Medical School and House Staff Days

After my work with Curt Richter, starting even before I entered medical school, I decided to pursue a career in clinical research in an academic institution. After courses in anatomy, pathology, and microbiology, I had my first contact with patients in a course called "Physical Diagnosis," or officially, "Introduction to Clinical Medicine." For the first time we were able to speak to and examine living patients. We defined diagnosis as the identification of a disease by investigation of its signs and symptoms. Today I refer to these and other data about the patient as "manifestations" of disease. We took courses in clinical diagnosis, laboratory diagnosis, physical diagnosis, anatomical diagnosis, bacteriological diagnosis, x-ray diagnosis, and electrocardiographic diagnosis. All of these courses showed us how to characterize a disease. We used the term "identify," rather than "characterize" a disease, because we were then in an "ontological" period of medicine where diseases were thought of as "things" to be detected and, if possible, eliminated.

Bedside teaching and the "clinical pathological conference (CPC)" were the two principal teaching methods. The most admired physicians were those who could predict during the patient's life what would be found at autopsy. This was called "the case method of teaching medicine," a term introduced at Harvard by the distinguished physiologist, Walter B. Cannon. In those days, after daily "rounds" of patients with the "attending physician," we would go to the autopsy room to see what was found in the autopsy of patients who, before death, had been on the internal medicine wards which were divided into "white males (Osler 6), colored males (Osler 2), white women (Osler 3), and colored women (Osler 4)". Private patients were on Osler 5.

As second year students, we attended the CPCs every Wednesday at noon, and after we heard the discussion by Professor Harvey of the clinical and laboratory findings of a patient who had died and been autopsied, we awaited with bated breath, the report of the autopsy findings by Dr. Arnold Rich, Chairman of the Pathology Department. Professor Harvey based his diagnosis on the clinical findings prior to death. Because his diagnosis was usually correct, Professor Harvey was universally admired and respected by the medical students. He displayed great intelligence, had enormous experience and revealed a wry sense of humor. The Clinical Pathological Conferences were viewed as contests between Drs. Harvey and Rich, and were a high point of the grueling weeks during our second year.

Dr. Rich was the first Jew to become chairman of a department at Johns Hopkins Medical School. His daughter, Adrienne, one of the most renowned poets in the world, challenged her father during her first year at Harvard University: "Why haven't you told me that I am Jewish? Why do you never talk about being a Jew?" He answered: "You know that I have never denied that I am a Jew. But it's not important to me. I am a scientist . . . I have no use for organized religion. I choose to live in a world of many kinds of people. There are Jews I admire and others whom I despise. I am a person, not simply a Jew."

Adrienne was told that in the late 1940s, anti-Semitism was not in peoples' consciousness in Baltimore; racism made much more of an impression. Her associates would tell her: "I would almost have to think that blacks went to a different heaven than whites, because the bodies were kept in a separate morgue (this was true at Hopkins), and some white persons did not even want blood transfusions from black donors." (From Rereading America, by Gary Colombo et al., 1992, Library of Congress 90-71613.)

The autopsy no longer plays the important role that it played in medical education in my medical school days. There is an unwarranted belief that we nearly always know why a patient died even without an autopsy. With the invention and development of three-dimensional imaging procedures, CT, MRI, SPECT, and PET, "bedside" skills have also diminished. In 1998, it was reported that in 25 to 40% of the cases in which an autopsy is performed, it reveals an undiagnosed cause of disease. Yet the percentage of patients who were autopsied has fallen from 50% in the early days to less than 10% by 1991.

During my last two years of medical school and during house staff training, considerable attention was paid to mastering the art of "taking a medical history." In the course on "physical diagnosis," we learned how to listen to the patient's heart and lungs with a stethoscope, palpate the abdomen, look at the "eye grounds" with an ophthalmoscope, and then examine the blood and urine. Excellence at observation, palpation and auscultation were the coin of the realm. We were taught that the two most effective computers in making the diagnosis were the brains of the patient and examining physician. Doctor Phil Tumulty, a master at history taking and physical diagnosis, was one of our role models. He would often spend an hour in speaking to and examining each patient. He also taught us interpersonal and ethical qualities, as well as clinical skills. I remember his telling a patient that "we have a test that will not tell us what is wrong with you, but will tell us whether or not you are seriously ill." I waited with baited breadth to learn what this test was. After an appropriate pause, he continued: "The test is called the eryth-rocyte sedimentation rate." I had never before heard this test praised so highly.

