MY FIRST FIFTY YEARS IN MEDICINE
This is a much-loved physician’s testament to the pleasures and pain of healing—and sometimes knowing he cannot heal—the sick and troubled. A doctor’s joys are like no others, he writes, as are his privileges: “Who else can command, the king?”
Dr. Alton Goldbloom
IT IS A GOOD FEELING, a satisfying emotion, this gift of time which fortunately permits me to look hack over the span of more than fifty years of studying medicine, training in a specialty and practising, learning and teaching. To remember three thousand medical students with whom I have had some contact in one of the great medical schools of the world and whom I hope that in some small way I have influenced for good. To look hack on a population of children — well over seventy-five thousand of them — whom over these years I have tried to treat, running the gamut from brilliant success to dismal failure. And to contemplate the myriad problems of disease, emotion, and daily life that come into the ken of a physician dealing with the young and with their environment. It is a good feeling to contemplate in retrospect how great have been the joys and the soul-satisfying compensations of being a doctor.
. In recent years the image of the physician has undergone a seachange which has tended to wash away some of the idealism which in other days surrounded him. Social change and the pressures of modern life have tended to alter our picture of the doctor as a. self-effacing idealist, somewhere between a scientist and a priest. In light of this
alteration I think it is well to look back and to try to evaluate what a
physician really is and why people still want to be doctors — indeed, to try to capture that side of the practice of medicine which makes the medical life so worthwhile and so rewarding.
Nothing basic has changed in the art of medicine, of being a doctor: a great deal has changed in the science of medicine. We are today in the happy possession of diagnostic aids which were unknown even a generation ago. we have achieved understanding of the nature and origin of diseases hitherto obscure and we have the tools and the techniques with which we can cure diseases previously fatal. We can remove parts of
diseased lungs: we can open hearts and repair defects: and many more
leaps ahead in medicine are still to come. Yet the art of being a doctor is as it always was and. I hope, always will be. Science threatens to overshadow the art, yet the two must ever remain mutually predominant and inseparable.
TREATING A CASE AND TREATING A PATIENT
The art of medicine derives from the fact that physicians are human beings, dealing with human beings. It derives from the fact that there are no “cases” of pneumonia, or tuberculosis or cancer, but there is John Smith who has pneumonia and John Brown who has tuberculosis and Jane Doe who has cancer. It is John Smith with all his emotions and his temperament and the problems of his family, who has pneumonia. A “case" of pneumonia recovers, but what has this disease done to John Smith and the man that he is? Has John Smith, free now from disease, been in other ways affected by having had the disease? In recognizing and handling medical problems in this way lies the difference between making a patient well with penicillin and being aware of all the problems that the illness created or complicated, and which must be sympathetically and understanding^ handled. This is what is meant by the difference between treating a case and treating a person.
It is therefore with the art of being a doctor that I have concerned myself over this span of years, always trying to profit by new advances and use them not with blind acceptance but with critical evaluation. And trying, too. never to lose sight of the simplicity with which many diagnoses are arrived at and the ease with which many illnesses are treated. Not being:
. . . the first by whom the new are tried
nor yet the last to lay the old aside
I have been careful not to lose sight of the fact that many diseases (of which measles is only one) are self-limited, run a predicted course uninfluenced by medication and usually have a favorable outcome. And to remember that in such diseases complications and the less common unfavorable outcomes are beyond the doctor's control. The intellectual honesty of the physician demands the recognition, not only of his own limitations, but of the limitations of medical knowledge.
What then are the compensations of being a doctor? Why to this day do young men and women tremble that their applications for admission to the study of medicine may not be accepted? Why are there still many more applicants than medical schools can accommodate? The compensations are inherent in the craft if it is practised with devotion and with dedication. They are in the joys of human contact under conditions which are unknown in ordinary social relations. They come not only from the glow of achievement, from the immense satisfaction of having made a correct diagnosis, of having lived through anxious moments waiting for the first sign of recovery and being able to recognize this before it was evident the and of having seen a sick child
well. But they come also from the immense and
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“I have never lost my feeling of wonder at a newborn child
ungrudging gratitude with which \ou are showered when vigilance comes to an end and the favorable outcome is in sight. These are some ot the things that "cancel out the interrupted dinners. the sleepless nights, the fatigue and all the disruptions of being a doctor instead ot a man whose private lite
is his own.
