Anti-Intellectual Movement in Medicine

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					Refer to: Moser RH: An anti-intellectual movement in medicine.
          West J Med 122:433-449, May 1975
                                                                                            Special Article

  Anti-Intellectual Movement in Medicine
                                          ROBERT H. MOSER, MD, Chicago

 IT IS NOT NEWS that Western man is reentering a                   before; and now that I have come to the big
climate of anti-intellectualism-a new Dark Age                     city and begun to wander about, and to take the
wherein some fight fear with long since discarded                  pulse of American medicine, the fears have be-
devices. We have witnessed the return of mysti-                    gun to crystallize.
cism as reflected in the reemergence of the black
and white magic of the Tarot, the simplistic non-                  First Signs of Change
sense of astrology and a wave of perfervid reli-                      It is a little like watching animals react to a
giosity. If these methods had ever worked, they                    small fire in the forest. The whiffs of smoke were
would not have been reassumed and discarded                        detected by sensitive creatures about five or ten
myriad times in the history of civilizations.                      years ago. You are all familiar with the tremors
   We are in a state of chaos, but it is nonsense                  that were felt by the academic community. Some
to blame the mess on the clean, flourishing, logical               whispered that our research and educational
and technical disciplines of science. Rather, it is,               establishments had become badly out of joint
once again, the lagging of practical humanism re-                  with the times. There were murmurings about
flected in failure of social and political systems to              excess fat in research budgets, escalating costs of
implement scientific knowledge that has created                    medical care and maldistribution of professional
a gestalt inimical to the health of the individual                 talent-geographically and socioeconomically.
person and, therefore, to the health of society.                   But just as you and I had, the bright young gradu-
And I fear the wave of anti-intellectualism has                    ates of the 60's continued to swarm the ivory
begun to encroach upon the borders-if not the                      towers and populate the specialties, while the vast
heart-of medicine.                                                 mass of patients-those who were less-than-vio-
   Let me explore this.                                            lently ill or less-than-interestingly ill-were all
                                                                   but forgotten in the academic scramble. And all
   One year ago I was battling the problems of                     of this had significant fallout.
providing patient care in an urban-rural com-                         Patients obliged to wait several hours in offices,
munity, with night calls, house calls and all the                  clinics and emergency rooms agreed most readily
joys and agonies attendant thereto. And one can-                   when they were told we were in the midst of a
not obliterate certain perspectives and attitudes                  doctor shortage. And for many lower and middle
simply by switching chairs: in this case, to one                   income groups good medical care was scarce, if
behind an editor's desk. So I would like to rumi-                  not unknown. The news media were replete with
nate some things that had begun to worry me                        stories of dramatic progress in the science of
  The author is Editor, The Journal of the American Medical        medicine but little of this was perceptible, little
Association, and Director, Division of Scientific Publications,
The American Medical Association.                                  filtered down to the vast mass of the less affluent
  Presented to the Calfornia Academy of Medicine, San Francisco,   sick. Words such as relevance and social responsi-
September 28, 1974.
  Reprint requests to: R. H. Moser, MD, Editor, The Journal
of the American Medical Association, 535 North Dearborn Street,
                                                                   bility began to creep into the conversations of our
Chicago, IL 60610.                                                 medical young.

