Re-Establishment of the Medical Profession

Annual Oration 1888

By B. Joy Jefferies, A.M., M.D.

Our profession cannot contend with what is called business in the accumulation of wealth. No man ever made a fortune as a physician. I mean no one ever paid his expenses and laid by at interest enough to live on, through the practice of medicine. I do not, of course, refer to those who have entered into business with their gains, by speculation or speculative investments. Such may have gained or lost as other so-called business men do. This we have in common with the other professions, though we are not so well positioned as they as we advance in life. Even with continued health and strength, and the largest possible amount of practice, a physician in this country can never acquire by his toil the incomes readily made in other occupations now recognized as professions. Moreover, many of these place a man in direct opportunity to become profitably interested in business enterprises, more or less associated with his special work.

It is therefore useless for us to contend with trade or business either in earning a living or in the accumulation of money. Our profession is most essentially not a trade. Those in it who attempt to make it so but lower themselves to the level of trade, or simply money-making. Our calling belongs to that department of man’s work recognized as scientific or knowledge seeking. We are simply men of science, that is, men of knowledge and its pursuit, the attainment of which is to benefit other people primarily. Now the world over, men who give themselves up to the pursuit of knowledge have been considered as worthy of only so much of this world’s goods as will simply keep them bodily in a condition to work with their brains and hands in science seeking.

When these other professional men apply science, knowledge, to the useful arts, that is, render money-making possible, then their recompense may be very large. But the physician’s science or knowledge is applicable only to relief of pain, the saving of life, or the increased healthfulness and bodily comfort of mankind. This the world does not similarly recompense. The world at large values knowledge only as a means of making money. I say the world at large; fortunately for mankind there is a body of truth seekers for truth’s sake. To this class our profession should belong. And we deserve recognition in it because we do not keep what we learn, but disseminate our knowledge as quickly as possible for the benefit of humanity. True, this humanity or the world at large simply regard us as fools for so doing. But the diligent study and the honest practice of medicine gives a man a power, and a self-respect, and a consuming interest, a love of his profession which lifts him above the assaults of the world. The physician has a contentment which aggravates as well as surprises those he comes in contact with. In this contentment we understand and hold by each other as kindred spirits.

No class in the community know better than physicians the baneful effect of what in general terms is called “filthy literature.” Here our knowledge is of value, and our opinions will be received by the community. Have we not dreaded giving them from disgust at cant, pseudo-morality and false sentiment?

But there are associated together for the suppression of vice, good, honest, mentally strong, shrewd and prudent men and women, who have in their work to contend with the best paying criminal rascality and foulness existing among us. Money will flow like water to prevent legislative control. Are we as physicians, knowing and seeing all, doing our share in helping those properly at work for the suppression of vice? There can be no false stigma attached to any professional efforts of the kind.

Certainly one thing we should do; namely, by united action and condemnation, prevent medical book notices from being distributed, containing wood cuts, often perhaps totally unnecessary in the books themselves, and which in the pamphlet advertisements never induced the rightful sale of a single copy.

The respect of the old due to the young — I do not think anywhere in life this applies more strongly than in our profession. The young have first what time and the wear and tear of life slowly but surely eat away, namely, enthusiasm. Without this but little can be accomplished, and that little only as a burden. The young have that power of adapting themselves to new or changing circumstances which old men have not, and progress in our profession means just this. Capacity for work, both physical and mental, exists in the young that the old no longer possess, or but very exceptionally, and only to prove the rule.

A man has had thorough preliminary instruction in youth, and subsequent professional education of the best. He has talent and ability, and knows how to use these. He is urged for some place of trust and influence for which he is well qualified. “Don’t you think he is rather young?” is heard from some over-prudent objector. No, I want to reply, but your saying so proves that you are already too old to retain your place. Respect for the young is prudence as well as justice.

How many years ago would it have been rank heresy to have urged any one under sixty years of age for the presidency of the then Harvard College, but the university has been built up by such an one, and not least the department we are interested in. Our Society should reverse the maxim, young men for action, old men for councillors.

What! would you throw away the value and weight of experience? Certainly not, if the latter had any knowledge to start with, and the power and ability to constantly accumulate further, and to impart it. Merely having lived or practiced so long does not necessitate the increase of knowledge or a greater power of its application. Quite the reverse, — it may have simply frittered away originality by dullr outine. Inexperience is often of real value, because it dares to do and try what experience has shown some one else he cannot do. Years of accumulated sameness is only worthy of the respect which age alone gives. Mere time does not make valuable experience; the latter comes from constant and progressive thought and study, and their intelligent application to professional life and work. Experience may or may not come with age; the latter does not of itself make it. This is one of the greatest fallacies of the present age in all departments of life.

