University of Miami Miller School of Medicine
FROM AN OUTSIDER'S PERCEPTION TO AN INSIDER'S INSPECTION: A LAYMAN'S ENCOUNTER WITH MEDICAL EDUCATION ¹
The honor which is accorded me by Henry Lemkau's invitation to deliver this afternoon the Biennial Gross Lecture is exceeded only by my appreciation of it. I am honored also by the presence in the audience this afternoon of Mrs. Ruth Gross, as well as the distinguished anesthesiologist and humanist, the Dean Emeritus of the University of Miami School of Medicine, Emanuel Papper; and his successor, the present Dean of the School, Bernard Fogel, a member of the Department of Pediatrics when I became president of the University on July 1, 1962. I will not comment on whether or not pediatrics is a more or less appropriate discipline than anesthesiology from which to draw the presiding officer of a medical school. Knowing something of the egocentric force generated by medical specialists that in turn can produce centrifugal force within the organization, I suggest that pediatric psychiatry might be the best training of all for a prospective Dean.
Mentioning medical school administration reminds me of the old bromide I sometimes used in my talks on the Medical School campus. I would speculate about the death of the President of the University of Miami and his going to his ultimate reward, which was Hell. His Satanic Majesty, while interviewing the new arrivals to determine their eternal assignments, noticed that Stanford had had university administrative experience. Then he asked Stanford about taking on the presidency of Hell U. Stanford replied blithely that he could handle that job, having been President of the University of Miami for nearly two decades. To which the Devil responded pointedly: "But Dr. Stanford, you don't understand! Hell U has two medical schools."
At any rate, I am deeply grateful to Mrs. Gross and my colleagues, Drs. Papper and Fogel, for their presence here and to all of you who have interrupted busy schedules to attend this lecture.
The preparation for this talk has not been without its discomforts. With me the pregnancy of a speech has always been more stressful than its delivery. Now you can all relax, sit back, and prepare for a natural delivery.
From my earliest memories onward through my childhood, medicine possessed an aura for me. It was held in such high regard by relatives on both my mother's and father's sides. My maternal great-great-grandfather, Thomas Clopton, was a doctor. As a 14-year-old, he saw service in the War of 1812 and then, following study of medicine somewhere and somehow in Virginia, packed a young wife behind him on a horse and rode down to middle Georgia. There he practiced medicine for several decades until his wife died and he married for the second time a young woman 18 years of age. The age discrepancy between the 62-year-old doctor and the young bride left the family so aghast that he moved to Southwest Georgia, Sumter County near Americus, to practice the rest of his life. He died in 1876, but his widow lived on into the 1920s, when she was one of three women living at that time drawing a pension from the War of 1812!
The other doctor in the family was Herod King Stanford, my great-grandfather. Can you imagine naming a little baby Herod? Anyway, this ancestor-studied medicine in what was then the Medical Department of the University of Georgia in Augusta, did some post-graduate study in Philadelphia, and eventually practiced for many years near Columbus, Georgia.
The pride expressed by the family in the professional achievement of these two forbearers placed medicine on a pedestal in my young mind. It surely was the noblest of the professions, even exceeding education, law and theology, because the efficacious results of medical practice, when it worked, were so evident. Some patients did get well!
Aside from the usual inoculations of those distant days, my first brush with medical practice I recall vividly was occasioned by a broken arm that had to be set three times! The first setting in a small town east of Atlanta did not seem to be properly done. About three weeks later an Atlanta doctor broke it and reset it without giving me any anesthesia. You can imagine how well I remember that procedure. Finally, because the fracture was not knitting properly, two orthopedists came to the house, administered ether, and set it the third time and that time correctly.
My next encounter with the medical profession was the time at six years of age I had to have an "onion" removed from my left groin, as I told all the children in the neighborhood. At least that's what I thought the doctor said he was going to do. Actually, I misunderstood the word "hernia" for "onion." The operation took place in the Davis Fisher Hospital on July 15, 1922. The hospital now is the Crawford W. Long Hospital, an adjunct of Emory University School of Medicine. Of course, the hospital is named for the doctor all Georgians think first used anesthesia in a medical procedure.
Mr. Lemkau, with this lecture I am giving you a copy of the Davis Fisher Hospital record for July 15, 1922, as Appendix A. In those very simple and less informed days, the entry contains only five lines: Master Stanford; Surg., Dr. Person; Asst., Dr. Weaver; Anes., Dr. Yankey; Nurse, Miss Player; Oper., Left Herniotomy."
During those early years I used to visit my mother's uncles down in Putnam County, Georgia. Hanging on the wall of one of the farm houses was a picture entitled "The Doctor," an idealistic portrayal of a doctor sitting beside a young female patient looking intently at her, while in the background the mother has buried her head in her arms in despair, while the father is standing trying to console his wife with one arm as he looks intently at the doctor and his daughter. It was a picture of utter professional devotion. Every time I looked at it, the medical profession rose in my estimation. A copy of it is attached to this lecture as Appendix B.
