Private Practice: In the Early Twentieth-Century Medical Office of Dr. Richard Cabot

Abstract

By Christopher Crenner, 303 pp, Baltimore, Md, Johns Hopkins University Press, 2005.Contemporary medical practice is based on the physician's ability to make a diagnosis. Indeed, it may not be possible for a physician practicing today to earn a living without specifying a diagnosis for each patient encounter. A century ago, during the professional career of Richard C. Cabot, MD, of Boston, Mass, the situation was quite different. Scientific medicine, as we now understand that term, was in its infancy, and very few patients received, or sought, specific diagnoses for their illnesses. Cabot was a key figure in effecting the transition to diagnosis-based medical practice. In Private Practice, physician and medical historian Christopher Crenner, MD, PhD, analyzes how and why Cabot accomplished this change.Cabot spent most of his professional time at his office in the Back Bay section of Boston, but he also had appointments at Massachusetts General Hospital, where he worked to develop integrated, multidepartmental systems in support of efficient patient care. His efforts in this regard were a forerunner of what is now called “systems-based practice” by the bodies that accredit undergraduate and postgraduate medical education. In this and other ways, Cabot was far ahead of his time. Within Massachusetts General Hospital, Cabot stimulated and nurtured networks of nonphysician professionals (nurses, social workers, pastors, and counselors) to complement the services of physicians.The most important of Cabot's innovations was in medical education, that is, establishing the clinicopathologic conference (CPC) as a regular component of physician education. Cabot's idea for the CPC was based on the teaching methods of Frederick Shattuck, MD, one of his most influential professors at Harvard Medical School. In Cabot's CPC, the autopsy was the gold standard against which a physician's diagnostic skills were measured and, in Cabot's view, improved. The CPC demonstrated publicly the physician's diagnostic acumen and helped establish the physician's scientific authority, but it also formally acknowledged the potential for physician error. The inevitable linkage between judgment and error was thus made visible. Beginning in 1924, Cabot's CPCs were published in the Boston Medical and Surgical Journal, and that practice continues today in the same journal, which has been renamed the New England Journal of Medicine. Few, if any, other models of medical pedagogy have enjoyed such longevity and impact.In his office practice, Cabot was an inveterate record-keeper. Fortunately, these records have been preserved in 36 bound volumes (Harvard University Archives) and were among the resources used in writing this book. Crenner researched many other primary sources in order to present fascinating details of how physicians of that era arrived at many common diagnoses. Cabot always specified in his written office record a specific diagnosis for each patient, and several examples of his diagnostic logic are detailed in this book. Crenner also illustrates how Cabot was among the first to use objective findings (eg, laboratory tests), in addition to symptomatic relief, to monitor the effectiveness of his treatments.Cabot, both by his actions and his words, placed honesty at the top of his personal list of desirable professional attributes. When his investigations of a patient revealed no disease, he entered the diagnostic conclusion of “not ill” in the patient's record. Moreover, he always disclosed his diagnosis and prognosis to the patient (and pertinent relatives). As a corollary to his policy of disclosure, Cabot vigorously opposed the use of placebos. His candor and transparency ran counter to much traditional practice and therefore attracted opposition from other physicians. Many who opposed Cabot in regard to the use of placebos were physicians philosophically inclined toward the views of another Boston physician, Francis Peabody, MD, whose famous JAMA essay, “The Care of the Patient,” published in 1927, emphasizes the physician's responsibility to act in a humane and caring way, even if that means concealing some of the objective findings and diagnoses from the patient. The tension between these 2 views persists today, and thus Crenner's historical analysis is still pertinent to physicians in practice.Private Practice is a scholarly work; its extensive references and annotations comprise 43 pages. This level of detail encourages readers to follow up on threads of special interest. For example, I was led to a 1910 JAMA article by Cabot comparing antemortem diagnoses with autopsy findings in 1000 consecutive autopsies from Massachusetts General Hospital and a 1901 article by Theodore Janeway about sources of error in laboratory results. Private Practice is an important reference for readers who are interested in the intellectual and organizational contributions of Richard Cabot and will be of interest to all who would enjoy an elegant look back at the pathways by which modern medicine has developed.