4 2.

Pd a A Had

The Hos giTak ae a M ical Calle cs. Assocvastia, Meckuags AKL hens
B44 1949

If you are asked to go to China on a week's notice, and limited
to two suitcases, then every article you take with you will receive some
careful consideration before it can establish its claim as essential baggage.
Where we are going at the present time and how much of our customary ideas
we can take with us as intellectual baggage are now questions calling for
prompt and pointed attention. Im such a meeting as this and at such a time,

we may well scrutinize our habitual ideas about hospitels with a view to
getting down to essentials,

First let us make sure we know what we mean by the word 'knowledge,'!
if we are later to speak of medical education. Knowledge is of two sorts
depending on how you have obtained it. If you have learned it throngh words
(spoken or written), formlse, abstractions or symbols of any kind, then you
have obtained the kind of knowledge I am going to cull erudition or book-
learning. If, on the other hand, you have leurned it through experience,
through contact with real things and not the names or sumbols of real things,
then you heve what I shall cell experience,

The main difference between knowledge of these two types is not the
difference between genuine and spurious, better or worse, useless and useful,
It is the difference in the way knowledge is obtained, But there are some
important secondary differences, Erudition has the great quality of being
almost infinite in extent, certainly far beyond the capacity of any one person
to experience, of being impersonal but articulate, readily transmissible and
easy to accumulate and preserve in books. The knowledge derived from experi-

ence, on the other hand, hes « peculiar property ~ it gives its possesser
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power, confidence, courage, exuitant delight - sensations rarely produced by
mere erudition, And another quality of knowledge obtained by experience -
it is not easy to transmit in the absence of personal contact and imitation,
reflection, or trial and error,

Now evary institution in this country will receive careful scrutiny
in the next ten years, scrutiny that will question its value. We might well
prepare outselves for those days by knowing quite clearly what hospitals are
good for, and, if you can learn anything in hospitals, then what kind of
knowledge is to be gleaned in hospitals, and what is that kindof knowledge
good for? Is it really valuable to obtain the knowledge that comes from ex-
perience with sick human beings, familiarity with the signs and symptoms of
disease, and the opportunity to witness the management of an iliness by a
skillful physician ~ or are book and lectures and the preclinical leboratories
in the schools all we need as the essentials of medical education?

In similar search of simple snd reliable mental equipment for use
over the next ten years of adventurous change, let us scrutinize this word
‘education.! Reduced to simplest terms education is what takes place between
two persons, one more learned, skilled or experienced than the other, and
willing to teach him who wants to learn, So supple and hardy a definition
dispenses with such items as "entrance requirements," "curricula," "credit
hours" - all the perephernalia and hocus pocus of educetion shich we shall
cast to the winds anyhow if the time comes to jettison non-essentials,

Cen a hospital intern eagerly watching the exemple of an experienced
end friendly chief laarn something from that contact? Of course he can, He
does;= atways, Now that brings out precisely the point I want to be sure that
you see: Forget erudition and book learning, libraries and lecture halls for

a moment; think of the other kind of knowledge that comes from experience,
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from familiarity, from trial and error, to the apprentice watching his
teacher end then trying himself - for that is the knowledge potentially
obtainable in hospitals, end certeinly obtainable when a person of larger
experience, wisdom and skill is within willing reach of one who wents to
learn, Obviously, then, the question is not can 4 hospital teach, but #ill
1t?

Now if you had seen in many different countries first-rate educa-
tion taking place in the absence of so many things you used to. consider.
essential, then you would begin to regard education in simpler terms, You
would realize that it is an event like friendship or teamwork, You cannot
describe friendship in terms of a time-table, nor education in credit hours.
You don't express the essentials of any human reletionship in list and inven-
tories. The kind of education I am talking about is e human relationship in
which there is e transmission, ea passege from one person to another, sometimes
of information, sometimes of method of thought, sometimes of skill, occasion-
ally of standerds of conduct and attitudes of mind and heart, These are but
some of the exchanges tuking place in the reiationship of teacher end pupil,
You don't have to be a professor to teach, nor pay tuition in order to learn,
If reflectively you will list ten relationships in which you have learned
mich, I would weger that at least three were outside schools and universities,
I want to make it clear that « hospital can give aducation whether or not it is
affiliated with a university. Indeed, so favorably placed is any hospital for
teaching medicine that if it makes the edditional effort to teach and forms a
university connection, we cen say that the hospital's share in medical educa-
tion almost equals that of the medical school, We could have doctors without

