promises to keep · promises to keep medicine seemsset fair. buthere wecomeacross a first...

Thorax 1984;39:481-486

Promises to keepANDREW DOUGLAS

Presidential address delivered to the British Thoracic Society on 8 December 1983

The woods are lovely, dark and deep,But I have promises to keep

And miles to go before I sleep.ROBERT FROST

When the council of the British Thoracic Societydecided earlier this year that there should be apresidential address there was no lack of well mean-ing advice on the form this should take, although inretrospect most of it turned out to be of negativevalue. One member said, " We don't want atravelogue"; another, " We don' t just want a favour-ite lecture"; and yet another said, "There will beplenty of science on the programme already." Onevery kindly colleague said, "Just talk about anythingyou like, even railways." Sadly, I know very littleabout railways so I found it somewhat difficult tofind a topic which would avoid these constraints andstill be relevant to our young society. It was whiletrying to resolve this dilemma that I happened tolook at a picture which came into our possessionsome 40 years ago (fig 1). It is painted on wood byan unknown artist and for almost a century it hadbeen set in the wall above the dispensing desk of awell known Edinburgh pharmaceutical firm. Itshows the casual encounter on a country roadbetween a doctor and a patient, both on horseback.It is called "The Diagnosis," and probably the scenewas set around the turn of the eighteenth century.The picture set off a train of thought. What, I won-dered, was the doctor's background? What were hisobligations to his patient, to his profession and tosociety as a whole? And how well do we do his jobtoday?

It is reasonable to believe that the picture relatesto a Scottish scene but even if it does not the chancesare high that the doctor graduated from a Scottishuniversity, for most of the medical training in theBritish Isles at that time took place in Scotland. Forexample, in the years 1800-50 there were nearly8000 graduates from the four Scottish medicalschools compared with less than 300 from Oxfordand Cambridge, the only other universities thenawarding medical degrees. Possibly he was an Edin-Address for reprint requests: Dr Andrew Douglas, Department ofMedicine, Royal Infirmary, Edinburgh EH3 9YW.

Fig 1 The diagnosis.

burgh graduate who studied under Joseph Black;conceivably he was William Dean, whose certificateof attendance at Black's chemistry class, signed byBlack himself, is shown in fig 2. Perhaps he took partin one of Black's lesser known experiments, whichmeant laying rugs soaked in caustic soda in the roofof a church. At the end of a long service Blackproved that the caustic soda had become a mildalkali and was eventually satisfied that air was not anelement but a mixture of different gases.The likelihood is that the doctor was at least of

middle class origin, perhaps a son of the manse or adoctor's son. The "lad o' pairts," the beneficiary ofthe arrangement whereby a poor Scottish commun-ity would collectively support the university trainingof an outstanding scholar, was more likely at thattime to opt for a career in teaching or the churchthan for medicine. The requirements for admission

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Fig 2 William Dean's chemistry class certificate signed byJoseph Black.

to university were vastly different from those today.William Dean could have matriculated as early as 15and, although some indication of a sufficient stan-dard of school education would be demanded, usu-ally this meant only the school teacher's recommen-dation and there was little competition for entry.The contrast with today is striking and the high

standards demanded by medical schools in Britain

No ofapplications(100's)

30

25-

20-

15-

105

5-

Douglas

Table 1 Admissions to the Faculty ofMedicine, UniversityofEdinburgh, 1982 *

Men Women

Number of applicants 863 669Number accepted 166 149Percentage accepted 19 22Number enrolled 100 91Percentage enrolled 12 14

Entrance qualifications ofthose enrolledScottish Certificate of Education(50%) Majority AAAAA plus

Minimum AAABBGeneral Certificate of Education(50%) Majority AAA plus

Minimum ABB

*Reproduced by courtesy of the Executive Dean, Faculty ofMedicine, University of Edinburgh.

are highlighted by some recent figures for Edin-burgh, which reflect fairly well the standardsthroughout the country (table 1). It would seem thatmedicine now creams off the top layer of academicpotential and there is no evidence that this is a pas-sing phenomenon (fig 3). As we stand on the brinkof Orwell's fabled year, with all its other connota-tions, the barometer of twenty-first century

1940 1950 1960 1970 1980Fig 3 Applications for entry to the Edinburgh medical school, 1940-80. Reproduced by courtesy of the Executive Dean,Faculty of Medicine, University of Edinburgh.

