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JAMA Revisited
January 7, 2020

The Teaching of Clinical Medicine

JAMA. 2020;323(1):96. doi:10.1001/jama.2019.13246

Originally Published January 3, 1920 | JAMA. 1920;74(1):35.

Teachers of technical subjects naturally fall into one of two groups: first, the type whose interests lie mainly in the philosophic aspects of the subject taught, and second, the type who think of problems in terms of the individual. As Addis1 has recently pointed out, this is true of clinical medicine, and it is equally true of clinical surgery or of any other clinical subject. Some clinicians who are mainly interested in underlying principles may be described as the investigative type. Others who are chiefly interested in the problem of the individual patient may be regarded as the practical type.

Quite frequently it has been assumed, particularly by the general practitioner and by the man on the street, that the two types are antagonistic, and this assumption is not without some basis in fact. It is doubtless true that the person with the investigative type of mind dislikes to be torn from his laboratory to attend to the details of the wards. We can all recall John Hunter’s famous remark under circumstances of this sort that he must “go out and earn that damned guinea.” It is equally true that the so-called practical clinician finds it difficult to detach himself from the study of disease in the patient to study disease by laboratory investigation. To this extent there is antagonism between the two types of clinicians; but the assumption that the investigative type is necessarily a feebleminded putterer when it comes to practical medicine is not correct. Nor is it correct to assume that the practical type of clinician is incapable of grasping the principles of research and of appreciating its importance.

As Addis points out, the teacher of clinical medicine at the present time is in difficulties because he is expected to combine in one person the attributes of these two types. He is expected to be a practical clinician capable of diagnosing and treating disease in the individual, and he is also required to demonstrate his ability to do laboratory research. True, there are those who possess the characteristics of both types, but they are exceptional. The details concerned in the study and treatment of disease have become more and more complicated as our theoretical knowledge has increased. New principles and new methods are constantly being discovered by the investigator, and new applications of these principles and methods to clinical work are continually being made. This has caused a great increase in the routine work involved in the study of a given case and has greatly complicated the task of the practical clinician. Indeed, as Addis points out, the complexity of modern diagnosis and of modern treatment is so great that all of the energies of one man may well be utilized in organizing and conducting this side of the work of a teaching hospital.

It is quite possible that, as has been suggested, we are approaching the time when there will be two types of persons connected with each clinical department, namely, the clinical physiologist, whose chief work will be the intensive study of selected groups of cases and the instruction of students in the application of the principles of physiology to the elucidation of disease, and the clinician, whose chief function will be the care of the patient and the instruction of the student in the practical methods of diagnosis and treatment. Obviously, some such arrangement already exists in some of our better schools. In institutions in which full time medicine has been introduced, there has been a distinct effort to appoint as heads of the clinical departments men of the investigative type. One question that Addis’ discussion raises is whether in our enthusiasm for laboratory research we have not overlooked the importance of purely clinical investigation and of the type of physician that naturally tends toward this.

Section Editor: Jennifer Reiling, Assistant Editor.
Editor’s Note: JAMA Revisited is transcribed verbatim from articles published previously, unless otherwise noted.
Addis: Edinburgh M. J., N. S. 23: 235, 1919.