the teaching hospitals but what a sorry profession it would bel If Clio, the
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Wuse of history, were at my side, she would add, "That is what you had in
America for years - medical schools but scarcely a teaching hospital.” It
is in this, then, that the hospitals sustain and enrich our professional
lives: they provide the real, the essential material of medicel education
and medical service ~ patients, shom the doctor mat learn to study and to
care for; and ut the same time the te.ching hospitals provide that simplest
element of an education - contect between persons of different degrees of
erudition and experience, but with the same purpose - learning. Of the. two
essential kinds of clinical knowledge the hospital, snd the hospital alone,
supplies one ~- the knowledge derived from experience, And since skill and
wisdom distilled from experience can survive only through human intercourse,
through example and imitation and use, the hospitals renders a service more
valueble than ever when it brings together every range of novice end expert
so thet through educution skill and wisdom cum be passed on and thus pre-
served,

But not all of you represent teaching hospitals connected with
medical schools, Indeed, if you did I should not be speaking to the title,
"The Hospital es a College," for you would be in the secret as thoroughly as.
I, As wal: lecture upon "The Father as a Mother" es discuss "The Hospitel
ag e College." As mother and father are both requisite for parenthood, so
hospital and college are both essential to medical educetion. Most of you,
however, do represent hospitals in which teaching could ba begun or empha-
sized by organizing or expanding the interne and resident services, and it
is to this possibibity and the consequences thereof that I would draw your
attention, A well organised internship calls for educational experiences,
deliberately fostered, Indeed, my principal thesis is that by so much as

you can develop and favor any and every opportunity for teaching in your
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hospital you will protect the hospitel from disorganization, insure it against
neglect, and notably enhence its services to patients and its stability as an
institution,

Not all hospitals can affiliate with a medical school, ideal as that
connection is for teaching, but nearly all hospitals can improve their arrange-
ments for intern end reaident staff in point of number, opportunities, and
quality. In urging you to improve the teaching your hospital accomplishes by
improving its internships, I should like to mention the more important implica-
tions of the internship for ali concerned, I use the term internship to include
residencies as well es internships, since in most hospitels the distinction is
only in the degree of maturity and responsibility - the purpose is to enhance
both,

If a system of wel! selected and well supervised interns and resi-
dents is planned and put into effect in « hospital, then either more patients
can be examined and treated at the old standerd, or the same number of patients
can be much mere competently examined and cared for, In other words, the hos-
pital's usefulness increases, Furthermore, internships effect the hospital
staff for the better. Where the work of the hospital has been organized to
teach the interns by gradually increasing their freedom and responsibility,
the visiting men, the chiefs of services are stimulated to their best work
by the presence, the inquiring minds, the critical eudience of their interns,
As often trust an officer who wants no men to lead as a doctor who wants no
younger men around him learning, Another result from a well organized intern-
ship concerns the ettitude of the doctor towards his education, Young physi-
clans and surgeons understand the implications of the fact that the internship
comes after the M.D. degree; they understand thereby that medicine is an art

as well as a science, where training, experience and ecquired skill are never
completed, and that one's educxtion continues fur beyond what is required

for the M.D, degree. sny doctor who has had & well orgenized internship

or residency will escribe his competence to that training above all others,
There ig no doubt of the almost phenomenal improvement during the past thirty
years in the level of professional competence in tha United States, In thia
improvement the teeching hospitals have had a most important share, But the
old type of hospital lags behind and suffers fer it,

