The Medicine of the Lateral Pass

THE MEDICINE OF THE LATERAL PASS STEWART WOLF* [When] some hhtorian traces the development of the profession . . . he will passjudgement—yes, severejudgement on the absence of the sense of responsibility . . . in medkal education.—William Osler [1] William Osier's signal contribution to medical education was the hospital residency in which, while learning by doing, young physicians can grow through graduated stages ofclinical responsibility. In a thoughtful and well-documented essay published recently in this journal, Alan Astrow traces the beginnings of such patient-centered clinical training to France before and during the Revolution [2]. Building on an idea proposed in 1778 by two prominent French physicians, Claude-François Duchanoy and Jean-Baptiste Junelin, Philippe Pinel, in 1893 proposed a pattern for clinical teaching that combined an emphasis on 24-hour availability to patients, personalized, humane care, and research [3]. Pinel's design was institutionalized in 1802 during the empire by Napoleon 's minister of interior, Jean Antoine Chaptal, and was actually used in teaching a selected group of the brightest and most promising students in Paris by Pierre Jean George Cabanis, professor of medicine at the Ecole de Santé, a post-Revolutionary replacement for the thenabolished university medical schools. Cabanis hoped that a hospitaltrained physician would have "the inquisitive attitude of an anthropologist as well as a zoologist" and would become "consoler of the suffering and the weak, indifferent to fame and wealth, subservient only to his conscience and patriotic duty" [4]. Astrow inferred that the need for precise observation of patients to further the science of medicine would require that the teaching physicians control the management of their hospitalization, an arrangement he viewed as having encroached on the Adapted from a forthcoming book, The Doctors and Their Teachers: A Fifty Year Perspective on Medical Education and Medical Practice. *Totts Gap Medical Research Laboratories, RD #1, Box 1120G, Bangor, Pennsylvania 18013.© 1992 by The University of Chicago. All rights reserved. 003 1 -5982/92/3502-0758$0 1 .00 Perspectives in Biology andMedicine, 35, 2 ¦ Winter 1992 | 189 independence and freedom of choice of the patients. He further speculated that, as physicians in charge focused more and more on the heuristic value of a patient's physical disturbances for teaching and research, they may have become less attentive to the needs of the individual, thereby gradually corrupting medical education to the point of "losing its soul." It would not be difficult to find hospitalized patients today who would quickly agree with Astrow's formulation, but whether erosion of the patients' freedom of choice or, alternatively, whether diffusion of responsibility in the care of patients has contributed most to corrupting medical education is not immediately evident. For at least a century after the Revolution, members of the French medical establishment engaged in a dispute about whether the emphasis in medical education should be "practical" or "academic." In the United States, with the strong support of the American Medical Association, founded in 1847, the exponents of the practical held sway until the opening of the Johns Hopkins Medical School in 1893. The Hopkins gave a powerful boost to the scientific emphasis in medical education and viewed the hospital as a teaching and, to some extent, clinical research laboratory. At the same time, however, there is little evidence that humanitarian concerns in teaching and in the care of hospitalized patients were in any sense bypassed or downgraded. William Osier described his residency program as providing "an education that begins with the patient, continues with the patient and ends . . . with the patient, using books and lectures as tools, as a means to an end" [5]. Osier's method depended heavily on having a relatively small number of students in each class [6]. "With a small class I have been satisfied with the results," wrote Osier, "but the plan would be difficult to carry out with a large body of students." I was exposed to the Oslerian approach to clinical teaching as a medical student at Johns Hopkins from 1934 to 1938. Although William Osier himself had left more than 20 years before to become Regius Professor of Medicine at Oxford, most of the still active senior faculty in the Department of Medicine had...