Rochester Academy of Medicine
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Rochester Academy of Medicine
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Interviewee: George L. Engel, Professor of Medicine and Psychiatry Interviewer: James Bartlett, Medicine Director/Senior Associate Dean at the Medical School for the Miner Library Date: December, 1987 Bartlett: Actually, George, this is the second video tape that you've made. There was an earlier one for the AOA series on Leaders in American Medicine where you. with Sandy Meyerwitz reviewed a good deal of your scientific and clinical career. Today. we want to focus on you and your time here in Rochester as a faculty member of the medical school. It was in 1946, I believe, after graduating some years before that from the Hopkins Medical School and going to Sinai for your house officership and then to the Brigham for work there with Soma Weiss and others. and on to Cincinnati to the Department of Psychiatry and Medicine there. that put you in a position in '46 to come on to Rochester. I wonder what you found here by coming in as a new faculty member to this medicine school that was then 20 years old. and what kind of faculty, what kinds of students and what kind of an atmosphere was there? Engel: Well, when I came here in 1946, I came with a very conditional frame of mind. John Romano had just been appointed the founding chairman of the Department of Psychiatry. I was an internist. had been in the Department of Medicine in Cincinnati. He and I had. in Cincinnati. been working towards developing what would be called psychosomatic teaching at that time within the Department of Medicine, which was my primary affiliation and the question was. was Cincinnati or Rochester to be the place where I would continue to do that. I made a visit here. met with Dr. Whipple and Dr. McCann and others. and very quickly got the feeling that Rochester was going to be the place to come. Why? It was quite an experience to come here in 1946. It was a small school. 20 years old: that seemed like an old school to me then_ but then I was only 10 or 12 years older than the school. But. there was a certain ambiance and a certain characteristic and certain flavor which I think had been established by Whipple from the beginning and by the people he brought with him. which I quickly sensed would be extremely conducive to developing something which was different and innovative. Remember. there had not ever been this kind of teaching program developed anywhere. We had already seen problems in trying to do this in Cincinnati. and my first meeting with McCann who parenthetically was the person who got the money for the endowment of the Department of Psychiatry and the money for the building of Wing R. in itself a testimony to a kind of openness and interest in the school as compared to parochial interest in one's on department. And I think that was the essence of what I sensed right from the beginning. that the people I spoke with seemed to have a sense of commitment and dedication to the school as a whole, and even more importantly to the education of medical students. Medical students in most medical schools hav e never enjoyed first priority among faculty. The proposal I made to McCann was one that 1 don't know that he necessarily grasped with full significance. I don't know how one could It was something brand new. but in essence what he said. not in so many words. but came through loud and clear. "We're open to new things here. go ahead. I'll support you in anything you want to do. and if you fall on your face. that's your problem. not mine ' Coming as I did as an internist with evolving and developing psychological and psypsychiatric interests. I found myself right from the start in two departments and administrative issue there. McCann with a twinkle in his eye. had told John Romano. "We're very happy to have Engel here_ but of course. you're going to pay for him, and you're going to give him space After all. who had gotten the money for Psychiatry? I didn't even give that a second thought_ what my primary appointment would be. and it ended up my primary appointment has been in psychiatry.. but my main commitment has been in areas elsewhere_ And one of the things that very quickly emerged well within the first year. was that this was a school which was small The Department of Psychiatry was brand new. and there were just John Romano. and myself. and a couple of residents beginning. one or two people who had been here; and in the Department of Medicine, I think I was the fifth full-time member of the Department. It was that small in those days. It was immediately post-war. And everybody knew each other. Everybody ate in the same dining room, and by everybody I mean students and nurses and nursing students, and faculty—senior and junior. There was none of the elitism that I had grown accustomed to at Harvard and Hopkins and other places where there were separate dining rooms for Chiefs of Staff and that sort of thing. I've described it many times as a school with very permeable interdepartmental barriers, and for what I was interested to do, to work across disciplines and around disciplines, and through disciplines, this was absolutely incredible. I quickly found that with my white coat I could go anywhere in the hospital or anywhere in the medical school without anyone asking me, you know, "What are you doing over here?" One got to know people quickly. One discovered interest in new people coming in. very