I I



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medicine seems set fair. But here we come across afirst obligation or promise. We must make the bestuse of this potential and as a thoracic society with ahigh proportion of its members heavily committedto medical training we have a duty to make thattraining match the capabilities of this extraordinarilygifted segment of society.Whether or not academic excellence at school is

the best index for selection of medical studentsremains debatable. But at least it is a quantifiablephenomenon and in a study of success in the finalexaminations in the Edinburgh medical school someyears ago it was the single most important indicatorof the likelihood of completing the course success-fully. This does not necessarily mean that this crite-rion ensures the best end product-given that wecan define what that is. It simply means an ability tocope with a defined curriculum and the attainmentof a certain standard of knowledge at a point in time.In medicine more than in any other profession,however, today's authority is often tomorrow's follyand the commitment to continue to learn is an essen-tial in the medical life. This was underlined by astudy published in June this year of the undergradu-ate examination performance and subsequent careersuccess of the 1950-1 intake of Cambridge medicalstudents. It was concluded that undergraduateresults were poor predictors of later performance.'What seems to determine quality in the long run isthe motivation to continue to learn, somethingwhich medical educators can inculcate only byexample.The relevance of the medical curriculum to

today's needs as well as the methods of teachingcontinues to be under active review. Traditionalistswho have experienced radical medical courses suchas that of McMaster University have usuallyregarded these as being several steps up theevolutionary scale from the courses of the tradi-tional university, but even their most fervent sup-porters are forced to admit that there is basicallynothing to choose between the end products.2 Thereason, it would appear, is that the "hidden cur-riculum" is a much more powerful learning forcethan is the written curriculum. The hidden cur-riculum largely reflects the attitudes and motivationsof the teachers, with the result that medical educa-tion tends to produce doctors in the image of theirteachers. Those of our members who influence andcontribute to medical education have a prime obli-gation to make that hidden curriculum worthy of theplace it holds in the shaping of tomorrow'sdoctors-another promise.

But to return to our horseback physician: it wouldbe wrong to believe that he lived in an unchanging,unchallenging medical world. It is true that the

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transforming influences of Pasteur, Koch, Lister,and Virchow were still to come but medicine in theearly 1800s was certainly not static. In his medicaltraining he would have learnt about the best piece ofphysiological work of the eighteenth century-namely, the completion of the modern theory ofrespiration, which stemmed from the discovery ofthe different gases in the atmosphere by Black,Cavendish, Priestley, Rutherford, and Lavoisier(table 2). These discoveries were to lead to the ulti-mate consummation of the work of the man whorevolutionised medical science and who has exerteda more powerful influence on modern medicine thanany other.3 He was, of course, William Harvey,another horseback physician, who allowed hisservant to follow him on foot, a fashion which hisbiographer John Aubrey thought "very decent."4Our physician would certainly have heard of Har-

vey's injunctions to colleagues and successors. Thesewere: (1) to advance natural knowledge by way ofexperiment; (2) to live in amity and friendshiptogether; and (3) to appreciate the acts of ourbenefactors, and through them to provide for thefurther development of our service to society. Theseinjunctions are still relevant to members of everylearned medical society and they amount to obliga-tions or promises. It was the reality of the secondinjunction in respiratory medicine today whichallowed the British Thoracic Society to be born. Inrelation to the first injunction, it is highly significantthat in the articles of association of our society thewords "research" and "study" occur six times andfour times respectively on the first page. You and Ihave subscribed to these articles.Our multidisciplinary thoracic society exists for

the advancement and communication of knowledgeand in regard to the various roles we can assume it isperhaps pertinent to remind ourselves that there areessentially only two kinds of scientific activity-firstly, investigations aimed at understanding natur-ally occurring phenomena-in other words,research-and, secondly, investigations aimed atapplying knowledge so gained to human needs-that is, development.5 The first is determined bynature, the second by human wishes and intention.Research is essentially a voyage of discovery whichcannot be accurately charted in advance and only inthe broadest terms can the aim of any individualproject be formulated. All that organisation can do

