Sir William Osler: A forerunner of mindfulness in medical practice

Abstract

Increasing work hours, patient loads, and regulations have increased burnout among health care professionals, forcing many to neglect their own physical and emotional well-being. In response, several health care organizations are encouraging physicians to adopt mindfulness practices to reduce burnout and difficulties maintaining work-life balance. It is unclear whether mindfulness will improve health outcomes and patient satisfaction or will become another passing trend. With the stakes so high, this discussion should involve the founder of our modern education system, Sir William Osler.

Residency remains a critical training period in which newly initiated physicians acquire the skills and competency to manage the complex social and physical hurdles facing their patients. However, increasing work hours, patient loads, and regulations have increased burnout among health care professionals, forcing many to neglect their own physical and emotional well-being. As a result, many health care workers have become “disillusioned [and] frustrated by the fragmentation of the health care system. Patients…experience the consequences of the commodification of medicine that has forced clinicians’ focus from healing of patients to the mechanics of health care.”¹ As Dr. David Rakel explained:

There are lots of times when I find it a struggle to stay in a room with the patient and give them the full empathic presence along with bringing to bear all of my evidence-based, medical and scientific knowledge. Of course, patients expect that we do this in every visit, but anyone who has been faced with a full waiting room, a couple of emergency walk-in visits, and a few talkative or dependent patients knows differently. Despite our best intentions to be caring, compassionate, and competent physicians, our daily reality may intrude and leave us (and our patients) feeling that we have not achieved those noble and lofty goals.²

In response, physicians have adopted mindfulness practices and meditation to reduce burnout and difficulties maintaining work-life balance. With roots in Buddhist philosophy, mindfulness practices refer to

the cultivation of present-moment awareness through nonjudgmental presence…to attend to relevant aspects of experience in a nonjudgmental and nonreactive way, which in turn cultivates clear thinking, equanimity, compassion, and openheartedness. Mindfulness is an inward-orienting, self-empowering practice that can stimulate the healing process and help patients and healthcare practitioners navigate through unsettling and turbulent experiences.²

Recent clinical studies showed reduced medical errors and improved patient care among medical residents who practiced mindfulness meditation.² Specifically, a German clinical trial showed that residents trained in mindfulness meditation had better treatment outcomes, physician-patient relationships, and joint problem solving.³ Other studies showed similar reductions in psychiatric conditions, such as stress, anxiety, and substance abuse disorders, among patients who applied mindfulness practices.^4–6 However, it is uncertain whether mindfulness will improve health outcomes and patient satisfaction or will become another passing trend. Because of the high stakes, this discussion should involve the founder of our modern education system, Sir William Osler.

Dr. Osler was a Canadian physician who practiced during the 19th and 20th centuries and was a pivotal proponent of the modern medical education system still used today.⁷ Osler’s emphasis on proper physical examination and diagnostic reasoning while remaining close to the intimate aspects of the physician-patient relationship has resonated through generations of physicians.⁷ More important, however, Osler’s hectic schedule matches the realities and challenges faced by medical professionals today. As one friend of Osler recounted:

At seven, he [Osler] rose; breakfast before 8. At a few minutes before nine he entered the hospital door. After a morning greeting to the superintendent, humming gaily, with arm passed through that of his assistant, he started with brisk, springing step down the corridor towards the wards. … The visit over, to the private ward.…A cold luncheon, always ready, shortly after one. 20 minutes’ rest in his room; then his afternoon hours. At 4:30, in the parlor opposite his consulting room, the clans began to gather, graciously received by dear “Mrs. Chief”, as lady Osler was affectionately known.…Dinner at seven to which impartially and often, his assistants were invited. In the evening he did no set work, and retired early to his study where, his wife by the fire, he signed letters and cleared up the affairs of the day. Between 10 and 11 o’clock, to bed. Such were his days.⁸

With his busy schedule, Osler certainly faced many of the difficulties in reducing burnout and maintaining work-life balance. Throughout his medical career, Osler faced periods of tiredness, lack of enthusiasm, cynicism, and diminished sense of personal achievement and satisfaction.^7,9 In fact, “William Osler’s decision to leave Johns Hopkins for the Regis Professorship in Oxford was based on ‘intolerable clinical demands’ and inadequate ‘protected time.’”⁹ Although Osler never directly addressed mindfulness practices, “many of Osler’s contemporaries pointed out his extraordinary ability to focus on the present moment.”¹⁰ Overall, Osler’s numerous writings provide insights into his thoughts concerning physician well-being and medical practice.

