What is a Profession? (Earle Scarlett)

We in the medical profession are at times apt to be confused and have our attention distracted by the temper and spectacle of the contemporary scene. There is plenty of talk about medical economics, bus less about professional aspects of our craft. To be sure, we cannot be indifferent to changing economic conditions or to the technical needs of the community which we serve. But we must also look to our own household and keep it in order. This requires constant alertness and something more than an occasional session of pious self-examination.

The of the matter is that any profession worthy of the name must forever be strengthening and re-creating its traditions. A profession is a sensitive organic growing thing, not a static order. And it is particularly important that we should remember this at the present time. The two great wars have disinherited and confused a multitude of sensitive minds, with the result that they have tended to lose their sense of the past and of the future. They are acquiring an experience of life not easily related to the great achievements of time past and to the ancestral wisdom of man. In consequence, they are with our roots.

Man is a time-binding animal and lives in three dimensions of time as well as of space. To maintain this point of vantage, we must constantly recover and build perspective. This neglected, a condition of things results in which perspective is lost and man comes to exist for the immediate present only. When this happens, it can have disastrous effects in a profession, reducing it to a time-serving trade, and producing in the individual a sense of futility and disillusion.

There is an old expression, “Seven Pillars of Wisdom.” With this concept and phrase in mind, I am bold enough to suggest seven pillars of a profession as I conceive them to be-in terms of the individual.

The first: technical skill and craftmanship, renewed by continuing education. That is a basic essential.

The second: a sense, of social responsibility with an interest in community life. This is the best corrective to a narrow concern with professional matters. Too exclusive a concern, whether with one’s

specialty or with the world of book learning, makes for mediocrity and tameness. Tameness because such persons have never been seared by the facts as they exist in the world outside their little province.

The third: a knowledge of history. This is essential for the cultivated mind and provides perspective. It is a corrective for the squirrel-like accumulation of facts which passes for education in these days.

The fourth: a knowledge of literature and the arts. This acts as a catalyst; here are to be found the world of values and the repository of what has been said and done by the best minds. Such knowledge provides a philosophy of excellence, and insight that comes from sensitiveness. It is well to remember, looking back no further than the years of this century, that the barbarians do not destroy science and technology. They destroy the vessels of liberal culture – the roots of the past-libraries, the press, religion, music, art, the belief in the essential dignity of man.

The fifth pillar: personal integrity. On this quality rests the concept of duty, a sense of responsibility. And on such things depend the dignity and the honour of a profession.

The sixth: a faith that there is some meaning and value in life. This belief must stand high in the credo of any physician worthy of the name. It is the great bulwark in a world in which, in Thoreau’s words, “The mass of men lead lives of quiet desperation.” And we cannot live on the capital of idealism built up by past generations.

The seventh and last: the grace of humility. The constant reflection, in the searching words of John Bradford, “There but for the grace of God, go I.” In this attitude is to be found one of the finest flowers of the human spirit. It is the solvent of intolerance and selfishness and the other deadly sins.

These, I suggest, are some of the qualities that make for the equilibrium of mind which is the mark of the professional man.Their expression in action and thought are what make a profession great.

These pillars are created by the faculties of medicine in our universities, and are strengthened by our professional association. Here knowledge and education are integrated to permit effective speech and action, and to meet the challenges of a world in ferment which require technical knowledge as well as a deep sense of values and relevance. These are the agencies charged with developing and maintaining a liberal and dynamic philosophy of medicine and of teaching and practising in the light of it. In so doing they will be countering the all-pervading secularism of our time, the narrowing influence of specialization, the inroads of creeping mediocrity, the tendency to forget the claims of the individual as a man, and the absorption in techniques oblivious to the wisdom of the past which alone makes man’s present intelligible and tolerable.

In the gruelling days of the First Great War, when men. gathered for a bit of respite behind the lines, there was a toast which was drunk after dinner-“Till the barrage lifts!” Now, half a century later, when the awful barrage of war has lifted for the moment, I have in my own mind replaced that toast with another. It is, if you will, a metaphorical toast, based upon some words which I came across years ago. It is charged with the memory of the ordeal of a generation in 1914-1918; it embraces the whole world which is now our parish; it is vibrant with hope. It goes in this fashion.

