It is that time of year again!
Students, trainees, fellows – everyone at the end of her educational period of learning – is now preparing to “graduate,” a verb and noun derived from the Latin for “step.” Latin gives us several such liminal words for boundary-crossing events: “January” comes from the Latin word for “door,” the God of which was Janus, who had two faces – one looking backwards and one looking forwards – to the previous and upcoming years respectively (but was not, as we might say today, “two-faced”). There was no God of steps, apparently, who looked both down and up (an oversight, surely, of those early mythography-makers).
This distinction of progression (again, Latin for “taking steps forward,” cognate with “gradus”) is as true for medical students advancing to residency as it is for residents advancing to fellowship status as it is for fellows advancing to attending status and attendings to administrative promotions. The sine qua non of all these distinctions is a step upwards or forwards to a higher level of achievement. At each major step of accomplishment, one expects to receive a diploma stating, in an antique language, the historical fact that one has successfully effected this progression. It is noteworthy that the controversy about the language of diplomas – ancient versus modern – is nothing new. As long ago as 1837, contemporary commentators had strong opinions:
“All these diplomas are in the complimentary diction observed by the older Institutions of Europe, a diction which no one would think of employing, were he compelled to furnish a document of the kind in English. Besides, what is the value of the ‘vir ornatus et summis animi dotibus instructus,’ when applied to everyone, who gains his degree; some of whom, it is well known, in spite of every endeavour of the examiners to execute their duty faithfully, will occasionally pass, without being by any means ‘abunde periti’ [i.e., without being “abundantly skilled”] in their profession.” 
Such tongue-in-cheek slurs aside, the age-old question of the worth of ancient tongues versus modern-day vernacular remains current. I for one favor modern-day English, despite my classical languages background. There are sufficient Latin and Greek influences in every word we utter that I fear not that our Graeco-Roman ancestry will fade.
Too, there is, not surprisingly, currently the same discourse about “how much and for how long” one needs to train to learn sufficiently well the practice of medicine to practice independently and safely.
This professional self-examination whether today’s future physicians and surgeons need more time or more intensive training has only grown increasingly contentious with the advent of duty hours.
“An animated discussion on this subject has occurred among some of the most prominent of those who have taken part in the efforts now, or lately in progress for the improvement of medical education in this country. One party holds that four months in the year are fully enough to be devoted to lectures and is opposed to any extension of the sessions. The other insists on six months as absolutely necessary and professes to consider the enforcement of this period as the articulus stantis vel cadentis academiæ — the sufficient test by which a good school may be discriminated from a bad one. They tell us that the extent of medical science has, of late, been so greatly increased that it is utterly impossible for the teachers in a school to go over the whole subject in four months, or in five, but that it may be done in six.” 
Common to the advancement of every student up the ladder of achievement is the transition from the top of one’s game at one level to newbie status at the next higher grade. A seasoned and highly competent fifth-year resident in surgery in June is, weeks later, a green attending with the novelty of being totally in charge, totally in charge – the final resting place of every clinical buck that residents will be bringing to her, as she did her attending the month before. As someone who is on the threshold of retirement from medicine altogether, I realize that that new phase of my life will be as new to me as all the preceding gradations. One soon realizes that at almost any age, on any ladder, this is a cyclical process, a Sisyphean challenge every professional must face again, and again, and again, a de rigueur challenge only ending when they retire our stethoscopes for good. Part of this metamorphosis is the advice, solicited or not, from many, wisdom from few offered to those about to embark on that next new journey. Here are some of what I perceived to be excellent suggestions to graduates of medical school from their professors going back 150 years:
1. Be prepared to change and assist in change:
“The Medical Schools of this country, like the Medical Schools of other countries, and like all schools and all useful institutions of all countries, require improvement, and, however much improved, will always require further improvement. Let such improvement be made and continued, and let no one connected with our schools feel any sympathy with that dull and wicked spirit of selfish conservatism which prefers darkness to light, and dreads reform as hostile to its interest.” 
Such advice brings to mind Pope’s equally salient advice: “Be not the first by whom the new are try’d / Nor yet the last to lay the old aside.” 
2. You are your own best professor after graduation:
Once again Samuel Chew offers advice as useful today as it was 152 years ago:
“What the schools, even the best schools, can do for their pupils is trivial and insignificant in comparison with what those pupils can do for themselves, with what they must do for themselves, if they wish to acquire knowledge, ability, and fitness for their profession.” 
