The Specialty Unit within a Teaching Hospital

THE SPECIALTY UNIT WITHIN A TEACHING HOSPITAL JOHN B. STANBURY* Those who try, however hopelessly, to keep in step with the march of medical science, discover that the wedge of concept and information that can be grasped narrows with each encounter with thejournals. The refuge, if there is one, is specialization, but this is not necessarily bad: narrowing one's field permits depth of understanding not available to the brave generalist. Within the framework of the teaching hospital specialization is implicit in the specialty unit. Departments of medicine and surgery have become composed of many groups sharply focused on a single organ system and its disorders. Further fragmentation is often necessary. For example, an endocrine specialty unit may find that it best attends the advance of information and its patient responsibilities if it disaggregates into subunits devoted to diabetes, thyroid disease, neuroendocrinology, and bone and calcium metabolism. Oncology begs for subspecialization. There has surely been a historical inevitability in the growth ofspecialization . Without it, research would be primitive or applied, teaching would be superficial, and patients would be denied the full range of services available through the resources and skills developed by those who sharpen their years of experience in narrow disciplines. This essay describes the origin and evolution of a specialty unit in a large teaching hospital, the Thyroid Unit at the Massachusetts General Hospital (MGH). Whether it was the first on the American scene is a matter of little consequence—perhaps it was—but its life has mirrored the life of the American teaching hospital and the American scene during this century. It, like others, is a product of its times, with its own hesitant steps, errors, strengths, failings, and contributions to the life of the hospital, its school, and research. The author thanks Drs. Gilbert Daniels and Robert Kroc for their careful reading of the manuscript and their many valuable suggestions. ?Address: 43 Circuit Road, Chestnut Hill, Massachusetts 02167.© 1993 by The University of Chicago. All rights reserved. 003 1 -5982/93/3603-08 1 3$ 1 .00 442 John B. Stanbury ¦ The Specialty Unit The History of the MGH Thyroid Unit The origin of the Thyroid Unit can perhaps most accurately be dated to a 1914 meeting of the American Society for Clinical Investigation in Atlantic City, when the young J. H. Means heard Eugene Du Bois describe calorimetry and measurement of the metabolic rate. After completion of his internship, Means had worked briefly with F. G. Benedict at the Carnegie Nutrition Laboratory at Harvard on the use of nitrous oxide in the study of pulmonary function, and had gone abroad to work with August Krogh in Copenhagen, where he studied pulmonary function, and had visited briefly the laboratory of Joseph Barcroft in Cambridge. It seemed that these measurements of respiratory function might be brought to the bedside. Means had returned to the Massachusetts General Hospital at the end of 1913, was given a small laboratory by David Edsall, the chief of the medical service, and told, "now do some research." He assembled the apparatus for measuring pulmonary function, but it was the paper given by Du Bois that set him on the path of measuring the basal metabolic rate (BMR) in disease states. It was soon apparent that these measurements were most strikingly applicable to patients with thyrotoxicosis, in whom they served both as diagnostic indicator and as guide to clinical course. Means set up shop, spent a few weeks at Belview Hospital with Du Bois, and within a remarkably short time, he and his associate L. H. Newberg were measuring the BMR of patients from the hospital wards. Means and Newberg were shortly joined by J. C. Aub. One might pause to reflect on the significance of the introduction of measurements of the BMR. Prior to that time the clinician measured the pulse, the respiratory rate, the blood pressure, and was beginning to apply certain elementary measures of renal function, but little else. The BMR introduced the era of quantitative clinical medicine. Since then, the hospital laboratory has come in large degree to dictate diagnosis and often to direct the course of therapy. Reactionary physicians, who in earlier days labeled those who relied on...