George Dunea, MD
Originally published in The Lancet, September 1, 1973, pp. 493-494
The year is 410 B.C., Socrates and the physician Democedes are walking in a shady grove, on the road to Megara.
Dem: Can you tell me, Socrates, how does one achieve excellence in clinical medicine? Can excellence be taught, is it acquired through practice, or is there another way? And if indeed excellence can be taught, should our young be instructed by the teachers of the academy or by the physicians who practice the art of healing the sick?
Soc: O Democedes, you must think I am singularly fortunate to know the answers to such difficult questions. There is hardly a day that I do not hear something about a crisis in medicine. Why, only yesterday Glaucon told me that the people at Piræus and beyond the Long Walls cannot find doctors to cure their ailments; that poor people are dying for lack of treatment; and that the rich get well only by paying many oboles to physicians and hospitals. But to return to your question, Democedes, I must confess I have always assumed that the best practicing physicians are also the best teachers, and I am surprised at your drawing such sharp distinctions between the two.
Dem: You must believe, Socrates, that many professors of clinical medicine, and also many younger men, never lay hands on a patient. Instead, they spend their time in the academy, reading, writing, working in laboratories, raising silver talents for their experiments, and going off to scientific meetings, sometimes as far as Sicily or the Pillars of Hercules. It is even said that they must leave the academy if they write too few dialogues or bring in too little silver. So you see, Socrates, they are so busy there is hardly any time left to be with the sick.
Soc: But surely, not everyone in the academy spends his time in these ways?
Dem: No, Socrates, there are others who are interested in medical education, organization, or politics. They plan new systems, reshape old ones, sit in councils and assemblies, and soon abandon clinical medicine altogether. Sometimes they see an unusual or difficult case, but they cannot afford the time to dwell too long by the bedside.
Soc: Are there not in the academy physicians who like to care for the sick and who spend most of their time doing just that?
Dem: Yes, there are some, Socrates, especially in the West, in Ætolia, in parts of Achæa and amongst the barbarians beyond Epirus. But in many other academies it is now considered more important to struggle with problems of more universal application and of potential benefit to the many, and perhaps even to posterity, rather than to spend time on the problems of a single sick individual. It follows that respect and advancement do not come from taking care of patients, and indeed the physician who practices mainly clinical medicine is looked upon as a failure, who hides in the sheltered environment of the academy because he could not succeed in the city. In some cities taking care of patients is still highly regarded, but when too many equally skilled physicians vie for one job, the one who has written more dialogues usually carries the day; and since writing dialogues takes time, the preferred candidate is likely to have spent the least time by the bedside. So you see, Socrates, the result is the same: respect and advancement come from doing everything else but taking care of the sick.
Soc: But tell me, Democedes, are there not enough physicians in the cities, outside the academies, who heal the sick and who can serve as models to our young people?
Dem: Yes there are, Socrates, but in many cities they have little contact with our young. In Ionia, there are still a few who come to the academy, and occasionally students are even allowed to visit their offices. In other cities, most physicians are too busy to go to the academies and have become somewhat isolated: some have lost their learning and are so ignorant that they would corrupt the young. Others are very skillful but refuse to teach because the students have been taught to admire the teachers from the academy but to look down on pure clinicians. In Thessaly and in parts of Bœotia, the practicing physicians are not even allowed to work in the hospitals of the academies, but must confine themselves to treating minor illnesses.
Soc: It seems to me then, Democedes, that many young people will never be inspired to strive for clinical excellence.
Dem: Why, Socrates?
Soc: Because students are not profoundly influenced by their early teachers, and will often model themselves, sometimes subconsciously, on those whom they have come to admire. But if the academies regard clinical medicine as of little importance or as something that can be learned later, and if the teachers do not set themselves up as examples, then the young people too will care little about clinical excellence.
Dem: I agree, Socrates, that is how the case appears to me too.
Soc: Tell me then, Democedes, do you believe with Eudoxus that the chief good is that at which all things aim, and that all subordinate ends are pursued for the sake of that good?
Dem: I certainly do, Socrates.
Soc: Is it not also true that the chief goal in medicine is to better recognize and treat human ailments, and that neither research, nor education, nor planning are of any use unless we have good physicians who practice medicine with skill and virtue?
Dem: Most certainly, Socrates.
Soc: And is not this state of utmost skill and virtue, where medicine is practiced slowly and carefully, with knowledge and sympathy, what you referred to as excellence?
Dem: Yes, that is what I meant.
Soc: Imagine then a young man who wishes to achieve excellence as a carpenter, and who has already spent some time in school. Should he go on listening to more speeches about nails, and wood, and chisels, or should he now seek out a master carpenter, so that he can learn from a true craftsman in action?
Dem: He should work with a carpenter, Socrates.
Soc: And similarly if a youth wants to make beautiful shoes, should he listen interminably to lectures on leather, and silk, and the shape of feet, or should he be sent to a master shoemaker?
Dem: He should be sent to a master shoemaker.
Soc: Then by the same reckoning should not a young man, who has spent some time in the academy, be sent to a master of clinical medicine?
Dem: Yes, he should work with the best in the land, Socrates. But tell me, how can this be achieved, and where can such masters be found?
Soc: My dear Democedes, I don’t know if I can fully answer your question; but at least I would like to tell you what I heard many years ago, during the campaign at Potidæa, from an old and venerable physician. It seems that at one time, before the coming of the Mede, there were, in Athens, and in Sparta, and in many Ionian cities, skilled and respected physicians who spent most of their time healing the sick, and who were so highly regarded in the academies that the young people wished nothing better than to emulate them and become like them. In those remote days it was understood that a greater part of medicine could not be taught, and that there were skills which every generation had to master by themselves; so that those who wished to learn clinical medicine spent long hours and many years working with patients to apply the examples they had seen, in order to improve their skills. And they did this because they had become inspired and had come to understand that it was largely by their own efforts that they would achieve excellence. So you see, my dear friend, it is neither from teaching nor from practice that our young people will derive much benefit, unless we can also inspire them by example as well as by precept to strive for that state of excellence which their souls should desire.
Dem: So be it then, Socrates. But let us be going, now that it has become less oppressively hot.
MD, FACP, FRCP, FASN is the President and CEO of the Hektoen Institute of Medicine. He is also a Professor of Medicine at University of Illinois at Chicago and the Medical Director of Chicago Dialysis Center and Founding Chairman Emeritus, Division of Nephrology, Stroger Hospital of Cook County.