welcoming. And then I became quickly aware of the place of students in this school. I think it was George Corner, he used the term the other end of the log.' I didn't grasp what that meant until I had been here for a while, but I had not been in anyplace, including Hopkins, which was supposed to be noted for that in which there was such an intimacy between student and faculty. And in which faculty really did spend a good part of their time thinking about and wondering about how to work with students. Very impressive people in that regard. Whipple used to have and run the monthly medical meetings, and we all came regardless of what the programs were, whether they were in our area or not. John Romano often used the term `citizenship' of the school. And at first, I thought that was something peculiar to John because he used it in Cincinnati, too, but it wasn't quite as meaningful in Cincinnati as it was here. By and large, people did have that attitude about the school and about what they were doing. Bartlett: What about the students, George? What kind of students did you find here? Engel: Uh, well, over the years I've come to feel that most people who get into medical school are pretty good students. My Hopkins elitism and Harvard elitism from the little time I spent there as a student and as a fellow, it didn't last very long. Most people who get into medical school are pretty good, and have gotten better, I think. It was a period of immediately after the war in which students coming in were largely... many of them were veterans, quite a few of them were married and had families. They had had their lives interrupted, but they also had lived more. Graves, of Graves' disease, 150 years ago—more than that, 1730—had written... I'm sorry, 1830s, had written and strongly recommended that before people come to medical school they should live a bit, because you can't really know what it is that your patients experience if you haven't shared. So, that was a very exciting time in terms of the students' interests and what we were interested to bring, and John Romano had the wisdom to decide right from the beginning that we should teach only the class that entered with us, which was the class of 1950. And then the next year, take on two classes. We didn't have the faculty to do any more than that, and whether he expected it would work out as it did or not, I really don't know, but it was a brilliant notion because within a year, the students who were not having experience in psychiatry and experience with us—my colleagues and myself, a group that quickly formed in Medicine, were howling that they were missing out on something, and we set up electives and so on. Bartlett: What was your first teaching? Engel: My first teaching was with house staff. Coming as I did, and with a primary appointment in Psychiatry, it became very critical for me to establish my identify in Medicine. I was a well established teacher as an internist in Cincinnati, and also at the Brigham. and so I volunteered to attend beginning in July a few weeks after I got here, and... Bartlett: Did people realize you were an internist? Engel: No, they didn't realize I was an internist and there were amusing episodes that occurred where I would be praised for knowing so much internal medicine for a psychiatrist. A memorable incident where I made the first antimorphic diagnosis of a perforated interventricular septum, and we were going down to view the autopsy, someone joined the group and the house officer who was very pleased they were attending and had done so well, mentioned to this man, "You know, Dr. Engel made this diagnosis of perforated interventricular septum." Thinking that I was a psychiatrist, he scowled, frowned a bit, and said, "How did you do it? Did you put air in the ventricles?" He thought the only ventricles I would know were up here. And Whipple looked over his glasses when someone said. "You know, Dr. Engel made this diagnosis..." "You mean the new psychiatrist?" But that eventually clarified in time. Bartlett: So you started out teaching with the house staff in Medicine? Engel: We started out teaching with the house staff. I didn't do any student teaching the first year. John Romano took the first class in Psychiatry and I got busy with our fellows. We had come with money from the Rockefeller Foundation and the Commonwealth Foundation, which had originally been awarded to Cincinnati, but which we brought with us to begin a program. And I began with a number of people who, most of whom were coming out of service, Peter Hamburger, and Dick McKay, and John (Herra, Herron) and others. Bartlett: Fellows in what, George? Engel: They were internists and the objective was to develop their skills in what we would now call the psychosocial... I think then we would call it psychosomatic...psychosocial aspects of medicine. And you have to remember that I had just gotten into this myself. I had been in Cincinnati for four years, but it had only been in maybe the last two years at Cincinnati that I began to interest myself. So, I was very much of a beginner. John Romano's taking a flyer on me and giving me kinds of responsibilities for teaching that were actually well beyond what I was prepared for, in fact, constituted a remarkable source of stimulation and education for me. Bartlett: But you and John had been together for all the years...how many years m Cincinnati? Engel: Well, we had been four years in Cincinnati, and before that... Bartlett: ...and before that at the Brigham... Engel: ...so he and I had been together for five years... Bartlett: ... so it was a flyer on five years of observation... Engel: ... yeah... but my interest in Psychiatry and even in that of psychological was very slow in developing. I talked about that on the other tape and don't want to repeat here. Bartlett: Yes, I remember after your stand as Acting Chairman of Psychiatry when John was on sabbatical, as I recall the house staff gave you a residency certificate for finally completing your residency in psychiatry by chairing the department. Engel: Yes, that was 1959/1960 and I was Acting Chairman for the year. John was abroad and on the very first meeting with the residents, they brought a patient and asked my judgment. It turned out to be a schizophrenic patient. I had to say "I know very little about schizophrenia." They were shocked. "How come I was acting as Chairman?" Fortunately, the Department of Psychiatry had very excellent people, and I had no concern about matters not being taken care of. But they gave me a certificate at the end. Bartlett: So. the fellowship program...the capacity to establish it came with you from Cincinnati, and you really went right into that. Engel: Yeah, the fellowship program was the first thing we did and we just began working, the fellows and I, on the medical service. We established an outpatient clinic, which we called the Special Medical Clinic, which actually became the precursor of the psychiatric outpatient clinic, although in those days we were seeing more patients with what would now be referred to as psychosomatic kinds of problems, and in the early days of the fellowship program, the internists coming in did not yet have any clear model with whom to identify, and about half of them moved over into psychiatry. There was a good deal of uncertainty about roles at that point. and the psychiatrists as the program began to evolve would press our fellows as to "why didn't you do the real thing?" and the internists would press them and say, "why are you fooling around with this stuff?" And it was about five years, I think, before what we referred to as a liaison identity' formed, that people began to recognize that it was possible to stay in medicine. I think Bill Greene was one of the first people to emerge in this role and continue to be an active and vigorous teacher and investigator in the Department of Medicine. We started with students in the second year, that would be 1947, the fall of '47. John asked me to take over the second-year course. And that was really a challenge. As I said before, it involved my undertaking teaching in areas with which I had no real knowledge or familiarity. I hurried to learn as much as I could. But it was a wonderful group of students, and don't know whether they knew how ignorant I was, but we got along very well. Even how anxious I was. I remember any number of classes I would come into wondering exactly how I was going to handle this, interviewing a psychotic patient when I had had very little experience. But it turns out by and large the patient usually made the exercise in any event, and I began distributing notes, write notes for myself and began to distribute the notes to the students, and that eventually became my book. Psychological Development in Health and Disease, which went through 17 versions. Bartlett: That sort of grew out of the syllabus of the second-year group. Engel: That grew out of the syllabus and it was 17 years before I finally decided it was ready to be published as a book. It didn't appear until 1962, I think it was. '62? Well.... and in the third year we began our teaching on the medical service with once-a-week, two-hour rounds in the regular medical schedule during the students' 12-week assignment. That was always very exciting. I continued to round with the residents in the summer and kept a very busy schedule in those days. The first...well, until 1961, I did the second-year course all by myself. And until 1950, I did the third-year rounding all by myself, so I had the second-year course once or twice a week through the year and then I rounded with every group on Medicine four times a week, four groups at any one time. Bill Greene was the first of the fellows who stayed on as a faculty member. He came through the residency in Medicine and joined us as a fellow in 1948, became a faculty member in 1950, so by 1950 Bill and I were sharing it, and then after that the group grew very rapidly. Frans (Reichsman), Art (Shmallie), and a total of more than 130-40 people went through that training program over the years. So, it was a very active clinical program but I think an important element of it was that, in one way or another, most of us were involved in the teaching. Because we were involved in clinical research, that means we were actually working with patients. We managed to interdigitate and to incorporate a good deal of the research aspect right into the teaching. Simple enough, I was working with patients with ulcerative colitis at that point in particular, and Bill Greene with leukemia and so on. Patients whom we saw on teaching exercises second year or third year readily became part of the material. And we were so involved in our evolving new understanding and new insights and new discoveries in these aspects, I think there was an element of intellectual excitement which was communicated to the students. Bartlett: George, you talked about that in terms of teaching the medical students and of the work in two departments—Medicine