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·FREDERICK CHRISTOPHER, MD
Emeritus Professor of Surgery Northwestern University Medical School
One Surgeon's Practice
WB SAUNDERS COMPANY
Philadelphia
1957
London

·1957 DY WB SAUNDER COMPANY
Copyright Under the International Copyright Union
All rights reserved. This book is protected by copy
right. No part of it may be doplated or reproduced
in mny manner without written permbasion from the publisher
Made to the United State of America at the Press of W B
Saunders Company
Love of Concurs CATALOo Curs Numin 57-11268

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·Preface TM this book are recorded some personal observations and expen ences not only in the preparation for and the development of an aretage general surgical practice, but also in the daily pracual and dewiled conduct of such professional work Included are anecdotes and illustrative samples. It is hoped that the information here presented may be of inter est to those who wish to obtain a picture of what a general surgical practice may be, aspecully those who are contemplating the study of mediane. It is intended, morcover to be of help to medical students, interns, residents, practiang surgeons and gencral prac duonen Included are discussions of the selection of a medical school choice of a loality in which to practice hospital staff and society memberships, the conduct of the surgeon in the operatmg room the teaching of mediaal students and house officers, medical re search, conversations with patients and relativa regarding opera tions and regarding cancer medial writing, surgical fees und surgical pitfalls FREDERICK CHRISTOPHER TVipnetka, Illinois July 1957 1

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·Contents 1 19 34 I Preparation for a Surgical Practice II Choice of Location Hospital and Society Memberships III Early Surgical Practice IV The Patient Meets the Surgeon V Nonoperative Hospital Activities VI The Surgeon in the Operating Room VII Anesthesia VIII Surgical Pitfalls IX Surgical Teaching X Surgical Writing XI Nonprofessional Activities XII Personal Injury Litigation XIII Surgical Fees XIV Imponderable Rewards of Surgery Epilogue References Index 49 58 73 84 89 99 105 110 115 120 134 141 143 147

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·CHAPTER 1 Preparation for a Surgical Practice TO IL deasion to study medicine is made with difficulty in some ases and easily in other. Frequently the ambition to become a doctor is aroused at an early age but, u in my own case some uma not until after graduation from college. Thus ambition evolves from a combination of many factors such as the character objec uvo und industriousness of ones parents, ones environment, one. Intelligence and ones concept of the practice of medicinc. Usually a young man takes up medidne because of adminton of a certain physiaan, ether a relative or a friend or has appredated the kindness shown to him during an illness by a physician and is impelled to try to imitate that phyucan. Regardless of the information he may bayt, a young man may fee] intensely inter ested in the subject of medianc or may be attracted by its occa sionally dramatic aspects portrayed in movios and on television and by the highly colored accounts found in some novels In the carly days, a physician was looked up to in bus community as one of the few outstanding men of the region. Admittedly this sodal prosuge has been diminishing No young man should contemplate a career of medidac if he thinks he will have in assy life. Nor should be enter medidne in anucipation of great finangal rewards for he almost certainly will not obtain them. Fortunate us the young man who hu his mind definitely made up before going to college I ·or shortly thereafter While ruch a decision is usually made on an emotional and idealustic rather than factual basis, it is usually unshakable To the young man trying to make a decision as to his life s work, certan books which likely will be more fully appredated and better evaluated during college year than in high school, may be helpful. The first of these guida u A History of Medicine by Ralph H Major 1 Another is A Surgeon's Life by J M T Finney: Older but still valuable is Aequanimitas and Other Essays by William Osler: In 1954 Noah D Fabricant publuhed Why We Became Doctors in which he gives, in their own words, the reasons why fifty doctor selected mcdiane as a career Any one who contemplates mediane as a career will learn much from reading an admirable anthology enuitled 100 Years of a Doc tor's Life' The authors hy "In this book the doctor's life is realed in all its uspects, so that reading it, you-the patient-may row examine the doctor For such i kuulny there is no better source of information than the doctor himosell. Out of many ventures in medial autobiography made dur Ing the past four centuries there have been chosen those passage which are most revealing of the medial haman being in the roundthat convey something of the substance and marrow of what it means to be a doctor The aim is to present an informal portrait which will show the doctor not only u the Great Healer or Great Scott (though these aspects are not neglected) but also a a ddren of everycans world. To achieve this alm, more than eighty personalities have been relected from among men and women who hure made significant contributions to the literature of medical autobiography Here you mect docton from Austria Canada, France, Germany Grat Briuln, Italy Russia, Spain, Sweden, Switzerland, and the United Sta" Certainly to witness an operation has slight value. It is a mere spectacle, since the novice cannot possibly understand what it is all about. The fint operation that I witnessed made me somewhat IIL Similarly a visit to a dissecting room is unplezant and does not give any inkling regarding the practice of medicine. I would recommend that a young man be shown the workings of an outpauent department in a medical school or a large hospital There he will see unfortunate sometimes dirty ignorant people whom he must later help while they in turn help hun to Icam about medicine. If he feels kindly toward them and if he is inter 2 ·ated in the fact that these people have problems which he, as a doctor should be able to help solve, he is on the right road. He should talk to some medical students in order to obtain an idea of the intensity of their studies and the time-consuming work required, keeping in mind, meanwhile, that any student a few years older than himself will probably be tempted to affect an air of cynical intellectual omnipotence. A friendly visit with a successful young pnciuoner will and greatly particularly if the latter lads him to realize the deep concern for his pauents which often lies beneath a doctor s cheery confident manner Best of all is a talk with an older physaan one who has had a finc career and who has the pauence to discuss matters with him. Such a man may help him evaluate hus interdu, mouves and capacuies. Such a conversation might clarify the fact that a studious mind us essential, and while aggressive confidence cheerfulness and a pleasing personality art splendid allies, they are never subsututes for intelligence. A university degree is a prereqwsite for the study of mediane. I have a firm belief that during the university period the student must learn to think and to make deagons and should become on riched 31 much as possible by the cultural subject matter of the humanitiesOnce in medical school, he must apply humself to such intensive and highly specalized courses that there is no opportunity for such studios. Only the minimum amount of time should be spent on so-called "premedical" work in order to comply with medical school entrance requirements. Of course, clementary chemistry u a necesity and physia, botany and zoology are legit imate preparatory courses. Frankly however I hope that the stress on science requirements will be decreased. Usually much of the liberal aru work in the sciences is repeated more intensively and more practically in medical school I am confident that the ultimate product-a surgeon-will be greatly profited by studying history Engluh literature economia, mathematia, philosophy ustronomy und geology before entering medical school. The currently proposed plan to make college and medical school an eight year anit in which the soalled memory" courses such as anatomy and physiology are taught in the first years and the so alled Teasoning" courts ure taught in the last years impressos me as a nather precnous experiment. The first pitfall lies in the assumption that only those students who deade at high school graduation on a medical career should be accepted. The second 3 ·pitfall is the wide separation in time of the study of anatomy physiology from the study of clunial surgery and medianc Will Mayol once said "If one of the year which I given to pre medial work in 01 univenta could be given to wocul eduauon, it would help t! phyldan understand the poychology of the emotional field. Abdul to evaluate emotional reactions and their relation to rodety woul often be of greater naloe to him and to the patient than the so-calle higher pre-medial culture" lo a comprehensive report on premedical education in United States' three eminent deans, Aura E Severinghaus 15 ate dean of Columbia Univeruty s faculty of medlane, Willian Cadbury Jr of Haverford, and Dean Ementus Harry Carman Columbia College deprecated the emphasis upon science cou and stated their belief that colleges and medial schools are & uating too many doctors with little or no interest in the culti implications of their profesion much less in those things wh. would enable thein to formulate for themselves a stufying ph} ophy of life. The university that is attended-if it u pomble to have a chou should be the one with the most stimulating and interesting Instr ton. Who could fail to profit from the inspiration of such men the late William Lyon Phelps of Yale and Gilbert Highet, Columbia. Moreover the student should choose, if possible a u veraty where the level of undergraduate intelligence is at le equal to hu own, and preferably bigtier Such a university shot give outlet to the exuberance of youth by means of sports in whi all partiapate and should minimize the spectacles in which majoriy of the students merely observe the game in spite of . faa that the spectacular contests are finandally important to ma univerwie). Where the fraternity system is strongly developed, t Hudent will probably benefit by becoming a member of one of u lading groups unce a good fraternity often adds to ones aduc uion in the humanities. Unlas abundantly subsidized, the stude usually is wise not to marry while in college and medial schoc although it is easy to ale notable exceptions to such counsel Never again in his life will the student have such an opportunit 10 acquaint himself with great thoughts and graat facts and to a quure valuable habits of mental discipline and drill To the extes that be avails himself of these opportunities, will his character an + ·his usefulness be strengthened and enriched. It seein's best to ad monush the student not to permit valuable opportunius to be mused because of excesive partiapation in such feverish student activities u rushing." parades, rallia, dan politics and the like. Of course, a certun amount of fun and of physical activity is necessary but there should have their proper place. It is often de arablc in the summer months to build up physical strength and health by means of outdoor activities. Those who can take a walk ing or bicycle trip in Europe arc fortunate. The choice of a medical school may be influenced by cost and location. The tuition while steadily increasing, does not approx imate the cost of educating a doctor The 1955 Annual Report of the American Medical Education Foundation gives the total four year cost of truning a typical medical student as $13,556 00 This figure wu based on 1948 teaching costs. The most important factor however u the quality of instruction which in turn is dependent upon many factors. A school must have enough funds so that it an secure distinguished teachers and provide them with the most up-to-date and adequate buildings and equipment. A medical school should be located in a aty of sufficient size that it has abundant patient teaching material in outpatient departments and in the hospital The growth of health insurance plans, both private and governmental u raising some problems for medial instruction which will have to be solved. The institution should have a satis factory record for its graduates in state board examinations and 10 their further progresi In the dinical branches, there should not be too many full time professors, as they tend to become more academic and la practical if they do not actually engage in some private pndice. If possible, young instructors should be paid a mall salary and should teach on the basis of their own experience, supplemented by textbooks. It u lamentable that the age of medical heroes seems to be pasning The reverence with which students at Johns Hopkins fifty years ago looked up to and admired Oiler Barker and Finney seldom finds its counterpart now Whenever Barker held a dinic, the largest amphitheater was always crowded to capacity His urbane manner his dear exposition and bus dignified beaning left an unforgettable impression on bus audience. The method of selecting the heads of departments in medical schools has a definite beaning on the quality of instruction. Often 5 ·these men are chosen on the basis of highly praiseworthy research work or prestige from the development of a technical skill but may be deficient in the administrative and pedagogic ability pecesary to coordinate und vivify teaching to us to "manufacture" the best physicians. A prospective medical student will do well to Hudy the 56th Annual Report on Medical Eduation in the United Suto and Canada" prepared by the Council on Medical Education and Hospitals of the American Medical Association Seventy five yean ago students seldom examined or talked to any patienu. That obvious discrepancy in teaching has been largely overcome since the pioneer efforts of Osler and other great leaders. In the fourth year and usually also in the third year a medial student when acting as a "clinical derk studies a patlent much a does a physiaan only in much more detail Physical diagnosis us taught on patients in the third year and even to a degree in the second year However the pendulum is swinging too far on the false theory that if some clinical work us good, a great amount is better It must not become a medical school fashion or supposed mark of programuve methods to increase and to accelerate this student patient contact and the performance of minor mechanical procedures at the expense of solid study of the fundamentals de tailed in the textbooks. At present the clinical approach is inacas ing almost torrentially in the fourth year intern year and residency period. Gibbon wisely observes As education is a life long process, it seems obvious that if a medical student fails to acquire the ability to educate himself he will be a poor physaan throughout his pro fessional life Michacl Davis' says "Preparation for medidoe has been oriented to the growing subject matter of a voation nather than the changiog needs of a sodety One is led to speat that the reason for this situation goes back to the control of medical eddation by specialists who have been thinking about teaching their subject matter instead of by educators who view the audent and the educational proceu u a whole, and whose ob. jective is to prepare men and women for professional krvice to society and for neli adjusted personal lines The subject matter of medidne has become to complex and voluminous that no student an master all of it cren with the most indefatigable concentration Therefore it is usually unwise to 6 ·permit the undergraduate medical student to engage in extracur ricular research. Often his time and energy are solicited by an in structor to help complete a task that may enhance the instructors reputation. The student hopes to gain favor but it is at the a pense of ume taken from study of the vast, solid subject matter of mediane. In many institutions every student seems to be regarded us a potential research worker or at least a test tube cleaner and animal dienet for an instructors project. It u argued that the weaker students will fall by the wayside. To my way of thinking, the truly dedicated research workers are few and far between. In order to select these men it might not be too whimsical to have an American Board of Research which will determine just who shall be permitted and encouraged to engage in research. The proponents of research by medical students maintain that such endeavors cultivate an inquring mind and logical reasoning Admittedly it often does this to a certain extent and trains the student in attacking and completing an Arbeit Nevertheles, a physidan s prime function is the care of sick people which entails maximum acquuntance with a vast and rapidly increasing medial Horehouse of knowledge and the study of people themselves so that the acquired knowledge can be correctly applied. The student will soon be clothed in authority and he must do hus utmost during his medial course to prepare himself to fulfil the responsibility and obligation so that he will not be found wanting When the student enter medical school, he finds hus work, assodauons and environment so different from what he has experienced in the past that he may begin to think he has made a mistake. This wa certainly true in my own case. I knew no one at Johns Hopkins except Dean Howell when I went to the first meeting of the new students in a dreary old amphitheater in an unprepossessing build ing in the older part of Balumore. Dr Finncy addressed the assembly in ringing, forceful tones "If any man in thus room has the slightest hautation about his decision to study medicine, let him leave at once! I almost did Undoubtedly the thoughtful choice and culuvauon of friendships and associauons with serious-minded fellow students will prove helpful in study and discussion. I have always been aware of my good fortune in having as a roommate Admont H Clark, who had a fine character and great intellectual strength. His parents et missionaries in Japan and he had worked his way through Oberlin College, 7 ·somehow finding time to play football and becoming a skilled vlo linist A genuine interest in research possessed him, and in 1918 he was perfusing the pancreas in experimental animals Had not inluenza ended his life that year it is not at all unlikely that he might have been the one to discover insulin All medical students are apt to overexpend their physical re- Serve. It is well for them to asign a definite dmc for physical ex ercise and recreation and to be sure of the proper amount of sleep It is now customary to grant the degree of Doctor of Medianc upon the compleuon of the fourth year of medical training Early in the fourth year the student tries to inform himself as to the character and availability of various types of internships in his own city and elsewhere about the country He then applia for an intern shup in three or four indicating his order of choice After an elab orate joint selection machinery has functioned he is awigned a certain internship The average student is prone to place the highest value upon an internship where he has the maximum authority in the treatment of patients and where he is permitted to do the most procedures of various kinds. As a consequence, the large charity hospitals have always been popular I am inclined to quer tuon the wisdom of this line of reasoning Whulc the matter is something that cach man will have to de. cide for himself to my mind the essential qualifications for a good internship include the following First, and by far most important, are the character and intellectual ability of the men on the attend ing staff. These men should be most keenly aware of advances in medical knowledge and should be actually paruapating in re search work. Usually the attending staff teach 10 a medial school but a man may be an excellent teacher without being a member of a medial school faculty The attending men should have the highest ethical standards as well as skill in the management of patients in their various specialues. It is difficult for the medical student to appreciatc that he will learn far morc by observing an expert physiaan in his dally practice of medicine than he will by attenpung the actual are of pauents himself if he is poorly super vised and aspecially if he is unsupervised The so-callal "rotating internship seems the best, since the intern will spend a centun amount of ume on ach of the various specialues and subspecialties, including general internal medidne, infectious diseases pediatria, dermatology neurology and Psy 8 ·chutry general surgery Orthopedic surgery otolaryngology opbthalmology neurological surgery wrology proctology obstetria, gynecology anesthesiology pathology roentgenology radiation therapy and oral surgery It is extremely important that the intern have a term of HIVICE in the accident of emergency room and also in the outpatient department. The interns work is more demanding physically and mentally than anything he has previously experienced. He now has serious rasponubilities in the actual care of patients. Toward them he should be unfailingly considerate, patient and kindly despitc frequent provocation to be otherwise. He must never allow himself to regard patients umply as individuals put there for his speaal benefit and from whom he must learn as much as possible. If he docs hus utmost to serve hus patients well, then he will indeed learn, in so doing, to be a good doctor His work must be accurate, complete and intelligent, but, of course, there is never time enough in which to do everything The intern must carefully write a com plete history of each new pauent, make a thorough examination, record his findings and make a tentative diagnosis Each day the intern endeavors to meet hus attending man promptly when the latter arrives at the hospital make rounds with him and write such orders as the attending man requous. During the entire twenty four houn of each day he must immediately re spond to all manner of calls, although some of them may prove to be quite unnecessary regarding any changes in a patients condition, and he will always try to keep the attending man informed of such change. If he is unable to reach the attending man, he must confer with a resident or a superior on the house staff or act on his own responsibility He should always be in the operating room prompuy for the beginning of an operation and be con stantly on the alent to try to minimize the patients apprehension and discomfort. He later writes "progress notes," that is, brief notes in the chart telling of the course of the patient s illness. He should be uniformly courteou to all nurse supervisors, nurse uds, ward Telpers and other hospital personnel. Throughout hus internship he should bear in mind that a record is being kept of his activities and will be the basis for replies to future requests for references for him when he u applying for other work. Needless to say the best realdenacs are awarded to the interns who have made the bat records ·During, or even before the internship year the young doctor will have to decide whether he is going to begin general practice mmmediately on completion of hus internship make a malaried position of some kind or prepare himself for a specialty General practice, or general medicine, as it is now frequently called, offer many attrac tions In an axcellent arucle Clarkii of Andover Manchusetts discusses the work of the generalust" in urban, suburban, mall city semirural and rural practices and defines the scope of each, Fifty years ago it wu usually thought unwise for a doctor to spearlıze unul after he had completed five to ten years of general practice. Mach can be aid for the basic wisdom of ruch a plan, but only a few men are able to achieve the finanaal maans or bave the energy to break out of the treadmill of general practice once they get into it. It is revealing and somewhat dusturbing to read one internists conception of the personal qualifiadons which are essential for the specialty of rurgery or of internal mediane. Whille carcely my conception of the situation the following words of Dr James Howard Means are of interest The personality truts and aptitudes that go to making the good phylaan differ from those that are oceded in the make up of the good surgeon The surgeon performs in the Ilme light He be the virtuoso of mediane. His profesonal work consists to a comiderable citent in daling mich aisee. At least to the patient the surglal oper ation is a culs. The surgeon, who enter and often laves the patients Ufe at this ume of aids, in a sense fs may on the spot He must make nul dedsions with great rapidity He must know his my around inside the human body with utter accuracy certainty and con fidence. He must be a robust resilient psychologically a troverted sort of person. If he did not have such qualities he could not take what the surgeon has to take "The function of the physician is quite diferent. He is len concerned, at leve if he is of the category that I have called geocralit, with crises than with the sustained are of patients, keeping them well if hc con, or trying to restore them to health if they become sick He applia any sort of treatment that he is qualiged to gire and alls in specialius when skills beyond his competence are indicated. The qualities required to make a good phridan ure understanding, In right, purposeful syropathy repombleness and patience. Also his personality must be one to Inspire confidence le is not on the spot # the surgeon is, and an more readily admit crror without losing other face or patlent, provided the patient has trust in hlm. Ils con cern is with the whole patient He is indeed the personal physician. 10 ·The specialut occupia in intermedlate position between the phyidan and the stogoon in the sense in which I have used these termi Often, he retalas charge of patients for long penods, but he is only taking are of a part of them. The difference, u I see iç between the three ategoria of pnditiones of mediane that I have mentioned is that the surgeon u interested primarily in the operation and the spedalist in the disease, but the conspedalloed phyican or gencralmı is interched primarly in the person." Needle to say there are pitfalls for the individual who has not experienced a surgical career but who nonetheless presumes to define the qualifications for a surgeon. At the 73rd meeting of the American Surgical Association in Los Angeles in April 1953 Di Frederick A. Coller reported that of the 201,277 physıdans in the United States on July 1 1919 27.3 per cent (54,891) were full time specialists and 11 4 per cent (22 976) were part ume speaaluts. The Amenan Medical Association gives the following figures for full-time specialists in 1938 1919 and 1956 respectively XUHXOT SPEGLALUSTI 1938 1949 1956 SPECIALTY (full time) Internal medicine Surgery Obatetitas and Gynecology Psychiatry and Neurology Pediatrics Ophthalmology Omalogy Laryngology and Rhinal gy- Otology Laryngology and Rhinology Roentgenology and Radiology Ophthalmology Orthopedia Urology 5 688 5,397 2,227 2,154 2,205 12,079 10,363 5,267 4 917 4 480 16,321 12,593 7 198 7048 6,567 5 860 1 472 1 451 984 1643 4,753 3 038 2,849 2,109 2,274 5 970 4,249 3 694 3083 2,746 Figures on cerufication by the various boards of medical spe aalto for 1954 are shown in table I The American Surgical Assocauonit bas stated that a "central authority for cerufication of purgeons and surgial specialist is needed in which all present and future Boards should be dis solved. Two ranks of cerufication are suggested." In an arucle enutled "The MI.D : Are Off Their Pedatal," in Fortune Magazine for February 1954 the following figures are given 11 ·AVZAME NIT COUR AYTROL HOUD WORI PER VE PROTONAL FIELD General Practice Surgery Obstetrics and Gynecology Urology Orthopedia $ 9561 17,500 17 000 16 000 19 000 61 59 61 55 59 The wide ramifications of present-day medical knowledge make specialization a necesity and it is certainly here to stay However spegalization is not an umixed blessing The Committee on Graduate Surgical Education of the American Surgial Anocation has warned against the dinintegrating influence of the ever increas ing trend toward specialization." One still hear the remark "You doctors make me tired! Alwayı sending us around to specialists. Why cant we have the good, oldfashioned family doctor who took are of everybody and every thing at a much more reasonable fee?" The answer which I have found most effective and undertandable is "Why don t you go down to your gas station and tell the men to build you a good, honat automobile from the bottom up with no specialization frills, no assembly line where one workman just know how to put on a wheel and another just how to fasten on the gasoline tank. Most people are impressed and even silenced by this argument, despite the fact that, to my mind, it is open to grave critiam. Coordinating a General Motors or Ford assembly line are men of top intelligence -commanding generals whose educauon and career qualify them to appraise the relative importance of each of the many component elements in a construction campaign. In the field of medlade however there are no exact counterparts to these commanding generals. Nominally the family doctor who lacks the specialists experience or training, is the one to evaluate the need of a spc cialist s services and to choose the specialist himsell. Furthermore every spedalust, who corresponds to a highly trained worker on the assembly line considers himself to be the outstandingly important element in each case but he lacks the broad perspective and appredauon of the significance and relative importance of the other field. The situauon is much like that in the fable of the blind man who attempted to decibe an elephant I regard as of utmost importance the impendlog development in mediane of a means of efficiently and intelligently coordinaung 12 ·Table 1 Approved Examining Boards in Aledical Speaallies TOTAL TITUICATE AWARDED TO YZAT OT KEY ACTIVA TON JULY 1953 JUNE 30 1954 KO MALG OT BOARD 1933 4,529 4 964 1934 1934 4 646 2,207 4 931 2,354 1932 1,512 4,341 1 809 1 603 4 649 1921 1935 1 American Board of Pediatria 2. American Board of Psychiatry and Neur ology 3 American Board of Orthopedic Surgery 4 American Board of Dermatology and Sypblology 5 American Board of Radiology 6 American Board of Urology 7 American Board of Obstetna and Gync calogy 8 American Board of Internal Medicine. 9 American Board of Pathology 10 American Board of Ophthalmology 11 American Board of Otolaryngology 12. American Board of Surgery 13 American Board of Anortheatology 14 American Board of Plastic Surgery 15 American Board of Neurological Surgery 16 Anelan Board of Physical Medicine and Rchabüitation 17 American Board of Preventive Medicine 18, American Bourd of Proctology (An Affiliate of the American Board of Surgery) 1930 1936 1936 1917 1924 1937 1937 1937 1940 3,908 8 404 2,494 3,880 4 964 6,158 1 023 275 488 4,291 9062 2,727 4 051 5 073 6 817 1 185 313 553 1947 1948 1949 239 1 068 144 240 1,255 165 1948 3977 4651 Total 52,486 56,619 * Journal of the American Medical Association 150 505 1954 Induded in total of American Board of Surgery the various specialties. Since enough all wise individuals to meet the urgent need may never be developed it may eventually be necesary to have an executive committee type of group similar o the committees which make high policy deditions in business corporations and bankı Perhaps it would not be too fanaful to suggest that such a coordinator of committee would be somewhat comparable to the conductor of a symphony orchestra. Certainly without the conductor there might be a tendency for each musiaan, 13.