As a boy I sold the Saturday Evening Post during the late 1920s in Atlanta. One cover by Norman Rockwell showed an elderly practitioner breaking the ice with a nervous child-patient. The girl has just arrived at the office with her doll. She obviously is very worried. The kindly doctor sets her mind at ease by placing his stethoscope against the doll's chest! Rockwell's painting is surely a sympathetic treatment of the medical profession. A copy of the Rockwell painting is attached to his lecture as Appendix C.
Finally, the illnesses of my father and sister made a deep impression upon me. When I saw my father in the hospital two days following a mastoidectomy, he was cheerful. Two days later he was gone, the victim of bacterial meningitis, I suppose. The doctors had done their best, but they could not cope with the resulting spinal infection in the days before antibiotics. On the other hand, my sister, seven year later, succumbed to osteomyelitis, but the valiant doctors made a new serum from her own blood and inoculated other parts of her body. In spite of 15 or more surgical procedures over the years, she is alive and well and happy today.
Those were my experiences with medicine on the outside, so to speak. Now let me begin a series of observations of medicine from the inside.
My first direct encounter with formal medical education came in the late Fall of 1939, when I was working on my Masters degree at Emory University in Atlanta after having taught two years, on my return from the University of Heidelberg, Germany, at Emory Junior College in Valdosta, Georgia, 1937-39. I decided to drop by the gross anatomy lab at the Emory Medical School. Mainly I was interested in seeing some of the students whom I had taught in Valdosta and who had entered the Emory Medical School in Atlanta. When I opened the door to the anatomy lab, I was confronted with a dense haze of cigarette smoke. In those days cigarette smoking was pretty well accepted by young men as a rite of passage, a kind of ticket to adulthood, a macho display! Never having smoked, I was appalled at the near universality of the custom among medical students, but even more appalled when I noticed here and there that the nose bridges of the cadavers were being used as cigarette holders! That observation rankled, but did not shake the higher ground which the medical profession held with me. The real introduction to medical education was yet to come.
I became Assistant Chancellor of the University System of Georgia in January, 1952. By then the Medical College of Georgia was no longer, as the name implies, the Medical Department of the University of Georgia in which my great-grandfather had studied, but was a completely separate institution. It enjoyed university status and reported directly to the Board of Regents in Atlanta. At a meeting of the Board of Regents in February, 1953, Regent Roy Harris from Augusta proposed suddenly: "I move that we send Henry over to Augusta to look into the problem at the Medical College." One Regent responded to his proposal with this: "What in the hell does Henry know about medicine?" To which Roy Harris blatantly replied: "Not a God damn thing; that's why I want him to go!"
I have always been intrigued by the philosophical implications of Regent Harris' statement. He seemed to be denying the old saw that "it takes one to know one." My answer to that has always been: "You don't have to be a skunk to smell one." Mr. Harris summarized rather pithily something young people have demonstrated to me on a number of campuses since that time. I call it "the advantage of inexperience." Every generation of young people has said to me something like this: "Don't tell us it cannot be done. We have not tried to do it." It is this fresh approach, the new way, the oblique think, that has turned human thought toward new directions that have in turn led to new discoveries. Professor Thomas Kuhn, Professor of the History of Science at MIT, has given any new approach the sophisticated name of "anti-paradigm." This refers to new thinking that challenges the accepted view or paradigm and eventually establishes a new position or a new paradigm out of an anti-paradigm.
Let me hasten to say that age does have an advantage: I cannot afford to knock it now! Age builds up experience which leads to knowledge which can lead to wisdom, but it can also lead to mindset. Perhaps it is best exemplified in this phrase: "If I have not done it, it cannot be done!" The contrast between oblique think and mindset was brilliantly described on the Coral Gables campus of the University some years ago when Paul Dirac, the greatest physicist of the 20th Century after Einstein, gave an autobiographical lecture. If I remember correctly, Dirac insisted that by all rights Heisenberg should have discovered the Theory of Quantum Mechanics, but he, Heisenberg, was resting so comfortably upon the plaudits he had already received from the world of physics, that he was hesitant to take the next brash step in his thinking that would have brought him to quantum mechanics. Dirac, as he said about himself, did not have any reputation to lose; in other words, Dirac had the advantage of inexperience and proceeded to win a Nobel Prize for his anti-paradigm that became the new paradigm of the physics establishment.
The problem at the Medical College of Georgia, which Regent Harris wished me to look into, was the relationship between the Medical College and the new Talmadge Memorial Hospital under construction that would contain 700 beds: How was it to be coordinated effectively as a teaching hospital with the Medical College of Georgia?
Thus the problem the Regents faced in Augusta was one of coordination. The Hospital was to report to the Georgia State Health Department and not to the Board of Regents; yet the Medical College of Georgia, a unit in the University System of Georgia supervised by the Regents, wished to use the Hospital as a teaching hospital. My assignment was to evaluate the relationship and make recommendations to the Regents for administrative coordination between the College and the Hospital.