                                                                   THE WESTERN JOURNAL OF MEDICINE             443
                                       ANTI-INTELLECTUAL MOVEMENT

   Meanwhile, many medical schools, still basking        or the vertical ghettoes of Detroit after they've
in the warmth of their post-Flexner era bonanza,         seen Massachusetts General or the National In-
began to sense the distant smoke, and some re-           stitutes of Health or Scarsdale or San Francisco
acted. Incoming classes were doubled and tripled;        or Maui?"
selection committees reached out for minority               And what about the graduates of the late 50's
group students; curriculum committees sought             and 60's?
new dimensions. Schools with unfamiliar names                Some of us anachronistic curmudgeons-erst-
mushroomed throughout the land.                          while bedside clinicians-could be heard to mutter
   Some clinical teachers became concerned about         darkly about the new breed of graduates and their
the capability of the existing, relatively finite pool   tutors, mechanical and otherwise. Nasty phrases
of medical educators to accommodate the surge            like laboratory-oriented myrmidons, molecular
of new students, and still maintain traditions of        biology buffs, disease rather than patient-oriented,
excellence in classroom and clinic. But these            bereft of human virtues, assembly line products
fears were assuaged with assurances that the new         crept into our cloakroom conversations.
mass media techniques would facilitate clinical              Yet, the first significant militant protests against
teaching. Yet some of us were still worried about        the educational grist mill came from the students.
relegating these critical responsibilities to mechani-   It was their forthright demands for relevance in
cal surrogates. But our concerns were only small         curriculum and for meaningful medical experience
eddies swirling against the mainstream.                  that arose in response to their expanding social
More Doctors, Faster                                     awareness. Students-not teachers-were the ones
                                                         who scrutinized the academic tradition which had
   Produce more doctors and do it faster was the         taught disdain of the local medical doctor, the
watch word. We were advised that we were 30,000          LMD, and had extolled the virtues of the investi-
doctors short throughout the country-but few             gative-teaching career pattern. Students were the
stopped to analyze this figure as it related to dis-     ones who studied this philosophy-and found it
tribution and specialty. Yet on the basis of gross       lacking, out of balance, out of synchrony with the
numbers alone the gates were thrown open to               times. While our generation focused mainly on
foreign-trained physicians, and they came in              individual patients, and accused our immediate
droves-to fill the need. This is not the time or         successors of looking mainly at disease mecha-
place to discuss the merits or debits of this most        nism, indeed recent graduates were the ones who
complex situation. But the fact is that this relaxed      looked beyond both-at the need of society.
policy of medical immigration did little to take
the pressures off American medical schools.                  There is a requirement that all three aspects-
   Thus, to accelerate the production of warm            patient, mechanism and society-be kept in mind,
medical bodies, many medical schools condensed            and they are not mutually exclusive. But it is a
the curriculum by emasculating or deleting "irrele-      difficult balance to strike. However, the point had
vant" departments (clinical pharmacology was an          been made.
early, costly casualty); some merely eliminated              Admittedly, many perceptive educators had
vacation periods and began to churn out gradu-            already began to suspect that perhaps the post-
ates in 36 months. Not much time for reflection,          Flexner momentum had crested, and that under
or emotional growth, or evolution of the other in-        their stewardship the thrust of medicine had
tangible elements that go to make up that elusive        carried beyond its cardinal purpose-the care of
quality we call medical maturity.                         patients. They began to realize that concepts of
   No one seemed to ask "What is the hurry?"              patient care had become lost, sidetracked some-
Also no one paid much attention to where the              where in the fascinating catacombs of scientific
warm bodies, foreign and domestic, gravitated.            methodology. Educators began to realize that
And there was no perceptible change in the pat-           through their teaching, diseases had replaced pa-
tern of physician distribution-geographically or          tients in the priorities of education in medicine.
by specialty. No one faced the problem of "How
are you gonna keep 'em down on the farm-after            An Awesome Body of Knowledge
they've seen Paree" or, to paraphrase, "How are            But one must not forget; the smoke in the forest
you going to keep 'em down on the Indian reser-          had originated in a most remarkable crucible. The
vation, or in the horizontal ghettoes of the delta,      golden years of research and postgraduate clinical
    444     MAY 1975 *      122 * 5
                                    ANTI-INTELLECTUAL MOVEMENT

