Learning To Be A Doctor (then) By Morton C. Creditor’47 Morton Creditor'47, today Morton Creditor'47, then During my many years as clinician, academician, and administrator I harbored the smug conviction that I had unique skill in clinical evaluation, a skill that became increasingly rare among the generations of physicians who followed me out of medical school. As years passed, I realized that I enjoyed special privilege in acquiring that skill, because I went to P&S in the 1940s. At that time the senior clinician-scientists of the Department of Medicine took part in the bedside instruction of students and house staff on a daily basis. Most of our indoctrination into the art and science of patient evaluation was provided by full professors of medicine who did not merely spout words to be impressed by, but did their best to convey the thought processes responsible for their erudition. Each put a somewhat different spin on their message. The blend provided the framework for superior physicianship. The indoctrination began during the last half of the second year with the course in physical diagnosis. The transition from classroom to clinic was symbolized by the exchange of our suit jackets or, more commonly, uniform tunic for the short white coat. (Whether in military uniform, all male students wore a coat and tie from the very first day of medical school.) The first weeks of the course were devoted entirely to history taking and it was not until instruction began in physical diagnosis that we placed the ultimate symbol of our transition, the stethoscope, into the side pocket, always certain that the tubing was casually, but not ostentatiously, displayed. (It is amusing that recently published research reveals that most young medical students and house officers cannot interpret what comes out of the stethoscope, but all now wrap them around their collars in full display.) Dana Atchley There was enormous emphasis on history taking. The subject was taught by Dana Atchley, a distinguished full professor of medicine who, with Robert Loeb, elucidated the pathophysiology of Addison’s disease, no mean accomplishment in times pre-dating the invention of the flame photometer. Atchley insisted the history was the single most important part of the evaluation of a patient. I continue to believe as he taught, that the history alone will lead to a correct diagnosis 85 percent of the time. That has been documented by published studies. Those whose experience is otherwise never learned how to elicit a proper history. Atchley hammered into us the fact that taking a history was not merely the recitation of a series of questions. He emphasized the importance of listening to the patient tell the story in his or her own words and then following up by probing for information and clues that would unravel the unique diagnostic mystery represented in each patient. He taught us that the proper elicitation of a good history was dependant upon understanding pathophysiology: that each question should be based upon the logical pursuit of clues in support or non-support of developing hypotheses. He emphasized the importance of formulating and reformulating diagnostic hypotheses beginning with hearing the chief complaint. He hammered away at the presentation of non-pertinent as well as pertinent aspects of the present illness as evidence of the fact that we did indeed formulate diagnostic hypotheses and we did understand the pathophysiological basis of those presumptive hypotheses; our questions were not just random expressions of a fishing expedition. He taught me to be impatient with the student who describes a patient such as a 30-year-old woman with symptoms compatible with angina but withholds information about factors that influence the presumption such as family history and the presence of hypertension and diabetes, protesting that he will get there in the review of systems. That tells me he does not know the immediate importance of those questions in hypothesis testing and, therefore, the importance of the history. Atchley was a prissy sort of fellow whose emphasis on detail was not universally appreciated. Professor David Seegal’s technique was to convert the diagnostic process into the analysis of a detective story. He challenged us to weigh each newly revealed fact in terms of its relationship to the developing pathophysiological explanation for a patient’s problem. As I look back I realize he was teaching us the process of decision analysis without making use of written algorithmic pathways. From initial presentation of the chief complaint, Seegal challenged us to engage in logical, step-wise speculation on the cause of the problem. He challenged our recommendations for further examination or testing unless the evidence could support the recommendation. Had enough medical students paid enough attention to enough David Seegals there would now be far fewer regulators looking over the shoulders of doctors, second guessing lousy decisions. The fourth-year students who were assigned to the Columbia Research Service at Goldwater Memorial Hospital had the privilege of tutelage by Dr. Alexander B. Gutman. I later enjoyed that privilege for a much longer period during my chief residency on his service. Gutman was a noted scientist who first worked out the pattern and distribution of the plasma proteins. He elucidated the pathophysiology and biochemistry of gout and discovered the value of uricosuric agents, the introduction of which revolutionized the management of the disease. Dickinson Richards Gutman introduced us to quantitative thinking without use of formal biostatistics. Each week the students were assigned an essay in the Cornell Conferences on Therapy which he helped us to analyze on the basis of the data. The one I remember best was the paper by Harry Gold titled “The Dose of a Drug,” a step-by-step rationalization of dosing procedure. I believe that of those students who spent time at Goldwater a disproportionate number went on to successful research careers, including one who was awarded a Nobel Prize. My greatest personal pride is based upon the fact that Dickinson W. Richards, who shared the Nobel Prize for the introduction of cardiac catheterization and modern cardiopulmonary physiology, was my mentor as a medical student and as an intern and assistant resident on the First (Columbia) Division at Bellevue Hospital. Dick Richards was the consummate clinical scientist, humanist, and physician. He personally displayed the attributes of each in teaching us to apply the methods of science to the care of sick people. He helped us to learn how to utilize logic and inductive and deductive reasoning while compassionately holding the hand of the sick patient who served as the text for discussion. I never heard him harshly contradict the most outrageous statement by even the lowliest medical student. A dissenting comment would usually be prefaced by “That may be possible, but I can’t remember experiencing or reading about what you describe,” followed by the correct explanation. This tall, thin “Lincolnesque” man, more than any other single person, was my role model for the ideal physician. Robert Loeb Robert Loeb, who became chairman of the department during my tenure at P&S and its affiliated institutions, is usually the first called to mind when reminiscing about this era. To be sure, this exciting, unforgettable, charismatic genius did more than anyone to convey the excitement of medicine and its practice as an expression of scientific inquiry and discovery. He was the icing that called attention to the cake and added its most delectable taste, but the ingredients necessary for complete nourishment were embodied in his colleagues. Together they launched a generation of the best doctors in this country. Morton C. Creditor, M.D., is a 1947 graduate of P&S. A professor emeritus of medicine at the University of Kansas School of Medicine, he lives in Mission Hills, Kan.

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