Among physicians with a humanistic soul, perhaps no quotation is more fondly remembered than one from Dr Francis Peabody. He was born in 1881 to a prominent New England family, trained at Harvard and Massachusetts General Hospital and was the first director of the Thorndike Laboratory at Boston City Hospital. Tragically, he died of sarcoma at age 46.
The quotation for which he is justly famous came at the end of a lecture he gave in 1925: “…the secret of the care of the patient, is in caring for the patient.” Thoughtful clinical practice regularly reveals the wisdom of this simple observation.
What is less well known is that Dr Peabody’s lecture included an extended discussion of patients who “have nothing the matter with them.” The value of these timeless observations is, regrettably, too often lost amid modern medicine’s focus on technology. His lecture (1), reprinted in the Journal of the American Medical Association in 1927, is well worth reading though it is long (6500 words).
Below are selections from his lecture that are fundamental to effective clinical care, with a few special favorites in bold:
The most common criticism made at present by older practitioners is that young graduates have been taught a great deal about the mechanism of disease, but very little about the practice of medicine—or, to put it more bluntly, they are too “scientific” and do not know how to take care of patients.
…it has been easy to overlook the fact that the application of the principles of science to the diagnosis and treatment of disease is only one limited aspect of medical practice. The practice of medicine in its broadest sense includes the whole relationship of the physician with his patient.
There is no more contradiction between the science of medicine and the art of medicine than between the science of aeronautics and the art of flying.
The treatment of a disease may be entirely impersonal; the care of a patient must be completely personal. The significance of the intimate personal relationship between physician and patient cannot be too strongly emphasized, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it, and the failure of the young physician to establish this relationship accounts for much of his ineffectiveness in the care of patients.
[Physicians] fall into much more serious error in their attitude toward a large group of patients who do not show objective, organic pathologic conditions, and who are generally spoken of as having “nothing the matter with them.” Up to a certain point, as long as they are regarded as diagnostic problems, they command attention; but as soon as a physician has assured himself that they do not have organic disease, he passes them over lightly.
After giving an example of such a patient: Mrs. Brown goes home, somewhat better for her rest in new surroundings, thinking that nurses are kind and physicians are pleasant, but that they do not seem to know much about the sort of medicine that will touch her trouble. She takes up her life and the symptoms return—and then she tries chiropractic, or perhaps it is Christian Science.
Now the chief criticism to be made of the way Mrs. Brown’s case was handled is that the staff was contented with a half truth. The investigation of the patient was decidedly unscientific in that it stopped short of even an attempt to determine the real cause of the symptoms. As soon as organic disease could be excluded the whole problem was given up, but the symptoms persisted. Speaking candidly, the case was a medical failure in spite of the fact that the patient went home with the assurance that there was “nothing the matter” with her.
Numerically, then, these patients constitute a large group, and their fees go a long way toward spreading butter on the physician’s bread. Medically speaking, they are not serious cases as regards prospective death, but they are often extremely serious as regards prospective life.
The ultimate causes of these disturbances are to be found, not in any gross structural changes in the organs involved, but rather in nervous influences emanating from the emotional or intellectual life, which, directly or indirectly, affect in one way or another organs that are under either voluntary or involuntary control.
Every one has had experiences that have brought home the way in which emotional reactions affect organic functions. Some have been nauseated while anxiously waiting for an important examination to begin, and a few may even have vomited; others have been seized by an attack of diarrhea under the same circumstances. Some have had polyuria before making a speech, and others have felt thumping extrasystoles or a pounding tachycardia before a football game.
There is certainly a very intimate correlation between mental tenseness and muscular tenseness, and whatever methods are used to produce mental relaxation will usually cause muscular relaxation, together with relief of this type of pain.
These symptoms, although obviously not due to anatomic changes, may, nevertheless, be very disturbing and distressing, and there is nothing imaginary about them. Emotional vomiting is just as real as the vomiting due to pyloric obstruction, and so-called “nervous headaches” may be as painful as if they were due to a brain tumor.
Moreover, it must be remembered that symptoms based on functional disturbances may be present in a patient who has, at the same time, organic disease, and in such cases the determination of the causes of the different symptoms may be an extremely difficult matter.
