Paul Beeson (1908–2006),Distinguished Physician

Introduction

I first met Paul Beeson (Figure 1) in July 1976. I had just returned to the University of Washington School of Medicine, from which I had graduated six years before, to join the faculty as an Assistant Professor of Medicine and Assistant Chief of Medicine at the Veterans Administration (VA) Medical Center in Seattle. Across the hall from me at the VA was an office with a placard comprising two lines: Paul Beeson MD, Distinguished Physician. I wondered what that title signified. Of course, I knew who Paul Beeson was: co-editor of a major textbook of medicine, previous Chairman of the Departments of Medicine at Emory University and Yale University, recently retired Nuffield Professor of Medicine at Oxford University, author of numerous papers, and one of the most eminent physicians of his generation. I entered his office to introduce myself and discovered a dignified man with a clean, crisp white coat, and snow-white hair perfectly parted on the right. He was friendly, gracious, and interested in my career plans. It was the beginning of a friendship that lasted 30 years, until his death at age 97 in August 2006. OPEN IN VIEWER

The title “Distinguished Physician” originated in 1968, when the VA began a program to honor doctors who “have made very significant contributions to medical science and have attained exceptional professional stature over long and distinguished careers.” The responsibilities of the award’s recipients were to provide scientific and educational expertise, leadership, motivation, and intellectual stimulation in the VA medical teaching programs. ¹ The first appointee was William Castle, who had discovered intrinsic factor when investigating pernicious anemia. Paul Beeson was the second VA Distinguished Physician, chosen in 1969, but he did not assume that position until 1974, when he had completed his term as Nuffield Professor. In choosing Seattle, Washington, as the site of his VA activities, he was returning to his origins in medicine, for it was there that he had decided to become a doctor 50 years earlier.

Early life

Born in 1908 in Livingston, Montana, Paul Bruce Beeson spent most of his childhood and adolescence in Anchorage, Alaska. His father was a physician and general surgeon who saw patients not only in his office but also on home visits. One “house call” was an exhausting mid-winter trip in 1921 when he traveled over 1100 miles by dogsled, intending to perform rib resection and open drainage on a banker with the putative diagnosis of thoracic empyema. Unfortunately, the patient instead had advanced pulmonary tuberculosis, then untreatable, and the arduous, month-long journey was in vain. ²

Having skipped third grade, Paul was ready for college at 16. Accompanied by his mother, who lived with him during his first semester, he traveled to the University of Washington in Seattle in 1925, intending to study Business Administration. When buying some clothes, they discovered that the clerk was a recent graduate in that very field. With a seemingly unprepossessing future in such a discipline, his mother insisted that Paul take pre-medical courses instead. He spent much of his spare time in college playing poker and drinking beer (illicit during Prohibition), hoisted by a bucket through the rear window at the fraternity house where he lived after his mother’s departure. ³

Medical training

In those days, the medical school at McGill University in Montreal, Canada, from which William Osler had graduated in 1872, accepted students with only three years of college preparation. His brother Harold, eight years older than Paul, was a medical student there and encouraged him to apply. In 1925, without having attained a college degree, Paul entered McGill’s five-year program, consisting of two years of conventional premedical courses, followed by three years of clinical work. Paul remembered that the faculty had few clinical teachers, who examined patients as though they were merely physical specimens for teaching, seldom questioning them or regarding them as individuals with differing backgrounds and experiences. Furthermore, intellectual curiosity and scientific inquiry were sparse. Instead, the teachers referred students to William Osler’s textbook of medicine, implying that it contained what they needed to know for a career in medicine. ⁴ He joined a fraternity, where he spent many weekends playing poker and drinking homemade gin. His academic performance, though satisfactory, was undistinguished.

His brother, after leaving McGill, had trained in urology in Philadelphia at the University of Pennsylvania, and in 1933 Paul followed him there, beginning a two-year rotating internship, the first year consisting of six two-month periods in such specialties as obstetrics, neurology, and pediatrics, followed by six months each of general surgery and general medicine. As at McGill, the faculty had few clinical teachers, and the students possessed little sense of intellectual enthusiasm. Paul could not remember ever using the hospital’s medical library or subscribing to any journals. ⁴

While Paul was completing his internship, his brother and father began a general practice in Wooster, Ohio, and in 1935 he joined them, staying for only two years. He made house visits and took most of the night call. He was not manually adept and did not enjoy performing procedures, such as inserting intravenous needles or suturing. He tended to develop a tremor, which worsened as he fumbled and the patients and other observers scrutinized him with alarm. He felt incompetent and helpless with surgical or obstetrical emergencies. Realizing that his future lay with internal medicine, he left for New York Hospital in 1937, expecting to return to Ohio and rejoin the practice when he completed his training.