“I drink to my country-bounded on the North by the Aurora Borealis, on the South by the procession of the equinoxes, on the East by primeval chaos, and on the West by the day of Judgement!”

Dogmas, Doctrines, and Dubious Practices

Medicine is made up of three main intermingling streams of thought-a practical art, an applied science, and an experimental science. As a practical art, medicine has not altered significantly since the days of Hippocrates. As an applied science, treatment is now more and more approaching satisfactory standards. As an experimental science, medicine has grown tremendously, and this feature, more than anything else, has been responsible for the great advances of the last fifty years which have transformed the whole medical world.

In spite of all this, because we are human, medicine has always had its changing fashions. We can leave aside the quackery and the cults which since time immemorial have been barnacles on the main body of medicine-homeopathy, osteopathy, Christian Science, chiropractic, and scores of faith-healing cults. Such things as these have always existed, and will continue to do so, for man is infinitely credulous and craves for magic and authority.

But within the actual world of medicine itself, there has been a long succession of dominant ideas, schools of thought, various methods of treatment, what we may call fads and fancies. If we are honest with ourselves, we can now see, in the perspective of time, that many of these ideas and practices were drawn from superstition, ignorance, and stupidly continued ritual. Indeed, it is clearly apparent that, more often than we care to admit, we were deceiving ourselves. Time has exposed our fallacies and the emptiness of so many traditional doctrines.

In a spirit of stern self-examination and humility, let us take a look at some of these myths and delusions. Or, to use the words of the poetic rhetorical question: Where are the customs and doctrines of yester year? Most have quietly disappeared; some died hard after a good run, others enjoyed favour only a short while. To prepare such a list is a salutary exercise, a monumental record of human frailty. The entries on the charge sheet which follow are those that occur to the writer; each physician could prepare a similar docket; Most of these practices have been current at some time in the lifetime of the older generation of doctors in practice today. It is only fair to point out that the worst features of superstitious practice and speculative philosophy in medicine occurred before the present century. Here is a contemporary list:

polypharmacy and elaborate prescriptions

routine purgation

the “cold tub” treatment for high temperature in typhoid fever

the focal infection theory

intestinal intoxication

forcing fluids to eliminate toxins

colectomy of Arbuthnot Lane

“flushing the kidneys” with draughts of Imperial drink

the roughage cult

securing a “free flow of bile” with magnesium sulphate

gall-bladder drainage

the vitamin fad

numberless dietary fads and restrictions with highly doubtful physiologic bases, but beloved by patients for whom their “special diet” provides food for mutual gossip

the widespread use of the sacred Fowler position

hot packs

the thick cotton-wool pneumonia jacket

the incredible immobilization of older patients

the gospel of infant rearing and child training which appearedto change about every twenty years

the severe restrictions on patients exhibiting a heart murmur but with no symptoms

the rigid distinction between “organic” and “junctional”

the widespread indiscriminate use of the diagnostic label “anxiety

state” or “anxiety neurosis,” the successor to the fashionable

term “neurasthenia”

the vogue of barbiturates and tranquillizers.

It is a sad catalogue, and in a small way parallels the enormities of world history in the past six decades. In many instances the rationale was dubious and the practical value negligible; in others a good thing was carried to excess. It may be that not many of these procedures were lethal practices, but certainly they caused the patient needless discomfort. This is not to say that many traditional procedures, customs and therapeutic agents are without value. Many of our methods in medicine are empirical. The criterion governing use should be: does the procedure, however attractive in theory or successful in guinea-pigs, really work with patients?

As we review the foregoing list of ideas and practices that have now been consigned to limbo, it is possible to see how we were the victims of human credulity, and of the over-enthusiastic application of laboratory research to the human patient. We have had too great a reverence for non-clinical research and have neglected bedside observation.

