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Thoughts on future relationships between physicians medical students and citizens walter bauer memorial lecture.

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Arthritis and Rheumatism
APRIL, 1965
Thoughts on Future Relationships between Physicians,
Medical Students and Citizens
(Walter Railer Memorial Lecture)
DID NOT IN ANY real sense know Walter Bauer personally, though I
met him on occasion late in his life. I know him, however, in the way most
in medicine know him, as a leader in medical eduction. I also know him by
knowing his associates and students and realizing the ways in which he influenced them. Two outstanding features of Walter Bauer’s life strike me:
his incessant effort to improve medicine and medical education, in particular
by demanding the highest quality of performance from young people while
simultaneously giving them large amounts of responsibility, and his willingness to go beyond the conlentional in thinking and acting in medical affairs.
This is hardly an adequate summation of the heritage which he left us, but if
we all were to emulate these characteristics successfully, perceptible improvement would occur. It is indeed an honor to give the Walter Bauer Memorial
The past decade has witnessed a concerted effort to make the study of
arthritis and rheumatic diseases a scientific endeavor. Significant accomplishments can be measured. These years have seen (1) the discovery of autoimmunity and confirmation of the suspicion that immunological abnormalities play a role in rheumatic diseases, ( 2 ) the emergence of evidence indicating a hereditary susceptibility to rheumatic diseases and ( 3 ) the appearance of relationships between rheumatic diseases and other illnesses with
identifiable immunological abnormalities such as lymphomas. The study of
the rheumatoid factor and of mveoloma proteins has led to beginning understanding of the structure of gamma globulin and the genetic control of its
synthesis. Because of techniques developed in the aforementioned studies,
it is now possible to begin the search for individuals who are susceptible to
rheumatic diseases, thus hopefully permitting introduction of preventive
The emergence of immunology as a major discipline for the study of human
biology has been central to these developments. Immunological techniques
and concepts have not only shed light on rheumatic diseases but promise to
do so on many biological and clinical problems ranging from embryogenesib
and cell differentiation to oncogenesis.
It would be appropriate to speak about these developments. In an oblique
sense, I shall. However, the transformation of medicine into a scientific discipline, to which the study of rheumatic disease has contributed, raises many
relevant issues for the physician and the medical teacher. I cannot resist the
temptation to speak about two. They are, first, the adequacy of current medical education for training the physician for the future and, second, future
relationships between the medical profession and the citizens.
Thc vision of one who attempts to peer into the future cannot be validated
by others at the time. What he perceives is quite subjective, and may contain
more than a trace of the prejudices of the seer. Furthermore, the above issues
are difficult to understand with clarity. However, they are of the greatest
importance; we have no choice but to examine them.
Before speaking on these subjects, some consideration of the current state
of medical science and its potentialities is relevant. Today the provision of
medical care is one of the largest industries in the country. In 1964, the total
cost of medical care in the United States will approach 33 billion dollars exclusive of the loss of income resulting from illness and death. Proportionately
many more citizens avail themselves of medical care now than in the past.
Techniques of medicine have increased considerably in number, scope and
expense. But, if one asks what is the state of the art so sought after and so
expensive, we must answer that it remains relatively primitive when compared
to what it can and will become.
Though the diagnostic skills of the physician have become quite good, his
Gbility to understand the disease process and to intervene meaningfully to
terminate it are grossly inadequate. The causes of such major illnesses as
cancer, cardiovascular disease, mental illness and arthritis remain obscure. In
the absence of knowledge of the cause of an illness, it is unlikely that a highly
eflective therapy will be available. None is for the aforementioned illnesses.
True, we have ways of helping the patient by the use of drugs, surgery,
supportive measures and sympatliy. The drugs which are used, however,
were discovered by chance. Their methods of action are usually not known,
the ways in which we use them have been arrived at pragmatically, and they
are not very effective. Indeed the mechanisms of action of three of the most
important drugs known to man, aspirin, digitalis and morphine, are unknown,
and the actions of a fourth, penicillin, are merely beginning to be understood.
Our ignorance is all the more apparent when dealing with the questions of
normal life and health. The processes of conception, growth, development,
learning, maturation and senescence remain unexplained. Thus, despite the
seemingly good care we are able to provide in a modern hospital, in an absolute sense the quality of medical care is poor.