Early academic career

Shortly after arriving in New York City, he accepted a position at the Rockefeller Institute working with Oswald Avery, who later made the seminal discovery that genetic material consists of DNA, but whose clinical interest at the time was using type-specific anti-pneumococcal rabbit serum to treat pneumococcal pneumonia. Paul’s responsibility was to administer this product to patients, but he also did some bench research, where he learned how to immunize rabbits against pneumococci. He discovered that hemolytic anemia occurred in some people receiving Type XIV antiserum because of the immunologic similarity between that pneumococcal capsular polysaccharide and Group A blood. ⁵ Because of these experiences, he decided to pursue a career in academic medicine.

In 1939, he became Chief Resident at the Peter Bent Brigham Hospital, a medical center affiliated with Harvard University in Boston, Massachusetts. His mentor was Soma Weiss, the Hungarian-born clinician and researcher who characterized carotid sinus syncope and, in 1929, with the pathologist GK Mallory described lacerations in the distal esophagus and proximal stomach produced by retching (the Mallory–Weiss syndrome). Weiss, who had just assumed the position of Physician-in-Chief, was a charismatic teacher whose compassionate and humane interaction with patients seemed far different from what Beeson had seen in Montreal and Philadelphia. His example was to have a profound effect on Paul’s own career.

In 1940, James Conant, the President of Harvard University, arranged with the Red Cross to form a hospital in Salisbury, England, to study the epidemiology of the diseases in Great Britain likely to arise from the crowding and unsanitary conditions of war. Appointed Chief Physician of the unit, Paul traveled to England by freighter just after Christmas. While awaiting the arrival of equipment from the United States, he stayed in London, where the explosion of a German bomb outside his dwelling broke windows, showered him with glass, and knocked him to the floor. Fortunately, he suffered only minor injuries. While there, he investigated outbreaks of salmonella gastroenteritis and an epidemic of more than 200 cases of trichinosis in England and Wales during the winter of 1940–1941 that arose from consuming inadequately cooked pork sausage. The eosinophilia that accompanied this infection intrigued him and became a topic of later investigations. ⁶ The Salisbury Unit, with 126 beds, opened in September 1941, and Paul remained there until the summer of 1942. While in England, he met Barbara Neal, a vivacious nurse from Buffalo, New York, where they married in July 1942.

Career at Emory University

By the fall of 1941, Paul had decided not to return to Boston, and in early 1942 he became Assistant Professor at Emory University in Atlanta, Georgia, with Eugene Stead, its new Chief of Medicine. They held the only full-time posts in the department. Earlier, they had worked together at the Peter Bent Brigham Hospital, where Stead had been a young faculty member chosen by Soma Weiss, who unfortunately died of a subarachnoid hemorrhage in January 1942 at the age of 43.

While in England, Paul had studied whether convalescent plasma from patients with mumps could prevent infection when given intravenously to newly arrived military recruits. He found that 45% of the recipients subsequently developed hepatitis, a complication, recognized since 1883, of inoculating people with human serum, lymph, or plasma. ⁷ Shortly after arriving at Emory, he learned that a previously hospitalized patient had developed hepatitis and, remembering the outbreak in England, inquired whether the patient had been treated with any blood products. He had received intravenous blood, and Paul found six other similar cases, which became the first report of hepatitis from whole-blood transfusions. ⁸

In 1943, Paul became responsible for distributing the precious, limited supplies of penicillin in the Southeastern United States. The range of its use was ill-defined, and his decisions, though usually judicious, sometimes faltered. Once, for example, he denied penicillin to a patient with syphilis because no evidence had as yet demonstrated its efficacy for that infection. Also in 1943, Paul began a study whose ethics he would later question. Curious about the fate of circulating bacteria in infective endocarditis, the investigators inserted catheters through the antecubital veins of six patients and measured colony counts in the blood of the superior and inferior vena cava, the right atrium, and the renal and hepatic veins, comparing them with specimens obtained from the femoral artery and vein. The major findings were: (1) the level of bacteremia in endocarditis was remarkably constant in arterial blood; (2) the colony counts in the antecubital venous blood and arterial blood were quite similar, suggesting that obtaining cultures from peripheral arteries rather than veins had no advantage in diagnosing endocarditis; and (3) the liver, but not the kidney, removed a substantial number of the circulating bacteria. ⁹ Although the patients had agreed to participate in the study and suffered no serious complications, Paul was later troubled by the fact that they had not been apprised of the potential risks of the procedure, from which they derived no clinical benefits. ¹⁰ In retrospect, they had not given “informed consent,” which did not even exist as a term then.