In preparation for my visit, I went to the library at Georgia State University to browse through some books on medical education. There I found Abraham Flexner's remarkable report on medical education in the United States and Canada, 1910, that he prepared for the Carnegie Foundation. It was one of the most revolutionary studies ever made of any facet of American education. Beginning in the 18th Century and continuing well into the 19th, medical education consisted mainly of proprietary schools with all their excesses toward greed and profits. I learned that various reforms were attempted during the 19th Century, but they were unsuccessful. In 1893 Johns Hopkins beat Harvard to the gun by establishing the first medical school in America of genuine university type: It actually required a Bachelors degree for admission! Harvard, under President Eliot, had affected a series of reforms that began with the grading of the existing course and ended in 1901 with the requirement of an academic degree for admission.
In the Medical Department of the University of Georgia at Augusta, as the Medical College was known in 1910, admission requirements were far below those for admission to the undergraduate college in Athens. In his report, Flexner urged complete "amputation" of the Medical Department from the University of Georgia. The Department, he asserted, "could not long survive such surgery." And this was the institution where my revered great-great-grandfather Stanford had studied medicine! As a result of Abraham Flexner's report in 1910, hundreds of medical schools in the United States had to close, and a genuine movement to reform American medical education was launched.
During my earlier assignment as Director of the University Center in Georgia, a consortium of universities, I had met the personable Robert M. Lester, Secretary of the Carnegie Corporation, which was one of the sources of support for the Atlanta consortium. When Lester heard that I was planning to go to Augusta to look into the Medical College, he alerted his long-time friend, Abraham Flexner, of my assignment.
On March 3, 1953, Abraham Flexner wrote me the first of several letters dealing with my new assignment. He was insisting from the first letter that I make plans to visit "the new generation who are advancing medicine at institutions like the College of Physicians and Surgeons of Columbia University and the University of Rochester Medical School." Also, in that first letter he said he was sending me a copy of his subsequent study, Medical Education, A Comparative Study. Between March 3, 1953, and June 30, 1953, Abraham Flexner and I exchanged three letters each. I am happy to present Henry Lemkau with copies of these letters this afternoon as Appendix D for the Calder Library. Also, I wish to place in the Calder Library this copy of Medical Education, A Comparative Study, that Flexner inscribed to me. I did not get to meet Abraham Flexner as I had hoped soon after our correspondence began, because the Regents interrupted my assignment in Augusta to send me as President to the Georgia State College for Women, beginning July 1, 1953, to save it as a women's college. It was mission impossible, but that is another story.
On my arrival in Augusta, I went to see the President of the Medical College, Dr. Lombard Kelly. Dr. Kelly's medical discipline was reproductive physiology. He had served as a research associate in the Department of Anatomy at Cornell University with Dr. Papanicolau, whose name I was to encounter so forcefully in my career as President of the University of Miami. In fact, Dr. Kelly and Dr. Papanicolau worked together at Cornell. Dr. Kelly suggested that I drop in to see various departments.
Taking his advice, I picked an anatomy class as the first activity to visit. There was not the smoking I had seen 15 years earlier in the Emory anatomy class, but I did notice something that seemed quite unusual to me: a torrent of water running down the wall from the ceiling above. When I inquired about it, the professor said fairly nonchalantly: "Oh, they are just hosing out dog surgery upstairs." What miserable facilities I thought! Then I was to discover during that first visit that somehow inadequate facilities had not prevented the Medical College from recruiting some top-flight professorial and research talent. I think back on that experience in the Medical College of Georgia anatomy class and realize that it was a harbinger of what I was to find nine year later when I arrived at the University of Miami and visited its School of Medicine for the first time.
From anatomy I went over to pathology. While I was talking with Dr. Edgar Pund, Chairman of Pathology, the telephone rang. He excused himself to take the call. Then I began to look around the office and discovered several bottles containing tissue of some kind.
When Dr. Pund completed his telephone conversation, I inquired as to what the tissue was in one particular bottle. He exclaimed: "Oh, that's a uterus." When I said I assumed it was pathological, he said: "No. There's nothing wrong with it." Then I asked him why he would have it in the Department of Pathology. He exclaimed: "I take this healthy uterus around to illustrate talks I give before medical societies. I want the physicians to see what a healthy uterus look like, so knife-happy have some of them become!" In fact, less than a week ago The Atlanta Constitution, April 23, 1993, ran a first-page story announcing that "an estimated 349,000 unnecessary Caesarean sections were performed across the nation in 1991 at a cost of one billion dollars, health officials said Thursday."