Old age is to be respected for itself, but when it would guide our actions by its experience we demand to know what that has been, and of how great value. Age as well as youth must prove its ability to have observed and drawn truthful conclusions; that is, to have advanced by intelligent study. Time does not make solid ignorance knowledge. But how eagerly the world seeks the experience of those who have proved themselves capable of having profited by it. The fancied accumulation of knowledge from the mere lapse of time is a dangerous mistake.

I often recall the following instance. In the Director’s room of a railroad corporation I had shown the officials the practical results of defective color-sense by instances from among their employés. They could not or would not understand or admit it. One otherwise pleasant old gentleman sank back in his arm-chair, and with almost a snarl of doubt und derision exclaimed, “Why, Dr. Jeffries, I have been railroading more than forty years, now if any such thing as color-blindness existed, I must know all about it.” And how far is the community from this now?

Education is the teaching the hands to work at advantage and the brain to think rightly. Certainly this applies to medical education. Proper medical education cannot be given the ignorant young man, and only young men should be made doctors. If the hands and brain have not been trained how to work, they cannot be properly employed in the higher field of human activity occupied by the physician. The advance in modern education comes not from additional amount of facts poured into the school boy or student, but from applying improved systems by which brain work tells better.

It is possible to teach the power of observation, deduction, the application of principles, and sharpen the brain, the wits, to seize the time for action. The medical schools admitting young men without such preparation, even if they attempt to teach well and thoroughly, never can turn out the best physicians.

The young man in this country who wants to go into medical trade thinks he has only to learn a little and get his diploma as he would fit up a grocery shop. The community thinks so too. The so-called medical colleges scattered over the country are ready to help him for the fees he can scrape together to pay them. This tradesman opens his shop for custom, and the world looks upon and patronizes it like any other shop. But in medicine as in all the true professions, work but commences with the responsibility of occupation, and never ceases while that lasts. Better for a man if it lasts through his life.

Now these medical colleges, backed by the community, want the profession to foster such trade doctors, and have us accept them as colleagues. These men themselves claim our support and recognition, and would pull us down to their level to help their trade. The time has amply come for this to stop. The physician must rest on his individuality, on his learning and his power of using his knowledge.

If you carefully observe the men teaching and learning in this and the two adjacent buildings, and then compare them with the men teaching and learning in the building farther on, in which we are or should be all interested, there will be found a difference of a peculiar and subtle character, the difference between the medical and the technical man. Perhaps only our profession can understand this. I have found very shrewd men in the other professions, even the allied ones, much puzzled by it.

Here in technology, arts, sciences aside from us, the students learn facts, physical laws, principles, and their adaptation to physical conditions, and relies on set and fixed laws and rules for action. His work in life is a continuation of this. Here two and two make four, and can always be depended on as making four, mathematically deducible and proved as we say.

Now in the other building the medical student learns also facts, physical laws and natural principles. But in practice he has to apply them to unnatural conditions, disease. And he learns that the conditions of disease render mathematical application of seemingly fixed principles impossible. Two and two may not make four, and he must be able to grasp this fact. The study of medicine is for this, and four years is little time enough to learn the needed facts, their application, and so to speak misapplication. This it is which besides all else separates us from other professions, and but puzzles them. They see us arriving at results from data that their knowledge and experience prove mathematically can not come. This elusive something is the spirit of medicine; he who has it most will most successfully be able to detect and cope with disease, be the most successful physician. I do not mean as to the number of his clients. That is no proof of medical talent. It is, in fact, in this country, more generally a proof of its absence. The pretender and the quack have the largest number of applicants for a time, till the next quack comes.

Since the slavery rebellion our nation has settled down to its civilization. Has our profession advanced with increasing education? Not the whole of it, for the reasons I have given. But there are many more men than ever before giving their strength and lives to the accumulation of knowledge in our calling, and its diffusion. Never before have there been so many men so highly educated in medicine as now. I cite as proof, the papers and discussions at our Society meetings, the articles published in our journals, the respect our best men are gaining from the thorough medical scholars and teachers of England and the Continent. I cite further the greatly increasing number of physicians in the various branches of medicine who are becoming good and valuable teachers among us. Never before have we had such competent and thoroughly taught practitioners under thirty years of age. Never before have we had so much true scientific work going on in our profession. The graduates of even our best schools are not content to stop their work, but seek in Europe the best teachers to compare their acquirements, and bring back to us the highest medical culture of the old centres of learning.