This human tendency to follow tradition and to blindly refuse to correct error is neatly contained in an old word that we would do well to resurrect and use more commonly. The word is a curious one and bears a strange look to modern eyes – mumpsimus. But it is a respectable word and has a most interesting history. It may be defined as “a traditional custom obstinately adhered to however unreasonable it may be.”

In time the word came to be applied in a scholastic textual sense, signifying a recorded reading that, although obviously incorrect, is retained by stupid and obstinate writers. Now when I think of the scores of words and statements that have been copied from one medical text to its successors purely on the strength of authority and usage, I am sure that medicine contains a vast amount of mumpsimus. And by the same token it would seem that a good deal of this mumpsimus attitude has seeped through into our everyday practice.

However that may be, the practical question arises of how best to meet this situation and keep myth and error down to a minimum. This is a matter that concerns the individual physician. Every physician should cultivate (a) a healthy scepticism, (b) a good conscience, (c) a sense of proportion. It is our duty as doctors to keep our practice of medicine in constant repair, to examine periodically what we are doing, to retain what is demonstrably yielding good results and consign what is obvious mumpsimus to the scrap-heap. Two examples occur to me. The first-to examine carefully the concepts which psychology and psychiatry are bringing into the arena of practice. The second-to develop a critical awareness of the current idea of stress put forward by Dr. Hans Selye. Failing to do this, the precise meaning and value of these insights will become perverted.

In some ways we are a sceptical and questioning generation. We have need to be. In a time when new knowledge is pouring into medicine, bewildering ideas based on laboratory research are being put forward, boundaries are being extended, and far-reaching practices are being advocated, we have need to raise the warning cry rom time to time – the words of Oliver Cromwell when faced by grave issues: “My brethren, by the bowels of Christ I beseech you, bethink you that you may be mistaken.”

And there is a further chastening reflection. Doubtless today, if we could be detached enough, we could see a similar group of instances of gross medical mythology. And we can be sure of one thing – many of our current ideas and procedures will be regarded as completely wrong a generation or two from now.

I hope that the name of Sir Clifford Allbutt is not forgotten by the younger generation of medical men. He was one of the medical giants of my youth. He was born in 1836 in the North Country of England, was best known for his work on cardiovascular disease, as well as being a great classicist and historian (his book, Greek Medicine in Rome is a masterpiece of its kind). He was latterly Professor of

Medicine at Cambridge. Allbutt, who was a friend of George Eliot, was the original of that author’s character, Lydgate, the doctor and one of the central characters in her great novel, Middlemarch. He also introduced the clinical thermometer as we know it today. He died in 1925.

In the following passage, Allbutt is speaking in his most characteristic vein. The words come from an address which he delivered at King’s College, London, on October 5, 1905. They are the words of an illustrious master of medicine:

If all professions have their safeguards they have also their temptations, and our own is no exception. Laymen, even those most friendly to us, tell us of our testiness, of our jealousies, of an angularity in our relations with our brethren, especially with those who live near us and ought to be our colleagues, but whom we are too apt to call our “opponents,” and so regard them as such. This, to say the least of it, is bad policy; it gives our enemies a handle against us, and grieves even our friends, who discern our faults but not our temptations. That members of other professions are free from this mutual distrust comes of the different conditions of their engagements. Unfortunately the game of medicine is played with the cards under the table. Whether a clergyman be a good preacher or pastor, whether a barrister conducts a case well or ill, whether a tradesman sells good soap or bad, is not only a matter of which the public can form some fair judgement, but also these transactions are, so to speak, in market overt. In the intimacies of medical counsels, on the” other hand, who is there to note the significant glance, the shrug, the hardly expressed innuendo of our brethren of whom it might be said, as it was said of Roderick Lopez – Queen Elizabeth’s physician – that he is none of the learnedest or expertest physicians, but one that maketh a great account of himself.” Thus we work not in the light of public opinion but in the secrecy of the chamber; and perhaps the best of us are apt at times to forget the delicacies and sincerities which under these conditions are essential to harmony and honour.