My memory jumps forward to a time years later when my sister telephoned me from Atlanta that an ophthalmologist there had just diagnosed her condition as a severe case of cataracts and that they should be removed immediately. I persuaded her to fly down to Miami so that Ed Norton could examine her eyes. His conclusion was 180 degrees different from that reached by the Atlanta ophthalmologist. He told my sister she would not need an operation for a number of years and then Dr. Norton telephoned the Atlanta ophthalmologist to say he had misdiagnosed my sister's condition and that Norton was referring her to an ophthalmologist at Emory University, a graduate from our School of Medicine, here in Miami.
Was my illusion about the medical profession, influenced by the experiences of my childhood and youth, now being turned into disillusion by adult experiences? No, it was not, but I was beginning to wonder about the ethics of the profession!
From the Pathology Department at the Medical College of Georgia, I went over to Endocrinology, and there I met an engaging and brilliant physician, Dr. Robert Greenblatt. Again, the physical facilities were miserable compared to what I thought it might take to attract and retain such an intellect as Greenblatt. He had interrupted his examination of a patient to come into the adjoining office to speak to me. He told me that he was treating a patient who had been discovered eight years earlier to be a false hermaphrodite. He showed me a picture of the person taken in the nude at that time when the individual was 12 years of age. There was an obvious clitoris, but no penis and no visible testicles. He said that the person had been born with some of both male and female organs. Then he asked me to don a white coat, saying I was a "doctor," and escorted me into the examining room. A pretty young auburn-haired woman was lying on the examining table. Dr. Greenblatt announced that "the doctor," referring to me, wished to see her breasts. I tried not to look embarrassed as she sat up, lowered the sheet, and exposed two well-formed breasts. Then Dr. Greenblatt told her that I wished to see the groin area. There I discovered a small incision in each groin and asked what they were. Dr. Greenblatt exclaimed: "These incisions represent my removal of the undescended testicles." He also said that he had refashioned the larger than normal clitoris into normal size.
When we returned to his office, I asked Dr. Greenblatt why he had chosen to turn the individual into a functioning female. His quick answer was: "Because she had the urinary tract of a woman, she always went to female restrooms and thus was psychologically oriented to be a woman." Then I asked the inevitable question: "Could you have turned the individual into a man?" Dr. Greenblatt was so excited at that question that he jumped straight up into the middle of the floor and exclaimed: "Yes I could have fashioned the vulva into a scrotum and drawn the undescended testicles down into it, resectioned the urinary tract through the penis, and I would have had a functioning male." The only purpose in this narrative is to point out what tremendous talent I found in endocrinology, again amid very inadequate physical surroundings.
From endocrinology I went to meet the Chairman of Medicine, Dr. Vergil Sydenstricker. Hematology and nutrition were Dr. Sydenstricker's fields of interest. While an intern at Johns Hopkins, he developed the system of blood transfusion that eliminated the need for direct transfusion from donor to recipient. In 1922, I learned, he published the first case report on sickle cell anemia with autopsy findings. In the 1930s and 1940s he focused his research on nutrition and vitamin deficiency diseases. He demonstrated the effectiveness of nicotinic acid in prevention and cure of pellagra.
Meeting such outstanding practitioners on that first visit helped strengthen the illusion I had formed earlier, in spite of the fact that it had been challenged by the Flexner report and Dr. Pund's observation.
When I became President of the University of Miami on July 1, 1962, I wasted no time in meeting my new colleagues in the School of Medicine and learning of its status in medical education. What I found was both pleasing and disappointing. I was tremendously impressed with the outstanding talent in a number of fields already at work in the School of Medicine; yet I was shocked over the inadequacy of so many facilities. I learned that the first two years of medicine were being taught in the servants' quarters of the Biltmore Hotel in Coral Gables and that the clinical offices and laboratories near Jackson Memorial Hospital were certainly inadequate for the most part. Some professors were examining patients in "cottages," a euphemism for shacks. But again, as at the Medical College of Georgia, I found that the institution had assembled an array of teaching, research, and clinical talent.
Listen to the names of some of the distinguished professors who were also researchers and practitioners as well: Peritz Scheinberg, Chairman of Neurology, whom I had actually taught at the Emory University Junior College at Valdosta during the period 1937-39; Edward W.D. Norton, Professor of Ophthalmology; Harvey Blank, Professor of Dermatology; Bill Anderson, Professor of Pathology; Victor Politano, Professor of Urology; William Deichmann, Professor of Pharmacology; William Cleveland, Professor of Pediatrics; Ryan Chandler, Professor of Otolaryngology; and Rafael Penalver, Director of the Continuing Education program for doctors who had migrated from Cuba to the United States after the Castro Revolution. I realize that it is invidious to mention some names when I may be leaving out others, but I do want to emphasize the quality in the School of Medicine I discovered amid facilities that were far from adequate for all departments.
Some incidents from those first years linger vividly in my memory. In August, 1962, the young ophthalmologist, Dr. Edward W.D. Norton, came for a conference in my office on the Coral Gables campus. By the way, I never referred to the Coral Gables campus as the Main Campus. I always insisted that the main campus was wherever I was at the moment! Ed Norton looked at me seriously during that first interview and said that his goal was to develop a world-famous department of ophthalmology within a few years. I was somewhat startled by the young man's vaulting ambition for a department in an institution that was not quite 10 years old! I was enthusiastic about his goal and offered to assist him, not in professional ophthalmology but in professional mendicancy!