However, the capabilities of the physician may soon undergo a dramatic
increase. The rapid delielopments in biological sciences since the 1940s are
beginning to have a major impact on medical knowledge. The ways in which
information is passed from parent to offspring cell are becoming known. The
processes responsible for the development of the complex mammalian body
from two original cells are now amenable to study. Some of the factors which
control cell growth, and go awry in cancer, can now be fruitfully explored.
The ways in which a virus or a bacterium affect another cell are being identified and, very recently, mechanisms of action of a variety of antibiotics have
been discovered. The process of learning by brain cells is now susceptible to
study. Control of the immune response to the point of permitting transplantation of tissues between unrelated individuals is in the offing.
Application of this new knowledge to the study of disease will almost certainly begin to lay bare the biological processes whereby we becomme iI1.
Such an understanding would then permit for the fist time, the design of
medical treatment aimed at correcting the abnormalities which lead to disease. If this should not prove feasible, it may be possible to substitute a norma1
or even a mechanical organ for one which is diseased.
These anticipated developments in medicine are likely to occur in the
context of major changes in the society in which we live. These changes will
also affect health and our ability to provide medical care. The availability
of- energy from nuclear and solar sources, coupled with automatic production techniques, may have extraordinary consequences. The magnitude of
the energy potentially available can be seen from the fact that once nuclear
fusion (the process involved in the hydrogen bomb) has been controlled for
peaceful purposes, 230 cubic meters of heavy water will provide the energy
now obtained from the entire annual coal output of the world. Harnessing
one-tenth of the wasted solar energy which strikes the earths surface could
provide industrial energy many times the total now generated throughout
the world. The availability of nuclear power sources of small size will permit
the construction of industry at virtually any place on the earth‘s surface, eliminating the necessity of building or maintaining industry near sources of
fossil fuel or transportation networks. Automatic production methods will
greatly increase productivity, reduce the need for continuous supply of manpower and thus reduce one of the major reasons for development of large
cities near industry. Decentralization of both industry and population will
be economically feasible and indeed it may become possible and desirable
to rebuild the face of the country. The eradication of poverty and slums with
their disease breeding consequences will be possible. Rapid transportation
will bring the best medical care within physical reach of everyone. The next
decade or more will likely witness the emergency of a new era in the history of man, marked by man’s development of the ability to control both his
environment and himself.
In addition to many extraordinary advantages, dangers will accompany
this assumption of power by man. As we begin to alter nature more and more,
there will be an increasing threat that our environment will be made harmful
to us by our own actions. The use of radioactive materials brings with it
ths problem of disposal of radiwctive wastes and potential environmental
contamination. The same is true for the use of poisons in pesticides, detergents in cleansers and many other products of the growing chemical industry.
The citizens, whose lives will be directly affected, will have a large role to
play in shaping government policy on the use of new technological skills.
They will have much to learn in order to fulfill that role. I should like to
speculate on some of the implications of these developments for the physician.
A far more advanced and complex understanding of human biology will
require that the physician be a thoroughly trained scientist in order to comprehend the problems of his patient and the available methods of treatment.
The power to alter heredity, to change brain function and to change an individual physically by transplantation of tissues, a11 of which are potentially
possible, will add enormously to the responsibilities of the physician to the
patient. Rarely in the past, or even today, have we had at our command
techniques which of and by themselves could radically alter the function
and life of the patient. The physicians of the future will. No longer will they
use a dangerous drug virtually only when confronted with a hopeless situation, usually with negligible likelihood of success. Treatment in the future
may at times not only save the life of the patient, but change him. The relationship between the physician and the patient will become more profound
in terms of the patient's need to understand the consequences of his disease
and treatment, in terms of thoughful and sympathetic advice concerning his
choices, and in terms of guaranteeing participation of the patient in the making of decisions. The physician may also be called upon to serve as counsellor
to the community on such matters as potential environmental contamination
and the design of laws and 1ieaIth measures which could protect against it.
The physician of the future must be a competent scientist, a practitioner of
medical skills, and an educator and advisor of both his patient and the public
at large. Anything short of wise discharge of these responsibilities will represent f ai'1ure.
Now to return to the two subjects previously raised. First, how well does our
current medical education prepare the student for the future?
Historically, medical eduction has been an apprenticeship training period.
