Contributor: Morton Bogdonoff, Chief Resident: 1954-1955

A memorable moment during my tenure as chief resident was when we were hosting Sir George Pickering, Professor of Medicine at Oxford. We were on rounds with Dr. Walter Kempner at the "Rice House."

When we returned to Dr. Stead's office, Gene asked Sir George what he thought about Dr. Kempner's program.

Pickering's answer was, "I say, quite remarkable! But it is rather difficult to tell what is due to the rice and what is due to Kempner."

Title: The Bigger Man with the Bigger Picture

One of my favorite Stead stories occurred at a departmental research seminar. When Jack Myers finished discussing his work on hepatitis blood flow, Gene Stead offered some severely critical comments that dramatically left Jack Myers speechless.

Then, from the back of the old conference room on the second floor near Osler Ward, came a voice in a stage whisper from John Burnum, "The Bigger Man with the Bigger Picture."

Title: Essays on the Practice of Medicine

For those who worked with Eugene A Stead, Jr. when he was chairman of the departments of medicine first at Emory and then at Duke in the 1940's to the '60's, this collection of essays edited by Barton Hayes provides an opportunity to once again engage Stead's ideas on medical teaching and medical care. For those who only knew him by reputation, this volume captures his voice. The discussions at bedside rounds, research conferences or morning report were always marked by a manner of definitive authority. The Professor (as he was referred to by almost everyone in all departments of the medical center) writes as he speaks, in a style that reveals no uncertainty.

Stead spoke eloquently of both the science of clinical medicine and its human touch. During the time he directed the department, he maintained his own roster of patients and thus could demonstrate what he meant when he discussed patient care. Three citations are particularly cogent:

• "The care of the patient should be carried out by doctors who are interested in giving service to people. Good doctors believe that patients can legitimately make demands on doctors, and because the ill are not rational, these demands do not have to be rational."
• "The code of ethics for a profession must require of its members behavior of benefit to society of a nature not expected from non-professionals. Today I see many non-professional doctors in practice.

  A few weeks ago on a Sunday, one of my neighbors, 55 miles away from his home, had a small stroke. He asked me to talk to his wife and call his doctor. He had a history of hypertension and atrial fibrillation. The doctor, who was the only one of his group of four who knew the patient, declined to talk on the telephone with my neighbor and referred him to his colleague. The colleague arranged for him to telephone on Monday morning and make an appointment with the doctor who had refused to talk with him Sunday. The appointment was for the following Friday at which time coumadin was started. I believe doctors who practice this way are not members of a profession. Either coumadin was not indicated or it should have been started immediately with coverage by heparin for the first three days. This doctor was certainly not a member of the medical profession. I doubt you could even call him a skilled craftsman." (p.198)

• "We know that any doctor who knows what he or she knows and can comfortably say, 'I don't know' is a safe doctor"

Title: Birth of the PA Program

Dr. Stead was like so many other chairmen of department of medicine of his time in that he had he had an outstanding record of clinical research, was recognized as a superb bedside clinician, deeply committed to the careers of the young people in his department, and very much aware of the politics of academic medicine. He belonged to all the important societies, served as a senior consultant to the National Institutes of Health and was a founding member of the Institute of Medicine. However, he was very different in one fundamental way: he was interested in all aspects of medicine -- its practitioners in the community, its faculties in private and public universities, its ties to government, to industry and the dynamics among all the disciplines that take care of people. But he was not only interested; he worked very vigorously at instituting changes in all those spheres. He was -- and still is -- as much a deliberate activist as any Young Turk could ever be. And this book includes essays that describe the innovative programs he had a major in developing, and it makes it clear how far he reached beyond his own department.

The most controversial at the time it was launched in 1964 is the Physician Assistant program. It is likely to be remembered with his name more than any other interest, including being one of the first people to successfully perform right heart catheterization to study cardiac output in man.

