Infectious disease, internal medicine and Paul Beeson

Paul B. Beeson, M.D., former chair of internal medicine at Yale and an internationally renowned physician and scientist, died on August 14 in Exeter, N.H., at the age of 97.

Beeson held leadership posts at major academic medical centers, was an editor of two major textbooks on internal medicine, advanced the study of fever and infection and was a member of the National Academy of Sciences. Among the honors he received was the Kober Medal, the highest award given by the Association of American Physicians. In 1973, Queen Elizabeth II named him an Honorary Knight Commander of the Most Excellent Order of the British Empire, a rare honor for an American, in recognition of his service as the Nuffield Professor of Medicine at Oxford University.

While at Yale Beeson conducted groundbreaking research, transformed the Department of Internal Medicine into a national model and cemented his own reputation in medicine. “When he came it was a relatively small department,” recalled Arthur Ebbert Jr., M.D., professor emeritus of medicine, who was hired by Beeson as an instructor in 1953. “He apparently had a mandate to expand the department and to encourage patient referrals from around the state. Before he came and reorganized the department, if doctors had a patient they wanted advice on, the patient went to New York or Boston.”

Beeson the scientist was the first to identify proteins in white blood cells now recognized as cytokines, signaling compounds used for intercellular communications, that also play a role in the body ’s response to infections. With one of his residents, Robert G. Petersdorf, M.D. ’52, HS ’58, Beeson subsequently wrote a paper on patients with persistent fevers of 101 degrees or more. Published in the journal Medicine in 1961, the article is considered a “landmark,” said Lawrence S. Cohen, M.D., HS ’65, the Ebenezer K. Hunt Professor of Medicine and Special Advisor to the Dean. Cohen, an intern and resident under Beeson, told The New York Times that the paper is “as relevant in 2006 as in 1961, in pointing out causes that were not obvious and teaching clinicians what they should be thinking about in making a differential diagnosis.”

Beeson grew up in Anchorage, Alaska, where his father, John Beeson, M.D., was a general practitioner and surgeon for the Alaskan Railway. When he was 19, Paul Beeson followed his older brother to McGill University, where both received their medical degrees. After an internship at the University of Pennsylvania, Beeson joined his father and brother in practice in Ohio. The lure of research drew him to Rockefeller University, and he subsequently took appointments at some of the most prestigious academic and medical centers in the country.

He came to Yale in 1952 from Emory University. When he left New Haven 13 years later to become the Nuffield Professor of Medicine at Oxford, internal medicine at Yale was regarded as the premier department in the country. In 1981, the Paul B. Beeson Professorship in Internal Medicine was established at Yale, endowed by a former colleague, Elisha Atkins, M.D., and his wife, Elizabeth. In 1996, the School of Medicine named its medical service in Beeson ’s honor.

In this article adapted from Physician: The Life of Paul Beeson (Barricade Books, 2001), author Richard Rapport, M.D., describes Beeson’s tenure at Yale.

Beeson sat behind a glass-topped desk, rolling a letter opener around in his fingers, while the patients admitted during the night were presented to him by the residents. Laboratory tests had become more sophisticated since Beeson ’s own house officer days, but history and physical examination remained central to the process of diagnosis. The impact of technological innovation was slight, in spite of cardiac catheterization and even early angiography. Laboratory values, X-ray results and physical examination were expected to be reported efficiently by the sleep-deprived residents. Long-windedness was abbreviated by an impatient tapping of the letter opener. The house staff soon learned that, while their new chair didn’t like mistakes, he tolerated them as a function of learning. What he could not tolerate was thoughtlessness. When it was uncovered that a patient had been treated unkindly or misused, as happened the day a resident referred to a homeless, alcoholic patient as “a 35-year-old bum,” the letter opener snapped unhappily to the desk and the room quieted while the offending resident searched in vain for an escape. This happened rarely, a testimony to both residents and chief, but when it did occur it was remembered for the life of the perpetrator.

