THE SOUL OF THE CLINIC

[Note.—During the latter days of his life Dr. Peabody set down on paper in a letter to Dr. Warfield T. Longscope⁠[1] his conception of the relationship and responsibility of the Medical Chief to his Clinic. Though he felt that it was not entirely complete in certain details, he finished the first draft and wrote the last sentence the day before his death. His friends felt that the letter was too valuable to remain as a private possession, and it was made available to the medical profession. The document was published, as it was written, a letter to an intimate friend in answer to sympathetic correspondence and discussion.—Ed.]

Dear Warfield:

Thank you so much for your good letter. Of course you are altogether too kind in what you say about the clinic at the Boston City Hospital and the part I have played in its development, but you set me up and stimulate me to write you at some length about the problems that many of us who are teaching clinical medicine have on our minds—Whither are we tending and what ought our aim to be? I have tried recently, without much success, to formulate a very brief statement as to the type of clinic I wanted to develop at the Boston City Hospital and I am glad to be encouraged to try my hand at the subject rather more in detail. First of all, I do not think we can or should all aim at having the same type of medical clinic. This must depend in part on local conditions. Thus you, in a university hospital, completely under your own control, have a very different problem and will produce something quite different from what I, a cog in a great municipal hospital, can produce. Each has its own advantages and its disadvantages. In part, moreover, the type of clinic will reflect the personality and interests of the chief, and the whole character of the clinic may alter when a new chief is put in charge of it.

One of the first problems to be considered is the kind of man who ought to be selected as professor of medicine. I quite agree with you that the requirements which are now generally put forward are so impossible to fulfil that they become almost ludicrous. May we perhaps take pride in the fact that we have been called to fill the shoes of such supermen even if we do rattle around in them! When a professorship falls open, the committee in charge of filling the position usually says somewhat naïvely that it is looking for a man who has had an intensive scientific training, has done important research, is a good administrator, is a competent teacher, and finally has had clinical experience. We have heard this string of specifications so often that they are becoming rather hackneyed. Such a man is, of course, almost impossible to find, and I have been wondering where the ideal originated. I think it results from the fact that in recent years—since what we may call the Reformation—the selection of professors of clinical medicine has been more and more influenced by laymen and by professors of nonclinical subjects. Both may be excellent pedagogues and experts on education and yet fail to grasp the difficulties and complexities which confront this particular type of position. Thus the administration of the department of medicine, with its large teaching and clinical staff, its responsibility for the welfare of a considerable number of patients, its interrelations with the hospital administration and its subdepartments (social service, dietetics, physical therapy) is a very different thing from the administration of a department of physiology or biologic chemistry. It is all very well to say that the professor should delegate most of his work to others, but you and I, who are practical laborers in the vineyard, know that this does not work and that actually the chief must do it himself if the department is to run smoothly. “Clinical experience” is apt to be put last among the specifications. This is because some of our friends think that clinical medicine can be “picked up” very easily by the prospective professor, while others believe that if a man is well trained in such sciences as chemistry, physics and physiology he has only to learn the technical clinical methods of percussion and auscultation. Clinical medicine is to them little more than the application of these sciences to the sick patient, which is, comparatively, easily acquired. As a matter of fact, however, we know that clinical medicine is a subject which is to be mastered only by years of long, hard experience, and if any of the members of the committee to select a professor were taken sick and were to be under his care, I am pretty certain they would rate “experience” higher. The argument actually put forward, that the professor need not be much of a clinician because some one else can tell the students how to take care of patients, is weak and beside the point because it begins by accepting as insignificant what is a very important function of the department.