To the true doctor, medicine means a dedicated life. The call is like the call to holy orders. Some years ago when I was professor of pediatrics at Metall, the dean, the late Dr. Frederick Smith, and I w'ere asked to meet a group of young people w'ho had just entered the premedical course. We wished to find out w'hat made them want to be doctors. One said he wanted to be a doctor because his father was a doctor and his grandfather was a doctor and he wished to perpetuate a tradition. One young man said, "Because I like people." That was all the answer I could have wanted. Another said. "Because there is good money in it." 1 would have excused him and advised him to become a banker.
Finally I asked one question. "Which of you," I said, "want to go into medicine because there is nothing else in this wide world that will satisfy you?” Five hands shot into the air. fluttering like flags in a gale, while mouths hung agape and eyes popped with eagerness. 1 turned to the dean and said, "Here are the ones 1 would take w'ithout further inquiry."
Enthusiasm, above all. is w'hat makes the doctor’s life a happy one. intelligent enthusiasm, critical enthusiasm, but enthusiasm. Nothing bores, nothing palls, nothing is ever the same. To the happy doctor every patient is a new and exciting experience, and nothing is routine even after halt a century. Singling out each new patient as a distinct and separate personality, distinct from all the creatures of earth, and recognizing him as such, treating him as such—this is w'hat makes the life of a doctor a constant renewed of rich experience. It lends meaning and pur-
pose to his own life, it fills him with the wonder of the infinite variety of nature and it must make him religious in the deepest sense.
It is not a prejudiced view to feel that in pediatrics these compensations are greatest and these emotions are deepest. 1 have lost track of the number of newborn infants 1 have handled, of the thousands that 1 have seen develop from tiny automatons to bright children and often brighter adults. Yet after all these vears 1 can-
not say ! have ever lost my feeling of wonder at the contemplation of a newborn infant and the more I learn about young infants the greater is my wonder and my enthusiasm. The cold contemplation of the scientific studies on newborns, which is still enhancing our knowledge of them, is still not a patch on observing the whole infant himself, on contemplating his movements and actions which have in them the forerunners of future behavior and which may have in them the forebod-
ings of abnormality. How great is the satisfaction in approaching the parents of a baby a few hours old to say, “You have a perfectly normal baby.” and to be able to say it with authority. No satisfaction exceeds this, and thank heaven I can still share to the full the joys of the happy parents.
Nothing else produces the heavy heart and the soul searching a doctor knows before approaching the unfortunate parents of a defective child, to break the sad news to them, tactfully
and haltingly. T he duty which must he met with courage and with sympathy is also part of the function of the doctor, and in the face of mystery there can be nothing matter-of-fact and nothing routine. The dedicated doctor is never hardened to such situations; no man is an island.
The doctor gives and the doctor gets. He gives himself. He gives his knowledge, his experience, his judgment, and above all his compassion and understanding. His knowledge he has acquired in his studies, preand post-graduate. His judgment derives from his knowledge, but is not inherent in that knowledge. Rather, his judgment is a product of his knowledge and his experience, wisely aplied. But compassion and understanding are the particular expressions of the doctor’s personality and his feeling for humanity.
* Here lie the differences between one good doctor and another. One doctor can be accurate but distant, detached and uninvolved; another can put his whole being into every case as if no other problem existed for him. I he great and busy doctors who have crossed my path were always able to forget the world in the face of a problem and give the patient the feeling that at the moment only he mattered. This is a rare gift, but there have been such doctors, there still are and there always will be. They are a constant inspiration to we who are not so greatly endowed, they set enviable examples for us to try to follow.
I remember among many others Dr. Alva Gordon, at his retirement professor of medicine at McGill, who was the same man when he had a small practice and charged three dollars for an office visit as he was when he was the head of his department. An hour at the bedside of a derelict in the public ward of the old Montreal General Hospital or an hour in his office with a tycoon, it was all one to Alva Gordon. No consideration of time or money, only the problem of a sick man to solve. Gordon was a very religious man. and his religion expressed itself in this type of devotion.
