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Cardiology as a specialty
CARDIOLOGY PAUL
AS A SPECIALTY D.
M.D. MASS.
WHITE,
BOSTON,
T
HE study and treatment of heart disease and the identification of a normal heart are of great importance and wide interest, the prerogative of no individual, group, school, or country. Every doctor and, indeed, every layman is vitally concerned : the obstetrician with the fetal heart action, the pediatrician with the heart of the growing child, the internist with that of the adult, although he often leaves the last ages of man, that is, geriatrics, to the general practitioner, the surgeon with preparation for the strain of operation and aftercare, the military officer with the soldier’s heart, and the family doctor and the layman with the entire period from birth to death. A varying degree and kind of knowledge is appropriate for each one of these. The pediatrician does not need to know much about the failing heart of coronary occlusion, with myocardial infarction; the internist and the military surgeon have little knowledge of the puzzling congenital heart problems of infancy; and the family doctor every so often encounters a rare or difficult case of heart disease for the elucidation of which he needs expert help in diagnosis and treatment. Man is not, however, just one age or one problem, any more than he is one organ, and so he must be viewed from every angle on the broad base of interest in him as a whole. It is in this respect that those who are not only interested but also trained in the study of the normal and abnormal heart of man from the cradle, in fact from the womb, to the grave, have a useful role to play, in fact, a role that cannot be, or at any rate has not been, played by any of the other medical workers I have mentioned. That is the role of the cardiologist. Anyone may be interested in cardiology, may read intensively or extensively on the subject, may attend meetings such as this, or may do research on certain of its problems, but the practicing cardiologist, as such, must do more than this to be worthy of the name, as must obstetricians, surgeons, neurologists, and professors of internal medicine in their respective fields. He must first have a solid foundation, based on training and knowledge in cardiovascular anatomy and physiolo,T. He must have a sound experience and knowledge of medicine in general, and of the vital interrelationships of all organs and systems in the body. He must have knowledge and experience in the jud,ment and handling President’s Remarks. Seventeenth Scientific sociation, Cleveland, Ohio, May 30, 1941. Received for publication Sept. 6, 1941. 161
Meeting
of the
American
Heart
As-
162
AMERICAN
HEART
JOURNAL
of personalities, one of the most critical of all attributes of practicing physicians. He must continue to keep abreast of, and have an actual, although necessarily a minor, hand in following (not initiating, of course, except in rare instances) advances in other fields of medicine and surgery and of his profession as a whole. Most important of all, based essentially on all this, he must have had, and he must continue to have, rich, first-hand, constant experience in handling patients with heart troubles, real or imaginary. A general internist does not have time to do this, nor does the fa.mily doctor, for, following the old adage, they must learn “less and less about more and more” while the specialist learns “more and more about less and less.” Medicine has become a very extensive profession and requires many different general and special workers. Truly, one field is as important as any other field, whether general practice, teaching, laboratory work and research, administration, or specialization. All of these fields are fascinating to many medical students and young graduates, as they were to me, but one must make a choice, guided often, of course, by opportunity. One cannot now, as one could a generation ago, do everything. To illustrate this point, I shall take the liberty of citing my own experience, for I know it best. While still an intern, I appreciated that it was impossible to do all of the things I should like to do in medicine. At first, I was very keen on obstetrics, and then on pediatrics. Later I thought I should like to be a practitioner or professor of general medicine, or a dean. Then came the opportunity, and, with it, the realization of the value of studying intensively in a special field, and so I selected cardiology with my eyes open, realizing that, if I wanted to become well grounded in that field, I could not spend so much time in the other fields. It was as plain as day and has continued t,o be so ever since. Patient perseverance during a good many years of preparat,ion and of practice has brought me so much satisfaction and happiness that I am eternally grateful to the fates and for the advice I received in the beginning from those who steered me into this career and to those who have helped to keep me there, although I have been tempted frequently to do otherwise in this day and age of restless change. I am also grateful to those who have insisted that I must continue every year to have first-hand knowledge through hospital experience and responsibility in other fields of internal medicine. I have stated my experience simply as an example of what I believe should be considered an essential for qualification as a special worker in the field of cardiovascular disease. Many of you here today are doubtless internists with a natural interest in heart disease, but without expectation or desire to concentrate primarily on cardiology. Some of you, however, are keen to do so, and to you I urge a program of the most careful grounding and intensive years of preparation, with your feet all the time firmly planted on the ground. We must recognize espe-
WHITE
:
CARDIOLOGY
AS
SPECIALTY
163
cially that electrocardiography, phonoca.rdiography, and other tests of cardiovascular function, both normal and abnormal, are simply parts of the complete whole. To own an electrocardiograph and to perform tests of the rate and volume of the circulation are but small beginnings. In closing, there is one other point I should like to mention, and that is the occasional remark one hears about the narrowness of specialists. Of course specialists may be narrow, but such a remark as a general Broad- or narrow-mindedness, philosophic observation is erroneous. points of view, and the value of the physician to his profession do not depend upon the particular kind of medical work that is being done; they depend upon the personality, training, industry, and environment of the individual. The family doctor may be broad- or narrow-minded, no matter how exten&~e his knowledge and experience may be; the specialist may be broad- or narrow-minded, no matter how intensive his knowledge and experience may be. It is of prime importance, therefore, for the specialist, as well as for the family doctor, to keep closely in touch with broad-minded associates in the field of medicine.
