Remembering the '40s
Mort, as I remember, started life early, literally, and had wife and kids while training at Bellevue, living on the munificent sum like $75 per month, so he qualified for those basking new Jacob Riis-soon-to-become-squalid housing developments on the East River. Mort was brilliant, compassionate, and tolerant. And we had a gaggle of guys and gals who worked unceasingly under the tutelage of the Columbia profs mentioned in the article, with the addition of Amberson, Thompson, Warshaw, and others who dedicated themselves to the furtherance of medical education. Sure, an occasional 36-hour stretch, but we learned by doing, and doing, and doing. There were Ivy DeFriez, Bill Field, Wes Oler, Ted McCrum, Martin Fitzpatrick, Eleanor Brown, Gerry Turino, and so many others who spread the gospel once our inmate time was done. There was Miss Thelma 'Merm' Mermelstein, one of the greatest examples of dedicated and capable nursing who could run a floor of 50 beds with humor, tolerance and somehow work with a spirit of unity for the good of all. And perhaps it was that milieu, that aura, that transcendent essence of the greatness of the medical profession that Mort and the rest of us carried away from the institution under the guidance of some of Columbia's greatest men, like Dickinson Richards.
What a life, for those of us who still have it, thanks to our forbears, our institutions, our friends and colleagues and teachers, fostering humanism and science, ideas and ideals, which were the wakening seeds of thought planted by the ancients and then growing with intellectual nourishment to the phenomenon of smaller particles and a larger universe we still attempt to understand in '99. Human nature seems unchanged. Thanks for the memories.
Charles A. Webster'43
The following was reprinted from the May 1999 issue of Academic Medicine, published by the Association of American Medical Colleges. The letter writer forwarded the letter to P&S Journal, and the AAMC gave P&S Journal permission to reprint it.
Perhaps a more useful way to prioritize topics in medical education would be to consider what physicians must keep in their heads vs. what they can look up quickly. For example, a clinician must have in his or her head three signs of Zollinger-Ellison syndrome: intractable ulcer disease, multiple ulcers, and ulcer disease with diarrhea. If the clinician has the knowledge to consider Zollinger-Ellison syndrome when a patient has these symptoms, he or she can easily look up the appropriate tests, treatment, etc. Similarly, if a clinician isn't able to think of Lyme disease when a patient presents the associated symptoms, his or her knowledge of the testing and treatment protocols for Lyme disease is useless. This sense of priorities putting the knowledge necessary to recognize symptoms and do differential diagnoses over the knowledge of tests and treatments' might seem obvious. However, I dont see' it reflected in the Medical Knowledge Self Assessment Program tests or in my contacts with students and residents.
My impression is that medical students are having more information thrown at them than they can possibly remember. One of the reasons for this is that too much teaching is being done by 'subspecialists. I see residents who have no good clinical approach to a patient with epigastric paintaking a detailed history regarding ulcers, biliary colic, functional pain, etc. Epigastric pain to them means ultrasonography and endoscopy.
Problem-oriented teaching may help. And I hope this letter will prompt educators to reconsider how best to prioritize the vast amount of medical knowledge they must present to today's medical students. If any reader wishes to discuss my ideas with me, I can be reached by e-mail at firstname.lastname@example.org.
Some two years after leaving P&S, Dr. Whipple was invited to return for a guest demonstration in the operating room, and I was able to squeeze into the standing room in the rear. I don't remember what the procedure was (not a Whipple operation), but at some point in the surgery, as he was tying a knot, the suture broke. There was a muffled gasp from the audience, and his assistants froze. Everyone was silent for what seemed like a very long moment. Then the master spoke:
"If you don't break a suture now and then, you're using too heavy a suture."
This thought has been my grateful refuge on more than one similar occasion through the years.
Craniectomy for ischemic stroke
In 1991, while living in Boston, my 32-year-old daughter suffered a right-sided ischemic stroke. After initial care at her community hospital she was transferred to the ICU at Boston University Hospital. Despite aggressive medical management her intracranial pressure rose relentlessly until, as a final desperate effort, a craniectomy was done. (Subsequently she was offered a plate to fill the defect but declined it.) After the surgery she regained consciousness, left the hospital, and went on with her life; she is hemiparetic and the quality of her life is good, though not as good as it was and far better than the alternative. (As her sister said at the time, the decision to try the surgery was a no-brainer.)
Since this all happened eight years ago, it seems the Lowells and Cabots still speak only to each other and to God.
Twenty-five respondents felt that cadaver dissection was essential for their current practice, and all felt that Gross Anatomy could not be taught effectively without dissection. This group included 13 surgeons.
Eleven respondents felt that cadaver dissection was beneficial, and 10 felt that Gross Anatomy could not be taught effectively without dissection. This group included two surgeons.
Seven respondents felt that cadaver dissection was irrelevant to their current practice, and two felt that Gross Anatomy could not be taught effectively without dissection. This group included two surgeons.
Several respondents provided additional comments, and I provide three representative excerpts below:
"Making that first cut through intact human skin is a rite of passage, in which you confront the reality of what you are choosing as a profession." Richard Hurd Jr.'67, Orthopedic Surgery
"My 10 years of residency training and fellowship gave me continued exposure to medical students [from other universities] whose anatomic dissections were often limited to single extremities or single anatomic regions such as the chest or abdomen. When asking questions about anatomy it was not uncommon, for example, to ask a question about chest anatomy and be greeted with the response, 'Oh, I am not sure, I only dissected the abdomen and not the chest.' [I] was even more thankful for my full year of cadaver dissection in Gross Anatomy at Columbia." 1988 P&S Alumnus, Pediatric Surgery
"There are so many good models and books plus our own superb teachers of anatomy [as alternatives to cadaver dissection]. The experience and knowledge gained by the tedious dissection of dried out tissue seems unjustified to me in light of the immense amount of other subject material which the students are required to learn." 1951 P&S Alumnus, Pediatric Surgery
I thank the respondents for taking the time to make their insights available to those (like me) who lack a detailed understanding of the relationship between medical training and practice.
Aaron P. Mitchell
Editor, P&S Journal