THE CLINICAL YEARS
The work after the third year should be taken out of the medical school entirely and transferred to the hospital, which , as Abernethy remarks, is the proper college for medical student, in his last years at least. An extraordinary difficulty here presents itself. While there are institutions in which students have all the privileges to be desired, there are others in which they are admitted by side entrances to the amphitheatre of the hospital, while from too many the students are barred as hurtful to the best interests of the patients. The work of an institution in which there is no teaching is rarely first class. There is not that keen interest, nor the thorough study of the cases, nor amid the exigencies of the busy life is the hospital physician able to escape clinical slovenliness unless he teaches and is in turn taught by assistants and students. It is, I think, safe to say that in a hospital with students in the wards the patients are more carefully looked after, their diseases more carefully studied and fewer mistakes made. The larger question of the extended usefulness of the hospital in promoting the diffusion of medical and surgical knowledge, I cannot here consider.
The objection often raised that patients do not like to have students in the wards is entirely fanciful. In my experience it is just the reverse. On this point I can claim to speak with some authority, having served as a hospital physician for more than 25 years, and having taught chiefly in the wards. With the exercise of ordinary discretion, and if one is actuated by kindly feelings towards the patients, there is rarely any difficulty. In the present state of medicine it is very difficult to carry out the work of a first-class hospital without the help of students. We ask far too much of the resident physicians, whose number has not increased in proportion to the enormous increase in the amount of work thrust upon them, and much of the routine work can perfectly well be done by senior students.
I envy for our medical students the advantages enjoyed by the nurses, who live in daily contact with the sick, and who have supplanted the former in the affections of the hospital trustees.
There is no higher mission in this life than nursing God's poor. In so doing a woman may not reach the ideals of her soul; she may fall far short of the ideals of her head, but she will go far to satiate those longings of the heart from which no woman can escape.
Practically, there should be for each of you a busy, useful and happy life; more you cannot expect; a greater blessing the world cannot bestow. Busy you will certainly be, as the demand is great, both in private and public, for woman with your training. Useful your lives must be, as you will care for those who cannot care for themselves, and who need about them, in the day of tribulation, gentle hands and tender hearts. And happy lives shall be yours, because busy and useful; having been initiated into the great secret- that happiness lies in the absorption in some vocation which satisfies the soul: that we are here to add what we can to, not to get what we can from, life.
A luxury, let us say, in her private capacity, in public the trained nurse has become one of the great blessings of humanity, taking a place beside the physician and the priest, and not inferior to either in her mission. Not that her calling here is in any way new. Time out of mind she has made ready to devise means for allaying suffering; tender hearts, surcharged with the miseries of this "battered caravanserai," have ever been ready to speak to the sufferer of a way of peace, and loving hands have ministered to those in sorrow, need and sickness. Nursing as an art to be cultivated, as a practice originated in the dim past, when some mother among the cave-dwellers cooled the forehead of her sick child with water from the brook, or first yielded to the prompting to leave a well-covered bone and a handful of meal by the side of a wounded man left in the hurried flight before an enemy. As a profession, a vocation, nursing has already reached a high development.
The problem before us as teachers may be very briefly stated; to give to our students an education of such character that they can become sensible practitioners- the destiny of seven-eighths of them. Towards this end are all our endowments, our multiplying laboratories, our complicated curricula, our palatial buildings. In the six years' course a division is very properly made between the preparatory or scientific branches and the practical; the former are taught in the school or college, the latter in the hospital. Not that there is any essential difference; there may be as much science taught in a course of surgery as in a course of embryology. The special growth of the medical school in the past 50 years has been in the direction of the practical teaching of science. Everywhere the lectures have been supplemented or replaced by prolonged practical course, and instead of a single laboratory devoted to anatomy, there are now laboratories of physiology, or physiological chemistry, of pathology, of pharmacology, and of hygiene. Apart from the more attractive mode of presentation and the more useful character of the knowledge obtained in this way, the student learns to use the instruments of precision, gets a mental training of incalculable value and perhaps catches come measures of the scientific spirit. The main point is that he has no longer merely theoretical knowledge acquired in a lecture room, but a first-hand practical acquaintance with the things themselves. He not only has dissected the sympathetic system, but he has set up a kymograph and can take a blood pressure observation, he has personally studied the action of digitalis, he has made his own culture media and he has "plated" organisms. The young fellow who is sent on to us in his third year is nowadays a fairly well-trained man and in a position to begin his life's work in those larger laboratories, private and public, which nature fills with her mistakes and experiments.
