William Osler: a model for the 21st century? Osler's teachings are as relevant now as they were 100 years ago
Whatever way my days decline, | 
MJA 1999; 171: 577-579 |
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William Osler's tribute to his mentor, Palmer Howard of
Montreal,1 can properly be applied to
Osler himself by those who practise medicine today. Osler is largely
responsible for so many of the things which we take for granted in
medicine -- medical education within a university environment,
strong roots in basic science, application of scientific methods to
clinical medicine, emphasis on bedside learning, involvement of
students in hospital routines, and the residency system after
medical graduation.
The highlights of Osler's life and career are outlined in the Box. From a humble childhood, he became the best-known, most-admired and influential physician in the world. The peak of his career was the 16 years (1889-1905) spent as Foundation Professor of Medicine at the Johns Hopkins University Medical School in Baltimore. The new hospital and university had been endowed by the bachelor merchant Johns Hopkins, who had profited in the Civil War, but was aware of the poor standards of medical education which prevailed in its aftermath. The standard for Johns Hopkins was to be that "the seal of its diploma should be a guarantee that its possessor is not only a well educated physician in the fullest sense of the word, but that he has learned to think and investigate for himself, and is therefore prepared to undertake, without danger of failure from not knowing how to begin, the study of some of the many problems still awaiting solution".2 Osler, the beneficiary of a liberal education, an acolyte of Newman's The idea of a university,3 an inspirational teacher and a more than competent clinician, was an obvious choice for Professor of Medicine and was appointed to the position at the age of 39. Osler's major books were his Principles and practice of medicine,4 first published in 1892, and Aequanimitas1 -- a selection of addresses to medical societies, students and graduating classes. The textbook was a masterpiece and became the standard text of internal medicine, retaining its pre-eminence for many years after Osler's death. The theme of the book, implied in the title, is that to practise good medicine one needs to seek principles of action and reasons from basic science. Works about Osler include the classic biography by Harvey Cushing,2 a recent book by C S Bryan,5 and collections from the American Osler Society.6 In preparing this article, I gained insight into Osler's influence in Australia from entries written inside a copy of Cushing's book held at the the Royal Australasian College of Physicians' library. The entries were made by prominent Sydney physicians of the early 1900s, Robert Scot Skirving and James Isbister, who had given the book to Scot Skirving. Isbister quoted William Cowper's words "Knowledge is proud that he has learned so much; wisdom is humble that he knows no more," and added himself "and Osler possessed both". Scot Skirving wrote of Isbister "a splendid doctor but too serious at times", and commented that he had met Osler twice and was extremely impressed by his character and influence on the young. In a review of Cushing's book,7 Scot Skirving presented an Australian perspective on Osler's appointment to the Regius Chair at Oxford in 1905, observing that "Amusing tales are told of the fears among some of the Old World port wine and high table dons as to the wisdom of importing such a foreign type into their midst . . . but . . . Osler soon won over all . . ." Osler foresaw that "At the end of the twentieth century . . . [t]he current [of student movement] may turn towards the schools of the great nations of the south . . . the Africander, the Australian or the New Zealander may reach a development before which even 'the glory that was Greece' may pale."1 Why was Osler so effective as a teacher, clinician and administrator? Answers come from reading his books and biographies. His skills came from hard work; he referred to work as the "master word" in introductory student classes. He urged mature students to cultivate a number of qualities: the art of equanimity, of detachment from personal feelings and distractions that could interfere with an issue at hand; the virtue of using a systematic method for organising work; the quality of thoroughness in assessing symptoms, signs, data and opinions; the grace of humility and a reverence for responsibility. He believed the two most important characteristics a teacher should possess were enthusiasm ("that deep love of a subject") and knowledge ("a full personal knowledge of the branch taught -- not a secondhand information derived from books, but the living experience derived from experimental work"). Osler himself displayed these characteristics, combined with another which further enhanced his appeal -- a keen sense of fun. Osler was a wag and practical joker throughout his life -- undeterred by a two-day stint in a Toronto jail following an adolescent prank.2 He invented an alter ego, Egerton Y Davis, who at various times threatened to call the police, attended conferences with Mrs Osler, and wrote letters to learned societies, and even had one inadvertently published in the Medical News, Philadelphia, on December 13, 1884. There was one other thing that endeared him to his students, colleagues and fellow citizens -- his keen sense of responsibility and ethics. He deflected praise from himself to others but shouldered criticism himself. He stood up for principle, even in the face of defeat. He would not countenance gossip. He criticised issues and attitudes (to parochialism, vaccination, sanitation, etc.) rather than persons. When he did have occasion to criticise individuals, he balanced this with whatever commendation was possible, and met with potential adversaries afterwards and in private. He was always constructive and unfailingly courteous. Osler's teachings are as relevant now as they were 100 years ago -- indeed, even more so given the explosion of knowledge and the frequent intrusions from phone, facsimiles and email which frustrate our routine and challenge our equanimity. The most important parts of our lives are still those precious personal encounters with patients, relatives, students and colleagues. In seeking to enrich these encounters, we need the wisdom which comes not from knowledge alone, but from a breadth of educated experience, and from humility. Medical courses are being reviewed, often with an eye to practicality and with exclusion of material not considered immediately relevant. "Evidence-based medicine" is being thrust upon us, with emphasis on large clinical trials, often cleverly designed, and supported by commercial interests. Results of individual trials are often considered more important than reason and logic as applied to individual patients. Osler's Principles and practice of medicine was stacked full with evidence, but carried in its frontispiece just two quotations: "Experience is fallacious and judgement difficult" (Hippocrates) and "Medicine . . . is an art which considers the constitution of the patient, and has principles of action and reasons in each case" (Plato). What did Osler mean by linking these quotations at the beginning of a repository of facts and detail? Did he not know of Conan Doyle's detective stories, written about the same time, depicting the characters Sherlock Holmes and Dr John Watson -- both were presented with the same evidence, but only one of them was able to use logic and reason to solve the case. Through Palmer Howard in Montreal, Osler learnt and applied the finest traditions of Graves, Stokes and Corrigan from the golden age of Irish medicine to emphasise the importance of bedside teaching. The motto of the Royal College of Physicians of Ireland, to which Osler received Honorary Fellowship, is Experientia, Ratione ("With experience and with reason"). This motto, the above quotations, and Osler's book itself provided a solid foundation for medicine in the 20th century, and remain a sound approach to the practice of medicine in the 21st. Michael F O'Rourke
©MJA 1999
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