Three times a week, we would "present" selected patients to Professor Harvey, Chairman of the Department of Medicine and the youngest physician (34 years old) ever to occupy the Chairmanship of a major Department of Medicine in a medical school in the United States ups to that time. He had carried out research even while serving with the Johns Hopkins Unit in the south Pacific during World War II. His picture appeared on the cover of Time magazine. His philosophy as Chairman was: "At Hopkins, we choose good people, and leave them alone." On rounds of the patient wards, by describing the illness of a specific patient in all of its details, he was able to cover all aspects of a specific disease for his residents and medical students.

Once, as Chief Resident on the Osler Medical Service, I was walking down a hospital corridor with Professor Harvey, and I woman stopped us, saying: "You won't remember me, Dr. Harvey, but I was nearly dead, and none of the doctors knew what was wrong with me until you came around with some medical students, and told them what was wrong with me. I began to get better right away." Professor Harvey asked: "What did I tell them was wrong with you?" She responded: "You told them I was moribund."

In our graduating class in 1952, there were 75 students. Two of the four women in the class subsequently went on to become the first women Chairmen of the Departments of Anatomy (Betty Hay) and Pediatrics (Mel Avery) at Harvard Medical School. We didn't use the term "Chairperson" in those days. One of the other women, Dr. Pat Mclntyre, graduated first in our class in medical school, and subsequently became an extremely valuable colleague in nuclear medicine at Hopkins.

We were always conscious of the patient as a person, but were also scientifically oriented. Once, an attending physician told the intern on medical rounds that a specific patient with heart failure should be considered as a person, not just a patient. The intern responded: "I just want to know whether the patient is taking too much or not enough digitalis." Another anecdote concerned a young intern who was speaking soothing words at the bedside of a patient who was gasping for breath. The patient wrote something on a piece of paper as he lay breathless in his oxygen tent. After the patient died, the intern read what was written on the paper. The patient had written: "You are standing on my oxygen tube."

Today there is diminishing interest in the role of physical examination. The time spent with a specific patient has also decreased for economic reasons. The failure of insurance companies to appreciate the enormous value of personal contact with the patient has also played a role. We can only hope that the interest in autopsies will be revived. All will benefit, patients as well as doctors.

What we call progress is not always viewed as such by everyone. An example of the "old days" took place during my third year of medical school in the Obstetrics Quarter. Background music, called "Muzak," was played for the first time in the labor room. After the delivery, all of us gathered around the new mother's bed, and asked, expectantly: "What did you think of the music?" Her response was: "It didn't bother me none."

In July 1953, I started my internship in internal medicine at Hopkins. Each intern cared for 14 patients at a time, supervised by an Assistant Resident, and the Chief Resident who was responsible for all the patients on the entire medical service, which consisted of four wards, and rooms for private patients. A Senior Attending Physician visited the wards with the Chief Resident three mornings a week. The Chief Resident also visited each ward every evening after supper. Three mornings a week Professor Harvey joined the Senior Attending Physician, spending two hours on each ward in sequence. We all wore "whites"—the familiar short coat and trousers with a stethoscope in the side pocket of the white coat. Today it is customary to drape the stethoscope around the neck, probably because of the large numbers of women house officers.

We were responsible for the care of all of our patients (14 per intern; 28 per assistant resident; hundreds for the Chief Resident) all of the time. We had no scheduled time off. Today, house officers take care of many more patients and have scheduled time off. Efforts have been made to limit the working week to less than 80 hours per week, to prevent fatigue from interfering with patient care.

I carried out a survey, asking the interns, assistant residents, and chief resident independently who had the ultimate responsibility for the patients. Each of the three groups responded: "Me." During an assignment of house staff in the Emergency Room, one of their most important decisions was whether or not the patient should be admitted to the hospital. An assistant resident served as the "Admitting Officer." When the patients came into the Emergency Department, clerks would write down the patient's chief com plaint, many of which began with the statement: "Patient's friend states . . . ," for example: "Patient's friend states that something is dripping from his penis." My internship, followed by two years as an Assistant Resident in internal medicine at Hopkins, was the greatest learning experience of my life. I learned how to recognize when a person was suffering from a serious disease, whether it was an infection, diabetic acidosis, heart failure, renal failure, or stroke. We were responsible for each patient from the time of admission until their discharge. This led to a great affection and strong sense of responsibility for each patient as an individual. One did not feel that "when 5 o'clock comes around, the patient will be someone else's responsibility."

In addition to the nightly visits to each ward by the Chief Resident in Medicine, the Chief Residents in Surgery also came to the medical wards to see if there were any patients who required surgery. An example of the extensive experience that these residents obtained on the surgical service at Hopkins is the fact that, Dr. Jerry Kay, during his year of Surgical Residency, corrected coarctations of the aorta in six patients. On one Christmas Day, Dr. Frank Spencer, Chief Resident in Surgery, carried out major surgery on four of my patients when I was an Assistant Resident.