This is what I mean when I say that what a doctor has to give is, above all. himself. And in this giving lies much of the joy of being a doctor.
What the doctor gets is bread upon the waters, always the result of what he gives. He gets an enviable position in the community where he practises, he gets prestige and the respect of his fellows. He has a power which only a few possess, his by virtue of his calling and by virtue of his personality, and not by virtue of ambition or wealth or a position in industry. Who else can command the king? The industrial magnate or the president of a great bank used to giving, not taking, orders will say. “My doctor has forbidden me to do or eat such and such.” It has been my good fortune in my time to be the doctor to royalty and I can attest to the respect and deference the doctor receives from the highly born.
The great compensations, however, at all levels derive from the awareness of the part one is playing as the servant of the processes of nature. The naked body knows neither rank nor station. Henry Van Dyck once contemplated a great lord and his butler bathing in the sea. both divested of the
trappings of their stations; how alike they were in their nakedness. The doctor can contemplate not only the nakedness of the body, but the nakedness of the soul. Illness is the great leveler and presents to the doctor the same problems, simple or complex, soluble or insoluble, exhilarating and humbling. In my very young days when I was once overawed by the status of the family whose child I was asked to treat, an older doctor said to me, “Treat him as you would a ward patient.” He knew that it was on the ward that the doctor could be most objective, for there nothing matters hut the patient and his problem. That was great advice.
The courage to do nothing
T he doctor gets confidence. This is the great challenge that each doctor faces with each new patient — the knowledge that a trust has been placed in him, and this trust must not be betrayed. The awareness that a mother has placed the problem of a sick child in his care, that she has presented him with a problem that wants solution, that she has placed in him the confidence and the hope of a favorable outcome, make the acceptance of that trust a constant test of his skill. It makes the doctor repeatedly ask himself if he is equal to that responsibility. His judgment and integrity are forever on trial and make him, with each problem, evaluate his own abilities and limitations. From these evaluations come the great inner satisfactions of knowing that in at least some aspects of his chosen field he has his place and his usefulness.
The satisfactions come to a doctor not only from having given the right advice, made the correct diagnoses and helped his patient toward recovery—they come also from being able to state fearlessly his own limitations and the present limitations of his craft. They come from having the courage to do nothing when nothing is to be done; to apply palliative measures and to be able to say that such measures are only palliative. They come from knowing the natural evolution of those diseases which are self-limited and for which there is no successful treatment, and to be able to say so frankly. Medicine is full of such instances, despite our antibiotics. A fairly common and simple example is what is usually called trench mouth—stomatitis herpetiformis, an inflammation of the mouth with a creeping eruption. (It recalls Maria Chapdelaine’s father saying that doctors know' nothing except how to pronounce the name of the disease in Latin.) Trench mouth lasts exactly eight days and no known treatments affect its course. How much better, then, just to say so? How much better to advise that irritating foods and drink be avoided and to just sit it out because that is all we can do, instead of plying the poor child with medicine, painting his mouth with foul-smelling and vile-tasting paints and using his buttocks as a pin cushion? This is the place for confidence. This is where the doctor has the great satisfaction of knowing that he is trusted and believed. Then, when the child is well again, and though the doctor did nothing more than make accurate statements and an accurate prognostication, comes that final ex-
pression of confidence and gratitude when the doctor is thanked and praised for having done nothing more than just being right. These are among the great satisfactions of practising medicine.
There are many other satisfactions not always related to the cure of disease or to correct evaluations. They are the satisfactions that come from a form of human relations which lies in the province of the priest and the doctor alone. Both men play a part in the great joys and the deep sorrows of those with whom they deal. Both alike stand before the great mysteries. The doctor, like the priest, is on hand at both ends of existence and shares w'ith his patients some of the great moments of their lives. As a pediatrician I have lived through the anxious days of precarious prematurity and have felt the glow of successful accomplishment; I have kept all-night vigils at the bedside of children w'ith pneumonia before the days of penicillin, seeking and at last finding the first signs of the awaited crisis. In the days w'hcn diphtheria was a daily occurrence I have driven dangerously over icy streets to reach the hospital in time to pass a life-saving tube into the windpipe of a child apparently dead from suffocation, and have had that feeling that no one else can have in the knowledge that at such times I really saved a life. These satisfactions bear no relation to remuneration; the remuneration is in the happy outcome.
