If you are asked to go to China an a W~C~OJ notice, and limit& to two suitcases, then every article you trike with ym sill reueive $OM aareful consideration before it can establieoh its olab a8 assmtlal baggage. %here we are gohg at the present time and how amoh of O"UT custoablry ideas ue can take with us as intellectual baggage &re nos quelstfons od.lFng for prompt and poihted atfrantlai, fn such a meting as this and at suck a tias, we my well scrutinise our bbitual idea about hospikls with (i vlew to getting 80- to essentials. First let us sake awe we ~QW what wt: Bean 'by the word 'howiLedge,* if we are labr to speak of medical litducntia, depending on how you have obtained it. If you have learned it though words (spoken Or mitten) , ~'OZYEU~~, Etbotreictims or symb28 of any kind, then you kve: obt~lned the kind of boarledge I EUP going to cull erudition or book- learning, If, on the other hand, you bve let*rnePd it through experience, through contact with red. thiags MU not toe nae3 or suasbols of real things, then you hive what I shall cdl experience, howledge is of tro tjarta 6 "he naaisl duference betwean knowledge of these tm types is not the differenae between genuhae and spurious, better or worm, usole~a rrnd useful.* 1% 5s the differenoe in the ray hawledge is obtainad, ;Zarportant seuondary diffsrmces, almost infhnite in extent, certainZy EEir beyund the capacity of any one gerrjm to sxperleace, of being inpersonal. but articulate, rPadiJy transloiiwibla apd eaq to accupruLate and preaerve in bo08;s. ewe, cm tha other hand, ks E. peculiar property - it gives its possessor But there are SOPB Erudition has the great quslity of being The hodedge derived from experi- 2. power, adidace, cowage, exuitant dell@ - sensations rarely produced by PDQ~ srudition. it is not ewy to transait in the absence of persona3 uontact and in&t&tion, reflection, or trial and QrrQr. Bnd ansther quality of larouledge obtained by oqwrleace - E~QW every institutiaao in this country will. receive cczreful sorutby ia the next ten years, scrutinJr that will question its value. #e might well prepare wtsslves for those days by knowing quite clewiy at haspftuls are good for, and, if you can Learn anything in hospitals, then what kfad of bowledge 2s to be gleaned in iaospibla, and what is that kindof howledge good fer? perience rlth sick hurap beings, Eamifimlty with the signs autd syloptarPs of disease, and the opportunity to witness the Bwnagmnent of an ilbsss by a skillfbl pbysitsiaa - or are book snd lectures and the preclirrioa labratorisa in the SChOQl8 all we need tis tha e;tsaitials of aedicd education? Is it redly valuable to obtain the bowledge tbat canes fros ex- Ib. siniilar search ai' simple und PslEable nrsntal equipment far use aver tbe next ten yecars of adventurous change, let us scrutinise this word 'education,' two persons, one more leh~ned, akilled experienced than the other, aDd willlag to teach hla who waats to learnr So sup21e and hrdy a ddinition dispewes +it4 such item as "entrrance requirwtents,fl "c%u?riml8," Weredit Iteduced to simplest terms education is da&t takes place between hours" - all the paraphermmlia and hocue poctts of education ephioh we shll chat to the ririnds anyhow if the time comes to Jettison non-essentials. fhn a hospital intern wgerly watching the e.mmp2.e of an experienced end frimdly chief laum something from thctt contact? dees you see: B moElerlltj think of the other kind of hoeledge that comes from axperfence, Of' course he can. He ahays, lor that brings out precisely the paint I wont to be 8tlre that Forget erudition ad book ls&rning, libraries and lecture halls for frola familfarity, from trial and error, to the appre~tiue watching his teacher end then trying hbse3-f - for that is the kaowledge potentially obtainable in hospitals, end cerbinly obtainable when a persotr of larger experience, nisdosrr md skill is within svilkixkg retch of one rho wmta to leiirn, Qbvioualy, then, the question is not ca)2 6 hoepital teach, but will it? Now if yau httd seen in may different countries first-rate educa- tion taking place in tb absence of sa my