Stead's idea that the practicing physician would benefit -- have more time for continuing education and manage a larger practice-was prompted into action by an experience I happened to witness personally. It occurred at a regional American College of Physicians postgraduate meeting held by members of the faculties of Duke and the University of North Carolina. So few were the number of practicing physicians attending that they were outnumbered by the faculty. Stead noted that one of physicians, Dr. Amos Johnson, was a solo general practitioner with a very busy practice in a small town in the eastern rural area of the state.

"Amos, how do you manage to get up here to attend our courses? I see you up here almost all the time. Who covers your practice?"
"It's easy, Dr. Stead. I have an assistant."
"Who is he? I didn't know you had another doctor in practice with you."
"I don't. I have a man who was a medic in the Korean War."

Later that evening, as I was driving Dr. Stead home from the conference, he talked about Amos Johnson's unfailing attendance at post-graduate courses. "We have to go see the fellow that Amos has working for him."

The next week we went down to Garland, NC, met the assistant who was seeing many patients independently, checking with Dr. Johnson when there was any uncertainty, and who was clearly well-accepted by the patients. On the trip back to Durham, Stead said, "We're going to make people like Amos' associate."

And thus was born the PA program.

Title: Birth of the Research Training Program

The Research Training Program was conceived primarily with Phillip Handler who was chairman of biochemistry at the time (later to become President of the National Academy of Sciences). Both young and senior physicians spent one to two years in the laboratories of basic scientists working with newest techniques and methods in the then emerging discipline of molecular biology. It set a model for what was eventually to become the MD/PhD programs now so important to sustaining investigative laboratories all throughout academic medicine.

Title: Stead's Introduction of Computer Technology

The introduction of computer technology to the daily work of the medical service was another new program launched by Stead. The emergence of the cardiac care units that were having such a remarkable effect on the outcome of patients with myocardial infarction were filled with new machines collecting an extraordinary amount of recorded data. Stead saw that the high technology required skills in collecting and analyzing the mass of data that was collected. He needed experts in working with computers. He began a program that linked the schools of Engineering and Medicine in ways that had not occurred before. Bioinformatics is now a thriving discipline everywhere and the computer has made it possible for the daily practice of medicine to be guided by the most up-to-date information provided by the Internet. The National Library of Medicine and the large array of electronic journals are at the right hand of every physician.

Not all innovations were successful, however, and Stead describes the extraordinary initial success and then abrupt failure of an experiment in nursing care. It was named the Hanes project for the ward of the hospital where it was based. Directed by a gifted Professor of Nursing, Thelma Ingles, the program would likely have evolved into the creation of the independent Nurse Practitioner long before such a training unit was developed at Columbia University. But it wasn't to be, and Stead relates the details of why the venture had to be cancelled. It is a most instructive story of administrative tunnel vision.

Title: Stead Essays on the State of Medical Education

There are several essays on the state of medical education -- what should be taught, and what should not -- on the role of community hospitals, and on the ever growing cost of medical care. Stead's ideas are provocative and he leaves no doubt that he believes the medical profession must look after its affairs with greater diligence.

An introductory note to the section entitled "Health Care and the Nation: Where are we Going?" makes clear his fundamental social philosophy:

"On May 25, 1961, President Kennedy announced that the United States would land a man safely on the moon before 1970. The resources of the nation were mobilized and the goal of moon walking was met. Many thoughtful people in this country are puzzled by the fact that we can undertake a project of this magnitude and yet have no solution for poverty, ignorance, prejudice, greed, racism and war."

We seem to be facing the same dilemmas now. In talking with Dr. Stead recently it is clear he would have us marshal our intellectual energies and political resources in a national effort to find those solutions. He would establish a compulsory two-year period of national service for all high school or college graduates, and he believes that the young people so enlisted would be the discoverers and the providers of the solutions.

As Bart Haynes points out, Stead at 95 years is still an enthusiastic spokesman for change and this volume makes it clear that has always marked his career.