The intellectual substance of medicine was developed through pragmatic experience on the part of doctors, who transmitted this information to the
student by having him join with them to learn. The good student was considered to be the one who best emulated the teacher. This is part of the historical genesis of the view that medicine is an art, not a science.
The introduction of science into medicine, which has been particularly
rapid in the last two decades, has somewhat changed the orientation of medical
education. Students are expected to learn about science and the scientific
method and to begin to apply this to work with patients. However, the current
teaching of clinical medicine all too often retains attributes of the old apprenticeship. It is commonly based on subjective impressions and experiences
of the teacher rather than upon the understanding, even though inadequate,
which we now have of disease mechanisms and the effects of treatment. Medical literature is characterized by generalizations and practical conclusions
which are not substantiated by fact. We are all familiar with the inadequate
proof of the widely disseminated assertions that diets low in fats will reduce
the incidence of atherosclerosis or that the use of anticoagulants will reduce
recurrent coronary occlusions or cerebral vascular accidents. An example less
obviously in this category is our common teaching that pulmonary edema
results from left ventricular failuie and is primarily cardiac in origin. Because of this view, our treatment consists in the main, of the use of digitalis
and diuretics, though fortunately morphine is usually included. What would
be our teaching, and perhaps our treatment, if Gamble had created acute
hemorrhagic pulmonary edema by placing a lesion in the hypothalamus before
Welch produced the same result by putting a hot iron to the left ventricle?
Contradictions are apparent between the practices of the past and the needs
of the future in the teaching of s t d e n t s . In the past, the student learned the
accumulated experiences and techniques of the teacher. Today he must 3ssimilate large amounts of scientific information gathered in many disciplines.
In the past he learned diagnosis and treatment by formulae passed on from
the teacher. In the future he will have to know the independent exercise of
the scientific method including conduct of an analysis, evaluation of data, and
application of conclusions to a given patient in terms of the likelihood of
success in diagnosis and therapy. In the past, the student was expected to
emulate the teacher. Now he must be taught to be independent, to accept
that part of teaching which can be substantiated and to reject and refrain
trom using that which cannot.
The persistence of the apprenticeship training method in current medical
education has a stultifying effect upon the student. By not perceiving the
scientific method themselves, many teachers tend to suppress the originality
of the student, to restrict his opportunities to probe unsolved problems, and
consciously or unconsciously to compel him to think as they do. As with
other diciplines which involve analysis followed by action, medicine and
science require teaching which gives the student impetus and opportunity to
learn independent thought, judgment and action. How long will it be before
medical education as a whole recognizes that medicine and science cannot
be taught by providing answers for students? The task of the teacher is to
pose problems for the student, to demonstrate what is known and what is
unknown about these problems, to make clear to the students the limitation
of the teacher’s understanding and to challenge and stimulate the students
tci go beyond the teacher. In this \yay, goals will be posed and the students
propelled toward their realization. Because characteristics of this type do not
dominate in medical education today, we are not appropriately preparing the
doctor of the future.
The increasing intrusion of science into medical education brings with it a
second problem which confronts all scientific disciplines, and which is of
great relevance for medical teaching. This is the problem of authoritarianism
in science. It is created by the increasingly intense study of narrower areas of
science. As a result the individual scientist’s knowledge of other fields is frequently reduced, forcing him to rely more and more on the stated views of
authorities in other areas. The scientist so afflicted, not knowing the observational basis of the conclusions or prevalent hypotheses in an adjacent
field, will be more likely to fit his conclusion into an erroneous framework for
generalization or may avoid generalization, being content to amass descrip-
tive information. The result may be either an incorrect general conclusion or
merely a collection of isolated bits of information, without identification of
natural laws which govern the phenomena under investigation.
The issue has been sharply focused by Hubbard, in an article entitled, “Are
we retrogressing in Science,” in Science, 8 March; 1963. Stressing that the
true authority on natural phenomena is the valid observation or experiment,
he states: “It follows that the acceptance of any conclusion, valid or otherwise,
hy an individual who is not familiar with the observational data upon which
it is based and the logic by which it is derived, is a negation of science and
a return to authoritarianism.”
Hubbard then develops the thesis that the evolution of science is not one
of increasing complexity, but, on the contrary, is a progression from the
complex to the simple. Science dervies, out of a welter of seemingly unrelated
pieces of information, a few generalizations which reduce wide ranges of
phenomena into relationships which are comparatively easy to understand.