AS A SPECIALTY D.
M.D. MASS.
WHITE,
BOSTON,
T
HE study and treatment of heart disease and the identification of a normal heart are of great importance and wide interest, the prerogative of no individual, group, school, or country. Every doctor and, indeed, every layman is vitally concerned : the obstetrician with the fetal heart action, the pediatrician with the heart of the growing child, the internist with that of the adult, although he often leaves the last ages of man, that is, geriatrics, to the general practitioner, the surgeon with preparation for the strain of operation and aftercare, the military officer with the soldier’s heart, and the family doctor and the layman with the entire period from birth to death. A varying degree and kind of knowledge is appropriate for each one of these. The pediatrician does not need to know much about the failing heart of coronary occlusion, with myocardial infarction; the internist and the military surgeon have little knowledge of the puzzling congenital heart problems of infancy; and the family doctor every so often encounters a rare or difficult case of heart disease for the elucidation of which he needs expert help in diagnosis and treatment. Man is not, however, just one age or one problem, any more than he is one organ, and so he must be viewed from every angle on the broad base of interest in him as a whole. It is in this respect that those who are not only interested but also trained in the study of the normal and abnormal heart of man from the cradle, in fact from the womb, to the grave, have a useful role to play, in fact, a role that cannot be, or at any rate has not been, played by any of the other medical workers I have mentioned. That is the role of the cardiologist. Anyone may be interested in cardiology, may read intensively or extensively on the subject, may attend meetings such as this, or may do research on certain of its problems, but the practicing cardiologist, as such, must do more than this to be worthy of the name, as must obstetricians, surgeons, neurologists, and professors of internal medicine in their respective fields. He must first have a solid foundation, based on training and knowledge in cardiovascular anatomy and physiolo,T. He must have a sound experience and knowledge of medicine in general, and of the vital interrelationships of all organs and systems in the body. He must have knowledge and experience in the jud,ment and handling President’s Remarks. Seventeenth Scientific sociation, Cleveland, Ohio, May 30, 1941. Received for publication Sept. 6, 1941. 161
Meeting
of the
American
Heart
As-
162
AMERICAN
HEART
JOURNAL
of personalities, one of the most critical of all attributes of practicing physicians. He must continue to keep abreast of, and have an actual, although necessarily a minor, hand in following (not initiating, of course, except in rare instances) advances in other fields of medicine and surgery and of his profession as a whole. Most important of all, based essentially on all this, he must have had, and he must continue to have, rich, first-hand, constant experience in handling patients with heart troubles, real or imaginary. A general internist does not have time to do this, nor does the fa.mily doctor, for, following the old adage, they must learn “less and less about more and more” while the specialist learns “more and more about less and less.” Medicine has become a very extensive profession and requires many different general and special workers. Truly, one field is as important as any other field, whether general practice, teaching, laboratory work and research, administration, or specialization. All of these fields are fascinating to many medical students and young graduates, as they were to me, but one must make a choice, guided often, of course, by opportunity. One cannot now, as one could a generation ago, do everything. To illustrate this point, I shall take the liberty of citing my own experience, for I know it best. While still an intern, I appreciated that it was impossible to do all of the things I should like to do in medicine. At first, I was very keen on obstetrics, and then on pediatrics. Later I thought I should like to be a practitioner or professor of general medicine, or a dean. Then came the opportunity, and, with it, the realization of the value of studying intensively in a special field, and so I selected cardiology with my eyes open, realizing that, if I wanted to become well grounded in that field, I could not spend so much time in the other fields. It was as plain as day and has continued t,o be so ever since. Patient perseverance during a good many years of preparat,ion and of practice has brought me so much satisfaction and happiness that I am eternally grateful to the fates and for the advice I received in the beginning from those who steered me into this career and to those who have helped to keep me there, although I have been tempted frequently to do otherwise in this day and age of restless change. I am also grateful to those who have insisted that I must continue every year to have first-hand knowledge through hospital experience and responsibility in other fields of internal medicine. I have stated my experience simply as an example of what I believe should be considered an essential for qualification as a special worker in the field of cardiovascular disease. Many of you here today are doubtless internists with a natural interest in heart disease, but without expectation or desire to concentrate primarily on cardiology. Some of you, however, are keen to do so, and to you I urge a program of the most careful grounding and intensive years of preparation, with your feet all the time firmly planted on the ground. We must recognize espe-
WHITE
:
CARDIOLOGY
AS
SPECIALTY
163
cially that electrocardiography, phonoca.rdiography, and other tests of cardiovascular function, both normal and abnormal, are simply parts of the complete whole. To own an electrocardiograph and to perform tests of the rate and volume of the circulation are but small beginnings. In closing, there is one other point I should like to mention, and that is the occasional remark one hears about the narrowness of specialists. Of course specialists may be narrow, but such a remark as a general Broad- or narrow-mindedness, philosophic observation is erroneous. points of view, and the value of the physician to his profession do not depend upon the particular kind of medical work that is being done; they depend upon the personality, training, industry, and environment of the individual. The family doctor may be broad- or narrow-minded, no matter how exten&~e his knowledge and experience may be; the specialist may be broad- or narrow-minded, no matter how intensive his knowledge and experience may be. It is of prime importance, therefore, for the specialist, as well as for the family doctor, to keep closely in touch with broad-minded associates in the field of medicine.