thisge you ulsed to consider essential, then you would begin tca regard education in sinphr terms, You amid realize that It is UQ event like frimdship Qr team#ork, You cannot deecribo friendship Sn term of a tiae-tt;bla, nor &ucc:tion in credit bra. You don't %xprsss the essrtntiaLa of any fglnan rsla.tflmship Sn list and hven- tsries. which there is L trassln;ictsian, u. pmse,ge froa one person to another, scwnetimes of iafcmmtion, s&arcltilaea of laethod of thoqht, scwwtimes of skill, occasion- ally af atanderraec of conduat and httitudas of Bind w(i heart, Th8se we but solfle of the sxckgsa traking ple,c% in the rahtionuhip 02 teacher ad pupil. The kind of eduoation I f;m tLrlking about 13 e3. human relstionshQ in Tm don't have to be If reflectively jrau will list tm mlhtionshipra in which you have learned much, 1 would we-5er tbt at least three were outside schoafe, and universltisa, f wait to We it alsw khat a hospitd can give education shether or not it is affiliated dth a university. teaching mediabe that if it osakes the eddltional effert to teach and ferns a rxalversity c~nncrctfm, we caz say that the hospital's share In medical educa- tion almost equals that of the medics1 schoQ1. Re couid have doctors without We Leaching hospitals but what a sorry profession it would bel If Clio, the professor to teach, nor pay tuition in order to learn. Indead, BO favorably placed is any hoslpitsl for 4. Ituse of history, were at rqv side, she wcluld add, WTh&t i5 wkt you had in &erica For yaw$ - mdicaf schools but scarcely a teaching bospihl," is in this, them, thbt the hospitals sustala and sarich our professional It fives: they pravhde the mal, the essential materid of pledice1 ducation md mdlcal service - patients, RLIoBl the doctor mst learn to study and to uwe for; and at the! same tine the teeching hospitals provide that siaplest element af an @ducation - amtact between parsons of different degree8 of eruditicur and mpperience, but with the sane purllu3se - learning, Of tb two sapplSes ma - the Imaalerdge derived from experimce. wisdoin distilled fror experiencet ow aul-vive only through kmwn intcsrooprse, And since skill and through example rpad idtation and use, the hospitals renders a service we vtiluable than ever when it brings together every range of novice ad expert But not all of you represent teaching hospitals oaannhtcted rrith medical schools. "The Hosplttd as a College," for you would be 3.13 the secret as thoraugbiy as X. Aa wel. lecture up "The Father 86 a lother" as discuss P'The Hospital as a Co1hge.n As Bother snd fkther tire both raqufsite far parenthood, so hospital aad college are both esseatfal to medid education, however, do represent bspltcjls in which teaching cauld be begun or empha- ktised by organiaing or expanding the interne ad resident services, atad it ie la this possibffiity and the consequences thereof tbt 1 would draw yuur attmtion, A well orgaaisaed inlernship oals for Yducatid v?xperiences, delibwlately fostered, you can develop csnd favar my and evry opportunity for teac-q in your Xndeed, if you did I should not be speaking to the title, &at of YOU, Xndssd, niy prinoipal thesig is that by 90 moh aa bspitaf you will protect the hoepit&. frm disorgaaiaatioa, insure It against neglect, and notably enbeace Its services b patients aad its stability ES ss institutioa, Not all Bospitals can affiliate with a medical school, ideal a@ that connection fs for teaahbg, hat newly elf bspithals can improve their arrange- ments for intern End raaident staff in point of number, opportunitiere, aad quality, iaproving its internships, X should like to sention the sore iaportwlt implica- tions of the Laternship for ali concerned, residencies as welL BS internships, since in wst hospitals the distinction is Ln urging you to iicprave the tatiahing pur hospital accomplishes by f use tb tern internship to inolude only ia the deg~ee of witurfty and responsibility - the purpose is to mhtaoe bath, ff LZ aystea of asli selected ad waU qxwvissd interns and resi- dsnh is planned ad put into affect in c hospital, then either more pntients wn be embed und treated