In our field of biology one recognizes the enormous unifying and clarifying
force of the Darwinian theory of evolution. the gene theory of heredity, the
germ theory of disease and the concept of homeostasis.
One of the harmful aspects of authoritarianism is its contribution to a decline of theory. Narrowness of perspective limits the ability to discern and to
use wisely the central theories of other fields. Commoner, writing recently
on this matter, stressed the way in which recent developments in nucleic
acid biochemistry have been interpreted by some to resolve the age-old
conflict concerning the origin of cell division in favor of the hypothesis that
there is a self-duplicating seemingly “living” subcellular material. By implication, this material, DNA, contains within itself and transmits all the characteristics of life. Commoner’s view is that a more inclusive knowledge based
upon the physicist’s concepts of complementarity, the embryologist’s concept of differentiation and the chemist’s knowledge of the role of protein
enzymes in replication of DNA would preclude this generalization as being,
at least, premature. Not all of the relevant data have been considered. Commoner’s criticism is not without substance, because some microbiologists
have clearly expressed the view that once the genetic code is cracked, problems of biology will be resolved.
It is particularly striking that current concepts of the role of DNA in inheritance have become known amongst some scientists as the “central dogma.”
What irony-the most modern descendant of the Reformation and Renaissance, the molecular biologist, endowing his recent hypothesis with the term
dogma at the precise moment that an antagonist of the Renaissance, the
Catholic church, is actively broadening its intellectual horizons and eliminating
untenable aspects of its theological beliefs.
Such matters are potentially quite relevant to medical teaching. Despite
the illuminating biological theories mentioned, there is a poverty of theory in
medicine. We have no appropriate concepts to clarify such major processes as
the intrinsic rhythmicity of cells (e.g., brain or heart cells), the influence of
one organ system upon another (e.g., the role of the nervous system in tissue
response to infection or renal effects on blood pressure), or the influence of
m e cell upon anothcr (e.g., cell differentiation or cellular hypersensitivity or
the effects of breakdown products of a liver cell upon, say, a cell of the lung
or the endothelium).
We have a tendency to attempt to apply to medical matters whatever biological concepts are current. Those of molecular biology are now fashionable,
witness the stream of articles interpreting human biological phenomena in
terms of nucleic acid biochemistry. Some of these interpretations will prove
correct and they will certainly stimulate important thought. However, concepts developed with unicellular organisms may not be directly applicable
to the mammalian cell or to the integrated functions of many organ systems
in the mammalian organism. It i y not a matter of minimizing the importance
of nucleic acids; it is a matter of avoiding the narrowness 06 horizons and
premature generalizations which give the appearance of universality without
the substance. We would be wise to imbibe the principles of various biological fields and to develop the discipline of clinical investigation which will
permit us to derive laws of human biology directly from observations on
human beings.
The undesirable consequences of authoritarianism in science lie less in the
delay which they cause in the emergence of true knowledge than in the
damage they do to the students. The student may become alienated from
medicine by lack of originality, flexibility and breadth in its scientific thinking just as readily as he will from a lack of scientific content.
If it is true that there is a major shortage of science in medical thinking
and teaching, and that the science which is present is afflicted with the
problems of parochialism, specialization and authoritarianism, then we who
are teachers of medicine have much to do before it can be said that we are
appropriately training the doctor of the future.
The second subject dealt with relationships between the medical profession
and the citizen. I should like to speak first of the citizen’s understanding of
medicine and second of the citizen’s role in the provision of medical care.
Medicine deals with the most personal aspect of a human being’s existence,
his health. No other branch of science possesses so immediate and personal a
relationship with the citizen. As science has burgeoned in recent decades, its
impact on the citizen has steadily increased. The desirable relationships between science and other elements of society in terms of financing, direction of
effort, understanding and ultimate control have not been established. The
relationship of scientific medicine to the citizen is no more clear. Perhaps
I can illustrate the point best by a brief digression into the general problem
of science and society.
Sir Charles Snow brought the issue to a head a few years ago by asserting
that the scientist, by virtue of his training, is slightly more objective and honest
and therefore slightly better equipped than any other person to lead society.
This unleashed a storm which has yet to subside. Robert Hutchins countered
with the view that his experience as a university president convinced him that
professors were somewhat worse than other people, and scientists were some-
what worse than other professors. Such is not the stuff of illuminating debate.
