Medicine

A REPORT OF TWO VISITS TO THE MEDICAL CLINIC OF PROF. THOMAS MCCRAE AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL IN OCTOBER, 1914

BY E. J. G. BEARDSLEY, M.D.
Philadelphia

Dr. Thomas McCrae, born at Guelph, Ontario, 1870; A.B., University of Toronto, 1891; M.B., University of Toronto, 1895; M.D., University of Toronto, 1903; M.R.C.P. (London), 1901; F.R.C.P. (London), 1907.

PROFESSOR MCCRAE was formerly associate professor of medicine and clinical therapeutics at the Johns Hopkins Medical School. He is now professor of medicine at the Jefferson Medical College and is attending physician to the Jefferson and Pennsylvania Hospitals. A visitor to the clinic of Dr. Thomas McCrae is at once impressed that he is in the presence of a successful and popular teacher. The amphitheatre benches are well filled with senior and junior students before the clinic hour arrives, and there are few late comers. The entrance to the arena is occupied by a number of visiting physicians and by assistants and house officers from the medical as well as from other departments of the hospital. Better attention could scarcely be given a lecturer, and the reporter noted no restlessness among the students, nor were there any departures, even from the upper rows of the benches, until the classes were dismissed.

That over three hundred undergraduate students should attend a medical clinic on a sultry Indian summer afternoon, in a building none too well ventilated, indicates that they fully realize and appreciate the value of practical clinical instruction by a clinician who well deserves the honorable title of teacher.

The reason for Dr. McCrae's deserved popularity as a teacher and clinician is well understood after a visit to his clinic. He has a pleasing personality, an attractive manner, and is a forceful, authoritative speaker, without appearing in the least dogmatic. That he enjoys

teaching no one will doubt who has seen him preside at a clinic or ward class. His attitude toward his students reveals not only a real friendliness for them, but a very real interest in their progress. He treats each student with the kindly consideration due a younger and less experienced colleague, and there is in his manner an entire absence of inferred superiority upon his part. It seems a noteworthy feature of this great teaching clinic that no self-aggrandizement is countenanced. It is evident that Dr. McCrae is much too busy inculcating the principles of diagnosis and treatment to devote his time at the clinic to the advertisement of his own skill or knowledge.

A visitor cannot but be impressed with the thought that it is a great advantage for any medical school to have the head of such a department as medicine devoting half his time to supervising the work of the department and teaching. Just what this means to the student body of such an institution is best understood by those medical men who were students during the days when justly popular and busy clinicians gave what time they felt they could afford from their private work to deliver lectures and give clinics, and left the important work of practical instruction to assistants.

With the head of the department giving half his time to research, supervision, and teaching, a notable change has occurred in the teaching methods employed. The younger teachers follow with enthusiasm a leader whose ambition is to make the medical course more systematic, more practical, and more interesting.

Dr. McCrae's attitude toward his associates in the medical department could not but increase their loyalty toward him. The apparent pleasure with which he advances the interests of his associates is refreshing to witness. If one of his assistants is interested in a particular line of work, not only does Dr. McCrae take personal interest in the work, but he makes it possible that the assistant be given an opportunity at the clinic or lecture of presenting a résumé of the work and its results before the various classes. His associates are assigned important series of courses of instruction, and are made to feel that their work for the college is as important and as much appreciated as is his own work. Conferences as to methods of work in which each associate is given the opportunity of expressing his views are held at intervals. In the practical work in the wards each teacher holding a ward class is requested to point out any deficiencies of the various

students, so that these men may be warned as to their low grades in time to correct their methods of work early in the year. It is evident that Dr. McCrae believes thoroughly in team work in the education of medical students, and his efforts are constantly employed in building up a more efficient teaching organization.

Another feature of this teaching clinic that attracts immediate and favorable attention is the consideration shown and the thoughtfulness exercised in dealing with the patients. Not only is their physical comfort safeguarded, but their mental comfort is provided for as well. So often in teaching clinics the consent of the ward patient to being shown at the clinic is taken for granted or is demanded, while at the Jefferson Hospital the patients' wishes are considered, and the matter of appearing at the public clinic or being made use of in the ward class teaching is discussed with and decided by them.

Every consideration is shown the patient, and the thoughtfulness of the head of the department in this regard is reflected in the attitude of the internes, nurses, students, and orderlies. Apparently the one happening that can disturb the equanimity of Dr. McCrae is to have any member of his corps of teachers, internes, nurses, students, or orderlies neglectful of the comfort of the patients under his care. It was noted with interest that this consideration for the sensibilities of the patients was further illustrated by the absence of all references to" cases." Each patient had, and was addressed by, his or her name. Usually it was the first name that was used, and in a very friendly, kindly way. No private patient could have been shown greater courtesy or have been treated with more kindliness than were these ward patients.

