Hobart Amory Hare
I am writing this paper because I am hopeful that it may direct attention to what is a crying fault in medical education to-day, remedy, the neglect of teaching students how to treat patients for the alleviation or cure of disease. I am hopeful that some good may come of it, because the Council on Pharmacy and Chemistry of the American Medical Association, for years past has been endeavoring to inform physicians regarding the use of proprietary products and to persuade them to prescribe drugs, proprietary or not, intelligently.
The work that the Council has done is, of course, praiseworthy in intent, and is good as far as it goes in one line, to wit, to improve medical practice among graduates; but the prime difficulty lies in the teaching of practical therapeutics to the under graduate and to the hospital intern. This embryo practitioner in almost every medical school has no training in pharmacy, little or no training in the use of the official names of drugs or of their doses, and no training whatever in the fact that doses of different sizes, although they be of one drug, may be useless, useful or harmful, or become so after some days. He, therefore, enters practice utterly at sea when he is called on to write a prescription.
I have known of eye drops to be ordered by the quart, oleoresins mixed with aqueous solutions, powerful alkaloids, such as strychnin, put in a mixture with potassium iodid, whereby nearly all the strychnin went into the last dose, and a host of other errors too numerous to mention.
I have seen a thousandth of a grain of arsenous oxid given three times day to an adult, and a grain of atropin put in each pill; and no druggist exists who, if diplomacy did not restrain him, could not humiliate almost every physician whose recipes come to his shop. Because the medical man knows nothing of the bulk of drugs or the most efficient vehicles, or excipients, he takes the easiest way out of his dilemma and orders products already prepared, which products are often the result of much experience and scientific pharmacy.
The remedy for all this is to have every student make in a pharmacy laboratory at least one representative of each class of preparations official in the Pharmacopoeia and the National Formulary. I believe that this is done in only one school of medicine in the United States.
The young graduate, having had no experience or teaching as to doses, naturally uses doses that some commercial laboratory names. He may have been taught “doses,” but he has no idea that small doses of digitalis may be useful in one case, whereas almost toxic doses may be absolutely essential in another, and so loses the patient that needed the large dose. He uses the compound mixture of licorice as a vehicle in a case of profuse bronchorrhoea or threatened pulmonary oedema, not knowing, or forgetting, that its most active ingredient is antimony, which is absolutely contraindicated.
When he becomes an intern in a hospital, he learns one thing of great importance, namely, that the chiefs who prescribe little and “let the patient get well” often obtain the best results; or if he is on a surgical service, the entire drug therapy may be in his hands, and the chief often boasts that he “knows nothing about drugs and dont want to.”
On the medical side in large hospitals he will find a hospital formulary from which mixtures are made up by the gallon with all sorts of drugs, and contradictions, with widely varying doses of the ingredients; but there is a standard dose of the whole mess whether it be for a young girl of 16 weighing 100 pounds or an old rounder weighing 200 pounds. Not only this, but these mixtures go by names which often do not mention the most active ingredient or, worse still, go by numbers, so that the order on the treatment card reads: “No. 23, dessertspoonful t.i.d.”
The fault does not stop with internship. Never having been taught practical therapeutics, the man steps into practice a fair mark for the loquacious traveling salesman, who places him in the vocative by being familiar with what he ought to know. Some years ago, telling a distinguished ex – President of the Association that a patient was getting acetphenetidin, I found he did not know it was phenacetin.
When he was told that the first term was the official one, he laughed and admitted that he had asked a student what he would use in a given case, and the reply was “phenol.” The clinician “long on pathology but short” on therapeutics then informed that astonished youth that “phenol was no doubt very good, but carbolic acid was better.”
The remedy for the state of affairs just described, is in teaching and experience when a student. This, is my experience, which is a fairly large one, is best accomplished by having the student, in his course, not only taught doses by rule of thumb, but also given the opportunity to prescribe for suppositive or actual cases, and to see the results of his order, both as the prescription itself and as to its effect on the patient.
Under the direction of an assistant professor the whole class may attend a therapeutic conference, or quiz, on the treatment of a given class of disease, and during the conferences several of the men who advise plans of treatment are called to blackboard to put in black and white what they have suggested. When they have finished, the instructor, who has continued his quiz in the meantime, criticizes the pharmacy, the doses, the form, the combinations, the therapeutics and the quantity in the whole prescription, as well as the Latin.
The number of occasions on which such criticisms lead to howls of delight at the discomfort of the man at the blackboard may be subversive of discipline, but all hands remember how John Jones wrote for nitrohydrochloric acid, iodid of potassium, tincture of gentian and tincture of iron in a quart of water, particularly if the mixture is prepared forthwith.
This large class teaching, is driven home by a junior teacher taking the class in sections and having it spend one or two hours a week for several weeks writing prescriptions, for suppositive cases, which are then criticized, and the writer asked to give his reasons for using each remedy.