But the more careful we make ourselves of these loyalties, the less we shall suspect others; the more candid and sincere we become with our brethren, the less they will suspect us. Most of such offences are due not to malevolence but to want of imagination or good breeding. There is none more prone, when alarmed by illness, to scatter medical etiquette to the winds than the doctor himself; he will run about between half-a-dozen physicians in a week, keeping his own counsel. Can he not put himself in the patient’s place? Life is dear, even to a layman. In any case, let us always remember that as we have many benefits, so we must be vigilant and forbearing in the perils to which the temper of the physician is exposed.

The Idea of a Profession

What is a profession? The best definition I know is that of one of the great American educators, Professor Roscoe Pound, Dean Emeritus of the Harvard Law School. In the course of an address entitled “Freedom Versus Equality.” later published in the American Bar Association Journal, he gave the following characterization:

By a profession we mean a group of men pursuing a common calling as a learned art and as a public service-nonetheless a public service because it may incidentally be a means of livelihood. Gaining a livelihood is not a professional consideration. The spirit of a profession, the spirit of public service, curbs the urges of that incident. An organized profession does not seek to advance the money-making feature of professional activity. It seeks rather to make as effective as possible its primary character “of a public service… What a member of a profession invents or discovers as to the art of his profession is not his property. It is at the service of the public. A tradition of duty of the physician to the patient, to the medical profession, and to the public; a tradition of the duty of the lawyer to the client, to the profession, to the court, and to the public; authoritatively declared in codes of professional ethics, taught by precept and example, and made effective by an organized profession, makes for effective service to the public such as could not be had from individual practitioners not bred to the tradition and motivated as in a trade primarily if not solely by quest of pecuniary gain.

It is noteworthy that in the course of the address Pound stressed the effect of the welfare state upon the professions. He stated flatly that the idea of a profession is incompatible with performance of its function or exercise of its learned art by or under the supervision of a government bureau. He remarked further that if the professional idea is supplanted by the trade union idea when all come to think of themselves as employees, this will ultimately lead to absorption of the professions into the service (welfare) state.

A profession, then, is a professionally conscious class, united by allegiance to certain ideals and by common agreement on certain practices and disciplines. It had its first anticipation in the ancient world at Athens and Alexandria. It emerged as an autonomous institution in the guilds of the Middle Ages. Later it was transformed and intellectualized by the advances of scholarship and natural science. Still later it acquired an international character; so that while the profession was carried on within respective nations, its source of life became world-wide, and its loyalties transcended sovereign states. At the same time, because the most important function of the profession concerned the supervision of professional competence and practice, it became linked with the universities and other specialized institutions of learning.

We may take a brief look at the status and function of the profession in modern society.

The monopolies that have come to be granted to certain professions are based on the idea that the man on the street should readily be able to distinguish the qualified from the unqualified; the systems of registration and licensure are designed to establish a standard of competence. Such exercise of regulatory powers requires a high sense of responsibility and an intimate knowledge of the nature of the profession in question, and can only be carried out by members of the profession.

There is another aspect of paramount importance which is rarely discussed in medical circles. The idea that the professional classes are the repositories of particular virtues upon which liberal civilization rests firmly was held by most of the political thinkers of the last century and has continued down to the present. The claim rested upon the following elements: (1) the belief that a strong professional middle class is a barrier against state tyranny; (2) the idea that the traditional professions have mastered the art of combining personal independence with public service based on an accepted corporate discipline; (3) the assertion that the professions are trained according to principles and traditions less affected by the idols of the market-place; and (4) the assumption that the professional classes have developed a way of life in society which honours exceptional ability and attaches high value to tolerance. These are some of the distinctive characteristics of the professions which have given them for decades a large measure of public esteem.

While they still enjoy some of this favour, there is no doubt that it has in recent years declined to an alarming degree. The political, social, and economic revolutions of the last fifty years have hit the professions hard. The effects of this attitude are bound to be serious. The professional conventions which we have just cited are those upon which society has depended for centuries. Their disintegration at the hands of the scarcely literate pushing public and the barbarians and philistines would not only destroy the professions as we know them today but would deal a death blow to the whole of society. These are not the thoughts of a few discontented alarmists. They are serious considerations which should concern every professional man and society at large if the professions are to continue their historic role in preserving a civilized world.