One excellent reason for Dr. McCrae's success as a teacher is his precept and example regarding the absolute importance of system and routine in diagnosis. He evidently does not encourage the so-called brilliancy in diagnosis which so often leads to humiliating mistakes. The blackboard and crayon are in constant evidence and are in frequent use throughout the clinic. All the essential features of the symptomatology, the diagnosis, and the treatment are placed upon the blackboard and are easily transferred to the note-books.

There was no attempt at eloquence, unless it was the true eloquence of plain speaking, in discussing the symptoms, the diagnosis, and the treatment. There were no references concerning patients seen in

private practice or in consultation, but frequent attention was called to certain features of disease as illustrated in patients who had been shown at recent clinics or had been studied in the wards by the students.

The first patient shown was a young Irishman, a miner by occupation, aged 29 years, whose chief complaint was "shortness of breath and cough." His family history proved unimportant. His past medical history was that he had an attack of measles and pneumonia as a child, but had never had rheumatic fever, typhoid fever, scarlet fever, or diphtheria. He suffered from an "abscess in his throat" in 1902 and an attack of pleurisy a few months later. He denied venereal infection. He has never had a severe injury. He drinks alcohol freely (ten drinks daily average), whiskey preferably, but on occasions beer. He smokes moderately (?), but does not chew tobacco.

The patient's present illness began three years ago, while working in a coal mine. His first symptom was dyspnoea on exertion, which seems to have been insidious in onset. The dyspnoea soon became very severe, and another symptom was added to it, namely, cough. At this time and for months past he has had a considerable expectoration of black and yellowish sputum. In February of the present year (eight months ago) the patient had a profuse hemorrhage from the lungs. He feels sure that this blood came from his lungs, as it came during an attack of coughing and was bright red. About this time he noticed a violent overaction of the heart. So violent was its action that those standing near the patient would notice the forcible beating. The patient was greatly distressed by "indigestion," and his appetite became impaired. He often vomited and was disturbed by dyspnoea at night. His weight has been much reduced in the past three years. He recalls that four years ago he weighed 184 pounds, but now he weighs but 136, a loss of 48 pounds.

After the history was read attention was called to the important points in it. For example, attention was directed to the mistake of depending upon the average patient's statements regarding past illnesses unless a careful inquiry seemed to confirm the history. Dr. McCrae pointed out how necessary it was to ascertain how long an attack of " pneumonia " lasted, and its symptoms, before accepting such a history. He advised a careful inquiry into the history of

supposed attacks of rheumatism to ascertain if red, swollen joints were really present or if it were not some other disease or condition in which pain was a symptom. It was pointed out that nearly all physicians are prone to accept such diagnoses as made by the patient or by the patient's friends, and special attention was called to the carelessness of accepting a diagnosis of "piles" or hemorrhoids without a careful examination. Dr. McCrae pointed out how necessary frequent examinations of normal conditions are in order that one may recognize abnormal states when they are met with. That it was much better to make many examinations that revealed only normal conditions than it was to overlook an abnormal condition through having neglected to make the necessary examination.

After reviewing the patient's history, Dr. McCrae asked one of the students what diagnosis might be suggested by the history. The answer was "pulmonary tuberculosis," and the grounds given for this opinion were placed upon the blackboard, as follows: (1) Pulmonary hemorrhage. (2) Dyspnea. (3) Gradual loss of weight. (4) The emaciated appearance of the patient. (5) The patient's occupation.

Another student suggested that dyspnoea was an unusual symptom of early tuberculosis, and that the diagnosis was quite as likely to be bronchiectasis, complicated by emphysema. Still another student expressed himself as of the opinion that organic disease of the heart could readily account for all the symptoms enumerated by the patient.

The susceptibility of coal miners to tuberculous infection was discussed, and it was decided that the hygiene of the miners' homes was quite as important a factor in the production of tuberculous infections as their occupation. One of the students was requested to look up the literature and report the latest and most complete reports of the incidence of tuberculous infection among coal miners. (The college has a well-equipped library, with some six thousand volumes of the more important text-books and works of reference, as well as the leading medical periodicals. A trained librarian is in charge to aid the students in their investigations, and the rules of the library allow the books to be removed to the students' rooms under certain restrictions.) The question was then asked as to how the diagnosis of pulmonary tuberculosis could be confirmed or refuted.

One of the students answered this question, and his reply was placed upon the blackboard. (1) By repeated sputum examinations.