Columbia University College of Physicians and Surgeons - P and S Yearbook (New York, NY)

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games in medicine is the making of snap diag- noses at the bedside. A diagnosis of this kind almost invariably generates an emotional at- tachment, and such emotion impairs a reasoned judgment based on subsequently acquired facts. Finally, good clinical judgment is dependent upon an ability to organise rationally all the known data about a pa- tient, giving proper rela- tive weight to what may appear to be conflicting facts and distinguishing important information in ' . I Y a mass of irrevelancies. X 5 The fourth essential is dj honesty in dealing with Fx' associates. One would think it superfluous to E W. ..... mention this, were it not for the fact that occasion- , is ally an interne may tell F an inquiring attending T physician that a patient could not have a carci- noma of the rectum when in fact he has not done a rectal examination-though he will do it im- mediately after rounds to confirm his statement. This is not honest, and the practice of good ward medicine is impossible when it occurs. The jifth quality is compassion. Compassion must be present in most of you or you would not now be physicians. This. also, cannot be im- parted by instruction, but it is hoped that the example of the teacher has been such that you have observed the difference that compassion can make to the well-being of the patient. s as Iil N M 1 However, the quality which most frequently seems to distinguish the superior from the med- iocre interne is the ability to pay meticulous at- tention to detail. The good interne knows every- thing about the patient's personal and medical historyg the bad interne invariably fails to know some point which is crucial to the management of the patient. The good in- terne has done a complete and accurate physical ex- amination and has prop- erly interpreted his find- ingsg the bad interne has invariably either failed to perform some important part of the physical exam- , - r ination or to interpret K Qs. properly his findings. The good interne has sudicient intellectual curiosity to j acquire more and perti- nent information about the patients disease: the - - had interne invariably has not. The importance of paying conscientious and meticulous attention to detail in the manage- ment of patients cannot be over-einphasized. Without it, intelligence is wasted, factual knowl- edge is worthless. reasoned judgment is impos- sible, honesty is irrelevant, and compassion is fraudulent. The perfect interne has probably never existed, and probably never will. The respon- sible interne, however, is not too distant a figure for your aspiration and endeavour. May I wish all of you the best as you take up your new duties.

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THE RESPGN IBLE INTERNE The suggestion of your Yearbook Committee that I write something about the philosophy un- derlying the third year clerkship in medicine appeared somewhat retrospective. Since all of you are about to embark on an internship as the next step in your career, it seemed to me that it might be more appropriate to try to define that rather nebulous figure, the responsible interne. During your last two years in medicine you have gradually assumed more and more respon- sibility for the management of patients. But you have not yet assumed the entire responsibility for a sick person. The successful undertaking of this responsibility is a pritical step in your de- velopment as physicians. Certain qualities, dis- tinguishing the excellent from the mediocre in- terne, seem requisite for success. The hrst essential is a reasonable intelli- gence. All of you have this, or you would not have competed successfully for admission to medical school. The mere possession of such native intelligence, however. does not necessarily insure its proper use. ln the third year clerkship great emphasis was placed upon the logical and scientific analysis of all the facts known about a patient so that one might learn to use this intelli- gence in an appropriate and effective fashion. The second essential is an adequate fund of factual knowledge about the pathophysiology of disease. Throughout your first two years at medical school you were presented with a large body of such knowledge. This process has con- tinued during your clinical years, but at a pace conditioned by your increasing assumption of BY DONALD TAPLEY responsibility. In the third year clerkship some of you were perhaps disappointed by the rela- tively less concentrated diet of facts provided by the faculty. Medical facts, however, are fre- quently transientg a knowledge of how to keep up with advances in medicine through an appro- priate use of books and journals is in the long run a more valuable asset. The third and most important requirement I have chosen to call judgment. This is perhaps the most difficult of all for the faculty to impart to students, and is perhaps best taught by exam- ple. Good judgment in the appraisal and man- agement of a patient is not necessarily directly correlated either with the fund of factual knowl- edge or with the native intelligence which the interne possesses. Both, of course, are essential but some of the most intelligent internes have the poorest clinical judgment. Rather, good judg- ment may be correlated with more elusive qual- ities: intellectual honesty, humility, compassion, and the ability to organise. To be honest intel- lectually is to admit to yourself your areas of ignoranceg to give full weight in your thinking to facts which disagree with your preconception of the patient's problems and to make careful distinction between those diagnostic and thera- peutic procedures which are essential to the man- agement of the patient and those which are de- signed simply to satisfy your intellectual cur- iosity. To be luunble is to admit the fallibility of your most cherished diagnosis, and be willing to re-evaluate your position and your approach as new facts emerge. One of the most dangerous

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THE IVORY TOWER Y DROME When some time ago I accepted the flattering invitation to write something for this Year Book, I promised myself that I would avoid rhetoric and slogans. and that I would try to discuss some topic pertaining to our daily life. This led me to the decision of writing about an interesting syndrome. This is a disease which is endemic in most important medical and teaching institutions. The disease. or syndrome. is not sex linked and is not limited to any age group. It is probably con- tagious. but the exact method of transmission is not known. We can call it the Ivory Tower Syn- drome. The patients who become affected by it may look perfectly normal except when they speak or write on topics pertaining to their field or speci- alty. A trained and keen observer will then detect the following symptoms: the patients become dog- matic and ignore, or at least disregard entirely. any opinion, point of view. research method or results. which originated in other institutions. They con- sider reliable and important only the results and conclusions reached by them or their group, Un careful interviewing, their rationalization goes somehow along these lines: a. This is one of the greatest medical and scientific centers: b, I belong to it lor it belongs to met: c. We have at- tained. or are near attaining, excellence in our field: d. Ergo, those who disagree with us must by neces- sity be wrong and misguided and we need not waste our time by paying attention to what they say. The By Raffaele Lattes Ivory Tower Syndrome is not a rare disease. With some experience. it can be diagnosed easily. It is apparent that while early detection can be of great help in combatting it by isolating the patients, adequate prevention is possible and more desirable. What was said above was not meant to imply that in the biological and medical sciences the opinions of a mediocre majority should prevail on those of one outstanding individual. What was meant is that' we must study and respect the opinions and results reported by others in our field, and try seriously to understand the reasons for the discrepancies that may exist between our point of view and theirs. For instance, one of the blandest manifestations of our syndrome is our frequent tendency to ignore the foreign literature. First rate basic and clinical research is done abroad as well as here. just as poor articles are published here as well as abroad. If we acquaint ourselves with what has been done and reported elsewhere, not only will we avoid reporting as new. observations already made and published by others, but we will without fail see our own field or specialty in a better perspective. In my opinion, the road to excellence is paved not only with hard work and superior intellectual ability. It also requires understanding and tolerance of other points of view. and thorough familiarity with work done by others. Without this, we run the risk to march down a path leading to narrow minded- ness and arrogance.