How can we make the work of the student in the third to sixth years as practical as it is in his first and second? I take it for granted we all feel that it should be. The answer is, take him from the lecture-room, take him from the amphitheatre - put him in the out-patient department-put him in the wards. It is not the systematic lecture, not the amphitheatre clinic, not even the ward class - all of which have their value- in which the reformation is needed but in the whole relationship of the senior student to the hospital. During the first three years, he is thoroughly at home in the laboratories, domiciled, we may say, with his place in each one, to which he can go and work quietly under a tutor's direction and guidance. To parallel this condition after the third year, certain reforms are necessary. First, in the conception of how the art of medicine and surgery can be taught. My firm conviction is that we should start the third year student at once on his road of life. Ask any physician of twenty years' standing how he has become proficient in his art, and he will reply, by constant contact with the disease; and he will add that the medicine he learned in the schools was totally different from the medicine he learned at the bedside. The graduate of a half of a century ago went out with little practical knowledge, which increased only as his practice increased. In what may be called the natural method of teaching the student begins with the patient, and ends with his studies with the patient, using book s and lectures as tools, as means to an end.
The most essential part of a student's instruction is obtained, as I believe, not in the lecture room, but at the bedside. Nothing seen there is lost; The rhythms of disease are learned by frequent repetition; its unforeseen occurrences stamp themselves indelibly in the memory. Before the student is aware of what he has acquired he has learned the aspects and causes and probable issue of the disease he has seen with his teacher, and the proper mode of dealing with them, so far as his master knows.
Of the student-teacher every faculty affords examples in varying degrees. It goes without saying that no man can teach successfully who is not at the same time a student. Routine, killing routine, saps the vitality of many who start with high aims, and who, for years, strive with all their energies against the degeneration which it is so prone to entail. In the smaller schools isolation, the absence of congenial spirits working at the same subject, favours stagnation, and after a few years the fires of early enthusiasm no longer glow in the perfunctory lectures. In many teachers the ever- increasing demands of practice leave less and less time for study, and a first-class man may lose touch with his subject through no fault of his own, but through an entanglement in outside affairs which he deeply regrets yet cannot control. To his five natural senses the student teacher must add two more - the sense of responsibility and the sense of proportion. Most of us start with a highly developed sense of the importance of the work, and with a desire to live up to the responsibilities entrusted upon us. Punctuality, the class first, always and at all times; the best that a man has in him, nothing less; fresh energies and enthusiasm in dealing with dry details; animated unselfish devotion to all alike; tender consideration for his assistants- these are some of the fruits of a keen sense of responsibility in a good teacher. The sense of proportion is not easy to acquire, and much depends on the training and on the natural disposition. There are men who never possess it; to others it seems to come naturally. In the most careful ones it needs constant cultivation- nothing-over-much should be the motto of every teacher.
On account of the peculiar character of the subject matter of your studies, what I have said upon the general life and mental attitude of the student applies with ten-fold force to you. Man, with all his mental and bodily anomalies and diseases- the machine in order, the machine in disorder, and the business yours to put it to rights. Through all the phases of its career the most complicated mechanism of this wonderful world will be subject of our study and of our care; the naked new-born infant, the artless child, the lad and the lassie just aware of the tree of knowledge overhead, the strong man in the pride of life, the woman with the benediction of maternity on her brow, and the aged, peaceful in the contemplation of the past. Almost everything has been renewed in the science and in the art of medicine, but all through the long centuries there has been no variableness or shadow of change in the essential features of the life which is our contemplation and our care. Amid an eternal heritage of sorrow and suffering our work is laid, and this eternal note of sadness would be insupportable if the daily tragedies were not relieved by the spectacle of the heroism and devotion displayed by the actors. Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought the true poetry of life- the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman, with their loves and their joys, their sorrow and their griefs. The comedy, too, of life will be spread before you, and nobody laughs more often than the doctor at the pranks Puck plays upon Titanias and the Bottoms among his patients. The humorous side is really almost as frequently turned towards him as the tragic. Lift up one hand to heaven and thank your stars if they have given you the proper sense to enable you to appreciate the inconceivably droll situations in which we catch our fellow creatures. Unhappily, this is one of the free gifts of the gods, unevenly distributed, not bestowed on all, or on all in equal portions. In undue measure it is not without risk, and in any case in the doctor it is better appreciated by the eye than expressed on the tongue. Hilarity and good humour, a breezy cheerfulness, a nature "sloping toward the southern side," as Lowell has it, help enormously both in the study and in the practice of medicine. To many of a sombre and sour disposition it is hard to maintain good spirits amid the trials and tribulations of the day, and yet it is an unpardonable mistake to go about among patients with a long face.
The strength of a student of men is to travel- to study men, their habits, character, mode of life, their behaviour under varied conditions, their vices, virtues and peculiarities. Begin with a careful observation of your fellow students and of your teachers; then, every patient you see is a lesson in much more than the malady from which he suffers. Mix as much as you possibly can with the outside world, and learn its ways. Cultivated systematically, the student societies, the students' union, the gymnasium, and the outside social circle will enable you to conquer the diffidences so apt to go with bookishness and which may prove a very serious drawback in after-life. I cannot too strongly impress upon the earnest and attentive men among you the necessity of overcoming this unfortunate failing in your student days.
