To you young men, full of enthusiasm for your new profession, and imbued with Utopian ideas of the mission which you have undertaken for the good of mankind, it would seem almost foolish for me to mention this as the first advice I would offer you. But I think I can see a smile of understanding flit across the faces of those who have for some years fought the battle of life, and who have had the wire edge of early ambitions and determinations blunted by contact with unappreciative patients and unworthy professional competition and the daily incidents of a busy life. They know that it is very easy to feel too tired, or be too busy, or have some other engrossing affair in mind which prevents that entire devotion to duty which all admit is essential to success in medicine. Half of success in life or in any undertaking is due to a successful start; therefore, let me ask you to firmly determine on one or two fixed principles, and to stick to those principles through thick and thin. Be fully assured that no halfway devotion to your profession will ever bring you prominence or success. The time-worn phrase that "Medicine is a jealous mistress" loses none of its truth by frequent repetition. Recently I saw in a prominent medical journal the advice given that doctors should take a prominent part in politics and bring themselves forward in other ways, and that thereby in some way unknown to me the glory of the profession would be enhanced, and much benefit result to the community. Far be it from me to discourage a proper civic spirit and a proper interest in public affairs, or to advise an avoidance of any duty which good citizenship imposes upon every honest, patriotic man, whatever his business or profession. But I take it that no more baneful, no more dangerous advice can be given to our young professional man than this. You cannot be successful in both politics and medicine, and while we can point to one member of our profession in the United States Senate, and to some notable exceptions in our own State, where men of our profession have, for a time, abandoned medicine and returned to it to win success, you can rest assured that the medical politician possesses little beyond a musty diploma to remind the world that he was once of our cult. So don't be a halfway politician and halfway doctor. Success in either field will take all of your best effort and all of your time.
What I have said of politics will apply, though not quite so forcibly, to any other engrossing business or pleasure. Time forbids me to elaborate this idea, and in concluding it let me say that you cannot be a successful politician, merchant, sport or what not and carry medicine as a side line.
It may seem useless to remind you that, in order to give the best that is in you, you must keep abreast with what is new and best in professional literature and scientific progress. You all have determined to be students, and even those who pride themselves on having passed through the University without having opened a book have a half-formed desire to really know something beyond spotting a possible examination question, and when once examinations are over, and they have reluctantly withdrawn themselves from the delights of the city by gaslight for the pine woods and mountain trail, they will burn the midnight oil and browse diligently through their musty tomes. May I tell you that nothing is harder than to find time for study. Many of us, even though city men, with the best and latest literature at our elbows, are ashamed to think how thoroughly we abhor the sight of a medical book or magazine, and how easily we can persuade ourselves that we are too tired and stale, and so engrossed during the day with scenes of sickness and suffering that we must have our brief hours of release from duty for recreation. We do need our hours of relaxation and rest and our too infrequent holidays, and they are absolutely essential to good health and good work. Don't, however, confuse the words rest and relaxation with sloth and idleness, and don't think your professional work completed when your round of daily visits is done. Indeed, if you would know medicine you must woo your mistress in the small hours of the night, and in many of the leisure moments that the day may bring you.
Much has been spoken of the man who practices by common sense, and whose school has been that of observation and hard experience. A most worthy brother he is at times, and many are his friends and wonderful his success. But if the science of medicine is to advance, more is required for progress than mere common sense, and observation untrained and experience undirected and unguided by the observation and experience of others will rarely discover a new bacillus or elaborate a side chain theory. So, to be truly ethical in the duty you owe to give the best that is in you, you should be reading men. Take one or more of the medical journals. Buy for reference the latest and best text-books. Make the opportunity to read the daily papers and something of current literature. A well-rounded man can afford to do nothing less. Besides the information you obtain, it pays in the respect of the community to have the reputation of being posted in your profession. Often the country man simply hasn't time at home to read. A busy life, with its miles upon miles of dusty roads to travel, precludes all chance for the easy chair. Then cultivate the habit of reading while driving. Many are the useful and happy hours I have spent in my carriage with my journals and magazines. I am frank to say that, but for this habit, I never could have found time for one-half of the reading I have done. Last year I was somewhat amused when a most worthy, well-educated and well-posted man summed up his opinion of another by saying that he was one of those who read magazines in his carriage. If I mistake not, this indictment was brought against the late Dr. Miltenberger, who as a young and busy man was forced to form this habit, and I could but think that, could I die with half the honor and respect and love that were his, I could plead guilty to even this mark of devotion to my profession and desire to advance in it.
