Annual Oration 1963
By Charles H. Bradford, M.D.
The Annual Discourse, as it seems to me, is not an occasion for presenting a scientific paper, nor for reviewing the routine problems of the year; rather, it affords a recurring opportunity for measuring the standards of our profession, and for evaluating the principles on which they are based. This is the topic that I wish to offer, pursuing it with no specific objective other than to indulge in a leisurely and contemplative discussion of our aims and ideals in the medical world.
The Vision
To begin with, ours is essentially a scientific occupation, based on a scientific point of view. We deal with facts, not with faiths. Yet we should not, on this account, allow ourselves to forget that behind every deed, there must be a dream. Actions can gain no true validity unless they proceed from ideal concepts. The further we progress into life's bewildering complexities, the more we come to realize that they confront us with only two major objectives: to frame a vision; and to perform corresponding actions. It is as true today as it was in ancient times that where the vision fails, the people perish. Therefore, let us begin by asking ourselves, What is our vision? And thereafter we may ask, What is our performance?
Some years ago, Dean Roscoe Pound addressed this society on the distinction between a profession and a simple trade. He pointed out that a profession possesses a common purpose, under which its individual members become united and to which their private interests are subordinated. In this sense, it might be said that all mankind are jointly engaged in the single profession of trying to build a better world. But within this universal category, each separate profession contributes its special effort. The law, for example, deals with more than the simple management of cases in court; for as a profession, it seeks to build a general basis for justice and stability throughout the land. Where business is simply a trade, its members bargain only for their own profit, but business, as a profession, strives to increase the economic welfare of the community as a whole, just as education aims at improving the general intellectual level, and religion at uplifting the moral and spiritual standards. What then shall be said of medicine? Are its aims confined to the treatment of people's health? This seems like too superficial an analysis, but rather than trying to define it with inadequate words, I shall attempt to typify it with an illustration that I believe holds its deepest meaning.
This occurred in the Philippine campaigns during the last world war, and it left a lasting impression on my mind. A messenger came running to our aid station to report that his patrol leader had been badly wounded and was being brought in by stretcher. We knew the man well, both as a fine friend and as a splendid soldier, and we hoped the wound would not prove too serious. But the runner immediately reported: "Captain, he's hurt real bad. He's shot through the chest, and he's bled a lot, and on the stretcher, he keeps moaning, 'Oh, God, don't let me die; I want to live!' "Before he reached the aid station, he was dead, but his words keep ringing in my thoughts, for they seem to me to voice the appeal that humanity makes to the medical profession. From this incident, we can realize that here is a responsibility we share, with God. "Don't let me die; I want to live."
Our activities take on tremendous significance when we view them in this light. With such compelling motives, the medical profession has developed traditions of devoted service that transcend private interests and surmount social barriers, and reach to all people, of all ranks, at all times. Because of this characteristic, the doctor is thrown into intimate contact with mankind as a whole, and his work becomes one of the most universal, as well as one of the most personal of all services.
This was a thought that my father recognized long ago, and described in words I have always cherished:
The Doctor must be broadly human. He deals with the vagaries of age and the fancies of youth; the sports of boys, and the appetites of men. In his profession, he tests the aviator, rations the soldier, estimates the endurance of the laborer, cares for the worried mother, and relieves the desk-ridden financier. His thought must reach to the ideals of the clergyman, and must interpret the flesh prompted dreams of the man of the world. And in this service, neither the precision of Science, nor the efficiency of business methods will suffice, for above all else, the practitioner must preserve and exercise the kindly indulgence of a considerate friend. In what academy can these lessons be taught?
The appeal that humanity makes, from death, for life, is more than a mere plea for survival, for life is never complete until every component in the machine for living is functioning perfectly, and without impairment. To restore life, we must restore activity, we must restore health, and we must restore happiness. Therefore, the doctor must look deeply into the intricate mechanisms of the body to gain a full understanding of their workings. This will bring him closer to the mysteries of nature, and from them he will learn something of what the Book of Job calls the "Wisdom of the Inward Parts." This includes the biochemistry of enzymes, the masterful secretions of endocrines, the carbon-oxygen exchange of alveolar membranes, the glomerular filtration of kidneys and a thousand other miracles of physiology. The doctor observes the anatomic perfection of the hand, and the stabilizing microphones of the ear, and the television screens of the retina, and the multiple batteries of electronic computers in the brain, and from all these, he gains a new reverence for the incomprehensible power that created man, "so curiously and so wonderfully wrought." Such a marvel could not have evolved without the operation of a supreme and divine intelligence. If this thought deepens the faith of the modern doctor, it only reaffirms the ancient texts of the Hebrew Psalms when they say, "He that planted the ear, shall he not hear; he that formed the eye, shall he not see; he that teacheth man knowledge, shall not he know!"