The causes of this decline are extremely complex. But many of the most perceptive thinkers maintain that it is, in large part, the result of the trend toward an increasing specialization of functions in the ordering of society. The professional classes have been swollen by a large number of auxiliary workers in special fields; the professional ranks, becoming more and more specialized, tend to lack a broad outlook; the government has moved in to take over many activities. The consequence is increasing difficulty for the professions to maintain even the minimum of freedom in their separate spheres necessary to integrity and health.

In the face of this dilemma, intensified by so many of the junior professions adopting trade union methods and outlook, there is a growing feeling among political thinkers that it is high time that the professions were given some measure of protection: first, because society depends on the work they do and on the habits and conventions which have so clearly provided the soil in which society has flourished; and second, because the preservation of their historic role is essential for the professions to carry on efficiently with their specialized work. It is becoming clear that the total disintegration of the professional classes in a proletarian wave would be disastrous for Western society, not only because they have been the recruiting ground for thought and action, but because they have played, as we have said, such a large part in setting the tone of a liberal civilized society.

The physician’s role is being changed by explosive and rapid social and environmental forces. Such issues as population pressures, wide-spread pollution, and the whole changing hierarchy of human values, are confronting us; and these demand medical knowledge and skills placed at the service of governmental and international agencies working in society. At the same time, the forces of prepayment medical plans, specialism, and the growth of hospital centres are altering our methods and, interstitially, our status. Broadly speaking, there has been the change from a deeply personalized profession retaining some vestiges of priesthood to a rapidly developing symbiosis of art and science, with science tending to overshadow art.

I admit that “the great tradition” of medicine in many respects speaks irrelevantly to our living problems, but there is a steadying counsel in such history nonetheless: a faith in the reasonableness of the universe, and a living in accordance with what one believes to be one’s reasonable place in it. This dissipates the sense of futility in one’s experience and replaces expediency as a virtue with a proper feeling of personal responsibility.

In this iconoclastic age, medicine has probably felt the crunch more than any of the other professions. Much of this criticism and of medical apologetics make very gritty reading. The sociologists, psychologists, and “gifted” amateurs of all shades of opinion have got into the act, and a swarm of commentators leap from the wings to take their turns on the revolving stage.

Without going into the details of the indictment, we must remember that the current medical scene is a confused one, and is in a state of flux. Life runs full but turgid. Admittedly some of the criticism is justified, particularly when there seems to be an increasing number of five-day-week doctors, when physicians refuse to have their sleep disturbed, and when arrogant specialism is too much the order of the day.

Then, too, there are too many philistines in our own ranks, men sadly guilty of la trahison des clercs: exalting the practical at the expense of the ideal, and selling the ancient pass of medicine for material advantage. As an old mediciner, I have wandered about the medical scene and have overheard such talk as this: “All this rhetoric about the essential nobility of the medical profession is a load of old rubbish”; “the Hippocratic Oath is for the birds”; “medical standards are downright hypocrisy”; “my chief aim in practice is to make money.” By the staff of Asclepius, this sort of thing will just not do! It is the harvest of too much preoccupation with economic matters and technology which has destroyed the humanistic heartbeat.

Now I may be a simple soul and be mistaking the prejudices and tastes of age for the eternal verities. But somehow I have got it into my head that all human activities, whether medical or otherwise, are projects whereby the individual with any integrity, sometimes consciously, more often unwittingly, points beyond himself and his immediate aims and interests toward a set of wider meanings and values.

There is one charge against the physician that may be mentioned briefly: that the doctor is too much the despot, and arbitrarily rides over the sensibilities and fears of the patient. I recall that Alan Gregg resolves this dictatorship charge in a most realistic and interesting way. He points out that, operating in an atmosphere of crisis, situations must be met firmly and authority asserted over partly informed laymen. It is not such despotism, he maintains, that matters, for circumstances usually temper it with benevolence, but the fact that such an attitude may degenerate into a kind of “professional provincialism.” “And such provincialism,” he goes on, “is apt to breed some of the deadly sins of medicine – intolerance, incredulity, indifference, ineptitude in public relations, and intermittent claudication of the mind.”