at tbe 016 s.t;eUrclad, or %be same nuber of phtbnt8 cm be narch sQr% compterttly cexanined Kpb crtred for, pital's usefulness fncrewms. I;"'urthemore, internships affect the hosgftal staff for the better. mere the wwk of the hospital has been orgmimd to teaoh the interns by gradually incrtssiag their freedom aci responsibility, fn other w0&8# the has- tha risitiag men, the chiefs of: sssvicets we stiaulsited to their best work by a@ presence, the hqi&m ads8 the QritiCfil audience Of thsk interns, As often tast an officer who wants ao m3n to lead ELS a doctor who wants no yaungar am around higl hamin@;, ship ooncerns the cttitude of the doctor towtwd~ his education, cianrp and surgeons mder8ttmd the ImpLicatisna of the fact that the intarnship OWLBS after %ha #.I). degree; they understand therraby tht aredfcfne is an art as we13 as a science, where training, caxperiense, end .axpired ski11 are never hother result fros e well orgmiaed intern- YouIlg yfysi- 6. coqiLeted, md %hats oneta eductition continues f'trr beyoad akit is required for the HODo degree. or res5dlenc-y will eacribe his competence to that training above &ll others. There fu no doubt of the aast phelaontentsl. ilaproveraent during the past thirty years fn the level of professfond cwPpatence fn tha United %&ties, ispravemcret the teeching hospitds lave had a aost important S~BFB. old type of hospftal lags behind ttnd suffer8 for ft, Any doctor who bas hi5 & well orgsaLzed intarnship In this But the 50 valuable to oaediccll education are them contributions of the hospital and so dlstbctive is the iiititmabip that we find other kinds of schools holding up medical education cs e. @el because it has the wanderful advastages of the internship, far example, bilve oreated a deliberate imitation - called the 'interm year' tx 'in ssmice training.t Tewhers' c&legss sltpilar3.y seek the zdvantbges of 61 kind of internship wc€ englnesring sehooLs urge ugan thvir students practical wwk under BOPLIB awsure of aupervisioa but Gith re&. reagonsibility. Schools for training govarnaeat executives, T~Y the hospitd Rith en effactfve temhing service 5~ the form of interaships and residencies providesi the nrost distinctive phase of aredical education - the type of profeudimel ducttion most. envied and nost enviable, If a0888 hospftexls akrsaciy render this sewkab3.e service ad if I suggest that more hospitds should do so in. their own interest, I should like yoa to undersbd clearly just ahat 8 teaching hospital contributes, and rhrst it gets in return, frm zi well organized internshi? system. The first of the hospital's contributions preserves far the future our prasent knovlledges. The hospital provides pat&&& to be, studied euid treated and thus the material and the CirouastbSces far traasazittlng to the next gemergtion the skifls &id the lcnoivladge we bve received fro= aprIence. teach by exmple ad ex-aerience, the next genercatfon of professional men and Hwpitds sat atmdtrde for, and all the .hila insistantly imply tbt there is always more to learn in sedi- cine. omes vary near to proving that when organissad as a tesohlng oolnruaity doctors can work togethtar more emsthly thw m any other baeis - ecoaosrie, political, or Oilitwy. For the patient with a severe illness is (i hospital, not an axclufsive nursing home 02;" 6~ secretive private raanitariurnt, but a teaching hospitaf. dth alert intarns aad observant residents discovering the mistakes rzhc3. disoussing the failures - not ignaring them. Still aore Iqmrtsmt, the teaching horspital certainly suggesttr and It is already a emonpiace thkt the safest pfaoe In return for better BE;^ of the sick, better professional, training ai' the dootora which the teathing hospital Gives the coauaurity, what &re the advantages, the gains to the hospital from an effective haternship and resi- dency? improved quslity of Ln2lems and eveatuslly a better senior staff selected in pert fro= former intern8 end rasidentes, & senior staff held at concert pitch by the critioal abilities ttnci the restless anergies of the interns themselves, a finer name and reputation for the hospikd on the