Should these men be classed with the ill-bred and half-educated graduates of the remaining nine-tenths of the medical schools of this country? Because they have the same title, must they be put on the same plane as the business and trade doctors our communities are overrun with? Yet this is precisely the way they are at present treated and regarded by the laity, who make no distinction between one physician and another. And this by all classes of the laity, high and low, rich and poor, learned and unlearned.

The scientific man is often now startled by finding “a doctor” familiar with his own department. It is quite a revelation to him. Why, nearly all the work in the various sciences outside ours, now followed as professions, was formerly done by men graduates in medicine!

Among us and in our Society, this advance in medical education has been brought about by the thorough and complete change in the plan of teaching and instruction of our University School, the raising the standard of requirement, and the absolute refusal to grant a diploma of Harvard to any graduate who falls below such standard. Moreover, this elevation of the profession has been helped by the Massachusetts Medical Society also raising its standard of requirement. This is by no means so easy a thing to accomplish. The School is strong enough to be independent and insist on a proved preparatory education before entering on its curriculum. Our Society can at present only insist, by increased severity of examination, on greater medical attainments.

But it can do much to support our School and its teachers in their position by letting it be understood, and acting on the declaration, that to enter our ranks, the applicant must equal the Harvard graduate. The laity have no conception of the character of the teaching of our School. Have all the profession, all the members of this Society, a knowledge of its work and standing?

The most learned and scientific men in other departments have, I believe, but little if any knowledge of what this branch of the University and the very few other schools of similar standing in the United States are doing for the world. I regret that there are those, to whom to give this my judgment and words force and truth. I must say, as did the first president of the Suffolk District Medical Society, when in his annual address eight-and-thirty years ago he praised the “Boston Medical School,” “I do not utter this under the pressure of the official toga which I have never worn; but I record it as the tribute of a grateful pupil.”

Having said this, I am free to ask, is our School and others like it doing all needed to fit men to practise medicine, to use their hands and brains professionally? The success and the growing number of polyclinics and post-graduate courses, right among our best schools, seem to me to positively prove that the student and the graduate find there is something more to be learned, and something worth giving time and money for. What better argument for the need of an additional year’s study, however this may have to be arranged in reference to the undergraduate department of our universities and colleges?

If there are men who can as teachers attract earnest students outside of the regular courses, I do not see why they cannot be employed as teachers in the schools of four years’ curriculum. This extra outside teaching I think has hindered the adoption of a four years’ course as compulsory. It has fostered, unfortunately, the worst form of trade doctors among us; namely, the “two to six weeks’” fully-fledged specialist with any “scope.”

I disregard the objection to four years on the score of cost. The men who built our present medical school did not stop for this sort of objection, and time has proved them right. I record here my conviction, and I wish I could record the conviction of this Society, in the support of the teachers and workers trying to elevate the standard of the profession, and thus, for only thus can it be done, replacing our calling in the respect of the laity, at the same time completely separating us in their judgment from the bands of quacks, trade doctors et id genus omne.

There is not in medicine the some danger of the teacher becoming the pedagogue as in general education. But I have suffered and seen others suffer so much from the latter that I cannot help giving a warning word. Medical teachers hold the same sort of relation as do other educators. They must not be too sensitive to the push and prod of the students and assistants in the struggle for existence. This should but keep them up to their work, as do the whole corps of young assistants the professors in Europe, whose places some of the former must finally fill. A man must wear his spurs after he has won them. Remember the respect of the old due to the young.

It is perhaps naturally expected of me here to say something in favor of those much used and much abused physicians called specialists. Whatever may be said against them, it must be admitted in candor that to stop the work they are doing would check the scientific advancement of the profession as a whole. Specialism means work, seeking science, knowledge, truth. It cannot be said that they keep from the profession or the world the results or benefits of their labors.

The same is now unfortunately true of the specialties as of the general profession. All I have said as to the laity’s inability to distinguish between the true and the false applies with ten-fold force as to specialists. Physicians recognize this even in their own inability to decide between pretence and talent, knowledge and ignorance, experienced training and assumed.

I greatly respect other specialties, and cannot see how we can get along without them. I have to thank the men of talent and standing practising them, and have always found them as willing to help me as I them. They can defend themseves better than I can. Of my own I will say but a word. A foreign body in the cornea cannot be prayed out or pried out. The first our patient’s wife has probably urged, the second been tried by a fellow workman, or the nearest doctor. But a drop of cocaine, a lens, a rightly shaped and sharp needle in a steady hand, directed by an experienced eye, quickly relieves our patient of his foe and fee. This is specialism, and as such is likely to remain among us.