And that opportunity came two or three years later. I received a telephone call from Mrs. Emily Vance of Coral Gables, a member of the Colonial Dames. It so happened that she and I had discussed earlier her Uncle Edgar Shipp whom I had met in Americus 14 years before when I became President of Georgia Southwestern College. Her cheerful voice rang out over the line: "Dr. Stanford, I have a Colonial Dame friend in Palm Beach who would like an appointment to have her eyes examined in your Department of Ophthalmology, but the schedule is so crowded there that she is thinking of not waiting, but going somewhere else." She said her name was Mrs. Anne Bates Leach and she was from Georgia. She wondered whether I had ever met her. My quick response was that Mrs. Leach had taught me Sunday School in the St. Mark Methodist Church at Peachtree and Fifth Streets in Atlanta. Ed Norton was able to see her fairly soon.
In several months I went up to Palm Beach to take her out to lunch. When the waiter came to take our order, he asked what we wanted to drink. I said that I would like a "Pink Squirrel." Mrs. Leach's eyes widened. When I told her I thought she would like one, she agreed to test it. One sip, and she was sold on a Pink Squirrel. From that moment on her interest in the Department of Ophthalmology quickened and eventually, of course, she gave the department more than $5 million.
One of my earliest experiences was to meet with the Executive Committee of the Dade County Medical Society. I discovered then the tension that existed to some degree between the private practitioners in the community and the professor-practitioners of the School of Medicine faculty. At that time the Medical School did not have a professional income plan centrally administered. After the pleasantries of the evening, including a fine dinner in the Miami Club of the Columbus Hotel, a Dr. Fitzgerald rose to read a kind of manifesto to me on behalf of the Executive Committee of the DCMA concerning the "private practice of your professors." His complaint was that he and his colleagues believed that the professors were making much more than the prescribed salary limits for the departments. I told him that we were operating under an "honor system," and each department was responsible for regulating its own private practice. His answer was sharp: "Dr. Stanford, you have the honor, but they have system." I was surprised at the intense feeling manifested during that meeting toward what the private practitioners in the community regarded as unfair competition. A few years later the University School of Medicine did adopt a professional income plan to be administered centrally. I never received any other complaint from the local practitioners.
I will never forget my first visit with Dr. Chester Cassel. I had asked the Dean of the School of Medicine, Haydon C. Nicholson, whom I should see for my periodic general examinations. He suggested Chester Cassel. When I told a friend some months later that I had an appointment with the Dean's doctor, he said, "Why he is the doctor's doctor!" My young son, then about 10 years old, overheard the conversation, perked up his ears, and asked: "Well, who is Dr. Cassel's doctor?" Obviously the implication of that query was that whomever Dr. Cassel went to for an examination would be the ultimate. So when I asked Chester on my second visit who his doctor was, I think he said he did not have one!
One of my most amusing experiences in my whole career at the University of Miami occurred after I persuaded Chester to send me over for a stress test in the Department of Cardiology. Chester said that he did not think I needed one, but at my insistence that I was curious about how the test operated, his office did make a reservation for me. I will never forget the young cardiologist who was waiting for the President of the University. He had two nurses there to help me off with my jacket. He then assisted me up on the treadmill. Before he started the machinery, he said: Dr. Stanford, please let me know if you feel any constriction in your chest at all." I assured him that I would. The young doctor started the machinery and then stopped it to ask another question: "Please let me know when you have any pain in your legs." Again, I assured him that I would. Then gradually the treadmill got faster and steeper. I looked over my shoulder at the young man. He was looking at the dials and looking at me and finally he blurted out: "Why in the hell are you here? You are in better shape than I am." I said I was just curious as to how a stress test worked and wanted to see for myself.
Attracting Additional Talent
Over the years we were able to attract some extraordinary talent to take their place alongside the fine talent I inherited. Of course, I was delighted when we were fortunate enough to attract the distinguished anesthesiologist from Columbia-Presbyterian, Emanuel Papper, to become Dean of the School of Medicine. Another outstanding appointment was Dean Warren, from the Medical School at the University of Virginia in Charlottesville, to be chairman of the Department of Surgery. Dean recruited Bob Zeppa from North Carolina. Among the earlier appointees was William Nyhan in pediatrics, who was interested in the abnormality of uric acid metabolism and brain disease, and if I remember correctly, discovered a syndrome known as the Lesch-Nyhan Syndrome. Some years later Bill Nyhan called me at home one night to say that he had decided to take a new professorship at the University of Southern California. Knowing that Bill was an avid tennis player, I teased him by this observation: "Bill, you have to be able to see the tennis ball to hit it!" And, of course, I was referring to the LA smog.