I believe that the primary function of a department of medicine is to teach students those things that will enable them to practice the best contemporary medicine and will give them a foundation on which to superimpose the advances that will come during their professional life. They must be taught medicine as a vital and expanding subject, and must be stimulated to keep abreast of its growth. If it be true that preparation of students for a career in clinical medicine, and more specifically for the practice of medicine, is the first duty of a department of medicine, then it seems clear to me that the backbone of the clinic is the general ward and the outpatient department, for it is here that one finds or can readily create conditions which most closely resemble those which are found in actual practice. In order to preserve this backbone intact I have always hesitated to encourage the development of wards and departments for special groups of patients. This is, of course, necessary to some extent both for intensive training and for research, but it should not be done at too great expense to the general ward, lest the general ward come to contain nothing but what are regarded as “uninteresting cases,” and the idea of specialization be instilled in student and staff too soon. After all, “intensive training” does not involve the study of many patients of a group at one time, and the rest can be left in the general ward, which should be as exciting in its variety and unexpected manifestations of disease as is the actual practice of medicine.

If the general ward is the backbone of the clinic, then the head of the clinic must be close to it; indeed, it ought to be directly under him. The importance of the general ward and what it stands for as representing the general practice of medicine can be impressed on the younger members of the staff and on the students only if the relation of the chief to the ward is real and not fictitious. The whole atmosphere of the general ward, and thus the attitude of the future practitioners to the profession of medicine, is here set by the chief of the clinic, for it must always be remembered that standards of thought, as well as of action, are set from above. If the chief has any conviction as to the relation of doctors to their patients, to scientific research, or to any other aspect of his profession, this is his opportunity to bring it out, and in so doing he will determine the character of the clinic. The growing tendency for the chief to delegate ward authority and responsibility to his assistants, and to “spare himself” from making ward-rounds and doing ward-teaching, seems to me extremely unfortunate. The wards may be run as well or better, but the dignity of the general ward becomes impaired in the eyes of staff and students just as soon as the chief separates himself from it. This is one of the reasons that I have not adopted the usual plan of having a resident staff over the intern staff in the general wards. I want the interns to learn to assume responsibility for the patients and then to come directly to the chief with their problems, rather than feel that they can take things up only with subordinates. This arrangement leads directly to a consideration of the status of the interns. On this point I feel very strongly. They should be regarded as advanced students, and as perhaps the most important group of advanced students that we have. They come with minds, characters and personalities in the most pliable and receptive states, and can be affected in an extraordinary degree even by the atmosphere of the clinic. Their very manner of dress and parting their hair changes. Social ease, and manners that will play a large and legitimate part in medical practice, develop. At the same time intellectual changes of a far deeper character are going on, and the chief has an opportunity to set his seal on them. Provided the chief has anything in himself to offer, here is his chance to turn out every year a group of selected men who shall represent his ideas and his clinic all over the country, and it is to be hoped that they will gradually affect the type of medicine in many remote communities. Again, this cannot be done as successfully through subordinates as it is if the chief undertakes to keep himself close to the interns. It takes time, but it seems to me that the results are well worth striving for.

This does not mean that all the subordinate members of the staff, including (with rare exceptions) those whose time is largely devoted to research, should not undertake direct responsibilities for the ward routine. I believe, indeed, that such responsibilities form a very valuable part of their training—so much so that the men must be made to assume them even if they are reluctant and prefer to stick to their research. This can usually be arranged for in the vacations and at such times as their research is not at a critical point. It is very easy for a man to get absorbed in his own little problem, or in the somewhat larger field of which this is a corner, and to neglect the opportunity to get a training in internal medicine. At the present time there are many men who have been associated with American clinics for several years and who have had only the narrowest contact with medicine as a whole. Few of the men who become members of our departments of medicine will become stimulating teachers and still fewer will ever do important research work, but almost all can be made into first class clinicians. This is in itself a very important contribution, for the majority of the staff are eventually going to practice medicine, and the chief should do his best to see to it that every one who has been attached to his staff for three or four years has at least made a good start at becoming a high grade internist, as well as being an expert in some narrow field of medicine. The necessary training is, of course, best attained by assuming actual responsibility in general wards, and very often the men have to be driven, almost by force, from their own laboratories to take up what is sometimes spoken of a little casually or even cynically as “ward routine.” Here, again, the example of the chief is vital.

