Duke University School of Medicine - Aesculapian Yearbook (Durham, NC)

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DVNPCI 9!q9S 'Cl 'U01 F E J 'G'IN COMMENTS FOR THE AESCULAPIAN MEDICINE: No other profession can boast ofthe same unbroken continuity of methods and ideals. We may in- deed be justly proud of our succession. Schools and sys- tems have flourished and gone, schools which have swayed for generations the thought of our guilds and systems that have died before their foundersg the philosophies of one age have become the absurdities of the next, the foolish- ness of yesterday has become the wisdom of tomorrow, through long ages which were slowly learning what we are hurrying to forget - amid all the changes and chances of twenty-five centuries, the profession has never lacked men who have lived up to these ideals. - Osler Medicine, which has attracted the most scholarly and commit- ted students for hundreds of years, continues to stimulate the aspirations of the finest graduates of our colleges and universi- ties. One cannot avoid being astonished at the variety of career opportunities currently available to all those in this select group. Until relatively recently, most physicians were largely of the same mold, but in the past several decades a number of specific opportunities for in-depth specialization have developed. It is this change, more than any other single factor, which has been responsible for the notable advances which have occurred in medical science during this period. Nevertheless, the student who wishes to pursue a broad approach to medicine and to have the responsibility as well as the gratification of caring for a large number of patients and treating a variety of illnesses may still pursue such a course by choosing the field of family medicine. Thus, the medical student today can specifically select a career designed to provide the opportunity to contribute to progress as well as finding happiness in life. This spectrum has been in the state of continuous change during the past several decades, and today a series of widely ranging opportunities are available including community medicine, group practice, part-time affil- iation with a medical center, or a full-time university academic appointment. Further still, challenging opportunities are avail- able for physicians in research institutes, industry, government, foundations, and civic enterprises. Bearing these features in mind as the background of modern medicine, it is very gratify- ing and a much appreciated experience to be invited by the editors of the AESCULAPIAN to comment on some personal thoughts about a career in medicine. 22 PHILOSOPHERS In reflecting upon my own experience, Alfred Blalock, a much respected mentor, provided the primary stimulus. In his daily teaching and example, it was apparent that he felt there were few satisfactions in life as meaningful as a combination of clinical and investigative medicine. Becoming convinced of the necessity for thorough clinical training and taking the time required to achieve it, it was also equally clear that if one is to undertake meaningful clinical investigation, then carefully disci- plined training in the laboratory is essential. This conviction became stronger as it was recognized that clinical experiences alone were inadequate in providing an appropriate foundation for objectivity in clinical research. For this reason I decided to spend two years in full-time research with Dr. Donald E. Gregg, who had a reputation for being a purist in investigative physiolo- gy as well as a world authority on the coronary circulation. To him much credit is due for teaching me the fundamental princi- ples and the basic concepts of research as well as the objective interpretation of experimental data. It is my own belief that such a laboratory experience must of necessity be full-time, without the press of any concomitant clinical responsibilities. Moreover, a significant and continuous period of time must be spent in order to adequately acquire the necessary experience as an investigator. A combination of these experiences places one in an optimal situation for a later combination of research and excellence in the care of patients. Few challenges are as reward- ing as original investigation, and one has the clear obligation of reporting such observations in the literature. This in itself is a learning experience since the investigator is called upon to state in clear and precise terms both the description and an inter- pretation of the specific research. If one is interested in assimi- lating data in the preparation of a textbook, earlier experiences in experimental and clinical laboratory are very helpful in pre- paring and editing such works. Moreover, the writing of texts provides a relatively easy way to remain abreast of the current literature and ofthe changing concepts in diagnosis and therapy. Teaching is another important challenge, especially since it provides an opportunity to relate closely and benefit others. Few privileges are more meaningful than the training of bright and committed students for careers in medicine. Their achieve- ments bring much more happiness than one's own successes, and there is the added gratification that the students themselves will rapidly experience the stimulation and happiness derived from such contributions. For example during the past decade, thirty-six Chief Residents have completed the training program in General and Cardiothoracic Surgery and thirty of them cur- rently hold appointments in university medical centers and six are in the private practice of surgery. It should be emphasized that in training programs a combination of those who are solely interested in academic work as well as those who are solely interested in clinical practice is very important, since neither alone is nearly as stimulating as the opportunity of working with both groups. There are many features which underscore the productivity of these residents including the fact that last year forty-four publications appeared in the scientific literature which originated from Residents in the Department as the primary authors. The leadership roles which these young men and Women achieve both locally and nationally provide them increasing confidence as well as genuine happiness which is also shared by their families and friends. In being asked to comment specifically on a philosophy of life, it is readily admitted that in the past I have seldom given much time on philosophical thoughts. Rather, it has seemed appropriate to learn as much as possible from respected leaders and to seize upon certain relevant quotations, both past and

