The “good” physician: Oslerian aphorisms in the 21st century

Abstract

On February 2, 1899, William Osler gave a lecture before the students and faculty of Albany Medical College. As a founding member of the Johns Hopkins School of Medicine, Osler had already established himself as a prominent physician and educator and would spend the rest of his career bolstering his reputation as a public speaker. This brief essay looks at four of the more salient points of this lesser-known address, discussing the ways in which he practiced his own advice and finally asserting that his contributions to medical education are still broadly relevant in the 21st century.

The year was 1899; William McKinley was 2 years into his term as president of the United States, and the Spanish-American War was drawing to a close. Within the previous decade, Wilhelm Rontgen had established the use of x-rays in medical practice while Emil von Behring had developed antitoxins against tetanus and diphtheria. William Osler of the Johns Hopkins University, already a preeminent clinician and professor, was invited to speak to the students of Albany Medical College. This was among his less-well-known addresses, escaping mention in the major anthologies of his works, including Osler’s own compilation, Aequanimitas.¹ In spite of this relative obscurity, however, this address contains his trademark distillation of medical knowledge and a trove of aphorisms for aspiring physicians to base their practice upon.

“I am happy to say that I am still a medical student, and still feel that I have much to learn.” This was, perhaps, a rather unexpected declaration. Osler had just been introduced by Dr. Samuel Ward, later the dean of Albany Medical College, who stated that “there is no man who is better known the world over, either as a medical author or as a successful practitioner of our profession.”² He would not have been faulted or disparaged for basking in his hard-earned glory; a personal pat on the back, proverbial or otherwise, would have been expected and encouraged by those in attendance. Osler, however, believed that physicians in particular “should illustrate the truth of Plato’s saying that education is a life-long process.”³ He never settled for the status quo, choosing instead to pursue knowledge throughout his storied career and beyond into retirement.

His example of educational pursuit has, in large part, become a standard practice through the formalized systems of graduate medical education and continuing medical education that we know of today. Each of us, as medical students, residents, and even faculty, have to attain specified educational requirements as part of our licensing process. One has to wonder: Would Osler consider these enough? I submit, and fully believe, that he would not. He would, rather, continually endeavor to expand his medical knowledge, in spite of his experience and his credentials, in order to give the patients the care they deserved and fellow “students” the inspiration they needed.

“Cultivate equally well your hearts and your heads.” This particular injunction was spoken in response to a growing sentiment that “doctors are given over nowadays to science,” caring more about the diseases than patients who had them.² He prescribed a multifaceted treatment for this ailment, one of which is discussed here and two of which are discussed below. Osler engaged with the humanities on a daily basis, sharing quotes in this address by Thomas Carlyle, a British essayist and historian, as well as by Mary Ann Evans, the novelist and poet who wrote as George Eliot. He firmly believed in the power of literature, encouraging his students to “spend the last half-hour of the day in communion with the Saints of Humanity” such as Plutarch, Cervantes, and Shakespeare.⁴ Not only did he advise students to collect such classic works, but he even gave them access to his own personal library, which was later endowed to McGill University. His words to medical students of more than a century ago are still as relevant today, and perhaps even more so with the “canonization” of greats like Hemingway, Morrison, Gawande, Steinbeck, and so many others.

“Care more particularly for the individual patient than for the special features of the disease.” Osler wrote and spoke a great many aphorisms on this particular topic, indicating both its importance and necessity in the medical climate of the late 19th and early 20th centuries. These words were spoken before the advent of magnetic resonance imaging, before penicillin, before acetaminophen, and before blood types had been discovered. What Osler practiced was patient-based medicine, but his words indicate that his method was already becoming the exception rather than the rule.

How much more does this precept apply in the 21st century, with our expanded medical knowledge, broadened armamentarium, electronic health records, and so many other competing requirements? In what ways would Osler put these words into practice? Fortunately for posterity, both for patients and physicians, this focus on patient care was institutionalized in the form of bedside rounds and clinical clerkships. His natural method of teaching set the groundwork for the medical education we know of today, where “the student begins with the patient, continues with the patient, and ends his studies with the patient.”⁵ His words on this occasion were not in vain and, in retrospect, grow more prescient with each passing year.

“Keep a looking-glass in your own hearts, and the more carefully you scan your own frailties the more tender you are for the frailties of your fellow creatures.” This command was the final redress against the notion that physicians were more concerned with disease than with the patients who had them. He spoke of the “poor, suffering humanity” who physicians see “unmasked … exposed to all the frailties and weaknesses”² when in the throes of disease. In speaking to the medical students at Albany Medical College, whom he identified as colleagues, Osler spoke also to himself and to future generations of physicians. We have “entered upon a profession that appeals both to the heart and to the head”² and must not lose touch with the humanity that we have pledged our lives to serve.

Osler concluded his address on that day in early February with another quote by Carlyle, adding a final morsel of advice to this veritable feast of axioms and aphorisms. Those who wish to do noteworthy things ought to “calmly await tomorrow’s hidden pleasures and fear not … the future whatsoe’er it brings.”² His exhortations to patience and courage were not mislaid, not for the students of Albany Medical College nor for the intervening generations of physicians over the past century. The enduring resonance and applicability of these excerpts from his 1899 address are illustrative of the continued inspirational value of aphorisms in general, and the special significance of those spoken by Osler in particular.⁶ If we, as lifelong medical students, maintain our connection to humanity through the cultivation of our hearts, treating our patients rather than their diseases, we can approach the future assured of success and filled with the foreknowledge that we walk in the footsteps of one Sir William Osler.