THE TEACHING OF THE SPECIALTIES.
By Hiram Woods, M. D.
Read Before the University of Maryland Medical
Association, April 21, 1909.
Teaching specialties to undergraduates must be carefully separated from the same teaching to post-graduate students. The latter may be supposed to have given such thought to their future career as to have reached the conclusion that they wish to devote themselves to a certain line of work. It is not these men whom I propose to discuss, save to say, in passing, that the average six weeks' or two months' course offered by post-graduate schools is totally inadequate. As a rule such courses attract a large number of men who do little more than follow the clinical work of some well-known specialist and pick up what they can. Either prolonged hospital experience, as interne or clinical assistant, or a special individual course, with a competent teacher, is needed for a decent foundation in special work.
It seems to me that with undergraduate work the first important step is to secure the attention of the men, and convince them that there is something in the special course worthy of notice. There is a state of mind, not unnatural to the undergraduate, regarding specialties. Most of them propose to begin professional life as general practitioners. They think they will never have use for knowledge in the so-called specialties, and that the little they will need in order to get a passing mark can be easily crammed at the close of the session. As a matter of fact, it is easy to frame questions so that this “crammed” information is of little use, and the most liberal grading hardly ever brings such men up to a passing mark. The mental attitude of these men is unjust to themselves, their teacher and the patients who, in the near future, will entrust to them their physical welfare. The very term “general practitioner” implies a general knowledge of medicine. If one lives in a city, where the services of specialists are readily obtained, he may, if he desires, refuse certain cases, and take only such as he wants—say such as belong to internal medicine. But in so doing he becomes a specialist himself, and if he has neglected a properly prepared special course for undergraduates while a student he will miss information of great use to him as an internist. Many men, however, do not practice where specialists are easily obtained, and, perforce, must take cases which would logically come under one or other of the recognized specialties. Here is a professional responsibility which it is the aim and duty of a special teacher to enable his student to meet. May I illustrate by directing attention to two troubles which it is my own privilege to explain to our students? Iritis, in eye, and acute otitis media, in ear diseases, are very common troubles. Both are, as a rule, readily diagnosed, and both offer good prognosis. Yet the responsibility for eyesight in one, and may be life in the other, may depend on the diagnostic ability and therapeutic resources of the man who first sees the case. Men are blind and children dead because a general practitioner has not known enough of what was offered him when a student to make a correct diagnosis. The red eye has been called conjunctivitis and treated with nitrate of silver, in spite of the absence of purulency, while the small, inactive pupil has escaped notice. The ear pain has been called “earache” without an aural examination, a hops bag and opium have been ordered, and the doctor has gone home with that false sense of security which is so dangerous. Why? If his teacher has known his business, it is not because he was not told how to look for iritis and acute inflammation of the drum, but because he had not given the subjects sufficient thought to get them drilled into his thinking apparatus. Probably he could tell the diagnostic points of iritis, if asked, or the signs of ear-drum inflammation; but this was “crammed” information, not part of his real knowledge.
If it is the duty of the student, anticipating general practice, to think about the specialties taught during his undergraduate course, it is still more the duty of his teacher to present him only such things as the general man needs. He will make a grievous blunder if he tries to make specialists of his men. His selection of subjects should be limited to the diseases which are of common occurrence, and stress should be laid on diagnosis. If one knows, first, what to look for, and secondly how to recognize signs and symptoms, he will generally find proper treatment. Troubles which would lead the patient to go to the specialist primarily, without consulting his family physician, should receive little attention.
Two other classes of lesions in such organs as are usually handed over to specialists should receive attention in the undergraduate course—those which are apt to cause remote or reflex disturbances, and those which are definitely symptomatic of central lesions. The first should, in my judgment, be dwelt upon only to such an extent as to enable the student to know causative relation and method of diagnosis. Treatment, unless very simple and easily within the reach of the medical man—i. e., the general practitioner—should be given little time. As to the second class, every neurologist knows that Tabes Dorsalis would often be diagnosed early, and proper treatment instituted, if the physician had known the meaning of association of gastric crises with Argyll-Robertson pupil, and had seen enough of these things to have them in his every-day thoughts. One could present many other illustrations, but this shows what is meant. With the student convinced of the necessity of thinking about the specialty taught, the instructor careful in selection of his subjects, a duty rests on those who fix the curriculum.
It is unfair to students to use four years for work which can be done in three. I believe that the object of the establishment of a four-year course was to furnish a year in which students, freed from the responsibility of examinations, might have time for guidance in clinical observation. The ideal plan, in my judgment, is to get rid of didactic lectures and examinations by the end of the third year, and to devote the fourth to clinical observation. Genito-urinary work, gynaecology, rhinology, neurology, ophthalmology, otology, cannot be learned from text-books or lectures, at least in such a way as to become integral parts of a man's daily thinking. And to my mind this is the only special information which will help the general practitioner in his daily work. A few hours spent in a large clinic brings more instruction than a whole year of lectures. The personal contact of man to man, the exchange of thoughts and impressions, are what sink in. A student is not to be blamed if he fails to attend these opportunities when he knows that in a few weeks he must face the ordeal of examinations on the didactic work, and that the result of these will determine his graduation. To put into a few words my idea of teaching specialties—it is the duty of the student to realize that nothing is put into the undergraduate course which is not important to him; it is the duty of the teacher to select only what is important to the general practitioner; it is the duty of the school authorities to so arrange the curriculum as to give students enough time to observe special practice personally, in small sections, so that what is taught may be so impressed by observation as to become a real factor in their medical thought.