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MEDICINE AND MEDICAL EDUCATION It is difficult to think about one's philosophy of medical education and about medicine in general without recalling those in the profession who may have had some influence on one's career choice. Such is the case with me. When I consider these topics, I naturally remember, among others, my former family physician who embodies those characteristics traditionally associated with the doctor - the iatros. Whether on a house call, in his office, or at the corner drugstore, he could be identified as the doctor by his demeanor, attire, mannerisms, and 'even by the faint aroma of tincture of iodine which lingered about him. The patient was the most important person in the world to this man, but his warm, sincere, and compassionate concern for the patient did not impair his professional objectivity and detach- ment so necessary in accomplishing his task. The epitome of discretion, he never betrayed a confidence. His enthusiasm for what he was doing was infectious, and he instilled a sense of encouragement and a positivity in his relationships with people, so that even in hopeless situations, despair was unlikely and dignity prevailed. In addition, it was obvious that his education had not ceased with graduation from medical school. He was constantly reading and improving his skills. He recognized his limitations and was unafraid to seek consultation. His omnipre- sence was legendary, his integrity, above question. In the words of another country doctor, This man had the three A's of being a good doctor - Ability, Affability, and Availability. In these contexts of ability, affability, and avail- ability, I should like briefly to discuss students of medicine and their teachers rather than medicine and medical education. Ability a It goes without saying that one must have a certain degree of intelligence to become a doctor. Certain other qualities in addi- tion to intelligence are important in becoming and remaining an effective physician. Most doctors have unusually well- developed powers of observation. Some seem to come by this naturally, while others make concerted efforts to develop and improve this faculty. Many advances in medicine have resulted from this ability in those intelligent enough to use it. Being alert and aware are characteristics of the good observer. Medical teachers must have the ability to help their students improve their powers of observation while inculcating the prin- ciples of the scientific method in them. Accurate observations and documentation of facts by both teachers and students make for proper interpretation of data which is essential for problem solving. Repetition breeds familiarity, and familiarity breeds learning. The ability of teachers to repeat in innovative ways to avoid boredom on the part of their students and the ability of the students to profit from repetition and to expand their under- standing from it are important components of any educational process. As one of my mentors once said after being com- mended for successfully controlling retroperitoneal bleeding during pelvic surgery, I've been there before! Practice tends to make perfect. We all recognize, however, that certain faculties are better developed in some people than in others. The ability of the teacher and the student to recognize those attributes during the medical school experience is helpful in channeling some people into pathology and others into pediatrics, gastroenterology, obstetrics, psychiatry, general surgery, etc. The student who has a specific interest and who can identify a teacher who has expertise in that area would do well to associate with that mentor as much as possible. Much is learned through sn JP Zi- 3' E -1 F9 CU 3' 2. CD I-I' S33 7? C CD 3 dialogue with those who know first hand about a subject. Herein lies one of the major strengths of the Duke curriculum. Many capable faculty are actively involved in the established procedures of their disciplines and are exploring the frontiers in those areas. Duke students have demonstrated their ability to profit from this over the years by associating directly with those faculty persons. Affability In addition to these various abilities, the successful student of medicine and his effective teacher share a secret which is found in their positive attitude. Those students and teachers who seem to be the happiest ahd most effective are those with enthusiasm for what they are doing. They are the ones who are motivated and have a sense of purpose. They are willing to sacrifice person- al pleasures, to be altruistic, to care for those for whom they have professional responsibility, and at the same time, they are able to maintain the balanced perspective necessary for their personal lives including spouses, children, families, friends, society, religion, etc. Availability The able and affable students of medicine and their teachers of the same ilk can be effective only if they are available. The teachers are obligated to make themselves available to their students, and the students are obligated to make themselves available to those situations that are most advantageous to learn- ing throughout their lives. They are also obligated to make themselves available to those people who have entrusted their health to them. The students of the Duke University School of Medicine impress me as able, affable, and available candidates for the privilege and responsibility of caring for sick people. The able, affable, and available physicians are the true spir- itual descendants ofthe Greats of Medical History. They seem to maintain bonds with Aesculapius, Hippocrates, Galen, Hun- ter, Simmelweiss, Virchow, Osler, Best, Taylor, White, Minot, Strudwick, Nott, Cushing, Holmes, Sims, Williams, Davison, Reed, Hohman, Markee, Carter, Smith, Swett, Hart, Stead, Alyea, Baker . . . Arthur C. Christakos PHILOSOPHERS 21