and Psychiatry, and also the low departmental barriers here. How did you find it with other departments? Did the focus go on and extend some into other departments, or was this mainly a medical/psychiatric.... Engel: Yeah. let me say a little bit more about Psychiatry. At this point it became very important to me to learn more about Psychiatry, which I started as soon as I got here, seeing the handwriting on the wall, so that in addition to what I was doing with our fellows, and then with our students, I also took to attend as best I could on Psychiatry. and learn as much as I could and then to supervise residents in Psychiatry with psychiatric patients. That's how I gained some familiarity with clinical psychiatry, although I never really undertook the care of psychiatric patients. I mean, in all the years I admitted a total of three patients to Wing R and two of them were a mistake. They shouldn't have been admitted to Wing R. It was in the very early days. An example of the permeability of the barriers is our study of the child Monica and Frans (Reichsman) sitting in the dining room, that wonderful dining room that doesn't exist anymore. and a pediatric nurse, Miss Murphy, who I think is still here, says to him. "We have a very interesting child with a gastric fistula who seems to be very depressed and upset, wouldn't you people like to see her?" See, that came from a nurse at the lunch table and Frans went up and did see her, and realized that this was an ideal object for study in our just-beginning study of behavior in gastric secretions. And to make a long story short, I went to see the child with him on her next admission which was a few months later. We recognized the unique opportunity here... we were all set to go ahead and it required only saying a word to the Chairman of Pediatrics, and at the moment I can't remember whether that... it was still Clausen, I think... '53 or '54. Bartlett: I think Bradford had just come in because... Engel: Yeah, I think Bradford had just come, 1 think you're right. But Bradford, just with a wave of his hand, said, "Sure, go ahead." And there we were, on the pediatric service, and it ended up actually that we studied intensively three children. Here. neither one of us had ever worked with children, other than a month or two in my rotating internship, but that didn't deter anybody, and then I got involved with gastroenterology, of course, in my area with ulcerative colitis and I got involved with surgery. Bartlett: Now, did Monica ever get involved in medical student teaching? Engel: Monica got tremendously involved in medical student teaching. She was so exciting to us, that we made films of her in the very beginning so that... we had not anticipated that we would continue to work with this youngster for any length of time, and actually it turns out we are still working with her. this is now 30 years later and she became an integral part and in fact, the major vehicle for the teaching of child development. As part of my teaching philosophy, that the patient is our teacher, that the well-studied patient no matter what the issues are with the patient, demonstrates, provides information, demonstrates data from which one can develop principles and develop generalizations. So it didn't really bother me that anyone could say that Monica was as unrepresentative of an average child as could be. I could also say, "Well, where else do you have the opportunity to take one child beginning early in infancy and follow her year by year?" And the students got very involved in this, actually the year that Frans (Reichsman) left to go to Downstate, which was 1964, the students of that class included Monica in their yearbook. And beginning in about 1955, there was no school student play which did not include Monica. She became an integral part of the teaching. So we would spend many, many hours just going over with the students the films and the tape recordings, occasionally have Monica come in as she got older, learning about observation of children, that's how I learned it, was watching Monica. And then we got other children, one of the house officers had a baby and so we wanted to have more information, more material, from which students could learn how to observe babies, and he and his wife made home movies and we edited that and used that. to show the first 15 months. There was such a... I'm merely still talking in many ways about the ambiance of the school... Bartlett: Yes, how you got involved in pediatrics and spread out from beyond just medicine and psychiatry. Engel: We got into surgery, not in... many of these areas we didn't ever get into formally but if I wanted to... I did pursue my patients wherever they went, so many of my ulcerative colitis patients ended up on surgery, so there I was on surgery seeing my patients. Some of them I took care of medically, some of them I took care of psychotherapeutically. I did get psychoanalytic training during this early phase, more to develop the skills and a perspective about this than to become an analyst as a practice, although I did that for about 20 years. With students and with fellows, what it really comes down to is that any patient is of interest. (side 1 of tape ends here) the development of which was influenced by the atmosphere that already existed. but in addition I think by what we were doing, that the teachers should be working in areas in which they were not necessarily most expert. We wanted to encourage internists to work on the surgical service