Address. medicine. The German mind is content to ex- pend its energies upon detailed work, to pursue a to the farthest zealous AND THE subject possible boundary, THE GENERAL PRACTITIONER rather in the search for ultimate causes than in SPECIALIST.* the practical application of knowledge. But BY JOHN L. HILDRETH, M.D., OF CAMBRIDGE. whether from the extension of the German influ- Mr. President and Fellows of the Massachusetts ence or from other causes there has come about Medical The modern toward the existing state of things, with specialists for Society, tendency of the Moreover, with this subdivision and specialization is very strong. every organ body. extension of specialism, there has come to pass It is manifest in education, where the elective in which the selection of a marked change the position and possibilities system permits particular of the The relations of the a or individual general practitioner. studies to suit special training the extends far back into the preparatory two —the general practitioner and specialist caprice to each other and to the community furnish an whole — schools and reaches forward through the I of for the active work of life. interesting and, hope, not unprofitable subject period preparation of to a and discussion of It in The watchmaker no study, hasty inadequate appears industry. which I venture to ask consideration. makes a watch or the shoe- your longer complete And in the first let us look for a moment maker a shoe. Each is place, complete engaged upon at the which each class of some swift and deft machine which turns out advantages practitioners to be to enjoys, and the disadvantages under which he parts of the complete product fitted is other other hands. The student of labors. Neither path wholly strewn with roses. parts by Success may be won in either, and the rewards of science specializes. He no longer attempts a comprehensive understanding of the whole realm success are great ; but they come only as the fruit of but out his small of labor and sacrifice. knowledge, early picks The work of the is harder chosen bit of the field and devotes his life to an general practitioner than it was a He is much cultivation of it. The successful mer- to-day generation ago. assiduous less and he has less time to himself. chant no tries to direct all the details of independent, longer The of makes him more business. These are subdivided and multiplication telephones his intrusted, to his who find this to that confidential representative, that to this subject interruptions by patients, it so easy to call him or to ask head of a department. So through all domains by day by night, questions some necessary, some unnecessary of activity. — — that leave him no time which he can call This is nowhere more manifest than they tendency his own. He is on call at all and it is not in So are the times; the medical profession. great he wnich it has about that they surprising that, while appreciates the uses of changes brought the he sometimes it as a device are realized even the members telephone, regards imperfectly by Evil is a slave to the of the In for of the One. He peremptory profession. general preparation call of the and must be the there has been a remarkable instrument, constantly profession to answer as in cases no one can advance during the last forty years. The dif- ready it, many in the amount of work to answer it for him. The telephone, and that later ference required gradu- invention, the each of in its ate from the better medical schools now and forty automobile, which, is indeed and the character way, annihilates space and time, greatly affect years ago very great ; in another of the men the seems to me the general practitioner way. They entering profession available for a much and better fitted for the scientific increase competition by making stronger who for reason has become im- and successful of medicine now than patient, any practice the services of a from a dis- then. Then was unknown; medical patient, physician bacteriology tance. These new and the and human were inade- appliances constantly chemistry physiology necessities of office outfit and experience counted for every- enlarging supplies quately taught; add to the expenses of the general practi- thing with a doctor, and scientific attainments for greatly little. With this in tioner. Altogether, it would be fair to estimate very change preparation the increase in the expenses of the for the there has come a change regular practi- profession equally tioner the last thirty-five years at least marked in the of it. as I have during " practice Formerly, If he is to as his to it was that counted as the 25%. be, patients say, up said, experience prime he must attend medical read the in and that was in date," meetings, requirement a doctor, gained medical and visit the in the medical centers of our own journals treatises, hospitals large hospitals or a service of his and from and other countries. have hospital own, time to time must see what is done in his were then no those who being There specialists except in other countries. devoted themselves to the and to the ear. profession eye All these make the There was, it is true, a distinction things general practitioner's recognized life much more laborious than it was a between physicians and surgeons, but the innu- generation merable classes of that exist ago. The simple life of the community has also specialists to-day and a strenuous and were unknown and undreamed of. disappeared, very complex A of the subdivision of work has life has taken its place. The practitioner has to part present himself to these conditions. He must be come about, doubtless, through the adoption of adapt German methods of study and instruction in alert and constantly on the watch to see that no one does better work than he, and whilst he does * Delivered before The Massachusetts Medical Society, June 13, 1906. not advertise or solicit patients, he must make The Boston Medical and Surgical Journal as published by The New England Journal of Medicine. Downloaded from nejm.org by JOSH ROSENFELD on April 25, 2016. For personal use only. No other uses without permission. From the NEJM Archive. Copyright © 2010 Massachusetts Medical Society. himself desirable enough to insure his being Under existing conditions, the general practi- sought for. Very few general practitioners who tioner cannot be expected to do original work. have been away from schools and hospitals for Everything of that nature, everything that fifteen years and are thoroughly established have promotes the progress of medicine in a scientific a moment's time to themselves, from the time way, must be done by the specialist. But the that their vacation ends in the summer or fall general practitioner must be alert to follow all until it begins the next summer. From early new discoveries and processes and to avail him- morning to late at night they are in the harness; self of them. It is a natural consequence of the some one wants them, wants them in a hurry. changed conditions that young men entering the If they want a half day off for leisure, some very profession are drawn towards specialism rather sick patient prevents. If they plan for a day's than the general practice of medicine. My recreation in the country, it is more than likely observation is that general practitioners who that some patient or expected patient will detain have sons in the profession encourage them, not them. All these conditions are much changed to follow in their own footsteps, but to become from those of thirty or forty years ago. specialists. I do not recall a single instance where Another important change affects the lot of the reverse is true, and where a father who is a the general practitioner. The medical profession specialist has a son who is a general practitioner. has come to feel that everything that is brilliant, One of the older physicians of my acquaintance everything that makes an impression upon the once said to me that it took a man of iron consti- laity, must be something that can be seen or tution to follow general practice, and he had on that can be touched with the hands; in other that account led his son to adopt a special form of words, must be something of a surgical nature. surgery. The man who gives advice concerning a difficult One strong reason which impels men to become problem in medicine, who helps to complete a specialists is not avoidance of night work and the diagnosis when the symptoms are complicated other hardships of the general practitioner, but and an accurate diagnosis extremely difficult, the increasing demand of the people for specialists. does very little to impress the laity by comparison More and more it is coming to pass that any one with the man who performs a surgical operation. who has or fears that he has some organic trouble The conditions are wholly reversed from those asks his " Who is the best " " family physician, of the time of the barber surgeons when the specialist in this or that? " or goes to a specialist surgeon sat at the feet of the family physician. without asking. It is in response to this ten- Now the surgeon is to be pacified only by the dency that we find that those doctors who adver- homage and admiration of the general practi- tise extensively, and who, while they may legally tioner.