training that began after World War II had pro-        present trends continue (the production of our
duced an incredible cadre of talent and an awe-        medical schools plus the continued influx of
some body of knowledge. New pathophysiologic           foreign medical graduates), within 12 years the
mechanisms had been identified. Dramatic dis-          United States physician pool will number between
coveries in molecular biology, immunology,             495,000 and 520,000. By 1985 we will have 220
cytogenetics, and enzyme and hormone chemistry         doctors per 100,000 population as compared with
had occurred. New diagnostic techniques and            160 in 1970. If you believe this projection (and
therapeutic tools were devised. All were products      this numbers game has been the subject of great
of these marvelous years.                              debate) we are facing a doctor surplus.
    This was reflected in gigantic growth in capa-        Listen to the words of Dr. Charles C. Edwards
bility for quality patient care. Admittedly, the       at the Association of American Medical Colleges
distribution and availability of this care were far    meeting in 1973, "I think that clearly we have
from optimal, however-as I said earlier-social         moved beyond the point at which concern about
and economic implementation always lags behind         a shortage of physicians was genuine if somewhat
advancement in sciences. But the capability was        exaggerated. Even more significant is the possi-
there. (I sometimes suspect that in the grand          bility we may well be facing a doctor surplus in
scheme of life, there are times when such sudden       this country." Later he said "The task the medical
spurts of genius and productivity must occur to        schools now face is to work toward solution of
maintain viability. But always, something else         problems that relate not to aggregate numbers of
must be sacrificed.)                                   physicians, but to specialty and geographical mal-
    Thus, despite this flush of success in science,    distribution, physician productivity, and the under-
some of us felt that during these grand years of       representation of women and minorities among
progress in hard science, something had been lost      the health professions . . . "
along the way. Perhaps it was that bedside senses
were being neglected and were becoming dulled.         The Government and Medical Education
We thought that some training programs were out
of balance; there was too much mechanization;             This can be translated into the fact that the
 too much stress on nuts and bolts-too little stress   government is taking a hard look at its philosophy
on people. In the passionate effort to master the      of financing medical education. The holders of the
 vast new knowledge, students were being deprived      federal purse strings are not satisfied with the cur-
 of something vital and wonderful and satisfying in    rent efforts by medical schools to meet the prac-
 medicine: the joy of eyeball-to-eyeball, personal,    tical needs of the citizenry. Another example:
 one on one, longitudinal communication with pa-       There was a bill (S-3585, Kennedy-Javits) which
 tients. The humanity of medicine was all too often    was approved by the Senate Labor and Educa-
 shunted aside in the headlong pursuit of hard         tion Committee. In its original form it would have
 science. There was more to be learned, and less       provided almost 2 billion dollars over a three-
 time to learn it. Something had to be sacrificed,     year period in federal aid for medical and other
 and we felt the choice, although it was perhaps       health profession schools. This bill would have
 inevitable, was unfortunate. In many cases the art    given the federal government power to allocate
 of medicine was left on the curriculum cutting-       and limit postgraduate training for physicians. It
 room floor.                                           included a provision designed to curb the reliance
     But the smoke in the wind became even more        on foreign medical graduates and to increase the
 perceptible about three or four years ago. Things     number of primary-care physicians. It would have
 began to shift back toward the bedside. Preceptor-    required the Department of Health, Education
 ships, neglected for 25 years, were being redis-       and Welfare to limit the number of postgraduate
  covered. Most clinicians viewed this with cautious    training positions in hospitals to no more than
  pleasure. A balance was being struck between          10 percent above the total of domestic medical
                                                        and osteopathic school graduates of that year, and
  bench and bedside. But in recent months, my           to assign the total number of physicians to various
  delight has begun to fade. It has been replaced       categories of specialty and subspecialty training.
  by something close to alarm. Let us look at what
  is happening.                                            Among other provisions of this bill were those
     We are told by people who should know that         that would require all young physicians to serve
  despite the current overall physician shortage, if    for two years in a sort of domestic peace corps