But I do not want to labour these matters too much. I rather fancy that the average hard-driven practitioner adopts an attitude of weary resignation to all such strictures and problems. For the conscientious physician, life does not afford enough leisure in which he may indulge in the luxury of being unhappy. Sometimes when he is in the full flood of activity, and is certain that his vascular and nervous systems are just about at their last stretch, the doctor finds at best only a wry consolation in recalling that medicine is a “noble vocation” and one of “the learned professions.”

But on other occasions, he may reflect on at least two significant and deeply rewarding consolations. The first: that the real stature and character of the medical profession of all nations was manifested, for all the world to see, in the wars of this century. Its members came out of these infernos pretty well. As a British medical officer wrote, they did not send up prayers for their side that must have embarrassed the angels; they did not create destruction. They went through the ugly business pulling their comrades out of danger, tending the wounded and sick without distinction between friend and enemy. They showed a spirit that may yet persuade the angry Fates to spare the world the fate of the Cities of the Plain.

And the second: that in the last analysis our one defence as a profession may be that we may claim that altruism, a rare quality, is an integral part of our tradition and practice. This may tip the scale slightly in our favour. I say this with no sense of self-righteousness, but as a matter of historical fact, however eroded this quality may have become in a competitive arena.

What can we in the medical profession do about all this?

The answer turns upon the sources of strength and prestige of a profession, no matter what its nature. A profession cannot force the community into accepting it at its own, or at an even higher, valuation. Our history refutes such an idea. As Vannevar Bush puts it, “A true profession exists only as the people allow it to maintain its prerogatives by reason of confidence in its integrity and belief in its general beneficence.”

In this connection, I should like to quote some sterling words which Sir John Charles wrote a decade and a half ago:

Whence does the prestige of a profession spring? How is it nurtured and how fostered?

It is a creature of almost invisible growth; but certain things may help its development. The existence of a curriculum vitae which is in accord with the progress of medicine, and not a sanctified odor of ancient rituals and obsolete practices. The knowedge that this system is organized and supervised to a reasonable extent, but free enough to afford scope for experiment both in methods and ideas. The possession of an ethic, a decorum, a standard of conduct and manners. An acceptance of the Hippocratic axiom-never intentionally to do harm or injury to any patient or person. An understanding of suffering and the compassion which should minister to it. A readiness to share in the duties and burdens which the State lays upon its members. A cognizance of the fact that the willing horse is given the larger share of the load. A decent modesty in voicing the claims of the profession for recognition. A proper reward for the labourer in respect of his services.

And finally …an acknowledgement of the fact that, just as man is born not unto himself alone, so in these days the craft of medicine is only one of the crafts concerned in the “healing business.” And because these crafts look to medicine for leadership, there should be a willingness to assume that responsibility.

In the light of such considerations, medicine has a continuing duty to look to its walls, its practices, and its ideals. We do not wish to see Medicine and Science like Samson, eyeless in Gaza, at the mill with slaves grinding the Philistine corn.

Some of the practical imperatives which may be followed are as follows:

We must not confuse economic considerations with the integrity, efficiency, and responsibility of our members.

Organized medicine’s role is to foster the skills and dedication of the profession, at the same time fighting for the necessary conditions for medicine’s optimal functioning, avoiding an overriding concern for class and individual self-respect. We should be talking not so much about free enterprise and personal relations as about the rights and duties that belong to a profession.

We should encourage more criticism in our own ranks on the scientific, medical practice, and humanistic levels.

Our medical schools have the duty to secure members of faculty who are dedicated to teaching and who will be exemplars of the best in the physician.