3. There is no substitute for practical experience which can only come with time and independent practice:
“You have already discovered that the handsome descriptive plates of your anatomical textbook are quite unlike the actual dissections which your scalpels have made, and what seemed quite simple, viewed by light of text and plate, was soon vested with unexpected difficulties when sought for with the knife; so also in the field of practice will you often strive in vain to fit the text of the book to the language of the sick-couch. You have studied with commendable zeal descriptions of disease and the action of remedies, but you have yet to study the nature of mankind and learn humanity as well as its diseases. This is particularly the case when we view the totality of a physician’s life. Like ordinary life, it is made up of little things. You are not going forth to wage a constant battle against grave diseases.
Serious cases will arise now and then, demanding your best medical skill and knowledge; but what will really try your abilities the severe stare the little things of daily practice.” 
4. Be humble:
You are not better than forces you do not understand!
Walter Bradford Cannon developed his teleologic concept of homeostasis from Claude Bernard’s proposal of the milieu intérieur:
“…[Bernard] clearly perceived that just insofar as that constancy is maintained, the organism is free from external vicissitudes. ‘It is the fixity of the “milieu interieur” which is the condition of free and independent life,’ he wrote, and ‘all the vital mechanisms, however varied they may be, have only one object, that of preserving constant the conditions of life in the internal environment.’ ‘No more pregnant sentence,’ in the opinion of J.S. Haldane, ‘was every framed by a physiologist.’” 
Sixty-five years before Cannon, and couched in practical but equally empirical terms was this advice from Thomas Laycock, a prominent Professor of Medicine at the University of Edinburgh and a neurophysiologist who influenced John Hughlings Jackson:
“There is no commoner fallacy than to mistake these orderly sequences of vital phenomena occurring according to natural laws for the effects of some favorite method of treatment. In the darker ages of physic, many disgusting, inert, and worse than inert, articles of the materia medica, and many cruel modes of treatment, were believed to be most efficacious from this fallacy. We no longer use scarlet cloth for the certain cure of variola or rely upon drugs for the cure of the exanthemata in general, because we know the order of development of their symptoms, and their natural termination. Our knowledge protects us from foolish mistakes as to these, but it is equally true that our ignorance leads us into foolish mistakes as to other diseases, and we too frequently rely very weakly upon medication, to the exclusion of a more natural method of treatment. 
Let us celebrate this time of progression, advancement, maturity (if only for a little while before the moulting at the next level commences), this time of celebration. There is no better way to do so than to recite the first lines of one of his more well known poems by my dear friend and colleague, whom I miss a great deal, the wonderful physician-poet, John Stone. I urge everyone to look up the original poem, already 33 years young. 
“For this is the day of joy which has been fourteen hundred and sixty days in coming and fourteen hundred and fifty-nine nights
For today in the breathing name of Brahms and the cat of Christopher Smart through the unbroken line of language and all the nouns stored in the angular gyrus today is a commencing
For this is the day you know too little against the day when you will know too much
For you will be invincible and vulnerable in the same breath which is the breath of your patients …”
Whether you graduated this spring or find yourself to be a lifelong student, I encourage you to peruse our Collection or read our other articles which may provide interesting tidbits, lessons, and stories to help you and our community grow.
- Dunglison, R. (1837) The medical student, or, Aids to the study of medicine: including a glossary of the terms of the science, and of the mode of prescribing, bibliographical notices of medical works, the regulations of different medical colleges of the union, &c. &c. Philadelphia. PA.: Published by Carey, Lea & Blanchards, pages 14–15.
- Chew, S. (1864). Lectures on medical education, or, On the proper method of studying medicine, Philadelphia, PA.: Published by Lindsay & Blakiston, page 140.
- Chew, S. (1864). Lectures on medical education, or, On the proper method of studying medicine, Philadelphia, PA.: Published by Lindsay & Blakiston, pages 145–146.
- Pope, A. (1711) Essay on Criticism. London, ENG.: Published by W. Lewis, page 41.
- Chew, S. (1864). Lectures on medical education, or, On the proper method of studying medicine, Philadelphia, PA.: Published by Lindsay & Blakiston, page 148.
- Palmer, E.R. (1874) Intellectual culture: a valedictory address delivered to the graduation class of the medical department of the University of Louisville, 1874, Louisville, KY.: Published by John P. Morton and Co.
- Cannon, W.B. (1932) The wisdom of the body, New York, NY.: Published by W. W. Norton & Co., page 38.
- Laycock, T. (1857) Lectures on the principles and methods of medical observation and research, for the use of advanced students and junior practitioners. Philadelphia, PA.: Publshed by Blanchard and Lea, pages 138–9.
- Stone, J. (1983) Gaudeamus Igitur. JAMA, 249(13), 1741–1742