and so on and so on, so that students would have instruction in that which is common to medicine irrespective of discipline. Some faculty were uneasy with this, but it worked. Bartlett: As I recall, even before that the medical psychiatric group was very active in the teaching of physical diagnosis... both physical diagnosis and history-taking, which were the old precursors in the traditional end of the second year that were eventually consolidated into the general clerkship in the beginning of the third year. Engel: Yes. Physical diagnosis was taught in the end of the second year two or three afternoons a week and while physical diagnosis had been...physical examination had been an important area of instruction, in most medical schools, probably in all medical schools in the early days, certainly it was when I was a student... a tremendous amount of time was spent learning how to percuss properly and so on. Very little attention had ever been paid to the interviewing of the patient and those aspects of the personal contact with the patient. The teaching of physical diagnosis, as it was called, meant "taking a history," which you were supposed to somehow or other know how to do out of your hip pocket... Bartlett: ....or follow an outline slavishly... Engel:... or follow an outline... .was something that it was difficult to get people to do. Most teachers found it somewhat tedious and boring and it didn't have the excitement of being the attending on the floor, etc. So, we had the good fortune of coming into a sort of vacuum situation. We wanted to teach interviewing and I recruited all of the people in our group and set them on this, and I can't remember whether Ralph Jacox was in charge of that at that point. I think someone before him had it, but he soon took it over. But in any event, he welcomed the addition of attention to teaching interview and we rewrote the format for the writing up of the history. It used to be OB had their form and Medicine had its form and Surgery had its form, and the student had this peculiar notion that there was something called the medical history and the surgical history and so on. So our group rewrote that, and as time went on over several years, we moved into a vacuum, so that by the mid '50s or late '50s we were in position to play a very considerable role in this teaching and to bring about I think a very considerable reform and again, the ambiance in the organization and the structure of the school, enough of this got generated so on the committee of six, I was not a member of the committee of six, and I wasn't a member of the committee that had to do with the general clerkship, but had gotten enough into the ambiance and the atmosphere that some of these people had been students here and some had been house officers and some had just worked with us in one way or another, but the work didn't go on in camera. Lots of people sought me out to talk about this and so on. So when the general clerkship emerged, it had already emerged out of experiences that we had had. Bartlett: Even if there was a vacuum in the examination of the patient, in filling it, you must have experienced an occasional resistance once in awhile. Engel: Yes, there's never been a period in spite of all the things that I have said in which there was not resistance. And the resistance came from a number of sources. Once source of resistance was what I refer to as the irreducible number of people that will exist anywhere and even under the best of circumstances... Bartlett: ...even in Rochester... Engel: ... .even in Rochester, who like people who are tone deaf or color blind, etc., simply do not have whatever it takes, and I'm being very vague, to grasp and sense and organize psychological and social material. And I would say very strongly that this is not a criticism. That's just a statement of fact. And those people are not necessarily opposed. They may be obstacles. They are not necessarily even obstacles. I can think of one person in another school who was able to say, "I just don't grasp what this is about, but inside I have the feeling that it's got to be important, so go ahead and do it." That was Ludwig (Eichner), at Downstate. He was the professor of medicine. So, there was the kind of resistance that came from that source. Then there was the resistance that came indirectly from people for whom this was threatening. There is no question that when you begin to work with psychological and social data, it is threatening to some people, and there is also no question that when you begin to do something new, it is threatening, regardless. That's human. And the third source of resistance, which I think has gradually increased over the years by the nature of the beast, the many people who join our faculty from other schools where this atmosphere has not existed, for whom this is strange and different and who make sort of apriori misinterpretations, namely they tend to think of all of us as psychiatrists, which then also becomes a convenient way of making us aliens. Bartlett: Alicnists, eh? Engel: Yeah, alienists. Uh, and there were times when the resistance got quite intense, and I remember on one occasion, I could hardly forget it, when Larry Young became Chairman, and the first meeting of the full-time staff, and it was at that point that several very respected members of the Department of Medicine spoke up and said, "Is this psychosomatic stuff really necessary during the clerkship?" Larry spoke up and said as long as he is Chairman, this