-pity. Our major disappoint-
ments in people come oftenest when
they are under temptations we have
not imagined or pressures we do not
know. On their side they may be at
the time too preoccupied to notice
’ our disillusionment. In any event
there is for the witness a speechless
finality about a fallen idol and a
loneliness that Jeads more often than
not to autumnal maturity and com-
plete independence.

* * * * * *

* *

It was in the days when Fowler’s
solution was widely used as a
“tonic.” At supper you had gotten
into an argument with another in-
tern on what was meant by the
word “tonic.” You’d gone to the
extreme of saying that you'd expect
more results if Fowler’s solution
were given in much larger doses.
Your adversary taunted you with
“teaspoonfuls instead of drops?”
and you had retorted “No! of course
not!” though at that instant it
flashed through your mind that you
had advised that very morning an
out-patient to begin a course of
Fowler's solution—and had you said
‘teaspoonfuls or drops? Well—to
shorten the story—you got that pa-
tient’s address from the record room,
took a street car as soon as you
could to a street in North Philadel-
phia, found your patient and his
wife and the bottle with the dosage
in drops all safe enough. But will
you ever forget those three hours of
anxiety and shame that prepared
you as nothing else could for your
patient’s parting remark as you
started back for the hospital, “Doc,
I would take anything you was to
put in a bottle for me just exactly
like you told me. Ain’t you the doc-
tor?” And all the way back to the
hospital, the while reorganizing your

24

February 1955

whole existence, you could only re
peat ‘Ain’t I?”

The events and interpretations |
have selected do not represent ajj
of the generic experiences character.
istic of the doctor’s anabasis or way
up into medicine. I well know that
any one of you could supply from 4
mere month’s clinical work mote
vivid examples of each type of ex.
perience than I have presented. As
I explained at the outset it is from
your own recollections that I shall
find or fail of corroboration. These
stories are offered as examples, not
proofs,~-examples to contrast in
their concreteness with the abstract
ideas that form the real substance
of this talk.

My essential thesis has been that
what binds our profession together
throughout the world is not so much
the facts we agree upon or the knowl-
edge we share, as the experiences we
have all gone through, and the way
we understand them and fit them to
the pattern of our values. Our fellow-
feeling rests as much on the simi-
larity of our relationships with pa-
tients as on the identity of our
formulated knowledge or beliefs.
And even more certain, the con-
tinuity of our professional heritage
from the past. cannot have come
from the changelessness of either
theory, practice, belief or admitted
fact. All these have changed too
much for that to be possible. Our
professional history hangs together
because the cardinal experiences of
the doctor with death, birth, re-
sponsibility and confidence, fear and
courage, ignorance and learning,
power and powerlessness, have re-
mained so little changed through
the centuries, and even through the
last few decades.

And now I beg you to let me rest
my case by naming these cardinal
experiences once again: Choosing to
be a Doctor, Experiencing Mean-
February 1955

while Great Encouragement, Facing
Death and the Machinery, Realizing
the Meaning of Narrative, Finding
Out What to Learn and How, Find-
ing Compassion as the Answer to
Detachment, Witnessing Birth and
Assisting Happiness, Taking Re-

25

Alpha Omega Alpha

sponsibility for Death, Seeing Your
Idol Fall, and, then as at once the
greatest danger and the greatest re-
ward in medicine—and so the deep-
est bond between us all—the First
Time a Patient Trusts You—with
his life. :