·consaously or unconsciously to make his part of a symphonic num ber the most important or most audible Certainly we are obliged to admit that it is now impossible for the family doctor or general practitioner to become skilled in all the branches of all the spe aalud. In his presidential address before the American Surgial Society in 1954 Dr Howard C. Naffziger15 said "Recently there has been among our medial sudents a daire to go into general practice This is a result of the adnce they have re ceived. The public regret over the passing of the family doctor and advisor i understandable. The lack of guidance of the individual patient by the specialist of the ailment not in hu lioc s i com mon aperience and the poor patient b left at ka. There hu been an understandable reaction against such 10 attitude on the part of the public and by our general practitionen again the emphasis on speciallation "Nevertheless, there has never been a time when there u lon need for general pradition than today With the growth of our country the population has become more and more condensed Sparsely met ted areas are less frequent. With our roads and rapid transportation, medial center with venous specialtia represented an supply a far higher level of are than an be given by an equal number of geren) praaidonen Most often the Internist will be the family advisor because of the greater frequency of allment of short duration Our aced in this country at the present time us for more specialists grouped in center wherever the population is abdent to support reveral doctors. This would make for 1 bugher level of service. The Deed for general pncitionen u diminishing, and the trend of our medical students towards general practice to unfortunate and short nghied. I believe it will be short lived Amuredly the general praitioner is sull indispensablc. Spencere azkely observer "The physican who chooses to cater the general practice of medi doe in a community far remored from bospitab and association with tralned surgeons mus lace and solve problems which do not confront the general practitioner in the dry These problems will lovolte major injuria. In the dty he might be aluded for attempting the are ol some of these que lo a remote area be may open himself to critidem if he does not are for ther. There are sull communities whare kilichien-uable murgery is not only jusufied but imperative. There us probably do field of medicine in which the patient is to come pletely at the mercy of the doctor as he is in the surgery of trauma." While the present high degree of specialization in the medial ·profession hu brought great benefit to the patient, tince greater skill and leaming are brought to bear upon his particular difficulty it u certainly not faultlen. Often a patient is orked when he is obliged to see three or four speaalusts before a diagnosis is made. The family physician may require the opinion of the gynecologist, the proctologist, the urologust or the allergut or all of them or others. This inevitably makes the cost to the patient higher unless be goes to a clinic where one fee cover all specialists servica. Without question, in the long run an accurate diagnosis and good treatment are the most economical. The internist has a difficult role to play On the one hand, he wants to be identified as a specialist in internal mediane, as evi denced by his certificate from the Board of Internal Mediane, with a reputation for advanced knowledge and skill in that speaalty On the other hand at present he is often the first physıdan the patient scos and thus, becoming the confidant and family physican, falls into the role of the presumably wise commanding general who guides in the choice of specialuts but wants to feel, in a sense, the pauents continued dependence He thus becomes a "chame leon"-both an erudite specialist and a good old fashioned" family physician The speaalist in other branches likewise has certain pitfalls to guard against. He must fight two perils one, the danger of in creasingly assigning more importance to bus specialty per se than to the over all pautat picture, and, two the danger of becomung too impersonal in hu relationship with patientHe must constantly girard against a narrowing mental outlook by reading about other branches of mediane, by attending general medical meetings and by discussing problems with hus colleagues. He will need to recon ale himself to the indubitable fact that the doctor who takes are of Johnnys broken arm will be much more dosely known and warmly regarded than the highly skilled man who resects a grand fathes colon or a grandmother s brain tumor Finally he must be consistently courageous in differing with thc refernog doctors when necewary even at the cost of losing their referred work. On one occanon I declined to remove what I considered to be a normal gallbladder and told the patient so and that was the last case that his physican ac referred to me At present, if a young man has deaded to become a spedalist, and what is more difficult, has deaded in which particular spe IC ·aalty his interats chiefly lie, he will have to take steps to find and apply for a fuitable residency beginning at the completion of his Internship Preferably such a resudency is for three or four yean duration, Certification is difficult to obtain. For full details of the rules and requirements the candidate writes to the secretary of the par ticular board in which he u interested 17 Before being permitted to apply for the examinations for certification by the American Board of Surgery the Group I candidate will have to give evi dence oL "Completion of a graded residency in surgery of at least four yean in an institation or Institutions acceptable to the board and approred for four ytan of training by the conference committee on graduate training in surgery The final year of the prognm must have been spent in the apacity of senior or chief raident in rurgery The Board of Surgery provides a second method (Group II) of becoraing eligible for examination. It states "Completion of a graded residency in surgery of at least three yean io an institution or imutations acceptable to the board and approved for three yean of training by the conference committec on gradoatc traimng in murgery The final rear must have been spent in the a pacity of senior or chief resident in furgery Credit will be granted for surglal internship to a candidate who ha completed one other year of acceptable internship when the sur gical internship is part of a gnded residency approved for three years by the conference committee Two additional yeans of training beyond the three year of rey idency to complete a tool of fire are necessary to meet the require ments for examination There may have been spent () in practice limited to surgery curied out ander acceptable supervision (b) in the Hudy of surgery and the basic sciences in an approved graduale school of oredicine (no more than one years credit is granted for work in basle sciences) and (c) in argical training acceptable to the board in the federal service" "Note In both Group I and Group II the supervisiog surgeon mit vouch for the candidates integrity surgical judgment and technical stil Suſfcient operative work performed independently under super vision to foruly residency training must be attested to by a statement submitted to the board at the time the andidate makes application" The examinations are in to parts-the first is written and the second is oral and practical. The fee for examination is $150 On April 11 1956 Dr John Stewart, chalrman of the committec on 16 ·the American Board of Surgery of the American Surgical Associa tion reported to that assocauon, in part, as follows "During the alendar yer 1955 816 andidates took the Part I a amination of the American Board of Surgery and of these 635 pared and 183 falled, a failure nate of 224% Dunng the same period 985 andıdata took the Part II examination and of there 653 paved and were certified, the failure rate being 33.5% From the founding of the Board in 1937 to the end of 1955 6,545 have been certified by examination and the overall failure tate in the Part Il examination has been 29 1% Occasionally candidates have passed the Part II com ination after the second, or even the third, try If we add to the andr dates certified by examination those admitted to certifiabon in the founden group who number 1 152, the total number of diplomata up to December 31 1955 wu 7 697 Failure to be certified does not mean that the doctor cannot practice surgery but it is a serious blow to his chances, since hos pital staffs cannot dusregard a fulure to be caufied. Generally speaking, a hospital staff will not exclude a man because he has failed to obtain speaalty certification, but nonetheless his chances of full staff membership are greatly improved if he does become cer dified. The Bourd stata 10 position as follows The American Board of Surgery has never been concerned with measure that mrght gain spedal privilegos or recognition for its diplomata in the practice of mergery It u neither the inlent nor has it been the purpose of the board to define tegurement for member shup on the staffs of hospital. The prime object of the board is to pass judgment on the education and truning of broadly competent and responsible forgcons, not who shall or shall not perform iturgical operation. The board speafically disclaims interest in or recognition of differential emolumenu that may be based on cerufication." Residences are of many grade of desirability and naturally an ideal surgical residency is visualized differently by different persons To my mind it should include a first year in the department of pathology under the guidance and instruction of a first-rate pathologisl During thu period the resident should perform as many postmortem examinations is possible and should become skilled in the diagnosis of cases by means of microscopic sections, both frozen and paraffin. He should examine and describe as many 21 possible of the fresh speamem brought daily from the operating room. He should inrosugate some specul subject with the view of prepanng a thesis or similar publication. He should learn to speak 17 ·before hospital conferences to that he can present a subject briefly clearly and in an interesting banner The residents last two or three years should be devoted adu. Avely to surgical work with a program of increasing responsibility He should be first assistant in all of the more serious operations, and gradually as he demonstrates his competency he should be permitted to perform operations of increasing difficulty He should supervise and instruct the surgical intern. He should at all time be fully aware of the condition of the most seriously ill patient in the hospital and should be available to give help in KITOUS cava in the acadent room. Oliver Cope" note that the average age at the time of completion of a raidency u 30.5 years and says Means must be found as medical knowledge advances to avoid further lengthening of the undergraduate medial curriculum There is much to recommend the teaching of medicine and surgery as a single discipline." McKittrick 1 ay "Probably the most difficult specialty in which to develop 1 fuccent ful practice is that of major surgery It is not easy for the young surgeon, who may have spent five or six years after graduation preparing to practice the specialty of his choice, to make the necesary adjustment from the protected life of a resident surgeon to the banards and truals asociated with a compeutive prctic Formerly everything be ponible ws done to belp him, now every powłble revistance may put in hu may There young men know wbut they are capable of do ing They do not realize that nelther the public por the potential referring phyadın share thu knowledge and that vodl they have become known loally and are able to win the confidence and respect of the local community the opportunida for them to demonstrate their ability will be infrequent 18 ·CHAPTER II Choice of Location, Hospital and Society Memberships G ENERALLY speaking, there are three broad dassifications of possible locations for a surgeon (1) a small town, of 5 000 to 10 000 population, with its surrounding rural community (2) a medium-ized aty with a population of 100 000 to 300 000 and (5) - large aty with medical schools and affiliated hospitals. A rurgeon cannot locate in a community which does not have a Alfactory hospital. I have seen a splendidly equipped, modern bospiul in a town of 3.500 people Often such a hospital will have no interns, and no training school for nurses, being dependent in the latter department upon salaried graduate nurses. The surgeon usually must depend upon other physicans to help him in opera uons. The lack of a salaried, full-time pathologist is a great dis advantage, but if biopsy tissues and surgical speamers art rent to the state laboratory or to a pnsate laboratory in a large aty thus defiaency an be partly overcome. However the amount of diagnosuc laboratory work is definitely limited. The surgeon will have to make more house alls and do more Hork in hu office and in pauents homes. His "doctor bag" will be of everyday pradial use, and its contents will bare to be carefully 19 ·considered. He will have to attend to all classes of injury including those of greatest severity and complexity such as a ruptured spleen and multiple compound fractures. He will have to operate in emergency cases, such as perforated ulcer acute appendiatis and ruptured ectopic pregnancy but he will find that many patients requiring elective surgery such a gallstone and cancer operations must be sent to a larger town or city Severe preuurt will be pot upon him to split fees in fact the pressure may be so severe that he will have to leave the community to avoid surrendering to it. The important measures which the profesion is taking to crediate fee splitting will be discussed in a later section In a small town the living costs will probably be considerably las than elsewhere. However the social Uſe may be intense and demanding, and it is almost impossible for one to be independent in this regard. Failure to partidpate actively in the sodal merry go-round may be regarded as mobbushnous and may lead to ostra CLSID with resultant possible loss of praice. In a large aty oncs social and intellectual activities can be much more a matter of per konal choice The imponderablc or spiritual rewards that is, the genuine grati tude and loyalty of oncs patents, bring the highest satisfaction and may suffice for a young surgeons wants However if he wishes to become profiacnt in increasingly difficult operation, to enhance hus prestige by means of publications and to enrich his knowledge by stimulaung professional contacts 1 small community usually raises an insuperable barrier By force of finandal pressurС a young surgeon may settle in such a community with the firm intention of going elsewhere when he has accumulated a little finandal resetve. But things seldom work out this way and it takes increasing courage with each passing year to KCVET ties and make a big change Secuniy for himself and for his family looms larger than possible greater opportunities in strange new fields Only an excepuonal man aan Lit himself out of a well-established pracuce. The medium-sized aty with a population of 100 000 10 300 000 has much to offer a young surgeon He can be assured of several first-class hospitals, with competent staffs and with standards arproved by the Joint Commission on the Accreditation of Hospitals He will probably be able to confine his work to the specialty of his cholce The staff mecungs of the hospital and of the various medical sodeties of the dry will be vigorous and stimulating The 20 ·anstance of a pathology department and of clinical laboratories will be on a high plane. The young surgeon may be able to become an asutant to a distinguished older curgeon, who will be his mentor and will stand back of him as he undertaka operations of increas ing magnitude. There may be opportunity to become affiliated with a fuccessful and properly operated group or clinic Generally speaking, in a medium-sized aty the young surgeon • children will attend better schools. A much wder arcle of acquaint ance will be available for the entire family from which to select real friends, and these valued friendships can be cultivated with less ruk of appearing snobbuh or exclusive Should the surgeon be interested in and have time for partiapation in anc affairs these activities may be more readily pursued than in a large aty For ultimate advancement and development, a large aty-and thus include the immediate suburbs offer the most for the young rurgeon. However large aties are most impersonal, and the acquwuon of a practice by the fundamental route of the stufied patient u much slower than in a small aty or a rural community At first the young surgeons practice seldom is sufficient to use up all hus time and caergy These are the years when carnest work in the medical school, without pay u most rewarding and necessary ind when supplementary salaried, part time (1) positions must be sought to help provide an income. If a young surgeon has a reasonably satufactory record, appoint ment to the medical school faculty should be obtained without dif ficulty An appointment below the professorial rank may be made by the head of a departinent without consultation with other faculty members. The beginning rank is wually that of instructor and the first work augnied is wnually that of helping to teach the third year Audents in the surgical outpatent department. If the instrudors Fork u sluſactory be may be promoted and become an assistant and then an "associate and given charge of some classwork. Beyond the grade of "associate" come the grades of "wutant professor associate professor" and (full) "professor all of which are granted only upon recommendation of an appropriate committee followed by favorable action by the medical counal. During these early year in a large aty the young wurgeon will have the opportunity and usually the ome to initiate or to parudpate in some research work. Older men in the medical school 21 ·are always needing the help of younger men to assist in some research project. For a young surgeon to engage in these projects is rewarding, as he will become proficient in the use of some of the techniquo of investigation, e.g., in animal surgery bacterologial studies and chemical studies. However the young surgcon must not be content for too loog to accept a subordinate role soon he must originate and tat an idea of his own. Moreover at the outset he mut face head on the cotcept that, despite the intense efforts of medical school departments to increase the mere quantity of research publications not every one is qualified to engage in research Truly dedicated research workers are relatively few and far between and should be well cared for protected and malaried by medical schools, not being obliged to engage in private practice. As I have stated carlic somewhat ironically pohaps some day we shall have an Ameri an Board of Research, which will decide who u competent enough and deserve to be permitted to engage in research work. This is quite at variance with the present plan, which tends to take it for granted that every medical student u a potential research worker or at least should be considered so until proved incompetent regardless of the waste of bu time and energy Often, the most valuable type of invaugation is the careful study of groups of cases in an effort to evaluate accurately a method of treatment. Henry K Beecher 90 hus wisely said "It is just posible, however that there is still a place in dinlal Investigation for the great idea preserved, protected, and developed with no more phydal tools than the notebook and peod! even the nevrat investigator does not seem to think he can function unleu he has one or more complex (and expensive) Instruments. The whole qazy upolde-down situation mus illustrated the other day in a short letter that uld, Dear Doctor I have bought an oximeter wdi you suggest a research problem to use it on? In his presidenual address before the American College of Surgeons Elkın noted that. mankind and out for light and will more highl Thuat light an be shed by men who do not have claborate laboratory fadlities at their command When Mackenzle began the research that ulumately made him the greatest heart spedalst of his time. It was because a young woman with a cardlac condition had died in childbirth. IIc had not expeaed her to die Like Hippocrates, Jenner Bright, Addison, the Hunter Colles, and a host of others, be had no xtas, no pathologke 22 ·laboratories, and not much in the way of diagnostic fedlitias except what he cated himself. He was, he old, under the prevalent belief that medical research could only be undertaken in a laboratory or at lent, la a borpital with all the appurtemance. So when he began. he merely sought to find out something about the mature of patients compluntThat Ame road is still open.“ In his colorful article enutled "Please Call a Doctor" James H Spencerlo says "Just as there are general pracutioners who long for opportunities to take things out of the human body and mm their chance to pot things back where they belong, so there are surgeons who dream of being propeens in the cutting art and in the supor of their dreams sleep away their chances of aning more lives and limbs than they would ever are by operidons which make the front pages of nown paper. The departments of research are combing the human body for DCW Cu of attack. I am not at all rure but what I am afer nding in my high powered ar or playing wth my machine tools than I would be to enter a university hospital mth high blood premore, chr thods of the liver or even cold feel Publication of the report of a rare case after a truly intensive search of the world s literature, is always useful and commendable. The study of groups of similar cases in hospital record rooms has been given a death blow or at least has been made immcasurably more difficult, by the introduction of microfilming of records. No longer is it possible to run through a pilc of charts and suft out one comparable item at a time. In a large aty many opportunities can be found for earning money profesionally outside of private practice. The commonest of those is the position as physiaan on duty in a large plant or industry Here the young surgeon makes rouane physical examina tions and arts for employees who have acadents and illnassa, Afost of these positions are full-time but it is almost mandatory for the young surgeon to find one that is part time otherwise he will be unable to develop his private practice or engage in medical school activities. Life insurance examinauon is another source of revenue Also there are malaried positions in student halth acurl tia and in various night clinia Alembership in an stablished group association or partnership u often possible and, if the conditions are proper is wually doir able. Many types of groups are found, and much has been written about them. The American Association of Vedial Clinic 23 ·(establuhed in 1919) has in its by laws the following provlsions concerning eligibility for full membership Any group of seven or more full time physicians maintaining a private organization for the purposes of providing general medical care of high quality shall be eligible for membership Such group or dinc shall have on its full time staff at least five phmcans in dli ferent major spedalies, two of which spedalues shall be internal medicine and general surgery Such group ball maintalo a separate building or suite of offices for the conduct of iu practice." Jordan # in an article adapted from a chapter cntitled "Group Practice from his book, The Physician Hw Business and Hus Prac tice mayo. "There are several methods by which group-practice dinia may be clanified-by dze, by nature of mrvices rendered and by lateraal structure and organtation Some are large with phyoldan suffs rang ing into hundreds Others are small partnerships of three or four met Most groups comast of practitionen who have banded together into private organizations In some, phyvians connected with a bow pital or medial school have joined in what surely one kind of Soup practice. Some groups are sponsored by consumer and are maally toown by the name of health co-openure. In a few cases the crtablinhaent of prepaid programa bas led to the development of medial groups designed to are for the patients enrolled unda auch Insurance plani. In some groups the physicans are all in onc speaalty such as radiology 10ternal medicine or darmatology All the phyldaru in mome cinia are speaalsts in various fields in other phyuaan in general practice play an important part, and in still other the groups are composed exdurely of general practitioner. Except in a few stata a corporauon annot proake mcdidne. For this reason the vast majority of group-practice dinla are organized as partnerships Again the rarution in the details of agreement is remarkable Some consist of two or three ongioal partner founders, the other physidans in the TOUP serving as employees of the partenbip Alore often, a definite pacem of entry into the partnership is available for pbruaans joining the group. A crial period averaglog two or three years before ad mmon co the partnerlup is common, but not invariable. Sometimes 1 junior partnership has been established as a sep preceding the atundent of full partnership latus Another aspea of mout partner ships that should be mentioned is that the more ciperienced group bare generally found it impraticable to continue indefinitely sa cqual division of income among the partners or even to weigh the Infuence of all parties in the affun of the group cuactly alike Con sequently maay devices hare been adopted to make the partnerhip structure fit into a moothly functioning operation. Il a orporation could legally praaice medicine it would bare nomcrous adranuga 24 ·ton S over the partnershup especially for the groups of larger dze. Sunce it usually annot, however & ne form of group practice has begun to develop. Thu L an organization that an be described briefly us an waincorporated asociation of phyldant This structure permits all the phyicunu in the group to be on i ulary aublished by an elected board of trustees or governor and therefore it an be operated in much the Ame minder u 1 corporation. As a long term propost equal division of Det earning is probably impraciable Jordan dacribes the many different schemes to divide the group income and concludes Certainly the physicans in a group should not apect perfection from any plan to divide their income, but should attempt to make it work as well as possible." He further atates that the Nauonal Association of Clinic Managers, organized in 1926 "has rendered the medical profesion great service in gather ing information concerning appropriate business methods and in standardizing certain types of business procedures." The Ameri can Association of Medical CliniC is more concerned with the professional aspects and also maintains a placement service to phynaans deinng to locate themselves with a group practice and to group-practice clinic that doire additional professional personnel. In 1954 the association estimated that 7 000 doctors in the United States are in group practice. Much can be said in favor of the general plan of group practice. Men of different interests and different speaalues can become asso ciated economically in one building and share the expenses of rent, services and the like. Moreover the many informal exchange of opinions arc educational und stimulating, being conduave both to the patients interest and to the physicuns professional educa tion. The group idea generally appeals to and attracts patients. A young man who becomes associated with a fine group will imme diately be busy seeing many pauents and carning money and will be afforded many opportunities for professional discussion. Hus ufc is wually much more congenial and stimulating than when he starts us a lone woll." Burrows,24 writing in 1925 was skeptical of clinio and wamed of the "fallacy of collective responsibility Mediane u an art, and no work of art an reach a hugh level when it is the produa of a group of individuals, each of whom has 2 controlling interest. Who will suppose that a first-class portrait could be produced by a congery of artists? The speaalists are useful are cssential. But in the last arbitrament the clinidan must remain supreme * Excellent guide for the young phyidan for 25 ·volving some of the problems of practice have been written by Joseph Garlands and George E. Hall.* Admittedly some groups which were started with enthusiam have failed, the chucf cause of fulure being an unjust and improper organizational plan The fundamental plan in setting up a success ful group must have two indispensable cornerstone. Fint, cach member of the group must receive finanaal return in exact pro pordon to his camnings for the group A useful method is to have in annual computation of the percentage of the total groups receipts which each man has contributed and let that be his percentage of income after expenses. Properly he may take vacat tions during the year totalıng but usually not over three months, since bus diminished contribution to the receipts would be reflected in his next years percentage. It may be proper that he share equally in some joint expenses, such as recepuon toom rent, or at a similar percentage. The second cornerstone to mccess is the fixed prinaple that no member of the group is obliged to refer a patient for special treatment only to some other member of the group He may refer the patient to come member of the group if he feels that that phynaın is competent to do the work and u acceptable to the patient. However it must be strictly understood by all the members of the group that such referrals are entirely optional A young surgeon who becomes associated with a group is usually taken on a probationary basis, with an agreement which may be rencwed from year to year He may be on a straight salary or on a salary plus a bonw which is dependent upon he amount that his receipts exceed hus salary The "probationer" usually has no rent, telephonc or office supply expenser. In the great clinia, such as the Mayo Clinic, the Lahey Clinic and the Cole Clinic, each doctor is in the fortunate position of being on a straight salary His daily work does not have a piecemenl relationship to his remuneration but of course the general excellence of his work is reflected in his salary Jordanhas recently contnbuted an acellent discusson on the business side of group practice, Another plan is for a young surgeon to become agodated as a salaried assistant to an older surgeon This is a common and usually mutually proflable arrangement. The junior suirgeon relieves the senior of many time taking tasks such as crening rounds at the hospital and house calls, helps in doing dressings in the olice and 26 ·hospital and in preparing medical papers and where a residency system is not involved, assists in operauons. The senior or proceptor teaches the younger man all he knows of surgery backs him up in his first operations, introduces him to patients and teaches him by example how to talk to them, helps him become a member of various surgical soacties and sumulatos him to study and to con tribute to the surgical literature. Almost invariably such an association must of necessity terminate after a worlable interval of ame As the junior surgeon becomes more profiact and if he is made of the night stuif he naturally years to accept greater responsibility and begins to chafe at being an assistant. In time he either tumbles out of the nest on his own or is crowded out. Meanwhile the senior rurgeon has felt increasingly that it is inappropriate to all upon the younger man for the tasks of an assistant. Inevitably some padents will show a prefer ence for the junior turgeon a arcumstance which tends to inflate the junior and to pain the senior Just before this time artives, it is best for the junior's future and for development of his surgial stature to go out on his own and it will be better for the senior to have a new and younger awastant Sometima the problemu solved by having the junior and senior form a partnerhip and acquire a third man as an ausutant to both of them. Such an army rangement is feasible only if the increase in operative work u ruch us to keep all three busy The matter of hospital staff membership has already been dus cussed, and all the observations apply with regard to a large aty hospital However in a large aty the hospital usually is affiliated with a medical school and us a "teaching hospital," the staff mem bers accepting the additional responsibility of instructing interns, residents, derks and third and fourth year medical students. No physician can become a member of the staff of a teaching hospital unless he us a member of the faculty of the medial school. A discussion of the manner of instruction in a hospital will be taken up later The subject of socialized mediane is usually discussed intem perately However it us the duty of all medical men to be thor oughly informed as to its implication and the current trends toward it Dr Maansowane "The impulse to reform in medical public affairs comes usually from without, and resistance to it from within 27 ·* the majority fold of organized medianc It is only under the lash of public opinion that organized medlane maka any sodal progros." Walton H Hamilton, a distinguished law professor at Yalo once said while dissenting from the 1932 report of the majority of the Committee on American Medicine "If we are to make the most of our human resources, for work and for life, it is necewry that our faalities for health shall be just as available for all who need them sure the schools and the churche Not abould the matter of a membenhip in a health service be left to the free choice of the individual. The reasonable man of our incewon, who was prudent and provident an uld always seek his own best advantage, now lives only as a fiction." I am not certain that competition requlus in the degree of progress in mediane that it does in automotive engineering, elec tronics and the airplane industry In the latter fields the consumer u better qualified to judge the products than u the patient with regard to the field of medicine, When a young surgeon is ready to start his own practice he must decide on the locality in which he wisho to work and live. In many instances thus problem has been retted by associations made Cin in medical school or during his internship or residency Since locallucs differ greatly many different motives must be considered in making a decision. However no matter what choice is made complete sausfaction is seldom achieved In fact, the surgeon may have to change to another locality but, by and large this is to be avoided, if possible. A man who has spent his life in a large aty may believe that he would have been happier in a small town or rural community where he would be closer to his friends and patients, closer to nature and at least in his conception of it, where the pace would have been slower with more time spent with his family and more time for recreation Likewise, the man in a rural com munity or small town, even after a long and successful areer may imagine that if he had only stayed in a large aty the sumulaung cllects of a medical school and large hospital associations would have made him more progressive and more alal to medial progress. Fortunately come surgeons find aty life abhorrent while others and it fascinating and essential to their happiness. compromise is diosen by some surgeons by settling in the suburb of a large aty a solution which has many advantages. He 28 ·can drive daily if necessary to a medical school for teaching or re search work, he can be on the staff of a "icachung hospital" which us affiliated with the medical school and he can attend important surgical soacty meetings more readily than if he lived in a rural community Moreover while he still takes care of charity patients, either at a medical school or at a hospital hus practice will have a larger proportion of families who live in the suburbs because they find better schools for their children, more healthful surroundings and more congenial friends. Such families are usually quick to consult a physician and may be more appreciative of his service The young surgeon may give some thought to finding a locality where there is a dearth of doctors. However thus factor should not be stressed too heavily as the best place to find work is where there are many doctors, since that is where the demand for surgical care is greatest Of course the newcomer must meet the competition from others by rendering his best services. Thc chief stimulus for building up a successful practice comes from utisfied, grateful patients This is why compeution rather than "socialized" or state mediane probably us most advantageous for the patients. Spencerli observes For the young physicun who by forte of circumstances needs to make for himself a reputation as soon » posible, I would suggest two things. Fint, deliver come babies. If you dont interfere too much with nature your fame will grow and spread Then don t mia in opportunity to stop the pain, soothe the nerves and restore normal function in u many acadents u poníble The young mothen and the Injured auzens will dng your pruses and oftentumes pay your bill“ In selecting a locality a young doctor must consider his professional career first, for of his career is successful, bus family will usually prosper But when he must make a choice between several more or leu equal opportuniue a consideration of the welfare and happiness of his wife and children become more vital As soon as a young surgeon hus chosen hus locality he must be come a staff member of a hospital of the highest possible quality Such hospitals are fully accredited by the Joint Commission on Ac creditation (ICAH). This commission was formed on January 1 1955 and is the outgrowth of the hospital inspection program conducted by the American College of Surgeons for the last thirty five years. The JCAH now us composed of representauro of the Amaian College of Surgeom the American College of Physicans 29 ·the American Hospital Association the American Medical Asso aadon and the Canadian Medical Assocation. Each accredited hospital has a staff that is properly organized, somewhat after the manner prescribed by the American College of Surgeon standards. Regular staff meetings are held, a president i elected annually and a number of active committees handle the muluplaty of staff administrative duties ruch us the selection of interns and the super vision of records library outpatient department, pharmacy and the like. The various branches and departments of the hospital hold their periodic meetings for the review and discussion of professional subjects. The entire staff attend weekly professional meet ingi, guided preferably by the department of pathology The hospital has a close liaison between the board of directors the administrator or superintendent, and the medical staff-a Lualson which is usually most effective If the governing group is small and meets frequently to consider matters of over-all policy and to make decisions. Such a group usually includes the chairmen of the various departments and the current president of the staft The chairmen may be appointed by the board or elected by the staff, cither for an indefinite or for a definite term. If the latter * penod of not lou than three years is desirable. It is important that the staff members feel that their representa tives on the executive committee really represent them and keep them informed For purely professional matters a smaller com mittee consisting of department heads and the administrator act on such matters as admission to the staff and instruction of interns The staff has a constitution and by law which have been approved by both the staff and the board of director of the hospital. One of the most important factors in an appraisal of a hospitals professional standing is the percentage of postmortem examinations relative to the total number of hospital deaths. Generally speak ing the higher the percentage of postmortem examinations, the higher the quality of professional are and standards. A necropsy rate of 75 to 80 per cent karanis a high raung Below 50 per cent is distinctly low grade 1 young surgeon before applying for lios pital stałt privileges should investigate the statistia in this regard as well as the organization of the stall and the standing and careers of its members. Such information an be obtained from the Ameri an College of Surgeons and the American Vedical Assodadon. An applicant cannot expect acceptance on a fine hospital stal 30 ·44 unless he has a record of intelligence and energy If he is "board certified," his chances are vastly better He may be made a member of a probationary group for three to five years after which time, if he has not made the expected progress he will be dropped in a to-called closed hospital only physicuns on the staff may admit patients to the hospital but most hospitals have a group called the courtesy staff," who may admit patients but who have no voice in staff deliberations. Both regular and courtesy staff appointments are made by the hospital board upon recommendation of the executive committee of the staff, usually on an annual basis. Once accepted the young surgeon should work hard at the various tasks assigned to him some of which will not be stimulating, such as work on the records committee or the library committee, but all medical leaders have risen via these humble duties. If the young surgeon settles in a aty having a medical school it is to hu advantage to apply for a teaching position. In fact, as previously stated, faculty membershup 13 a prerequisite when apply ing for staff membership in a teaching hospital, that is a hospital affiliated with a medical school. Membership on a medical school faculty is of great value to the young surgeon, as it brings him into contact with men of high professional standing, it obliges him to study rigorously and keep up to date regarding medical progress, and u a factor leading to admission to speaal soacties. At present these advantages are of such value and the expense of maintaining a medical school are so heavy that young instructors are not paid for their services It is to be hoped that some way will soon be found to remedy this defiaency since better instruction would result of competition was keen for teaching posicions. While much of the teaching us done on the premises of the medical school, an increasing amount is being done at the affiliated hospitals. The young surgeon should make every effort to become a fellow in the American College of Surgeons and to win certification by the American Board of Surgery He should promptly apply for membership in the county medical society which includes membership in the state medical society and in the American Medical Association The next step in the ladder of special societies is the surgical society in his city if it is large enough to have one for example the Chicago Surgial Soacty or the Vinneapolis Surgical Society Usually one does not apply for membership in such a society but must be proposed by three sponson If the applicauon ·u passed by the executive council of the soacty the candidate us voted upon at the annual meeting by secret ballot. Needlew to my the executive counal has a heavy responsibility in maintaining the high quality of society s membership but it should avoid the pitfall of permitting the mere number of paper published by a candidate to be the deading factor in its deliberations. Alembership in the local surgical soocty is of extreme importance, perhaps more so than membership in the distinguished and more select national or sectional group. Take the Chicago Surgical Society for example. Except during the summer months, meetings are held on the fint Friday of each month. In the moming art scheduled operations dry dinio and presentations of research work at cach of great Chicago area hospitals and teaching cen ters in rotation Many out of town men make a habit of attending these instructive morning sessions which are followed by a lunchcon. The evening or scientific meeting is preceded by a dinner a most enjoyable affair at which lasting and valuable friendships are formed. Many a surgical problem u discussed, and by the exchange of experiences with old friends the surgeon continuo his education The formal evening program consists of four or five paper, each followed by a general discussion Many new pieces of work are presented first before this society sometimes by 2 young surgeon who is not as yet a member of the society but by invitation of one of the membert reports the results of some Investigation. This has an important place in the stimulation and encouragement of the younger men, but must not be overdone at the cost of reduang the number of clinical reports presented by the oldes leading surgeons. Furthermore the program committee must not permit the soactys forum to be overused as a reward for the many workers who perform a piece of work for an older sur geon. The president or presiding officer should encourage free duscussion of each paper and should all upon the older men to give their opinions The next objectives in the matter of society memberships to be aimed at by the young surgeon are the more acusive surgical soacties, which are not national but are comprised of men from a limited area of the country Examplos of these soccues are the Western Surgical Association the Southern Surgical Association the Padſic Coast Surgial Association and the Central Surgical As sodauon. These sacues wually have an annual three day of lour 32 ·day mecting in a large aty in the area The sessions are long and w many papers are presented, often fatiguing Since all of the paper can be read later in the published transactions, the chief advantage of attending the meetings is to meet and talk with some of the leaders in surgery In the United Stata the surgical soacty which is generally considered to carry the most prestige 1 the American Surgical Association This great society sometimes referred to as the 'Brahmins, was founded in 1880 by Samuel D Gross who became its first president Among ita presidents have been many of the great men in American surgery including Senn, Warren, Keen, Macas, William and Charles Mayo J M T Finocy L L Mc Arthur Cule, A J Ochsner D F Jones, E. W Archibald and Evarts Graham. Thus society whose active membership is limited to 250 has had a powerful influence in aguring and maintaining the high standards of surgery in this country Next in importance to the American Surgical Association come the Society of Clinical Surgery and the Society of University Surgeons In addition, there are numerous Mote specialized societies such as the Amccan Asso aation for the Surgery of Trauma, the Society of Neurologial Surgeons, the American Urological Association, the Amcan Orthopedic Assoazuon, the American Goitre Association and the American Soaety of Plasuc and Reconstructive Surgery One hun dred and reventy seven American and foreign societies are listed in the American College of Surgeons directory Another type of surgical society is the so-called travel club composed of a mall group of congenual surgical leaders who meet annually in a different medical center where new work u presented and discussed and a great deal is learned from conversations with old friends over the three to four days of meeungs. I am happy to be a member of the Halsed Socety named in honor of William S Halsted, the illustrious professor of surgery at Johns Hopkins This club has ninety-three members, twenty-seven of whom are now luted as senior member. Nearly all of the men are professors of surgery and many are heads of departments in the great medical schools, a highly interesting and sumulating group ·CHAPTER III Early Surgical Practice I CT is of utmost importance that the young surgeon make arrangements so that he can always be reached by telephone at any time in the twenty four hour. I found that my life was much more peaceful if I had z telephone in the dining room in my den and in practically every other room in the house Ready accessibility saros not only time but temper is especally desirable in cases of coner gency and is of vital importance when the condiuon of a hos picalized patient takes an unfavorable tum The surgeon must resign himself to the fact that he must be readily accessible in any Testaurant or theater for example in a movie theater he must ask an usher to note where he is sitting to that he can be noufied of a telephone call Years ago when I wed to try to get in some golf my game was frequently spoiled by having a addy bicycle out to any part of the course to notify me of an emergency Sports such as saling should not be undertaken unless one or two substitutc rurgeons are available. If a plıyılcians telephone achange service is available a surgeon should always subscribe to it. This SCTVICC includes some such listing in the telephone directory after each doctor's name as this "If no answer call DA8-1789 Wheneva leaving his home or office, the physician register with the exchange so that lie can be reached quickly if necessary Vuch has been written about doctors olices and reception rooms speaal emphasis being placed on a friendly atmosphere, courteous personnel including the receptionist office nurse and 34 ·bookkeeper and proper filing of patients records, ahich must be kept strictly up to date. The young surgeon s first patients usually have minor injung which require prompt attention such as lacerations, burns and lesser fractura. As there are certain practical considerations which are helpful in the proper care of these conditions, I shall illustrate them in the following section by aung actual cramples. I often tell interns and residents that the most important and instructive cases they are studying will be of value to them through out their areas. The pertinent facts are stored away in mental pigeonholas, seemingly forgotten, but ready to be called out when needed even years later Many cases are notetvorthy either because of their professional aspects or because of their social value. Various inadents of my practice that occurred twenty or thirty years ago come to mind as nvidly as though they had happened yesterday The diagnosis of most fractures is usually self-evident from the hutory of a recent injury and a painful immobile, sometimes deformed extremity No doctor who wishes to be successful in hus practice palpates unduly or perhaps at all when a fracture us suspected. If an extremity is painful after an injury never try to save the pauent expense by omitang an x ray examination. Occa sionally a pauent grumbles when no fracture is found in the xray and complains that unnecessary expense has been entailed, but when an x ray u not taken immediately and a fracture is later (perhaps elsew here) discovered the patient seldom forgives you and may even rue. The phymaan is not always as fortunate as I was in a certain case. A woman telephoned me that her little girl had fallen while roller skating and had hurt her wtul "Do you think you should see it?" she asked I not wanting to appear to be trying to "run bursi nas" for myself and unaware of the pitfall in the situation replied, No. The next day the mother called me and complained that the chuld had cried all rigtit, so I insisted on having an x ray made, which revealed a slight, impacted fracture of the lower end of the radius without displacement Vo setung was required, but the chiud felt soinen hat better when the aim was put at rat with a splint and sling The mothers comment was, "Well docor me certainly were fooled, weren t wel" I saw the same thing happen to another physician but in lus case the patient, an adult, took 35 up ·revenge by continuous malicious gossip and injured the doctors reputation. About 70 per cent of all malpractice suits are concerned with fractures. Failure to apply a cast or splints properly and to follow the patient carefully for the first few days is rarely con doned. I have set a grcenstick" fradure without using an anesthcuc in a