Would you be ethical in giving the best that is in you to your patients, you must give ungrudgingly of your time. This may again seem a useless piece of advice, and yet almost all of us are familiar with the man whose motto is "Veni, Vidi, Vici"--"I came, I saw, I conquered." This intuitive diagnostician is by no means a myth. The man who comes in a rush and goes in a rush, and who, with pencil in one hand and prescription pad in the other, feels the pulse while the thermometer is under the tongue; who sees at a glance, without necessity of personal or family history or of physical examination, just what is the matter, and who, giving four or five prescriptions, rushes out, trusting that something in his shotgun therapy may hit the enemy. Perhaps the next day he prescribes four or five more remedies or combination of remedies, and should the patient begin to improve, prides himself that he has made and confirmed a diagnosis by his experimental therapy. Is it necessary for me to say that no ethical man with any regard for the rights of his patients and his obligation to his profession can really practice medicine in this manner? The plea that you are too busy to give the proper time to your cases is no justification for your neglect. Anything less than a careful inquiry into family and personal history, followed by a painstaking and thorough physical examination, is unjust to your patient and unjust to yourself. No ethical man can give the best that is in him by doing less than this. If you haven't the time to do your work thoroughly, make a clean breast of the matter and take fewer cases. But you will say that a man, even in large practice, cannot afford to give any of it up. He needs every dollar that honestly comes his way, and to say that he hasn't time for his work is only another way of throwing practice into the hands of a rival. This is, indeed, a proposition hard to solve, as most of us do need every dollar that honestly comes our way; but if our work is only half done, if we have neglected some important point in diagnosis, and thereby omitted some equally important measure in treatment, have our dollars been honestly earned? Let us start out with and carry in mind this axiom of a truly ethical life, that success in medicine cannot be measured by commercial success; that, while no sensible man can neglect the business side of his vocation, or refuse to demand and collect just compensation for his service, such compensation cannot be measured in dollars and cents alone; that a good conscience and whole-souled devotion to duty, giving ungrudgingly of the very best that is in you to those that have confided in you, will be your very best asset when the final account is made up.
May I impress the fact upon you that an ethical man, with a just appreciation of his duty to his patients, can never be a vendor of patent or unofficial medicines. Indeed, I would be lacking in my duty if, with the opportunity this paper offers me, I did not, from the standpoint of experience, impress upon you with all of the force at my command the necessity of being wary of the detail man and the alluring advertising literature with which your mail will be flooded. You will scarcely have opened your office, and be waiting with what patience you can command that rush of the halt, the lame and the blind to which you feel that your talents entitle you, before the suave detail man, having heard of the new field, puts in his appearance. What you lack in therapeutic experience he can supply you by drawing liberally on the experience of others who have worked little less than miracles in an adjoining town by the use of his pills and potions, his elixirs and tinctures. You will find him smooth and oily, placid and plausible. He knows his story well, and even by his much speaking can almost persuade you that what you knew, or thought you knew, or what you had recently been taught, were all out of date; that by some stroke of genius the chemist of his house had discovered some way by which compatibles would combine with incompatibles into the formation of a new and staple mixture, possessing all of the virtues and none of the defects of its original constituents, rendering chloral as soothing as the strings of a lute and as harmless as the cooing of a dove, extracting from cod-liver oil every disagreeable feature and leaving nothing but its supposed virtues behind. He will show you the short road to fortune and success. Treat him kindly; the ethical man should not be rude, and brusqueness is not a sign of Roman honesty or virtue. Be assured he feels his position keenly, and is dreading the catechism which will sooner or later display his ignorance of everything but the story that has been drilled into him like a parrot.
