580 



SCIENCE 



[Vol. LV, No. 1431 



class distinction, for many assume that the 

 services of specialists are far beyond their 

 means, -when, as a matter of fact, such is not 

 usually the case. The charge that the medical 

 profession, as a whole, has rapidly become an 

 organized iinancial institution is as untrue as 

 it is unjust. Misapplied specialism is at least 

 one explanation for the recourse of many mis- 

 guided individuals to some one or other of the 

 commercial cults, which prey like parasites 

 upon their human victims. The greatest danger 

 of all to clinical medicine lies in the fact that 

 specialism carries with it the inherent danger 

 of narrowness and monotony, potential foes of 

 the faculty of concentration, the power of ob- 

 servation and decisive correlation. It tends 

 fundamentally to destroy those intimate rela- 

 tions between physician and patient that con- 

 stitute the very essence of the healing art. 

 Osier, in 1919, wrote: "The extraordinary de- 

 velopment of modern science may be her un- 

 doing. Specialism has fragmented the special- 

 ties themselves in a way that makes the outlook 

 hazardous. The workers lose all sense of pro- 

 portion in a maze of minutise." The profes- 

 sion and public, as a whole, appreciate the 

 great services rendered by specialists. They 

 are certainly indispensable. Specialism can 

 probably not be checked, but unless its abuses 

 are restrained a dark era in clinical medicine 

 will have to be faced. Sanity and extremes 

 never mix. 



(C) Changes in Medical Practice 

 The development of "group clinics" is the 

 most striking contemporary change in the prac- 

 tice of medicine and is a direct result of mod- 

 ern specialism. Group practice unquestionably 

 has many definite advantages, but it is unques- 

 tionably destined to failure unless it consist- 

 ently deals cooperatively and unselfishly with 

 the general practitioner. All arguments that 

 may be advanced in favor of group practice 

 are outweighed if this fundamental considera- 

 tion be neglected. This is but another way of 

 saying that group medicine can justify its ex- 

 istence only in so far as its superior facilities 

 for study and diagnosis can be directly trans- 

 ferred back to the patient through the medium 

 of his family physician. The difficulties and 

 dangers inherent in specialism become even 



more real in "diagnostic groups" unless there 

 is the highest type of analysis and integration 

 of the work done by the several specialists 

 practicing together. Such analytical power is 

 not possessed by many. It can be acquired 

 only through long clinical experience, active 

 clinical teaching and the opportunity to keep 

 in touch with the advances in those specialties 

 useful in clinical practice. It is rather hard to 

 believe that men who possess these qualifica- 

 tions of the "diagnostic integrator" will serve 

 the public and profession best by analyzing the 

 reports of specialists. Granted that the work 

 skillfully done is correctly analyzed and prop- 

 erly applied, failure none-the-less threatens 

 "group medicine" if it be forgotten that im- 

 personality in the practice of medicine inev- 

 itably foreshadows loss to the public. 



(D) Changes in Medical Education 

 That there is something wrong with medical 

 education almost every one will admit. Just 

 where the defect lies, what the reasons are, 

 and what constitutes the solution, remain some- 

 what obscure. Probably the most significant 

 change in contemporary medicine from an edu- 

 cational standpoint has been the introduction 

 of the so-called full-time system in the clinical 

 departments. It is advocated by those who 

 believe "that there exists, or can be created, 

 such a thing as a science of medicine, which 

 can best be fostered by giving it a place in 

 which it can grow unhampered by the restric- 

 tions of practice." They claim that a close 

 association between medical education and 

 practice is by no means essential, and seem to 

 resent the conception of clinical medicine as an 

 application of the science" to an art, or craft, 

 or vocation. In these university medical schools 

 with whole time clinical teaching, the number 

 of students is to be limited and the selection of 

 applicants would seem to favor most those of 

 research tendencies and scientific trend. "The 

 teachers should be carefully chosen young men 

 who have shown ability not only to teach but 

 also to aid in extending the boundaries of 

 medical knowledge." The plan, as outlined by 

 one author, whom I quote, "will not provide, 

 the student with the wide experience with dis- 

 ease in its various manifestations which would 

 make him an able practitioner. Modern devel- 