few cases in which a chuld was courageous and cooperative, but practically always an anesthetic is necessary To give an anesthetic to an unprepared child, whose stomach is full or at least partly so takes great skill and is far more dangerous than the laity realize. The doctor u importuned to "give something so he will not feel pan This, of course, the doctor wants to do and, moreover must do in order to relax the muscular spasm which otherwise might prevent or at least greatly interfere with the reduction (setting) of the fracture. Minor lacerations in the case of a very young child with fright cned, solicitous exdtable parents may tax the skill, tact, patience and ingenuity of the doctor As a rule a child will cooperate better of the parents are not present, or at least are alent and cooperative. The ordeal becomo more severe when a parent reiterates Johnny the doctor will not hurt you!" or Johnny be sure to tell the doctor when he hurts you! Never fear Johnny will always let you know when it hurts and sometimes when it does not C. Anderson Aldrich made many sage observations regarding children, but one włuch sucks in my mind particularly and which I have passed on to many medical students is Never ask a child if it hurts." Aldrich, from his rich and wide aperience knew that a child will always volun canly let you know when something hurts and will practically al ways answer in the affirmative when asked if something hurts, regardless of whether it does or not. The ability to get close to a child and to win hus confidence trust and cooperation is largely a reflection of what kind of man the doctor is, the sum total of his upbringing, experiences and nature. Some men are magically blessed with the right quality while ouers never aan develop it. Oversolicitude or "gushing voice usually arouses instant suspiaon in a child, as past experience has taught him that some malevolent plot is probably associated with that approach and that a preliminary subuic conspiracy is under way to get him to do something he does not want to do. Certainly a loud voice should tot be used Tic doctor simply 36 ·explains what has to be done. He should never say "I will not hurt you," but I will be us careful as I can and will hurt you just as little us possible. Of "It will not hurt much, and I will tell you just when to expect the worst hurt By conversing with a child, one an usually dutract hus attention from his injury and from your treatment of it but the language used must be what the child understands Always all him by his first name. Discuss subjects which make sense to him, such as running "Can you run fast? Can you run as fast as a dog? As fast as an automobile? Do you like ice cream? What u your favorite kind?" Always tell the mother that the child should have more ice cream. “Do you have a dog? What s hus name? A cat? An elephant Have you been to the zoo? Were you roured? Did the elephant bite your" Sometimes the doctor 15 rewarded by a loud laugh in which went he has indeed made progress. No more difficult ordeal is confronted by the physician (and by all others concerned) than the dressing of a painful wound or the placement of stitches in a Inghtened child of three or four years attended by his mother in the physicians office. Sometimes the doctor can get the assistance of some one close at hand, but occa sionally he must have recourse to the primitive procedure of tightly wrapping the child in a sheet us 1 restraint More and more the prosent-day practitioner has the good fortunc of being able to do this work in the acadent of emergency room of a nсarby hospital twhere he has the trained assistance of nurses and usually interns. Perhaps the most difficult test of the surgeon s finesse patience, wisdom and skill is an abdominal examination of a child of two or three years. A serious dcasion depends upon the findings of such an examination and it u virtually impossible to learn anything of the chud is crying The surgeons aim 4 to secure, in hu small paucot, complete relaxation of the abdomen as a result of the child s disocation of interest in the examinauon. Usually the surgeons introduction to the situation is in the chulds room, with the par cnu vuibly grim and anxious to have a decision made quickly and accurately (of course) "Tell us the truth doctor We can take it." Before the doctors arrival every child becomes infected by the parents anxiety aspecally in those fex homes where the "agadous" parents way to the child, "If you re not good, ill all the doctor I hare found the following technique of value. On entering the room, do not look at the child or pay any particular attention to 37 ·him You can almost feel the intensity of the childs appraisal ol you. A direct approach to the child, with smlles, honeyed words ind blandishments is usually doomed to failure. Instead of looking at the child become interested in something connected with or in the room the view from the window a dog or cat, pictures on the wall a desk or bookcase, but best of all some toy particularly a mechanical one. Under no circumstances work the toy successfully struggle vainly to operate it and unless a dull witted parent inter cedes, the child will practically always demonstrate how the top work. The small course of instruction should be prolonged as much as possible, and during this time the chuld discovers that the doctor has human qualities at least. If you can casually approach the child. bedside and sit down in a chair you can then proceed with 2 more or less man to-man conversation with him on such sensible topics u running, food and animals as previously mentioned. Now comes the time to use a most important maneuver You must tell The Bear Story not in simple narrative form but in terrupted by many questions on your part I was driving through the Canadian Rockies last summer when what do you think walked right out of the woods (Several guesses by the child we hope.) "It was a bearl A big black bear And do you know what I did?" "No what? I stopped the car and gave the bear a mndwich. He stood up on his lund legs You know you can t give a bear half a andwich because he will grab for the other half and may hurt you. Then do you know what I did? No what?" I took the bear's plature. I have the picture in my pocket. Would you like to see it?" Always the anstrer is, "Ya Now two details are important. Fint, your hand must be warm No child will tolerate a cold, dammy hand on his stomach The fact that you must "feel lus stomach to make bira better" will by this time become usually quite sub ordinate to the interest in the bear picture. The second detail is that the child must hold the picture with both hu lands which further distracts his interest from you and lets you use both your hands, one to liſt up the bedcovers a littic and the other for palpaung gently Wlule the child is examining the bear picture you must keep up a running clatter of information and questions about the bear I have seen a child forget the examination entirely If at this juncture the mother brightly say on Jolinny tell the doctor if it hurus!" then the whole campaign may collapse like a louse of cards and you are tempted to tell the mother what you 38 ·think, which of course would only make matters worse Meanwhile, you should be palpating with utmost gtateness, always starting in a region wbuch you think will not have any tenderness and last of all reaching the suspected tender part, the nght lower quadrant letter press hard chere you knor 11 tl not hurt as the child will apect you to press beard where he knows it does hurt and will give a moleadoz defensive reaction Often he will beg to keep your bear paure, so be sure to have a few at copios for that purpose One time I operated on a large, strong, intellectual, high-strung Dane, whose mle called him a "Viking" He was courageous and uncomplaining on the pamfal dars after the operation and had himself rigid and tourse. In an attempt to drvet hurm, I described the manner in which I told my bear story to children and then showed him the snapshot. This stratagem w roy successful 25 he was gounely interested. Then I found lie aus interested also in the Kansmgton Scone," the stone with lotse characters on it wbuch was found in Vmesota and thorogbit possibly to have been left by the Vikings, I began to register my gepune interest in it Soon his thoughts were bwly engaged o sugesting smable artidos for me to read on the subject. These, m doe time, were leat to me, but happily he was then recovered and I no longer needed the story in order to examine him. Ippareatly I did not show former - terest, for his wife later reported that they had concluded that the Kensington Stone was just another type of "Bear Story™ I bare racluded these details because of their importance. Lite ally life or death may hang on the result of a successful womina tron, albeit less so now than m the carly days when no 20ubrouo were available to help when a correct diagnosis could not be made I shall never forget the instance of a certam fnghtened, com four rear old boy in oldo rey destroguished pediatricuan bad made a diagnosis of acute appendiatis. I was a young man then and bad considerable lementy to disagree with my older colleague Soon anotha surgeon wis alled, and he agreed with me. The dat dar "rose spous" appeared on the child's abdomen, trpbord fever being the correa diagnosis. Had an appendectomt been performed, hurm could have resulted. The human understanding of a phrican my be judged by hus reply to the frequentlr posed question of a patient regarding a pain. "Could it be a gente, docor The wise doctor mar justifiablr 39 ·him. You can almost feel the intenuty of the culds appraisal of you. A direct approach to the child, with smiles, honcyed wonls and blandishments is usually doomed to failure. Instead of looking at the child, become interested in something connected with or in the room the view from the window a dog or cat, picture on the wall, a desk or bookcase, but best of all some toy particularly a mechanical one. Under no circumstances work the toy succesfully struggle vainly to operate it and, unless a dull-witted parent inter cedes the child will practically always demonstrate how the toy works. The small course of instruction should be prolonged as much as possible and during this time the child discover that the doctor has human qualities at least. If you can casually approach the child a bedside and ut down in a chair you can then proceed with 2 more or lau man-to-man conversation with hun on such sensible topia as running, food and animals as previously mentioned. Now comes the ume to use a most important maneuver You must tell The Bear Story not in simple narrative form but interrupted by many questions on your part. I was driving through the Canadian Rockies last summer when what do you think walked right out of the woods? (Several guesses by the child, we hope) It was a bear! A big black bear And do you know what I did?" No what?" "I stopped the ar and gave the bear a sandwich. He stood up on hus hind legs. You know you cant give a bear half . handwich because he will grab for the other half and may hurt you. Then do you know what I did?' 'No what "I took the bears picture. I have the picture in my pocket. Would you like to see it?" Always the answer is la. Now two details are important. Fint, your hand must be warm No child will tolerate a cold cammy hand on his stomach. The fact that you must feel his stomach to make him better" will by this time become usually quite sub ordinate to the interest in the bear picture. The second detail is that the child must hold the picture with both his hands which further distracts his interest from you and lets you use both your hands, one to liſt up the bedicotets a little and the other for palpauing gendly Ilhile thic duld is examining uic bear picture you must keep up a running chatier of information and questions about the bear I have seen a child forget tlic cxamination entirely If at this junaure the mother briglitly says, "low Johnny tell the doctor if it hurul then the whole campaign may collapse like a house of Cards, and you are tempted to tell the mother what you 38 ·think which of course would only make matters worse. Meanwhile, you should be palpating with utmost gentleness always starting in a region which you think will not have any tenderness and last of all reaching the suspected tender part the right lower quadrant Never press hard where you know it will not hurt as the child will expect you to press hard where he knows it doos hurt and will give a misleading deſcnsive reaction Often he will beg to keep your bear picture, so be sure to have a few extra copies for that purpose. One time I operated on a large, strong, intellectual, high-strung Dane, whose pare called him a Viking” He was courageous and uncomplaining in the painful days after the operation and held himself ngid and tense. In an attempt to divert him, I described the manner in wtuch I told my bear story to children and then showed him the snapshot. This stratagem was very successful as he was genuinely interested. When I found he was interested also in the "hensington Stone," the stone with Norse chances on it which was found in Minnesota and thought possibly to have been left by the Vikings I began to register my genuinc interest in it. Soon his thoughts were busily engaged in suggesung swtable artides for me to read on the subject. These, in due tome were lent to me, but happily he was then recovered and I no longer needed the story in order to examine him. Apparently I did not show my former interet, for hu wife later reported that they had concluded that the Kensington Stone was just another type of Bear Story" I have included these details because of the importance. Liter ally life or death may hang on the result of a successful examina tion, albeit less so now than in the early days when no antibiotics were available to help when a correc diagnosis could not be made. I shall never forget the instance of a certain frightened, crying four year-old boy An older very distinguished pediatriaan had made a diagnosis of acute appendiats. I was a young man then and had considerable temerity to disagree #7th my older collcaguc. Soon another surgeon was called and he agreed with mc The next day "rose spots" appeared on the chulds abdomen typhoid fever being the contea diagnosis. Had an appendectomy been performed, harm could have reultad. The human understanding of a physain may be judged by his reply to the frequently posed quouion of a patient regarding a pain. "Could it be a nerve, doctor?" The wise doctor may justifiably 39 ·reply Yes there is a strong probability that such us the case. I think you have the right idea." The inexperienced doctor however would reply with perhaps a superior air Any one should know that the only way pain u reported is by a nerve. There an be do ensation of pain without involvement of a nerve." When I began to operate at the Evanston Hospital I kept con stantly in mind the sage advice of my one time chief Dr Albert E. Halstead "You are a young man. When a pauent is in a grave condition and is likely to die always have senior consultanon even if you feel confident that nothing different can be done it will save the family worry and will enhance rather than detract from their respect for you. I was somewhat surprised to find that after I had ared for a cook or gardener with great patience his wealthy employer would engage me for himself and hus family later when medical help was needed. A good safe rule which should be obvi ous for every young doctor is to treat each patient with all the care and skill he can regardless of the number of patients he has or the financial standing of cach patient. Often a small community provides a fine stimulus for a young doctor His work and degree of patience and his kindliness are observed and discused minutely there, whereas in the junglos of the big aty any brusque action an often be overlooked and a surgeon u more likely to become im personal and unsympathetic One day Dr Frank W Blatchford called me to bec a shrewd, highly intelligent millionaire who lived in a veritable palace on the lakc front. My model T Ford looked ill at case in the sweeping dnreway banked with beds of flower. From the moment I first heard the patients name my heart ank and I quaked in dire foreboding Would he recognize me as the idiot who had tried to sell him the idea of a noiseless plate? To explain my perturbation it will be necessary to turn back about iho years, to the period when I was spending much time in the John Crerar Library preparing medical articla. I often ate lunch at what was then called the Automat," where one put coins in a slot to get the plate of food seen througli a little glass door Somehow the clatter and bang of the china on the tables and injt seemed unnecessarily loud and annoying I dreamed up a noiseless plate and the more I thought about it the more practicable it semed. I drew plans of a plate with special inscus over the prom inences and Rich rubber nngs to slip over these Insets. Such places 40 ·could surely be banged around (reely without noise The next thing was to interest somcone in my invention, and no one would know better than Mr president of the huge organization dealing with restaurant supplies. It was difficult to get an appointment to see him personally but finally the day amived when I was ushered into the great mans office He listened to me politely but with a definite twinkle in hu eye and finally ended the interview by com menting "I think your best interests would be served by confining your actriues to the field of medicinel la, the man of the noise less plate inadent was none other than the patient Dr Blatchford asked me to see. Fortunately Mr I did not recognize me. I examined hım care fully made a diagnosis of a severe attack of acute appendiatus and advised prompt operation. Dr Edwards, then dean of Northwestern University Medical School, was called into consultation and con curred with my diagnosis. Although the patient had confidence in Dr Blatchford, who vouched for me, I believe his final decision to let such a young man as I was operate on him was influenced by my stating "Nest to you Alr I am the person most concerned, since my reputation is at stake because of your prominence. So I operated on him for a ruptured appendix, and he made an ex cellent recovery I cannot deny that thoughts of the size of the fec I should charge hun had flitted through my mind However I was really unprepared when one day as I was completing the dressing he looked at me sharply and said. "How much are you going to charge me?" He had caught me off balance, and I could not muster the speech I had been trying to formulate. All that I managed to stammer out was a comment to the effect that my fee had to show come relauonship to his income and assets, and that saving him from grave danger meant more in actual dollars to him than to a poor man. I finally gulped out. "I believe I should charge you $500 Thu seened like a tremendous rum to me. Quick as a fizh Mr X said. "I give you seven fiftyl" And that was what be paid me. We became very good friends and I later operated upon keveral met bers of tu family One day he gave me what he considered good business advice, namely to get a better looking car as the one I had did not enhance my reputation. So I turned in my old Ford At long last I had the courage to tell him about the novelas place, and we bad a good laugh ovu it. 41 ·Early in my private practice I considered it permissible before opening an abscess to inject a local anatheuc into the infected area. On one never-to-be forgotten day I had in the hospital a patient with an exquisitely painful abscess adjacent to the rectum, and I said to him "Now I am going to inject some Novocain so that you will feel do pan. You will feel just a little discomfort when the needle 19 introduced. I took the syninge which the nurse had prepared and injected a goodly quantity of ſlud Immediately the patient began to yell loudly What was my surprise, as I gozed at the abscess to see it expand like an erupting volcano and blom off lu top By mistake I had been given a syringe full of hydrogen peroxidei Truly the abscess had been opened dramatally and the patient ultimately thanked me for the relief of his pain. How ever I have never endorsed this method of opening an abscess. Another time I was summoned to care for a workman in rough clothes whom I found bending over a fire hydrant He was la cvi dent agony and seemed unable to answer questions. I examined his abdomen as best I could under his shirt and ſound it to be rigid Fearful that he had a perforated ulcer or some other serious condi tion I put him in my ar rushed him to the hospital and did a laparotomy Instead of finding a perforated ulcer as expected, I found nothing abnormal I had been fooled by a malıngerer I recall vividly the skillful manner in which Dr Lewis Pollock exposed a certain malıngerer The man stoutly contended that he had unbearable pain and tenderness in the left fank and that he was unable to move his left leg Pollock put on his stethoscope and listened to the man heart, bu face assuming such a krious ex pression of alertnes and attention that the patient became fasdnated in observing It Meanwhile the patient was uiterly unaware that Pollock was firmly and deeply palpating the allegedly tender flank Cleverly Pollock made no comment about this finding but inquired about the pauent s left leg Sorry Doc, I can t move it at all." "How is the right leg?" queried Pollock. "Finel" mld die patient and proved it by moving it briskly in all directions Pollock asked if the nghe leg was strong enough to more upward if there kas pressure on the knee? Pollock then placed both hands on the patients nght knec and put hus full weight on It The paucnt gare a mighty here and raised the nghit leg. completely unaware of llic fact that to effect this liſt he had to brace himself by prosung 47 ·strongly on the bed with the allegedly paralyzed leg Pollock said nothing to the patient but wrote on the chart Feebleminded malungtter" Another patient was a highly nervous, sensitive woman with severe suppurative (enosynovitis, gas anesthesia being required whenever the dressings were changed. As the original wound had been a puncture from a can opener I thought it would be serving her best interests to gire her some telanw anutoun At that ome, over thirty years ago this involved the somewhat painful injection of 10 cc of serum which I carried out after changing the dressing and whule the anesthetic was sull in effect. The patient did not come to properly and at first I thought the anesthetic had been improperly administered. Finally she became very cyanouc (blue) and almost pulseless, seeming about to die when I heard her murmur the word Adrenalin. Thus I promptly gave her and she responded a little and finally recovered. It seems she was highly allergic to horse serum, and it was indeed a miracle that she had not died from the reaction to the tetanus antitoxin injec ton. Thereafter I always took great care to determine a patients sensitivity before giving an injection Onc young woman almost killed in an elevated train wreck on the north ade of Chicago was taken in profound shock to a nearby hospital where I took carc of her She had numerous injuries, 10 cluding a broken femur (thugh bone) and a head injury A tre mendous wound of her face and scalp had not been attended to because of her precarious general condition. Since a general anes thcuc could not be given to her I had to proceed with greatest gentleness and patience to share her hair and deanse the large wound of all street dirt. Then, as it w a los shocking procedure than taking autcha, I approximated the skin edges of the womd with many tiny bridges of adhesive tape. Fortunately when the patient finally recovered, the scar on her face was quite inconspic LOUS. One day two young girls were slowly riding in an automobile, one of them at the wheel, trying to deade what andies to select from a box, when their car suddenly crashed into a telephone pole. One girl sustained a dislocated hip and for tivo days lay in a friends bouse while a doctor of the "old school“ frequently meas ured her legs, ach ame concluding with perplexity that they were 43 ·normal despite her intense pain. An x ray casily settled the matter and all coded happily after the dislocation was reduced at the hospital Inadentally the final blow for the grrls was a bill from the Village of Winnetka for the broken telephone pole. One night, about 2 AS I was summoned by a wealthy woman who was having a gallstone attack. I knew approximately the locat tion of her huge residence one of several mansions set far back from the main road and reached by a long, curving driveway As I was driving along slowly peering through the darkness for the proper dnveway entrance, I was surprised to have a rough looking man in shirt sleeves jump out from yomc bushes and try to lag me down. I did not stop for him, but drove on and turned into what I believed to be the right entrance, but soon I became increasingly doubtful of my whereabouts when I reached a wooden gate bar ring my passage. I got out, moved the gate aside, drove through and then dutfully closed the gate again only to discover that I was at the edge of a cornfield. In order to turn the car round on the narrow road. I had to 'back and fill" repeatedly Before I knew it, the shirtsleeved hitchhiker had opened the car door and had settled down beside me. While I was debaung what my strategy should be I was relieved to be able to analyze his voice and re marks and conclude that he was merely drunk. "Take me to the station, he muttered. Necessity accelerated my cerebration, and I quickly replied that he must first cooperate by getting out of the car and opening the wooden gate, which I had luckily closed. He docilely climbed out of the car and managed to bold the gate open while, like a flash I sped past, leaving him standing there. After all I had to hasten to my suffenng patienti The fact that superior intelligence in one field annot alwayı ingure it in another w borne out by the case of a certain appellate court judge. He called me at 3 o clock one morning, almost er sanguinated from hemorrhage from the site of a hemorrhold opera uon done the previous afternoon in a doctor s office! In the case of a thelve-year-old girl who fell out of a trec and sustained a fracture of the spine, with complete paralysis of the lower extremiues, I had to consult with a plumber Together we contained a longitudinal windlass over her bed with attachments to a special canvascovered (rame to support her By means of this contraption the spedal nurse, who weigbed las than the patient, could easily and unaided liſt the patient in bed for pursing are 44 ·I described this arrangement in an arucic published in Surgery, Gynecology and Obsteincs in April 1925 Onc especially difficult diagnosis was that of ruptured appendix in the schizophrenic son of a wealthy couple. This poor fellow had for years required tube feeding in a sanatorium. After I had oper ated on him and he had recovered from the dangerous appendiceal predicament, my pride was somewhat shaken by the remark of his psychiatrist. "You re a hell of a surgcon!" One day ragadous Dr “Andy" Aldrich called me to see a ten year-old boy nho tras desperately ill with vomiung some blood in the rectum and a large man in the right side of the abdomen. The diagnosis was intussusception which is a telescoping of part of the bowel into itsell, an almost invariably fatal condition unles properly treated. Frequently an operation 13 necessary but in some cases the bowel can be turned nght side out by means of an enema (more recently a barium enema given under x ray observation) After my amal, Dr Aldrich had another enema given which happily resulted in a cure. Later however the parents were in censed to receive bills for house calls from two doctors for a child who "needed merely an enema." A young lady who was making a short visit to Evanston was dis turbed by the appearance of unsightly bluc spots on her gums. So she and her 'boy friend" started at the top floor of the main doc cors office bulding hanung for sooncone who looked like a suitable doctor By almost a miracle they chanced to visit the office of Dr Wayne Fox, one of the best hematologists in the part of the country He immediately recognized that she had an acute hemor rfagic purpura of the thrombocytopenic type, and at his insistence I did an emergency splenectamy that night. The operation was in deed a thriller us bleeding was profuse unul I could compress the splenic pedicle with thumb and forefinger and ligate il The pa uent made a fine recovery At one time I took care of a boy of four years who had an ecchymotic mask, or traumatic asphyxia. The youngster had climbed into the familys car which was parked on the gently sloping drive way to the house. Somehow he had released the brakes and then climbed out of the ar and run behind it as it slowly rolled darum che driveway The boys father happened to glance through a win dow and was horrified to see his little boy pinned to the ground, a rear wheel of the car auhing hus chest Minculously this frantic 45 ·father summoned suffident strength in hu desperation to lift the 500 pound weight of the corner of the ar thus releasing his son and aving his life. At the hospital one time while on rounds I sent the nurse and interns out of the room as it was necessary to discuss some bighly confidential matters with the patient. After about ten minutes, I was astonished to see a colored maid crawling out from under the bed. Apparently her curiosity had been sufficiently satisfied, and she wanted to leave. Over the years I have taken care of many Christian Sacntists, and for the most part they have been cooperative patients. There is much which is constructive and commendable in their philosophy but it is regrettable that theu fanauast regarding medial problems plays such a prominent part. However I have really ad mired some of the practitioners who have consulted me, and I feel that their vigor and cheerfulness have doubtles helped mang a quaking personality I recall one fine woman, in particular who had broken bones in both legs and one arm. During her long stay at the hospital while she was suspended in traction by ropes, pulleys and weights we became well acquainted. One morning, RS ONC professional addressing another she asked “How : your business, Doctor?" I replied that it was satisfactory Whereupon she proudly volunteered the information that stic had made $150 that week by telephoned absent treatment" from her hospital bed. I venture to asume that she had not told her clients where she was located, but knowing her fine qualities, I believe that she gave them their full money's worth of help Not long afterward, this practitioner wrote au follom "I was so happy to read of your appolotment as head of the surgery department at the hospital that I learned to love during my long ruit there. My very splendid health today is largely due to what you know and put into pracuce coupled with wonderful care Alysons and I are inceanngly grateful to you My heariou congratulations for your AKT, kell med One of my most grateful patient was a Christian Scientist who had a huge orarian cysl It had become so large that its weight was a lettific burden to her emadated body After the umple operation for remoral of the st, this wonin regained her full health. Il ell do I recall a certain woman who walked grmly into my office and demanded that I examine her ankle. Nothing seemed 46 ·wrong with it. Thereupon she produced an x ray picture of die ankle, and again nothing appeared to be wrong. I said The ankle is all right. Do not worry about it. Try to think of other more pleasant subjects." Her face lit up with a bright smile as she ard, Well that will be easy for me as I am a Christian Saence pradiuoner!" An excellent arrangement is possible if one parent is a Christian Scientist and the other is not I recall one case in whuch the mother was a Samust and the father was a Congregationalist. When their son broke a leg the mother told me that she had to humor her hus. band in the matter and summon a doctor However she refused to look at the x rays of the fracture. The worst faux pas I ever made was in the mise 2 woman weighing some two hundred and fifty pounds. She rushed breath lessly into the emergency room and imparted the dreadful informa tion that she had at on a needle. Indeed a minute wound was visible in the appropnace area, and my heart sank, for I knch how difficult and sometimes futile a search for a needle can be. Soon however the x ray picture gave the good news that the patient had been merely wounded and that no needle fragment remained. In my intense relief I made the following naire statement "Vadam you are very fortunate. The vray picture shows that your skin must have been merely packed, as no fragment of needle is present. This is great luck, as otherwise it would have been like trying to find a needle in a haystack." From her cold look and the interns efforts to suppress his mirth I suddenly became aware that I had really chosen an unfortunate similc. Certainly house calls briog the doctor into closer and more intimate association with patients and their families than the more formal office and hospital contacts, and I enjoyed countless pleasant and amusing inadents and anecdotes of a nonmedical nature. One ume an elderly pauent told me with pride about bus grandson. It seems that the boy had appealed to his mother to wrap up a present he had purchased for his girl friend "Why Tommy she said, "Do you mean to say that you paid fifty cents for this handker chief Rather sheepubly the lad admitted that he had pad only twenty-five cents but had changed the price mark so as to make a more favorable impression on the roapient It is extremely useful to have a fund of stonds with which to entertain and divert ones patients. Some sono may even have 47 ·therapeutic value but it is difficult to keep a frah supply The following are some of my old standbys 1 Two mall boys are talk ung "My father is a doctor and he keeps me well for nothung. ways the first boy The other retorts My father us a minuter und he keeps me good for nothing" 2 A German band leader trying to praise a band member who bas repeatedly been tardy to rehcanais but had shown some improvement, sayx Mueller you are early of late you wsed to be behind before but now you are fint at last." 3 The advice the doctor gave his patient in one of O Henry's storia (''Let Me Feel Your Pulse 7 What you need is absolute rast and exercise. One of my most harrowing experiences as a speaker occurred in the carly day. Trying to be useful and public-spirited, I addraved a large group of girl scouts, who at in open mouched respectful solemnity while I tried for an hour to make slings, splint and other first aid subjects as thrilling as possible. When I stopped talking, there was a dead silence which I finally unwisely broke by saying "If any of you have any questions I shall be glad to try to answer them. After some time, a little girl rose and shyly but with utmost seriousness inquired "Could you tell me what makes my grandmother have gas on her stomach Evidently that was a serious problem in her household and here was a chance for her to come home with glorious good tidings For my part, I was non plussed and soon dismised the audience. 48 ·CHAPTER IV The Patient Meets the Surgeon Α' PATTENT requnng an operation seldom comes to the surgeon directly almost invariably being referred to the surgeon by a general practiuner or an internist. If the patient is ambulatory hc u referred to the surgeons office, but if he has been admitted to the hospital the surgeon will see him at the request of the internist for 2 surgical consultation. The referring physiaan must make up bus mind that the case is definitely surgical or possibly surgal In the latter event, many an internist may be prone to procrastinate. This is unfortunate since he may evaluate too highly hus own dugnostic and discriminatory powers and delay danger ously long in avalling himself of the surgeons experienced opinion. In a xense the internists hentation, while not uncommonly detrt mental to the patient, is understandable. In some hospitals, un fortunately surgical consultation usually means a pronouncement, which may be difficult to dispute, on the surgtons part that an operation us mandatory often immediately rather than an exchange of viens between internist and surgeon When a surgeon disagrees with an internut, he must speak up decisively despite the fact that he may displease the internut by not accepting his diagnosis. Naturally the surgeon must lean heavily on the internist in the apprawal of the surgical risk, based 49 ·on the capacity of the heart and blood vessels the kidneys and the Liver to withstand the operation. After an operation the internet usually leave the prinapal are of the patient to the surgeon, and sees the patient only in a friendly and encouraging apadty not writing any orders unless invited to do so by the murgeon Only one person an have full responsibility and authority after an operation, and that must be the surgeon. His task us indeed trying during thc postoperative course if the 16- ternist takos an active independent part in the patients are, even to the extent of changing the murgeons order. However patience and forebearance will usually see one through. Needleu to my in internist often makes valuable suggestions, which should be grate fully accepted. In most instances, a surgeon sees a patient during only one episode while an internist may see him many times over a period of year and the term my patient" acquires such increas. ing possessiveness that the patient himself may become uncomfort ably awarc of the situation A general practitioner or "generalust,“ often has some justifiable complaints about surgeons in general and about some turgeons in particular The hidden drama of the operating room often over emphasizes the part which the surgeon play in a patient o recovery The surgeon s stature is magnified in the patient s cyas, and his fee though large may be cheerfully paid, while grumbling arises over the internust{ee (usually smaller) although the internist actually may have saved the patient, life by making the correct diagnosis and promptly insuring the receipt of the proper surgical treatment Frequently a surgeon must withdraw from a hopelou ase of cancer after an operation has achieved "everything possible" to save the pauent, life, and with relief he turns the patient over to the relerring physician Occasionally a certain type of surgeon may make the medical man task for more dificult by Myuccessfully performing some atensise muulating operation which has but slight chance of prolonging the patients existence. Often the sur geon crosses the rene of somnc illness briefly it is the general prac titioner or the internist who must plod along to the end of a lask that draws increasingly upon his patience his strength and his ability to encourage the patient and his family The patient himself or certainly his medical counselor should know something of the approximate percentage of probability of lufc prolongation with and without operation in various stages of a 50 ·disease. Such statistia are dificult to obtain and not many surgeons know them, but they should supply them on demand. For instance: What are the percentage chances of longevity in cancer of the lung which has spread to the adjacent lymph nodes, with and without operation? What is the relative suffering of the patient What is the Cost No posiure ansuers an be given, but the probabiliuo must be thoroughly discussed and carefully considered. Often the diagnosis offers little problem, as in the case of hernia breast tumor or ancer of the rectum. When the internist has made the diagnosis at his office, he informs the patient that an operation will be necessary and asks him if he has a preference as to a sur goon. Somcuma the patient will name a surgeon whom the in ternist deems competent, and the referral is decided at once. More often the patient will ask the internist whom he would recommend. The internist wually names two or three men whom he believes suitable, naturally naming bus first choice first. How the internist determines upon his first choice way involve a complicated pattern of thought and experience. Actually he is not ideally equipped to enluate the quality of a nurgeons work. He has had virtually no surgical experience, and rarely takes the ume to watch an operation from beginning to end, perhaps spending only a few minutes 10 the operating room. For an evaluation of a surgeons skul judg ment and temperament, the collected opinions of his five most re cent residents would be most accurate. Naturally an internist is strongly influenced in his appraisal of a surgeon by the opinions expressed by a patient after an operation is finished. He does not want to be reproached for having chosen a surgeon whom the pauent doo not like. The internist, properly is chiefly influenced by the surgeons record of successful experience in each particular type of operation, but he is usually not able to make fine disunction, one surgeon being as good as another in the internet a cyes. Moreover the internist is not immuc to "the line" diplayed by some surgcons. A solemn authoritative manner in a dtuation not intimately familiar to the internist frequently camo more than it jusufiable weight Many surgeons learn to exhibit a hearty ussured manner which the internists wme is a reflection of the proper temperament for a surgeon. The best method for insurance of referral of patients by an in ternut us for the surgeon to give skillful, courteow and gentle treat ment to every patient, to inform the referring internist completely 51 ·about all the details of any operation and to widence his actual experience by means of presentations before medical meetings of by publications. After every operation the surgeon should write a personal letter to the referring internist and enclose a decailed account of the operation a carbon copy of the report of the pathologic specimen and any other pertinent details which will help the internist in the future care of the patient The patients first meeting with the surgeon is of great impor tance. Often, in the fint few minutes, the patient makes up hu mind about the character and abilitia of hu surgeon-to-be. All types of patients visit the doctor and his manner of winning their con fidence varies with their education, temperament and state of apprehension. Frendliness patience and attentive interest in the pauent a story are exsenual. But one must not forget the merit in Burtows*?4 slightly cynical remark "The public are so lacking in discernment that it matters not how much or how little a man may know provided he has the qualities of plausibility and per suasiveness. Moreover one cannot for practical reasons, agree with Plato s pronouncement, which was echoed by Montaigne that "good doctors themselves ought to have had the diseases they want to cure." Many times in my first conversation with a patient I have ald "What is your difficulty?" To which the patient has replied "Thats for you to find out Doc. Such an answer is due partly to what he considers witty self asurance and what he fandes to be shrewdness that will not mislead the doctor to any preformed opinion. One doctor is purported to have replied to such a retort "If you will excuse me just a minute I will be back with a veterinarian Hes the only one I know who aan make a diagnosis without asking ques tions. Admittedly the pauent must tell the story of why he ame to the doctor and when he fint noticed that something was wrong-pain abnormal function a lump a bloody discharge. The manner in which the patient presents hus complaint reveals much concerning his emotional make up On one side is the patient whose complainus arc obviously largely imaginary while on the other elde is the pa ulent typified by the man who had suffered from pain and romiting all night because he "didn t want to disturb the surgeon John Homans has made these comments on what constitutes a "good" or a bad" patient 52 ·"A good patient is one who has an interesting allment capable of cwe and at the same ume continuts to look pleasant, understands directions, anks rary few questions and never complains. A bad patient begins by telling a poor story full, not of fact, but of the alleged opinions of many physiaans is not easy of diagnosis and contre to umuate and berrilder the attendanu Such a patient complains continually sols questions innumerable and whether things go well or ill never gives the attendants the mtblacion of seeing her made happy There are, of cours, degrees of badnes. Some padenu are terrible while others are just difficult. The truth is that they are all ach," In some instances, as in a case of hernia the entire matter of the operation can be settled at onc visit In others such as cases of suspected gallstonos or of intesunal tumor various x rays and laboratory tests will have to be made before a final decision can be reached as to the need and wisdom of operating It is my preference to mine for hernia first with the patient standing while I am seated. I am always gentle and considerate and for my own protection ask the pauent to turn huis head sideways before coughing to help demonstrate the presence of a hernia. Then I usually eximine the pauent while he lies down. Parentheucally I might say It practically never fails that if a patient is asked to lie down on the table, he will lie on his back, but if he is told to lie on his back, he will, for some unknown reason lie on his stomach. It is extremely important to have a nurse present during the examination of a female patient, both out of consideration for the patient and for protection of the doctor Also it is highly desirable to avoid making a quick diagnosis, as one will naturally tend to try to fit symptoms into a preconceived pattern. The best method us to defer making 1 diagnosus until all the necessary tests and enaminations have been completed. After a diagnosis has been made, it is the doctor's duty to explain the situation in simple terms, patiently telling why surgical treat ment u indicated, the type of operation required, the average length of time the patient will need to be away from work and the proba bility of cure. Not the questions of bospital accommodations, spe au nuria and the surgeon ı fee (referred to later) are discussed Ac thu point the patient may say that, while he has confidence in your doing the operation, be feels that he should have a confirma tory opinion from another surgeon and such a request should 53 ·I always be met. The only reservation that I insist upon is that consultant be a mad at least as experienced as I am in the par lar problem involved and preferably of greater experience. ally give the pacent the nama of three or four surgeons » ability I respect. If he questions the impartiality of my recomu dations I suggest that he call the dean of the medical schoo the administrator of a large hospital for the name of a consult If the consultant disagree with the original diagnosis, a third sultant may have to be called, or the unfortunate patient may the decision on the basis of hu own knowledge of the medical p lem. As suggested previously one s remarks to a patient neck vary with his intelligence and with the type of operation requ For example, the following is a paraphrase of what I usually ha a man with an inguinal hernia "You have an inguinal hernu, coramonly called a ropture on th nght side. I have examined the left side but find none there Thl type of hernu is an enlargement of the ring in the abdominal wa' through which the spermatic cord pames. Thu enlargement mata weak place in the wall, allowing the abdominal contents to protrud through in varying degree according to the dize of the weakened arta "A man in your dtuation has four alternatives to consider The fin is to do nothing about the hernia. However this alternatreba duded dnce the hernu If untrated will become larger will cau more discomfort, will interfere with your capaty for physical exa dire and sports, will not dluppear spontaneowly and may cren be come caught and result in strangulation of the loop of intestine While strangulated harnua b a relatively uncommon complication every large bospital has a number of casos each year Unless the patient is giren the relief afforded by an emergency operation the outcome l: fatal." I usually minimize the likelihood of strangulation as the risk mall, apecally in urban communiuas where the patient can given prompt help Morcover it u best to try to give the facts accurately u posible and certainly not give the patient the pression that he is being scared into having an operation. I dien continue the preliminary discussion "The second alternative is the injection treatment I mention this only to condemn it and because some of your friends may have ad. vised you that it is an easy way to avoid an operation. Some twenty aan ago the medical schools of the Unirersity of Allancouz, Morth- Western Unirehty and other universities thoroughly investigated this 54 ·method and repudiated It I beliec the injection treatment is more dificult to carry out tllan an operation. But the outstanding argument against this method is that in a carcfully studied large aria of cases at a distinguished New York liospital the rate of recurrence was at least 81 per cent. "The third and fourthi alternatives are lo xar a truss or to have an operation, and the patient must do one or the other I recommend an operation. In many instances a man lias wom a irtiss for twenty or thiny years and has become as used to it as to lw shoes, but in most cases the man who insists that he will not bare an operation and wil use a truss aqually daards it in about a Heck. The disadvantages of a inuss are numerous. Find It will not cure the hernia. In inlanis a bernia may olien be cured by a triks, but the cllorts to keep the trwus in place are harrowing, and operation has usually supplanted this Drethod. The second disadvantage of the inss is that de protects only then properly fitted and properly mom and morcorey only while it a being word Pracuically crety man remores the truss at night and is therefore unprotected phen he jumps out of bed to close a window or to get up in the morning. The third disadvantage is that a truss is almost always uncomfortable, and its pressure on the skin often produces painful imitation of Inflammauon Finally many men object to baring their infirmity advertised when dressing in a golf dub locker room or gyanadum "The fourth alternative, and the one I usually recommend, s opera tion. Admittedly a hernia operacion does not offer a 100 per cent i surance of corc. Several ycars ago I made a careful follow-up study of a large group of my cases which I had reported in the surgical literaturre. In all of these cases the one type of operation was used regard lew of the size of the hernia or the patients age, and the incidence of recurrence proved to be 31 per cent. Therefore, a patient who agrees to have a bernia operation has at least a 06 per cent prospect of a cure. Even in the rare event of recurrence a second operation can be done bat offers a somewhat lower percentage prospect of are than for the "Naturally you are concerned about the risk of an operation since po operation is enurely devoid of it, but in hernia operations the risk batremcly Hight Likewise no ride on a train or in an automobile is devoid of rhk, bat no one is deterred from riding because of this. In the case of a hernia, the risk of doing nothing is greater than the risk of the operation, to my nothing of the discomfort and limitation of activities that are relieved by operation. "I shall aspect you to be able to stand beside the bed on the day of the operation and ceruinly to mit e llule the next day A general anesthetic will be used, and u won us you make up you should make a point of moving your feet many time since it tos of great importance to insure proper arculation follomrlog opention. You will feel pain in the wound, especially upon movement, but the wound is strong You should more about freely and must cough up any mucus in the 55 first operation.

