By James Tobin
If we only heard loud sounds we would not have to take the trouble to listen carefully. You can’t expect your patients to go around with sirens on them.– Dr. George Dock, teaching the proper use of a stethoscope
Chapter 1 “First, the Eyes”
One day at the turn of the 20th century, Dr. George Dock, professor of internal medicine at the University of Michigan, chose a member of his small class of advanced students to begin the afternoon’s lesson.
Dock’s method was to watch as students examined an actual patient. One by one, the students would peer, feel and prod. Dock would tell them what to do, then ask a question.
On this day, the patient was female.
“First, the eyes,” Dock told the student.
The student leaned in for a close look at the patient’s eyes.
“I don’t see anything the matter with them,” he said.
“Your eyes, I mean,” Dock retorted. “Not hers.”
In that dry remark Dock may have summed up his cardinal tenet—that the physician’s single indispensable tool was the power of observation.
In the eyes of his colleagues, Dock was more or less without peer. He was the first full-time professor of medicine in the United States. His mentor and friend William Osler, the founding figure of modern medical education in North America, called Dock “a man who knows more about clinical procedures than anyone in the United States.” Years before technology transformed the methods of diagnosis, Dock was regarded as a superb diagnostician. And he was said to be the best clinical pathologist in the country.
Yet for all Dock’s fame as a practitioner, he made an even greater impact as a teacher.
Chapter 2 An Extraordinary Document
We know a great deal about Dock’s teaching because he had it written down.
Every Tuesday and Friday afternoon in the academic year 1899-1900, and again in 1907-1908, Dock held diagnostic clinics with fourth-year medical students at the old University Hospital on Catherine Street. At each session, Dock employed a stenographer to transcribe the exchanges virtually word for word.
The result ran to some 6,800 pages—a document “very likely unmatched…in the history of medicine,” according to the medical historian Horace W. Davenport.
The transcript fills 16 volumes in U-M’s Bentley Historical Library. Davenport, a professor in the Medical School from 1956 to 1983, chose excerpts from the massive work and published them in 1987 as a book entitled Doctor Dock: Teaching and Learning Medicine at the Turn of the Century.
It reveals a man who personified the original meaning of the word “professor”—that is, one who professes allegiance to an intellectual discipline. In every lesson, one sees Dock’s whole-souled devotion to medicine as a fascinating and exacting enterprise. He conveyed information, certainly. But more important, he set an enduring example of how to study and think about the problems of the human body.
Chapter 3 “A Thorough and Broad Approach”
Born in 1860, Dock was educated at the University of Pennsylvania, where he learned medicine via lectures—a method that left some students so deep in the dark that they sometimes paid patients to submit to examinations.
At University Hospital in Philadelphia, Dock worked closely with Osler, who was beginning the transformation of medical education by taking his students directly into the wards. Dock also studied under pioneering physicians in Austria and Germany, where, for a time, he performed five autopsies a day, six days a week.
When he came to U-M in 1891, he was a firm convert to hands-on medical education. His students peered through microscopes, palpated organs, poured oil down children’s throats, inserted fingers in rectums, and administered ice-cold “tubbings” to patients with typhoid fever.
In Dock’s era, there were some 70 to 100 fourth-year medical students at Michigan each year. Ten to 15 percent of them were female, and, according to Davenport, “Dock treated the women exactly like the men. The only difference was that, whereas Dock usually addressed a man by his last name, he called a woman “Miss or Mrs. So-and-So.”
A small, slim man with a trim mustache and a center part in his hair, Dock was not the sort of professor who dazzled or entertained. He was not even the sort who struck students as inspirational, recalled his son, William Dock, also a physician— “until one decides to imitate his thorough and broad approach.”
His students peered through microscopes, palpated organs, poured oil down children’s throats, and administered ice-cold “tubbings” to patients with typhoid fever.
Chapter 4 A Sense of Humility
A single symptom in a patient might launch Dock on a mini-lecture that covered much of the history of the disease in question. Once, for example, he and his class were examining a pneumonia patient whose white blood cell count had dropped, indicating that the patient was well along the road to recovery.
Dr. Dock: “What aborted it [the cell count]?”
Student: “The treatment he received here.”
Dr. Dock: “That is a good way to look at it. It speaks well for your charitable heart. There is nothing more natural than to think his care has been the cause of his change.”
But “the fact is that pneumonia aborts itself,” he continued. He recalled that as a medical student he had been taught to apply big poultices to the chests of pneumonia patients, “drawing literally quarts of serum”—but a “poultice has never shortened the disease by a minute.”
The best treatment, he said, as with smallpox, was “an intelligent, cool-handed, kind-hearted nurse.”
Over time, digressions like this one added volumes to students’ store of knowledge and instilled a sense of humility.
He described symptoms in phrases calculated to stick in his students’ memories.
Hemorrhoids, he said, felt “like a bunch of earthworms.” When one student had a stethoscope pressed to the chest of a pneumonia patient, he described the patient’s tortured breaths in terms too vague to suit Dock.
Dr. Dock: “Did they sound like hair rubbed between the fingers?”
Student: “They were much larger than that.”
Dr. Dock: “Did they sound like crackling in a flame? It seems to me there is a comparison more like it, and that is crackling a piece of rather stiff paper.”