                                                         THE WESTERN JOURNAL OF MEDICINE            445
                                      ANTI-INTELLECTUAL MOVEMENT

program, whether or not they received federal          internists, pediatricians and obstetricians. So
loan or scholarship help. Also, within two years       evidently there is a long way to go to meet the
the Department of Health, Education and Wel-           current need in numbers-as well as in         distribu-
fare. would establish national standards for li-        tion.
censure of physicians and dentists. Under this bill,       But in recent months have experienced a dim
licensure renewal would occur at least every six        sense of uneasiness. I have detected a subtle anti-
years. A physician or dentist licensed to practice      intellectual, antispecialty, antiresearch movement
in any state would qualify in any other state in        developing at several levels, and it is expanding.
which the national standards are in effect. If a        Some might say that we had it coming-after
state had standards exceeding the national stand-       years of pejorative comment about the LMD on
ards, a physician coming into that state would          our wards and in our clinics. Yet, while we all
have to meet the additional requirements.               advocate more family physician training, I can
   Thus it was designed to require all recent          see no useful or rational purpose in denigrating
medical graduates to serve in shortage areas, to        investigative or specialty medicine, while pursuing
limit the number and variety of postgraduate posi-      this new venture. I have heard such things as "stu-
tions and to ensure the relicensing of all physi-      dents with good science grades do not necessarily
cians. The final, much modified version-as              make good doctors." This may apply to some
amended by Beall of Maryland-was passed on             few, but it is the implication of the statement that
September 24 by the Senate, 81 to 7. It would          is disturbing. It has an anti-intellectual ring. No
provide federal aid to medical and dental schools      one can deny that there is a need in the selection
that agree to allocate 25 percent of their class-      process to seek out students who have qualities
room spaces for students volunteering to serve in      of compassion and human warmth. Also this
urban slums or rural areas short of medical care       aspect of personality must be nurtured and en-
workers. In return for their service, the students     couraged during the years of education in medi-
would be entitled to government scholarships.          cine, yet one must not ignore the seminal im-
The bill would require one year of service for each    portance of a firm foundation in the sciences.
year of scholarship aid.                                   Human compassion and academic excellence
   To say the least, all of this is most provocative   are not mutually exclusive virtues. Some of us
-and I will not speculate upon it at this time.        are egotistical enough to think that we have come
Suffice to say that it is perhaps an indication of     close to this ideal. And we are many.
what is in the wind, a cardinal demonstration that         This is not a time for intemperate generaliza-
the government is indeed concerned about prob-         tions; these are indicators of panic and reaction.
lems of contemporary medicine in America at all        It is the time for balance-rational creative plan-
levels. And I will not speak of the implications of    ning and the initiative should come within the
Professional Standards Review Organizations,           profession.
Health Maintenance Organizations or national
health insurance on medicine overall. But let us           It is encouraging that many of our medical
return to the problem of medical education.            young are highly motivated to family practice.
                                                       And we do need more of them. Yet we must
                                                       continue to produce a proper proportion of
New Educational Directions                             specialists and investigators to complement the
   In an effort to anticipate this need to qualify     health care team.
for such federal support of medical education,             And I must express my concern that govern-
many schools have reevaluated their priorities in      ment through its fiscal power over medical educa-
curriculum planning. One major thrust of all of        tion is seeking means to control the input into
this has been the creation of departments of family    medical specialties. It is antithetical to traditional
medicine-a welcome, long overdue development.          American freedom of choice for government to
The popularity of these programs is evident            exercise control over one's selection of his life-
through the progressive increase in positions and      work. Yet unless medicine itself can solve this
applicants over the past three years. One estimate     problem of specialty growth and distribution, it
by the Division of Manpower Intelligence places        may well become a function of government. As I
the current shortage at 27,000 to 30,000 family-       look ahead 10 to 20 years, my crystal ball be-
care physicians such as general practitioners,         comes distressingly cloudy.
   446     MAY 1975 * 122 * 5
                                     ANTI-INTELLECTUAL MOVEMENT