·throat, even if it dous increase the pain temporarily You may expect to leave the hospital on the third to the sixth day and to be away from office work for about two week. You may drive your ar in from seven to ten day after the operation If difficolt parking and sudden stops are arolded. Golf may be started in three weeks and tennus ex weeks after the operation. If powuble, you should always avoid heary lifong (100 pounds or more) * Often the patient will uk. As a matter of interest, Doctor ju! cxactly how do you do thu operation? Tell me in plain, common rense Engluhi Thus poses a dilemma The padent, knowledge of anatomy and the terms descriptive of the surgical procedures will render an account as intelligible to him as the explanation of analytical geometry to a grade school child. Usually the patient is satisfied by the statement that the weak arta is sewed over in layer and made strong, but if he insists on having all details, I tell him with entire truth, that I did not understand the anatomical details of a hertua and its repair until after I had graduated from medical school and was krubbed up at the operating table. In performing a herniotomy too much care cannot be taken to insure against the crtor of operating upon the wrong side. (See the chapter on Surgical Picfalls.) One of the most trying duties of a surgeon us that of telling a patent he will be required to have a permanent colostomy after an opera uon for instance in a case of cancer of the rectum. The devastating fact must be presented in a kindly sympathctic and optimistic a manner as possible. Nurses are the worst counselon in this regard, as they have had the digreeable task of caring for a colostomy in iu early stages, before its relatively clean management is established. I recall one fine nurse who in her ignorance cleaed death from the disease rather than have a permanent colostomy Often I am able to state definitely that a colostomy will not need to be permanent In a few ases I must rezerve final judgment unut the operation is being performed w the patient will supply have to depend upon my judgment at that time. When convinced that a colostomy u unavoidable I say something like this "In order to erdiate thus growth, it wil be necouary to OTOT the rectum enurely and you will uman bare to bare bowel move menu through an opening in the abdominal wall (colostomy) Jour natural reason of disease to this unplannt information is all out of proportion to the actual faa. Ilhen you learn that in most ans a ·person with a colostomy can continue all of his business and social acinus without anyones knowing about his condition and when you know that the care of a colostomy is minimal you will feel much more relieved at your prospects." A person with a colostomy has a bowel movement by means of un encta every day or once in two or three days depending on his preference. He takos an enema while seated on the toilet, using a specially designed apparatus. No asistance is necessary and he usually prefers to be entirely independent. An enema may be taken in the morning or in the evening depending on convenience, and between times no bag or apparatus is uom over the colostomy The patient follows a relatively constipating diet, according to a detailed list that is given to him, and after several months the new opening will function moothly and without annoyance I always tell a patient, in anticipation of contrary advice from friends, that the arc of this abdominal type of colostomy is relatvely simple, while that of a perincal colostomy is usually a nightmare. Despite the claims of the proponents of a periacal colostomy that some muscular (sphincter) control u possible, such control is almost al ways a failure, and daily deanliness and digital dilatation annot be obtained as well as with an abdominal wall colostomy I always provide the patient with a set of mimcographed instructionu, in cluding the detalled diet lust, which will enable him to control the bowel movements For yean I have been waiting for a patient to ask me, Just how many times have you done this operation, Doctor?" but the question has sull to be asked. However I am ready for it, as I have kept an analytic record of my surgical experience in over 8 000 major operations I am often asked to do highly specialized opentions in which I have had no experience, such as neurologic surgery thoraac surgery and surgery for cleft palate and harelip Invariably patients requir ing these operations are referred to men who are killed in these speaalties (sce the discussion of Spedalization) ·CHAPTER V Nonoperative Hospital Activities "N CONIMERING the surgeons activities at the hospital those out tant for the turgeon to regucer in and out of the hospital prompuy without fail so that important messages can reach him. In somoc hospitals the incoining surgeon moves a switch opposite his name on an clectric board This lights up his name on several boards throughout the hospital including the one in the main telephone office from which paging calls originate. If he fails to sign out when leaning the hospital, he greatly complicates the telephone operators work. It has seemed to me that certain doctors "forget oftener than others us a roult they are paged endlessly thus giving an exaggerated impression of professional aclvity This mancuit is much like that of a young practitioner in a small town years ago who used to drive bus horse and buggy furlously through the main street cvery once in a while cren though going nowhere in par ucular It is dairable for the surgeon to drive at the hospital as Dearly as possible at the same time ach day and follow the same route through the hospital This will enable interns and residents to meet him more quickly Olien of course, more attending men are visiung their patients in the hospital at the same time than there are intems to accompany them. The house stall endearot to 58 ·meet with us many attending men as possible both to learn from thern and to be of service to them. The visiting of patients by a doctor is dignified by the term rounds if there are enough patients. Rounds usually start at the head nurses ofice, where the paucots charts are kept. Careful suuny contemplation and discussion of the charu is one of the physicans heaviest responsibilities and intellectual exercises. The many detailed entries 110ce his last visit must be studied clanbied if necessary and evaluated. Often it is necessary to review the enure chart in order to appraise the significance of nen data. Tempera ture pulse respiration blood pressure output of urine, defecauon, passage of gas dyspnes coughing degree of activity and Intake of fluids by mouth rein or prococlysis must be considered. Labora tory reports must be studied to determine a patients clectrolyte Deeds figures for gas and fluids when conunuous gastric suction is employed must be analyzed, and blood counts and blood chemistry determinations must be heeded. The medications which have been given and their effects, if recognizable, must be noted. A campaign for treatment of each padent for the next twenty four hours must be decided upon and the orders clanfied with interns and nurses. This latter duty u usually attended to after thc patient has been visited. These activities require the closest applicauon and deep thought, corresponding I should think, to the high level conferences in a law firm in deciding the strategy in momentous pieces of Litigation or the meetings of the executive committee of a large corporation to deade upon an important change of business policy As a rule, the conferences of lawyers and business men are held in the undisturbed quiet of a high executives office protected from intrmons of people and telephone alls. Considered opinions an be voiced without interrupton. The decinons a doctor must make at the head purse . office often require the same degree of concentration and cogitation as those of the lawyers and business men, but in what a different environment must he make them! The loud speaker is incessantly paging physı dans the telephone ning over and over again before a nurse can answer some perbaps trival quation student Durres, proud of their new rasponsibility in charting minor information spatch charts from cvery direction, trying at times to make entries in the charts that the doctor is trying to study Worst of all are the breezy, ·and facetious interruptions of colleagues who stroll in and whox patients art not sufficiently ill to require serious concentration. Well how's the old golf game, Bill?" often shatters a trun of thought I must admit that the confusion in the head nurse s office has always been too much for me, and unless it is merely to inspect the course in a case in which convalescence is amooth I prefer to take the chart and with the resident and intern try to find a quict, peaceful come in the hospital where we can give vital matten our deliberate, undivided attention The primary purposes of visiting a patent in the hospital are first, to appraise hu phyucal condition and search out the possibill tes for helping him and, second, to convey to him encouragement and spintual uplift. It u a matter of considerable judgment to determine the degree by which these objectives are aded or hun dered by the number of the house waff who accompany the surgeon on hu rounds and what conversation can be had with them in the patients presence. At times it may be best for the argton to visit a patient alone. After a patient has become somewhat accustomed to the house staff, particularly after the intern has taken his history it is usually profitable for the house staff to listen to your conversation with a patient and observe how you dress hus wound. Certainly all profound discussion of the pros and cons of the diag nosu and treatment, while educational to the house staff must be conducted outside the patients room and not within canhot. Patienis differ in their reactions to having the surgeon accompanied by two or more men in white suits" Some, especially when con valescent, find it entertaining and complimentary that their cases are of interat. Others resent the presence of a reunue as an Invasion of their privacy Tact and judgment on the doctors part are required to combine the maumum help for the patient and the maximum instruction for the house ital Occasionally in an especially interesting ase a patient may be presented before a roomful of medical students, but only if his full consent has been obtained Vany an intern unfortunately comes to regard the lospital patient very impersonally as an exhibic put there solely for educa tional purposes. He is prone to become lost in the professional aspects of the casc Such an atutude rosulus in disadvantage not only to the patent but also to the intern for hc may tend to acquire an unsympathetic manner of questioning and examination 60 ·which will diminuh his value to patients and will be a deterrent to him in the development of his private practice. This is one of the pitfalls of an internship in a large urban charity hospital. Much may be aid for the teaching hospital. Such a hospital is affiliated with a medical school is staffed by members of the medical school faculty and stresses the instruction and training of medical students and house staff. But it is not an unmixed blessing I am inclined to think that the most vocal of the proponents of the teaching hospitals are the leaders in the medical schools who eloquendy extol the advantages of medical school affiliation in usuring patients of the most up-to-date and alert care. The con suant association with the medical school faculty and the intellectual stimulation furnished by the "profound" and searching questions of the third and fourth year medial students and house waff art claimed to keep the phyriaan "on bis toes." True, the patient often does benefit, but the physican may be especially stimulated by the accessity of convinang hus medical colleagues and superiors that he is keeping up Alas, much of his time may have to be spent pre paring for and giving lecturos on subjects about which he is not presently concerned Relieved of this time taking obligation if hc u properly constituted, he would have more ume to study his individual patients and engage in clinical research. Some leaders in medical schools are naturally pleased when they an apound with regard to hospital affiliations and teaching plans. By their report to associations of deans and medial teachers and univeruty boards of trustees, their own statut is inacased, while uteproachably proclaiming the great good to the sick of their teaching method. These are the men who have the car of hospital boards and university board. While their ladenbip generally is wise, it is certainly not infallible and their motives are not entirely dwnterested. Baually the prime function of the phyrıdan us care of the sick if this be so the leader argue, the education of the physician transcends all other responsibilities. There is danger in carrying this line of reasoning too far for one might go so far u to say that the physaan s automobile or other means of trans portation is the most important factor for without it he would not be able to see hu patient. Understandably Wartman refers to the fear that the pert in (medical) education, although always en thusiastic as to methods, may sometimes be sterile u to knowledge." Competition in mediane, by and large, makes for better medical 61 ·care, just as competition in auto manufacture and a plane build ing makes for better products. The hard core of medical competi tion is the are of the sick. He who curo or relieve the most pa tients in the most expeditious and sympathetic manner should and almost always is the most successful in his practice. But, in thu connection, it is well to reflect upon the remarks of Walton Hale Hamilton Is who said. "The incidence of competitive medial enterprise falls heavily upon all the partia concerned. Although the perconal choice of a phyldan is an acellent idal, it does not, under current conditions, work well in practice. An old marm, long known to every student of social philosophy alls for a restriction of personal choice when the consuma bas not a proper judge of the quality of the ware. The art of mediane is intrate, the relation of the traatment of the rich to re rulus obtained annot be approved by the layman jo mediane almost more certunly than anywhere else, the patient has not the knowledge requulte for judgment. In almost every dty reputable phyıdans will admit-at lezu in private-that the competence of their fellom is not in accord with their respectire reputation" With the complicating factor of the medical school faculty and the teaching hospital staff membership the physician a energies and fortunes become inextricably involved in competition of a different nature He must impress his medical school and hospital colleagues by making contnbutions to medical knowledge. A few men make solid additions and many who try to do to gaually improve their munds by the study and effort involved but still others are wasting their time Councils of medial schools passing upon promodons and leaders on hospital stalls are increasingly falling into the questionable habit of judging candidates on the more number of their publications. Certainly this practice is the greatest incentive to the production of mediocre work. If, u occasionally happens the judges themselves have attained their positions of crainence by the quanuty rather than the quality of their own cfforts, the viaous arcle us enlarged. Moreover the hard working man whose chief objective us the care of the sick and whose waking houn arc dicfly spent in studying to increase his ability to care for thic sick will come to be patronized and looked down upon by the so-called "leaders. It must never be lost night of that the good clinloon is the comierstone of sound medial care if the physican, in addr tion to being a good clinican can make a judicous contribution lo thc literature hu wefulness will be increased. Admittedly the 62 ·optimum functioning of this man is augmented by the widely diversified work of all the research scientists. It is to be hoped, therefore that hospital staffs have an equable balance of clinical and research teachers or best, that the finest qualities of each type are included in each individual The hospital staff is required to have a constitution and by laws wbuch have been approved by the lay board A great part of the staff pork can be delegated to committees whose authority has staff backing To insure the highest possible standard of professional work the staff should adopt some type of annual staff audit. The Amer ican College of Surgeonski is studying plans for such appraisals. To my mind such an audit would be compiled from a formula which includes properly weighed consideration of the number of hospital patients, the hospital mortality the percentage of necropsy permits, the length of hospital stay (according to illnas or injury?) the number of consultations, the discrimination shown in ordering laboratory work, the attention to completion of hospital records, the ability to insure good intern service, the amount of time spent in teaching nurses classes the significant contnbutions to medical literature, aime spent in free clinia service on staff committees and cooperation with local service workers. Myers and Sleet define a medical audit" as the cvaluation by phylcuns of the quality of patient care, as re realed by the medical records, in order that four quortion may be answered. (1) What did the patient haver (2) What was done for him? (5) Was the treatment optimum? (4) If CoC, why not? The answers obu tained, when collected, tabulated and analyzed, provide a man of cyaluaung the care of a single patient or of groups of patients and afford a method of documenbing the performance of doctors, individu ally und collectively Any method which does not include the judg ment of phyidans is not a medial andit Myers and Slee conclude, in part, that "the medical staff of any hospital u qualified to conduct its own medical audit Ope category of disease or operation should be evaluated dunng a single audit penod Lombokat has contributed an important article cautled Medı cal Auditing by Saentific Methods. In his summary he states To place medical auditing on a scientific bas it u necomary to (1) employ uniform definitions for damfying diagnosis and treatment, 63 ·(2) venly Hatements in the dinial record by means of writen report of laboratory examination or of compuluton, of other forms of documentation (%) determine whether the pathology iny and other clinical Laboratory reports on which many of the altera are based are comparable in accuracy and terminology with those of control hospitals (4) judge renults according to objective alterla ud (5) measure the degree of complunce with ateria gains Handards de rived from observations in control bospitals." He describes in detail the application of these methods to major female pelvic surgery and finds that. they an be highly effective in bringing to light and helping to correct situations where the type of operation is unrultable or the dlagroutic study by Inadequate and aspecally where the number of operations is excentre" A recent development in the matter of review is the newly recog nized "Tissue Committee fostered by the American College of Surgeons and adopted by the Joint Commission on Acarditation of Hospitals. Myer" definos thus committee as 2 committee of the medical staff of a hospital, which evaluates the surgery done by the medical staff and rates the competence of cach surgeon on the basu of hu performance.” He adds, "For the proper functioning of the time committee, several cssen tals must be present 1 A cooperatire medical staff which desires to have the surgical work audited and I willing to perform this often unpleannt tuk 2 A uue complice composed of appolated members of the medical staff bo are responsible to the executire connait tee and the medial tut. 3. A pathologze who to competent honest and forthright He sbould preferably not be the chairman of the thuc committee. 4. The requirement that all surgical tisue shall be sent to the pathologist for examination 5 An accuuve committee and med ial staff willing to discipline those surgeons whose work I found to deviate omskeady from accepted rundard." Elsewhere Mlyen" says The sole ſunaion of the usue committee of the medical staff ks to chabluh the fusillcauon for Rurgery done at the hospital It can accomplish this purpose by one meam only The evaluation by phidians of all clinical indication for surgery la each individual case. There us at present no other salld method for making this de cision. The pathologist s tissue diagnosis alone is not the yardstick of the justifauon for surgery and a normal tissue rate (the ratio of normal usue removed to the total number of surgkal procedores 64 ·done) is likewise invalid for this purpose. (See also the chapter on Sugral Pitfalls.) In 1949 my senior raident in surgery Dr Theodore T Myre, camined between 15 000 and 20 000 cards in the Evanston Hos pital record room in order to make a survey of the work done by the members of the Department of Surgery A study of thc sur gial mortality at the hospital for the 136-month period from July 1 1929 to November | 1940 ras compared with the 105-month penod from November 1 1910 to August 1 1949 Only the com moner standard operations were used as a basis for comparison, but all of these operations for those periods were included regard less of the patient s age, the ruk involved or the severity of the surgical condidon. If death occurred from any cause, regardless of the length of time following an operation it was considered to be a surgical death of the patient had not left the hospital. The compiled staustia were summarized in the hospital maga zine, The Pilot in the May 1950 number as follows "In the yean klnce 1940 afety for a patient undergoing any opc of a standard operations at Evanston Hospital has been four times greater than it mu in the prenous ten year. The six operkuloms cor cred by these figures are 1 appendectomy 2 cholecystectomy gallbladder operadon 3 hernoribaphy or hanla operation 4 thy Tondectomy or removal of the thyroid gland, 6 nadical breast amper tation, and, 6. Rammstedt operation, or the opening of an obstruction (present at birth) from the stomach to the intestinos in young infants The mortality rate for the 4 720 operations performed since November 1 1940 has been on u arerage of 6 1 deaths per 1,000 u compared with the average of previous years of 24.B per 1 000.- From July 3 1946 to January 1 1950 there were 1 186 consecu tive appendectomia without a death, and from February 1 1946 to January 1 1950 there were 510 consecutive cholecystectomies without a death. Moreover in this study a careful record was made of the number and mortality of cach of the standard operations done by all the surgeons doing the prinapal amount of work In this way it was ascertained how many of each of the operauions the vanous surgeons were performing and what their over all mor tality was for the two periods under comparison I had mimeo graphed copia of these studios prepared and distributed to all the members of the surgial department. One of the surgeon s most important responsibilita u to talk 65 ·with the anxious waiting relatives after un operation. If the start of the operation is delayed or if the operation itself is unduly prolonged, I try to send a message to the family that all u well, since there is probably no more trying ordeal than waiting for several hours while a relative is in the operating room. No matter how tired the surgeon is, no matter how far behind he is in his schedule and no matter how long ance he has had anything to eat, he must patiendly and in some detail recount the details of the operation to the family Fint of all they must be usured that the patient withstood the operation satisfactorily I usually start by saying "He went through the operation very well and hus present condition is very Atufactory He is now the recovery room, where specully trained attendants will are for him until he is returned to his hospital bed. We have exceeded in doing what wa nccciary and we are very optimistic that the pauent will nopidly regain his full health." It may bc necesary to report to the family that something differ ent was found than was anticipated, or even that dapite the definite indications for operation no condition requiring surgial treatment was found. For instance, I have had to tell a family that the patients appendix was normal and that the cause of the trouble was inflammation of the lymph noda of the intestinal mesentery-a condiuon which often cannot be differentiated from acute appendiatus preoperatively I have had to report failure to find a suspected displaced semilunar arulage of the knec. Unfor tunately it is frequently necessary to report that an inoperable malignant growth was found or that only a palliative operation could be done. No matter what the operation has been two of the commonest questions asked by the family are "Was everything else all night TVas there any sign of cancer?" To the first question I believe the correct answer to be In the area in which I was operating I saw nothing abnormal, and I did not consider it wise to risk unwanted compliauons by searching about in the abdomen when there were no indications for doing to In the second instance, when there is no actual sign of ancer it is important to state this fact so definitely as to leave no doubt in anyoncs mind. Ilhat to tell the pauent with cancer is a difficult question no simple answer being possiblc Each surgeon will have to dedde for himself wluat is best in each case since, even among men of the 66 ·highest professional and ethical standards no agreement has been reached. I have seen a group of some ten leading surgeons and phyiaans at an informal meeting discussing this problem and their opinions were about equally divided as to the proper solu uon. On one side was a distinguished surgeon who intoned loudly and with evident parade of virtue "There is no substitute for the truth." On the other side of the argument, a wise old physican told of the case of a physician friend who was found to have a malignant tumor of the cye which proved fatal in a year The patient was told that the condition was innocent, and he continued his professional work almost to the end. Those who knew hus temperament ſelt ibat, had he known the truth his last year of life would have been spent in melancholy idlenets insupportable to himself and to his family rather than hopefully in his accustomed useful occupation. The late L. J Henderson, a noted Harvard biological chemist once sud "The nouon that the truth the whole truth and nothing but the truth an be conveyed to the patient is a good specimen of that cus of fallaads called by Whitehead the fallacy of musplaced concreteness. Vany facton must be considered. Whm question nura are sent ont to large groups of well people asking them what they would want to be told, almost invariably the reply is a cour ageous and resounding the truth? But "when the chips are down” the doomed person usually prefers otherwise. The age of the patient, hu famıly responsibilities, his emotional make up and the family relationships must be considered. No two patients and Do two familias are alike and the doctor must try to develop Solomon like sagaaty Most families importune the doctor not to tell the patient when ancer is discovered Louis ) Regan" one time professor of legal medianc in California, once said "It is extremely doubtful of a physican has a therapeutic privilege to withhold a specific diagnosis from a patient with seriow or fatal illnon. On the contrary it appears to be dar that, in ordinary arcumstances, the confidential relation require that the phyuan make a frank und full disclosure when hos patient is adult und mentally competent." Most of the published statements of surgeons and physicians on tha subject affirm that the patient should be told that he has a fatal disease even though a considerable, indefinite interval may 67 ·intervene before hu death. By making such a statement, certainly the doctor clcars himself of any possible legal risk and he con boast that his consaence is clear because he tells the truthl Bot alas, this conventionally correct act, while enabling the surgeon to sbrug his shoulders may crush the patient and hus family under an almost insupportable burden In many cases I have ared for a patient who has been fatally ill with cancer but who has been merafully spared that knowledge and until he lapsed into final unconsciousness was made to feel that he was getting better I have always been proud when I have succeeded in making a pa tient feel this way or at least have encouraged his optimudc out look. In one of the few instance in which I had about decided to tell a man that he had widespread cancer of the liver his wiſe, at a private conference with me, said reproachfully 'You would be giving him the death sentencel I therefore changed my tacta, and for months this patient was cheerful and optimistic 2ttnbuting hıs lack of well-being to an unusually slow convalescence from the operation. Finneya hays The true province of the doctor has been well stated by the late Dr E. L. Trudeau To cure some times, to relieve often to comfort alwapi I feel that Warren Colest bas stated the problem most admirably in the following words "I wish to bring up another controverilal point about lay edocation, namely the question us to whether patients abould be told when they bare a ancer I do not believe this question an be amwered categori ally Ench pauent should be individualued. Some people are so apprehensive that this knowledge would make the rest of their le miserable. Under sac arcumstanco I believe it ba better to be completely frank only with some responsible member of the family the patient an be told he has a growth whid must be removed let it Imrade the body However on many coulons, businew men will ask you to be sure to tell them if they have a cancer which might result in their premature death. Under such arcumstances, and astuming wc are dealing with a fairly stable Indindoal I am convinced we should be frank for two reasons In the first place it is usually very important 10 tbc luture care of the patients family for the head of the family to be aware of the possibility of a premature dath to the second place such people usually have enough srength of character to adjust to this knowledge and live the rest of their lives without jeopardizing ther emotional rability Whea metastases develop and the packene is aware of their possible significance I strongly emphasize that after we hart wilired and perhaps exhaused our therapeutic measures we make strong psychologic use of the fag that occasionally malignant 68 ·tumon spontaneously stop growing Under such drcumstances most people are supraingly content so long as they know there is a possi bility the tumor will be brought under control even though that posibility is remote. The medical profesion has not made proper usc of this valuable asset lo allaying the fears and apprehcnuon of the patient or relatira" After camining the ethics of this question I have concluded that the best guide is to adopt such a course as will give the patient (not the doctor) the maximum of happiness. Generally speaking I have not told a patient he has cancer even in toponse to a dutct question or at least have grossly understated the penl. Unless he hus heavy financial responsibilities, or important legal matters to settle such as revising a will or making changes in his business organization, I do not believe it helps either him or his family to tell him that he is doomed to certain death. If he can still have a ray of hope men if it is faint and remote he is much strengthened in his resolve to show courage, patience and kindliness. Moreover a patient may actually know the truth but may choose to pretend to be deceived. This gallant role makes it far casier for his visits with his family which is perhaps the most important facet of the problem. The husband and wife, or other relatives, set and talk to cach other many times daily Sad indeed if their conversation must dal with or be haunted by the certainty of death. How much happier for them if the surgeon say "Well, thus has been a bad day but tomorrow will be better " or "We'll get this thing licked!" More over who knows, the racntific world may be startled on some tomorrow by the news that a chemical cure for cancer has been found. In many mstances I have told a patient, for example when can Cet of the breast or of the colon has been discovered that a "few cancer cells were found but the entire area was widely removed. I tell cach patient that he u fortunate that the disease was dis covered early and that he is cured Indeed, in many cases a cure does follow operation. Usually nuch a patient will ask, "Is there any possibility that this will ever come back?" To this I reply "Of course, nothing in mediane w mathematically certain, but I believe this condition will never return. You are much more likely to meet your end from an automobile acadent, atom bomb or eyen old agela Apropos of this discussion is a letter I received from a man whose 6 ·mother was dying of cancer By means of a biopsy and x ray study hopeless spread (metastases) of cancer into the skull had been found In fear and trembung the patient and her husband came to my office. That I succeeded in reassuning them and making cytry one concerned much happier is evident from the son a letter "This is just a pathetically inadequate effort on my part to tell you how beautfully you are handling mother o czx, and how grateful my brothers and I are for men like you. I arrived home just a mother and father had come from your office after the i ny picture. It was a revelation-the change you worked on them both wus wonderful to see. Mother bus talked of nothing else all evening of how relieved the is-and of a completly renetred hope. Again with many thanks and 2 Luting appreciauon of all you have done for our family Sometimes a patent squarely faces the fact that he has a fatal cancer and he emphaucally insists that the diagnosis be kept secret from the family This may ostensibly be agreed upon but the doctor and the family must always be in full confidence. It is axiomatic that a doctor must tell the family the diagnowu and, u accurately as he can predict it, the probable durauon of the Illness. No amount of consideration for the family's feelings permits a doctor to withhold from them the true state of affaur. There are few occasions in which a physicians skill, understand ing and kindnes can be of more value and importance, both to the patient and to his family than when death is inevitable. Fatal illnesses are wually the greatest test of a doctor a patience and sympathy The time has long passed unce one heard the expression "Old Doctor Smith never lost a patient" Such a reference is actually uncomplimentary because it stigmatizes the doctor either us dis honest or as to incompetent that no one trusts him with anything but the most minor ailment. When a patient a life is slowly ebbing, and inevitable defeat is looming more and more clearly then, if ever do the family and the pauent lean upon the doctor for support While I believe that one should never admit that defeat is sure, although it seems so I do not think it is justifiable or fair to the patient or his family when the end seems close, to give trcaunents apecially costly blood transfusions to prolong the life only suf fiaent intravenous fluids should be given to alleviate discomfort from dehydration And of course the use of narcocia is always 70 ·indicated for pain in such a case. The family s clue concern is that the patients suffenng u allayed. During such a trying period the phynaan must expend his ume and cnergy to the important task of bolstering the family's morale. They as well as the pauent are suffering and the physician s duty is to help them all he can At this point it is appropriate to comment upon cuthanasia, the painless putung to death of some one suffering from what is be lieved to be an incurable disease, an act to which the dubious term "mercy killing has been applied in the present state of avilization for reasons based upon the most good to the most people," this type of killing is legally forbidden and is ethically improper For generations, physidans have donc everything in thar power to minimize the sufferings of those afflicted with a painful malignant growth To this end they have decreased pain and avoided efforts which Rould merely prolong a hopeless exist ence. To entrust one s late to a physician of kindly sympathy and highest ethical standards us the best solution of the problem. It vecms unfortunate to have euthanasia brought forth as a subject for lay debate, as it is almost impossible for those who are inexperi enced in medical matters to evaluate the premises of the argument. To me freeing a pauent of most of his pain by means of drugs us no more reprehensible than eliminating pain during an operation by means of anesthetia. However to put the power of execution into a doctors hands u perilous In recent years the term "palliative operation has come to be used with increasing frequency and with a matter of fact assurance which would imply that it has a well delimited, generally accepted significance. The words mean the miugation of a disease process when cure u considered to be impossible. Ius indications ind its applications to a parucular situation may well require soul kearching consideration on the part of the surgeon. A ategorial indiation for the severance of certain perves is the presence of an inoperable malignant tumor which u causing intolerable pain. On the other hand, there is seldom any justification for exclaon of a nonobstructing malignant growth in the stomach which has already spread (metastazed) beyond its primary site. An intermediate situ aton u presented when the liver is found to contain metastases from the cancer of the colon wbuch is threatening to cause inter unal obstruction, a condition which would be fatal many months 71 ·before the hepatic involvement would cause death. In such a case the palliatre renoval of the cancerous mass in the colon would be highly proper Some of the most severe strain to which a surgeon is subjected coma not in the operating room but during a difficult, prolonged, sometimes fatally ending postoperative cours. Such an ordeal may last for days or even wecks, during which time the surgeon must stimulate himself and all those connected with the case to act maximum energy and thoughtfulness. I can recall many periods of terfic stress. In one case, an embolum of the pulmonary artery simulated for days a leaky duodenal stump following gastric resec tion but at the postmortem cxamination the stump proved to be entirely exonerated. Similarly in another case, gallstone colic was thought to be a symptom of a leaking duodenal gustac reseaion In an espeaally difficult case an unsuccosful fight for the life of a patient with necrotizing pangautis subsequent to a common duc operation demanded most of our time thought and strength for a month. Hump after ·CHAPTER VI The Surgeon in the Operating Room F Rou the perspective of many years of experience it may be proper to offer some counsel on the general conduct of the surgeon in the operating room. First of all he should be courteous and businesslike when "booking an operation that is when he calls to reserve the date and time for an operation. He may find that it is impossible to secure a desirable time and will have to take a second choice. This » not the booking deks or nurses fault (unless she is obviously inexperienced) and the surgeon should not argue and try to squeeze his case in the schedule, regardless of cawing inconvenience to other surgeons and their teams. IE, Over 2 period of time it appears that the operating room staff u not being uulized to maximum efficiency usually the matter an be traightened out by a conference between the operating room supervisor and the chief surgeon or the staff operating room com mittee It has long been my belief that the smartest and most effiaent service in an operating room u developed by rigid insistence on good technique combined with uniform courtesy A mature surgeon often forget how almost completely ignorant of surgical procedures 2 young inton and/or a young nurse may be. Almost invariably each a trying carnatly even desperately to give all the help he an Thu spint an be fully utilized to produce the highest pro 73 ·fiaency if simple courteous polite instructions are given and 11, when possible an explanation of the purpose of any service re quested is patiently made. Development of an enthusiastic esprit de corps will evolve e brilliant operating tam, each member having pride in his team membenship A surgeon who u a loud, bitingly harcastic, unjust martinet will never develop this precious team spirit Despite the fact that the surgeon is working harder and is under much greater strain than anyone else in the operating room he is not excused from remembering that the others also are working hard and, in fact, may be acartr to the point of exhaustion than he is The surgeon alone has the great stimulation of invating and carrying through vanous manual procedures, so the motivat ing force is much less strong in the first assistant and pradically nonexistent in the retractor men. I frequently all for momentary rat periods for the entire team, during which the retractor men can relax and exercise their camped fingers Exchanging the post- Lions of the second and thurd assistants to opposite side of the cable may prove restful to them. The surgeon should show his awareness of the necessarily delayed or missed mealtime of his assistants and try to avoid their becoming ancewively fatigued. I believe that it often helps the partnership in the operating room to make the homely comparison of the surgical personnel and a football team. The surgeon is the ball carrier wbose perform ance is relatively easy if the recractor men and the fint asistant do the proper "blocking and if they open up holes in the line." Another measure which contributes to a favorablc esprit de corps us the "signal system." I saw this system developed to a high degree by my former chief Dr Eugene Pool in New York in 1916 Ac cording to this system thc surgeon puu out his right hand in the direction of the instrument table and makes one of many dil ferent hand signals which an alert nurse interprets and abt then quickly places the indicated instrument in his hand Every onc on the team learns the signals and develops pride in the smartnes with which the system is put into play this signal system has the menit of minimizing the number of spoken words and hence the number of mouth organisms extruded into the face mask and pose sibly through it to the operative ficid I believe it is also liclpful for the surgeon to address each member of the team by name for instance referring to an assistant as “Dr Smith the term “Doctor being used as a courtesy After a resi 14 ·dent has worked with me for a year I usually address him by his first name. The chuief nurse is alivajs addressed as "Miss (or Mrs.) cien if the surgcon must take a few seconds before the operation to learn what her name is by inquiring of the super visor The great English surgeon Sir Frederick Trevas surgcon ex traordinary to Queen Victons, is said to have remarked concen ing surgeons that a shaking hand offers a slight obstade by prolonging the duration but not the success of an operation but that a shaking mind is an insuperable obstacle. As Barrows puts it. "The alm well-stocked brain is of much more consequence to the operator than the steady hand and wonderful dexterity that appeal to popular imagination." It is taken for granted that the surgeon starts each operauon with all possiblc knowledge of the problem presented by the case and with the proper knowledge and technical skill for taking care not only of what is likely to be found but whatever may unor pectedly be encountered. The value of all those essentials us diminished, however if the surgeon