he felt was an integral part of the education of a student and the house officer. And there it rested. It does say something I think very significant, namely, the leadership—in whose-ever hands leadership is— whether we like it or not is a very powerful factor in directions; that when a department Chairman takes that position, barriers come down. And McCann took that position and I was never convinced that McCann really understood what we were doing, but to me the mark of a scholar and of an open person is the ability to do that in areas with which they are unfamiliar. It takes courage. Bartlett: Yes, it's an interesting kind of leadership, isn't it? Engel: Yeah. Bartlett: Because it goes beyond one's own capacities. Engel: Yeah. Bartlett: George, in speaking of the general clerkship, a book came out of that also, that you and Bill Morgan wrote, that probably a great many of our students read, and the rest of us, too. Clinical Examination of the Patient, was that title? Engel: Clinical Approach to the Patient. Bartlett: Clinical Approach to the Patient... would you... how did that develop? Engel: Well, that evolved again like my other book, out of the syllabi that we had prepared over a number of years, and it gradually expanded and it existed in mimeographed form or photocopied form that we handed out to the students and then at some point it just seemed logical to put it into book form. It was actually the first text in that area which gave any attention, strangely enough, to the patient. Bartlett: Yes, the texts before that used to be called physical diagnosis and had a lot of pretty or unpretty pictures of various normal and distorted things about patients, and very little about the approach. Engel: Yeah, it's interestingly parenthetically, Evelyn, my wife, who was trained as a medical illustrator at Hopkins did the illustrations, and when we were doing the illustrations, she of course was supplied with textbooks of anatomy and so on, and Bill and I somewhere along the line, and Evelyn, got into great conflict because we kept saying these pictures are wrong, and she would say, "Yes, but I've gone to the other textbooks of physical diagnosis and so on, and I've checked them out." And do you know that in the pictures in most textbooks of physical diagnosis of that period showing the regional location of the viscera and also hernia and the genitals, were taken from cadavers, and are incorrect? The liver is way too low. We say the liver has to be above the costal margin. She'd say. "Well, look here. Here's the best recognized text and look where the liver is." Bartlett: I remember Evelyn not only drew the pictures but you were the model for some of them, including the hernias. Engel: I was the model... Bartlett: She could be the only appropriate artist. Engel: Some students modeled. Bill Morgan appears in some of those. You will recognize him. Bartlett: What about the curriculum? We've talked about students and faculty and the organization of the medical school here. What have you seen about the curriculum over the years that you've been here? And also you've looked at the organization of curricula in teaching around the country in many medical schools. Would you talk about that here? Engel: Well, rather than get involved in details of curriculum, because that's a word that stirs up a particular context, I'll pick up on your last remark. I've visited about 75 medical schools now in this country and Canada and abroad, Britain and Australia mainly, and if there is a distinguishing feature about Rochester from all other medical schools. it is that in one way or another, the educational program—I use that term rather than curriculum—the educational program has evolved in such as way that students at Rochester are more oriented, and everything is relative—when I say more oriented, I'm saying more oriented than students at other schools towards the patient. Rochester students and Rochester graduates are more likely to see themselves working with patients not just with disease, the nature of our curriculum as it has evolved, as it evolves for the student from the first to the fourth year incorporates a great deal more opportunity for the student in a paced, orderly and systematic fashion to begin to learn about human beings in the context of health care, illness, etc., and it is done in such a way that is natural. In moving, for example... if you look at time allotments in other schools you'll see that the amount of time that is devoted to these areas of patient is in most schools miniscule. Even the time devoted to psychiatry is very limited. I've often said that if... and many of these courses are open to a great deal of criticism by students, and I've often said that if pathology, for example, was given as little time to deal with its subject matter as psychiatry and what I call the people sciences, whatever names they use, as those courses are given to deal with, all that's involved in human behavior and illness, etc., pathology would be damned as a terrible course. You know, this is a growth process for students, so often the educational organization of a school is heavily biased towards content. That's a reflection of the nature of the beast. that much of what students learn in the first two years does involve concepts, should involve. but doesn't as often as it should, general principles and so on. But the fact is, that the physician is not going to become, with rare exceptions—a biochemist or an anatomist or a physiologist—and