In 1946, Eugene Stead became Chairman of Medicine at Duke University in Durham, North Carolina, taking nearly all his department with him, and Paul became Chief at Emory with only one other member in his faculty. Nor did it grow much: during his time there, it never had more than six salaried physicians. While there, he published papers on a wide variety of clinical and research topics, primarily related to infectious diseases, including lymphogranuloma venereum, chancroid, typhus, leptospirosis, and the mechanisms of fever. In addition to his clinical, administrative, and research activities, in 1948 he became an editor (for two editions) of a new textbook of medicine whose editor-in-chief was Tinsley Harrison, a cardiologist and Chairman of Medicine at the University of Alabama. That year, Paul also reported one of his most important studies. Because the neutrophil count is often elevated in febrile patients, he wondered whether fever might originate from something within the white cells themselves rather than from an external source. He discovered such a substance, which he labeled “endogenous pyrogen,” a cytokine now called interleukin-1. ¹¹

Chairman of medicine at Yale

In May 1951 while in a stall in the men’s room at an Atlantic City hotel, he overheard a physician from Yale University suggesting that Paul was likely to be offered the position of Chief of Medicine there, and, indeed, he accepted the appointment in 1952. That same year, he began his most famous clinical study—on patients with prolonged fever of unknown origin. Earlier investigations of that entity were retrospective, had differing or undefined criteria for fever, involved various intensities of investigation, and failed to identify the etiology of most cases. The commonest recognized causes were infections. Recording the names of patients with unexplained fevers from the daily morning report that he held with his residents, Paul began his study. He developed three criteria for inclusion: (1) an illness of at least three weeks’ duration; (2) a temperature higher than 101°F (38.3℃) on several occasions; and (3) an uncertain diagnosis even after one week of study in the hospital. He chose these characteristics to exclude: (1) acute, self-limited illnesses, (2) healthy people whose temperatures slightly exceeded the normal range, and (3) readily identifiable disorders. His intent was to compile a series of genuinely puzzling and diagnostically challenging cases. Paul shrewdly predicted that infections would not constitute the majority of the identified causes. He ended enrollment in the study in 1957, and in 1958, just before taking a year’s sabbatical in England, he asked his Chief Resident, Robert Petersdorf, to review and write up the cases with him. As Paul later mischievously asserted, he left his co-author to do most of the work. This masterful paper, still replete with clinical wisdom, was published in 1961. ¹² Paul had been right in his premonitions: infections were responsible for only 36% of the 100 cases, while neoplasms (19%), rheumatologic disorders (15%), miscellaneous conditions (23%), and undiagnosed illnesses (7%) accounted for the remainder.

Paul’s sabbatical was at St. Mary’s Hospital in London, where he performed laboratory investigations on a topic that he had begun studying at Yale, the pathogenesis of pyelonephritis. During this time, he also accepted an invitation to join Walsh McDermott, Professor of Medicine at Cornell University School of Medicine, in assuming responsibility for editing the textbook of medicine that Russell Cecil and Robert Loeb had previously co-edited. It became “Beeson and McDermott” for five editions. They each read every chapter, suggested numerous alterations, and, sometimes with unsatisfactory submissions, reassigned the work to other authors or rewrote it themselves. He was a gifted writer and a fastidious editor, who made numerous suggestions and corrections. Shortly after we met, he advised me that academic physicians should ask a colleague to examine their manuscripts before submitting them to scholarly journals. I chose him as my reviewer.

After his sabbatical, Paul returned to Yale in 1959. During his 13 years as Chief of Medicine from 1952 to 1965, he transformed the department, enlarging it from 18 full-time faculty to 65. He attracted gifted medical students for residency training and acquired a sterling reputation for clinical excellence, wise judgment, and personal warmth. He was renowned for his generosity and kindness to patients, students, and colleagues. His research diminished during those years, but he managed to publish papers on the role of obstruction in the pathogenesis of urinary tract infections and a very influential editorial on the risks of bladder catheterization entitled “The Case against the Catheter.” ¹³

Nuffield Professor at Oxford

The administrative burdens of being Chief at Yale became oppressive, however. Accordingly, in 1965 he accepted an offer to become the Nuffield Professor of Medicine at Oxford University, a position endowed by William Morris, Lord Nuffield (1877–1963), who had founded the automobile company, Morris Motors, and had donated much of his wealth to Oxford University. Paul was the second person to hold that position after LJ Witts, who served from 1937 to 1965. He assumed clinical and supervisory responsibility for a firm (medical service) that consisted of 40 hospital beds, six house officers, and five full-time faculty members. ¹⁴ He now had much more opportunity to do what he really enjoyed: patient care, teaching, and research, which included studies on a rabbit model of endocarditis. What he especially cherished about academic life was “time to talk with patients and with people working in different fields and to learn from one’s colleagues.” ⁴ Paul helped reorganize the medical school curriculum, improve faculty relations, and oversee research projects.

