When I turn my mind to the environment in which I was educated as a physician, to my teachers and my colleagues, a certain radiance surrounds this circle of people. What kind of people were they? What kind of person did I try to become? The general attitude to which I refer is difficult to define. We did not analyze it, we lived it; I only became fully aware of it when I was confronted with the very different conduct of "modern" doctors.
Years ago I coined the (only slightly ironic) term "Grand Seigneur Attitude" to describe the cast of mind, the manners, and the rules of conduct that have distinguished clinicians for a century and a half.
For many of us in Lodz, Poland, my teacher Dr. Jerzy Muszkatenblit-Jakubowski (1887-1967) was the embodiment of a great physician. Born to a middle class Jewish family, in his youth he got involved in leftist politics, knew tsarist exile to the far North, escaped, studied medicine in Paris, served as a military doctor with the Russian Army in World War I, lived through the revolutionary years in Russia, and returned to Poland to become one of Warsaw's most successful practitioners and later the popular and revered teacher of clinical medicine in Lodz. Trained in excellent hospitals, disciple of Huchard, Vaquez, and Widal, at home in three great cultures, having a native's command of the three languages, a friend of Polish, French, and Russian writers, theatre people, painters, and poets, he had broad interests and saw medicine in proper perspective. He realized how helpless we ultimately were, yet he knew, too, what a difference we often were able to make; and he had the calm certainty that ours was a unique art, one that made exceptionally high demands on a person's learning, diligence, judgment, emotional balance, and moral strength. All his diverse interests notwithstanding, Jakubowski had the gift, and the firm habit, of focusing his attention entirely on a patient. While he was listening to a patient's history, examining the patient, pondering a decision, he wouldn't let an irrelevant thought enter his head.
Jakubowski's diagnostic insights which impressed us so much were the workings of his quickly associating mind that drew on a solid medical learning, vast knowledge of life, and intuitive understanding of fellow human beings.
He knew very well that money did not matter, but good name and being faithful to the rules of the art did; and he lived up to his convictions. He calmly dismissed all authorities' attempts to meddle with our work, was smilingly skeptical before high dignitaries, and trustful and invariably attentive to all who depended on him, whether patients, students, or subordinates. Many of us tried to be like him.
Jakubowski was a very special person, but he was a representative of the entire class of traditionally educated clinicians. Many prominent doctors whom I had the privilege to know were "Grands Seigneurs," each of them in his own way.
The traditional medical education, both the medical school, and in particular, the subsequent hospital training in one of the main specialties, instilled in the physicians the belief in their high calling, a conviction that the work they were doing was important and unique. The physicians' lofty status, the power they wielded, and the extreme vulnerability of patients justified especially high ethical standards, set for doctors high above those required from other members of the society.
There always has been a great diversity of individuals in the medical profession, but we should not fail to acknowledge the existence of a typical personality representative of traditional clinicians, one that served as a model, was generally appreciated, and facilitated promotion to the positions of senior consultants and teachers of medicine. This model personality of a traditional clinician was particularly harmonious. With my children and then grandchildren leaving home and entering the world, I often thought of people who would lead them further and influence their destinies; and I always have wished that those teachers, sport coaches, military commanders, civilian bosses might deal with my youngsters the way a traditional clinician would.
The Clinician and the Powers That Be. The attitude toward health care administration, hospital managers, and all kinds of regulations, and every officialdom, prevailing among doctors in Eastern and Central Europe at the time when I worked there, and to some extent in France, is worth mentioning. We had the unyielding certainty that whatever an authority could conceive must belong to a much lower order of phenomena than medicine. It goes without saying that each of us believed--and I must avow I still believe--that our work made much more sense, was more noble and more important than the activities of some prime minister of a country. While the view itself is debatable, we certainly were not isolated in our opinion. In Poland, every opinion poll in the 1950'S, 60'S, and up to the 90's placed the doctor, among all professions, highest in public esteem.
In Moscow, in 1952, when everybody sagged under the oppression, I was delighted to see that doctors preserved a good deal of independence. I don't mean the ultimate situations in which a dissident's life would be at stake, but those more frequent circumstances under which a person may, or may not, show civil courage. Dr. Dmitriy Pletniov, great Russian cardiologist of the 1920's and 30'S, was convicted in 1938 on fabricated charges and, as far as I know, was never released. The usual Soviet way was to erase the unfortunate's name from all publications and from memory. However, at the Moscow hospital where I stayed for two months, the Medical Academy's Institute of Therapeutics, Pletniov was openly revered, quoting Pletniov's diagnosis settled the discussion of a case, and Pletniov's textbook of heart disease stood on a place of honor in the department's library.
At the meeting of the Moscow Internists' Society, with Dr. Lukomskiy presiding, a man tried to introduce some ideological rubbish into the proceedings. "What is your name and where do you work?" somebody asked harshly. The debater, a Dr. Ivanov, had to disclose that he worked at "Special Hospital #3," an institution run by the NKVD, (94) whereupon the gathering resumed the discussion Ivanov had interrupted.