Everyone on the house staff was in the same boat. There was great esprit de corps and group social activities for our wives and children. The house staff were in the Hospital from 14 to 16 hours per day. There was no apparent difference in lifestyle, regardless of economic status of the individual members of the house staff, because everyone was living in the same type of housing in the immediate vicinity of the hospital. The wife of Professor Harvey, Elizabeth Harvey, together with other wives of the Professors, established a nursery school in the living area for the children of the house staff. One of the medical student's wives, Jane Anne Norton, led in the establishment of a "Staff and Student Wives Association." Without financial backing, they organized a formal dance at the Belvedere Hotel, the finest in the city. Fortunately, the event was sold out, even oversold, because of the strong support of faculty wives, led by Elizabeth Harvey. Senior faculty, house staff, and students all had a wonderful time.

In those days, we had "no scheduled time off." We were expected to take care of our 14 patients from the time they were admitted until they were discharged (or died). We could "sign out" to co-workers if there was no acute problem to be solved with "our patients." This continuous responsibility of the same persons—intern, assistant resident and resident—around the clock was of great benefit to the patients.

We had two children during the three years when we lived at 1900 McElderry Street, across the street from the Women's Clinic of Hopkins Hospital. Nick, the older child, went to the Nursery School supported by the Women's Board of Hopkins. Gentleness, love, tolerance for everyone and the desire to get ahead were the principal values of the house staff and their families.

After two years as an assistant resident at Hopkins, I joined the National Institutes of Health in Bethesda, Maryland, as a Clinical Associate in the Laboratory of Kidney and Electrolyte Metabolism of the National Heart Institute. After two years at the NIH, I spent a year at Hammersmith Hospital in London.

After we moved from living near Hopkins Hospital to 3410 Guilford Terrace, during vacations we took automobile trips to the west coast and Canada in a Volkswagen Microbus. On these camping trips, which covered over seven thousand miles, we took along our weekly helper and best friend, Nellie Moody. Anne and I slept in one tent; Nellie and

Figure 21 Wagner family during the year at Hammersmith in 1957.

the children in a larger tent. Our children today tell us that these were the best vacations they ever had. They remember them in great detail.

Ten years after I joined the Hopkins faculty, we purchased 17 acres of land on the Chester River, and built a "Deck" house, where we went every weekend. The "house in the country" provided a focal point keeping all of us close together. Two of our children were married there. The "house in the country" was also a focal point for lab parties and informal meetings of leaders in nuclear medicine. The requirements for certification by the American Board of Nuclear Medicine were written at the dining room table of this house in 1970.

During my years as an Assistant Resident, because of my interest in infectious diseases, I established weekly infectious disease rounds, rotating among Hopkins, the University of Maryland Hospital, and Baltimore City Hospitals. I was very eager to learn from Dr. Ted Woodward, Chairman of the Department of Medicine at the University of Maryland. He was famous for his work in infectious diseases, including typhoid fever, Q fever, and dengue. He was Chief Medical Officer during the Fifth Army's movement up the boot of Italy during World War II, in the army led by General Mark Clark. Subsequently, I participated in several collaborative studies with people in Dr. Woodward's department at the University of Maryland, focusing on infectious diseases at the Maryland House of Correction, a maximum-security prison, where prisoners would volunteer in studies to test the effectiveness of vaccines. Such studies would never be permitted today.

During my assistant residency, I carried out a study indicating that hydrocortisone therapy did not have a beneficial effect in the penicillin treatment of pneumococcal pneumonia, a common disease at that time. Between October 1, 1954, and May 31, 1955,

125 patients were admitted with subsequently proven pneumococcal pneumonia to Johns Hopkins and Baltimore City Hospitals. We commented on the dramatic effect that penicillin had in the treatment of this formerly often fatal disease. In George W. Gray's book, The Advancing Front of Medicine, he wrote: "Come, physician, put my hand in poulticee, Give me a drug in which some healing volt is, Come, antibiotics, sulfanilamide!" "Up, Doctor Jekyll, down with Mr. Hyde."

One of my classmates, Wilbur Mattison, whose first assignment on the Osler House Staff at Hopkins was in the Emergency Room, told me: "I never felt so alone in a crowd." Every patient was first asked for his or her "chief complaint," which was then recorded by a receptionist. In some cases, an accompanying friend would provide this information. Once when the chief complaint was: "Patient says she hasn't seen anything for two months," the receptionist referred the patient mistakenly to the ophthalmology department.

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