Teaching on the wards

Tuesdays and Thursdays, after morning report, Beeson left his office with the residents and students assigned to his service, walked past the Fitkin Amphitheater and climbed upstairs to the wards where he consulted for two hours—all year long. Beeson approached the bedsides of the patients, who were exposed on all sides and confronted by a crowd of people they barely knew, and immediately sat down. He had come to believe, possibly from his practice experience in Ohio, that standing by a patient’s bedside places the doctor in a position of dominance that makes many ill people want to be somewhere else. He wished to place them at ease and so he reduced the distance between them by sitting unhurriedly, an act that suggested interest in each patient, rather than the disease being discussed. As the resident presented the history, physical examination, laboratory and X-ray findings, a task that sometimes took a while, Beeson said nothing. He allowed the younger doctors to discuss the problem themselves, develop a differential diagnosis, and argue about what made one possibility more likely than another. If speculations behind the curtains drawn around the bed grew too outrageous, Beeson gently guided the discussion back toward reason. Sometimes he said nothing at all, or simply agreed with the diagnosis and what was being proposed to manage the illness. Occasionally he differed altogether, as in the case of a third-year medical student admitted late one night in 1953.

The student was Sherwin B. Nuland, M.D. ’55, HS ’61, later a Yale surgeon and gifted writer, who had been brought to the emergency room with a very high fever and, the admitting resident thought, an enlarged spleen. The temperature elevation alone wasn’t a great worry, but Nuland was clearly sick, and a spleen that can be palpated expands the possibilities in several nasty directions. Because they didn’t know what was the matter with him, the residents did what they often did then (and now)—they gave him antibiotics and started to work up the fever. Nuland later noted, “I was evaluated from one end of myself to the other, carrying a diagnosis of either mononucleosis or hepatitis—no one being sure which. After about three days like this the Professor came to make rounds, examined me briefly, looked at his retinue and pronounced, ‘This boy had a strep throat a few days ago, but he’s fine now. He can be discharged.’ I don’t suppose this is a major triumph diagnosed by Dr. Beeson, but what impressed me most was the gentleness with which he treated his residents when he had shown them to be in error, and his certainty.”

A growing faculty and more specialists

The tendency toward subspecialization had begun, and the Department of Medicine was forced to add faculty members with more focused interests than only general internal medicine. While recognizing this requirement, Beeson was reluctant to abandon his lifelong view that internists should be generalists. But by 1954, this position, learned from both his father and Soma Weiss, M.D., the legendary Harvard physician and mentor, was difficult to defend, and new fellowship-trained faculty members were hired. With support from Vernon W. Lippard, M.D. ’29, dean of the medical school, Beeson and the Yale department were now in a position to recruit from the best talent available.

As the department added more faculty, it also grew in other dimensions. Space was always an issue (one cardiologist ’s lab was in a remodeled coat closet off the Fitkin Amphitheater), and was relieved only slightly when the West Haven Veterans Hospital opened. The private Memorial Unit was constructed, allowing department attending staff to admit insured private patients and residents an opportunity to care for them, as well as for the nonpaying patients admitted to the Grace-New Haven Hospital. All of the faculty, with the exception of the dean, were entirely indifferent to the funding sources for the care of any of these sick people. The faculty and house staff were paid a salary by the medical school; this income was not linked to nor influenced by months spent attending on the wards, number of patients seen or procedures performed, number of research papers published nor volume of work done as measured by any other scale. Patients were admitted through the clinics, emergency room or privately, and they were taken care of by the same attending physicians and the same house staff regardless of their type of insurance—or its lack.

Such administrative issues always impose on the time of a department chair, and Beeson expected them. What he did not necessarily expect was the growing line of petitioners that never seemed to shrink outside his office door.

Beeson still ran the entire department with only a secretary. Of course, the tasks were far beyond those of a routine secretarial job. His secretary, Betsy Winters, who would later have an award, the Betsy Winters House Staff Award, named in her honor, was responsible not only for scheduling appointments, phone calls, typing and mimeographing —the general business of running the office—but also for managing grant applications to the National Institutes of Health (NIH), intern and resident applications and medical student evaluations and monitoring the queue outside Beeson’s door. Whenever people showed up, regardless of their rank, Winters found a way to coax a few more minutes out of the chair’s schedule for them.

A caring mentor

Dedication to the careers of students, residents and faculty is a labor-intensive activity. The students, who often entered medical school with no idea about what clinical medicine really involved, were sometimes overwhelmed when they found out. Patients admitted to teaching centers in the late 1950s were often so sick they could not be cared for in a community hospital, and the mortality rate was as high as 10 percent on the Yale medicine wards. These patients were hospitalized for long periods, and the house staff and students developed relationships with them not available in today’s technology-rich day-surgery and outpatient environment.