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present, which have meaning and special appeal. If one follows the mainstream of life, problems, perplexities, and disappoint- ments can be anticipated as well as success and happiness. Win- ston Churchill provided sound advice when he said, The only guide to a man is his conscience, the only shield to his memory is rectitude and sincerity of his actions. It is very imprudent to walk through life without this shield, because we are so often marked by, a failure of our hopes and upsetting of ouricalcula- tions, but with this shield, however the fates may play, we may always be in the ranks of honor. Another feature deserving specific recognition is the im- portance of flexibility in daily life. This is very aptly expressed in the Socratic statement, A man though wise, should never be ashamed of learning more, and must unbend his mind . . . and so the ship that will not slacken sail, the sheet drawn tight, unyield- ing overturns. She ends the voyage with her keel on top . . . The message of being alert to the need for change, when change is prudent, is indelibly clear. Finally, this writer has never found a statement which cap- tures the prescription for a successful and happy career in medi- cine as well as that of Sir William Osler. When asked by the medical students at Yale for the reasons explaining his own attainments, Osler was very forthright, It seems a bounden duty on such occasions to be honest and frank, so I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself. . . This I propose to give you in the hope, yes, in the full assurance that some of you at least will lay hold upon it to your profit. Though a little one, the master-word looms large is meaning: WORK. It is the open sesame to every portal, the great equalizer in the world, the true philosopher's stone, which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it. . . To the youth it brings hope, to the middle-aged confidence, to the aged repose . . . It is directly responsible for all advances in medicine during the past twenty-five centuries. David C. Sabiston 5 .T 3 FD JP E '4 as 3 3 F THE FUTURE OF MEDICAL EDUCATION A View Toward The 21st Century It is tempting to say that I never look back, but it simply is not true. Though it is more fun to think and plan for the future, past history has the sobering impact of attempting to minimize the recycling of previous mistakes made in the United States and abroad. Medical and health science education in the past 200 years provides an objective launching pad from which we may ex- trapolate future changes. Some of the directions we are current- ly following have proven disastrous in other countries. At times, elements of our national leadership appear to be wearing blindersg the day-to-day preoccupation with complex problems in education and health care are not conducive to careful plan- ning for the future. In this column, I shall endeavor to touch only a few of the major issues which loom before us in the next two decades. A more complete rendition would require a monograph. Changes in Admission to Medical School Today, the starting line to gain admission is located where your parents have decided to work and live. You are locked in an environment which can determine whether or not you are in an educational channel that might lead to admission to medical school. The valedictorian of a small rural high school in North Carolina may not gain admission to one of the nation's top fifty colleges that produce the bulk of successful applicants to medic- al school. The new North Carolina Residential High School of Science and Mathematics is an experiment to correct this dispar- ity in opportunity. Lessons to be learned from such a model may be replicated in other states and provide one solution to the problem. At the collegiate level, currently there prevails a unitrack quantitative science rat race to compete for admission to medi- cal school. Only one out of three applicants is successful on the national scene. The remaining two-thirds end up frustrated, angry, and sometimes hostile towards medicine, they may go into careers that surround medicine, but they and their families will never forget the four years of the vicious college race. The Program to Strengthen the Medical Science Education in College, supported by the Commonwealth Fund of New York City at Duke's Trinity College and seven other universities, is one attempt to provide alternative pathways to medicine. It makes available respectable tracks to other careers in health and fields related to medicine. It defuses the quantitative biological science unitrack as an all or none option. Youngsters gain a practical field experience in health care to get a feel for the trenches by Working as volunteers in hospitals and clinics. It provides the opportunity to sample the basic medical sciences while in college. The early provisional acceptance to medical school as sophomores in college gives the student an opportun- ity to select broader non-science courses in the humanities and social sciences. Consideration for future careers in economics, political science and law at the interface with medicine have exposure to what medicine and health care is all about in the process of formal collegiate education. Current medical school admission committees do the best job possible today. They are more discriminating than other profes- sional and graduate programs that tend to formulate criteria that consider grades and aptitude tests exclusively. Interviews and letters of recommendation may be helpful at both ends of the intellectual spectrum, they can weed out the genius who belongs PHILOSOPHERS 25