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

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Immediately, I was quite pleased, and a little flattered, to be asked to write for the 1965 edi- tion of the AESCULAPIAN. When the request to submit a short essay of your philosophy of medical education and practice was more thoughtfully considered, however, it became apparent that an immediate rendering of such a philosophy was difficult, either because of complete lack of it or because of inadequate introspection concerning it. Once the invita- tion to write had been accepted the challenge had to be met. It is easier to write of medical education than of medical practice, because more of my time has been spent in working with medical students than with patients. To a considerable degree, however, Work with the two groups is similar. Each student and each patient is an individual with certain specific needs in addi- tion to, or in spite of, certain non-specific or generalized qualities. These specific needs call for specific handling rather than routine pro- cedures. ln addition to specific treatments though, there is a common ground of care in a medical education, as there is in medical practice. In my concept of medical education one is always a student. He is an adult all along and is to be treated as such. He should be indepen- dent to a degree, but will need guidance and cooperation as well as challenge. The last, how- TALMAGE PEELE, M.D. ANATOMY, NEUROLOGY, PEDIATRICS The concept of the patient's being an ordinary human in need of specific help should be upper- most in the student's mind. ever, should be administered as pleasantly as possible and still be meaningful. A family-like spirit should be engendered by the faculty, not one similar to boot camp. And there should be ample opportunity for social exchange not only at student-sponsored events, but in faculty homes. A student should learn that it is just as valu- able to know where to find more useful facts as it is to have them immediately available. The pursuit of more facts may lead him spon- taneously to a research program. Toward this he should be encouraged, but not driven. Not every medical student is emotionally or intel- lectually suited for research in the basic sci- ences or even in the clinical field. Neither is every enrollee in a medical school suited for administeringito and caring for patients. Varia- tion in curriculum appears necessary therefore. The medical student should have fun in his studies of biologic systems, and he should not lose sight of systems that are not biologic. The Arts have a place in medical education. While he should learn to classify and categorize for reasons of simplification, he should avoid dogma and learn that nothing in medicine is absolute. The concept of the patient's being an ordi- nary human in need of specific help should be uppermost in the studentis mind. The patient should not be a number merely subject to a set routine of tests. A need for each study should be apparent, and a so-called shot gun survey should be avoided. Many times per- sonal inconvenience to thepatient and undue expense to him or his sponsoring agency can be avoided by the careful exploitation of the old fashioned techniques of palpation, percus- sion, and auscultation. The medical curriculum should permit the student to have ample con- tact with those practitioners of clinical medi- cine who are masters of these simple tools. It is my impression that the more practical aspects of medicine can be learned at the bed- side, rather than in a laboratory. Once these are acquired, the student who desires to, may move into the laboratory, temporarily or per- manently. The other student will continue to learn at the bedside. ffl twenty-six