Table 2 Steps in the theory of respiration

Joseph Black 1757 Carbon dioxideHenry Cavendish 1766 HydrogenJoseph Priestley 1771 OxygenDaniel Rutherford 1772 NitrogenAntoine Lavoisier 1775 Gas interchange in lungs



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is to choose the right person as leader, equip him aswell as possible with coworkers and materials, andtrust to his judgement. By contrast development ismore amenable to wishes and intentions. Develop-ment starts with a modicum of knowledge that iscertain and accepted. It is therefore possible to chartthe general course of development, to estimate theresources required, and to follow its progress fairlyaccurately. So the outcome should be predictablewithin reasonable limits. Between these twoextremes of research and development lie everyshade and combination of activity. After the rarepioneers comes the vast army of colonisers. Thencome those concerned with the generalities of appli-cation and after them those who combine experi-ence of both science and practical activities, whosetask it is to develop scientific knowledge for special-ised purposes. Over this range of research anddevelopment there is no break, either intellectual orpractical. Knowledge must flow in both directions,from practice to research just as freely as fromresearch to practice. The context of that knowledgecan stretch from the most abstruse to the most prac-tical considerations. It follows, then, that the posi-tion of any individual worker in the range of sci-entific inquiry is not a fixed one. According to thetrend of his work and his capabilities he will at dif-ferent times move more or less towards the theoreti-cal and towards the practical. It is on this natural ebband flow around an investigator's primary interestthat the integration of scientific knowledge rests.5The researcher cannot be indifferent to the use to

which his work is put, nor can he be without interestin its implication for the wider body of knowledge.At all times he is bound to be concerned with inter-ests which touch on his own. And so it becomespossible to have concerted action over wide rangesof scientific inquiry. It is salutary to remember thatthe theory of respiration arose primarily out of thework of mathematicians, physicists, and chemists.Nearer our own day the development of the control-led therapeutic trial, devised by Fisher and BradfordHill, neither of them physicians, demonstrated thegreat importance of outside influences and perhapsalso the weakness of closed intellectual societies.6The British Thoracic Society, with its basic mechan-isms and clinical epidemiology groups and itsbroadly represented clinical interests, is ideally con-stituted to promote widely ranging inquiry andmultidisciplinary scientific activity-indeed we havepromised to do so.Research is broadly of two kinds, observational

and experimental. Until recently research wasaccorded such prestige that it was in some danger ofbeing elevated into a mystique. This was particularlytrue of the experimental method, so that in conse-

Douglasquence the observational approach declined inattraction. But although the experimental method isthe single most important tool that man has devisedfor extending knowledge it has the inherent weak-ness that it depends for its inception on the formula-tion of an idea, and consequently can be no strongerthan the imagination of the person who uses it.5Observational research, however, relies on the care-ful collection of data and the interpretation of them.It maps out the association of events and it can gen-erate hypotheses regarding cause. Observation isour main contact with natural reality; it is also ourmost frequent source of the unexpected in scientificdiscovery. Darwin's whole work was based on theobservational method. Edward Jenner, also a coun-try horseback physician, made observations whichwere to be the foundation of immunology and ulti-mately were to rid the world of its most infectiousdisease. The observations of Parry and Addisonwere the beginnings of endocrinology, and it was thealert observation of Fleming which led to the dis-covery of antibiotics. With the great elaboration oftechnical methods for extending the range of oursenses the observational method has become ofincreasing importance. We should therefore devoteconsiderable attention to its promotion, but havingsaid that we immediately come up against anintrinsic difficulty. Observation, being dependent onthe occurrence of natural events, is of necessity amore lengthy process than experiment, which canprovoke events at will. It does therefore raise prob-lems of maintaining consistent standards of observa-tion over long periods, of sustaining attention andcoordinating efforts, and also of obtaining the neces-sary long term funding. Our inaugural presidentclearly indicated the vital need to review the sourcesof funding available for clinical research. This isespecially pertinent in the current climate of relativeunwillingness of grant bodies to underwrite thisform of scientific activity. Now, as in Harvey's day,the advancement of knowledge depends for its mat-erial support on the interest of benefactors. Todayour major benefactor is society itself, and only to theextent that we can convince its members of theimportance to them of our work will the necessarysupport be forthcoming. It is our bounden duty to doso.

