Wrapping it up.

Wrapping It Up

Today was the time for wrapping it up. The office has been moved for several days. Not the office where patients were seen; the administrative office needed to be vacated for the new medical director. The new office has no room for the paper, brass, and simulated bronze that adorned the walls of the two former offices. Today was the day to pack it all up, and to be transported back in memory to the occasions when the items were bestowed.

First was the diploma conferring a degree, bachelor of science, upon a young man during the early days of WWII. This artifact arrived by mail, the recipient already three months into medical school. Some memories of that time came back--the best friend down in a Naval air craft, the blending of a defense-related job with academics, the dedication of college faculty to our education.

Doctor of medicine was granted just as the war ended. The sheepskin had been proudly displayed on the walls of three offices. Study was not hard; the alternatives were very hard. A classmate who fell below school standards was one of the first men over the Remagen Bridge. Four years of medicine packed into three. Much of the time in medical school blurs with the passing of years--long hours of study; learning much by rote; most important, developing reasoning discipline in searching for the truth in medical practice. The sheepskin may not be displayed in public again; part of wrapping it up.

The one document required to practice is the state license, obtained soon after graduation. All of the other paper is of no value, at least in making a living in practice. I remember being seated in a large hall in the capital with some 300 peers, all of us very concerned about our ability to recall the foramena of the base of the skull, the stages of labor, the autonomous zone of the radial nerve, and other facts studied long ago. Most of us passed, never again to be so tested. The license today does not carry the sovereignty of the one granted 40 years ago. We were then the only professionals fully licensed to provide medical care. Many other groups are in competition today, with more in line to try.

The internship document, more a certificate of service than a diploma, indicated the right of passage that has been the burden of many generations of physicians. The year stretched to 15 months--36 hours on duty and maybe 12 off. With all of the fatigue, peer pressure, and desire to succeed, it was still the best year in medical education. Rotation through medicine, surgery, pediatrics, OB, emergency, and three electives gave an overview of the medical disciplines before a career choice was made. Perhaps it's time to consider its resurrection.

Another document, this one given six years after the internship, was the residency certificate. Four years spent honing surgical skills, narrowing the scope of study to one discipline, becoming a specialist. The residency was a good time, part preceptorial, part academic, a time of shaping the future. The paper certified the time of exposure to tutors. Thirty years later, having taught surgical skills and patient care to a long line of residents, it occurs to me that the teaching of such skills is still a preceptorial, hands-on endeavor.

Then came board certification, given after examination and upon completion of four years of specialty training and two years of practice. If one is not careful, the board document may be given status above the diploma, which confers the right to be called physician. The board document has never made a surgeon or other specialist either competent or skilled, but it is a great satisfaction as an instrument certifying peer acceptance. Today, certification by a board is mandatory in pursuing a hospital career, in caring for patients of third-party arrangements, and in easing the legal burdens of practice.

Next, a group of paper scrolls, certifying memberships in various organizations. My specialty academy, deeply involved in continuing education with an opportunity to socialize with friends. The American College of Surgeons, deeply involved with quality as well as political and social issues. A regional clinical society brought practical knowledge to our attention. Each organization played a role in keeping the physician qualified as a specialist and a citizen. There are documents attesting to presentations at meetings of the specialty academy, very small efforts at giving a bit back to the system that nurtured me.

Then there are the bronze plaques and inscribed plastic. The plastic document for a year of service as chief of staff, a tough year--many issues needing solutions, none easy to come by. The board accepts a doctor as a voting member after many years of saying no; my bronze plaque was the third issued to a physician. The miniature shovel mounted on a walnut base, the Bull Shippers award, was presented by the house staff, their way of thanking me for my teaching endeavors.

As the career winds down, a brass on walnut item signifying membership in the American Academy of Medical Directors, a new organization supporting a new career. Understanding of the ways of peers led to a 6-year period as medical director kf my hospital, a period of enrichment in knowledge of the changing scene in American medicine. The job now belongs to a younger practitioner. The next medical director must have full managerial skills and training. The future of medicine belongs to those who will manage their own courses. Ideally, physicians will be the leaders.

So it is packed away, the diverse array of wall hangings. One not mentioned above is a plaque with two instruments of my craft above the statement "Master Technician," presented by my peers, mostly former residents. Through it all, it was important to remain a physician. As a third career is started, a consultative role, the values of prior experiences will be of great importance, but none greater than remaining a physician.

William M. Davis, MD, is a medical management consultant in Akron, Ohio. At the time this article was written, he had just retired as Medical Director of Akron City Hospital.