Over and above all, there must be continuing vigilance against the materialism and dehumanization tendencies that are infecting our ranks. An eroded profession will end up as a complete State service, make no mistake about that. We must assert and act upon our aims and our ideals in spite of the sneers of those both within and outside of the profession. This does not mean that we must guard the Ark of the Covenant in a bigoted and irrational spirit. Just as the universities are at the moment concerned with their realignment to society, so the profession must learn a new and more flexible citizenship. We can still defend our prerogatives while agreeing on terms which accept State agencies as a necessary complement to individual effort and practice. We must meet government and society on new terms. The alternative is to be swept away in the onrush of “the new morality,” abandoning the old ideals, hardening into a cynical materialism, and joining in the mad pursuit of “the bitch-goddess, success.” The profession of medicine can work out a modus operandi with social change. There is the strongest possible case for the republic of medicine to resist being pushed to the edge of disintegration, as is happening in many of the areas of the arts and the humanities.

The future of a profession depends upon the dynamism and excellence of those who practise it. To be content with a general air of well-seasoned mediocrity or to refuse to budge from the rigid

and traditional customs of the past without regard for other circumstances, is both sterile and, in the long run, fatal.

As Herbert Spencer once told us, there is no alchemy by which we can get golden conduct out of leaden instincts. But if ideals are of gold, there is an alchemy that will transmute our external activities, so that our contribution will be precious and durable.

If we in the medical profession are to answer the challenge of our time successfully, we must somehow manage to combine the new economy and the old morality. This poses a conflict of principles and a dilemma which, I admit, I cannot resolve at the moment. But, at the same time, I am convinced that our duty is clear. It involves at least two things. First, we must express what we feel is

necessary to the integrity of the profession, and not what we are told by the planning authorities of the bureaucratic State. No one knows better what medicine means and involves than physicians themselves. It is a disastrous departure from that knowledge for medicine to be parasitic for its ideas and ideals on the State, business, or society at large. Second, we must impose a discipline on ourselves, rater than accepting one from without. This is what I may call the physician’s imperative: the assertion of the standard of medicine by example, moral force, and stern measures of our own organizations.

What are the fundamental thins that must guide us in discharging this duty? They are simple, absolute, and compulsive. They cannot be tailored to suit any time or any individual’s convenience. They may be stated in different terms, but to one physician at least they are the following: respect for man, personal integrity, the virtue of work, the dignity of our profession, deep interest in the craft as a high adventure and an imaginative art – all crowned by Osler’s more intimate prescribed qualities, the art of detachment, the virtue of method, the quality of thoroughness, and the grace of humility. These are the things which have given our calling its strength and which have made it one of the activities of the human spirit which has brought man out of the original darkness.

Lord Horder once said: “Successful Medicine is understanding touched with sympathy.” And so it is that the real Medicine stands for the things of the spirit; it shares this mission with religion, It acts on the assumption that the individual is important, and that in the eye of eternity, all are one and the same. It believes in consideration and in doing its best for all, ”even unto the least of these.” It knows that naked we came into this world and naked we shall go out of it. It is kept humble and free from self-seeking by the memory of birth and the expectation of death, and by the knowledge of the fundamental loneliness of man on this earth. Medicine one of the forces which has served to separate man from the brute. We must continue to practise this Medicine and respect it through the darkness and uncertainties of today.

Discussion Questions:

1) To what extent does our current medical education provide the teaching necessary to develop the seven pillars introduced above? What about the “ability to cultivate a healthy scepticism, a good conscience, and a sense of proportion?” This author is obviously well read in philosophy and history and considers these key in the critical thinking he demands of us – how, given all the demands of learning basic competence and medical knowledge – do we maintain the skills and, perhaps more importantly, space for criticism in our profession?

2) The author speaks frequently of a tremendous sense of duty to society, not only to provide a service but to be leaders in civil and liberal thinking, to keep tyranny at bay, as it were (this position brings with it a fair amount of entitlement and arrogance it must be said.) To what extent do you feel it is our duty to be political and, given how our profession and its social role have changed, are we equipped to speak with the authority he entrusts?

3) Attempts at self-reflexion run throughout this piece, at moments more successful then others, how do we keep from “mistaking the prejudices and tastes of age for the eternal verities”? What tools, times, places, activities etc. do you use to take stock and reflect on your practices and beliefs?

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