does not possess the full measure of that most priceless quality equanimity This does not mean that he should not be quick and energetic and make decisions promptly Sir William Osler: in his superb valedictory address entitled "Aequanimitas, delivered at the University of Pennsylvania in 1889 wud. bility "In the physian ar surgeon no quality taka rank with imperturba coolness and presence of mind under all arcumstances, abneu umid storm, dearness of judgment in moments of great peril, immobility impasutreness in a true and perfect form, imperturba bility is induwolubly usocuted with a wide experience and with an intodate knowledge of the nined aspects of disease." Finneya merges that the surgeon in order to cultivate the much datured quality of equanimity should give areful study and im plidt observance in his work to the following fundamental rules of good surgery "Let me emphasize a strongly u I an the adriability Indeed the absolute necesity for the exacise of unremitding anigence and scrupulous are in the performance of a surglal operaton A large part of good purgery condut in and attention to detail in eterything that concerns the operation i arefully taken bistory 1 thorough phrial examination the makuog of a correa diagnoses the prepara- 75 ·bon of the patent mentally as well u popucally for the operation the choice of Destbetht und anesthetic absolute ikpais careful and gentle handling of the timua, absolute hemostasis avoidance of the devitalization of time in the wound by Ilgation of coneccharlly large ming of tigue or by too nght sutures, the use of the anat allt in future and ligature material (with certain accepiboni FC) ominion of drainage in dean, dry rounds, accurate approximation of wound and akin flaps phylologial rat after operation (compatible with judicious early ambulation FC] avoidance of too tight drendngs and bandages. These ure the fundamental lum of good surgery u instated opon by that juster morgeon Profesor William Stewart Halsted, my honored chief for thisty-three reart." Certunly a surgeons equanimity in the operating room beans direct relation to the scope of his experience and the frequenc with which he has encountered and dealt with unusual findings happenings. Equanimity is a noble and indispensable qualit never to be confused with the pernidous quality of conceited an flippant self amurance. No matter how many times a surgeon ha performed an operation and no matter how simple it has become i him he must always approach it with maximum care and watch fulness. I have told my reudents many time that when a surgco comes to consider an operation as casy” hu soul 4 lost A though some operations are admittedly more difficult than other it is best for the surgeon (and for his patient) to remember that operation is really easy As I review the technical crrors I have mad in my surgical career I feel that they happened usually when thought I was doing something that was easy When an operatio is most dificult, the surgeon is most attentive, careful and watch ful but whenever he feels ultraconfident, his concentration ma suray That is when danger lurts beide hun. The aitcal teus of a surgeons equanimity at the operating table come in many formos. Sometimes he meets these tou whes fortified by a good night o sleep but many times the tests come a 3 All after an exhausting day or near the end of a five-hour opera uion It is then that he must draw on his nervous and physica resen a which it is hoped, he has arcfully guarded against deple tion due to acuvities unrelated to his profesional work and due li inadequate are of his own health The first type of cost of cquanimity is concerned with the pa uence and care necaury to complete long, delicate operations such as an anastomosis deep in the pelvis, or a total gastrectomy 76 ·The second type deals with unanvapated findings for instance, when the preoperaure diagnosis was acute appendiatis but opera ton reveals aranoma of the cecum or a perforated duodenal ulcer necessitating a different incision and an operation of much greater magnitude and difficulty The surgeon must have the mental clas tidity and adaptability to adjust himself to every ncu problem He must avoid the rigid, stubborn type of thinking wluch attempts to make inadequate findings fit a predetermined diagnosis, at thc expense of failing to make a complete search and actually over looking the real trouble. I have in mind a surgeon who removed an appendix even though its normal appearance womed him somewhat, but not sufliacntly to stimulate him to make a areful search which would have disclosed the perforated diverticulum of the ascending colon in ume to repair it successfully and save the patients life. A surgeon should never be content with an in adequatc explanation of any physical findings but must search for come other explanation, which is often found. The third type of test of the surgeon s equanimity is concerned with the unexpected happenings of infinitc variety such as a loud Dome phen an instrument pan crashes to the floor or an electric light bulb explodes. The lighting system may fail and require the use of emergency battery lights, with which every operating room should be equipped. During an operation I have seen a nurse slip on a wet floor and fall down, breaking her arm, and I have seen an akistant or a nurse become ill and have to leave the operaung room. Occasionally an assutant may make an error requiring the re-doing of many tedious steps. I have had an anesthetut let my patrent get too "light" before a large inagon had been secured and ause it to rupturc, 2 mishap which required the repetition of an hours work An unexpected hemorrhage may be a rigorous text of the sur geon s cmotional stature. A small artery an shoot a vigorous stream of blood into the surgeon & face (including his eyes and glasses) but can be readily secured. However a hemorrhage deep in the recentes of the abdomen, where the source is concealed by a rapidly forming lake of blood, u most difficult to control, for instance when a ruc artery of the gallbladder or a renal artery is uncontrolled. An inexperienced and frightened surgeon may plunge a hemos ut into the puddle of blood in an effort to grasp the bleeding artery a procedure that carla the great risk of injury to some adjacent 77 ·structure. For example, the common bile duct might be injured in the case of hemorrhage from the cystic artery In such an instance the surgeon should control the bleeding by inserting a finger in the foramen of Winslow and compressing the hepatic ligament until the bleeding point can be accurately located. Most hemorrhages can be retarded or stopped by firm pressure with a warm laparotomy pad. This may be applied for five to twenty minutes and then quickly spatched away with resultant clear demonstration of the source of the bleeding In that instant the bleeding point can be seen and grasped with a hemostat. I have used such a pack long enough to send for an extra assistant and keep up the pressure on it until he has scrubbed up for the operation. To me one of the most alarming hemorrhages is that resulting from injury to the portal vein during removal of the gallbladder In one case in which the hemorrhage was from the portal vein and in another case in which it was from a renal artery I was able to damp the bleeding point but was unable to ligate it. In cach instance I had to leave the clamp on for a week. Both patients recovered. The beror rhage from a duodenal ulcer may tax the surgeon s resource he mwt work rapidly while masive transfusions are being adminis tered. In operating upon a patient with intesunal obstruction due to adhesions the surgeon occasionally opens the intestine inadver tently during the course of the delicate dissection No blame is at tached to this occurrence but the wound must be patiently re pared, sometimes by time-consuming, painstaking resection. One of my own most difficult situations coma to mind vividly This patient was an elderly woman with cancer of the right colon Her heart was none too good. In fact, before the operation the anesthetist stated with finality 'You will be able to do only a colostomy Why he thought an opening in the bowel distal to the cancer would do any good was never explained Nevertheless, the patient did tolerate most admirably a dificult, three-hour resec tion of the nght colon Afterward, I went to lunch with my tired team, and then te stopped in at the pathology laboratory to inspect the excised specimen. The head pathologist, Dr John VcCarter examined it and made the alarming statement that a large piece of die urinary bladder was attached to the upcomen. I immediately telephoned the specal nurse who was taking care of the patient and was told that urine had been obtained by catheterization. Ilow 78 ·ever her report could not have been correct, as Dr McCarter's frozen section proved that the ussuc in question actually was from the bladder wall. Evidentally the cancer liad becomc attached to the bladder and during the operation some of the bladder wall had been oased along with the tumor Uncorrected this situauon Fould have been fatal So with heavy heart, I had the little old lady taken back to the operating room that afternoon and opened the abdomen through a new incision. The bladder was "porc stringed around a mushroom catheter This last ditch" stand was successful, and the patient made a fine recovery Seren years Later she was alive and well with no sign of recurrence Nowadays, cassation of breathing seldom occun, but during my surgical career I have witnessed a number of these alarming occur rences. The most vivid recollection is that of a fine sturdy boy about six years old who sustained 2 mall laceration in a fall. As he was too ſnghtened to permit sutures with local anesthesia only a general anesthetic had to be given, unfortunately when the stomach was full It would have been best to have used no anes thesia despite the parents indignant reproaches of cruelty As I was about to suture the wound, the boy vomited and chunks of meat blocked his windpipe. His pupils dilated breathing stopped and hu color became dusky bloe. The nurse anesthetut threw up her hands and cried (helpfully) 'He's gone! The latern and I dropped all sterile precautions dug the food out of the air passage and kept up artificial respiration unul the boy was breathing satis factorily I then completed the surgical work, but must confess that while I was doing it the thought kept flashing through my mind of how dose I had been to the oncrous duty of informing the par ents that their boy was dead. When the heart stops beating (cardiac arrest) the situation is even more dangerous. If the surgeon s hands are in the abdomen, he an masage the heart outside of or through an inarion in the duphragm. Otherwise, he must make an inasion in the thorac wall in order to grasp and massage the heart. There are numerous reported cases of success by both methods but neither has been successful in my lands in thic few instances in which I have wed them Another striin upon the surgeons cquanimity is to hear as he 1 about to close the abdomen or may have completely closed it, the soub nurse stale ominously "The sponge count is incorrect. 79 ·This means that one of the counted pieces of gauze or one of the laparotomy pads is missing and despite all hunting in floor basins und elsewhere, cannot be found. This is a most trying situation and fortunately u infrequent. The surgeon may feel virtually turc the missựng sponge is not in the abdominal cavity but could evi dence points to the possibility that it may be. The matter must be settled before the patient is taken from the operating room or waka up from the anesthaia. Unually another search will disclose the Mining gauze under e drape sheet or under a towel in a basin. I recall one instance in which a fourth year medial student, about to leave the operating room for a class spied a bloody piece of gauze on the operating room floor Doubtless wishing to do his good deed for that day he discreetly picked up the object and walked out in the hall. But what to do with it? After 6011e search he found a trash an in a duty room at the other end of the hall where he disposed of the gauze and went happily on his way Meanwhule, back in the operating room, the surgeon did not dare dose the inasion and all of the operadog room personnel con tinued searching until the missing gauze was found. It is now mandatory that all pieces of gauze introduced into the abdomen contain a snall piece of metal impregnated ardboard which 19 x ray opaque. When a piece of gauze cannot be accounted for a portable x ray machine is used at the operating table. If it shows that the gauze is not in the abdomen the surgeon may mely complete the closing of the inaslon Burrow24 say "Anothe kind of surgal occuon which calls for firmaets of dur 1er is when at a cloal moment during an operation come onlooker intervena with an Ill-timed remark. The effect upon the surgeon may be compared with that exerted upon a sprinter who happens to be Jontled by a competitor in a hundred yard race. Whether he deviatos to the right or to the left us a result of the collision will depend upon whether action or reaalon is greater but in either creat his balance will be disturbed and bu yen wride be broken In the case of the surgeon the disturbance caused will be proportional not only to his mental concentration at the moment, but also to his instability of charador I have more than once heard some audc remark made by a by llander at an operauon with the intention of being humorous, only to find to his dismay that the pauent was under local anes thesia and must have heard the remark. 80 ·During my more than fire thousand major operations, I have always felt conscious of my obligation to instruct those who were helping me. The foremost fador in this instruction is to perform each operauon with the maximum skill care and adequacy pos sible. The assistants thus learn what I believe to be the proper way to do ach particular operation. Despite my own zeal to any on I have med to be ever mindful that an assistant holding a retractor may not be able to see the area on which I am working or what I am doing Whenet er I think that it is not incompatible with the pauents best interests I call for a momentary pause and point out the various landmarks and the steps I am taking Thus not only ures the assistant from a virtual waste of ume but actually because of the brief rapite, makes him a more rested and valuable assistant I bare always felt in the case of a private patient who engages me to do an operation that there is an unwritten contract or un derstanding that I do all of it therefore I almost invariably close even the skin myself and then dictate my operative report and check the immediate postoperative orders. The Board of Regents of the American College of Surgeons in supporting the surgical rodency training program us a little sensitive that this domain not overlap that of perniaous "ghost surgery - At their meeting in Cleveland on Vay 1 1954 the Board clarified an carlier (spring, 1954) definition of ghost surgery by making the following statement: "A surgical operation represents a cooperatire effort by the re possible surgeon and his asistant. The eua part which ach plays during a particular operauon may well und frequently doos vary Gbost angery has been defined by the Regents us that surgay in which the patient is not informed of, or is mbled us to the identity of the operating surgeon. The Board considers it to be a breach of ethia when any pauent who has made an agreement with a sogoon is oper ated upon by another without knowledge and consent of the patient. However the Board conaden it proper for the responsible surgeon to delegate to his assistant the performance of any part of a given operation, provided the surgeon u in actire partiapant throughout the curentii part of the operation. The Board of Regents approves the iocimion of all patients in residency training programs." Nyering comments upon the defiaenas in training obtained by preceptorhip as contrasted with an approved residency program "If the preceptee attaches himself B un ftant or a partner to the preceptor and bopes to learn argey on the private patients of the 81 Ath ·preceptor the legal responsibility of the preceptor for the ads of the preceptee must be kept in mind. In a recent malpractice mult in which the plaintiff patient was arrded $200 000 damages from a furgcon and the hospital the following u an except from the instruction of the judge to the jury An attending phynoun who has undertalen the arc und treatment of a patient cannot assign the performance of en operation or procedure to un assistant which fact bunknown to the patient and esape lubülty for negligence. A few residents are resentful if they are not permitted to put in the skin sutures themselves, but they learn little from doing it and will have more than ample opportunity for this later When I was chief surgeon at the Evanston Hospital I acted for many years as the first assistant to the resident or intern in all nonprivate cases in which he was eligible to operate and capable of doing so. Later as I became more pressed for time, I delegated these teaching tasks to the younger surgeons on the staff. In an excellent editorial on the Teaching of Surgical Technic, in the March 4 1954 issue of the New England Journal of Medicine the following ques tion from a report of the New England Surgical Society is quoted Can surgeon ethically turn over all or part of an operation on one of hus private patients to a member of the resident staff for teaching purposes? The Journal adds "The very fra that the report usks such a question and goo to nome pans to answer it indicata that in the minds of the authon the teaching of surgical technic is a serious problem. Any attempt to separate surgical technic from the totality of a surgical operation leads to the concept that a man might be trained to be a good techoidao whille ret a poor surgeon, whereas by any reasonable dealfation a man wbo does poorly by his patient at the operating uble ba poor exponent of rurgical technic and must be regarded us a poor techplaan no matter how flashy hus handling of the knife. There is a deplorable tend. ency to regard the mare teaching of the surgical operation us somc. thing that a below the dignity of an educator who should be more concerned with psychiatry social service, blochemistry or phriology Tlus unfortunate state of mind urisos from much too Darrow a defini con of the cechnical aspects of surgery When it is put in its proper reference and the act of surgery is defined as the surgal operation and everything pertaining to it it looms as one of the most important if not the most important, single crent in the care of the surgical paucal" For years it lias been my practice when doing the more or less routine procedures requiring less concentrated attention such as closing the abdomen to quiz my assistants Informally Various 82 ·hypotheucal questions not only revive them mentally and physically but are intended to instruct them by making them think about the anres. Such questions include. "How would you recognize a postoperative hemorrhage from a large branch of the inferior cpı gastric artery causing a huge hematoma just outside the peri toneum?" How would you handle a severe wound disruption?' What would you do if you were the surgeon and those Penrose tubing drains, which we have just placed after a cholecystectomy were inadvertently pulled out before the dressing was applied?" 'What would you do for the first ad of a sucking wound of the chat at the scene of an automobile acadent I usually let each of the men present give an answer 83 ·CHAPTER VII Anesthesia I OTPORTANT factors in the patients safety and the surgeon s frec dom to concentrate hus attention on an operation are the all, atutude and emotional make up of the anesthetist. Great strides have been made in anesthesiology in the last fifty years, and we have come a long way from the carly crude methode Forty years ago an intern might be summoned in haste to give his fint anes thetc without previous instructions because the operaung room was shorthanded. This happened to me in 1915 the surgeon merely Haying that he would advise me how much cther to pour on. After a long struggle with a cyanotic short necked, fat man whose false teeth as I afterwards learned, were bumping around in his throat, I finally completed the anesthesia and the patient miraculously Survived. Most of the best early anathetists were women chiely nurses, but a few were doctors, and they were always gentle and consid cratc Today some states permit anesthetla to be given only by a doctor of mediane. Today anothesiology is a definite dutinct speaalty and has ius Board of Cerufication, one of the nineteen specialty boardı. Before becoming cligible to take the examinauons for board certification an applicant must, among other things submit proof to the Board that he las limited hus practice to Anesthalology as a specialty for five clendar years of which at least two have been in forroa) training approved by the Board He must be a member in good standing of the American Sodety of Anesthesiologists, Inc." Ilc 84 ·must also prove to the satisfaction of the Board by such written survey oral and practical examinations as the Board may pre cribe that he is qualified to practice Anesthesiology and personally prepare such case history abstracts of personally con ducted procedures pertaining to Anesthesiology as the Board may speafy" The written examinations include "anatomy chemistry phyacs, pharmacology pathology and physiology" The fee is $125 00 Alany young doctors are attracted to anesthesiology as a speaalty because there is usually more regularity of hours and more finanaal security after one has become established. Up unul recently and in some situations this system still obtains, the anesthetist was mlanied by the hospital, and his services were paid for by the patient when he setuled his hospital bill included under the subbeading "charge for the operaung room" or charge for anesthou. The current, widely prevalent pracucc is for the anesthetist to send his own separate bill directly to cach patient. Furthermore the pauent must pay thus bill although he has not personally selected bus anesthetist. Indeed, the surgeon also usually has no voice 10 the matter but must accept whoever is assigned him and is ex pected to tell the pauent that the anesthetists bill whatever it may be, is proper In general however this system is an improvement, 23 it develops competition among anothetists to give the best kervice posible and insures a more careful preoperative scrutiny of the patient by the anesthetust and more attentive aftercare Richard K. Gulchristio recently maid The surgeon is very willing in laching insututions to my We are now approaching a danger point, and unfortunately we have had some thing happen, but in my aperience it is almost impossible to get the anesthetist in the teaching imutubon to my s the operation progrosses and you have residents and student present, The patients condition is this the preoperative mediawon is thu the drugs given to this polnt or there and we will now add this, that and the other We will cooperate. They ure very reluctant to do so. Koontzi hay Certainly the anesthetist should do nothing to the patient to start violent struggling without ducussing the matter with the surgeon first. In general, should never be lost nght of that surgical anesthesia us an adjunct to surgery and not an end in itself." Potts has well and that "a few" physician anathenolo gusts an justify the long period of trainmg "only by doing un ·usual things for the routine operation when a simple method would be saler Of course, the picture is not always as gloomy us thuI have known many anesthetists for whom I have the highest regard and whose loyalty to me was unquestioned. During an operation I needed only exchange a glance with the anesthetist in order to hoow my patients condition Hu look or a few quiet words have often given me the added encouragement I needed to go more slowly and more painstakingly When such an anathetist looked grave, I knew he was sincere in warning me to hasten the operation in every way possible. Some other type of anesthetist might give the wme warning, but being largely self-centered he is motivated more by what someone might say of the manner of the anestheuca ad ministration than by team spirit to help the surgeon through a difficult period. An admirablc statement of the opumum surgeon-anathetlu rapport has been made by Cole and Sadovet "Efficiency of operaure care of the patient s dot posible without complete cooperation between the surgeon and anothełologist. The added responsibilities acquired during the past deade or two by the 100thcuiologtat have condiderably changed the role of the anaihestologist in the operauit care of the patient. The anesthesiologists knowledge of such subjects us pharmacology and phyuology hare made him very helpful to the surgeon in the art of the patient. There are no many variable factors in hospitals throughout the country that the reponabilitia of the surgeon and anothuiologist annot be defined dogmatally Many of these functions will have to be worked out ac cording to arcumstanca however certain of them are rather obviou, For euample the surgen und anesthesiologtat should consult preopera uvely and, after the encuhatologist has had opportunity to cumine the patient and his chart, the nurgeon should inform the anesthai ologist of the type of operation planned and the anesthesiologie should loform the rurgeon of the type of anothetic he contemplates using The anesthesiologist should loform the surgeon promptly of any diange in the patients condition during the operation. Likewka the argoon should infarto the inathalologlit immediately of any change in the operatire plan The surgeon aspects the anathetologia to keep constant watch over the patients condition, and the anastbc uologut expects the surgeon to perform the operation with the least amount of trauma and minimal blood lost the operation L no place for prejudice or anger lle must remember at all time that the welfare of the parent is the paramount issue during an operation. Complete cooperation will result in maximal elbdency 86 ·Το get the training prerequisite to the taking of the examinations for Board cerufication in anestlicsia physıdans naturally try to obtain rodenas in anesthesia in insututions where they will get the most experience and instruction We do not know just what the Anothosia Board speafias when it requires the candidate for ex amination to personally prepare such case history abstracts of per sonally conducted procedures." Certainly the candidate will natu rally wish to submit the largest number of reports on spinal anes thestas, intratracheal intubations, clc., that he can There may be pressure upon him or on the chicf anathetist to employ a more complicated procedure when a simpler one would be better I have felt strongly about my responsibility for the unconsaous patient in the operaung room. The pauent or his family annot protect his interests there, and they rely upon me to do it. If a new intern is unfortunate enough to have to puncture the patients arm four or five times to find a vein one not surprised to hear a patient loudly protest and a call for someone who is not "prac uang on him. Happily the patient in the operating room cannot see the resident in anothesia getung the material for his "per ronally conduced procedures" in support of his application for Board certification It is the surgeon who must "explain to his paueat after an operation why he has a sore throat that may be more annoying than the pain of the inasion. The solution of this dificult problem lies in a combination of factors a chief anos. thetist with time to supervise and a conscience that will put the pauents interest ahead of the residents rate of progress and his own teaching prestige, the use of more nurse anathetists in simple sses, and the forthrightness on the part of surgeons to defend their patients interests in hospital executive arcles. Beecher and Toddh have recently published an important con tribution entitled A Study of the Deaths Associated with Anes- They made a study of all deaths attributable to anesthesia in 599 548 operations at ten partiapating university hospitals from January 1 1948 to December 31 1952 Twenty one physicians and eleven secretaries worked on this report conunuously for five years. The results have been a revelation. It used to be and some forty yean ago that the death rate from ether was about 1 in 20000 With the improvements and discoveries of anesthesia, Purgeons have come to feel that moden anesthesiology is really much safer than it was a generation ago However it is only a cour 87 thoua and Surgery ·ageous and laborows study ruch as that of Beecher and Todd, which proves that the reverse is true They say Dau are presented to show that dath from anothala is of auf dent magnitude to constitute a public health problem. Anesthesia küll several time u many duzens ach year out of the total popola tion of the country u doa poliomyella Condideration of the millons of dollars rightly spent in attacking poliomyelith and the not to nothing, comparaurely spent in anesthed research makes car an urgent need." [Of course during the period of this study many more deaths from poliomyelius occurred than, happily occur now with the protection of the Salk vaccine. F C} Beecher and Todd found that 'Inhalation anesthesia is by far the single most important technic but the use of intravenous anathesia has doubled in the period of study while the use of the spinal technic has declined somewhat It accounts surprisingly for less than 9 per cent of the asses." 2. "The use of other us a primary agent u steadily increasing, while the use of cyclopropane is not rising 'When muscle relaxants (curare) were used the anesthesia death rate increases nearly six fold. 4 The over all anetheia death rate, that is, primary anathaia death and death where anesthesia was described as an important contributory ause of death, was 1 1560 which is quite different from 1 20 000 5 A fifth of the anathetia were administered by nurses. 6. Forty per cent of anathula were administered by anesthesia residents. 7 Fifty ninc per cent of the non-curarc deaths and 65 per cent of the "curare deaths" were at the hands of residents in anet thau. 8 Eighteen per cent of the non-curare deaths and 19 per cent of the curare deaths were at the hands of nurse anesthetats. $$ ·CHAPTER VIII Surgical Pitfalls ONE who enters into the speaalty of surgery should delude long surgal carcer every surgeon looks back upon cases in which he wishes that he had done differently Perhaps, here and there a different step or procedure might have spelled the difference be tween life and death. He can only prepare himself most fully and intensely and operate with greatest arc coolness and judgment. No human being can be free from crror but it must be ones constant effort to reduce these crrors to the minimum. A surgeons ctor may be inalculably costly since a human life is at stake. Each day the surgeon must alert himself continually to the posu bility of error of judgment or of technique and never think of RDY decision or procedure as easy In the determination of an error postmortem examination u of prime importance. It is one of the great foundation stones of medical progress. If a surgeon maka an ator he must bear it with dignity and courage and not "fold up He knows that he must carry on, that it has taken a long time for him to be manufactured" and that his serica must be available to those who need them-Senica that after an error has been made will be glore valuable and more skilled, rather than lets so. Should the surgeon fall into the reprehensible attitude of feeling sorry for himself he should be cnheartened by compariog hus rc sponubllius with those of military leaders. A surgeon s error may cost one life, but a generals error may send hundreds of thousands of one young men to their death. "Someone had blundered 89 ·Thers not to reason why Theirs but to do and die." And the states man s error in judgment or the rulers need to strengthen bis popu. lanty may plunge whole nations into catastrophe. I think that most people realize that no surgeon an be absolutely infallible. All that they want are hu utmost efforts and deepat thought That no one, no matter how skilled and convaentious, is immune to citor is discussed by J M T Fancy' He tells how even Sur William Osler failed to recognize acute appendiatis in a Johns Hopkins nuti, dapite Finney's warnings and her appendix per forated and peritonitis developed. After a stormy session on the Ochsner Treatment and drainage of recurrent pelvic abscessen, thc patent finally recovered. Finney sayı "Nuku are not confined to people of low intelligence or of Hitle experience, although unquestionably they are far more common in tbok classes. It is the wise man who benefits by his crrors, and often onc learn more from hu mlatata than from ho successes. Although it only natural that one does not want to herald widely one s mladceda Hill it is well in all bumility to report them lo order that othen may profit by Auch miaka und so avoid u for u poable ther repetition in the future. A thorough study of a mistake in order to huufy oneself, If posible, us to just hom It occurred and how it could have been avoided, may prove helpful" In 1922, Harold Burtown, of Portmouth, England, published a volume cnutled "Mustakes and Acadents of Surgery” In his preface he said. "Sea aptulns of old alled in water that were ancharted. Their guida wete nebulous and doubtful their dangert graal The steep coast, the gendy shelving short-rach poor marks as these-Inter preted by them, nguely and with much haard, what now b told truly 2nd surely in the chart house. The surgeon of today is like the wallor of a part agt. He, too u embarked upon oceans that are unmapped and wide. Forcyer and with much labour (cellog hl my with the lead, u it mere he is baset with incent troubla Ionumerable ore the curgial dkasten with which he is menaced, unnoticed or un recorded are their ausa, uniroidable their repetition. My aim has beca to make a commencement of better thingi by locatng some of the danger points in the univers of surgery The chardog I have ac compilhed is rough and Imperfect--almost absurd my be-like the carly maps of the world in lus umplidty and codity Neverthelem there is value in the ID-abapen beglobing of a thing for we know that all the complet inacery of completion will come eventually us the gift of time" go ·In less than three yean a second edition of Burrows book was called for and in the preface of this new edition he remarks "The first edition of this book fell into the hands of the lay press Sensational copy could be extraced by unscrupulous journalists, and to material, which had been intended for medical nen alone, was ploited and mlaepresented in order to amuse the public. Therefore, in isulog a Kecond, enlarged and amended edition It has been thought well to change the tide from Mistaka and Accidents of Surgery to Putfall of Surgery and it is hoped that any prejudice or announce that was unwittingly acated by the former may not be sustained. Tattbooks and teachers have been so much concerned with construc tive information that relathely little has been said about this subject of the difficulties and dangers of surgery A minor rolume devoted to these matters may therefore be a useful supplement to the major works opon which the surgeons confidence has been nounshed" (The author asks) "to be pardoned for any appenace of pomposity and assure the reader that many rers of labour have taken away all the pluma of pride which once us a young man he possessed and fondly florrubed. While Burrow's book is now somewhat out of date, it still con tairs much sound advice. He groups surgial crrors under four main headings ignorance, carelessnes misjudgment and defective technique. In the more than five hundred pages of his valuable book are startling and instructive examples of these various crons. He sagely observes "We lam by personal experience. To utilize the openiece of our colleagues forever is difficult. And yet life is short-is in fact too brief to yield us all that ample knowledge founded upon direct observation which we properly prefer to any second-hand lemon which has been collected by bruns other than our own." The surgeons energy and fuity of purpose in the unpleasant task of obtaining permission for an autopsy from a grief-striden and uncomprehending family is an index of sincerity of his search for his errors and his willingness to impart the valuable lesson to other surgeons and thus to benefit other patient. The surgeon who is lukewarm or cold 11 hus efforts to secure necropsias on patients who die after he has operated upon them naturally aroues some suspicion that he is fearful that an error may be revealed. A very fuir index of the grade of surgery at a given hospital is the per contage of deaths which come to a postmortem examination. At 91 ·Evanston Hospital we have always been proud that the percentage is in the cighties The surgeons consaence may become a battleground between the instinct of self-protection and the necesity for determining the ause of an error not only for his own identification but for the instruction of othen. I have had to get ap at midnight and go to the hospital in order to persuade the anguished mdow of a patient on whom I had operated to give permion for a postmortem examination. She had become SUTTOunded by a number of suddenly important and in part, bostile advisen who constantly and loudly interfered. Every surgeon will find it advisable to carry physician s llability insurance," for protection in posible malpractice" suits. One of the leading insurance companies in this field suggests to its policy holders among other things, that they "make no statement, prom isex, or take any action which may amount to an admision of liability on your part. In the event of a dath under arcum. stances which may give rise to a clum or suit covered by your policy report to the company before attending autopsy or inquest." Certainly it is contrary to the advice of insurance companies to admit to a family any technical error which is disclased at neaopsy but I have not regretted doing so in a ungle instance. It is to one colleagues, however that crrors should particularly be explained in order to help prevent their repeution. In bu excellent article on "Medidne and the Law Regan** estimated that 50 to 80 per cent of all malpractice suit would be eliminated of destructive aitam by other physıdans could be stopped. He also said "A charge of malpraakce is not warranted even by the fact that (the phyſaan) made a mistake in diagnosis or was guilty of an ctor of judgment, that he might have employed other medidon or used other methods of treatment that expert witnesa totify that they them sell as would have employed a different method or that a bad rosuit fol lowed louad of a muficoty one Experience has taught that the most areful attention to the dictates of good medical practice is not Anfident to ward of the unjust caum and that no phridan is 101- mune The likelihood of being ned for malpractice pust now be regarded as a definite accupauonz) hazard for the paaldng pbysklan. Cereal medicus A patient who bu 1 [riendly Iceling for the phyldan and who believes that everything powłble has been done for bft is not likely to sue for malpractice tren when the result b bad" 92 ·Regan stressed the importance of taking xrays in cases of fracture or suspected fracture, undertaking only such proceduro as one is qualified to perform, the employment of consultants in scious or fatal cases, keeping “ideal records in all cases, obtaining writ ten consent for an operation and approval by special hospital staff commitice or reputable consultant before terminating a pregnancy and the danger of telephoning a prescription In a recent issue of the Bulletin of the American College of Surgeons's appears the following statement. "In recent years, the number of malpractice claims has increased fanurtally and, today approximately 5 000 cues are reported ach year-or one case for every 55 doctors in private practice. Io some ruta, the rate us even higher with s many as one doctor in 12 beng intolved. Stalbug on the subject are not precise, but one authority estimates that the number of malpractice suits has increased twenty fold unce World War II. "Moreover judgments have soured along with dam, and it s not ao-common today for junes to award $100 000 to a patient they dedde has been damaged by his doctors negligence, arelessness or bad judg mont. "Of course, insurance losses and rato hare kept pace with the inacases in claims and judgments. In one state alone, two companios reported lonkas aggregating $3 million since the war The average cost per malprakce claim to another large company bas increased five tumo nnce 1911 "During these years of mounting malpradice claims, the law hamt changed, and mandards of medical and surgical practice harc been constantly improved. The blunt truth u that the majority of all malpractice rula filed are without menit, ad the late Dr Low J Regan of Los Angeles, who was one of the nation, foremost author Itia on forensic mediane. More than half the malpractice suits filed today involve plyucans and surgeons who are above the median of the respective groups lo skill, esperience and professonal standing, Dr Regao uted. The bringing of 2 malpractice action does not even suggest that the claim has more for any patent may bring such 10 action againt any phman who has attended him professionally be added. Io 1940 a volume of over 700 pages mas poblushed cnuded Foreign Bodies Left in the Abdomen by H S Crossen and D F Crossen. 