lips of former interns They ere these; nore pa.tients card for, @ad cerad for better, an ~ts well as formasr patients, and the steady advantages of doctors aesociating for the sake of improving their knowleclge of how to owe for people, sperctial tlttentlon to ohzs fmtr czolbborate often dsrtetrsMw Che future of that professfon, of assmiation is better for doctors thnn the basis, of education, many tried - eeniority, self-pratectiaa, money aakfng, religloua piety, the terms of ancient bequest, ailitary r"61ik - none Is as affective asr lm~ul- edge, uompetence and character, the traits most honored where lemming is the I ask The basis on which members of CL professfa lo other bsis I've seen go81 of all, site evidently, then, the hospital set upon teazching receives re- waxxis for its ccmtributiaaa, As 8ome brash adverticriw genius will doubtless day w-WS~ US in a ftU-pttge Plossbige in &OBI@ BletrQpolit8Ul daily, "IT PAYS TO RQRK FOR TfIIG COM#OM GOOD&' Ihy have we siaplified und reitlgratcad the hkportsJsce of teaeblng, sf systems to bring more sxperiaced mn in deliberate and alose aewrtact with interns QC residents so that education can take placet and re-examined the essentials of howLudge, of: education, of the r6le of the hospital in aedical ducatla, EuLrt the msentikl advantages teach- brings to the hospital txhich is orgsJlize8 arounjj teaching? have we reviewed 1 Lived k &XWp fY'& 1q& to 1931, Visitblg 8QeW COMtrY there except Portugal, tmcation wbich prepared %e for wbt we shall hkve to f&ce 19 Chis country, bat it couhd not have pmpred yau. irJe shall bve to tKk;e care of sick people in our hospitals in any went~if taxation crushes the wpperters of the volun- tary charity hospitds, the =re oJ tha sick wilk be curfed out frtsnr public taxation, M racanngsd by lstadiocre bileat using ecasygoiag aethoda. the best brains in gotternaent in order to have enough governeat survive. hove aedicd orgmizatfaa in raind in saying this, cgn haare something m~re th tha care of the poor as tt basis for 85king fcsr gifts, bow can they expect gifta frora an upper and middle class tared almost out of existence? doctors' tinre and bowLadge rfth clx~ absolutely exhsaplsry esprit de corps and effectiveness, then these hospitals ail1 bve schnt funds and no rsrgulllsnte to keep them out of reorgssniaatian at %ha hads of the city or county* I aaw 8 dagr-cse of suffering and impoverlsbnent and excessive Be shrefl see oondftions so unpleasmt and dangerous that they cennot Re shall hve to have I bless the charity hoepitals Unless the charity hospitals are organized to use their 9, And If, as €n Dgland tit present, the bulk of physicians' time is spent 3.n oaring for their fellow Ben in haspitals and on salaries prOQided hy the government, the problem wili pose itself for us too - wrbt is the best bsLs for doctors to wurk together upon? aifithry rank, inctllaa from privat.3 practics, ar character and cosptenae a8 revealed by teaahing and resmrch? Seniority, political prefamant, Ybu dll note I have constantly raferred to residencies along with fntemahips. One mrd of coment: way roedical aduoat%oa 8erws &ttochty catlceslls the extraordinary waste XIUEXX the sharpst critlcian I can level at tb of the first five to ten years of professional life - when (1 man at t.ke top of his strength, interest and education must ao nothiag - waiting to use all he has, It is stupld for such excellent doctors not to be worldag at their be& as resident# in hospitals. the batter determination, the restless resentment, the merciless 11-688 keep us all frora seeing the best thing to do. And I canqt blme a graup SO s0upidly victimized . Experience hag taught me that in that group one can fiDd aoat of I have spoken to you about the educational work which a hos$bl cm lea to do becaruee, that is a3.mast the only course whiah will preserve eqp independence oad leadership for hospitals and because I do not believe that just a record of caring for the sick fs emu$@ to save the oharlw hospital fn the mergencies ahead of us. From such renarks you will comectly conclude that I think the present is more decisive, and the