The regular medical ward classes should emphasize therapeutics; and, in addition, clinical, not laboratory, pharmacology should be taught. This is done by demonstrating a case of auricular fibrillation both at the bedside and with the electrocardiograph, and then giving full doses of digitalis, a second demonstration revealing the effects. So, too, the mode of action of atropin in partial or complete heart block is demonstrated, and the effects in nitrates, in lowering pressure are taught, by seeing a patient to-day with high pressure and again at the next visit with a reduced pressure.
Any number of these therapeutic demonstrations can be made by the regular ward class teacher, and made still more useful if a demonstrator of clinical pharmacology who can use the polygraph and electrocardiograph, is given proper hours. By this means the student is taught how drugs act and how various doses act, entirely apart from the didactic lectures on therapeutics or the general therapeutic clinics given by the head of the department, who deals of necessity with principles and practice.
All this seems to obviously practical that the question arises, “Why is it not done?”
The answer is that there is not time. If there is not, why not? There is not time for two chief reasons. The first is that the student is taught too much of the special part of the specialities, many of which he will never attempt to practice; and unless he takes a postgraduate course after several years in general practice, he ought not to try to practice. At present the young graduate can talk learnedly of the difference between paralytic and concomitant squint or about the Barany test, but is stumped when told to write a recipe for diarrhoea.
The second reason is that the laboratory of pharmacology has drowned practical therapeutics, and has done it so effectively that in most schools literally no bedside therapeutics as a separate branch is taught, the original chair of therapeutics being filled by a laboratory pharmacologist who in some instances is not even a doctor of medicine, or if he has the degree of M.D. has never practiced a day in his life or even been an intern in a hospital.
When he attempts to tell students bedside facts, it is as if he were an astronomer trying to teach a sailor how to navigate a ship, without ever having been to sea. As he lacks bedside experience, he teaches, for example, that the best treatment of fever is a combination of the cold bath and coal tar antipyretics, when every one who practices knows that this is a great error. It is enough to bring the grey hairs of Dr.Simon Baruch, the great apostle of hydrotherapy, in sorrow to the grave, and if carried out will bring many patients there.
Valuable time which should be spent at the bedside learning how to use drugs is employed in having students carry out pharmacologic technique in a course of six or eight weeks or their equivalent. It is safe to say that not one man in a thousand who takes this course becomes a pharmacologist or learns to be an efficient technician. What the student needs is not to do the experiments himself but so see them done by a man so well trained that results are produced that make a demonstration that really demonstrates the fact to be remembered.
I can see no more reason for making a group of students, designed to be practitioners, make bungling experiments with a kronecker – Bowditch heart apparatus than I can for their performing amputations and visceral operations on dogs or cats with the idea that they will become good surgeons; indeed, there is less reason. One cannot make a man who has no music in his soul a violinist in a six weeks course, and probably it is safe to say that the majority of excellent physicians have not the qualities which produce original contributions to medical knowledge.
My point is not that there should not be teachers of pharmacology. On the contrary, there should be, because it is only by the efforts of these men that the scientific or investigative side of therapeutics can be advanced and the errors of empiricism corrected. Their existence develops those who have the talent, initiative, the power of proper deduction and the love of investigation, and their methods of thought and mode of study are examples of the highest type of medical man; but in their enthusiasm they should not forget that 999 of their pupils want to know how to make the sick well and do not want to know by personal experiments on dogs the effect, for example, of cutting the animals sympathetic or the action of cocain on the eye. If this is to be taught, let the pharmacologist make the experiment and demonstrate the result.
It may be said that I do not know where of I speak; but I do, for I was once a pharmacologist myself. In the eighties I worked in laboratory pharmacology, and taught it, too, as a somewhat long list of titles in the Index Catalogue will show. I am not an iconoclast, and no one rejoices more than I do that the only pharmacologic laboratory in the United States in 1886 has been followed by two score of such laboratories from which a wealth of wonderful work has originated; but it is post – graduate work. I am pleading that hours now used otherwise may be employed to teach not only the theory, but also the practice of therapeutics.
When this is done, the work of the Council on Pharmacy and Chemistry will be helped to its completion; for when the practitioner knows how to prescribe, he will not tolerate the commercial concern that poses as his teacher. At present an attempt is made to make pharmacologists out of men who are going to practice medicine. A real pharmacologist is a highly educated man in physiology and chemistry, an investigator, a discoverer, and by rights a leader in the higher realms of therapeutics – one who should teach medical students how drugs can be studied and should be studied in the laboratory, and to determine fundamental facts about remedies.
But to try to train the general run of students, who will never have a laboratory, to be pharmacologists without first teaching elementary practical therapeutics is somewhat like a great opera singer trying to make every one a great singer, or as if one should attempt to make his infant son sing before he tried to teach him to walk. The use of instruments of precision necessary for the study of drugs, if taught at all, should be at the bedside. I repeat what I said above:
The lack of training as to what to do, what not to do, and when to do, as to remedies, is one of the weak spots in medicine to-day. I firmly believe that if the present generation of students is properly taught practical therapeutics, the chief labor of the Council on Pharmacy and Chemistry will be an accomplished fact, for the right way will be the easiest way. Let us first make good physicians and from these may be sifted out those who can and want to become laboratory pharmacologists. J.A.M.A.