especially since the laboratories have gone out as part of student experience, and science has become more complex from a technological point of view, students are all too much placed in a situation in which they deal with content, with substance, and don't really have much ground to be involved in process and experience. You are also suggesting that students grow during medical school and that the educational experience should work hand-in-hand to facilitate the growth of the student to become a physician. Engel: Yeah... that you have to... that when you are learning to become a physician, you are learning a role. You are learning to become someone and to do something. That's not happening when you are learning biochemistry and anatomy. etc. You have to do it. That's not what's happening. So in the evolution of the teaching of the psychosocial aspects of medicine, which broadly refers to everything human, behavioral, social, all those aspects of medicine, for the student to a much less greater extent requires content. The content you're learning as you go along, but unless the student also learns how to elicit the information upon which that content is based, how to interview, how to relate, what's involved in interacting with another person, whether it be the patient or family or visitor or whatnot, and do this in an orderly systematic fashion and to come to recognize that this area is just as accessible to the scientific method as any other area. By scientific method I mean systematic, careful observation, checking for reliability, using methods which are reproducible and so on and so on, and so on. Much that's taught in other schools leaves no impact. As a matter of fact, it's really not much more than the average person can pick up in lay publications. You know, there's all kinds of articles about psychological and social things in the public press these days. What has evolved in our program, in the University of Rochester program, and has sort of gotten built into it as a way of approach, is that from the first to the second, to the third and to the fourth, the student more and more becomes a participant, more and more is beginning to use that which is going to be his or her way of life, and our graduates leave the school...they don't know this is happening while they are here. It's only after they get out. And I have innumerable feedback from... Bartlett: You've surveyed students as well as visited a great many, and many have kept in contact with you spontaneously. Engel: Yeah, I did a survey of the class of I think it was 1968/'69/'70. Or maybe '69/'70/'71 a year or so after they were out, and I sent out a very simple, open-ended type of questionnaire. I just asked in which ways did you feel yourself better prepared than your peers as an intern from other medical schools. In which ways did you feel yourself less well prepared? How long did it take you to catch up in the areas you felt less well prepared? How long did it take them to catch up in the areas in which you felt less well prepared? And the upshot of that was that 90%--and we got something like a 75% yield on the questionnaire... and 90% of our respondents, who were free to write as much as they wanted to, responded to this question by saying that they felt more comfortable, more competent, more capable in all the areas, and I'm using that broadly, that had to do with dealing with patients as human beings. And where they didn't feel as competent, scattered among the graduates, some said, "Well, I didn't know as much dermatology as someone else, or I didn't know how to do certain procedures." But whatever those were, by and large, the students, the graduates reported that they caught up within months or certainly by the end of the year, whereas with respect to their peers catching up, uniformly it came back that they never caught up. And several of them wrote eloquently saying that nothing happened in the house officership which would facilitate their catching up, and in essence that if you haven't got this built in, in the course of your undergraduate education, the chances are it's not... it may not ever come. Bartlett: We're working more nowadays with residents, most of whom are coming from other schools, in the Associated Hospitals Program and in the General Medicine Unit and so on, and this is quite evident that after all, the people who elect to do this are people who are genuinely interested as the people who've applied for fellowships. But it's a long haul for many of them, and I've had a number of residents just this fall, a number of residents or fellows who made this kind of statement: "When I just begin to see, yeah, I'm finishing my residency or four years out or five years out, and now I discover that I don't have at my fingertips the kinds of skills to work with people that I need, and I'm angry." One man said that. "I'm furious. This all was neglected." Such ordinary, simple, day-to-day circumstances of how do you behave when you walk into a patient's room and there are visitors there? Do you follow a rote, and say, "Will you please leave?" And so on and so on. All of these are what I call microdecisions, behavioral decisions, for which there is available a body of information which allows you to say that one thing works better than another or that if A, B, and C comes out, you make decision 1, and if C, D, E comes out you make decision 2, that there are no... Bartlett: George, you've been a teacher here for awhile, a good deal longer than anyplace else in your