Others we recruited were Hubert Rosomoff in Neurological Surgery; Bill Little in Obstetrics and Gynecology; Jim Sussex in Psychiatry; Lynn Carmichael in Family Medicine; Mike Gordon, who developed his famous torso named "Harvey," which he uses to teach cardiology and cardiological surgery; Azorides Morales in Pathology; Werner Lowenstein in Physiology.
Bill Whelan came to us in the Fall of 1967 in Biochemistry and organized a number of outstanding conferences on recombinant DNA. He enticed Earl Sutherland and Feodor Lynen, Nobel Prize winners, to participate in these conferences. Earl Sutherland actually became a professor at the University for a short time.
I received an insight into relative departmental status when I boarded a plane for New Orleans once and discovered that quite by happenstance, Dr. W. Dean Warren, the new Chairman of Surgery, and I were seated next to each other. Dr. Warren soon made this announcement: "President Stanford (he was so formal in those early days), as you know, we have a vacancy in the chairmanship of the Department of Medicine. We need to recruit an outstanding person for this important post because medicine is the guts of the Medical School!" I gave Dean a sober look and then began to pinch my cheeks, my shoulders, my knees, and my feet. He was astounded and asked: "What are you doing?" I replied: "I just want to see whether or not I am conscious and am thus hearing correctly that the Chairman of Surgery is telling me that Medicine is the guts of the Medical School." Dean let out a yell that could be heard from the tail to the cockpit of the plane. When I asked him what he was talking about, he told me that there was a young man in St. Louis, at Washington University, a hematologist, who would make an outstanding Chairman of Medicine. He said his name was Bill Harrington. Those were the days of the good-old-boy system, not fair, but quick. I urged Dean to get him down to Miami so that we could all try to persuade him to come. And Bill Harrington did elect to join us and achieved an outstanding reputation.
One of the most memorable experiences I had in fund-raising followed the announcement that the Federal Government was willing to provide a $3 million grant to the University of Miami with which to construct a child development center. There was a condition accompanying the grant that the University would have to raise additional funds to complete the construction of the Center. Knowing of the Joseph P. Kennedy family interest in child development, Dr. Nyhan urged me to seek an appointment with Mrs. Eunice Kennedy Shriver to ask for support from the Kennedy Foundation. The appointment was easily made, and Dr. Sam Giamona, a pediatrician who had come with Dr. Nyhan to the School of Medicine, accompanied me to a Washington suburb in Maryland for dinner with Mr. and Mrs. Sargent Shriver. Dr. Giamona and I arrived on time, but Mr. and Mrs. Shriver had returned home from an earlier afternoon engagement much later than they had anticipated. While Dr. Giamona and I were sitting in the parlor of the Shriver home, two little Shrivers burst into the living room to meet us. Soon they began jumping from one piece of furniture to the other and finally decided to see who could jump the farthest from the sofa or an adjoining chair into my lap! Their behavior demonstrated forcefully those dominant maternal or Kennedy genes!
The matching requirement established by the Federal Government was met one evening with Mr. Abraham Mailman and his daughter, Dr. Marilyn Segal, in Mrs. Segal's Hollywood home. Following dinner, Mr. Mailman invited me into the library. There, he gave me the exciting news: "My brother, Joe, and I have decided to give the University $1 million so that the construction of the child development center may proceed." I was overjoyed. Of course, the University named the Center for the Mailman family, and one division, the Debbie Institute, for Mr. Mailman's granddaughter and Mrs. Segal's daughter, Debbie.
Not Only Therapy, But Prevention
One aspect of medical education that interested me over the years in Miami was the growing interest on the part of educators in prevention in addition to therapy. Three personal experiences underscore this growing interest. During the first few weeks of my tenure, Dr. Harvey Blank, Chairman of Dermatology, saw me after a meeting and said very formally: "President Stanford, may I speak quite frankly to you?" When I assured him that he could, Dr. Blank said this: "With your expanded forehead (a euphemism for baldness) and your Anglo skin, I want you to wear a sun block every day you are in Miami and cover your head with a hat." Although I played a lot of tennis over the years of my "survival" in Miami, I never forgot Dr. Blank's admonition and wore a sun block and a hat whenever I was on the court or anywhere in the sun.
Another example of prevention I experienced was Dr. Ed Norton's decision after one of his examinations of me during the first 10 years to prescribe timolol maleate for incipient glaucoma. I remember as a boy seeing several of my great uncles go blind up in rural Georgia. Everybody said it was just old age! There was not an ophthalmologist in the county. The advice from Dr. Norton has kept my vision steady in spite of the glaucoma.
Another example was Chester Cassel's observation that my uric acid level had risen to the point where it needed to be corrected or I was in danger of succumbing to gout. That is a genetic predisposition in my family as well. Several of my relatives have had terrible cases of gout. Thanks to Dr. Cassel's prescription of allopurinol, I have never had a single symptom.