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a student. The role of the faculty is to prepare the student for a lifetime of learning. We must introduce him to the basic principles of human biology with just enough specific information to illustrate these principles. We must provide him with a series of clinical experiences that will allow him to deal comfortably with pa- tients and to use all the facilities of the health field in understanding the sick, and in caring for them. We must also help the student iden- tify that area of medicine in which he will be most productive and happy. The practice of medicine is becoming more complex, both because of the pace of scientific advance and because of impending changes in financing of health care. Increasingly, physi- cians are enjoying the practice of medicine more when they join together in groups so that each may emphasize most strongly that area in which he has special training. The intel- lectual satisfactions are greater because the physician has mastered an area of specializa- tion. The personal satisfactions are greater be- cause he has rendered his patient superior care. In internal medicine, fewer and fewer of our residents enter the community as un- differentiated internists. They want also to be equipped as cardiologists, allergists, or gastro- enterologists. The communities expect them to bring more than could have been obtained in a residency at a non-teaching hospital. The trend toward subspecialization within large diversified group practices will continue. I ex- pect also that more and more community hos- pitals will establish complex special care units and supporting laboratory facilities, and ap- point geographical full-time staff members. This will enable them to compete more effec- tively with the continuing education of the community physician. Greater governmental participation in financing will bring this about. The report of the Presidential Commission on Cancer, Heart Disease and Strokes previews one aspect of coming changes. The Medical School and the Department of Medicine are facing these new challenges, for if we did not, our graduates would soon not be equipped for the roles of leadership and dis- tinction. We will continue to admit a hetero- geneous student body and to train practicing physicians, teachers, research workers, public health workers-professional manpower for the health field at all levels. In all branches of medicine the physician of the future will need a stronger basic science competence. This need not, indeed cannot, be catholic. One physician will need depth in neurophysiology, another in developmental biology or behavioral science. I have been impressed with how much more a student gets out of the laboratory after he has had an introductory clinical experience, has identified an area of curiosity, excitement, and relative ignorance, and has found a faculty member willing to guide his learning. Our curriculum most offer all students such an op- portunity. Our graduate programs in internal medicine must come seriously to grips with the problem of early career differentiation, so that our resi- dents and fellows can choose from the best opportunities in community or academic medi- cine. Their training must increasingly reflect the basic sciences relevant to their fields, and must equip them to deal with the complexities of scientific discovery and application. Our men must be skilled not only in ward and clinic medicine, but also in the intricacies of complex special units, such as the hyperbaric chamber, the chronic dialysis unit, the hemodynamic laboratory, the metabolic laboratory. This will require more individualization of residency training. We are unusually fortunate at Duke in having excellent working relationships be- tween clinical and preclinical departments. Within clinical departments the faculty in- cludes physicians oriented toward patient care and physician-scientists oriented toward dis- ease mechanisms. All have equal honor, and all are essential to the training of student and physician. It seems to me that one additional oppor- tunity will become increasingly urgent soon, and that is the chance of the practicing physi- cian to have a free year without incurring financial disaster. The universities long ago discovered the value of free years for their faculty, to enable a member to renew his out- look and keep up to date. Often this involves leaving one seat of learning and going to an- other. The practicing physician also needs this opportunity. The larger groups and community hospitals with full-time staffs should build such a provision into their structures, and plan its financing, in their own enlightened self inter- est. The university hospitals, the clinical, and perhaps the basic science departments also, should remain receptive for constructive ex- plorations. The career opportunities open to the medical student have never been more diverse or more attractive. The earlier he can identify the area which will permit full play of his talents, the better he can be trained for the future, and the more successful are the measures for his continuing education, the more significant will be the satisfactions that come to him. twenty-five

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GEORGE J. BAYLIN, M.D. RADIOLOGY Be critical, but understanding, be skeptical, but receptive to change and innovation, be provocative, but not punitiveg strive always to excite your col- leagues, never to incite them. Distinguish critically between growth and development and understand the basic differences between bigness and greatness. Graduation heralds for each of you a porten- tous change. You shift from medical student status to that of student of medicine. No longer is the storage of facts, the cramming for exami- nations, the attainment of grades, and the fear of superiors the way of life. Now you must make decisions, assume great responsibilities, shape the destinies of others, and acquire not only knowledge but wisdom. The challenges are great and will tax your ability and in- genuity severely. lt will require intense ef- fort and dedication to meet them successfully, but you are being launched with a sound back- ground buttressed by a magnificent Duke med- ical tradition. Lest you not be conversant with that tradi- tion, I will wax nostalgic and detail brieiiy some of the pillars on which it is founded. Graduation from the Duke Medical School endows you with stature and prestige even beyond that which accrues to you by virtue of your newly acquired distinguished degree. Why? Your school was founded on a bold new pro- gram of medical education that immediately caught the imagination of all involved. More- over, it soon commanded the attention and respect of physicians, scientists and educators throughout the country, indeed, throughout the World! Its basic discipline was hinged on a teacher- student interchange that featured mutual un- derstanding and respect. The prime emphasis was on hard earnest effort featured by a phi- losophy that learning, though infinitely diffi- cult, is nevertheless exciting and enjoyable. Student knew teacher-teacher knew student, not merely through the written regurgitation of facts, but via daily personal exchange. The interplay was based on intimacy. Each chal- lenged the other to greater effort and achieve- ment. Another major attribute that characterized the young new school was the inherent disdain for intellectual complacency manifested by its members. Everyone was constantly engaged in determining how best to improve all the phases of school activities. Fortunately, the young, in- dustrious, and energetic staff members pos- sessed magnificent maturity, particularly with respect to their own errors. Even the student was permitted the privilege of being wrong- given the chance to try once again to collect his thoughts, to regroup his ideas so as to re- cover from the inevitable false starts which beset us all. Also, infinite wisdom prevailed with regard to the recognition of those important differ- ences in individual ability, thus permitting each student to be directed in a meaningful fashion toward the attainment of his goals. The zest and dedication of purpose was con- tagious. The result was almost electrifying. Cln a few brief years Duke Medical School had acquired more than a reputation-it had ac- quired character that was destined to be ap- preciated in all cultural and scientific regions.J Graduates from such a program were obviously destined to carry forth a message that would soon be heard and understood. twenty-seven