career. What's it been like personally? What have been the satisfactions, the frustrations, the changes that have gone on? Engel: Well, I've had innumerable opportunities to leave... Bartlett: I know. And you've stayed. Engel: And I've stayed, and that in itself says a lot there, and now that I've retired from the directorship, and am phasing out my activities, people still say, "Why are you staying in Rochester?" Well, it's been an absolutely marvelous place to be, and I know people are likely to say that about many institutions, but I know that it would have been impossible for me to do what I did here in many schools of this country. Notably, the name schools, the big schools. There's no way I do think that anybody could accomplish this kind of... have this kind of experience that I've had which has been exciting and generative and creative and lots of gratifying feedback, and the opportunity to innovate: no way that one could do that in schools like Harvard or (BNS) and so on and so on, because they are so weighted by tradition and so structured in independent, almost independent units that hardly relate to each other. I've grown with the school. The school now is what? 60 years old? Bartlett: Almost. Engel: Almost 60 years old, and so I've been here 2/3 of the school's life, and that makes a difference. I have to say that it gets more difficult as the school gets bigger, but at least so far. and I hope it continues, those in leadership have had the wisdom not to let happen here some of the things which have plagued other schools, such as not allowing there to develop the kind of independent operations and fiefdoms and power centers. We have our share, but they nowhere compare. People around here who grumble about how things are in Rochester, I very quickly find out that they've not been anywhere else. They don't know how difficult it can be in other places where there are power structures and so on. We have a large enough sprinkling of our own graduates which I think serve a very important moderating effect. Bartlett: Yes, most people speak of the desirability of bringing together people from all over. You've spoken several times of the desirability of having a core of Rochester people. Engel: I think that is a historical anomaly, perhaps. I think it is a historical anomaly because Rochester unfortunately still is the main center for this kind of development, and it's lonely. I would hope that it's not going to be much longer before these kinds of changes begin to take place elsewhere, and that will no longer be an issue. I see this still as a somewhat delicate plant in the recent couple of years, the recent five or six years, within the educational planning. I think we saw what happened when we had someone who was thoroughly versed in the basic philosophy of the school and then someone who came from outside, and now someone again, who the first person as I said was not a graduate of Rochester, but had been in the program for awhile... and now we have someone who is a graduate of the school who has... those two people have the sense of what certain, almost intangible strengths are here, which are very difficult for an outsider to grasp, unless they've really worked at it. Bartlett: George... Engel: I might say too, I don't want to leave the impression, simply because someone comes from the outside, they are incapable. That's far from true, and I'm very gratified you know, that the last... we've only had four deans, but the three deans who came, all came from the outside, all came with no knowledge or familiarity about this, and the second and third who have finished their tenure, not only left with a very strong and positive supporting view, one even joined our group, Don Anderson, and the present dean, you wouldn't find him saying the kinds of things he says if he were at some other school. Bartlett: Yes. George, you've been emeritus several years now and you've been an important part of this focus of (recitative) soil, but how are things going to continue? I know there's going to be a professorship, is there not? Engel: There is going to be a professorship, and I have very encouraging news about where the... how the fundraising for that is coming along. Bartlett: So there'll be an Engel professorship, and what role can that play in preserving this? Engel: Well, I think it plays a very important role, not because it has my name attached to it, because it is the first acknowledgment, first of all the unit which now is headed by Robert Ader who is an experimental psychologist, and whom we brought here 25 years ago. It's the first acknowledgment by the university, that discipline now called Behavioral and Psychosocial Medicine is meaningful, is significant, it's a new discipline, just as Immunology once was a new discipline and biochemistry once was a new discipline. And for our university and for a medical student to publicly acknowledge that, I think is a very important occurrence. I've often said that what we need is some kind of public acknowledgment whether it be by a foundation or by whatnot, that this is an important area of education and training, and if they were to establish the so-and-so foundation scholarships in psychosocial medicine or whatever, whatever they are called, for funding to develop chairs, that's a social support, and there's no question that things don't move without social and society support. So I think this is a very important development. I hope it will become a reality soon. Bartlett: Well....that's it |