On a chilly morning on October 21, 1926, Dr Francis Peabody stepped out of his house to deliver a lecture to the graduating students at Harvard University. He had prepared carefully, as was his norm for any lecture he gave. Little did he realise that the talk, which was later published in JAMA, would become one of the most quoted articles in medical literature.

A little less than a year later, on October 13, 1927, he was dead from a cancer of the stomach. He was only 47 years old.

When he gave the lecture on that autumn day, he was fully aware of his illness and dire prognosis. Yet he went about his duties with a cheerful demeanour and was working on scientific papers just a few days before his death. Who was this remarkable man and what lessons can we learn from a lecture delivered nearly a century ago?

Francis Weld Peabody was born in 1881. As a boy, he was a mediocre student, but found his calling in medicine. He graduated with honours from Harvard Medical School in 1907 and later gained a faculty appointment at Harvard, where he became a well-known researcher and teacher. His pioneering work on the origin of pernicious anaemia might well have won him the Nobel Prize for Medicine if not for his untimely death.

In 1926 he was admitted to hospital for a gastric bleed, which was initially thought to be from a gastric ulcer. Unfortunately, it was later diagnosed as an inoperable cancer of the stomach. Knowing he did not have long to live, he moved into a rented house near the hospital so that he could be readily consulted by colleagues and staff even if unable to go to work while still spending precious time with his wife and two infant sons. This was the background to his famous lecture.

Let us look at some of the key points of his lecture and what valuable lessons they teach the doctor of today and patients. Titled “The Care of the Patient”, the lecture essentially covered three topics. First, the importance of individualising patient care, second the dehumanising experience of a hospital admission, and third, the care of patients who have symptoms for which no organic cause can  be found.

“To begin with, the fact must be accepted that one cannot expect to become a skilful practitioner of medicine in the four or five years allotted to the medical curriculum. Medicine is not a trade to be learned but a profession to be entered.”

Broadly, he was concerned that some doctors thought that the end of medical school was the end of medical education. He continues, “All that the medical school can hope to do is to supply the foundations on which to build.”

He was concerned that with advances in science, medical schools were more concerned with imparting knowledge and less with teaching the importance of the doctor-patient relationship. “The practice of medicine in its broadest sense includes the whole relationship of the physician with this patient…. 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 emphasised, for in an extraordinarily large number of cases both diagnosis and treatment are directly dependent on it.” What profound advice for a young doctor.

“When a patient enters a hospital, one of the first things that commonly happens to him is that he loses his personal identity. He is generally referred to, not as Henry Jones, but as ‘that case of mitral stenosis in the second bed on the left’”. How true. When a patient is admitted to a hospital, he or she is immediately categorised into a surgical, medical or other category of speciality, depending on the diagnosis of the patient. Once in the ward, he or she may be referred to as the liver patient or heart patient in bed number two on the left from the entrance. The patient may also be asked to dress in hospital clothes. No doubt this facilitates administration and efficient running of the ward. It may also facilitate the treatment of the patient’s medical problems, but it may not help the patient’s feelings.

Peabody continues, “The disease is treated, but Henry Jones, lying awake nights while he worries about his wife and children, represents a problem that is much more complex than the pathologic physiology of mitral stenosis, and he is apt to improve very slowly unless a discerning intern happens to discover why it is that even large doses of digitalis fail to slow his heart rate. Henry happens to have heart disease, but he is not disturbed so much by dyspnea as he is by anxiety for the future…”

Now we come to the third theme of Peabody’s lecture; the care of patients who have symptoms for which no apparent cause can be found. Today, we call this category of patients as having medically unexplained symptoms. This is an important group and constitute around a third of patients visiting the outpatient department of a hospital. If troublesome enough, they get referred to the psychiatrist for evaluation. Sometimes the psychiatrist may find an underlying depression, but often a definite psychiatric disorder is not found.

During Peabody’s time there was little knowledge of this group of conditions sometimes referred to as psychosomatic problems. Peabody was a pioneer in the understanding of this group of patients whom he referred to as suffering from ‘psychoneuroses’. In his lecture he gives detailed advice on how to deal with such patients and his advice is valid even today when we have a much better understanding of the problem. “Diagnosis is the first step in treatment. In the second place, 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.” How true.  In medical school today we try to teach medical students the proper management of such patients as they will make up a main proportion of their practice whatever the speciality. Such patients, even if referred to psychiatrists, will not take such referrals kindly and will often refuse to see a psychiatrist. Peabody points out that the establishment of a professional but personal relationship with such patients is an important part of the management. “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 you must appreciate and consider if you would be a wise clinician.”

He ends his lecture with these often-quoted words of wisdom: “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.”

I hope that all of you, especially medical students and doctors, will take the trouble to read the Peabody lecture in its entirety. It is freely available on the web.

 

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