4 The work was undertaken "to emphasize to surgeons the danger of occurrence of the serious acadent of leaving a foreiga body in the abdominal avity to work out the best plan of treat ment for vanous types of such anses, to call attention to the dif 93 ·ficulues of avoiding such acadent under the many stresses of abdominal work, and to arouse interest in the serious study of the problem of prevention. It makes volemn and valuable reading to study their analysis of 250 reported instances in which a sponge was left in the abdomen and of 86 cases involving a forceps, a part of an instrument, a needle or a drain Court actions in 108 cases are analyzed. The book includes over 900 reference Foreign bodles have been left not only in the abdominal cavity but in all of the numerous types of surgical wounds. A small gauze sponge may bc left under a scalp flap or in a wound of an extremity An entire needle or a fragment of a needle may be lost in a wound. Operating on the wrong side is always a menace. Thirty years ago Rutherford Morrison 47 said. "It seems almost incredlblc to any but surgeons in a busy hospital that ruch a horrible mistake mus pouble I have seen the wrong side operated upon for inguinal hernia, the wrong kidocy explored, the wrong knee joint opened. A house-curgeon of my own amputated the Ieft ning finger of a woman instead of her night He would have Aved himself and the patient much pain and regret and the hospital com pensation money if he had remembered my rule always mart with a crom, before the patient is anothetized, the dde of the body to be operated upon." Operating on the wrong eye is an espeaally cruel tragedy I am thankful that I have never had the musfortune to operate upon the wrong side of a patients body but I know of two cases of inguinal hernia in which this happened. I also know of an instance in which the surgeon noticed when the patient coughed during the induction of another that there was a hernia on both udos Instead of just on the one ade that had been found at the office examination, and repaired both hernias. The patient, a lawyer later sued the surgeon for doing more than had been contracted for but lost his suit. In view of the fact that when a patient with hernia is uncon scous on the operaung table it is usually impossible to tell írom inspecuon which side requires operation, the surgeon should always write down which side is inrolved at the time of the first examina tion and as an added precution should always ask the patient again in the operating room before the anesthetic is started to addluon, the intern should write this information in the chart, and it is always helpful for the anesthetist also to ask. It is valuable 94 ·to have the intem mark the proper side with indelible ink or dye when he makes his examination the night before the operation Extreme care should be taken to avoid confusing language such 'Is the left side the right side' Better Is the left side the onc needing operation?" Regarding malpractice cuius the following observations are given in the Bulletın of the American College of Surgeonsta "Careful attention to detail, superriaon of personnel in the operat ing room and on pursing floors, and insistence of completing records and carrying out procedura according to the boot will also protect the nurgcon against liability In a New York are not long ago two pri vate pacients, both children, were brought to the operatog room floor at the same time. One wus scheduled for tonullatomy the other for artumdision, both surgeons were on the floor preparing for the operations "At this point, carelames instad of scrupulous attention to details of operating noor procedure cook over and the children were switched. The child that wus to have had a tomillectomy was artum auxed, and the one scheduled for draumdision had the tonsillectomy "Later it developed that instad of following the proper procedure for identifying the patient, one of the surgeons had simply asked the child us he was being wheeled into the anesthetizing area. Are you Fred?' ind the child answered, Ya "Quationed about this, the chilld remembered that the doctor hud spoken to him but thought he had asked, Are you afrud? "While this ase did remult in 1 lawsuit against one of the surgeons, I was not a serious as some cases of midentification-ruch # the dunic case in a Coago hospital in which a limb was amputated from the wrong patient, or the Alichigan axe a few yean ago in which a woman who us taken to the hospital for treatment of an infected finger wound up in the operating room getting a cholecystectomy "In addition to prudence and scrupulous are in the selection and trulning of employees, record keeping and 10 actual procedures, there are some specal problems in which the malpractice hazard is such that the wise surgeon is well advised to take specul preautions in advance of operation. Thus, for ample, in all ause of forgery of the had and neck, or the chest, it is adriable to bare i preoperative X-ray aunina tion of the uur to zroid the poolbility that the patient may daim Later that the openiion resulted in damage to the month or teeth. The daim that teeth have been damaged by 20theuc equipment, bronchoscope, laryngoscope, or surgical Instruments is a frequent one following burgery of the head, mooth or not, no ft srlso wise to make a careful enamination of the teeth beforc opaton, and see that a deralpoon of their condition is acted in the record, for deferesc in Que of tait. 95 ·treatment The following statement appears in another article 15 **Studies made by the insurance company that underwiltlog the Profcwional Liabllity Inrunnce Program of the American College of Surgeons have identified the following arcumstances u mbstantul awes for profenlopil lubility of malpractice actions agalost nur gtonus “1 Hasty or inconsiderate treatment resulting in poor patient phyncian relationship *2. Cnadım by one phyican or surgeon of another 5 methods or ruults. "3 Fallure to call in well qualified consultants promptly when surgeon of patient is disatufied with progress. *24. Permitting patient to become oratoptimistic about outcome of 5 Failure to maintain complete records of history findings treat ment and opention 6 Fullure to obtain proper written consent to perform operation muy Fulure to loud and supervise office or hospital mpirants properly as to their respopabilities and conduct ". Fulure to see that office and hospiul equipment and expplies be adequate and maintained in perfect condition. *9 Patient, dina tisfaction with amount of bill and surgeons fall ure to discuss Evances in advance of operation "10 Fuilure to poufy insurer or attorney of Indident that might result in malpractice aut About 1935 it became apparent to the leading surgical clinic in the United States that silk ww generally speaking, superior to at gut for future material. I began to use it routinely cxcept in cases in which there was frank pu as in a ruptured appendu because it makes a strong wound repair and less reaction occurs around sllk than around atgut. Of course, if infection develops in a wound. ulk knots or even long pieces of silk may be extruded. On one or two occasions I was obliged to do a minor operation to remove a silk strand that was maincaining an annoying discharging sinus. Of course a caigut knot also may be atruded if Infection occurs before the atgut has disolved. Almost every patent good bu moredly accepts a ulk knot extrusion as only a minor compliation One man who went to Florida for his convalescence sent unc a pic ture postal ard with the statement There is a little present for you under the postage stamp" When the stamp was pecled off a tiny knot of fine silk was disclosed One Jetter from a patient inviting us to be house guaus in Florida included the comment that "a stilch abscess delayed the healing of the indsion somewhal." 96 ·One grateful lady patient sent me a card to which was attached a small piece of silk with the following note "Dr Christopher- You planted this in July 1917 It bloomed Easter Sunday 1950 No storage charges." One of the research workers at Abbott Laboratories, on whom I had done a cholecystectomy had to come into the office because of persutent draining sinuses, from which I removed silk knots with a wall artery forceps He wrote “Enclosed us a check to cover the bill for your recent fishing expedition. Your superior angling technique and amazing catch have yielded excellent result. Both anuses were completely healed within a week. Although I am likely to arouse some speculation among observers as to whether I am the possessor of three umbilia I think I shall be able to expose my midnff at the beach this summer with little embarrassment" It was because of one of these silk knots that the only nut for malpracuce against me was instituted. This was after over thirty yan of active surgical practice and the performing of over 5,200 major operauons. Some years after I had operated on a man for acute appendiaus, hus eleven-year-old son mifered a severe attack of appendiatis, and at night I removed an unruptured but gan genous appendix, probably stieg his life. Immediately thereafter a wound abscess complicated the recovery but responded to drain age. Four years later when the boy was on his high school wrestling team and had driven bus car to California, a twelling developed which a surgeon judged to be due to an incarcerated hernia. How ever inasion disclosed an abscess with some silk knot in the pus. When the surgeon reported thu finding to the boys family they started suit against me (in 1953) their attomcy alleging that my upkillful treatment had been very harmful to the boy and bad probably impaired his future earning poner However after the abscess healed, the boy was soon playing baseball The suit never came to tnal Early in 1955 the attorneys for the medical liability company were successful 10 securing from the plainuff a release in both Superior and Probate courts and the lawsuit wu distused. A phyudan must never practice without the protection of medial lability insurance The amount of insurance to any and the com pany in which to arty it will have to be decided by the individual und deserves study and inquiry The amount and the companio many in different parts of the country (See also the chapter on Personal Injury Lidgation.) 97 - ·About a dozen amo I have operated upon children after making a preoperative diagnosis of acute appendiau only to find at operation that the symptoms were due to inflammation of the intednal lymph noda (mesenteric lymphadenitis) a condition which would not have required operation as it would have xubsided spontaneously Were the question to be raised, "Was the operation necessary?" the answer would be deadedly affirmative, for without operation, the correct diagnosis could not have been made and thus the peril of acute appendicitis could not have been eliminated. In cach case I have told the parents just what I found and have never been reproached, as they have known that I was only safeguarding their child welfare moreover unce the innocent appendix had been removed they did not have any fear of appendidus in the future. A surgeon must never promise a cure before operating But after an operation he may tell his patient, in order to encourage him, that he is cured, taking care to inform the family a definitely as possible of the probability of cure. I have tried to impres on interns, raidents and younger sur geons any mistakes I have made in the hope that they may not only avoid those same mistakes and be on thc alert to avoid others but, morcover that they may acquire such a constructive atutudc of mind that they in turn, mil pass on to succeeding generations the lessons so painfully learned. 98 ·CHAPTER IX Surgical Teaching HAVE always been interested m the teaching of medical students, or us it might better be called, the manufacture of doctors to take care of sick people. While some graduates in medi anc enter into speaal lines of research administration, and so forth the great majority spread out over the country to perform the accouary task of caring for the all Dunng my thirty five years of teaching experience my ideas on this type of instruction have undergone a gradual cvolution leading me to certain conclusions My first experience with medical teaching was, naturally from the students viewpoint at Johns Hopkins. There from 1911 to 1915 I beamc imbued somen hat with the Hopkins spirit. It was usumed by the faculty that the students were eager to lam and that the faculty's province was to pour out their knowledge for receptive students. There was never the slightest feeling of "polic ing" the students or of making them study If a student did not are to study that was amply hu loss and no one else cared. In fact, as I have said before, in Anatomy under Dr Franklin P Mall the requirements for an opportunity to learn were simply "a barn and a stift. In anatomy no quiz was ever given there was only a final oral examination u a mechanism by which undesirable students could be eliminated. Although thu plan was based on the assumption that the college graduate us a mature and thoughtful individual I think the idea was carried a little too far at that time at Hopkins In the Chicago medical schools, however it was assumed that the applicants earnestly desired to study bu no chances were 99 ·taken. The students jolly well had to study and the degree ind intensity of their effort were frequently appraised by means of tests and examinations with many gradings In the end very Ausfactory doctor was manufactured. Over the year my ideas on medical teaching have been somewhat modified I have had considerable experience in teaching and observing the effects of instruction upon medical students and young graduateh A new crop of doctors mut be produced 10 nually to care for the nation s sick. The present system in medial schools is certainly a vat improvement over the days when Flexner wrote bu shattering report, but I feel nire that there is room for much improvement. Perhaps most of the goals are impossible of achievement, but their consideration may be of value. The first area of improvement is in expoung high school and college students to an accurate presentation of the lifework of a physıdan what steps are decemary for preparation what qualities make for success in the various fields of medical endeavor what are the costs in time and money and energy for qualifying what are the sausfactions and spiritual rewards of a successful physi aan and what are his possible average financial rewards what are the necessary health requirements to start with when is the opti mum time for the student to marry what are the possible dis appointments and imitations of medical practice? The average high school student has been making his conclusions on the basis of immature and incomplete premises, as discused in the opening chapter The use of young instructors in medical school is an absolute necessity but I cannot remember ever receiving great inspirauon from them. The young instructor in the clinical branches are often quite inexperienced in the subjects they reach. I believe that these young men would be much better cachers if they were pald amall salaries, as u done in law and dental schools, rather than being rewarded by the prestige of association with a university I am inclined to think that the effort to avoid the evils of forraal didactic lectures of a genctauon ago has made the pendulum swing too far in the direction of getting the student in contact with pa uents. A third year students time is better spent in studying books the written words of the master than in pulung on a white coat and in a group of ux or more staring at an embarrassed patient Of course the student must learn early probably in the third year Too ·rather tban the second the elements of physical diagnosis, inspec uon palpation percussion and auscultation but this is best done as it is at Cook County Hospital in Chicago in groups not larger than four ach and on free patients only I do not believe these students can be or should be taught on private patients in a com munity hospital although the increase in the various hospitaliza tion and insurance plans is steadily decreasing the number of "frec patients, and use of private patients for teaching material may be necessary Not uncommonly the heads of departments in a medical school have won their positions by preeminence in research and/or prac uce in relatively narrow fields. Many have never engaged in gen cral practice, and when they try to teach the proper way to handle paucnu, "just as general practitionen do" their instruction is based only on what they imagine is common practice. I certainly do not approve of the practice sometimos employed by beads of departments, of solidting from students their anonymous opinions as to the quality of teaching given by their instructor The heads of the departments themselves are better qualified than the stu dents to form such opinions Moreover instructors when aware of this type of popularity contest, tend to supply entertainment rather than education. The cornerstones of the acquisition of knowledge by the medical student are textbooks and medical journals These can often be vivified by a gifted professor but they can never be supplanted by him. All through a phyuqans career he will have to think for himself, and his thinking must be based on an inumate knowledge of medial facts as nearly as they can be determined at the time. I have always felt that my bat teaching was to deks interns and raidents in the hospital with one, two or possibly three at a time working with me at operations. On daily rounds we would spend time discussing together the strategy of treatment in critical ces, examining patients and letting them hear me converse with pacients and their relatives, wing words which years of experience have taught me will be of help and comfort Often I have told these young men that, u it has been in my own as, ko it will be with them, an instructive case may seem to have been forgotten for yoans only to be pulled out of a hidden pigeonhole of the mind when a current situation areato a demand for it. I have watched with interest and pnde the succesful careers ·of scores of young men, and it u a great sausfaction to me to hear from them and to feel that I have been of help to them. Every teacher of mediane receives letters of grautude from former stu dents, so the following quotations are in no sense singular to me. Even though I do not deserve the praise, these remarks at least delineate what a surgical teacher should try to accomplish After helping an applicant win a position at the Mayo Clinic, I received a letter in which he said "Aly fellowship at the Mayo Clinic beglos in a few days, and I want you to know how much I appreciate all that you have done for me. As buy us you have been you were almay able to find time to help me. These few lina are inadequate to express my thanks, but if anyone ha done you a great favor which you found impossible to repay you will understand bow grateful I am to you" Another letter contained the following “I would like to take this opportunity to expreu my dnceret thanks for the most enjoyable residency I find it most difficult to express my gratefulnes to you for your teachings and opinlons especially when things appeared gloomy for your untiring patience with me in your effort to instill some of the proaples of nurgery I feel that I have not only gained in the prinaples of the practice of surgery but in the practice of the urt of surgery which is unfortunately avulable to only a few of the younger men in our profession." The following letter was signed by two interns This is but a brief note and sent in an attempt to express our appredation for your kindness in inyung us to your home for dinner We were quite thrilled and felt bighly honored. During World War II I kept up a correspondence with many of my former clerks, interns, residents and associates who had joined the armed services. Their letters came from all parts of the United States Aluska the Pacific, Australia Bunna, the Middle East and Europe I have saved nearly two hundred of these letters, of wbich about a thud were V Mail and an analysu provides material for a detailed and intimate description of the care of the wounded and life in isolated camps, hospitals and ships Several examples of GI V mail Christmas cards are interesting Many of the letters contained comments of personal interal. One V mall letter which I later leamed was written at Fenton Field ninety milo south of Daruın, Australia said "I was very proud the other day when we opened up the library that was supplied u. There are 19 rolumes 102 ·corering the field of mediane and surgery and, surc cnough, the surgery textbook was A Textbook of Surgery' by Christopher The fellows kidded me a little, saying that I could now refer them to the book instead of giving a discourse on how Dr Christopher would do it." Another letter read "You have no idea how much I hare en joyed working with you and how much I have apprecated your Instruction" In thanking me for some Christmas presents of salted nuus and candy "The un containerı really have the vidous Little red ants buffaloed. One of the majors at division headquarten made a statement that you ll appreciate, remembering your army days, and which I thought was pretty good He mud that one sure way of beating the Jeps would be to give them all the paper work we have to do From an officer in the Amphibious Force of the Navy -Sloce I last wote you, I ve been on the more almost continuously Adventures of all sorts seem to come my way and the future looks very promlilng, too. We are passed thru a beauty of a storm, u I write this we are all playing roller coaster and a few of the more sa ack allors are poking thar beads out of their bunks for the fint ume in several days. As luck would have it, my immunity to searches s apparenuly very good and that alone is the greatah blessing on these soall Landing caft. Many e-douroja ailors turn up their tocs after 24 hours on these little 'bouncing bedpadu The following letter was dated 29 April 1945 and contamed such interesting on the spot accounts that several sections must be quoted. "We only dallied a short time at Eniwetok and then went on to Saipan. The Army and the Sabees are as usual brusy moving mountains and everything else in ther way preparatory to making military establishments. We aw the huge bases for the B-29's and watched them lare und return from their rauds on Japan. It be thrill to see those huge babica whiz down the runway and alowly take the air They are magnificent machines and are certainly Lord and Master of the Pacific uir From there we went to Iwo Jma und our first baptism of fire. The trip up there was pretty aneventful considering the fra that we expected to be pretty well worked over by the Nip ur force. They never showed up much to our rellef, and so we enjoyed perfect weather and ate like kings Iwo u old stuff to you now but it will never be forgotten on this ship. From the night during which we approached uoul we left, it mus i most unul aperience. The first big guns that I am firing in the distance, I thought were thooder TO3 ·sotme. We got into posidon for the amult undercotte of the early morning darkness, and as dawn ame you could see hundreds of ships all about in every direction. We were backed up by xotic real maxdo which cared off everyone i tenuion a great daal We had all seen the Intelligence maps of the islands and, us predicted it was rust about glutted mth guns. Just before the bour set for the landings everything grew silent, not even a machine gun popped off and I think the sell neus as we crept up toward the nland was the worst part of it all Suddenly all Hell broke loose, as the newspapers ay and the show was on. We got fired at quite a bit, but for some reason the Jap artil lery in our sector had a hard time getdag lateral bearing on us, the whells would start walking up on w and then suddenly no more would come. We figured that they were in care and the ave side limited their field of fire. So by keeping on the more we emerged unscathed, but pretty well worn out after the first day was over ·CHAPTER X Surgical Writing He wrlung of medial papers for publication or for delivery is not a vice and may cven be 2 virtue. It benefits chiefly the writer because more than average study of one parucular subject is in volved. Albert Einstein “ with the apology that A serious-minded man enjoys a good laugh now and then " quotes Alfred Berliner the editor of Die Naturwissenschaften as defining a scienufic author as being a cross between a mimosa and a porcupine," in fact, a Taru aus The man who never writes papers may indeed be a paragon of knowledge, but he annot escape some suspidon that he may not really have studied hu lessons. When I asked Dr Sam Harvey then Professor of Surgery at Yale Medical School if he would contribute 2 hection on benign tumon of the breast to the Textbook of Sur gety which I was editing, he replied that he would be glad to as he didn t know much about the subject. In other words, he pould study and inform himself I have publuhed over a hundred papen ach of which has taught me something, and a few have been of mportance, but they have all been the result of mental THERE" and overtunc work. Almost anyone can produce aruda if he has the resolution to keep at it. Nothing annoys me more than the remark of many physicans with a note of plaintive envy. Oh, I wish I had the knack of writing! Also to be deprecated were the words of a fine surgeon, who although in one of Chicago s buscast hospitals, never wrote an article but said loftily "I will 105 ·Never write anything unless I have something worthwhile to write about. Every busy surgeon has unusual and instructive cases. The ax report is the simplest form of medial paper If accurately whiten and accompanied by a concisc review of the pertinent literature, it is one of the cornerstones of medical knowledge. Alone or part of a review of similar cosesIt forms a rcal guide for practicing surgeons and for author of textbooks. Nearly all surgical journals will publish worthwhile case reporth In 1923 I attended a querulous 64 year old business roan who had had a rib resection for empyera performed under loal anesthaia. Orginating from this wound was a spreading arbuncular infec tion which caused him great pain Despite many types of treatment by a succeuion of doctors, this virulent infection bad spread widely On the eighty third day after hu admision to the hospital I was placed in charge of the surgical care. The carbuncular infection then atended from within 2 inches of the left of the umbilicus to within 3 or 4 inches of the midline of the spinc. The upper level was the spine of the scapula and the lower level within 2 inches of the crest of the ilum. The problem was solved by ten separate operations under general anathesia cach time a section of the neaotic infected skin being cut away The patient left the hospital on the 139th day completely recovered The great medical artist Tom Jones made graphic illustrations of the condition and the method of cure and my article was published in the Surgical Clinics of North America for June 1924 It was almost a "fint" Unbeknown to me, Dr Thomas A, Cullen, of Johns Hopkins had an identical but much less severe case involving the abdominal wall The publication of his case report occurred only about a month before mine, so he was rewarded with the honor of first desanbing this condition He was good enough to write me on May 16 1924 It is particularly fortunate that I got mine out first because the case I reported in comparison with yours is like a side show to the main arcus. Since then the condiuon has been observed and studied many umes, particularly by Frank Melency of Not York Cullen 1 mentioned as the first to olisert it, but usually my case is referred to also Voter of Budapest in 1910 sad According to reports in the literature Cullen was the first to observe the condition after the removal of a suppurale appendix in 1994 The same year Christopher reported 106 ·a similar process following nb resection for empyema thoracis." The condiuon was finally named progressive postoperative gan grene of the skin by Brewet and Melency On another occasion I was a close second in describing a new laion. In Oaober 1991 181 described a fracture of the anterior process of the alcancus (heel bone) After my paper had been submitted for publication I discovered that again I had lost out in prority thus uime to an x ray man " who had publubed a paper In May 1931 In bus most stimulating and valuable article on "The Physician in World Afairs, Trimbles aptly says "Physicians regard for human welfare transcends their nationalistic feeling" It is indeed moving to realize that men in all parts of the world are mecting the nme problems of injury and disease which you are and are dipping cagerly into the great pool of medical Lnowledge, which gradually but inexorably transcends language barriers. The great medical librunas are the indispensable mcans of dispersing and sharing this information In 1936 14 published a paper entitled "Inflammatory Tumon of the Ceam Simulating Acute Appendiatis." In it I alled atten tion to the fact that the surgeon who with good reason makes a diagnosis of appendidus must be prepared occasionally to find a more serious lesion requiring extensive surgical correction. I re ported a case of regional uleitis in a 31 year-old woman requiring relection of the right colon a case of carcinoma of the cecum in a 28-year-old man requinng resection of the right colon a case of direruculitis of the cecum, requiring resection of the cecum and terminal iletm and an abscess involving the cecum caused by Amoeba histolyuca. Seventeen years later the medical librarian of the Evanston Hospital called my attention to the publication of a fine paper in the British Journal of Surgery enuitled Acute Phlegmonous Cacatis" by R. E B Tagart, of Addenbrooke s Hos pital, Cambridge, England. The opening paragraph of Tagart article us as follows "Frederick Christopher (1936) has drawn atten uon to four morbid conditions, which, though not often seen in the average surgical practice stand out as a constant threat to all who enter the peritoneal cavity expecting to find pathology in the appendur onlyi The diseases to which he referred xerc terminal regional ulcitu caranoma of the cecum with abs.coss formation, acute accal diverticulitis, and pericaeaal umocbic abscess The 107 ·H purpose of this paper is to draw attention to a fifth member of thus anister community I wrote Tagart complimenting him on hus contribution which was beautifully illustrated in color and he replied 'It was extremely kind of you to take the trouble to write and a great encouragement to me In 1931 I received my first request from abroad for a reprint. It was from Dr Giuseppi Pistocchi in Bologna, Italy who wanted a reprint of my paper "Ieus Following Rib Fracture.” Thu re quest was flattering and stimulating and at the same time was further support of the thou that interest in medial problems is not limited to national boundary lines. Further requests for rcprints or medical quenes and comments ame from Bohler in Vicona from Stettin, Germany from Gutierrez, in Buenos Aires from Leningrad from the Royal Australasian College of Surgeons in Melbourne Australia from Ruthin Castle North Wala Amster dam Padova, Italy Japan Punjab India Leige, Belgium Plovdiv Bulgarla Abadan, Iran and Manila, Philippine Islandı. All in all alone or with joint authorship I published 128 papers. In addition to this there were also published reviews of coone 75 books, of which 16 were foreign. Some of the medial papers were delivered before societies prior to publiation. In 1927 I began to prepare the manuscript for a book on minor surgery Dr Allen B. Kanavel kindly wrote a foreword to the first edition which was published in 1929 by WB Saunders Company of Philadelphia In the ensuing years I amed this alinor Surgery through aix edi uons The fifth edition was translated into Spanuh (Espasa-Calpe, S.Ag of Madnd, Spain) The seventh edition was published in 1955 under the joint editorship of Alton Ochsner Professor of Surgery and Head of the Department of Surgery at Tulane University New Orleans, and Michael E. DeBakey Prolet bor of Surgery and Chairman of the Department of Surgery at Baylor Univenity Houston Texas. Early in 1934 I assumed the editorship of A Textbook of Sur gery (also published by W B Saunders Company of Philadelphia) which was comprised of contributions by various authorities in surgery This textbook I arried through five editions and by September 1954 over 115 000 copies had been sold. The fourth ediuon has translated into Spanish in Mexico City (University Society of Vexico) and the fifth edition was translated into Itallan by Dr Vana Aldı Guarnien under the supervision of Professor 108 ·H Exorc Ruggial Director of the Surgical Clinic of the University of Naples and published (1956) by Societa Editrice Universo Rome, Italy Dr Loyal Davis Professor of Surgery and Chairman of the Department of Surgery at Northwestem University took over the editonship of the sixth edition which was published in Febnary 1956. Including the various editions of these two books and the Span ish and Italian translations, a total of over 200 000 copies have been printed. The young surgeon must rigorously disapline himself to regu lar babits of medical reading The best incenure to enlargement of his knowledge of medical literature u to read up" on every condition encountered in practice. If he does not have ready access to a library he must see that his textbooks are recent editions not obsoletc. A loose-leaf system” is of value to throw light upon a current professional problem. He may avail bimself of the many "package libraries, which will be sent by mail by the Ameran Medical Association and the vanous consultant and research serv ices. He should always read the Journal of the American Medical Association making a rapid survey of the abstracts therein, includ mg those of other speaalues as well as his own. He should subscribe to as many surgical journals as he can afford, including the Annals of Surgery Surgery Gynecology and Obstetras Archives of Surgery Surgery If he has access to an excellent hospital library with a generous file of bound periodicals, his problem will be much simplified, but he must regularly preferably dally be sure to visit the library He must be thoroughly conversant with the value of rapid searching through the Quarterly Cumulative Index Bledicus and will be surprised how often he finds therein im portant information bearing on the solution of a difficult problem posed by some case which is troubling him. He is still more for tunate if the great libruna of a medical school and a privately endowed technical library such as Chicago - John Crerar Library are easily available. He will find hu reading most interesting if he is trying exhaustively to cover all the literature concerned with a are or a group study which he intends to report Hus mind will be far more enriched by a half hour in the library than the same time spent in jesus pleasantos and gossip in the doctors lounge or coat room, even though the latter is watertaining and to a certain extent may invite referral of patients. 109 ·CHAPTER XI Nonprofessional Activities AN N ACTIVE surgeon has little time for nonprofessional activities To care for his parents conscentiously to keep abreast of advances in his profession by reading and attending medial meet ing, to carn his living, to care for and counsel his family perhaps to teach in the medical school and perhaps lo contrlbute to the medical literature are enough to claim all the time and energy of most men However it u to be hoped that there will be refresh ing diversion. Richard C Cebot vras probably quite accurate when he named the four essentials to a mans happiness in his book What Alen Love By us work, play love and worship We have devoted most of this book thus far to the subject of the surgeons work He must take dmc to enjoy the companionship and to be conunuously on the lookout for ways of increasing the happiness of bus wife and children and of others dependent upon him The busy surgeon seldom can attend church regularly but he must give the church his fupport I have come to believe that a surgeon I caal relationships reflect hus taste, and that no matter what types he most enjoys, Dearly all of them are quite apart from any advancement in his profession. Indeed, they may be a deterrent to his progress. To me a few loyal trusted friends with whom I an enjoy the benefits of in formed conversation or perhaps a game of bridge or the like arc far more ennching and direrung than a host of acquaintanca. The competiuon necessary for success in newspaper broadcast "la dety 1 an exaung rather ruthless and expensive pastime which 110 ·has never appealed to me. This is fortunate as I confess ao talent in that direction Large affairs are painful to me, and although onc doos Occasionally see old friends for a few minutes whom one would otherwise rarely see there is little chance for any reai conversa uonal exchange. The large country-club (more or less alcoholic) dances are enjoyed by many but the intensity with which some persons try to project themselves back into the days of high-school Airtations presents pitfalls for the loss wary or the more headstrong The surgeon who figures largely in such parties may think he is cutting a dashing figure, but his conduct does not suggest to those whom he hopes to have as patients the picture of a surgeon with the granite like imperturbability dear head and cool judgment required in the operating room. Hu fortunas are further defeated if he falls into the error of casually entertaining a danang partner mith accounts of his surgical exploiu which may seem like subtle adretting to him but as the identity of the pauent will probably be recognized, it wually implants in the listener a warning that she does not ever want to be the subject for the entertainment of some other dandog partner Patients should never be discussed at sodal functions even when only doctors are present, for even though no names are mendoned, there is no assurance that ident fication will not be possible. A doctors wife should never know" whom her husband u treating or for what A surgeon s wife pref erably should not know the names of patients for then she an more easily avoid embarrassing questions asked by her acquaint unce While I enjoy a cocktail before dinner I know most definitely that alcohol and surgery do not mix. A surgeon who is addicted to alcohol will be a failure. It is only hoped that such failure will octur early in his career and give many patients from his eTons of judgment or of technique. I feel that the realization by doctors m general that alcohol and their profession arc incompaubic may explain the regrettable tendency of many of them when away from their work and at medical meetings to drink too much. When an average-tized man consume one ounce of whukcy within an hour or let it u doubtful if his cerebral cortar is affected, and he has only 2 subjective feeling of warmth. His behavior is sociable and pleasant. But if the amount is two to three ounces, the alcohol in the blood becoma 0 05 per cent, and the cerebral corte is affected. The inhibitions are weakened and judgment is blunted. He be II ·como boastful and impulsive though while highhe is suill considered, more or less officially sober The convenzonal cocktails served at dinner parua arc becoming an increasingly difficult problem. The host and hostess desire to be hospitable to the nth degree, and the thirst of some of the guests may prolong the cocktail period for an hour or more. This u really a trying ordeal for the fcw who do not drink ut all and won ture of toying with tomato juice and listening to the laughter becoming louder The cocktail us not only the enemy of good cooking, u the late Howard Vincent O Brien once said, but after the lugh-calorie cocktails and each hostes-want-to-have the best appetizers any interest for the real pièce de résistance the actual dinner u perhaps by nature s providence greatly reduced. The talk may be very lively in fact, participated in amultaneously and even competitively Under these circumutances it I no great train to gain a reputation as a wit or to regard almost any anecdote u convulsively humorous. Many persons find this fun, but each to his own taste. The surgeon must indulge in some sports and hobbies to re fresh and divert himself Those which get him out of doon and involve exercise are best but must vary with his age, pbyucal capac ity and individual tutos Golf is a general favorite and fulfills most requirements with the additional advantage of good fellowship. It was never a success with me, however I joined the Indian Hill Club when I was in the earliest und bunat stage of my career Perhaps the frequent interruption by a addy on a bicycle summoning me to talc are of an emergency or perhaps my rather rotten game despite funou and intense efforts to improve it was to blanc, or perhaps I was more interested in other thing. At any rate, in a les years I gave up golf and resigned from the club I envy those who enjoy golf and are profident in it Earlier I played considerable tennis and got some exercise mowing the lawn but I never really Icarned to garden The surgeon must get adequate rest, but the com adequalem is open to dispute Edison needed only a few hours of sleep at night (plus a possible nap or two duning the daytime) and I suspect, but do not presenbe that we need less sleep than we gets Serious surgical cases harc aused me wakeful nights, but not Infrequently valuable ideas have come to me during those umes and I hare implemented them by phone calls to the hospital. A certain - 112 ·amount of nomedical reading It Indreu toylu! Blograply kat always interessed me more than fiction and the works of Winston Churchill leave Ixen scail and read with orlislı But after years nl retrated expatience I have found the first sleep including bond in he Сstasy's filtren decise dialties of the ff'oslil, which was se bestel in 1015, with nine additional batlles ilesoleil by Robvestil Murray, ly lic Military Service l'utilishing Company, of Baniy burg l'ennuylvanla Alier the plıysician a long louis ol work and his conilletabile malical scailing and presliaqui medical writing. It is not superbolag that lila mimd ucks ligiit reading such as deleciire Horley railier than mort esou wosks for refralıment White locallu alrerit in London I saw a good deal of physicians Alier their day's work when they plehel up their innk of paper they WATC 10 Jant to think on what ilicy scad" Although there is much smli in tlic maxim 1 you want in ge! something dine take it in a busy man“ nonciliclens it is nnly Lellom that a alimsful murgeon will be able to finil murli timc alirt bis otirgical work caching and wiling to levoie to rivic duties TTic nature of his prolessioni nereultating his being constanly on all male it imposible for him in be sure that he will have any given time lree from Interruption, Incal Arwernmenit serong nue illis in exempiing tlic gileysician from jury duty In Amc Insuances le may be usibilc for a mirgcon lo dio a clic office to kre on governing Board of varlous kinds on Rol (rous or ollier charitable minmittees in Rotary or other organizations in so doing die urings ilic broadlening viewpoint of the pluysician in the group arut also enlarge his own outlook someilincs lc «lll le conjustly Meused by mlleagues of allvertising, and comcilmes tlicy may lx right In thic current generation scarcely n daciar li to lx fomu who lias inot at one time or another serveil in the armel fomes in perform Ing Hole incessary and essential duty be lias umally donc at milderal le armi in luis peiessional develazimene lult never with Out OK lanclit in his character and social anlentaniling Tliesc *Thule of military service bring lione in hlm tlic cul al war and should instill in lint all awareness of the part le should play in destrating It In 1955 ) Ridlgcivay Trimble gays a splendile! wilmi Rt thic Ainerican Malical Asaxlation meeting entitlal Oppmannitles and Responsilia of the Physician in World AVAIL" lle salil, in part " Honld like to develop the following ·cordes boastful and inpulare, though while "high" he: considerad, more or less wifically sober The conventional cocktails served at dinner parties are 1 ing an increasingly difficult problem. The hou and hostess to be hospitable to the nih degree, and the chuse of some guests may prolong the cocktail period for an hour or more is really a trying ordeal for the few who do not drink at a soon tort of toying with tomato juice and listening to the la becoming louder The cockwl us not only the chany of cooking, as the late Howard Vincent o Bnen once said, bul the high-alorie cocktails and "each-hostess-with-lo-have-the appetizers, any interest for the real pièce de résistance the dinner is perhaps by nature s providence greatly reduced. Th may be very lively in fact, partiapated in simultaneously and competitively Under these arcumstances it is no great sro gain a reputation as a kit or to regard almost any adeci convulsively humoroul Arany persons find this fun, but each om taste The surgeon must indulge in some sports and Hobbies 1 frah and dirert humself. Those which get him out of doon involve acrese are best but must vary with his age, physical c ity and individual tasta. Golf is a general favorite and fulfils requirements with the additional advantage of good fellow was never a success with me, however I joined the Induan Hill when I was in the earliest and busiest stage of my arcer Per the frequent interruption by a caddy on a bicyde summonio to take care of an emergency or perhaps my rather rotten despite furious and intense effort to improve it was to blame perhaps I was more interested in other things. At any rate, in : years 1 gave up golf and taugaed from the club I envy those enjoy golf and are proficent in it. Earlier I played consider tenals and got some exerox mowing the law but I never r learned to garden. The surgeon must get adequate rest, but the term "adequ is open to dispute. Edison needed only a few hours of slec night (plus a possiblc nap or two during the daytime), and I sust but do not presarbe that he aced les sleep than we gel. Ser surgical ases have caused me wakeful nighis, but not li quently valuable ideas have come to me during those unes al have implemented them by phone calls to the hospital i cer 112 ·amount of nonmedical reading is indeed ratful Biography has always interested me more than fiction and the works of Winston Churchill have been read and re read with relish. But after years of repeated experience I have found the best sleep-induang book to be Creasy s Fifteen Decisive Battles of the IVorld, which was reished in 1915 with nine additional battles described by Robert H Murray by the Afilitary Service Publuhing Company of Harris burg, Pennsylvania After the physicians long hour of work and his considerable medical reading and perhaps medical writing, it is not surprising that his mind secks light reading such as detective stories, rather than more serious works for refrahment. White heads observed In London I saw a good deal of phyidans After their day's work when they picked up their book or paper they were too spent to think on what they read." Although there is much truth in the maxim "If you want to get something done take it to a busy man" nonetheless it is only seldom that a successful surgeon will be able to find much time after his surgical work, teaching and wriung to devote to avic duue. The nature of his profession necessitating hus being constantly on all makes it impossible for him to be sure that he will have 1ny given time free from interrupuons. Local government recog nize this in excmpung the phyuaan from jury duty lo some instances it may be possible for a surgeon to hold a divic office to crve on governing boards of various kinds on Red Cross or other chantable committees in Rouary or other organizations. In so doing he brings the broadening viewpoint of the physician to the group and also enlarges his own outlook Sometimes he will be unjustly accused by colleagues of advertising, and sometimes they may be right. In the current generauon scarcely a doctor is to be found who has not at one time or another served in the armed force In perform ing this necessary and essential duty he has usually done so at considerable cost to his professional development but never without some benefit to his charade and sogal understanding These periods of military service bring home to him the evil of war and should inxill in him an awareneu of the part he should play in decreaning it In 1953 ) Ridgeway Trimble gave a splendid addrew at the American Medical Association meeung enulled "Opportuniua and Rosponsibilities of the Phyuaan in World Afaire" He sud, in part “I would like to develop the following 113 ·related thoughts. that only international understanding will prevent war that physicians have a common language and enjoy the con fidence of the people more than any other profesion that phyurcians know the true meaning of war better than anyone else that politidians and statesmen and soldiers have thw far falled to prevent war and that physicians have a great opportunity and obliga tion that they must acize und fulfill without further delay while, certainly physicians cannot alone prevent war Trmble emphasizes that they have more influence than they suspect and it is incumbent upon them to exercise it to the maximum. Certainly the physicians function has a universal common regard and value despite a mde disparity of races and language. Medicine is indeed a common denominator The surgeon should make appropriate contributions to charity from his earning. I have little patience with the phyudan who proclaims that his good deeds are confined to taking are of charity patienu. Actually there u intense competition to secure a position as attending surgeon or physıdan on the staff of a large frec hospital, for at 18 there that the surgeon inevitably acquire more profiaency and skill, which be all "sell to his private pa tient. Or it is there that he can partiapate in research work or instruct students, which affords hum enjoyment and increases hus prestige. Charity work has its own professional reward, and it ill becomes a doctor to clothc it with an aura of nobility and self sacrifice Wbut really counu is how much money he actually given Thc physican should contabute at least to the church the Red Cross and the local Community Chest. 