So valuable to medical education are these contributions of the
hospital and so distinctive is the internship that we find other kinds of
schools holding up medical education as a model becauss it has the wonderful
advantages of the internship, Schools for training government executives,
for example, huve created a deliberate imitation — called the ‘intern year'
or 'in service training.'! Teachers! colleges similarly seek the sdvantages
of a kind of internship and engineering schools urge upon their students
practical work under some measure of supervision but with real responsibility,

| Thus the hospitel with an effective teaching service fin the form of
internships and residencies provides the most distinctive phase of medical
education - the type of professional education most envied and most enviable,

If some hospitels already render this remarkable service and if I
suggest that more hospitals should do so in their own interest, I should like
you to understand clearly just what a teeching hospital contributes, and what
it gets in return, from a well organized internship system, The first of the
hospital's contributions preserves for the future our present knowledges. The
hospitel provides patients to be studied and treated and thus the materiel and
the ciroumstances for transmitting to the next generation the skilis end the
knowledge we have received from experience, Hospituls set standards for, and

teach by example and experience, the next generation of professional men and.
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all the while insistantly imply thet there is always more to learn in medi-
cine. Still more important, the teaching hospital cartainily suggests and
comes very near to proving that when organized as a teaching community
doctors can work together more smoothly than on any other basis ~ economic,
political, or military, It is already a commonplace thet the safest place
for the patient with a severe illmess is a hospital, not an exclusive nursing
home or a secrative private sanitarium, but a teaching hospital with alert
interns and observant residents discovering the mistakes chd discussing the
failures - not ignoring then,

In return for better cure of the sick, better professional training
of the doctors which the teeching hospital gives the community, what are the
advanteges, the gains to the hospitel from an effective internship and resi-
dency? They are these: more petients cared lor, and cared for better, an
improved quality of interns and eventually a better senior staff selected in
pert from former interns end residents, a senior staff held at concert pitch
by the critical abilities and the restless energies of the interns themselves,
a finer name and reputetion for the hospital on the lips of former interns
as well as former patients, and the steady advantages of doctors associating
for the sake of improving their knowledge of how to care for people. I ask
special attention to this fact: The basig on which members of a profession
collaborate often determines the future of that profession. No other basis
of association is better for doctors than the basis of education, I've seen
many tried - seniority, self-protection, money making, religious piety, the
terms of some ancient bequest, military rank - none is as effective as knowl-
edge, competence and character, the traits most honored where learning is the

goal of all,
8.

Quite evidently, then, the hospital set upon teaching receives re-
wards for its contributions. As some brash advertising ganius will doubtless
one day advise us in a full-page message in some metropolitan daily, "IT PAYS
‘TO WORK FOR THE COMMON GOOD."

Why have we simplified and reiterated the importance of teaching,
of systems to bring more experienced men in deliberate and close contact with
interns or residents so that education can take place? Why have we reviewed
and re-examined the essentials of knowledge, of education, of the rdle of the
hospital in medical education, and the essential advantages teaching brings
te the hospital which is organized around teaching?

I lived in Burope from 1924 to 1931, visiting every country there
except Portugal, I saw a degree of suffering and impoverishment and excessive
taxation which prepared me for what we shall have to face in this country,
but it conld not have prepered you, We shal: heve to take care of sick people
in our hospitals in any eventjif texation crushes the supporters of the volun-
tary cherity hospitels, the care of the sick wili be carried out from public
taxation, We shall see conditions so unpleasant and dangerous that they cennot
be managed by mediocre talent using easygoing methods. We shal! have to have
the best brains in government in order to have enough government survive, I
have medical organization in mind in saying this, Unless the charity hospitals
can have something more than the care of the poor as e basis for asking for
gifts, how can they axpect gifts from an upper and middie class taxed almost
out of axistence? Unless the charity hospitals are organized to use their
doctors! time and knowledge with an absolutely exemplary esprit de corps and
effectiveness, then these hospitals will have scant funds and no arguments

to keap them out of reorganization at the hands of the city or county,
9.