Although the practice of medicine remains a perpetual challenge for both newly initiated and seasoned clinicians, Osler managed his busy clinical schedule and teaching responsibilities through an intense focus on present tasks while cultivating humility and kindness in his patient interactions. As Osler described,

The way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work, Life in day-tight compartments.¹¹

I have had three personal ideals. One is to do the day’s work well and not to bother about tomorrow.…The second ideal has been to act the Golden Rule…towards my professional brethren and towards the patients committed to my care. And the third has been to cultivate such a measure of equanimity as would enable me to bear success with humility, the affections of my friends without pride, and to be ready when the day of sorrow and grief came, to meet it with the courage befitting a man.¹²

After a long day in the clinic and teaching, Osler would refresh his mind reading stories, plays, and biographies of notable clinicians and humanitarians of his day. Specifically, Osler recommended that his colleagues

start at once a bed-side library and spend the last half hour of the day in communion with the saints of humanity. It helps immensely to be a bit of a hero-worshipper, and the stories of the lives of the masters of medicine do much to stimulate our ambition and rouse our sympathies.

He added:

There is no such relaxation for a weary mind as that which is to be had from a good story, a good play or a good essay. It is to the mind what sea breezes and the sunshine of the country are to the body—a change of scene, a refreshment, and a solace.¹³

If the daily hassles of medicine proved overwhelming, Osler applied humor with his patients, students, and colleagues amidst the challenges, frustrations, and disappointments in the clinic. As Osler suggested,

Whatever you do, take neither yourselves nor your fellow-creatures too seriously. There is a tragedy enough in our daily routine, but there is room for a keen sense of the absurdities and incongruities of life, and in the shifting panorama no one sees better than the doctor the perennial sameness of men’s ways.¹⁴

There is a form of laughter that springs from the heart; that defies analysis by the philosopher, which has nothing rigid or mechanical in it, and totally without social significance. Without egotism and full of feeling, laughter is the music of life.¹⁵

Hilarity and good humour, a breezy cheerfulness, a nature “sloping toward the southern side,” as Lowell has it, help enormously both in the study and in the practice of medicine.¹²

However, Osler’s main prescription for managing his own disillusionment, increasing work hours, and patient loads while remaining compassionate and caring toward his patients included a daily recognition of his own limitations, frailties, and humanity. As Osler described:

Things cannot always go your way. Learn to accept in silence the minor aggravations, cultivate the gift of taciturnity, and consume your own smoke with an extra draught of hard work, so that those about you may not be annoyed with the dust and soot of your complaints.¹²

Courage and cheerfulness will not only carry you over the rough places in life, but will enable you to bring comfort and help to the weak-hearted and will console you in the sad hours.¹²

Keep a looking glass in your own heart, and the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.¹⁶

To have striven, to have made an effort, to have been true to certain ideals—this alone is worth the struggle.¹⁷

Although residency encompasses a significant proportion of a physician’s young adulthood and requires significant commitments and sacrifices, physician well-being and burnout remain a growing concern among experienced clinicians.¹⁸ Specifically, “Burnout has reached rampant levels among United States (US) healthcare professionals, with over one-half of physicians and one-third of nurses experiencing symptoms.”¹⁹ Despite recognition and attempts to reduce physician burnout, the rate of physician burnout continues to increase in the US and abroad.¹⁸ For example, one-fifth of all residents in the Netherlands reported moderate to severe burnout symptoms, with those in other countries reporting similar levels of physician burnout.²⁰ Furthermore, many physicians exhibiting burnout symptoms do not seek professional help.²⁰ Several studies have shown that the three psychological needs for resisting burnout include autonomy, competence, and relatedness.¹⁸ As Kristin Raj summarized:

Succeeding in an activity (high competence) while feeling pressured to do so (low autonomy) leads to happiness but not well-being, but when succeeding (high competence) at a task controlled by one’s own motivation (high autonomy), greater well-being results. Autonomy and competence are found predictive of well-being, both between-persons and within person. Relatedness satisfaction is achieved by meaningful conversation and feeling understood and appreciated.¹⁸

In response, current recommendations suggest that “organizations…furnish resources encouraging individual physicians to practice self-care; examples include offering healthy food in cafeterias, providing mindfulness or exercise programs at the hospital or clinic, and facilitating memberships to local gyms. Furthermore, physicians can be equipped with protected time to devote to these practices.”¹⁹ In Sir William Osler, we see a physician who embodied all three components of resisting burnout while facing the many challenges of modern medicine. As professor Faith Wallis summarized:

His [Osler] energy, productivity, and humanity blossomed out of a deep vulnerability. Between the pages of his books, we can still encounter an Osler who is…a perennial model and source of authentic inspiration to the modern physician, who each day confronts, as he did, the tension between the scientific challenges from without…and the human values that spring from within.²¹

ACKNOWLEDGMENTS

The author thanks Dr. Kenneth Nugent at Texas Tech University Health Sciences Center for his advice and support in writing this article.