It was said in praise of a physician who died some years ago that he was never seen in any place his profession did not call him. It was a proof of devotedness to his calling. In the then relations of the doctor to the community perhaps it was wise and necessary. All that has certainly passed away never to return. We are now forced to be en rapport with the world, its people and affairs, and, I believe, with a gain thereby to our usefulness in the practice of our profession. The more a man knows outside of and in addition to his medical work, the better physician will he be. Such knowledge will never hurt his professional judgment, and will very often give him thereby a better opportunity to enforce what he knows to be necessary.

When a patient finds that we are by no means ignorant of his special work or business, can express an intelligent opinion thereon and have some interest in it, then that patient is nowadays much more likely to respect our professional advice and follow it. We have to guide and govern men and women, and we cannot without respect from the governed.

The community somehow still have an idea that physicians as a class are not capable of anything else than their own work, without business capacity, not practical. This certainly is not now the case. Well educated men in the profession are most practical, most prudent financially from necessity and experience, always recognizing and deploring waste and extravagance. In the expenditure of money for public and private charities they are now recognized as conservative and shrewd. Physicians, and most busy ones, had greatly to do with the collecting money for and its expenditure in the building of the great educational institutions on this street, including the one in which we are now assembled.

Not only is a physician nowadays allowed, if I may so say, to have some knowledge of the world of affairs, but he is beginning to be granted some familiarity with literature or with scientific pursuits, even when the latter are not directly connected with medicine. The profession at large and a part of the laity now begin to recognize the value of scientific thought and scientific study in our calling. It does not now hurt a man to be known as scientific, that is, seeking knowledge by mental labor. There was a time when this was a positive detriment, and militated against a man’s opportunity to gain a livelihood.

When you ask an ignorant man to sign his name or read a sentence, he rarely with shame, more often with a certain brutal indignation, announces that he is no “scollard.” This is but a relic of the time when a feudal lord would have spurned the ability to write as his scrivener did. I see the same in the uneducated doctor when he declares, with a touch of pride, that he “doesn’t pretend to be resisting scientific,” as if all he did know was but the first step of science, in the path of which he has trod or has lost his way. It is a dangerous thing for the profession to attempt to decry or belittle any scientific work its members are engaged in.

In the great world of scientific work our profession is needed and has its place. Its labor is special and separate, but calls strongly for thinkers, observers, truth seekers. This is the study of medicine, whilst the practice calls for the greatest endurance, patience, forbearance, toleration, and courage physical perhaps as well as moral. A thoroughly educated physician is a man of no mean parts, and will be able to hold his own with others in the world’s affairs. His training makes him a good “all round man” and a gentle-man.

We should not resent but welcome the coming into the profession of young men with wealth and means that render them independent of work. Even if they practice they have the right. It was once said with some truth that the possession of thirty thousand dollars would kill any man’s advance and work in our calling. That is not true now. But the young men I speak of are most valuable in softening the spirit of gain and strife. There is work in abundance for them, and to advantage of us who must delve for our living. Their position enables then to do for us what we most need but cannot accomplish. They have hours for work without anxiety.

To study medicine and take a degree in a first class medical school after a collegiate course is a training most valuable. The knowledge gained is aside and besides all other, placing the graduated physician at very great advantage over his literary, artistic, and other professional friends. Moreover, the study of medicine is earnest, serious, mentally stimulating, and gives a man breadth of character. It teaches him the value of work. One of the class of young men I am speaking of whom I had advised to follow our profession, said to me with great satisfaction and self-respect: “To graduate here at our school sickens one for loafing and idleness.”

The student learns that life and happiness mean work, work for others or self, but work, without which life at last is found not having been worth the living. The graduate learns also that there is no place in medicine for the Bohemian or the dude, that all attempts to act or imitate the one or the other are wholly out of place, as any of the peculiarities which were the marks of a physician in gone-by days. Even the white cravat worn at other times than when socially demanded, is now pretty well recognized as a medical hypocrisy, Chinese mourning for departed patients. The true physician does and should dress as any other quiet gentleman.

Fortunately for us in this present day, and for the communities in which we live, the absence of means does not preclude the possibility of preparatory and medical education, and that of the highest grade. The State and the individual citizen has now given every man a chance who has brains to use and is willing to use them. It is the State’s and individual’s charity. Harvard University is an endowed educational charity of which every graduate is a recipient.

But absence of means must be an incentive to action, to labor, to study. For myself I know that any good which I have done for the community or for myself, has been done from the pressure of complete dependency on my own action. I believe every man finds this the case in life, hard as it may seem to him. Necessity is the mother of invention and the father of success.

In the Kampf um Dasein let us join hearts and hands and brains for the re-establishment of our beloved profession.

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