I have been interested over the years in seeing how practitioners have become interested in nutrition as a way to prevention. I will never forget my first visit with Dr. Cassel. He did his usual, thorough job in examining me. When he had completed that first examination, I asked him whether or not he was going to make any suggestion about nutrition. Dr. Cassel answered quickly: "Well, I assume you get a balanced meal." When I told my wife, a self-made nutrition nut, what Dr. Cassel had said, she exploded: "That sounds just like a doctor!" Anyway, after Dr. Cassel's comment, I did tell him what my wife started giving me after breakfast in July, 1948, and I was taking it then when Dr. Cassel was examining me in the winter of 1963 for the first time. And I am still taking it today. It is a concoction recommended by two early nutritionists, Adele Davis and Victor Lindlahr. It consists of Brewer's yeast, which of course contains a lot of Vitamin B, and iron-rich black strap molasses mixed into non-fat, dehydrated milk reconstituted in water. Dr. Cassel raised his eyebrows and asked: "What is that good for?" I said: "My wife's disposition!" It is a little enough sacrifice for a man to make to keep a wife on an even keel!
I was fascinated by the article about Dr. W. Jarrard Goodwin, Chairman of the Department of Otolaryngology, that appeared in the Fall, 1992, Spectra, a periodical issued by the University of Miami/Jackson Memorial Medical Center. He is described as telling his patients to eat carrots or take beta-carotene because they may be particularly helpful in fending off cancer of the respiratory and upper digestive tracts.
Another great change in medical education during my University of Miami presidency and continuing throughout the eighties has been the introduction of new technology. One that comes to mind readily is magnetic resonance imaging.
The information revolution of the last part of this century has had its effect in medicine as well. In the winter, 1992, issue of Today, the magazine of the Medical College of Georgia, I was tremendously impressed to read of a communications system that enables physicians at the Medical College of Georgia "to peer down throats, listen to heartbeats, examine x-rays, and see and talk directly with patients 130 miles away in Eastman, Georgia." As the magazine emphasizes, "for patients this means improved access to specialists at the Medical College of Georgia often without leaving their home town." At Miami, the School of Medicine is reaching out to extend care to the community. A notable example is the Pediatrics Mobile Clinic.
One of the most dramatic changes in medicine over the years is attributable to research in genetics. I first listened to the marvels of recombinant DNA research at Dr. William Whelan's conferences and then saw results of this kind of research being applied to disease therapy.
Rush to Specialization
Everyone knows, of course, of the rush to specialization that has characterized medical education over the last two decades. This should be no surprise, as we become fascinated with newly developed areas of interest and new approaches based upon new technology and new pharmacology. Yet I was pleased with the establishment in our School of Medicine of the Department of Family Medicine pioneered by Dr. Lynn Carmichael. As the nation looks more and more to the reduction of the cost of medical treatment and care, I hope there will be more and more emphasis on the development of excellent primary care physicians to whom the great majority of patients will come first for consultation.
Sometimes I think I maintained my sanity during 19 turbulent years at the University of Miami by escaping to the north shore of Jamaica for a few days every six months. There I used to jog in the early morning and late afternoon along the sandy beach of a cove sharply defined by outcroppings of volcanic lava at each end. As I jogged, I noticed that the sand along the beach was being continuously reformed and redesigned by the incessant pounding of the waves and the ebbing and flowing of the tides. Yet the boulders at each end of the beach maintained their craggy appearances, at least during the years I was jogging, although I realized that over eons of time they must have been eroded by the wind and water. But at least during my visits, they always seemed firm and solid in spite of diverse elements.
The unchanging boulders and the ever-changing shoreline provided an inspiration in contrast for me: Some things in life do change and properly should, but some things, of transcendent principle, should not change. Let me conclude this very personal series of observations about medical education by emphasizing a triad of transcendent relationships every doctor faces: the doctor and the profession, the doctor and the patient, and the doctor and himself or herself.
As a profession, medicine has in common with all professions the requisites of training and ethical standards that should guide service to human beings. We all know of the vigorous discussion of medical practice that has dominated the media in recent months as the Clinton administration moves to propose a new national health program. Letters to editors complain of the materialism of physicians, their exorbitant fees, their impersonal attitudes, and their increasing propensity to treat one bone, one organ, one spot. Increasing medical and scientific discoveries do proper medical training to the production of an increasing number of more specialized practitioners. Yet in spite of all the pressures generated by advancing science and technology, medicine must remain a profession. Thus if it is a profession, each doctor has a responsibility to regard it as such. The service motif is interwoven, and when it fails to show through the strands of multiple activities, the public readily recognizes its absence. The emphasis in a profession is on giving and not on getting. The individual who will not or cannot subscribe to his idea of service has no place in the profession.