One further point with regard to the general ward. I have spoken of it as the backbone of the clinic because it represents general practice, which is the backbone of the medical profession. It is proper, therefore, that it should be the meeting place of those who devote themselves to different fields of medicine; and here the active full-time practitioner should come in contact with the man who is devoting most of his time to research and teaching. In clinical teaching the active practitioner of internal medicine plays a very important rôle, and he should receive positions and titles corresponding in dignity to the contribution he makes. These conventional details must not be neglected, for they help to make clear to the staff that the work of the practitioner is going to be completely recognized by the school. In my own mind there is no question but that the man whose practice is largely outside the hospital can bring something to students and staff that is difficult for the man whose practice is largely inside the hospital to bring, and several years of experience have confirmed this view. On the other hand, the practitioner should also get a stimulus from contact with the research which the hospital group is carrying on. In the Boston City Hospital Clinic, representatives of the two types of men alternate in making ward rounds during the school term and, as far as possible, the same plan is continued by the younger men in the summer. Curiously enough, it has seemed to me more difficult to find enthusiastic and competent clinical teachers among the practitioners than in the hospital group.

Research should always be regarded as one of the activities of teaching clinics. Such clinics are usually relatively well equipped in the way of laboratories and endowment; and the very fact that the laboratories are closely associated with the wards gives an exceptional opportunity to the staff and thus places a responsibility on its members for the investigation of disease. It is fair to assume that a large part of the progress that will be made in our knowledge of the diagnosis and treatment of disease will come through the medical clinics, even if much of the fundamental work on which this practical advance is based is the outcome of investigations which have been carried on in the laboratories of so-called pure science. (As a matter of fact, it has interested me recently to see how frequently the clinical investigator, studying a problem in disease in man, is forced to go back and tackle the most fundamental aspects of it—anatomic, physical, chemical—because the necessary facts have not been made available by workers who specialize in these various fields.) Research should also play a part in the clinic because it is a type of training which develops critical judgment; and even a limited experience in a research problem, undertaken under skilled guidance, is a valuable discipline for every one, including the man who subsequently goes into practice, for among other things it teaches him to estimate the worth of the publications of other men. Finally, it is generally true that the investigator is a more stimulating teacher than the man who is not actively laboring at the forefront of scientific advance.

By what members of the staff should active research be carried on? The strictly clinical group, engaged largely in outside practice, should be encouraged, but, of course, one cannot expect that they will produce much, as they do not have the time or the sense of leisure that is necessary for research. If any of them produce an occasional clinical study, they are to be congratulated. This must not be considered to be their field. The younger members of the hospital staff, residents and assistants, should all take part in some research problem, but as they are apt to be almost wholly untrained they can be regarded only as extra hands at the beginning. They receive a training that is of utmost value to them personally, particularly if they are, as they should be, under the personal supervision of an experienced investigator; but one cannot anticipate that they will make important contributions. Experience has made it clear to me that one of our common errors is to expect too much of these men, in that we allow them to work too independently both for the good of their own training and for their productiveness. With rare exceptions few men are qualified, either technically or intellectually, to carry on clinical research of any great importance until they have had several years of experience in laboratory work and in the study of disease in the wards. This means that it is only the older members of the medical staff who may be expected to undertake continuous problems of any particular significance and it accentuates the importance of providing adequate salaries for assistants who are five or ten years out of school. These are the men who can plan for prolonged periods of time devoted to one problem, and they will also be the men to guide and train the recent graduates. Of course, even among the selected groups of older members of the staff there will be few who will produce research that is important in itself, for in any field high grade investigators are unusual. In general, one can only expect good solid research of a more or less routine character. Such work is, however, not to be depreciated, as it plays an important part in keeping up the tone of the clinic and in the long run advance in our knowledge of disease probably depends as much on this type of conscientious, honest investigation as on the gifted researches of brilliant geniuses.