114 ·CHAPTER X11 Personal Injury Litigation Has a difficult problem for me to decide between the study of been much interested in fundamental legal decisions and processes. Surgeons must invanably are for patients who have been in acadents. The arc of the injury in most cases is inextricably in volved with the patients real or alleged indignauon at the other party concerned in the acadent. "Get your money from him-it was his faule" is a common remark. It was told some time ago that a survey of x ray caminations in accident cases at one of the Chi ago hospitals showed that only 8 per cent had ever been paid for The worst feature, however us that many of the cases end up in personal-injury litigation. The walung period before the trial may be several years, during which the patient (and hus attorney) must not allow himself to forget his suffering. In fact, the agony caused by the accident occasionally seems to increase, and not infrequently the patients recovery to well being is actually retarded. While, of Curse, many of the cases are of a serious nature and it is the doctor s duty to describe the injury as objecurely and accurately » posible, many injuries are trivial being magnufied by the patient for the purpose of obtaining a large settlement at the trial. In one case in which the 10junio has occurred three years before I was put on the stand to toufy and were of such a minor nature that I could not remember them, the patient's attorney pointed at me and shouted fiercely "Did she have a bump on her head?" Because of its frequent dishonest use, the expression "I do hus finger 115, ·not remember seemed to me something I should avoid at all costs, although in this case it certainly was the truth. Faring I might do her a wrong if she had had a bump and I did not remember it, or if she had not had onc and I said she did, I would hurt the defendant, I pondered the answer Finally I came forth with what seemed to me a most sagacious reply "Vell she might have bad." I was started at the general laughter even from the judge which my remark cvoked. A rude awakening for the young doctor is caused by a subpoena. Up to the moment that this hanh, unfeeling hand of the law bai been laid upon him, he has felt himself to be a free agent each day involved with the heavy responsibilita and unscheduled calls of seriously ill people. But the attorney also thinks he himself is busy and, u the law us on his side, he can compel the surgeon to come to court. If you do not do it gracowly the lawyer can punish your lack of cooperation by keeping you for long periods in the court room-may even secure a "bench warrant," which keeps you there on call Several years elapsed before I abandoned my naive idea that, if I could avoid a subpoena I could escape going to court. Never was there a more fallacou idea. Perhaps I had paid too much attention to the yarn told about Dr Coleman Buford at the old Alan Brothers Hospital in Chi cago One day while operating in the single-doored operating room, Dr Buford was told that a process server was waiting outside to serve a subpoena on him when he came out. Buford completed his operation lay down upon a cart, had himself thoroughly draped with sbects and wheeled out past the process server much to the delight of the doctors and nurses. My final recogniuon of the fuulity of trying to avoid a tubpoena ame about after my learniog, on one occasion that I was likely to be tubpoenaed in a minor acadent case While sitting at dinner one night I received an unusual phone call from the local druggist who said he was sending over a patient who had inquired of him the directions to my house. This ruse seemed to me so superficial that I refused to open the door to this "pauent The next morning whưe I was in the operating room suite at the hospital I was told that there was a patient downstairs anxious to see me. I asked to have the pauent come to the telephone and inqaired about his symptoms. When he said he felt bad all over " it seemed to be almost certain that he had a rubpoena in his hand, so I referral 16 ·him to another doctor When he said But, Doctor I have con Edence only in you" my choler completely overcame my judgment and I made some regrettable statements concluding with the altogether treasonable and childish remark. "And if you cver do succeed in getung me down to tesufy you ll be sorry you ever did These dire happenings were reported to the judge with I have no doubt, flourishes exaggerations and emphasis. The next thing I knew a slightly embarrassed polite but none the less determined armed cheriſ ame from Chicago to Evanston found me in the hospital and placed me under arrest. He drove me to Chicago and brought me to the courtroom where the trial was in session. The judge looked thunderclouds at me, and for the first time I began to rellect that perhaps this was going to be seniou. Contempt of court was punishable, especially when a judge looked us angry as thus one did. I was put on the stand and qualified, and the attorneys for the patient began to shout loudly at me And you said it mould be too bad for us if we did get you down to court!" After my teulmony which was not important at all, the judge turned his mind to my misconduct. He regarded me long, silently and with autreme disfavor I hoped I was not going to jail. Finally he said. "Doctor you know we expected better things of you. I will fine you the cost of the sheriff's trip to arrest you-four dollan." I con cealed my relief as I paid my fine. Once more I could breathe the beautiful free air of Chicago! The men who usually represent the plaintiffs-the personal injury lawyers do not seem to be chosen from the ornaments of the legal profeuion. A penalled note that I prize was written by a patient on whose behalf I was to testify and delivered to me while I was sitting in the courtroom one day It read 'Dear Doctor I regret your having to come into a sordid matter of this kind A man of your profesion should not have to spend time away from the sources where he does so much good. In 1927 17 reported two unusual cases of mulaple fractures One of these patients was a man of forty nine who was brought to the Evanston Hospital after a train accident in which he sustained twenty eight separate fractures and lost a leg While still in a cital condition, he was vidited by a personal injury attorney and interviewed. The attomcy assured the apathetic patient that he would fight for his financial interests, but this necesitated setting down all the facts connected with his case. The lawyer would have 117 ·to talk to the landlady of the bouse where the patent roomed and as she would not know who he was, would the patient please sign this little "note of introduction. The patient signed what he later found to be a contract engaging a certain law firm to repre sent him. I became incensed at this misrepresentation and appealed to an attorney friend of mine. He brought the matte before the Chicago Bar Associations committee but no action could be taken as the culprits were too skillful in protecting themselves. When the final settlement was made by the railroad, the signed note of introduction" secured half of the money for the disreputable law firm, although another firm one of high repute had done all the work. About this time I took care of a woman who was injured while nding in a taxicab She sustained a relatively minor injury of the neck-a fracture of two of the cervical vertebrae without any paralysı. The treatment, however was not minor u I had to place her in a plaster art to hold her head, neck and shoulder ngidly After the cast was removed I had her wear a firm leather shoulder ape, from which was supported by many adjustable turnbucklos a leather collar supporting the head It took the weight of the head off the fractured bonds of the neck and was rather comfortable to wear Its appearance however was indeed dramatic, for it rcsembled some strange torture engine of the aliddle Ages. Alter she had worn it for a number of weeks, its use was disconunued. I discharged the patient from the hospital when her neck was vir tually painless and she had about 98 per cent of normal motion A few months later I learned that the patients husband, the pro prietor of a poolroom on the west side of Chicago had returned to the hospital and had obtained the formidable looking neck brace from the supply room, where it had been stored. Somewhat con cerned that she might have had a relaps, I telephoned the husband, who aid Oh don t worry Doc Shes Oh. But her inal begins Monday and she has to have the brace to wear to courti" When I appeared at the courtroom hung of course been subpoenacd, I found the jury assembled in the jury box reading newspapers and glancing occasionally at the tragic figure of my patient, scanng the leather brace and grimly turning her head neck and shoulders as though they were in one piece. The attorney were in chambers** trying to settle the axe out of court. The attorney for the patient realized that he had a strong and to play just by exhibiting the 118 ·patient in her brace. Although the patients hospital and doctor bills had not exceeded $500 her attorney was putung on strong pres sure. He would come out from time to ume to report his progress in the struggle and I was astonislied to licar that he had them up to $10,000 Later it was $12 000 and the patient said to her lawyer "Ax lets take it. Im ured of being what I aint. I never bare understood why the defending auorneys did not let the case go to trial, put me on the stand and ask, Doa she have to wear that brace?" My answer in the negative would have collapsed her case. However my patients attorney announced that we were all going to lunch "on him." Late in the afternoon the ause was settled for $18 000 and her attorney did not seem displeased with his share, $9 000 for his day's work W L White, in an excellent article entitled "The Personal Injury Racket," tells of a newspaper report of an early morning col Ilsion of two street cars By noontime thirty four persons had pre sented claims for injunes sustained in that acadent, not knowing that the newspaper account had omitted mention of the fact that one of the cars was empty and returning to the ar barns and that the other was a repair car carrying no passengers ·CHAPTER XIII Surgical Fees THE HE subject of surgical fees is a difficult one. The patient does not wish to have an operation and often does not have insurance or savings to cover the unexpected and unwanted costs. The sur geon on the other hand, has had costly educauon and training and is usually over forty before his surgical practice provides much of an income. He has hu family to provide for 11 expendable in a sense and must attempt to provide for his later years, as a surgeon Leldom continues remuneraave activity 29 long as an internut docs. Usually the subject of fees is not discused in medical school, roost medical teachers seeming to think it a somewhat unmenuonable and hush hush subject, not to be discussed with cager young stu denu who presumably devote their thoughts exclwirely to the study of mediane and guard themselves from the sordid idea that they must eventually support themselves and their familia by the practice of mediane For my part, I have often discussed focs with intern and residents and have never failed to find them keenly interested and wually most woefully uninformed. Advice and in formation on this subject may save them from alienating many patients and may provide a policy and plan which will give thien more time for the purely intellectual and professional aspects of medianc The matter of fees is inrolved and changes with any variadons in the economic well being of the country and with the spore general utilization of health insurance plans such as the Blue Cross and even such extremes as the complete rogalization found 120 ·in Great Brain Aichacl Darzs10 says "We can be fairly certain that fee-for-service payment by the consumer of medical services will conunue to diminish. It consututed some 85 per cent of all expenditures for medial are in 1929 and had fallen to 60 per cent in 1951 - Long experience has made me feel that the following observations an be of value to the young practitioner Contrary to the notion which is someumes expressed that a mans competence is judged in the patients cyes by the fee he charges, in general a physiaan docs himself far more harm by orercharging than by undercharg ing There are very les individuals, indeed, to whom medical ex pense u not a real and often serious matter I do not deny that there are occasional pauents of great weath to whom a large fee is a matter of little moment but that same fcc rould consutute a real hardshup to most person. Let no young doctor harbor the illusion that he can treat only wealthy patients there simply are not enough of them. Furthermore a wealthy man immediately recog nues an overcharge and resents it In the long run the offending doctor is harmed far more than he is benefited by the one exorbitant fce. A doctor who is obsessed and preoccupied with professional earnings can never succeed and is harmful to the profession. How CTCT a businesslike awareness of charges is expected by the patient and when the amount is compered by mercy and kindness he is most apprecaure. Undue delay in sending bills is usually annoy ing to patients. When, dapite the fact that a charge has been made with thoughtfulness and kindness, the patient asks for a reduction thus may be proper If the patient prefaces such a request by genuine appregation of the medial services and by sincere explanacon of his own finanaal difficulty the phyucan should usually reduce the bill. But when the patient starts bis request for a reduc dion by stormily declanng that the services were not worth the price and that he was grossly overcharged, the doctor is, humanly much less likely to grant a reduction. It is therefore of first importance that daily charges be made with areful conscienuous thought and that the total bill should be reconsidered before being rendaed. On one ocadon I was consulted by a woman who uked me the 1 wen from her scalp I replied Oh, five or ten dollan" at which the announced that she would take the five cort of removing 121 ·dollar operation! However she still seemed to worry that I might charge her ten so dunng the operation under local anesthaua her convertation was directed prinapally in the hope that I would charge only five dollars, giving the following amazing reason "You know my husband hasnt worked for a year and he us getting to nervous that we are going to have to take a Mediterranean trip and therefore must be careful of our expenses. On another occasion a wealthy woman, accompanied by her elderly housemad, came to the office to ducuss the arrangements for an operation which the maid needed to have. The conversa uon" was for the most part a monologue by the employer with frequent emphasis that the maid had been with them for many years that she "was like one of the family" and that they wanted her cared for like one of their children. Finally nience prevailed, 50 I knew that the subject of the fee was about to be broached. Sure enough, the hitherto silent mad timidly asked, "What will you charge me Doctor?" The employer to say the least was prudent. Many years ago an employee of one of my friends was advised to have a leg amputated at the hospital on the Wat Side of Chicago where he was a pauent. Nothing would do but that I should see this patient and have a consultation with his surgeon. The consultauon was a mere formality as the mans leg was gangrenous and had to come off. The patients wife asked What do you charge to take off a leg? I replied that it was $160 By that time it was well after midnight, but this obviously poor family went into a prolonged, worried huddle. The result was that they called up Dr Edward Ryerson, one of Chicago : leading orthopedic surgeon. It was a cold night, and Dr Ryerson could not have been in the best of humor to be wakened by the telephone and abruptly asked How much do you charge to take off a leg? He grullly replied Four hundred dollars," and the family chose bim! Certainly since hus price was so much higher he must be a much better surgeon! Parentheacally I may mention that on three occasions I was paid several hundred dollan more than I had changed-a most heart warming experience. Dr William S Thayer of Johns Hopkins used to tell his gradu ating classes "Hare one regular charge for cach of your different Krvices and reduce it when the patients arcumstances warrant Il* This is merely another way of saying that the patients ability to pay should be related to the fee. While this prinaple seems proper and 122 ·thical to me it is bitterly attachel in some quarters. Iloward thiumban" has said "Soaking the rich (or malical care is a device of the lee gouger today Il springt not from social justice but from teel. If one of the biological blackmailers ciet tells you. But this enables me to do other work free of charge-for chanty just ask nim, in what other business or profesion does a man insist that us chanty be paid back at the next rich man s expense? " I do not Feel that these harsh remarks are justifia. A wealthy man-and Efter all there are not very many these days-may find it much less of a hardship to pay $50 than nould a man on a small salary to pay $10 for the same senice. Vorcover many men of higher income are prone to think that if the change wete $10 the #7110C would be a ifch as skillful or valuable as it nould be if the charge were $50 I know of one healthy man who reproached an interist for re ferring him to a young surgeon alo said he would charge $15 for remoring a nen. "I dont want any $15 man!" he told the Internut. The latter replied “lou must have misunderstood the surgeon. He must have said $50 Go and see him again." This the patient did but before he could get there, the internist telephoned the nurgeon and told him sternly lou aid $50! In Chicago some sixty yean ago Dr N S. Daris annoyed his fellow practiuoners by charging uniformly only şi for an office all. Dr Herrick in hrs most interesting autobiography relates two episodes regarding Dr Davis "Dr I N Danforth told me how a patient from Dakota came storming into Dyche s drugstore at the corner of State and Ranulolph streets and asked if there was not some other doctor than N S. Darts to whom he could go he had not come to Chicago to see a onedollar doctor Mr Dyche adrsed him to go upstain in the Ame building and contult Dr Danforth. While the man was dimbing the two or three flight of stairs, Dyche wbutled through the speaking Lube that com municated with Di Danforths office and told him the drcunstance Dr Danforth reported to me I gare that man a good honest, thor ough amimation and the best advice I was capable of. I charged him treoty-fire dollars. He wu nuisfied and was I. That was a well authenticated story that once Dr William II Byford was asked by a lady bow he could charge her three dollars for consulting him in his office, while Dr Daris charged her only one dollar Dr Byford quietly replied, Madam, I am not responsible for Dr Daris fca, but I uume he know the value of his own retries better than anyone else, The courts have considered the matter of adjusung the physi 123 ·dans fee to the patients ability to pay The Supreme Court of Iowa (Robinson vs. Campbell 47 Iowa 627)01 stated the belief that the value of a service depends on the skill required in its perform unce, and sometime on the results accomplished but not on the nchos or the poverty of the person for whoun the service is per formed, and this court said. "There no more reason why this charge should be enhanced on account of the ability of the depend. ents to pay than that the mechant should charge them more for a yard of cloth or the druggist for filling a prescription or a laborer for a days work. However the Supreme Court of Tas (Caulk 26. Anderson [Texas) 37 S.W [20] 1008) took the opposite view saying "Since a cardinal object of a phyidan s employment is to prolong the life and restore the health of a human being, uny coldcoce bearing on the pecuniary value of such life and health annot be logrally ignored in search for the truth u to reapnable compensation for the Hervices rendered under the employment. The principle which must govern in thu case is the priociple that underlies the setuled rale in negligence causa, that la ascertaining the pecunlary lou roulting from death or permanent bodily Injuries, the jury may comider not only the age, occupation habiu, and health of the deceased or injured person, but also the amount and value of his property and ho caming apadty Had the patient (Brackenridge) suffered permanent Injury or lont hus life as the proximate result of the negligence of his phyldan in performing his profesional duties, no one could question that be or a dependent relatire might hare proved the pauents wealth and businon capadty under the establubed law of Texas, in an action to recover the damages for which his physican would then have been llable. Such testimony would be admisible because it would help to detamine the pecuniary value of the patients health and life. For the ame reason, testimony of 1 patients wealth is admíuble u a circum stance to determine the value of service resulting in the restoration of his health and he capacity to perform his customary dutie, as well as in the prolongation of his life.” An authority on medical junsprudence mays "In most sales, though the patients finanaal status is not a legally admisible factor in lee determination. In only a handful of states (eg, New York, California Louisiana Missouri Pennsylvania and Wash ington) have courts held that a physiaan may properly consider the patient o income when setting the fee." To one questions that it is enurely proper for a lawyer to fix his fee in relation to the amount of money involved in a caxe It 124 ·may require exactly the ame or nearly the same amount of legal knowledge and of work to set up the aruces of incorporation for 2 small corporation with $100 000 capital as it does for a huge cor poration with $100 000 000 capital but no one questions the propriety of the attorneys fee being much lugher in the case of the larger corporation The doctrinc of the consideration of the clients Health or poverty in the determination of the attorneys fee is in accord with the opinion of Associate Justice Gricrel of the Supreme Court of the United States (Lombard v Bayard) who said Every gentleman of the bar well knows that there cannot be any one rule of charges in the nature of a horizonul rand for all cases, Often, where the parties are poor and the matter in contest 18 small counsel receive but very inadequate compensation for their exertion of body and mind and for myself I know that for some of the most severc Labor of my profesional life I have been least well paid. In other auses, where the parties are wealthy and the sum in controversy large, they will receive a tenfold greater compensation for perhaps a lithe of the umc Labor In some are the wbole rum in dispute would be poor compensation. In others, five per cent of it will be very liberal Hence, in all cases, profesional compenstion is gaged not so much by the amount of labor u by the amount in controversy the ability of the party and the result of the effort. And this a perfectly fosc." According to Maurer the average gross endual incomc of phymaans is $24 000 and the average net income is $14,300 The atimated present cost of medial training u $22,000 The general practitioners net income averages about $8 000 and specialuts average about $15 000 of the specialists, the average net income is highest in orthopedic surgery ($18 000) and in roentgenology and radiology ($17,500) and lowest in internal mediane ($12,500) and pediatria ($12,000) The average number of hours per week worked by doctors in all fields is fifty-seven and ranges from forty four for the dermatologist to asty two for the pediatrain. According to Whitman," some fifteen thousand doctors display in their waiting rooms plaques obtained from the American Medi al Association which read. "To All My Patients--I invite you to discuss frankly with me any questions regarding my services or my fee. The best medical service is based on a friendly mutual an dentanding between doctor and patient I was always pleased when a patient asked me the cost of an operation I am sull amazed at the haitation and embarrassment exhibited by some in bnaging the matter up and I fear many incrpliably lack the courage to do 125 ·gou to tion it A glib confident demand may betray the "shopper who several surgeons trying to get the lowest price. This type houerer us infrequent, and most patients are sincerely interested in trying to see hot an unwanted expense can be fitted into their budget. The patient may open the discussion of charges by the flat quct Doctor what will your fee be}" or "How much is all thus going to cost me?" My reply to this question is according to one of the following methods The first method u to state my customary charge for the opera tion, if it is a standard one. For example $200 for a hernia or $350 for a gallbladder operation. Several years ago when the prices of food and clothing were half what they are now those figures were $150 and $300 respectively Somehow or other professional fees lag behind the rise in living costs. When a flat sum is mentioned It is always qualified by some such phrase as barring unexpected complications which might require additional professional care." The second method of reply is used when you do not know whether the patient is on a small salary and is making a formidable finanaal sacrifice to have the operation and is too proud to reſer to it, or whether he is a relatively prosperous man. In the former case I would be inclined to quote a ſec somewhat lower than customary I then say "The expenses involved in this operation come under three headings The hospital the special nurses and my own fee. The hospital cost will vary with the hospital and the type of accommodation. A bed in a 4 bed ward costs $17 per day and in a 2-bed ward costs $19 75 per day either of which is completely cor ered by a comprehensive" Blue Cross policy The private rooms vary in cost from a few at $22 per day to $35 with an average of $27 Additional charges are made for the operaung room anes thesia (often a separate bill from the doctor administering it) laboratory fees and unusual medianes. I expect you to be in the hospital for six to eight days." Ac thu point the patient may interrupt and say Doctor my financial arcumstances are such that I must take the very cheapest accommodations. Or he will say "I must have a private room At this time it is wise to tell the patient that while you will ask for the type of reservation he has requested he must not be surprised to find that when it is time for admittance to the hospital a STICS of unpredictable emergency admissions will oblige the hospital to give him somethung less desirable As to speaal nurses, it may be 126 ·that the operation is of such a type that I have been able to say Special nurses are not mandatory You would have more attention with special nurses, but the floor nursing will be adequate The cost of the three eight-hour shifts for full coverage of special nurses 11 about $50 per day Special nurses are difficult to obtain many more could be employed if they could be found, so that you must pot be surprised not to find one ready on the moming of the opera ton even though a 'booking was made one or two months ahead of time" As in the matter of the type of hospital accommodations, the patient may here interrupt to say I simply cannot afford spe aal nurreal" or 'I must by all means have full coverage, day and night. With information as to the patients preferences and hus finanaal ability to take care of them, the doctor 1 Zow in 2 much better position to state the fee he will charge. He will be able to sense that a charge perhaps low than his regular one will be indicated. Or he will find that the cost is not of too much importance to the patient and that the size of the fee may have some relationship to the patients estimate of the surgeons skill and apericace. Those patients who most anxiously inquire about the doctors charges aan usually be most depended upon to pay their bille Whenever a patient says 'Spare no expense, Doctor!" it may mcan that he is not interaced in the slightest since he has no intention of paying When the doctor feels that his charge will be a real hardship for a hard rorking person with a small salary he may give a lower figure immediately But the doctor is rightly annoyed when, because he has been impressed by a patient s stringent need of a ward bed and has fixed his fee accordingly he finds that the pa tient finally take a private room. Such a patient may feel that he has shrewdly reduced the doctors charges and can put the money Aved into fanae accommodations at the hospital. In other words the doctor is really paying for the more expensive room! Some times the patient will sheepishly remark Oh, Aunt Kate gave me a present of the money for a private room. Although I have never done so I can understand why some doctors at the outset way that their fee will be a certain amount of the patient is in a wurd bed, that it will be a larger amount if he is in a private room and a sul larger amount if he has special nurses. The third method of reply to the patients query about charges for the operation is one I have been using more in recent yean I ·especially if the operation is one #bich will require protraded after care with many dressings. An example of this type is obstruc are resecuon for caranoma of the left colon a type of operation which is to some exten, being supplanted by primary resection Here there is a temporary colostomy much detailed advice and Hound care are involved and the whole postoperative period lasts for possibly two months. To the patient, "an operation is an operato ton and his limited knoirledge of the costs and the amount of Tork involved may be based upon casual conversations with acquaintances. If you say $500 before the work is done, the patient may feel that the charge us high (because his naghbor had an operation" for $250) On the other hand if he receives his bill after he has seen how much work us involved and what the surgeons services have meant to his comfort and recovery he will seldom protest at the charge. These considerations bear on the develop ment of my third method of reply The answer is "I do not know at present what the charge will be, as I cannot predict with accuracy the amount of work I will have to do when I have completed my work and you are discharged u pauent I will send you a bill which I believe to be fair and proper If however the bill is not suited to your financial circumstances I will ask you to name the charge and that will be it" Note that it is pointed out that the pauent may name the fee if the doctor s charge is not in accord with the patients finangal arcumstances but not if he considers the doctors work to be worth less, I have used this method many umes and have never regretted it on the fear occasions when a patient has requesied a reduction of my charge, there has been no com plaint of my work but an explanauon which has invariably been sausfactory to me as to why the fee rould work genuine hardship on the pauent. In requesting a smaller figure no patient has ciet taken an unfair advantage of my permission to have hım name the fee I am inclined to think that young surgeons panicularly are likely to make errors in charges. As they gain in experience they will be much less likely to make errors which an rault in loss cither ol friends or of justly camned income. Written on one man s bill for $200 was the note "lly wiſe and I are deeply graiclul for your skill and devotion and the fine resulos of your work. I am ashamed to send you a check, as the charge is absurdly lon" 128 ·Another man was sent a statement for $75 and on it I wrote This is just a suggestion I really dont know what you would think sultable. Send whatero you want to and I will all it square." He sent $75 and replied “This is the first ume a doctor has given me the option of deading the amount of the bill. It is a pleasing privilege. Based on the time devoted to my case I had asumated your charge would be $50-which I thought fair But your way of leaving it up to me is so considerate and liberal as to discourage argument." From a grateful woman "I just must tell you how happy your bil made me today-that sounds old-being happy over a doctors bill but we know we couldn t afford your services and yet just couldnt be content with anyone else. I was more unhappy over putting my husband under the burden of debt again than over the operadon But your kindness has not only left us hope of that fint vacation in cight years but your consideration for our ar cumstances has brought a warm cheer and we want to thank you for it A surgeon is supposed, generally to do something visiblc or mechanial for his money Mere counsel such as an attomcy gives, often seems to the layman to be noncompensable. One time I was surprised to get a note enclosing a check for $50 for thoughtful advice to a man since I had not sent him a bill. The note read In appreciation of the counsel and service given us for which you have not sent a statement." Fee splitting is a secret deal between a surgeon and a family phyudan in which the former rebatos to the latter a part of the fee collected from the patient for an operation The evil lies in the tendency for the family physican to find the surgeon who will give him the largest rebate, rather than to find the surgeon who will do the best surgical work. Morcover there is a temptation to form dishonest teams of family physicans and surgeons to promote un necessary operations. In the present state of perfection of sturgial technique, such operations can be done with little ruk to the pa tient, who is none the wist The first line of defense against this pernicious practice is the quality of the standards at the hospital where the operation u done. All surgical work should be an open book all usia removed should be reviewed by an honest, fear less pathologut and/or committee and the hospital should have at least 60 to 70 per cent of the hospital deaths covered by necropsies 129 ·The public has been warned against the evils of lec splitung and unstacessary surgery The many devious procedures of fee splitung and how the public may be on guard against them were fully de Kribed by Steven Spencer in the Saturday Evening Past for January 16 1954 in an article which carried ulic endorsement of Dr Paul R. Hayley Director of the American College of Surgeons. The October 30 1955 issue of Colliers carried a story with the lund udle "Why Some Doctors Should Be in Jail" The article entitled “Dip jusufied Surgery" by Greer Williams in Harper's Mfagazine for February 1954 notes that public opinion was to aroused that The North Dakota legislature passed a lat requiring all surgeons to notify the clerk of the county court and get the approval of two other doctors before every operation, and after tard to deposit with the clerk as a matter of record whatever was removed from the patient" The governor record the measure beause 21 Williams says he was "unuilling to see county court houses become museums of either normal or pathological ussuc." Williams quite properly says Hospitals which live up to the requirements of the Joint Commission on Accreditation of Hos picals (ICAH) are the publics best assurance that surgery will be dependable although rascals pop up even in accredited hospitals. The essence of their requirements as they apply to surgical care of the patient may be summarized in four Rs-responsibility rules records and review Responsibility refers to die duues of the governing board to insure the best staff and the highest standards. Rules are those laid down by the staff with the sanction of the board, for its outi conduct Such rules should empower the proper committee to determine ahat surgical privileges if any a doctor may have Vyers an administraure assistant of the American College of Surgeons, says The determination of surgical scal prrileges is probably the most difficult and important dcasion which confronus die medical staff of any hospital." Myers suggests minimum standards for what he terms full surgical privilegos" and limited surgical privileges He proposes a system of "meilical audit" of the hospital practice of crery physican both medical and surgical The third R deals with records In all hospitals it is necessary to have a records committee to insure the keeping of full and up-to-date records. Such a committee should be backed up by hospital authorities so strongly that doctors who are delinquent in the matter of records will be denied liospital privileges. The 130 ·fourth R deals with reflex All surgical departments should have weekly or at least biweekly rerichs at which the operations and surgical deaths are discussed. The Columbus Surgical Society has arried the war on ſee splitting a step farther In its by laws it states "There shall be in annual audit of the profesional records and accounu of tach member of the Soday including lacome tax returna. The accountant or auditor shall be designated and instructed by the Counal The examinar i report shall be strialy limited to the dau showing the presence or absence of fee splitung as defined abore Each member of the Sodety shall supply the cramper with whatever waiver or pamut he may need to conduct the above camination and to permit him to report his findings to the Society Failure to perrol the zodit shall be construed an irregularity and sufficient reason for investigation and disciplinary action" The society retains the accounung firm of Ernst & Ernst and in the first toro years turned up three men who were using two sets of books one for the society and one for income tax purpose. The Columbus plan has been taken up and followed in one form or another in Bloomington, Illinois Indianapolis Detroit Lincoln Nebraska Brooklyn New York, and Iowa On November 12, 1954 the Chicago Daily News reported that "members of the medical staff of Michael Reese Hospital announced yesterday they have re quested that institution s board of directors to approve their volun. tary agreement to dusclose their income tax returns to prove they do not split fees A spokesman said the action was taken as a pre ventive and not a curative measure, because {ee splitting has never cilsted in the hospital. The staff president said that the new system will reassure the public that doctors ethics are above crit- Cum." On August 23 1956 the Supreme Court of Ontario Canada, dumissed the attempt of three London Ontano doctors to have the Victona Hospitals and feeuplitang by las declared invalid. The three docton objected prinapally to the by law which enabled the hospital to have a staff doctors books audited and gave the trustees power to deny doctors the privileges of the hospital MT Justice LeBel said that the patient is entitled to asune that the doctor who recommends in operation has no pecuniary interest in it. He said that, while the practice is not forbidden by the Criminal Code of Canada, nonetheles in hus opinion it is illegal 131

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·which is $100 less than I might otherwise charge. Of course, you and Dr will have to deadc yourselves what bill you comider proper I do not think that tlicreafter I was referred a single case by this man unless a patient had definitely requested my services Fortunately in the better hospitals these influenca arc minor but they ure mentioned here for the young surgeon s gudance. In most in stances the surgeon s ikill, kindness and fairness in the matter of charges are the factors governing an internist s referral. The patient will often ask the internist "Vhat will the surgeon charge me? I much prefer to have the internist tell the patient that I will be fair but that the patient must discuss this matter with me directly preferably before an operation.