The Doctor's Well-Deserved Fee. I was raised in the belief that we should be decently paid for our work, but we were also willing, and had the obligation, to treat sick people without pay. We accepted a fee not just as what was due, but as a token of acknowledgment. If the patient did not pay, I did not want his money. And we made it a point of honor to treat a number of patients without pay. In Lodz my list of non-paying patients was patterned after that of Dr. Jakubowski, and was, therefore quite ample: it included doctors, veterinarians, university students, teachers, artists, actors, writers, journalists, and the close families and parents of the above. The situation with poor people was rather delicate: if a person of very modest means appeared as a patient at my private office, my refusal to accept payment would offend him. I therefore accepted a small fee. We jokingly called the non-paying patients "praxis aurea," "the golden practice." The funny thing about it was that the larger it grew the better off we were. Apparently the non-paying patients were sending in the paying ones.
Whatever money a doctor had was to be used for the good life, art, travel, and education of the children. Investing money in commercial enterprise or the stock market was unthinkable. But these injunctions have been forgotten. I remember the day in the 1980'S when the Hong Kong stock exchange (or was it the commodities market?) collapsed. With awe and pity I watched two of my colleagues in Den Bosch, good people and good doctors, struck by the disaster, trying to guess it's possible causes, and devising means of damage control. A doctor should never allow this kind of garbage to clutter his brains.
Dissolution of the Doctors' Exclusive Club? From Den Bosch I once mailed a letter to a gynecologist in another town, asking for information about a patient of mine, a lady of 35 who had a skin blood vessels' disorder of unknown origin. Two years before that she had undergone gynecological surgery but did not know why or what had been done. If there had been a malignancy and/or the ovaries had been removed, the knowledge of these facts might contribute to the understanding of the patient's present complaint.
The gynecologist sent me a stunning answer; it read: "What do you need this for?" He didn't simply assume that whatever I asked must have been for the sole purpose of helping the patient. No, he thought, apparently judging me by himself, that I might pursue some other goals. Gone was the traditional doctors' conviction that we all were pure and honest men acting solely for the patients' good.
The traditional doctors' esprit de corps often bordered on elitism. If you entered at lunch time any European hospital's cafeteria in the 1950'S or early 60'S, you could see the doctors sitting at tables with other doctors. Now they preferably sit with nurses. It is not that I don't like the company of nurses whose work I greatly appreciate and many of whom I like and admire, but we were irresistibly attracted by other doctors' company, vividly interested in what other doctors had to say, how they saw things, how they reacted. As my good acquaintance at Hopital Lariboisiere in Paris, Dr. Sikorav, crisply put it: "Ce qui est interessant dans un hopital ce sont les autres medecins," "other doctors, that's what is interesting in a hospital." The shared experience of lifelong learning, the participation in the same chain of intellectually challenging, highly emotional events that is the daily practice of medicine, used to create a closeness, a spiritual bond that we cherished so much.
The traditional doctors' esprit de corps, like the Latin of late-medieval scholars, caused national borders to lose importance. Ockham was welcome at Sorbonne, Copernicus in Bologna, and in my time a doctor from whatever country, especially a hospital doctor of your own specialty, used to be welcomed as a brother. Not much was needed to recognize somebody of your own crowd; sometimes a single word or gesture. In Lodz, we immediately opened our hearts to doctors from Prague or from Kharkov when we saw how they examined a patient. At Lariboisiere, I met Dr. Sikorav at the bedside of a female patient who fired all sorts of atrial arrhythmias. Sikorav saw that with my hand I was reaching out to the patient's neck--and immediately understood I was his brother: my first thought--and his--was to check whether she had a nodular goiter. I was at once accepted at Lariboisiere when together with Dr. Slama we saw a patient who suddenly deteriorated on the third day of his myocardial infarction. We listened to the patient's heart: there was a loud blowing murmur. "Sa cloison!" I said; meaning that the partition between the heart's two ventricles ruptured. Slama thought the same. Quick catheterization confirmed the diagnosis, and the patient had surgery to patch the hole. In Rotterdam, Dr. Arntzenius took me to the intensive care at Dijkzigt Hospital to show me a special case. There was a huge elevation of the ST-segment on the patient's ECG, and I said "Oh, Prinzmetal" because such electrocardiogram is typical of "variant angina," chest pain due to a spasm of the coronary artery, as described by Dr. Myron Prinzmetal. Arntzenius looked at me and invited me to work at his department of cardiology at Leiden University.
There are signs indicating that the medical esprit de corps is still alive, but there are also observations showing that this spirit becomes alien to a growing number of doctors. The doctors' confidence in each other is fading together with their self-image. Their interest in each other also disappears, it seems, under the influence of the idea that the new scientific medicine is a sum of established objective truths. If so, there cannot be anything important or interesting to an individual doctor's views.…