4nd if, as in England et present, the bulk of physicians! time is
spent in caring for their fellow men in hospitals and on salaries provided
by the government, the problem wili pose itself for us too — what is the best
basis for doctors to work together upon? Seniority, political prerferment,
military rank, income from private practice, or character and competence as
revealed by teaching and research? |

You will note I have constantly referred to residencies along with

internships, One word of comment: the sharpest criticiom I can level at the

way medical education serves society concerns the extraordinary waste wRmEXK

 

first five to ten years of professional life ~ when a man at the top of his
strength, interest and education must do nothing - waiting to use all he has. It
is stupid for such excellent doctors not to be working at their best as residents
in hospitals. Experience has taught me that in that group one can find moat of
the better determination, the restless resentment, the merciless narrowness that
keep us all from seeing the best thing to do. And I can't blame a group so
stupidly victimized.

I have spoken to you about the educational work which a hospital can
learn to do because that ig almost the only course which will preserve eny
independence and leadership for hospitals and because I do not believe that just
a record of caring for the sick is emough to save the charity hospital in the
emergencies ahead of us.

From such remarks you will correctly conclude that I think the present
is more decisive, and the approaching changes more extensive than most peaple
seem ready to admit. You will note that I emphasize change, not disaster; the
corallary is that I would advocate adaptability with which to meet those changes,
rather than resignation or pessimism. Change spells disaster only to men too old,

too tired, or too obstinate to adapt.
10.

Changes call for elasticity of mind but quite eas much for a surefooted
knowledge of what is what. Surely it is sensible to reexamine our baggage if we may
have to go far and travel light. A valuable part of the intellectual baggage
of a hospital trustee is his idea of what a hospital can do, what are its
natural strengths, its peculiar capacities.

Amid the changes that will be proposed for his hospital a trustee can
bring to all decisions a kmowledge that his hospital not only cares for the patients
of today but through training and teaching physicians cares for the patients of
the next two or three decades, and determines the quality as well as the quantity
of professional services given the people. He can realize how timid and lacklustre .
is the institution which exists merely for successful doctors to perform in
worshipful solitude or thankful isolation the procedures learned years ago.

Never forget Lord Acton's observation "Power corrupts - and absolute power corrupts.
absolutely".

Precisely because the whole system of interns and residents is now in a
confusion that will probably be worse before it is better, I would suggest that you
begin to think and plan for the organization of teaching in your hospital after the
war. It may be that your medical and surgical staff even in war time can be
encouraged in the direction of organized teaching. Through early planning your
institution an be ready to receive incorporate and train some of the large nunbera
of demobilized doctors who will need and want specialised training - and hospital
appointments - at the end of the war.

Do you know the difference between strategy and tactics? Trustees at their
best always recall these definitions to me. Strategy is defined as the art of
deciding when and on what you will engage your strength: tactics is the skill,
economy and adroitness with which you apply your forces to any problem. Selecting
a theme involves strategy, dealing with it is a tactical performance. Hospital policy

is a matter of strategy: hospital management is tactical. As trustees you decide
il.

the strategy of hospital work. The tactics are usually for the administrator

to choose. On what will you engage the hospital's strength, its efforts -

and when? In stable routine years most trustees try to use new methods to reach
old objectives. Thus they tend to become consultanta on tactics - which to reach
old objectives is natural enough in peace times. But in times of rapid change
such as the present it is wise for trustees to reexamine their strategy -— when and
on what will they engage theyhospital's strength. I urge you to do this and

to keep uppermost in your minds that a hospital teaches as well as cures, and
that the medical professicn can be helped to do its best when organised around
teaching in hospitals.

I have given you no clearly defined or elaborately detailed method of
procedure today. Methods and plans of that sort belong to tectics and to your
executive machinery. If, as trustees, you kmow what you think and can express it,
then the path is relatively easy for your executives.

You have the positive réle of strategists and a negative rdle you almost
never think of. Trustees are in some senses the conscience of an institution:
when the hospital executive says to himself, "I just wouldn't feel comfortable
recommending that proposition to my Board" the trustees are acting as his conscience,
they are in action without being called upon. They are of use without knowing it.
That is why many Trustees say they cannot see what good they do.

But let me assure you, gentlemen, that if you have arrived at the
wisest strategy for your hospital and have expressed yourself clearly upon it,
you have discharged a large, perhaps the largest share of your duty and you imve

done a very great service to your day and generation.