But what happens if the cause does not pass away? What if, instead of having to face a single three-hour examination, one has to face a life of being constantly on the rack? The emotional stimulus persists, and continues to produce the disturbances of function. As with all nervous reactions, the longer the process goes on, or the more frequently it goes on, the easier it is for it to go on. The unusual nervous track becomes an established path. After a time, the symptom and the subjective discomfort that it produces come to occupy the center of the picture, and the causative factors recede into a hazy background. The patient no longer thinks “I cannot stand this life,” but he says out loud “I cannot stand this nausea and vomiting. I must go to see a stomach specialist.”
Quite possibly the comment on this will be that the symptoms of such “neurotic” patients are well known, and they ought to go to a neurologist or a psychiatrist and not to an internist or a general practitioner. …is it not rather narrow minded to limit one’s interest to those disturbances of function which are based on anatomic abnormalities?
…the patients themselves frequently prefer to go to a medical practitioner rather than to a psychiatrist, and in the long run it is probably better for them to get straightened out without having what they often consider the stigma of having been “nervous” cases. A limited number, it is true, are so refractory or so complex that the aid of the psychiatrist must be sought, but the majority can be helped by the internist without highly specialized psychologic technic, if he will appreciate the significance of functional disturbances and interest himself in their treatment. The physician who does take these cases seriously—one might say scientifically—has the great satisfaction of seeing some of his patients get well, not as the result of drugs, or as the result of the disease having run its course, but as the result of his own individual efforts.
[Physicians] do not pay as much attention as they should to the functional disorders. Many a student enters practice having hardly heard of them except in his course in psychiatry, and without the faintest conception of how large a part they will play in his future practice. At best, his method of treatment is apt to be a cheerful reassurance combined with a placebo.
The successful diagnosis and treatment of these patients, however, depends almost wholly on the establishment of that intimate personal contact between physician and patient which forms the basis of private practice.
Remember that you want to know [the patient] as a man, and this means you must know about his family and friends, his work and his play. What kind of a person is he—cheerful, depressed, introspective, careless, conscientious, mentally keen or dull?
If, however, you finally exclude recognizable organic disease, and the probability of early or very slight organic disease, it becomes necessary to consider whether the symptomatology may be due to a functional disorder which is caused by nervous or emotional influences. You know a good deal about the personal life of your patient by this time, but perhaps there is nothing that stands out as an obvious etiologic factor, and it becomes necessary to sit down for a long intimate talk with him to discover what has remained hidden.
Sometimes it is well to explain to the patient, by obvious examples, how it is that emotional states may bring about symptoms similar to his own, so that he will understand what you are driving at and will cooperate with you.
Often the best way is to go back to the very beginning and try to find out the circumstances of the patient’s life at the time the symptoms first began. The association between symptoms and cause may have been simpler and more direct at the onset, at least in the patient’s mind, for as time goes on, and the symptoms become more pronounced and distressing, there is a natural tendency for the symptoms to occupy so much of the foreground of the picture that the background is completely obliterated. Sorrow, disappointment, anxiety, self-distrust, thwarted ideals or ambitions in social, business or personal life, and particularly what are called maladaptations to these conditions—these are among the commonest and simplest factors that initiate and perpetuate the functional disturbances.
The causes are manifold and the manifestations protean. Sometimes the mechanism of cause and effect is obvious; sometimes it becomes apparent only after a very tangled skein has been unraveled.
If the establishment of an intimate personal relationship is necessary in the diagnosis of functional disturbances, it becomes doubly necessary in their treatment.
In all your patients whose symptoms are of functional origin, the whole problem of diagnosis and treatment depends on your insight into the patient’s character and personal life, and in every case of organic disease there are complex interactions between the pathologic processes and the intellectual processes which you must appreciate and consider if you would be a wise clinician.
…in man the disease at once affects and is affected by what we call the emotional life. Thus, the physician who attempts to take care of a patient while he neglects this factor is as unscientific as the investigator who neglects to control all the conditions that may affect his experiment.
The good physician knows his patients through and through, and his knowledge is bought dearly. Time, sympathy and understanding must be lavishly dispensed, but the reward is to be found in that personal bond which forms the greatest satisfaction of the practice of medicine.
One of the essential qualities of the clinician is interest in humanity, for the secret of the care of the patient is in caring for the patient.
1. Peabody F. (1927). The Care of the Patient. JAMA Vol. 88, pp. 877-882, Mar. 19.