In Harvey's day, and indeed at the time ourhorseback physician lived, researchers operated asindividuals and the range of medical and biologicalknowledge could be spanned by a single mind. It waspossible then for the researcher to effect the neces-sary synthesis of knowledge in his own person. Notso today. Medical knowledge is now seeminglyinfinite and since life is a single experience any indi-vidual can be familiar only with a fragment of that



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knowledge, far less be expert in its practical expres-sions. By the same token it follows that there isroom in medicine for talents of every kind. The tre-mendous broadfronted advance in scientific know-ledge after the second world war has never beenequalled at any time in man's history, and medicinehas consequently been influenced and directed bythis new knowledge into channels previouslyundreamed of. Man is always at the mercy of hisown ingenuity and new knowledge always clamoursto be used. It would be unthinkable, say, to havediscovered the internal combustion engine and notto have used it. A modern example is the computer,which increasingly is influencing medical practice.As a measure of the rate of scientific progress, it isestimated that 98% of all contributors to mankind'sscientific knowledge are still alive today: and it is anawe inspiring thought that only some 60 years afterman falteringly flew a few yards in a heavier than airmachine he was walking on the moon. The future ofmedicine will largely be determined by how we candirect and control the products of the present sci-entific revolution. It is proper that society shoulddemand from us a promise to do this responsibly.

Let me now turn to another aspect of medicalpractice where promises are pertinent. As Sir Chris-topher Booth has remarked, it seems fashionable toconsider that modern medicine has grown out oftouch with the human condition, that so called hightechnology medicine is somehow inhuman, and thata new breed of doctors, arrogantly scientific, hasreplaced the beloved physician of a bygone age.' SirChristopher could not share such views; nor can we.Almost everything we do to help our patients,whether by effective prevention or by treatment, isbased on scientific or technological achievement. Itis true that there remain many areas where medicalscience has yet to cast light and where care andcompassion of themselves are more important. Butmany would feel that there is as much humanity inreplacing a damaged aortic valve with the high tech-nology of cardiopulmonary bypass as in caring forsomeone with an irrecoverable hemiplegia or achronic mental illness. Of course, not all medicine is"high technology." There are, and always will be,areas of the unknown which will continue to con-found the greatest expert. For example, the scientificbasis of many disorders of the mind or the personal-ity remains obscure and in this area "fringemedicine" flourishes. Yet it is well to remember howmuch we owe to fringe medicine. Vaccination anddigitalis had their origins in the beliefs and practicesof country folk. Ophthalmology was originallydeveloped by unqualified practitioners. Orthopaed-ics owes much to the old bone setters. Evenacupuncture, initially derided by the medical establ-

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ishment, seems likely to achieve some scientificrespectability.7 Who would doubt that the spiritual-ity which permeated the work of the late DrWinifred Rushforth had an integral part in the careshe was able to give to troubled minds and bodies?A similar spirituality is threaded through DameCicely Saunders's work today. Advances in treat-ment certainly may come in unconventional waysbut, as with any other therapy, their worth can beestablished finally only by scientific analysis. Wheresuch analysis has not been carried out in the past themedical profession itself has been responsible forthe perpetration of therapeutic horrors just as bad, ifnot worse, than the excesses of chiropractors andquacks.7 Blood letting was a prime example.The passion for general theories to explain all

unexplained disease has permeated medical thoughtthroughout history and persists today. When I was astudent the era of focal sepsis was just coming to anend but patients were still being asked to sacrificeteeth, tonsils, and other of their less necessaryorgans in the hope of cure of some chronic ailment.This gave way to the psychosomatic era, then thediseases of adaptation, and now autoimmunity andits extensions. Holistic medicine is currently beingadvocated, but since it has been described as being"a new map of old territory"8 perhaps it is pushingon an open door. In all previous eras of embracingtheories the refining tool of the controlled clinicaltrial was not available. But it is now, and while wemust always be receptive to new thought there is adifference, I would submit, between an open mindand a hole in the head. We owe it to our patients toremember this.