There has been no greater shame in our profession than the influence these men and their houses have exercised, and incidentally the indorsements and recommendations that thoughtless men have furnished them. The blame is all ours, and we cannot shun it. We pride ourselves on our scientific attainments; that we take nothing for granted; and, now that the age of empiricism has passed, we accept nothing that does not bear the stamp of scientific approval. And yet, before the campaign of the American Medical Association and the revelations of Collier's and the Ladies' Home Journal, we accepted our treatment from the hands of the manufacturing houses, and dosed our patients with nostrums about which we knew nothing except the statements of those whose sole purpose it was to sell. There are few of us who have been many years in practice to whom a blush of shame does not come at the recollection of our gullibility and our guilty innocence. Can any man deem it ethical to give even to a good dog something about which he was totally ignorant? And yet this is just what we were doing. A short time ago a particularly shrewd detail man was discussing this very point with me, and claiming that, as the formula was now required by law to be printed in each bottle and package, this most formidable objection could not now hold good. Handing me a bottle of his patent cure-all, he glibly called my attention to the six or seven ingredients, with the amount of each contained in the fluid ounce. Among other potent quantities I can recall 1-48 gr. of morphia and 1-240 gr. of strychnia. The dose was a teaspoonful three times a day. Any man can imagine the more than homeopathic effect of 1-48 gr. of morphia divided into eight doses. These well-known and well-tried drugs were not, however, the life of the nostrum, and presently we came to the twenty minims to the fluid ounce of the fluid extract of the drug from which the remedy derived its name. Something I had never heard of. Something unlisted in the U. S. P. Something discovered and owned and controlled by this house alone. As my ignorance became more apparent his eloquence increased, and I have no doubt that a few years ago, before my moral conscience had become aroused to the therapeutic sin of prescribing something whose botanical family, whose chemical formula, and even whose physiological effects were totally unknown to me, I would gladly have accepted a sample and would have tried it on some poor soul too poor to pay for a prescription. It is nothing short of a shame to think of what we have done in this line. The sin has been one of carelessness and laziness rather than of ignorance. Here we had ready to hand some remedy, beautiful to the eye, palatable to the tongue; then why take the time and trouble to bother about constructing a formula of our own when someone else of equal experience had constructed one for us? I am ready to thank God that most of these nostrums are as harmless as they are beautiful, and, while I may not have done good, I rarely did harm by their use. I am not discussing the opium and cocaine laden classes. I wish to emphasize incalculable harm that must result to the physician himself who allows someone to do his thinking for him. I am also referring to the attitude of the ethical man to his patient, and beg to ask if we are doing even part of our duty when we are doing no harm. Allow me to conclude this topic by asking you to spend an hour some day in casually glancing over (a deep study would fully repay you) the pages of the U. S. P., or a list of the remedies that have in one year received the sanction of the Council on Pharmacy of American Medical Association. If you don't find enough drugs and combinations to meet every case and every conceivable situation, you had better desert practice and exploit some wonderful cure-all as a detail man.