As the doctor treats these tissues of mystery, he realizes how different is his profession from that of the engineer, who deals with physical forces and the physical materials, from the merchant, who exchanges commercial goods and commodities, or from the industrial laborer, who stands for long hours in the tedious production lines. The materials the doctor handles compose the very fabric of life itself; the mission he serves, the objective he seeks, and the vision that guides him, are best expressed in the words of the Gospel, Give life, and give it more abundantly.
The Performance
Here we should pause and turn from the aims and ideals of our profession to ask how far we have been able to convert our hopes into performances. Strangely enough, in the long course of medical history, progress has been extremely slow; it was not until about a century ago that modern medicine began to be born. Up to that time, and even at that time, pharmacology was restricted to the use of unreliable and often irrational drugs having only a slight therapeutic value. Surgery confined itself almost entirely to dressing wounds, lancing abscesses, setting bones and amputating injured limbs. The specialties hardly existed at all, and medicine as a whole succeeded more through the Vis mediatrix naturae — the healing force of nature — than through the physician's skills. It comes as something of a shock to us today to realize that if we were practicing in 1863 instead of 1963, there would be little more that we could do for the serious illnesses than was done by the priests of Aesculapios at Epidaurus, three hundred years before Christ. Since that time, progress has moved fast, and then faster, as each new discovery expanded and accelerated those that followed, until the unbelievable became the commonplace. Diseases that men at first feared to treat yielded, one by one, to cures, and even the great epidemics have gradually been subdued.
It would be tedious to dwell on these familiar, though nonetheless astounding, triumphs, but we cannot help enthusing over the remarkable rapidity of their advance, for most of their major developments have fallen within the living memories of our present, senior members, or in the lives of their immediate predecessors, who taught them. They grew up in an age that is hard for us to visualize, filled as it was with "the pestilence that walks in darkness, and the destruction that wastes at noonday." They sat at the bedsides, and shared the sufferings and the tragedies of numberless patients who died hopelessly from complications that modern medicine could have relieved or prevented. If these conditions are hard to appreciate, how much more so the circumstances of pioneer surgery, which our older members can describe to us from their own experiences as they tell of the days when they operated in patients' homes, on kitchen tables, using smothering anesthesia, without any restorative drugs, and not even knowing the blood types that make transfusions possible. Yet out of their work, and in their lifetimes, has grown the whole art of modern surgery, with all its skills and refinements. Today they can talk without astonishment of removing the abdominal aorta and replacing it, of opening the valves of the heart and repairing them, of pinpointing vital nerve centers in the brain and freezing them, of exchanging kidneys, of substituting tiny ossicles of the ear, to cure deafness, of patching down the separated retina, to prevent blindness, and of resuturing freshly amputated limbs, with good expectation of functional recovery.
And all this is only the beginning, for medical science today is like a rocket that has just left its launching pad and is approaching the edge of darkness, about to zoom off into unfathomed space. A new world of microscopy awaits further electronic research. A new world of surgery awaits modern, scientific instrumentation. And many new worlds of medicine await the accessions of knowledge that already seem imminent. It even seems possible that biologic skills will learn to treat defects in the chromosome, and if this is accomplished, medicine will have borrowed the role of destiny, in shaping man's future, and molding his fate.
The Joys
These, then, are the extraordinary capabilities that any earlier generation would have considered supernatural but that, today, our profession has bestowed on us so generously. As we wield their healing powers, we should pause to acknowledge our extreme good fortune in having been given miracles to work with, rather than myths and fables, like the doctors before us. This has made our generation the most privileged that ever entered the ranks of medicine, and by the same token, it should bring us more joy in our work than came to our predecessors. Some doctors are apt to complain of their frustrations, their hard hours, their heavy responsibilities and their perilous decisions, but here for a change, let us take the time to say a few words about our joys.
Joy is a more profound emotion than pleasure or happiness, for it dips its buckets deeper into the wells of the spirit, and draws up satisfactions that superficial experiences could not reach. What joy, for example, could compare with mastering the knowledge that enables us to lift the burden of sickness off men's bodies and to liberate them from the thralldom of disease? We cannot escape being cast down by the discouragement of our incurable cases, by the tragedies of premature deaths or by the grief that Oliver Goldsmith described when he wrote: "Why was I born a man, yet live to see the suffering of wretches I cannot relieve?" But now we have been endowed with this magic touch of modern medicine, with its power to reach out and offer new remedies. What doctor has not thrilled with elation to find that he can reverse a disease, that he can restore health or that he can cure his patient? Is there in the whole language any word as joyful as cure?
Another of the joys of medicine was suggested by Dr. Richard C. Cabot, who pointed out that the physician is stationed at the crossroads of life, where men encounter adversity and suffering and where the clearest view of character is obtained. From this vantage point medical practice discloses the frailties, the defects and even the debaucheries that make up so much of human experience. But here, also, practice reveals life's tenderness and its self-sacrifice, nobility and affection. Human worth towers so high over human weakness that it is a constant joy to watch the two on this critical proving ground, where they encounter their severest tests and display their fullest splendor. Perhaps it was for this reason that Charles Dickens wrote approvingly of a doctor's work: "Wherever he was, something real was."