What is to be expected of the chief in the way of research? One hears a great deal about research ability as a qualification for the professor of medicine and about the necessity of his carrying on research personally while he occupies the position. Capacity for high grade research is so rare a quality in itself that it will always be almost impossible to find it combined with the other qualifications demanded of a professor of medicine. Ability to do good, conscientious, independent work, interest in stimulating and assisting others to carry on research, and an appreciation of the rôle that research plays in the medical clinic are more important than great personal research genius. The professor must keep in close touch with the work of his staff, guiding where he can, suggesting and encouraging, and he should always try to keep up some independent work if only for his own intellectual satisfaction, so that he may set an example to the staff and may have some little field in which he excels his assistants. Even if he had great ability as an investigator he could not expect to accomplish much, as the multifarious demands on his time make it almost impossible to obtain the sense of leisure which thoughtful work requires. Indeed, I feel that if a man really has this rare gift he ought not to be the head of a department of medicine lest his talent be wasted.

One may reasonably question whether the large proportion of the budget of the department of medicine that is devoted to research and the great stress that has been laid on research ability in the selection of teachers is entirely justified, when one considers that much of the research output is of a routine nature and that really significant research is unusual. My personal feeling is that it is justified, although I think the pendulum has swung too far in the matter of choice of professors. Here there is a very unfortunate tendency to pay too little attention to broad clinical experience, something that is acquired only by many years of hard work and too much attention to research ability, or, what is worse, to the possible development of research ability in some promising young man. The publication of a number of good papers does not really indicate any marked capacity for investigation, and such papers certainly offer limited evidence of ability to run a department of medicine. Even in the preclinical laboratories and research institutes the proportion of research that is very noteworthy is not always particularly high, and, when one considers all the other functions required of the men in the department of medicine, I think that we may be rather proud of what they are accomplishing.

There is a common tendency to attempt to select assistants in a department of medicine whose training represents the different preclinical sciences, physiology, organic chemistry, physical chemistry, physics, bacteriology, so that one may have a well rounded clinic. There is obviously much to be said in favor of such a plan as it helps to bring together an experienced group of “scientists”; but there is also an inherent practical danger which I am sure we all have observed and to which more attention should be paid. These men, thoroughly trained in one direction, quite naturally look for their research problems in the fields in which they are trained. They seek the problem to suit their particular tools. This must necessarily be the attitude of workers in a fundamental science when they attempt to study a clinical problem, and this may explain why they often are not more successful in formulating and working out problems involving a knowledge of disease in man. The approach of the internist to the study of disease in man should be quite different. He is, first of all, absorbed by an interest in the problem and then seeks the type of tools necessary to solve it. This is the intellectual, rather than the technical, method of approach. Once given an absorbing passion for the solution of a clinical problem, the man who has a good, general scientific training can usually acquire in a few months or in a year or so enough of any of the fundamental sciences to enable him to tackle it. The clinical investigator, with his knowledge of disease in man, thus finds the problem first and determines the practical way to study it, turning to his colleagues in the fundamental sciences especially for technical experience. We often discuss what the difference is between the function and opportunity of the man who is primarily a “scientist” working on a clinical investigation, and the man who is primarily an “internist” using methods of exactly the same highly refined nature, and also working on the same general type of investigation. The real difference is, I think, to be found in the point of view. The medical clinic should encourage its staff to use methods of any sort, no matter how difficult or specialized, that are needed for the solution of their immediate problems; but their first interest should center about the general subject of disease in man. The first interest of the “scientist,” on the other hand, is in the development of his own particular field. Each has his proper rôle, but in the medical clinic it is better to have an inspired “internist” than a skilled “chemist.”

