Illustration: Dan Bejar

Annals of Medicine

Medicine has come a long way since 1924, when Davis Thayer Gallison, a member of the Tufts School of Medicine’s graduating class, delivered his valedictory address on the dangers of specialization. And yet the kind of health care he warned about is still recognizable. Even though Gallison himself went on to specialize—practicing cardiology in Boston until his retirement in 1959—we imagine he was a cardiologist with a heart. His granddaughter preserved the speech, which we present in abridged form.

With the multiplicity of new methods of diagnosis and treatment that are constantly being presented in the field of medicine, there is a decided tendency toward specialization, which may lead to certain evils. In employing laboratory methods of diagnosis, so much attention is given to the results obtained by instruments of precision that the patient is ignored. When a report comes from a specialist or a laboratory, the patient is not mentioned, unless it be merely incidentally. And of course the report from the laboratory does not contain any reference to the phenomena that are perceptible to the unaided senses.

An actual occurrence in one of our well-known hospitals illustrates clearly this defect in our present system. There was admitted recently a patient suffering with a fever of unknown origin. His blood was tested, the sputum and excreta were examined, the cerebro-spinal fluid was analyzed. Various microscopic, chemical, and bacteriological tests were employed. The basal metabolism was determined. Electrocardiograms were made of the heart action. The thoracic and abdominal viscera were examined by x-ray. Specialists went over his eyes, ears, nose, throat, and teeth. But nothing was found to explain the patient’s fever.

A general practitioner from a nearby town visited the hospital and, as he was being shown about, passed through the ward in which the patient lay. He passed by the bedside of the sufferer, and turning to his colleague remarked casually, “I am surprised to see that you still have an occasional case of typhoid fever in your neighborhood.” Experience had taught him to see the case as an entity and he recognized the disease at once.

Unfortunately, there has arisen the type of physician who sends his patient to a series of specialists or laboratories and gets their report—and then on the strength of these, plus his own examination, which is usually superficial, makes a diagnosis and believes he can deal with the patient’s complaint. There are two defects in such a procedure.

First, it is difficult for one physician to assess the true value of a symptom or sign detected by another. Second, the most important source of authoritative information is lost when the patient is handed over to another for examination.

Also with specialization there is apt to come the unfortunate attitude of regarding the patient as a case. There is the fatal mistake. When the physician becomes so deeply engrossed with the laboratory aspect of medicine that he loses, or ignores, the human side, he is not giving his patients their just due.

Here is where the old-time general practitioner excelled. He knew his patients intimately. He lived in their community. He realized their problems. He understood them. He took care of them. He did not depend upon laboratory tests or complicated instruments to make clear the diagnostic signs and symptoms. He was trained to observe the patient, to detect the conditions incident to the disease with his five unaided senses.

Let us view the problem from a different angle. Disease is the result of natural laws. The effects of disease are rarely if ever confined to a single structure or organ. Organic lesions of one tissue result in disturbances elsewhere. The tendency has been to pass lightly over these associated phenomena. The pendulum has swung to the extreme of specialism. The present-day physician is too apt to depend upon scientific devices which aim at demonstrating some special symptom, and to overlook the original hostile forces.

We have said that disease is the result of natural laws. Therefore to overcome disease the physician must so far as possible understand these laws. And how can he better gain this knowledge than by study of the patient as a whole? This is the attitude to be emphasized: the physician should consider each case as a patient—not each patient as a case.