For his contributions as Nuffield Professor, he received an honorary knighthood from Great Britain in 1973. During his life, he garnered many other tributes for his contributions to medicine, including Master of the American College of Physicians in 1970, the John Phillips Award in 1976 from the same organization, and the Bristol Award from the Infectious Diseases Society of America in 1972. In 1981, Yale University established the Paul B Beeson Professor of Medicine, and in 1994, what are now called Paul B Beeson Career Development Awards in Aging Research were initiated, sponsored by the American Federation for Aging Research and the National Institute on Aging. He received honorary degrees from several universities, including Yale, Oxford, and McGill.

Late career

In 1974, he returned to the US, and, until his retirement in 1981, he held the position of Distinguished Physician at the Seattle VA Medical Center. There, he became involved in the emerging specialty of geriatrics, encouraged more teaching about that topic in the medical school curriculum, and edited Journal of the American Geriatrics Society from 1978 to 1984. He also became alarmed at the threat of nuclear weapons during the presidency of Ronald Reagan, whose bellicosity he loathed, and joined the Physicians for Social Responsibility, which opposed nuclear proliferation. Even after his retirement, he remained remarkably well informed about news and gossip in academic medicine through his network of friends, who often consulted him for his astute advice about administrative, political, and personnel issues.

Personal characteristics

Paul did not have a dynamic, imposing personality. He had few interests outside of medicine, but he was an enthusiastic supporter of Seattle’s professional baseball team, which is a testament to his loyal perseverance, for the Mariners had numerous hapless seasons. He was not a brilliant conversationalist, but speaking with him was a memorable experience. A woman who had dined on consecutive nights with the two preeminent Victorian Prime Ministers contrasted her impressions: “When I left the dining room after sitting next to Mr Gladstone, I thought he was the cleverest man in England. But after sitting next to Mr Disraeli, I thought I was the cleverest woman in England.” ¹⁴ A conversation with Paul was like hers with Disraeli. He was a quiet, unassuming, and reserved man with an intense interest in hearing the ideas and stories of his companions rather than relating his own. He was modest, with a wry, self-effacing sense of humor accompanied by a configuration of his lips described as an “enigmatic Mona Lisa smile.” ¹⁵ Once, in a disagreement between the medical and surgical teams about the management of a patient, the conversation became heated and devolved to a dispute about a fine point of anatomy. Paul interrupted, saying, “Unencumbered as I am with any knowledge of anatomy, I would like to return the discussion to what is best for the patient.” This comment relieved the tension, re-directed the discussion to its appropriate focus, and demonstrated the value of a revered clinician publicly acknowledging his informational lacunae.

At home, he was humble as well, performing his assigned domestic chores with genial resignation. He washed the dishes after meals, cleaned the kitchen, and prepared morning coffee, amiably muttering that he was certainly not the boss in his own house, which was clearly the domain of his vibrant, outspoken wife. A vivid memory for me was the sight of him—with jeans, a red flannel shirt, rubber boots, shovel in hand, and a half-embarrassed smile—emerging from the stable where Barbara kept horses and where Paul had just mucked the stalls.

Although generally kind and generous, he could be tough when necessary. While Chief at Yale, he had a refractory and unproductive, but powerful, colleague whom he wanted to sack. His faculty member departed only after Paul took away his secretary and reassigned him to a tiny office. When his house staff at Yale complained about some irritating rules and regulations, he admonished them that their job was to learn medicine and take care of sick patients, not to gripe like common soldiers. ¹⁵

Clinical qualities

Despite his long career in academic medicine and his experience giving numerous addresses, he was not an accomplished public speaker. He read his lectures from a script and seemed uncomfortable in front of an audience. Even in small groups, he was not a fluent, captivating teacher when giving prepared talks. He excelled, however, on bedside rounds, where he brought a sense of dignified calm and an intense focus on the patient. He particularly wanted to demonstrate the importance of a sensitive relationship between doctors and patients, especially those with fatal diseases. After hearing the presentation from the student or resident, he went to the bedside, introduced himself, sat down, and not only reprised the history but also elicited further information from the patients—their background, life experiences, and the nature of their real concerns. He performed a careful physical examination, demonstrating the proper technique and relating the findings to clinical physiology and pathogenesis. His bedside presence mesmerized both students and residents.