Improving Physician Distribution                       them there long enough, they will find cures for
   The problem of physician distribution is ad-        cancer, heart disease and stroke."
mittedly difficult, but I do not think it is insur-        Well, timetables may be applied to mathemati-
mountable. There are several possible options.         cal and physical sciences. And the pharmaceutical
Federal subsidy of students with a mandatory           sciences have been successful in the creation of
two year pay-back time is one possible solution.       new molecules through a goal-directed orienta-
But again the implication of univers!l compulsory      tion. Propylthiouricil and several synthetic anti-
service has ominous overtone. And, parentheti-         biotics (most notably rifampin) have resulted.
cally, I might add that if indeed this comes to            But biological arts do not work this way. In
pass for medicine, why should we be singled out?       medical research there is, unfortunately, one
Why not dentists and lawyers and teachers and          variable that cannot be manipulated: the patient.
perhaps even engineers, architects and plumbers?       The myopic bureaucratic philosophy that seems
Certainly these services are also maldistributed       to say "If we can get to the moon in ten years-
throughout the country. But I am wandering;            certainly we can cure cancer in 15," was imple-
down this catacomb lies madness.                       mented through various mechanisms resulting in
   Also regarding distribution, I am convinced         a significant constriction of research funds, most
that there are many physicians who can be in-          of which were diverted from "non-goal-oriented
duced to care for patients in less desirable geo-      research." The alleged fat was trimmed merci-
graphical areas. This can be done by a reorienta-      lessly. Those who could not be enticed or coerced
tion of philosophy and priorities, by offering a       into "target-oriented" research began to drift
rewarding lifestyle, by a team approach, with          away. It is probable that a significant portion of
perhaps three or four family-oriented physicians       one or two generations of young investigators has
working in a group each trained in a different          already been lost. It is a tragedy of dimensions
 discipline-internal medicine, obstetrics-gynecol-     that may never be fully appreciated, since it can-
                                                       not be measured. How do you evaluate something
 ogy, pediatrics.                                       that was never discovered?
    There must be professional recognition by col-          Throughout the history of art and science
 leagues and an end to the denigration of the LMD.      there have been some free spirits that cannot be
 There must be realistic financial compensation
 and rapid access to specialist backup. These phy-
                                                        tethered. They must be recognized, cherished and
 sicians must also be provided a practical continu-     given their heads. These have always been our
                                                        most creative people; this is the nature of art and
 ing medical education program, perhaps through         science. Alas, it is a concept alien to the bureau-
 periodic sabbaticals, while they are replaced by       cratic psyche.
 someone of comparable background and training.             And how much progress have we made in the
    It is beyond the scope of this discussion to        war against heart disease, stroke and cancer? We
 consider the role of physician assistants in this      are still a nation of slaves to cultural indolence;
 plan. But their potential contribution to patient      we are overindulgers in food, alcohol and ciga-
 care in remote areas and in other sections where       rettes, and underindulgers in exercise, seat belts
 physician distribution is a problem, is another        and self-restraint. No magic bullets have been
 distinct aspect to the solution of the distribution    forthcoming; no earthshaking breakthroughs from
 dilemma.                                                those locked into target-oriented research pro-
                                                        grams. There is statistical indication that there has
 Changes in Investigative Medicine                       been some reduction in the deaths from myo-
    Now let us talk about what has happened in           cardial infarction over the past five years. And
 investigative medicine. It was about seven years        some have related this to a more rational diet
 ago that we began to hear new words such as             among American men. But aside from this glim-
 targeted research and goal-oriented investigation       mer of light, there is little evidence of success in
 -words sprung from the lexicon of the bureau-           other areas.
 crat. It epitomized a pragmatic philosophy that             Too often, solutions of medical problems are
 seemed to say, "Trap the brightest investigators        inextricably interwoven with cultural, social and
 you can find; lock them in a laboratory with the        economic phenomena. As all of us know, quite
 finest equipment and limitless resources; feed,         often major discoveries are the result of seren-
 water and pet them occasionally. And if you keep         dipitous observations in disparate disciplines-
                                                         THE WESTERN JOURNAL OF MEDICINE             447
                                     ANTI-INTELLECTUAL MOVEMENT

seemingly unrelated-small discoveries made by          to the absurd, each time we treat a patient with
bright, independent, non-goal-oriented people who      an approved drug or submit him to a well-tried
just happen to meet and chat on boardwalks or in       surgical procedure, it is indeed a miniature human
coffee shops.                                          experiment. We speak of a risk-benefit ratio-this
                                                       is itself a euphemism for human experimentation.
Continued Support for Basic Research                      It is a truism that every significant advance
    There is an urgent need for continued support      throughout the history of medicine has been based
                                                       on human experimentation. One wonders how
of investigation in basic science and clinical re-     Pasteur, Koch, Jenner, Reed, Florey and hundreds
search. Perhaps investigative medicine should not      of others would have fared at the hands of some
be as unstructured and insensitive to fiscal reality
as in the past, but there must be a mechanism for      protocol review committees? And should they
                                                       have been permitted to do such studies? Were
recognizing and encouraging investigative vir-         they less moral, less sensitive? Was life worth less?
tuosity. This is the heart blood of medicine-the          It would seem that at some periods in history
source of new knowledge.                               the rights of the individual person weigh more
    We must not overreact by a return to pre-
Flexner attitudes-just as we must not continue         heavily than those of society. Then the pendulum
                                                       will swing again. The dilemma is this: protection
an unrealistic spiral into superspecialties at the
                                                       of the rights of the individual balanced against
expense of primary care physicians. I will repeat
                                                       the good of mankind. Is there ever an occasion
-there is need for balance.                            when the civil liberties and moral rights of an in-
    I believe there will always be room in medicine
for men and women of talent and dedication, and        dividual can be set aside to achieve a greater
I think this essential freedom can be preserved        good? Answer that, and all other factors fade
without limitation of professional options as seems    into insignificance. It is impossible to generalize.
to have occurred in England and Sweden. And            Must we begin to think in terms of lesser morality
I repeat-I fear the incursion of government into       and greater morality? What is our moral obliga-
this seminal aspect of medical education-as it         tion to women with breast cancer now, who might
fills a vacuum-a void left by the indolence and        be tested with a drug that may arrest the tumor,
indifference of medicine.                              but may have significant toxicity-as opposed to
                                                       our moral obligation to untold future generations
Human Investigation and Morality                       of women who we know will die of breast can-
                                                       cer? How does one measure the morality of pres-
   Finally, one other area deserves comment. The       ent risk against future benefit? Clearly, it would
third direction of the anti-intellectual fire in the   be immoral to stop research in cancer, stroke and
forest is human experimentation. This unfortunate      heart disease.
expression seems to conjure up images of Buchen-          And who are to be the volunteers who provide
wald. I will confine these remarks to research on      informed consent (that nightmare of social, eco-
humans, the problems of abortus research, use          nomic, psychologic and legal entanglement which
of materials derived from human sources and            defies universal definition)? Should the volunteers
animal investigation would carry us far into the       be restricted to research scientists? (Well, surely
night. But let us talk about human investigation.      in this group there could never be a question
   No rational person will deny the virtues of a       about full awareness of present risk or full cogni-
sensitive but rational protocol review committee.      zance of possible future benefit.) Are we ever
And there have been lapses in our vigil to pro-        justified in the use of children (How do you in-
tect human individual rights. But I submit that        form a child?); can a parent give consent for a
most often these lapses have been caused by            child? How about prisoners (whose situation
carelessness, or overwork, or overenthusiasm           always might be construed as intrinsic coercion)?
rather than by callousness. There are exceptions.         As an aside, after publication of a recent edi-
   No matter what semantic gambit one may wish         torial in JAMA-an eloquent plea to protect
to employ, we are all in the business of caring for    prisoners-we received several letters from
human beings. Therefore, we must learn about           prisoners who expressed anger and frustration-
human beings. And in the final analysis, I know        at the possible restriction of their rights as human
of no other way to do this than to try procedures      beings to volunteer for medical research projects-
and therapies with human beings. To extrapolate        in an effort to square themselves with society or