If we, as physicians, had nothing but our duty to our patients to consider, and incidentally our own profit and glory, the practice of medicine would soon degenerate into a mere trade. I may even say that, had we nothing but the promptings of our consciences to keep us in the straight and narrow path, if we had nothing but the knowledge of work well done, and if the desire and determination to give the best that is in us were our only incentives to an ethical life, the profession would be so beset by the temptations of commercialism, and the notoriety and prominence which commercial success brings, that the halls of Esculapius would soon need a scouring and purging greater than Hercules gave the Augean stables. Despite the high incentive to all that is best and purest in life which our noblest of callings should beget in us, physicians are only human, and human weakness, like disease, is no respecter of persons or of callings. It may have been that the medical fathers, with a knowledge of the temptations to which they were subjected, and a desire to save others from the pitfalls which beset their paths, were imbued with a determination to place their profession on a higher plane than others; or it may have been the natural evolution which inevitably resulted from and followed the promptings of man to help his fellow-man, to devote himself to the relief of pain and sickness, to sacrifice his comfort and ease and almost every pleasure in order that others might have ease of body and peace of mind and soul, which from the earliest days have placed medicine as a profession apart, and have imposed upon those who have entered its ranks certain standards of conduct and insisted on certain ethical relations which have lifted it above mere questions of gain and the vain acquisition of renown. We have been taught that Hippocrates himself was great not only as a physician, but greater still as an ethical teacher who has left with us certain maxims and proverbs which, though handed down through the ages, have lost none of their truth and none of their spotless morality. Even in the Middle Ages, when learning, not to say science, had sunk into such an abyss of ignorance that the ability to write one's name lifted one into the ranks of the educated, when human ills were relieved more often with the sword than with the scalpel, the leech was a man apart. His education, his scientific investigations, and even his supposed communion and partnership with the evil one, placed his on a pedestal above other professional callings. Then, as now, though men might scoff at our profession of superior knowledge and skill, when "pallida mors" stalked abroad or knocked at the hovels of the poor or palaces of the rich, all arose to call us blessed. It has been often said that, could a medical man live up to the ethical standards of his profession, his chances without creed or priest would not be small at the last great day. But with all of our high ideals we are only mortal, and we know and have sorrowed at the fact that many of our ethical standards are not lived up to, and that the Hippocratic law is frequently more honored in the breach than in the observance.
We have in every community where one or two are gathered together in the name of medicine the man who is everything to your face and everything else behind your back; who damns by faint praise; who sympathizes with you in your sorrows and trials, who visits the family of the patient you have lost to assure them of your skill and to insist that everything was done that could have been done, "but"----and that one harmless little conjunction, meaning nothing in itself, is more eloquent than a thousand terrible adjectives or burning, blistering adverbs or participles. So many things can be said by the pious uplifting of the eyes, the sanctimonious upturning of the palms. He would not for the world leave a doubt in the minds of your people, and, no matter what in his inmost heart he thinks of your mistakes (from his standpoint), it is not his place to injure a brother, but, alas! he is not responsible for the unguarded tongues of his friends, and he usually sees that they do his work well for him. Often it is "if I could only have reached him earlier," which, being interpreted, means a miracle would have been wrought. Almost every community has its miracle worker, its medical resurrectionist. His cases are always a little worse than others, his victories a little more wonderful. Where you have a bronchitis, he has a desperate pneumonia, your transitory albuminuria is with him acute Bright's, and hopeless cases follow him to undo him, only to meet defeat at his skillful hands. You hear that Mr. A. is desperately ill with pneumonia on Monday, and on Friday you meet him on the street, looking hale and hearty, firmly believing that, had Dr. X. been one hour later in reaching him, he would ere this have been gathered to his fathers. Should you mildly suggest that some error in diagnosis might have been made, that even the best of us at times go wrong, and that resolution in true pneumonia could hardly be expected in four days, you will find that he has been prepared for you, feeling that Dr. X. has used some potent remedy as yet unknown to you and his less skillful brethren, and firmly convinced that your suspicions of his case are based upon your ignorance or your jealousy of poor Dr. X., who was not there to defend himself, who had always spoken so kindly of you, and had uttered nothing worse than the harmless little conjunction "but"----
A little bragging is not a sin, and indeed is usually harmless, and in the long run reacts on the miracle worker. But the ethical man does frequently suffer from it, and it is a fact, absurd as it may seem, that the average man or woman would much prefer to be considered at death's door about three-fifths of the time--indeed, almost a walking Lazarus--than to be deemed the picture and personification of vigorous health. Dr. X. knows this, and plays upon the credulity of his patients. He frightens them to death's door, works a miracle, and has tied them to himself forever. We all have suffered from this, and will continue to do so until the little grain of truth has grown from the tiny mustard seed to the vigorous bush. Dr. X., with his faults, has his virtues. He aspires to be the busiest man, the richest man, the most popular man in his community. All of these ambitions, if properly guided, are laudable, and, indeed, while enhancing his power and prestige, may be redounding to the good of his people, for a man to be the busiest and most popular man in his profession must usually be the best posted, the most highly educated, the hardest working man, not only for himself, but for those he serves. So, while we may smile at Dr. X. and his big ways, we may love him for his virtues and forgive his small faults.