In the early part of last century, when our horse-back physician practised, most people lived and diedwithout the help or hindrance of doctors. His meet-ing with his patient in the picture was obviously acasual affair. Doctors worked mainly in the citiesand made their living by attending to the middleclass of society. The primary function of hospitalsthen was largely the care, not the cure, of the poorersick members of society. The well to do would neverhave dreamt of going into hospital when ill. Theexpectations of society in relation to the medicalprofession were limited, and naturally so whendeath from disease was all around.The dramatic improvement in health in recent

times has to some extent plateaued, so that theobserved impact of new knowledge grows progres-sively less. Some would say that this has led tounrealistic expectations about health, and the failureof the medical profession to met these expectationshas resulted in a degree of disillusion. This shinesthrough some recent criticisms of the profession inthe press and on television. Criticism from within



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Fig 4 The Good Samaritan: eleventh century miniature,Escorial, Spain.

the profession is also not lacking. Let me give threeexamples.

Professor John McCormick in his thoughtful bookentitled The Doctor-Father Figure or Plumber?examines the thesis that modern doctors haveperhaps neglected an ethical responsibility con-cerned with service, an unwritten promise to societywhich transcends any written contract of duties andresponsibilities.9 This, he feels, has led to an altera-tion in the relationship between society and the pro-fession, so that doctors may be in danger of losingthe special place in society which has been theirprivilege since organised communities began. Heemphasises the fact that in the eyes of society serviceis the price of privilege.

Sir George Pickering in his 1964 Harveian Ora-tion "Physician and scientist" rejoiced that he hadbeen privileged to be both.6 But in his later years hefelt that medicine had reached a crossroads and hefeared that the profession had already chosen adownhill road that would reduce it from the level ofa learned profession to a technological trade union.

Before he died in 1981 Walsh McDermott, a goodfriend of British thoracic medicine, addressed him-

Douglas

self to the criticism that medicine was perhaps beingoverinfluenced by the rapidity of technical advanceand that a mechanistic, technically orientatedapproach was supplanting the so called caring com-ponent of medical practice. In an unfinished paperentitled "Technology's consort" '0 he emphasisedthe importance of the personal support function ofthe doctor, which he called Samaritanism from theBiblical story, depicted in one of its earliest artisticforms in an eleventh century miniature produced forEmperor Henry III (fig 4). McDermott's theme wasthat medicine is deeply rooted not only in sciencebut also in the Samaritan tradition. He believed thatSamaritanism must be included as a legitimateobject of serious biomedical study and he pointed toour obligation to link it with technology in our everycontact with the sick. In our picture Samaritanismwas almost all that our horseback friend had tooffer.When we attempt a synthesis of the thoughts of

McCormick, Pickering, and McDermott we are ledto the conclusion that the spirit of free inquiry has tobe blended with a heightened sense of humanity inthe doctor who truly matches up to his obligationsand promises.

Finally, when I have reflected on some of thereally outstanding respiratory clinicians of the past Ihave been conscious not only of their allegiance toteaching, to research and to high clinical standardsbut also of their awareness of the social responsibil-ity of medicine. The times we live in demand such anembracing commitment and I am confident that theBritish Thoracic Society will continue to ensure thatthe response is intelligent, rational, and relevant.

References

'Wakeford R, Roberts S. Thirty years on: examinationperformance and career success of the 1950-1 intakeof Cambridge medical students. Br Med J 1983;286:1796-8.

2 Kamien M. Radical versus traditional schools: are thegraduates different? Medical Teacher 1983;5: 104-6.

Thomson A. The consummation of William Harvey. BrMed J 1961;ii: 1303-9.

4Turner ES. Call the doctor-a social history of medicalmen. London: Michael Joseph, 1958.

Himsworth H. Society and the advancement of naturalknowledge. Br Med J 1962;ii: 1557-63.

6 Pickering G. Physician and scientist. Br Med J 1964;ii: 1615-9.

Booth C. The human touch. World Medicine 1983;14:15.

Hawkins J. Time to treat the whole patient. WorldMedicine 1983;24:35-6.

McCormick J. The doctor-father figure or plumber?London: Croom Helm, 1979.

McDermott W, Rogers DE. Technology's consort. Am JMed 1983;74:353-8.



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