However, Hannah Arendt, writing in the October 1%3 issue of The American
Scholar on “Man’s conquest of space,” has presented a most succinct statement
of the issue. “Has man’s conquest of space increased or diminished his stature?
The question raised is addressed to the layman, not the scientist, and it is inspired by the humanist’s concern with man, as distinguished from the physicist’s concern with the reality of the physical world.” Professor Arendt continues: “The answer is not likely to convince the scientist because he has been
forced under compulsion of facts and experiments to renounce sense perception and hence common sense by which we coordinate the perception of our
five senses into the total awareness of reality.” Dr. Arendt’s fundamental concern is that science, by reducing phenomena to abstractions, has developed
a perception of man in the universe which is not understandable in human
terms. It thereby becomes antihuman.
Dr. Arendt continues: “For the point of the matter is, of course, that modern
science-no matter what its origins and original goals-has changed and reconstructed the world we live in so radically that it could be argued that the
layman and the humanist, still trusting their common sense and communicating
in everyday language, are out of touch with reality, and that their questions
and anxieties have become irrelevant.”
Quoting Nils Bohr to the effect that “only by renouncing an explanation of
life in the ordinary sense do we gain a possibility of taking into account its
characteristics,” she continues, “the very integrity of science demands that
not only utilitarian considerations but even the reflection upon the stature of
man be left in abeyance. The simple fact that physicists split the atom without
hesitation the very moment they knew how to do it, although they realized
full well the enormous destructive potentialities of their operation, demonstrates that the scientist qua scientist does not even care about the survival of
the human race on earth or for that matter about the survival of the planet itself.”
These are strong charges, and they are all the more difficult to refute for
they in no way challenge the scientist’s motives. These may be absolutely
pure and humanistic. The point is that the method by which the scientist
works, which is abstraction, is potentially antihuman and may lead him into
actions which are antithetical to the interests of the citizen. For one involved
in medicine, it is particularly striking to read Dr. Arendt’s article and substitute the phrase “the achievement of biological understanding” for “the conquest of space.” The effect is made even sharper by considering how one would
feel to be a layman in the hands of a physician possessed of the power to
change one’s mind or one’s reproductive function or one’s physical capabilities.
The issue is perhaps sharper for the physician than for any other scientist.
I n pure science, the subject is a fragment of nature. In medicine, the subject
is one’s fellow man. In abstract terms the difference is meaningless. In social
terms the difference is absolute. Unless scientific medicine is made understandable to the patient and the patient participates in the decisions as to
how it will be used, scientific medicine may become antihuman. Science, in
order to serve humanity, must be understood by human beings and its applications must be subject to their will.
Clearly the introduction of scientific medicine will require change in the
relationships between the physician and the citizen. The application of scientific medical knowledge to a patient will be one form of the use of specialized
knowledge by one citizen for the benefit of another. This will involve an intellectuaI compact considerably broader than discussions at the time of the
illness. The citizens will wish to know the powers of the profession, and the
ways in which the profession expects to exercise and control these powers. The
citizens will probably choose to identify those issues which are purely technical or professional and separate them from those which involve humanistic or
social judgment. The latter may well be removed from the jurisdiction of the
physician, as has been the case in the decisions concerning who will receive
protracted dialysis treatment for chronic renal failure in the city of Seattle.
Because of the deep personal character of illness, and the potential biological
powers of the physician, the relationship between physician and citizen could
become a prototype of the desirable relationships between men in the age of
To what extent are these matters represented in our curricula or on the
agendas of our medical societies? To what extent do they appear in our
thoughts as medical teachers and physicians?
The second aspect of the relationship between the physician and the citizen
relates to the financing and organization of medical education and medical
care. More immediate and controversial than the preceding issue, it is also
probably more easy of solution. Indeed the lines of solution have already been
demonstrated in the debate on Medicare. The public and its representatives
are beginning to make decisions about the ways in which medical care shall
be financed and organized.
We physicians are in a position to say, figuratively, to the citizens: “We can
treat effectively many simple disorders and we are beginning to cope well with
certain of the major diseases of man. We anticipate in the near future a great
increase in our ability to treat most diseases. While we can not stop the
processes of aging and death, disease is not a necessary accompaniment of
aging. We should be able to control and perhaps prevent much of the chronic
illness which our older people experience. However, to do all this will be
expensive and in any individual case the cost of medical care may become
extremely high. You the citizens must think about ways in which you wish to
take advantage of these developments.”