Paul had great respect and concern for the patients’ welfare, decisions, and insights. When a man with esophageal varices and gastrointestinal bleeding indicated that he wanted no more treatment, for example, Paul agreed with honoring the patient’s wishes by withholding further interventions. Once, after hearing about the complicated course of a very ill patient in the intensive care unit, he asked the simple, but profound question—what did you do to help him?—querying whether all the technologic interventions that had been employed genuinely benefited the patient or, in fact, had made an inevitable death more protracted and painful.

He also emphasized how personal interactions with patients could usually reveal the nature of a medical problem. When the cause of an illness remained obscure despite a thorough assessment, he suggested beginning again, with a fresh history and physical examination, confident that if clinicians were observant and listened carefully, a clue to the diagnosis would emerge. For example, one day at Emory he examined a patient whose fever and fluctuating mental status remained unexplained despite numerous tests. Paul had the insight to ask the patient what he thought was happening. “I’se got rabbit fever” was the reply and, indeed, he had tularemia.¹⁶

Educational ideals

Paul believed that such teaching rounds were very important. In 1947, while at Emory, he compiled a list of “rules for visiting men [supervising physicians],” recommendations that he had elicited from the somewhat disgruntled residents on how the faculty could improve rounds. These suggestions recognized the impact that supervising physicians have on trainees. “Students and house officers both consciously and unconsciously model their conduct toward a patient after your own.” One of Paul’s most powerful lessons was the exemplary kindness, graciousness, care, and sympathy that he displayed when interacting with patients. He emphasized, however, that a critical part of the responsibility of the supervising physicians on rounds was also to teach:

Your primary function is to give knowledge and not to receive it. Everyone realizes that you are not omniscient, but something more than an expression of amazement is called for. If you have nothing to offer the first time you see a patient, be sure to have something the next time.

Being so concerned with patients, Paul disliked teaching programs that omitted case-based discussions. He regularly attended the weekly clinical conference at the Seattle VA Medical Center during his term as Distinguished Physician and in retirement, until he moved to Exeter, New Hampshire in 2002. He sat at the front of the audience, and, for many years, three other former Chairs of Departments of Medicine joined him: Robert G Petersdorf (University of Washington), who succeeded him as Distinguished Physician at the Seattle VA; William Hazzard (Wake Forest), a geriatrician at the Seattle VA; and William Parson (University of Virginia and Makerere University School of Medicine in Kampala, Uganda), who had retired in Seattle. These four former Chiefs represented a formidable group of eminent, experienced clinicians, from whom the sometimes terrified discussants would often have to answer probing questions. Whatever the topic, however, Paul remained focused on the patient, and at the end of many conferences he inquired about the patient’s outcome if it had not been mentioned. Moreover, he did not want to intimidate anyone in clinical discussions. Once, a medical student was so overcome with the idea of presenting a case to this legendary figure that he was nearly mute. Paul’s response was to recommend that the student pretend that he was talking to his roommate about an interesting patient that he had seen that day. The tactic worked wonders, for the student relaxed and gave a confident, coherent presentation.

Even decades later, he remembered lessons from his own experiences as a general practitioner in Ohio. When a trainee in Seattle told him that he was going to become an internist in a small town in Montana not far from Paul’s birthplace, he predicted that it would be a remarkable experience. The clinician would bring new levels of patient care, make diagnoses that would improve people’s lives, and treat disorders that had previously been managed inadequately. Paul recognized, however, that the most grateful patients might be those whose toenails the trainee trimmed and whose ears he cleared of wax. Paul knew that what bothers the patient most may seem trivial to practitioners, but also that these humble acts reveal a caring physician who treats patients as special individuals.

The Beeson mystique

Many people who knew him talked about a “Beeson mystique.” How did an unprepossessing, quiet, even shy, man elicit such intense loyalty, devotion, affection, emulation, and awe? One answer is that his quiet intelligence and human warmth were strangely magnetic. In discussing what made Soma Weiss the best clinical teacher that he had known, Paul could well have been describing himself:

His teaching was not a virtuoso performance, making astonishing diagnoses in a way that the rest of us could hardly aspire to. Instead he held everyone’s attention on the analysis of a problem, while contributing from his own extensive background of experience and reading….In addition to his great skill as a clinician his ability to win the confidence of patients impressed us all. When he came to a bedside, he would take a moment to explain what he and those with him were doing….It was clear that he was considering a medical problem affecting the life of one human being….When we moved away from the bedside we could see that the patient was glad that Dr. Weiss and his team had come. ⁴