·CHAPTER XIV Imponderable Rewards of Surgery 776 young man considering the study of medicine, to the pleasant duues and to those unconnected with the practice of medlanc itself a considerauion of the imponderable or spiritual rewards and stufaction of the phyriaan may be enlightening The fint type of rewind us the entirely impersonal and purely intellectual wuslacion of finding and evaluating the evidence of ducase of maksog a correct diagnosis, of choosing the correct or optimum treatment and of keing this treatment produce the an ticipated resulu Such satisfactions are not disimilar from those associated with evolving a new and more efficient piece of me chunery with the construction of legal instrument designed to serve muluple long term purposes with the solution of a mathe wataal problem or with completion of some literary work. Thilc 11 ss true that diagnosis and therapy to be successful require the physicians intense interest, dicre are some in whom this interat It so great that it tends to make them inocauingly impersonal While physicans with the purely intellectual approach may 521c the highest type of service to dicir patients they are prone to be impauent or eren annoyed with liuman folules, emotions ind ignoniace 1 uave seen docton with the highest intellectual atuain ·ments who are unable to secure their patienu confidence and co operation. A second type of reward u that of manual accomplishment of seeing the results of the use of the lands whidi only long practice and increasing still have made possible. Such sathlacuions are those of the surgeon who surveys a completed resection of the right colon before closing the abdomen or who views thic x ray of a highly successful reduction of a difficult and complicated fracture or who inspects the Improvement in a patient after plastic surgery has corrected an unsighty defect. Such satisfactions are no doubt akin to those experienced by an artist upon completion of an oil painting, by an architect when he sees the finished house his mind has fashioned on paper or by an engineer who gazes on the finished span of a bridge which he has designed. Satisfaction in manual skills must be sought by the surgeon particularly but if they are bis only or predominant concern, he can never achieve disunction. He tends to become an operator albeit a skilled onc. His technical achieve ment becomes hus chief objective, rather than a mcans of gaining his main objective--the patients improvement The third type of reward comes in research. Here is the intel lectual fascination of probing and hunting for the unknown. Search of many blind alleys, infinite patience, and fortitude in disappoint ments are involved in the adventure. Techniques may have to be learned and then discarded when found to be impracticable or use las. Many delicate tests must be endlessly repeated. The researcher faces daily the strong possibility that his work may lead to nothing But, hovering over him are the shadowy examples of Roentgen of Cune, of Fleming Some workers seek fame, some yearn to lighten the burden of mankind s suffering, but all of them have the mostaning enjoyment and aatement of the hunt. Those who find their greatest happiness in such efforts should for the most part, be in great instituuons of research and society should make it possible for the relauvely few who are gifted in this way to give their full time to research and to be free of financual worry The Latter requirement should be met easily us most of these devoted individuals have relauvely simple material want. The research Worker seems to be constituted epurely differently from the practic ing phynaan, and the latter is dependent upon the resulu obtained by the researcher 135 ·of Of course many instances could be cited in which a busy prac uſuoner with a flash of intuition or inspired apprecation has dis covered or devised some improvement in medical diagnosu or therapy Moreover there is the almost limitless field of clinical research to which men in adive practice can always contribute. Painataking study and impartial analysis of methods of treatment help greatly in the evaluation of those methods. In a sense, every practitioner should be a contributor provided his records are care fully made and periodically reviewed. The rescarch worker is often much involved with animal re search. Without vivisecuon medical progress would be stopped. To me it seems entirely proper that the lives of mice guinea pigs, rabbits and dogs should be humanely sacrificed in order to save the Ines of human beings Inadentally animals themselves are often benefited by the advances in knowledge made possible by vivisec tion The fourth type of reward and to me the most satisfying and important of all us the human satufaction-to see a patient relicted pain to see health and hope return. Inextricably bound up with this reward is the satisfaction derived from a patients expression of grautude, which is usually verbal. Rewarding also arc thc elo quent thanks expressed by a patients relauves the grateful look from frightened parents when their child s injury has been repaired or an operation successfully accomplished. Probably no words arc spoken more sincerely than those of a grateful patient to his doctor Words of gratitude are spoken daily and they warm the doctor's heart, spurning him to carry on although fatigued. Every doctor knows this but he can seldom recall just what was said the inflec tion of the voice or its depth of emotion The written word hou ever can be read and re read. Just what docs a pauent say when he u deeply grateful? How does he put it on paper? Words diller with the depth of the emotion involved and with the individuals educauional background but the com mon denominator us sincerity A patient is not competent to ap praise the skill required for an operation which in a given case may not have been too demanding, but his words of gratitude depict the skill as it appeared to him iis recipien. Morcover a surgeon is usually praised more often than en inicmnist because the surgeons services are often rendered at an aspecially mitical 136 ·moment and frequently are of a senous and dramauc nature. The general practitioner who cares for numerous, often minor alments for many yean in the same family has loyal regard and raport, but in perhaps less likely to be the reapient of letters of prase. It has Kemed to me that reading some of these expressions would bave a beartening influence on students and physiaans and on patents and relauves, themselves. I do not knon that it has ever been done before and this is indeed understandable as doctors who receive Ictters of gratitude are modest about them. These letters are private, and the doctor abhons putung humself in the position of “blowing his own hom," of advertising or of painung a glowing picture of himself. Because of these factors, a great quantity of preaous human material lost pregous because of its inspira tional nature to those contemplating the study of medianc and those plodding in the traces of daily practice and precious because it helps others realue what these feelings are and how they are cxprewed. The distinguished philosopher Alfred Morth White head," has said. I think you get a truer picture of a period from intimate letters written spontaneously and without a thought of publicuon than you do from its fiction and often better than from 10 historians." And Harvey Cushingee quota Southeys dictum that "a man s character can more surely be judged by those letters which his friends addressed to him than by those he himself penned, for they are apt to reveal with unconsaous faithfulnd the regard held for hum by those who know him besla Morcover it is not mappropriate in these times, then so much sensational matenal us being published dealing with unworthy members of the medical profesuon, to read some of the words of appreciation which pa tients have addressed to a doctor Accordingly I have deaded to quote anonymously parts of some of the letters I have received from grateful patients. I have saved over a thousand of these letters and have pasted them in cap books. They bring back vivid memories of battle with disease and injury ind of the courage and fortitude shown by the pa tients. I have not retired from all profesional activities, so I can not be accused of advertising and it u certainly not my intention to be boastful The reader is asked to keep in mind that the follow ing letters are merely given us example of what most doctor recare but keep to themselves. 137 ·A letter from a prominent Chicago attomey whose wife I had operated upon for a severe tendon-sheath infection resulung from a wound made with a an opener included the following words "Mr. and I both feel that you need her life and that we shall both be grateful to you u long as we live. Words cannot pres our approantion of your skill, detotion, patience and resourcefulness" A recent patient wrote. "I appreciate so much the modesty of your bil, which b a real help to me at this time. I only wish I were a wealthy woman that I might more materially evidence my thankfulness for your skill-ibo I feel too that nothing could ever quite fully exprew it all." The father of a four year-old boy upon whom I did nol operate (despite the recommendation an eminent pediatriaan) and who subsequently developed typhoid fever an incident which I have described previously wrote "There is really no way that my wife and I can really tell you of our appreciation for what you did for in. We have spoken of it many many times together and with deep gratitude for your judgment and courage. Of course, ruch things are common in your dally existence and It must be the biggest atlifaction of your professon but a single instance Iſke that leaves an indelible impression on is to whom it means the most With this you have the gradtude and apprecation of Mn—and mysell. We are rery thankful that your prompt action and accurate dlagaosis ured the day One night I went to the house of the high powered" irritated and suspicious prendent of a large Chicago corporation who ined (unsuccessfully) to block the steps I took to operate upon his son, who was seriously ill with severe acute appendiciti. I prize the letter the father Later wrotC “Looking back over the recent experience with our boy I am impressed with the faa that your handling of the situation was no ordi nary service. I an Dow see more clearly that, besides the Illnes, you had to deal with un obstreperom boy and a doubulog and acted father To know that your dlagnosts was correct-that your paucnt has guned olx much needed pounds slace the operation and that the father has returned to normalcy obould gire you moch satisfaction We will never forget the decisiveness, firmnes and will which you duplayed and will alwan be thankful to you." From a doctor whose daughter I operated upon "Although it is impossible to express ones full appredadoa la wit ing. I feel that I must tell you of our fcelings toward you because of 138 ·the splendid service rendered our daughter Many times in the past we have faced aisa of various kinds with our children but never before with such confidence A doctors family is often the worst neglected medically because no one cares to assume full responsibility Your quick decalon and action lifted the task from the shoulders of a doctor father whose judgment regarding his own child is necessarily biased. In childush penmanslıp from a doctor's daughter whose cut tendons I sutured "I am sending you this program to let you know that I can play the plano. Padercorski may play it better Levinc may play it louder and Harpo Muti may play it funnier but not with more satisfaction. You will remember that you spent a hard afternoon sewing together all of the cut tendons on the top of my left arm following an automoble accident." The following humorous letter is from an attorney friend on whose wife I had done a cholecystectomy "My mie ay you are a wonder and that the operation was a conplete success. I am not so sure that I agree I had counted on getting a glimpse of my bride once or twice duning a leisurely convalescence, but us faroſan see, there was no such period. She didn t muss a ongle local engagement and was ugain running all over the country apparcnuy from the very moment you withdrew the knifel Anyway here is my check, but if, when I finally do atch up with my bride, I find there is no war and there was no operation, then I want my money back!" Also when death occur the expressions of appreciation from the family are usually verbal. It has been my custom to write a letter of sympathy to the bereaved family The doctor better than almost anyone else, can write such a letter for during a terminal illness he is closer to relatives and knows more of the details and facts than anyone else. Three general themes seem to help the family and lighten their corrow Fint, they are always appreciative of words of admiration for the deceased, particularly 1 child, and for the gallant fight he put up Second, they need reassurance that no stone was left imturned to aave the patient s life. This may or may not indude speafic or general recapitulation of the steps in the treat ment and the reasons for making them. It may also deliately sum marize the autopsy report. And, third, it is almost always possible to thank the family for their cooperation patience and understand. ing, and to prove their loyalty and devotion to the loved one who died 139 ·The following quotations have been selected from letiers received from relatives of deceased patients From a widott "Your letter bas been one of the grate consolations in my ad hours. You were more than kind to write, and it is with the deepen appreciation from mpelf and the family that I write these few lines which so feebly express what I feel When all earthly sources fall we rull have the everlasting arms to lean upon and I am sure my dear husband is by our God and Savior s side helping me to anyon." From a young widow in Oklahoma, whose husband died of peri tonius from a ruptured appendix which at that ume was a far more perilous condition than now "Your good letter of a week ago recaried the first of thu week and I Lnow not how to express my deep gratitude to you. With so many loving relatives, new and old good friends and strength given by God I have been able to keep going I really wash you might have known my husband when well. He surely did admire you and It was our whole family faith in you that kept us so well. We knew not what to do at times but you were always so kind when we knew well you had many other patients and their families to comfort too" From the mother of a fine young doctor who died of a malignant discare "Afy husband and I have never forgotten your kindly consideration for us when we were with There is a very deep satis Laction in knowing that all was done for him that the best minds knew He felt that comfort himself and often aid so During all his months in the Evanston Hospital you were instrumental in giving him courage He told us bow secure he felt in your hands. His oper misuc atutude made everything curier for himself and all of w, did it not? He w a wonderful son and we are rich in memory Please accept the sincere gratitude we feel in our hearts for all you did for him." From 2 man those wife I cared for in a fatal illnas "I have been wanung to write you for some ume but hare not been in the mood to do it until now I do want to express to you my sincere thanks and appreciation for your many kindness shown to my wife and mywell during bo long illness. She had great confidence in you and I Lnow he many visu to the borpiul to me you were made more pleasant by your und and personal atiention to her and the ex change of friendly repartce between you had much to do to buoy up her spirits lou sympatheuc interest in your patients is an outstand Ing chanacrisuc seldom found in men of your profession and is in deed something in which you well may take great pride." 140 ·Epilogue L achievement of a satisfying surgical career is not easy Unvital in overcoming discouragements, but these qualities, of cours are the same as those which are necessary for succes in practically every field of endeavor All doctors are rewarded by deep spiritual utisfaction. In the ase of the surgeon these are particularly clear and impresive. All who contemplate the study of mediane or those studeau of medi ane who are considering surgery as a spedalty should be given every encouragement and hope. There is much to be done, there is room for many

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·References I Major Ralph H. A History of Nedicine. Springfield, IL, Charla C Thomas, 1954. 2 Flancy J ML T. A Surgeons Llfe. New York, G P Putnam. Som, 1940 3 Oiler Willum Acquanimitas, and Other Addresses. Philadelphu, P Blakstons Son & Co., 1904. 4 Fabrant, Noah D Why We Became Doctor Not Sort, Grune E Stratton 1954 5 Rosen, George, and Caspen Rosen, Beate. 100 Years of a Doctor - Life. New York, Henry Schuman, 1947 6. Mayo Tytham H Proc Staff Meeting, Mayo Clinic, March 30 1932 7 Sereningbane, A Em Cadbury WE, Jr, and Carman, H. A summary of ther report is given in Time, Nov , 1953 8. American Medial Association, Comcil on Medial Education and Hosplais 56th Annual Report on Bledical Education in the United Suates and Canada Journal of the Amalan Bredical Association, 160 1637 Aug 25 1956 9 Gibbon, John H. Jo Prendential Address before the American Sur gial Asocation, Philadelphia, Pa, April 27 1955 Transactions of the American Surgial Association 73 I 1955 10 Davis, Michael M Medial Care for Tomorrow New York, Harper & Bros., 1955 11 Clark, Donald M New England Journal of Medidne, 151 157 1954. 12. llaam, Juma H New England Journal of Medidne 250 766 1954. 13. Journal of the American Medical Assocnuon, 1956 14. Amaccan Surgical Association Report of the Committee on Graduate Surgical Education. Annals of Surgery 138-937 1955 15 Nafrigts Howard C. Annals of Surgery 140.261 1954. 1& Spencer Jama H Bulletin of the American College of Surgeons, 39 119 1954 143 ·17 The present secretary of the Amelan Board of Surgery is Dr Jobo B. Flick, 225 South Fifteenth Street, Phladelphia See Journal of the Amerian Maial Awodation, 139-479 1953 18. Cope Oliver New England Journal of Medianc, 250 1 1954 19 McKittrick, Leland S. New England Journal of Medidoe, 251 61 1954. 20 Beecher Henry K. Journal of the Amerian Medical Asociation, 151 44, 1953 21 Elkla, Daniel C Bulleda of the Amerlan College of Surgeons, 12:5 1957 22. Mam, Jama H Doctors, People and Government. Boston Little Brown & Co. 1953 23 Jordan, Edwin P New England Journal of Medidoe, 250:558 1954 The Phraun, Hu Badnan and His Practice, Boston, Little Brown & Co. 1954 24 Burrow, Harold Pitbull of Surgery Net York, William Wood & Con 1925 25 Gurland, Joseph Thc Phyidan and His Practice. Boston, Little Browo & Co., 1954. 26. Hall, George E Legal Aspects of a Medial Partnenbip Journal of the Amerian Medical Association, 156 1912 1954 27 Jordan, Edwla P The Business Side of Group Pradice. Journal of the Amerian Mediaal Asocution, 135 1871 1954. 28. Hamilton, Walton H The Place of the Phyidan in Modern Sodety Quoted by Cortu, Charla P, and Grenalet, Ferrba The Practal Cogitator Boston, Houghton, Malin Co., 1945 29 Homens John. Obituary New England Journal of Medidne, 31-210 1954 30 Wartman, William B. Quarterly Bulletin of Northwestern Univerilty Medial School, 29 69 1955 81 Slee, Varga N Bulletin of the Amerian College of Surgeons, 39 597 1954 32 Myer, Robert S., and Sice, Veryth, N Bulletin of the Amelan College of Suryton, 41 109 1956. 33 Lombcke Paul A Journal of the American Medical Apodatlan 162 646 1956 34 Myers, Robert S. Bulletin of the American College of Surgeons, Nor Dec., 1953. See also Alger RS. and Stephenson, GW Eraluation Form for Time Cotamittees, Suggested Method for Tubulating De cbion u to justifiation for Surgery Journal of the Amerian Medical Association 136 1377 1954 Daseler E H., Bulletin of the American College of Surgeons, 10-22, 1955 35. Myers, Robert S. Bulletin of the Amerlan College of Surgcons, 11 173 1956. 36. Regan Loos ) Medidoe and the Law New England Journal of Medicine, 250465 1954 37 Colc Warren H Bulletin of the American College of Surgeons, 11 67 1958 $& Bulletin of the American College of Surgeons, 19 152, 1954 144 ·59 Myers, Robert S. Bullcun of the Amencan College of Sargeons, 41 207 1956 10 Gilchrist, Richard h., in duscussion of a paper by Wose John P. Cardiac Arrest Daring Anathola and Surgery Annals of Surgery 140 623 1951 41 Koontz, Amos R Journal of the American Medical Association, 156 1629 1951 12 Potis, Willus J as reported in the Chicago Tribune on Blarch 16 1955 43 Cole, Warren H and Sadove, Mar. Journal of the American Medial Asxodation, 162437 1956 14 Beecher H h, and Todd, D P.. Annak of Surgery 140.2. 1954 13 Balletin of the Amaian College of Surgeons, 11 126 1956 16. Crosen, H. S., and Crossen, D F.. Foreign Bodio Left in the Abdomen. St Louis, CV Mosby Co. 1940 47 Morrison, R. Bntah Aledical Journal, Feb 9 1924 p. 255 18. Bulletin of the American College of Surgeons, 11 441 1956. 49 Einstein, Albert The World As I See It New York, Philosophical Library 1949 50 Moter A. American Journal of Surgery +7 660 1910. 61 Christopher F Journal of Bone and Joint Surgery 13-877 1931 52 Dachter H. W Amman Journal of Roentgenology 25629 1931 53 Trimble, I. R. Journal of the Amerian Medial Association 153 1145 1953 54. Christopher F Infummatory Tumors of the Cecum Simulating Acate Appendidas Surgial Clinic of North America, 16-215 1936. 55 Tipart, R E B.. Acute Phlegmonous Caedtu. British Journal of Sur gery 10-437 1958. 56 Dialogues of Alfred North Whitchad, As Recorded by Lucien Price. Boston, Lille, Brown & Co., 1954. 57 Christopher F Bulople Fractura Amcian Journal of Surgery 2 122, 1927 58. While W L The Personal-Iojury Racket. Rader : Digor, Jan, 1955 See also Regan, L.) Mulpractice, an Occupatiomal Haard Journal of the Amaian Medial Association, 156 1917 1954 69 Whitman, Howard Woman Home Companion, July 1953 60. Hanck, Jama B. Nemodos of Eighty Year University of Chicago Press, 1949 61 Journal of the Amerian Medical Asociation, Feb 20 1932 62. Swetlow George L. Medical Economia, 1954 63 Muurer H. The DID s Are Of The Pedostal Fortune Feb., 1954 64. Myers, Robert S. Bullain of the American College of Surgeons, 39 69 1954 65. Williams, Greet. The Columbus Plan Begins to Roll Balletin of the Amenan College of Surgeons, 39 153 1954 66. Coshing, Harvey The Life of So William Osler Oxford, Clarendon Press, 1925 Vol. I p. 128 145

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·Index ARDOIN child s palpation of, 58 forem bodies left in during sun Books helpful in evaluation of med. Idne as a carcer 2 Breathing, cessation of in operaung gery 93 room, 79 CANCER patient, what the surgeon should tell the 66-71 Cardiac arrest during operation, 79 Case report as basis of medial paper 106 Abscess, sich, due to silk sutura, 96 Accredited hospital, 29 Alcohol habits of surgeon, 111 Amerian Association of Medical Clinia, 23 American Board of Surgery certifice tion by 16 81 Amencan College of Surgeons, fellow in, 31 Amerian Medical Association, mambership in, 31 Amalan Society of Anesthesiologists, OC 84 Amalan Surgal Asociation, 35 Anesthala, 84-88 Board certification te, 87 deaths due to, 87 Anatheologist, and surgeon, co operation between, 85 requireziena of 84 Aulantı, instruction of, during op aration 81 Audit, medial, 65 staff, annual, 63 Certifiauon, Board, in anesthesia, 87 by Amenan Board of Surgery 16 31 for specialty 16 Charity surgeons contributions to 114 Chicago Surgical Society 52 Child abdomen of, palpation of handling of, 36 City large-sized, loauon for surgeon in, advantages and diadran tage of, 21 medium-sized, locaton for FIT goon in advantages of 20 Cinc duties, surgeon ind, 113 Clinic, group-practice, 23 24 Cocktails, surgeon and, 111 112 Colostomy patient, surgeons pre operatire remarts to 56 BOARD certification in inathesia, 87 Boark, cumining approved, in medial specialties, able, 13 T

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·Index ARDOWCY child's palpauon of 38 foreign bodies left in, during sur Books helpful in evaluation of med idne as a carce 2 Breathing, censation of in operating gery 93 room, 79 Abscen, stitch due to allk rutures, 96 Accredited hospiul 29 Alcohol babiu of airgeon 111 American Asociation of Medical Clinia, 29 Amelan Board of Surgery certifica tion by 16 81 American College of Surgeons, fel low in 31 American Medical Asociation, men benthip in, 31 Amerian Soaety of Anesthesiolo ghts, C., 84 Amerian Surgial Anocauon 88 Anerthala, 84-88 Board certification in, 87 daths due to, 87 Anesthalologist, and rurgeon, co operation between, 85 taurelient of, 84 Assistants, instruction of, during op arathon, 81 Audit medial 65 staff, annual, 63 CANCER patient, what the surgeon whould tell the, 66-71 Cardiac antet during operation, 79 Case report us basis of medial paper 106 Certification, Board, in anesthesia, 87 by Amaian Board of Surgery 16, 31 for speculry 16 Charity surgeons contribuuona to 114 Chicago Surglal Soacty 52 Chuld, abdomen of, palpation of, 38 handling of 36 City large-wed, location for surgeon in adrntages and diadran tago of 21 medium-wired, loation for sur geon m, advantages of, 20 Cmc duties, surgeon and, 113 clig, group-pndice, 23 24 Codaills, surgeon and, 111 112 Colostomy patient, surgeon, preopentre remarks to 56 BOARD certification in anesthair, 87 Board, cumıning, approved, in medical specialdes, table, 13 17 ·Community large sized, location for surgeon in advantages and disadvantages of, 21 medium-sized, location for sur seon in, adrantage of 20 mall location for surgeon in ad notages and disadvantages of 19 20 Cost, of medical education and thin ing, 5 125 of surgery See Fees surgical Courtesy staff of hospital, 31 Deaths due to anathesia 87 EDUCATIOY medical cost of, 5 125 research and, 7 premedial, 3 Euthanasia, 71 Examining boards in medial spe aalties, approved uable, 13 HALSTID Society 53 Hart beas, cesnation of durins oper ation, 79 Hemorrhage, unexpected. during operation, 77 Hernia, cuminaton for 55 furgeon s preoperaure remarks to patient with, 54 Hobbies and sports for surgton, 112 Hospital accredited, 29 acquiring Haff membership in, 29 activities, nonoperative of sur foon, 58-72 "closed, 31 courtesy staff of 31 patients visiting of, by surgeon 59 profesional standing of appraisal of, 29 30 "rounds" of surgcon, 59 signing in and out of by surgeon 58 Hours everage working and income of physicians, 12, 125 ILLNESS, fatal surgeon and. 67-72 Income and average working hour of phyuidans, 12, 125 Injury litigation, personal, 115-119 Insurance, physicians liabilty 92 Intern, duues of 9 Internist, duties of, 15 Internship choice of 8 rotating," 8 FACULTY medical school appoint ment to 31 ranks in, 21 Fatal illness, Rurgeon and, 67-72 Fee splitting, 129 Fecs, surgical 120-135 adjustment of 122-129 patients inquiry concerning 125 reduction of 121 Fellow in American College of Sur gcons, 31 Jort Commission on Accrediution, Foreign bodias left in abdomen dur ing surgery 93 Fructures, 55 GODAL pracuce, qualificauons for 10 Tersus speaaliy choice of 10 Goll, surgeon and, 112 Gratitude, exprewon of by patient 136 Group-pracuce clinic, 23 24 Liabilin insurance phnician . 92 Liugation personal Injury 115--319 Location for surgeon, cholce of 19 28 in large sized community ad vantages and diedrantago of 21 in nedlum tired community ad nguage of 20 in small community adranlages and disadvantage of 19 20 148 ·MALINCDUYC detection of, 42 Mupnaíce nuits, 92 Vicial audit, 63 Mladial eduation cost of 5 123 research and, 7 Bledical pape 105 ause report us basis of, 106 Medial reading 109 Aledical school, choice of 5 faculty appointment to 31 rinks in 21 Medial soactia membership in, 31 Medial specialues, approved cum ining boards in, uable, 13 Mcdidine, ma carter caluation of 2 books helpful in, 2 reasons for undertaking, 1 general, practice of, qualifications for 10 TOITUS specialty choice of, 10 varlized, 27 rady of, prerequritas for 3 Alembership in medial soacties, 31 in surgial soccues, 32 "blacy kuling" 71 Nilitary service of purgeon 118 Albidentifiaton of purgal pt tients, 95 PALLIATIVT operation 71 Palpation of child s abdomen 38 Paper medical, 105 case report as bases of, 106 Part-time profesional positions for young surgeons, 25 Patent(s) "bad. 63 cancer what the purgeon abould tell the, 66-71 colostomy surgeon s preoperative remarks to 56 expression of gratitude by 156 first, of young surgeon, 55 "good," 55 hernia, surgeons preoperative remarts to 54 hospital, young of, by surgeon. 59 inquiry of concerning surgal fees, 125 misidentification of, 95 psychological preparation of, for operation by surgeon, 54-57 referral of, to furgeon, 49 relativo of, surgeon s remarks to immediately following opera tron, 66 surgeon and, meeting ok. 49-57 Personal injury litigation, 115-119 Phrican, annual income o£ 5 125 liability insurance of, 92 qualifications for 10 working hours of, 12, 125 Pouitions, professional part-ume, for young sungcot, 23 Practice, peneral, quulllations for 10 Tersus speculty choice of, 10 eorgial, early 84-18 Premedial education, 3 Profesional positions, part-time, for pung turgeom, 23 Psychologial preparation of patient for operation by nurgoon, 54-57 NATIONAL Auociau for Clinic Alanagers, 25 Nonmedical reading for surgeon, 118 Nonoperative bospiul activits of Forgton, 58-72 Nonpoladona aamio of sur geon, 110-114 OFFICE and reception rooms of Art gton, 34 Operating room, dgnal sitem" 10 74 Hurgeon in, 7583 quanimity of, 76 general conduct of, 78 unexpected happenings in 77- 80 Operation. See Surrey READCYO medial, 109 nonmodial, 113 ·Reception rooms and office of sur geon, 34 Relatives of patient, surgeons re marks to immediately following operation 66 Report, case, as bases of medial pa per 106 Roxcarch, imponderable rewards of 135 medical eduation and, 7 of young nurgton, 21 Raidency choice of, 16 rurgial, 17 Rost, adequate for surgeon 112 Rewards, imponderable, of surgery 134-140 'Routing“ Internship 8 "Rounds, hospital 59 gcon 58 SCHOOL, medical choice of 5 faculty of appointment to 31 ranks in, 21 "Signal system" in operating room, 74 Sigalng in and ont of hospital by eur Silk sutures, stitch abscess due to, 96 Social relationships of surgeon 110 Socialized medicine 27 Societia, medical, membership in, 31 surgical membership in 32 Society of Clinical Surgery 35 Society of University Surgeons, 33 Speculis number of in United Suta, table 11 pitfalls of 15 Specialues, approved examining boards in uble, 13 cerulication for 16 Sponge masing 79 Sports and hobbies for surgeon, 112 Suff audit annual 65 courtesy of hospital, 31 memberuup in hospital acquis Stiich abscess due to silk sutura, 96 Subpoena surgeon and, 116 Surgeon, adequate rest for 112 alcohol babits of, 111 anenthenologist and cooperation between, 85 cancer patient and, 66-71 ciric datius and, 115 cocktails and, 111 112 contributions of to charity 114 fatal illness and, 67-72 general conduct of lo operating room, 73 hobbies and sports for 112 hospital "rounds" of 59 imponderable rewards of 134- 140 in operating room, 73-83 equanimity of, 76 general conduct of, 73 junior duues of 26 location for choice of 19 28 in largetized community ad vantages and disadvantages of 21 in medium-sized community ad rantages of 20 in mall community advantages and disadvantages of 19 20 medical reading by 109 medical writing by 105-109 military service of 113 mistake of 89-08 nonmedical reading for 113 nonoperative hospital activities of 58-72 nonprofesional salvides of 110- 114 office and reception rooms of 4 patient and, mecung of 19_57 preoperative remarks of to colos tomy patient, 56 to bernia palical 54 psychological preparation of pa went for operation by 54-57 qualifications for 10 referral of patient to 19 remarks of to patients relatives iminediately following opera Lon, GG ing, 29 150 ·gon, 26 Surgeon senior sodation of young Surgical fees, 120-135 surgeon with 20 adjustment of 122-129 sigoing in and out of hospital by patients inquiry concerniog 58 125 social relationships of, 110 reduction of, 121 rubpocna ind, 116 Surgial patienus, misidenuficauon routing of hospltal patients by 59 of, 95 young accessibility of to tele Surgical practice, curly 34-48 phone 34 preparation for 1-18 usodation of, with senior sur Surgical taldency 17 Sugical sodetia membership in, first patienu o£, 35 32 group pracuce for 23 Surgical writing, 105–109 part-time profemional positions Soturas, silk, stitch absceu due to for 23 96 research work of 21 Surgery cardiac utest during, 79 TEAQUINO surgical, 99-104 comoon of breathing during 79 forelgo bodies left in abdomen Telephone, accemibility of young during, 93 rurgeon to 34 Tissue Committee, 64 imponderablc rewards o£, 134-140 Trainint medical, cost of, 123 fostruction of wastants during, 81 on wrong ade of body 91 palliaure 71 VLOTTO of hospital patients by aur pitfalls in, 89 98 remarks of surgeon to patients relative immediately following, 66 WORKING hours, rengs of phyu sponge mbing during, 79 cans, 12, 125 teaching of, 99-104 Wounds, surgial, foreign bodies left unexpected hemorrhage during, in, 93 94 77 Wrong, surgical, 105–109 foon, 59

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