approaching chwgev mare extensive than roost geipla seem ready to admit. COrd13Iy is that I road adwxate ada3Cability with which to met thoae ChtLZllgea, rather than resignation or pessimism. too bird, or too obstinate to adapt. You w%U note that I emphasize uhange, not disastsrj the Change spella disaster odly to men too 0x4, 10. Changes call for elasticity of mW but quite as muoh for a surefooted knowledge of what is what. hme to go far and travel light. of a ho-spital tmsbee is his idea of what a hoogital am do, vthat are ita natural ertrmgthrj, its peculiar capacities. Surely it ie sensible to retaxambe our baggage if we nay A valuable part of the intellectud baggage Amid the changes that will be proposed for his hospital e trustee can bring to all decisions 8 knowledge that his hospital. not only cares for the patients of today 3ut through training and teaching physicians owes for. the patients of the next two or three decades, and deternines the qaallw as well. as the quantity of profer9simal services given the, people. iB the Institution which exists mere& for auccessf'ul doctora to perform in worshipful eolitude or than- isohticin Vns procsdursa learned years ago. Rever forget Lwd Actorrfs observation "Power corrupts - and absolute power cornrpte absolutely". He can realize how tiria and lacUwtra Precisely because the whola system of interne and residents is now in a cvnfasion that will probsbly be worse before it ie better, I would suggest that you begin to thiak and plm for the organisation of teaahlag in your hospital after th~ war. IC may be that your tosctjlcal and surgical staff eva ia war the can be encouraged in the dtrection of argaaiaed ternching, institution of deaobfiieed doctors who will need and want specialised tralniag - and hospital appointmertter - at the end of tho war. Through early planahg your rn he ready to receive incorporate arrd train sese of the large numbera Do you how the difference betwean strategy and taatica? Trwtees at their best always recall these definitions to me. Strategy is defined 88 the art of deciding &ea and on what you will engage pour etrePIgthr econoay and adroitness with which you apply your forrres to any problem. a theme involves strategy, dealing Kith it iar a tactiual performanoe. Hospital poliqy is a mater of strategyr dactitx~ $B the skill, Sqlsating hospital mawgment fs taatloal. As tmtees you dec& 11 . the strategy of hospital work. to choose. and when? old objectivee, old objectives is natural enough in pace tims. such as the present it is wim far trustees to r6BxaW.ne the- strategy - when and on what will they engage whosagital*s strength. to keep upperm that the sledical professit13 CBI~ be helped to do its best when organioed around teaching in hosg3.td.e. The tactics are usually for the administrator On *at will you engage the hospital's strength, itis efforts - In stable routine years most trustees try to use rim rnethds to reach Thus they tad to Seems consultants aa tactics - ahicrh to reach But in times of rapid change f urge you to do this land your minds that a hoapi.t;al tenches as well as cures) and I have given you 110 clearly defined or ehborately detrrfled mthd of Methods and p1-s of that sort belong to tectics and to your procedure today. executive machinery. then the ,path is relatively easy for your executives. If, 88 trusteea, you bow what yzu think and can express it, You have the positive rale of strategists and a negative Ale you alnoest never think of. Trustees are in sora8 senses the conmiace of an hstitutlonr when the hospital executive says to hirtlself, *I just wouldn't fed, ~OBfOrtabh recommending that proposition to my Board" the trustees are acting as his eascienee, they are in action without being called wpm. That is why amy Trustees say they amnot Bee what good they do. They are of u8e dthout knowing it. But let poe assure you, gatleaen, that If you have anrived at tbe wisest strategy for your hospftd and have expresscad yourself ulearly upon it, you have discharged a large, perhaps the largest ehare of your duty aMZ you hoe done CL very great serdae to yous day and gensrathx~.