While we are speaking of the satisfactions of our profession, there is one other that we should mention. It does not rise from the compassionate joy of healing, nor from the fascination of watching the human drama, but rather from the intellectual delight of pursuing medical studies, with their rich and varied and deep interests. These are intensely scientific; yet all the while, they are filled with the pleasant colloquialism of people and events. They exercise the highest imaginative faculties of inventive thinkers and also the keenest practical ingenuity of mechanical technicians. Their endless quest for knowledge inspires the most painstaking scholarship and research, and the instant peril of their sudden emergencies challenges more adventurous intellects to match their wits in competition with the maneuverings of disease. There is, in fact, no other profession that so constantly engages in this game of mortality versus survival, with its members ranged on one side of life's chessboard, and grinning death on the other.
Science and Personality
In this contest with fate it is quite obvious that science will serve as the doctor's foremost weapon — in fact, it is hard to think of medicine except as a science. But we must not think of it only as a science, for that would deprive it of the intuitive skills, the sound judgment and the deep personal insight that contribute so much to its effectiveness. The earlier practitioners recognized these qualities more fully than we do today, and employed them better. This is well illustrated by the aging physician who devoted so much care to one, hopelessly terminal case that his younger associate protested by asking, "Don't you think you are wasting your time, giving so much of it to a patient you can't cure?" The older physician merely smiled as he answered, "But, Doctor, I cure her every day: that's what takes so much time." Cure her of what? Of loneliness, despair and dread of dying. Cure her with what? With friendship. The older doctor had a quaint, outdated habit of quoting Latin verse, and he repeated the lines of Horace, "Solamen miseris socios habuisse doloris" (it is a solace to the misery of grief to have friends). Though the quotation may be outdated, let us hope that there will always be physicians who will practice its precepts.
This last thought uncovers one criticism of modern medicine that may represent its most basic weakness today. As science advances, it brings with it an artificial precision that supplants the experienced judgment of the physician with the inadequate data of laboratory tests and procedures, and as this tendency increases, it converts the relations of the doctor to his patient into a cold atmosphere of impersonal testing rather than the cordial attitude of friendly assurance and reassurance that should exist. This factor, more than any other, is responsible for swinging public opinion away from the doctors or at least away from the automated type of medicine that is too frequently practiced. We are very familiar with the questions that are repeatedly asked today: What has destroyed the medical image? Why are there so many malpractice suits? How have the doctors lost their prestige? The answer is the same for all these questions. It is because science is interposing this screen of laboratory technics and laboratory thinking between the physician and his patient, so that neither can see the other in a sympathetically human and intimate light. If medicine is to regain its former status, it must resume its service of friendship; it must renew its personal interest in the patient, and it must reaffirm its faith in the mission to give life and give it more abundantly. Though medicine is scientific, life is spiritual.
Medical Security
Notwithstanding any criticisms there may be regarding modern medicine, we must still remember that it is now giving the public a new type of security that never existed before. Curiously enough, in an age when people are unduly conscious of their economic security, and their social security, they more or less take for granted this miraculous form of medical security that surrounds them. Surely among the many hazards of life, there are none greater than the hazards of health. No one, young or old, can rise in the morning to start the day, or retire for the night, without anticipating the possibility of some emergency in which a physician's help will be urgently needed. Thus, people everywhere, whether they realize it or not, live under the constant shelter and protection of the medical profession, and it becomes our obligation as doctors to make sure that adequate help is always available. We occupy both the front rank and the rear rank, the outermost and the innermost positions in the protective network of medical defense that shields the community; in this responsible position, we must never forget the lifesaving nature of our service, or the insistent duty that it imposes. If we neglect either, we cease to be physicians in the true sense of the word and become mere technicians, or merchants of health.
So much then, for our vision; so much for our performance. Of both, it may be said that they have created and thus far maintained the finest medical care ever conceived in history. Here, in America, they have produced a standard and quality of care that is nowhere excelled, and seldom equaled. Patients journey here from every continent to share its benefits, and from every nation, doctors arrive seeking its knowledge. Here, we study and adapt the brilliant contributions of foreign clinics, together with our own, and in return we render a co-ordinated type of medical practice that leads the world.
We should not close without recognizing that there is always need for further progress. What has been done well today must and will be done better tomorrow. Medicine must march with the times, not against the times, and wherever it can enlarge its service by governmental programs, it should welcome the opportunity — so long as this does not destroy the individuality and initiative and personal responsibility on which its effectiveness rests. For the future, let us hope that medicine may escape from political entrapment, that the splendid treasure house of healing will never be exposed by visionaries to the plunder of demagogues and that physicians may always continue to confront the perils of life and the challenges of death with unhindered freedom in their God-given profession.
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Bradford, Charles H. "Medical Aims and Ideals." New England Journal of Medicine 268, no. 21 (1963): 1147-50.
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