My dear Dean,
You seemed surprised in Faculty when I raised objections against extended leave of absence for Johnson to act as visiting professor in Chile. I have been brooding about this business for some time, and here is my considered opinion. Travel broadens the mind. A meeting of minds spreads knowledge, aids research, and brings scientists together so that they may take each other’s measure. Ergo, it is a “good thing” that jet aircraft daily carry doctors from Edinburgh to Peru, from Sydney to Houston, and from Oslo to Pernambuco—all of them busily bent on improving their minds and the minds of their hosts. So runs the syllogism. True or false?
Photography by John Perivolaris
Let me begin by saying that the Wandervogel impulse is of course not confined to doctors. The briefcase—modern equivalent of the rucksack of the Wandervogel—accompanies academics, journalists, engineers, lawyers, and businessmen, as well as doctors, on global journeys, but I am not concerned here with these others. The question is: How much does this to-ing and fro-ing benefit the practice of medicine and medical education?
Scholarly wanderings are nothing new; Montpellier, Paris, Padua, Oxford, and Amsterdam were regular places of call for medieval physicians. (“If a man wishes to become acquainted with many diseases,” wrote Paracelsus, “he must set forth on his travels. If he travels far, he will gather much experience, and will win much knowledge.”) For the young, there is much to be said for sitting at the feet of the great, wherever the great may be found. After the hard grind of apprenticeship, time spent in well-run, well-equipped clinics and laboratories is stimulating and commendable. To produce the mature physician didacticism must be blended with a touch of scepticism.
But with maturity the case for incessant jaunts to congresses, conferences, visits to foreign clinics, and stints as visiting professors becomes much harder to justify. In the United States, this haring-about has reached farcical proportions. Heads of departments and their immediate juniors move restlessly and continuously between city and city, State and State, and coast and coast, lecturing, holding seminars, taking part in symposiums, conferences, and congresses, visiting laboratories and clinics—and in general neglecting the work they were appointed to carry out. And all this at vast expense, financed by their institutions, some of which even maintain their own travel bureaux.
First, as to conferences and congresses. These are almost wholly a waste of time and money; in Europe many of them are mounted merely to lure foreign visitors and their currency. The proceedings have reduced themselves to absurdity. Someone gets up for five minutes, gabbles his message (which in any case is already in print), and projects the slides, without which no “communication” can be held to be respectable. Often his audience is limited to others waiting impatiently for their five minutes at the rostrum. “Ah!,” one is told, “but you are forgetting the tea-breaks and the coffee-breaks, and the informal chats with colleagues from Johannesburg, Perth, Stockholm, and wherever—these are the things that really matter.” But what, may I ask, has happened to the pen and the typewriter and the medical journals? There was a time when kindred workers all over Europe and America and parts of Asia could acquaint each other with work proceeding in their laboratories and clinics without leaving their benches. The net result was not so different, though long-range correspondence had less disastrous consequences on the practice of medicine.
Visits to foreign clinics and spells of duty as visiting professors are applauded as “good things.” Yes, so long as one ignores the consequences on the home ground. For this is the crux. Someone has to take over the work of the Wandervogel. Most often it devolves on persons who ought to be busy with their own regular duties. Patients are left in mid-air, and students, housemen, and registrars are deprived of the teaching and supervision which they ought to have and which the institution has contracted to give them. The key figure is often the registrar. In the United States it is the resident who has to shoulder responsibilities which he may not be (and often is not) fitted for. Show me your registrars and residents, and I will tell you what sort of hospital and medical school you have. If they visit their patients twice a day routinely and their gravely ill patients more often, if they are readily available for emergencies, if the housemen under them are working like horses (for this is the time when they should be doing so) keeping their records straight, seeing patients and relations, shepherding the students, keeping nurses up to the mark, speeding up as far as they can special investigations, and learning their craft at first hand—if all this is being done, you may be sure that at the head is a man who has little time for flitting from continent to continent. And you may be equally sure that the doctors who are trained in his institution are responsible, well taught, and disciplined in their future careers to the needs of their patients and the exacting demands of their profession.
It needs to be said that the preoccupation with what is called “the wonderful progress in medicine” ought not to take precedence over the practice of what is known and well established. For most illnesses, the standard requirements remain standard—early diagnosis, correct treatment, good nursing, and sympathetic handling of the patient and family. These requirements don’t call for frequent trips to New York, London, Detroit, or Rome. True, early diagnosis and correct treatment may reach different levels of achievement in these places; far too often, however, the Wandervogel comes away impressed with some new, gleaming, expensive piece of equipment and moans about the parsimony of the financial controllers in his own institution who are depriving him of the new toy. Come hell or high water, he wants his hyperbaric chamber and his computer.
What does all this talk of the “great advances in medicine” amount to? Degenerative and malignant diseases still elude us, and advances have been marginal. Clearly, there must be pioneers at the frontiers exploring new territory and charting future paths of progress. Nobody wants to cramp the molecular biologists (though Burnet has sounded a cautionary note), the transplantation workers in their vineyard, and the innovators in the half-lit world of the psyche and the body. But frontiersmen, by definition, form a select group. The rest of us would be better cultivating our own gardens and setting our houses in order.
I am too bereft of illusions, my dear Dean, to hope that what I have to say will have much influence in this matter. The Wandervogel syndrome is too widespread. One way out, however, is open to the committees and boards that select heads of units and senior teachers. Don’t necessarily go for the candidate with the longest list of published material or with glowing testimonials from Wandervogel who wish to reward them for carrying the can for them. Choose the man who has been taught in a school where slackness is frowned upon, where the routine care of the patient is constantly under critical review, and where the head of the unit is a man whose assistants have probably hated him at first and then thanked their lucky stars for the rest of their lives that they worked with him. The most unlikely chief to fill the bill attends every meeting, conference, congress, and symposium, his brief-case bulging with drip-dry shirts, well-worn lecture notes, and interminable slides.
You will ask how one is to find these paragons without travelling to see them at work. Am I not being inconsistent? My answer is the Aristotelian tag of the “golden mean.” Travel abroad there must be—but travel with a purpose. Seek men and not machines. Be clear what you are looking for.
Fraternally yours, G.