It is not easy for everyone to reach a happy medium, and the distinction between a proper self-confidence and "cheek", particularly in junior students, is not always to be made. The latter is met with chiefly among the student pilgrims who, in travelling down the Delectable Mountains, have gone astray and have passed to the left hand, where lieth the country of Conceit, the country in which you remember the brisk lad Ignorance met Christian.
A student may know all about the bones of the wrist, in fact he may carry a set in his pocket and know every facet and knob and nodule in them, he may have dissected a score of arms, and yet when he is called to see Mrs. Jones who has fallen on ice and broken her wrist, he may not know a Colles' from a Potts' fracture, and as for setting it secundum artem, he may not have the faintest notion, never having seen a case. Or he may be called to preside at one of those awful domestic tragedies- the sudden emergency, some terrible accident of birth or of childhood, that requires skill, technical skill, courage- the courage of full knowledge, and if he has not been in the obstetrical wards, if he has not been trained practically, if he has not had the opportunities that are the rights of every medical student, he may fail at the critical moment, a life, two lives, may be lost, sacrificed to ignorance, often to helpless, involuntary ignorance. I place it first because it was the most needed lesson, I place it first because it has done the most good as a stimulating example, and I place it first because never before in the history of this country have medical students lived and worked in a hospital as part of its machinery, as an essential part of the work of it s wards. In saying this, Heaven forbid that I should obliquely disparage the good and faithful work of my colleagues elsewhere. But the amphitheatre clinic, the ward and dispensary classes, are but bastard substitutes for a system which makes the medical student himself help in the work of the hospital as part of its human machinery. He does not see the pneumonia case in the amphitheatre from the benches, but he follows it day by day, hour by hour; he has his time so arranged that he can follow it; he sees and studies similar cases and the disease itself becomes his chief teacher, and he knows its phases and variations as depicted in the living; he learns under skilled direction when to act and when to refrain, he learns insensibly principles of practice and he possibly escapes a "nickel-in-the-slot" attitude of mind which has been the curse of the physician in the treatment of disease. And the same with the other branches of his art; he gets a first-hand knowledge which, if he has any sense, may make him wise unto the salvation of his fellows. And all this has come about through the wise provision that the hospital was to be part of the medical school, and it has become for the senior students, as it should be, their college. Moreover, they are not in it upon sufferance and admitted through side-doors, but they are welcomed as important aids without which the work could not be done efficiently.
The student starts, in fact as a practitioner, as an observer of disordered machines, with the structure and orderly functions of which he is perfectly familiar. Teach him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves. For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself. The whole art of medicine is in observation, as the old motto goes, but to educate the eye to see, the ear to hear, and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do. We expect too much of the student and we try to teach him too much. Give him good methods and a proper point of view, and all other things will be added as his experience grows.
The family doctor, the private in our great army, the essential factor in the battle, should be carefully nurtured by the schools and carefully guarded by the public. Humanly speaking, with him are the issues of life and death, since upon him falls the grievous responsibility in those terrible emergencies which bring darkness and despair to so many households. No class of men needs to call to mind more often the wise comment of Plato that education is a life-long business. The difficulties are partly adherent to the subject, partly have to do with the individual and his weakness. The problems of disease are more complicated and difficult than any others with which the trained mind has to grapple; the conditions in any given case ,may be unlike those in any other; each case, indeed, may have its own problems. Law, constantly looking back, has its forms and procedures, its precedents and practices. Once grasped the certainties of divinity make its study a delight and its practice a pastime; but who can tell of the uncertainties of medicine as an art? The science on which it is based is accurate and definite enough; the physics of a man's circulation are the physics of the waterworks of the town in which he lives, but once out of gear, you cannot apply the same rules for the repair of the one as of the other.
Variability is the law of life, and as no two faces are the same, so no two bodies are alike, and no two individuals react alike and behave alike under the abnormal conditions which we know as disease. This is the fundamental difficulty of the physician, and one which he may never grasp, or takes it so tenderly that it hurts instead of boldly accepting the axiom of Bishop Butler, more true of medicine than of any other profession; "Probability is the guide of life." Surrounded by people who demand certainty, and not philosopher enough to agree with Locke that "Probability supplies the defect of our knowledge and guides us when that fails and is always conversant about things which we have no certainty," the practitioner too often gets into a habit of mind which resents the thought that opinion, not full knowledge, must be his stay and prop. There is no discredit, though there is at times much discomfort, in this everlasting perhaps with which we have to preface so much connected with the practice of our art.
Listen to the appropriate comment of the Father of Medicine, who, twenty-five centuries ago, had not only grasped the fundamental conception of our art as one based on observation, but had laboured also through a long life to give to the profession which he loved the saving health of science- listen, I say, to the words of his famous aphorism; "Experience is fallacious and judgment difficult!"