There arc sorrows, too, in the life of a pediatrician. The sorrows of having to give bad news and to help the unfortunate parents to bear it bravely. Yet in such situations the doctor is somehow grateful for the role he is called upon to play. It is a peculiar privilege to be able to share heavy burdens with the unfortunate. I once kept vigil for three days together with a Jesuit priest at the bedside of a child who, after a long and difficult and baffling illness, lay at the point of death. We were waiting with the grieving parents for the end which fortunately never came. Together we watched the miracle of recovery, and together we shared the joy of a joint achievement. We are now old friends, that Jesuit and 1. because of this common and humbling experience.
I have watched infants sick and healthy grow up into manhood and womanhood, 1 have attended their confirmations, their weddings and attended their babies. I have attended their ordinations as priests, ministers and rabbis, all with a peculiar avuncular pride. 1 have had to write sorrowful letters of condolence to the parents of children who passed through nearly fatal illnesses in infancy and who grew up only to be killed in action in the last war.
All of life, its joys and its sorrows, its pleasures and its pains are part of the existence of a doctor. How can it ever pall? How can it ever be a bore? It is an ideal life for all its hardships, yet the doctor lives it calmly and with an inner contentment. He does not flout his idealism like Ben Casey or Dr. Kildare. Such wearing of the heart upon the sleeve would be almost repugnant to any real physician. He lives his life to the best of his ability, often unaware of the part he plays in the lives of his patients. He often listens
with amazed incredulity to the praises ol' his grateful patients for acts which he never considered unusual. Yet he finds himself not only in the role of healer of the body and often too of the soul, but he finds himself also arbiter, counselor, soother and social scientist. He learns that the most rewarding part of his life is that which goes beyond his function of trying to relieve suffering and curing disease.
It is being said that because of increased opportunities in other fields— chemistry, engineering, physics and industry — the medical schools are finding it difficult to get young people to go into medicine. Let me say that all the major schools in North America still have from three to five applications for every vacancy; the same in England and the same in Europe. It is not the lure of a remunerative post or craft but the lure of the craft itself. That is why there will always be doctors, just as there will be teachers and ministers and novitiates. The call is to the calling and he who has that desire that nothing else will satisfy will become the doctor and pursue the doctor’s unique joys.
To me and to my generation there is another satisfaction in having been a doctor: my generation has grown up with and has been part of the greatest era of medicine the world has ever known. 1 was born only thirty years after the first great discoveries of Pasteur, when antiseptic surgery was in its infancy. When 1 entered McGill in 1909 there were still antagonists to the germ theory of disease. As a medical student 1 watched the ravages of diphtheria, scarlet fever, erysipelas. I saw children die of tuberculous and other forms of meningitis. The infant mortality from “summer diarrhea” was appalling and any but the simplest operations on infants were undertaken with the greatest hazard and with high mortality. Practically every sick infant on a ward had running ears and many had mastoiditis.
My generation has seen those great developments which now save lives. I he sulfa drugs, the penicillins and other antibiotics, have made the incurable curable. The knowledge which we have laboriously acquired of what happens to an infant with diarrhea has enabled us to save thousands of infants who in my early days would have died. Diphtheria has all but vanished. Scarlet fever has become a mild and curable disease. Erysipelas, almost always fatal to infants, is now unknown, and a mastoid operation today is a fairly rare occurrence instead of a daily experience. Operations of the greatest complexity are now undertaken with safety on the youngest infants' on their intestines, their lungs and their hearts.
To have lived as part of this era of medicine, to have helped to lift but a single grain of sand from the mountain of our ignorance, to be able to contemplate the great future and to regard with pride the young men and women oí genius who are opening new and undreamed of horizons, here is joy indeed. That is why it has been so good to be a doctor, and particularly a doctor for the young of the nation. That is why when I am asked if I would do it all again, if 1 had the chance, my answer is always, “Yes!” ★