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The concept and development of postgraduate medicine owes much to one outstanding physician: Sir William Osler (1849–1919). Born in Canada he trained as a physician in Montreal and established a reputation as a skilled and popular diagnostician and teacher. Invited as a young doctor to practice and teach at the Medical School in Philadelphia, he was a few years later appointed as the first physician to St Johns Hopkins Hospital, Baltimore, a medical school founded with the objective of being the best and most innovative medical school in the USA. Osler’s textbook, Principles and Practice of Medicine first published in 1892, and frequently revised and translated into several languages, was the leading medical textbook for half a century and in many respects it remains relevant to today's practitioners.
Medical students have long been taught through lectures, by reading books and journals and as ‘apprentices’ by observing experienced practitioners. Osler, in contrast, took a patient-centred approach to teaching. By teaching at the bedside, he was able to demonstrate, watch and assess students as they examined patients, blood and urine samples using ward microscopes, and, following death, he discussed postmortem findings. Such a student and patient-centred approach contributed to his popularity as a teacher. He was also the author of many seminal papers and as an avid reader of medical texts his publications were richly referenced.
Osler’s reputation as a fine teacher and author spread beyond Canada and the USA. He visited and discussed medicine with the leading physicians of France, Germany and Great Britain. In 1905, he was invited to become the Regius Professor of Medicine at Oxford University. In Oxford, he taught medical students weekly at the Radcliffe Infirmary, took every opportunity to increase his medical library by purchases in London and by collaboration with the Bodleian Library and he accumulated a very fine library on the history of the medicine. He incorporated this passion at dinners to which he invited small groups of students where he displayed and discussed a few of his books. He founded both the Association of Physicians and the History of Medicine section of the Royal Society of Medicine.
Once established, he was invited to give advice to medical schools in London and later in Wales. Major developments in medical teaching in the USA were reflected in London’s review of its own teaching and Osler’s thinking on medical education was apparent in Flexner’s report in 1912 on Medical Education in Europe and the Haldane report on Education in London 1913. Haldane quotes Osler’s views when he was helping to set up the Welsh School of Medicine’s programme, ‘A professor of medicine requires the organisation of a hospital unit if he is to carry out his threefold duty of curing the sick, studying the problem of disease, and not only training his students in the technique of their art, but giving them university instruction in the science of their profession’.1
Osler is considered to be the instigator of postgraduate medicine. Many American doctors had a long wait in London on the way to the 1914–1918 battle front and several American Hospitals were set up in the South of England and were regularly visited by Osler, who recognised that these doctors, although graduates, needed to have professional engagement and so he arranged with colleagues a programme in London of Medical and surgical updates on current practice, possibly the first ever CPD course and the beginning of defined postgraduate medicine.
Medical practice has advanced considerably in the 96 years since Osler's death. In 1919, the year of his death, mechanisms underlying the development of diseases were just beginning to be understood, and ‘the germ theory’ was a recent major advance. There was no concept of molecular biology and it would be over 30 years before Watson and Crick unravelled the structure of DNA. Osler would not recognise most of today's drugs or surgical techniques: the discovery of many treatments now taken for granted, including antibiotics, cancer therapies, insulin, treatments for myocardial infarction, techniques of minimally invasive surgery and most immunisations, were decades away.
Other aspects of practice have changed. Information provided by modern imaging modalities—ultrasound, CT scanning and MRI—have made a huge difference to the accuracy and speed of diagnosis. Today, postmortems are performed by specially trained pathologists and are rare, generally done only when the cause of death is not known. In contrast, Osler himself undertook postmortems on all his patients and used them to teach his students. As recently discussed in this journal by Sherbino and Frank,2 information technology—the world wide web, laptops, smart phones and social media—is having a massive influence on many aspects of practice including knowledge transfer and the speed of communication. Today, there is also a much greater understanding of the influence of environment on disease. Osler occasionally smoked and at 13 Norham Gardens, Oxford, where he lived and where today there is a collection of his papers, books and other memorabilia, there is on display a cigarette case given by Osler to a friend with a card stating ‘Smoke and think of your friend’. Ironically, the career of another ‘medical great’ Sir Richard Doll is also celebrated at 13 Norham Gardens, including details of his work demonstrating the links between smoking and cancers and other diseases.
Osler was a beacon of best medical practice—an effective and much loved bedside teacher—and can reasonably be considered one of the ‘fathers’ of ‘postgraduate medicine’. But, given the differences in medical practice between his time and ours, what can he teach us today? His thinking was remarkably modern. This quote, describing his approach to practice could apply to medicine today: ‘The physician needs a clear head and a kind heart; his work is arduous and complex, requiring the exercise of the very highest faculties of the mind, while constantly appealing to the emotions and finer feelings’.3 He would have certainly applauded the influence of Cochrane and the emergence of evidence-based medicine. He wrote of efficacy ‘the greatest difficulty of life is to make knowledge effective’4 and of evidence ‘our work is an incessant collection of evidence, weighing of evidence and judging of evidence’.5
The campaign to prescribe ‘less medicine’ might well have been supported by Osler, who would almost certainly have advocated withholding antibiotics for minor sore throats and colds. In 1895, he wrote ‘it took the profession generations to learn that many fevers ran their course and money spent on drugs was better spent on a nurse’3; and ‘even for minor ailments, which would yield to dieting or to simple home remedies, the doctor's visit is not thought to be complete without the prescription--the temptation is to use medicine on every occasion’3 And again, in 1907, ‘I would urge you to cultivate a keenly sceptical attitude towards the pharmacopeia as a whole, remembering the shrewd remark of Benjamin Franklin, that “he is the best doctor who knows the worthlessness of the most medicines”’.6 And his views on complementary medicine might well have been in tune with that of today's allopathic practitioners: ‘I feel that our attitude as a profession should not be hostile, and we must scan gently our brother man and sister woman who may be carried away in the winds of new doctrine [alternative medicine]’.7 Osler's natural leanings as a scientist and a seeker of evidence was tempered with an understanding of emotions. He wrote in 1904, ‘The man of science is in a sad quandary today. He cannot but feel that the emotional side to which faith leans makes for all that is bright and joyous in life. Fed on dry husks of facts, the human heart has a hidden want which science cannot supply; as a steady diet it is too strong and meaty, and hinders rather than promotes harmonious mental metabolism’.8
Osler was one of medicine's ‘greats’. In any walk of life it is tempting to wonder how the ‘greats’ of the past would have managed in today's environment and how they would have stacked up against the stars of today. The two characteristics that made him a good teacher and a good doctor, his fine intellect and his ability to listen well, would have been as important today as they were nearly a century ago.
Osler would surely have given ‘two cheers’ for this issue of Postgraduate Medical Journal. First, although PMJ was not launched until 6 years after Osler's death, as the father of postgraduate medicine he would have supported its purpose and celebrated its 90th anniversary. Second, he would have been delighted to see how much postgraduate medical education has advanced as shown by the programme of this year's International Conference on Residency Education (ICRE),i now in its eighth year, based in his native Canada and with ‘Residency Rediscovered: Transforming Training for Modern Care’ the conference theme for 2015.9
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
↵i Since last year the Postgraduate Medical Journal has been a silver sponsor of this conference and this issue is available to all conference delegates at ICRE 2015.
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