Perceiving this, the public will certainly concern itself with many aspects
of medical education and medical care. The profession will be unable to
avoid doing likewise. Indeed, a compelling case can be made for the view
that the public and the profession should work at the problems together.
Imagine that you were a member of such a working body. What would be
your views?
IVould you agree, as a beginning principle, that it is a proper objective of
physicians and of society to provide the finest medical care of which man is
capable to all citizens without subjecting any citizen or his family to economic
distress? I would hope you would. But if you do, many questions of considerable importance flow from there. What methods would you consider to finance
the care of patients? Despite the rapid growth of insurance in the past fifteen
years, only one third of medical costs are covered. Unless some means of financing are found to meet swiftly rising costs, large segments of the population are going to remain with mediocre medical care or worse. Will you agree
with the insurance principle? If you do, how widely would you extend it? TO
what extent would you consider that every citizen must contribute if every
citizen is to benefit? Would you accept the view that sound insurance funding
involves the insuring of the low risk (i.e., the relatively healthy young) simultaneously with the high risk (i.e., the elderly)?
How would you finance the education of doctors? Over the past decade,
with modest improvement in the past two years, the quality and quantity of
applicants to medical school has diminished strikingly. We are not now attracting into medicine the best young people in our country. Would you wish
to give the powers of which we have been speaking to persons who are
less than the best available? Will you tolerate a situation in which intelligent
and devoted young people cannot obtain a medical education for lack of
scholarship funds, or because of their color, or because they are women?
How would you solve the problem of guaranteeing maximum efficiency
of financial management and maximum quality of medical care? We know
that problems exist in the latter area as, for example, a recent incident in
which over 18 per cent of obstetrical deliveries were accomplished by Caesarian section until sharp criticism was levelled. The rate then dropped to
less than 3 per cent, indicating the real need for this procedure. Will you
seek to devise some sort of review boards? Do you believe that the consumer,
that is the patient, should have a voice in the planning and management
of medical care? If you do, how should this be expressed, and how should it
relate to questions of professional judgment? If the time arrives when the
medical profession has the power to alter the minds and bodies of patients,
how would you recommend that the patients and their families participate in
the decisions about whether this awesome power should b e used?
Up to now these questions have been left unanswered or only partly answered. As a result there is doubt that the existing forms of medical care are
compatible with the best development of medical science and the best distribution of the benefits of this science to the people. I do not believe they are,
for they have not resolved current problems, much less given evidence of
being able to meet the more demanding requirements of the future.
It is likely that a new relationship will emerge between the medical profession and the citizen. In this relationship the physician will retain the responsibility for professional aspects of his work, but will join with the citizen
in elaboration of the ways in which that professional knowledge will be provided to the patient and imparted to the student. The relationship of physician
to citizen will be a special case of the broader relationship between science
and society; and if I may hazard a guess, that broader relationship will be re-
dressed to place in the hands of the citizens a stronger rein over those applications of science which influence the well-being of society.
This relationship will also contain the seeds of resolution of the apparent
conflict between abstract and humanistic thought. Abstract thought, as practiced by scientists, is not inherently anti-human; it is, after all, the highest
product of the human mind. It appears anti-human when applied as a seemingly uncontrollable force in social affairs without the consent of the citizen. Abstraction will not be anti-human if the new relationships identified by abstraction are resolved again into common terms. An intellectual cooperation between the scientist and the citizen should provide the vehicle for accomplishing this.
It is indeed exciting to contemplate what the mind of man enables him to
do. In the field of meldicine for the first time the goals of a scientific medical
education and of medical care of high quality available to all are in sight.
The methods of achieving them are emerging. Considerable thought on the
part of both physicians and citizens will be needed, and probably much cooperative action between them. Such combined effort, not present in the past
or today, could provide the key to rapid utilization of scientific advance for
the improvement of medical care. I suspect that we could all come to enjoy
such an effort. I also suspect that if Dr. Bauer were alive, he would be in the
thick of it.
Halsted R. Holman, M.D., Prof. of Medicine, Stanford Uniuersity School of Medicine, Palo Alto, Calif.
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