He described symptoms in phrases calculated to stick in his students’ memories.
Chapter 5 “This Isn’t Psychology”
Dock’s manner with students was all business but respectful. He corrected by offering a new question. A quick, dry wit was always at the ready, as when he summoned a student named Larson to look closely at a patient.
Dr. Dock: “Larson…come down a little nearer the scene of action. What do you think about his face?”
Student: “It is rather serious.
Dr. Dock: “This isn’t psychology. Miss Crozier.”
Dock was not always happy with U-M’s hospital facilities.
Dr. Dock: “What do you think of his skin that you can see?”
Student: “It seems pigmented in both inguinal regions.”
Dr. Dock: “Part of that pigmentation looks like what? It looks like dirt. One of the unfortunate features about this place is the difficulty to bathe our patients because we haven’t enough bath tubs.”
Chapter 6 “A Sound or a Murmur?”
Reading Dock’s exchanges with students is to see a precise mind working at the height of its powers, probing and clarifying with every question, forcing his charges to grasp the nettle of a patient’s problem.
Here, for instance, Dock interrogates a medical student who is applying a stethoscope to the chest of a patient suffering from rheumatism. In spite of the specialized vocabulary, a lay reader can follow Dock’s determination to get his students to listen carefully and interpret with precision.
Dr. Dock: “Now what is the matter with his heart?”
Student: “He has a loud blowing murmur which reflects the first sound at the apex.”
Dr. Dock: “But what causes that?”
Student: “It is caused by mitral regurgitation.”
Dr. Dock: “Has he any other signs of mitral regurgitation?”
Student: “The sound is conveyed out to the axilla.…”
Dr. Dock: “What else is there? … Is there anything else in the aortic area?”
Student: “There is also a murmur, a systolic murmur.”
Dr. Dock: “Is it conducted anywhere? Did you hear it in the neck? Did you listen for it?”
Student: “Not especially.”
Dr. Dock: “Wouldn’t it be a good thing to do? [Summons a second student.] Suppose you come up… What do you think?”
Student: “I get a sound below the carotid.”
Dr. Dock: “A sound or a murmur? By sound we mean a tone that isn’t murmurish, a pure sound. Now is it further transmitted? Is it transmitted up in the neck?… Did you follow it there? That would be a good thing to do. Do you hear it?”
Student: “It is faint.”
Dr. Dock: “I know, but that is the point. If we only heard loud sounds we would not have to take the trouble to listen carefully. You can’t expect your patients to go around with sirens on them.”
“If we only heard loud sounds we would not have to take the trouble to listen carefully.”
Chapter 7 “Your Fathers and Mothers”
Dock had little sympathy with medical students who were out to make a lot of money. He advised students never to refuse treatment to a patient who could not pay, and if they thought their fees were “not good enough,” he said, “the way to improve that is to do more work.”
“If you follow this course,” he told one class, “…acting in a decent and honest way in regard to your patients and colleagues, taking pains in your examinations, keeping careful records, doing careful treatment, you will find that you will get the success that you will all deserve. And if you don’t, I shall be sorry, but still take a certain grim satisfaction in hearing that you have become real estate agents, writing land contracts, etc.”
If they learned nothing else from Dock, they learned that patients, “although they may seem nothing at all to you, are, after all, human, as your fathers and mothers or sisters are human.” They should never be regarded as mere medical “material.”
One day Dock was seeing a patient he knew well, an elderly woman with cirrhosis of the liver, her body swollen with fluid. Dock was accustomed to performing abdominal taps on her. This time the procedure was done by one of his colleagues, a Dr. McCormick.
Dr. Dock (addressing the patient about McCormick): “He comes from the same part of Ireland you do.”
Patient: “If Dr. Dock had not been here I would not have let him touch me.”
Dr. Dock: “You haven’t had your whisky yet. I think it is time you had some.”
Patient: “God bless Dr. Dock.”
Dr. Dock: “Happy days.”
* * *
For years, Dock battled with his powerful superior, Dean Victor Vaughan. In 1908 he left Michigan to teach at Tulane University. Later he moved to Washington University in St. Louis. At one point Vaughan asked Dock to return to Ann Arbor, but Dock said no. He was “a fighter by nature,” said a colleague.
In 1922 he retired from teaching and moved to California, where he maintained a private practice for many years, lecturing occasionally at the University of Southern California and Stanford University. He died of pneumonia in 1951 at the age of 91.
This is an expanded version of an article that appeared in Medicine at Michigan (Summer 2010). The massive transcripts of Dock’s teaching were excerpted and annotated by Horace W. Davenport in Doctor Dock: Teaching and Learning Medicine at the Turn of the Century (Rutgers University Press, 1987). Other sources were Horace W. Davenport, “George Dock at Michigan, 1891-1908” in Joel D. Howell, ed., Medical Lives and Scientific Medicine at Michigan, 1891-1969 (University of Michigan Press, 1994); William B. Bean, M.D., “Dr. George Dock: Excerpts from the 34th Dock Lecture,” Southern Medical Journal, Vol. 72, No. 3 (March 1979); and Suzanne C. Fallot, “George Dock, M.D., 1860-1951.”