An intern from 1958 remembers his young female patient with meningitis being treated with the new technique of injecting intrathecal penicillin, the drug infused into spinal fluid through a lumbar puncture needle in order to achieve high concentration at the site of infection. This was a procedure advocated by Beeson, who recommended that, even though she was improving, the spinal taps be continued until the patient was completely without fever. An arithmetical error was made by the nurse preparing the infusion, and instead of 10,000 units of penicillin, the intern pushed in 1 million. The patient convulsed and died. The intern, who had been taking care of the young woman since her admission, also collapsed. Beeson was called by someone still left standing, and immediately came to the ward, gathered both nurse and intern and took them into an empty room. After the tears slowed and a little calm had been restored, he explained to the two young people that errors are certain to be made in the care of the desperately ill, and that everyone involved in their care assumes part of the responsibility for what happens on the wards —the triumph and the loss. By involving himself in the accident, and reminding them that it was he who chose the treatment, Beeson comforted the nurse and intern at least a little, and helped them to know that they were supported. Next, they told the family exactly what had happened. There was no lawsuit.

In the first rank of internal medicine

By 1960, the administration of a major department of medicine such as Yale’s had become much more than the chair and one secretary could manage. A business manager was added to the staff and took over fiscal responsibility for the department, as well as management of the growing volumes of reports that the NIH and other funding agencies expected. Even this increased manpower did little to allow Beeson the freedom for laboratory research and unhurried individual meetings with students he had so valued at Emory and during his first years at Yale. He became a clever and capable administrator, but never the kind of merciless program director consumed by competition for money, faculty and patients.

The Department of Medicine had joined the first rank, competing with Harvard, Johns Hopkins and Columbia. A 1964 article about Yale in Newsweek describing the medical school as “good, if not outstanding,” brought this quietly outraged response from John Bowers, M.D., who had been dean at two medical schools, member of the Atomic Bomb Casualty Commission and later president of the Macy Foundation: “The medical school at Yale has consistently ranked as one of the top schools in the country, with an excellent faculty and students. ... Recently a distinguished colleague at a New York medical school told me the Department of Medicine at Yale was unquestionably the most outstanding in the country—and neither he nor I are sons of Old Eli.”

Beeson’s students make their mark

While the department expanded both in depth and scope, some people left, of course. The vast majority of Beeson-trained academics found careers in the best medical schools in the country; 27 went on to hold major administrative positions at other universities. All of these academic physicians continued to train their own students and house staff in the image of their teacher, valuing patient care, instruction of house staff and clinical research above their own advancement.

As the success and size of the department continued to grow, so did Beeson ’s own prestige, both at Yale and nationally. This was not the result of self-promotion, but happened as a natural function of his unassuming manner and what Lewis Landsberg, M.D. ’64, HS ’70, and the rest of the house staff called the “Beeson mystique.”

“What was it, we wondered, that contributed to the aura of greatness that surrounded this man? When Beeson walked into a room everybody stood up. His very presence imbued the Department of Medicine at Yale with an organic unity that was felt by third-year clerks and full professors alike. No one wanted to appear unworthy in behavior, demeanor or medical knowledge in the eyes of Dr. Beeson,” Landsberg recalled in a letter.

At Yale, Beeson continued to take morning report himself in his office at 8 o ’clock, he still attended on the wards throughout the year and he gave the introductory lecture to the third-year medical students annually as they began their clinical training. At this lecture, a gravely ill person was chosen from among the hospitalized patients and brought to the Fitkin Amphitheater. As students who had studied only basic sciences, these 24-year-olds about to enter the wards for the first time had little understanding of the disease being presented. Neither was it their professor’s intent to teach them details of that specific illness or class of diseases as he carefully and slowly interviewed and then examined the patient on those fall afternoons. What a comfort it was to these bewildered students when they were then told:

“As your acquaintance with clinical teachers grows, you will observe that although each of them has special knowledge and experience in some area of clinical medicine, they make no pretense of knowing it all. You will also find that clinicians frequently disagree, and that each of them comes to wrong conclusions from time to time. ... Biochemists and pharmacologists have ‘hard’ facts to propound. We, on the other hand, deal with such commodities as pain and nausea. We must accept any kind of problem. We cannot insist on working with inbred strains of people, we cannot control the environment from which they come, we know that their recollection of past events is faulty and we cannot reduce them to subcellular fractions to determine what is going on. ... We live, therefore, in an atmosphere of doubt and uncertainty, and make our decisions and take our actions on the basis of probabilities. ... So these are some precepts you must consider: Give each patient enough of your time. Sit down; listen; ask thoughtful questions; examine carefully. ... Be appropriately critical of what you read or hear. ... Follow the example set by William Osler: ‘Do the kind thing and do it first.’ ” YM