   448     MAY 1975 * 122 * 5
                                      ANTI-INTELLECTUAL MOVEMENT

to indicate their desire to cooperate with society      from Helsinki-to vilify the investigators. To me,
or even just to earn extra money and privilege.         this is destructive, purposeless sophistry.
So there is never black and white-in any situa-            Thus, I submit, it is time to stop and take
tion.                                                   inventory.
   And how about using the mentally retarded
(who may certainly be incompetent to give in-           The Three Cardinal Issues
formed consent)? Are we justified in using any             Some may say I have erected three men of
of these groups of persons who are less likely to       straw-hobgoblins of my own nervous invention.
make a contribution to society than are research        I hope this is true. But in my opinion postdoctoral
scientists? And who is to make such a judgment?         education, research in general and human experi-
   I pose to you an insoluble dilemma. All one          mentation are cardinal issues, at risk in the
can ask is that each situation be studied with con-     present and in the foreseeable future.
summate circumspection and be approached ra-               I believe we stand at a major impasse. I see
tionally and compassionately. Again I am not            a vast swampland of intellectual impoverishment
convinced that ironclad guidelines, even etched         in medicine looming ahead. Yet scattered through-
in tablets from on high, will solve the problem.        out I see tender saplings of what could become
   One might say that no person has the right to        a magical forest destined to flourish and bring the
involve another person in an experiment that            bounteous blessings of an improvement in the
could maim or kill, regardless of the desire of the     quality of life to all of our people.
volunteer or the probable benefit to mankind.              So we must select our options with prudence
And this is a debatable point. It has more shades       and circumspection. If we do less, if we falter
of gray than a charcoal drawing.                        and despair, one day we may all awaken clutched
   Yet, we cannot let progress in medicine grind        in the doughy embrace of pervasive mediocrity.
to a halt in a backlash of neurotic guilt and sancti-   And so I say let us look to the forest.
mony. You know it has become almost fashion-               Let us approach the future with courage, born
able-a herd instinct-for anonymous referees             of the conviction that man is a most remarkable
of medical manuscripts and rare, timorous journal       creature-capable of rising to the need of the
editors to respond to papers that include the use       hour, capable of inspiration to solve his problems
of human volunteers (in almost any context)             with vision and tenacity and practical genius.
with pharisaic castigation-hurling thunderbolts         These have been the hallmarks of our species.

                                                         THE WESTERN JOURNAL OF MEDICINE           449

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