Public relations are really no better than the impressions created by individual practitioners. Millions of dollars spent on public relations by the American Medical Association can never counteract the ill effects of an unprofessional act. Doctors must ever have regard for their relationships to their professional ideals, lest the public may be inclined to conclude its examination of private medical practice in the United States with the phrase: "prognosis guarded." No one believes more than I do in the principles of freedom for the college campus, for business enterprise, and certainly for the medical profession. But freedom is safeguarded only insofar as its corresponding responsibilities are assumed. Persons who enter medicine only to reap financial security or social prestige may achieve that, but they will be "doctors" in the hypocritical, rather than in the Hippocratic sense.
The Doctor and the Patient.
The second relationship I commend for consideration this afternoon is that between the doctor and the patient. After years of laboratory and clinical study and observance of the human body, the doctor must be tempted to regard it as a physiological machine or an anatomical structure. If disease and accident impair the body, there is the opportunity to apply scientific techniques to rehabilitate it. If virus and microbes threaten it, the doctor rushes to apply therapeutic measures. Surely there must be the subtle temptation to treat the body as devoid of personality. This I can readily understand. Technical education contributes little to the knowledge of human nature. It can let experience with laboratory animals color the doctor's outlook on human beings. Diagnoses, techniques, and pharmacopoeia are designed to rebuild functions and processes and structures.
But medicine is more than a science. It is also an art. In spite of all efforts to make it more and more scientific, medicine is likely to remain an art as well. The doctor's concern is not just with disordered metabolisms, specific infections, or physiological malfunctions, but with sick human beings. Thus patients become more than just symptoms. The professionally-successful doctor is one who, in his practice, transcends the machine-like, the structural, the procedural, and looks, too, for the spark of personality.
Each patient, I believe, yearns for a relationship of confidence with his doctor. I would exhort all doctors to look for the humanity in their patients and prescribe for that, too. In their kit of prescriptions, they will wish to consider when to draw upon doses of kindness, understanding, and tolerance, as well as frankness, sternness, and reprimand. A pharmacopoeia for human nature is developed by close and sympathetic observation of the species.
Is there anything to the old phrase "bedside manner"? I may sound old-fashioned even in bringing up the question, but it relates to the idea I am trying to get across here. The phrase implies consideration of the humanity in the patient, as I have just emphasized.
The phrase "bedside manner" reminds me of a scintillating experience I had with the hat-check woman as I was leaving a restaurant with a group in New York City years ago. As I was waiting for my coat, having turned my check stub in to the woman, someone spoke to me as "Dr. Stanford." When the woman arrived with my coat, she overheard the conversation and asked me pointedly: "What kind of a doctor are you?" My answer was: "I am not permitted to operate or prescribe, but I have a good bedside manner." She burst out laughing and exclaimed: "Honey, there ain't nothing wrong with that!" So again, I suggest there really is nothing wrong with a "good bedside manner," whether at the bedside or in the office.
The Doctor and Himself/Herself
Finally, there comes a time of the day or night when the last patient is examined, the last test conducted, the last chart or report read, and there is no further medical activity for that day or night. Then the doctor luckily may find himself confronted with an elusive moment of leisure. Here practitioners face a relationship as significant as the relationship with their profession and their patients. It is the relationship with themselves. To fulfill their mission successfully, with its emphasis upon service and human personality, doctors must try to become well-rounded individuals, sensitive to literature, the arts, and social and cultural heritage, something more than the technician and the practicing scientist.
I have long admired Manny Papper's ability to deal so successfully with medicine and at the same time become a humanistic scholar as well. Back in high school I had to memorize that portion of Cicero's oration given in the Roman Senate on behalf of the poet Archias. I will not brag or bore you by quoting the Latin, but I will only summarize by saying that Cicero regarded liberal learning as a companion who lives or travels with us. There is the idea of closeness, of intimacy, of friendship, of comfort in concept.
I will never forget the experience I had with the postman who dropped into my office one day to bring me a special delivery letter. After I had signed for the letter, he lingered to ask me a question: "What do you think of John Dewey's pragmatism?" I was astounded by that question, but nevertheless launched into a discussion of Dewey's philosophy with him. Afterwards I learned that he had received a degree from my alma mater, Emory University, in 1931. A job was a job in those Depression Days, and for some reason the postman had never moved beyond his original assignment, but I knew from talking with him that the liberal studies of his undergraduate education freed him from the burden of his daily routine. At home he was free to soar through the universe of the human intellect, exploring galaxies of literature, philosophy, and history.
So if doctors are true to themselves, they will keep the windows of their minds open to the stimulation of fresh ideas from the arts and the humanities. They will regard their scientific and medical specialties as in continuous need of supplementation, both to provide a greater understanding of human beings and to provide intellectual liberation from the servile learning of office and hospital environment.
The triad of relationships I have described here point up idealized responsibilities. I urge doctors to grasp Asclepius' staff and holy snakes with a keen sense of responsibility to their profession, to their patients, and to themselves.
Henry King Stanford, Ph.D.
¹ Also Published in: Stanford HK. Campus under political fire and other essays. Columbus, GA: X-PRESS Printing, 2000. pp. 85-115.
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