The administration of a department of medicine, with its complicated relationships and responsibilities toward a large group of various types of men, to the students of three classes, to interns, to the medical school administration with all its subdivisions (wards, social service, outpatient department, dietetics and other clinical departments), to patients and their families, and to laboratories, represents a problem which is unapproached in any other department of the medical school with the possible exception of that of surgery. One frequently hears it said that if the chief is a good administrator he will divide all this work up and put it on the shoulders of his assistants. To a certain extent this is possible and is, indeed, absolutely necessary; but experience has shown me that beyond a certain point it is unwise to do so and that the major part of the administrative responsibility must be assumed by the chief. The representatives of the medical school, the superintendent of the hospital, the chief of the roentgen-ray department, the assistant in charge of the chemical laboratory, all want to deal directly with the chief; and the smooth running of the clinic demands that they shall. But to my mind it is not only to these dignitaries that the chief must leave his door ajar. How often one finds interns and students lurking outside the office, waiting to catch the chief as he hurries by. “Can I have five minutes with you, sir?” You let him in, sit down, and find that what he has approached so modestly is the problem of his whole career; and who can tell whether it may not be a career with very significant possibilities? Is there, on the whole, anything more important than giving advice about a man’s life? Of course, a first class administrator might say, “Tell him to return next Tuesday at 2:30, at the time appointed for such conferences.” All right; but usually the youth has worked himself up and is full of his problems now, and it is now that you can help him most. We hear a great deal about the necessity of the professor “closing his door” and “protecting himself.” I fear that some of this “protection” is made necessary by the fact that our professors are apt to be rather inexperienced, and they have to get their training after they get their job. The real question is whether the professor ought to devote himself to looking after his own career or whether he ought to regard as his first duty that of stimulating, helping and advancing his assistants. Of course, this is largely a question of personality; but there are so few men whose research ability is extraordinarily valuable (and, as I have said, they ought not to be professors of medicine) that I believe in general in the “open door policy.” This is, at any rate, the policy that best suits my temperament and capacity. I have always attempted to keep some of my own work going, partly through assistants, and, so far as I can, with my own hands (although this comes more and more to what can be done in the summer vacation) for this is what keeps me alive intellectually and is where I get my real fun. On the other hand, I feel that probably I accomplish most in the long run, not by protecting myself too closely, but by accepting as my major function that of helping my students and assistants. Much greater contributions to the advancement of medicine will come from the training of these men than through my own individual efforts.

In all this lengthy letter I do not think I have once used the phrase “full-time” as applied to a clinic or a teacher. This is partly because I have become as tired of discussions of “full-time” teaching as I am of discussions of the Eighteenth Amendment, and partly because I do not think the issue is any longer of importance. There was a time when discussion of the system had a distinctly healthy effect on the teaching of medicine in America; but the whole situation is altered. A complete “full-time” system is impossible from an economic point of view, even if it were desirable medically, which I do not think it is. Experience has made it perfectly clear that the men who are in successful outside practice have something very definite and important to contribute to the teaching, and, as already indicated, they must be regarded as an integral part of the teaching service and receive proper recognition in the way of titles, salaries and clinical opportunities. I am, moreover, also convinced that it is not desirable to have any hard and fast rule as to the members of the hospital staff having private patients. For many, if not for all, it is desirable that they should have a few patients of their own, with whom they have the same relations that one does in outside practice. Occasional consultations, even outside the hospital, office practice and a few private patients in the hospital form the basis of a valuable experience for the teacher and investigator; but, of course, his other work will not allow him to assume the care of sick patients in their homes. There is no question in my own mind that I am a much better teacher for having had a limited number of such patients in recent years. These are the patients to whom I talk at length personally, and they are apt to be the cases that stick in my mind, so that I refer to them continually in talking to students. One can always say that the same thing may be done as well if the patients belong to the clinic and if, for instance, their fees are paid to the clinic; but I fear I do not agree to this. If they had been the patients of the clinic I should have had most of the work done by my assistants and I should have missed exactly that personal relationship with patients which many people say cannot be obtained in a hospital. If, however, I have been continually confronted with these personal relationships of practice, even though it be with few individuals at a time, it is much easier for me to keep accentuating their importance in the course of my work in the ward. In all of this, moreover, I do not believe that I am very different or more sordid in attitude than most men. It is not wholly a question of to whom the fees are paid (often there are no fees), although this certainly is a factor in establishing and maintaining the personal bond. The main point is that the patient has sought you or me personally and not the hospital.

In the last analysis, the whole problem resolves itself into what kind of men you select for the hospital staff. If they do the type of work they are expected to do, they can never see more than a very few private patients—fewer, indeed, than come now to the private wards of some “full-time” clinics. If they want to see more patients they must be transferred to the clinical staff. Practically, the issue has seemed to me to solve itself without presenting any great difficulties, and without resorting to an overorganization that limits the freedom of the individual. What we want is less of the system and law that kills and more of the spirit that gives life.