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Osler Centenary Papers: William Osler in medical education
  1. Helen Leach1,
  2. Jamie J Coleman2,3
  1. 1 Undergraduate Medical Education, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham, UK
  2. 2 School of Medicine, University of Birmingham, Birmingham, UK
  3. 3 University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
  1. Correspondence to Professor Jamie J Coleman, School of Medicine, University of Birmingham, Birmingham B15 2SP, UK; j.j.coleman{at}bham.ac.uk

Abstract

William Osler combined many excellent characteristics of a clinical educator being a scientific scholar, a motivational speaker and writer and a proficient physician. As we celebrate his life a century on, many of his educational ideals are as pertinent today as they were in those Victorian times. Osler’s contributions to modern medicine go beyond his legacy of quotable aphorisms to a doctor, educator and leader whose proponent use of bedside teaching, careful clinical methods, and clinicopathological correlation was a great inspiration for students and junior doctors. He was also a great advocate of patient-centred care—listening to and closely observing his patients, an important message for modern medicine as the reliance on investigations strains modern healthcare systems. This review of Osler’s contribution to medical education summarises his development as an educator and provides reflection on his influences to modern clinical education.

  • History of Medicine
  • Medical Education
  • Bedside Teaching
  • Assessment
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Introduction

The study of the history of medical education is fraught with the anachronistic risk of comparison; indeed, the study of medical history is permeated by the measurement of modern medicine against its previous counterparts. However, comparison can also highlight the similarities between our own educational systems and those of our predecessors. The sphere of medical education, in whatever form, has not materialised out of thin air but has been dependent on social, cultural and political contexts from which respective curricula and understandings have developed. Equally, the influence of previous scientific breakthroughs or medical ancestors can be felt in how medicine is practised and taught. While secular Hippocratic medicine may be one of the earliest forms of medicine that we recognise as close to our own, the birth of the education that most resembles modernity originated much later in the 19th century under the guidance and instruction of William Osler (1849–1919). Most medical students will know of the name ‘Osler’ but perhaps only in conjunction with the cardiovascular examination (although it is perhaps true that few have ever seen or could identify Osler’s nodes in practice). Some may recognise Osler’s name in conjunction with italicised quotes slotted into lectures commending the importance of the process of history taking and good clinical method. However, very few students might appreciate how his life made such an undeniable impact on the development of modern medical education. Osler’s aphorisms have come to define how he is perceived: the forefather of modern medicine, a proponent of bedside teaching, a bastion of scientific and clinical method and an advocate for patient-centred care. However, the face of education today cannot, and does not, directly mirror that of Osler’s students. Perhaps, while his influence is still evident in some areas, the move away from Osler’s paradigm methods is felt more keenly in our modern-day education and health service.

Osler’s journey in early medical education

Osler’s route into medicine did not start perhaps in the typical way that one might have assumed for someone who is regarded as a pivotal influence on modern medical practice. Born in rural Canada in 1849, Osler’s childhood was spent as a prankster with little interest in the academic environment; this changed in his adolescence and early adulthood under the tutelage of James Bovell and William Johnson. Osler developed an interest in scientific naturalism, a school of thought also shared by Charles Darwin, wherein the world was observable and explainable to its simplest terms.1 2 Reverend Johnson, Osler’s early mentor in his adolescence, was not a physician himself but the founder of Trinity College School, where he opened Osler’s eyes to a world beyond the typical classics-driven schoolboy education of the time. Osler delighted in a new passion for science, spending his time studying algae and polyzoa under the newly available microscope. Michael Bliss’ biography of Osler details him as an ‘intense observer, careful classifier, a thorough searcher’, skills that undoubtedly would have assisted him in any scientific apprenticeship.3 Even so, he opted to follow in his father’s footsteps to train for the ministry at the University of Trinity College, Toronto. Here Osler met Dr Bovell, a naturalist physician and friend of Johnson, who taught physiology and pathology at both Trinity and the Toronto School of Medicine. Osler increasingly attended Bovell’s lectures, also living in his house for a time, and eventually made the move away from theology in favour of medicine instead.

Osler’s love for physiological and pathological processes continued throughout his early medical education and may have in part influenced his decision to transfer to McGill University, Montreal, which was known for its museum, extensive library and emphasis on cadaveric dissection.3 Dr Palmer Howard nurtured an interest in anatomy, and Osler’s graduation thesis consisted of multiple reports of postmortem autopsies and specimen examinations.4 This continued even after graduation while spending time in Europe under the tutelage of other eminent physicians, including Rudolf Virchow.

Osler’s early career as a lecturer and clinical teacher

Osler’s early career was certainly based on his interest in pathology, leading him to spend much of his clinical work managing smallpox. His first formal teaching post from 1874, as a lecturer and professor at McGill, found him primarily responsible for teaching anatomy and pathology with postmortem cadavers.4 He was not, reportedly, a natural lecturer, but it was clear that his knowledge and enthusiasm were unmatched. In 1884, Osler moved to the University of Pennsylvania where pathology continued to be his main interest, although the laboratories were notably inadequate.3 He carried on publishing extensively and also began presenting his pathological and clinical research internationally, including in London on endocarditis in 1885 (the condition arguably he is most linked to in modern practice).3 The pages of the journals sparkled with published articles, correspondence and lectures on topics ranging from platelets to pneumonia, and from cerebral palsy to chorea, a diverse subject matter even by today’s standards. Ironically (given this article), he even wrote about the benefits of learning from medical history telling the students that they ‘may be helped to get into the habit of looking at a subject from the historical standpoint’.5 His multiple publications and wide breadth of knowledge and experience as a pathologist and a clinician placed him in good stead when it came to beginning to write a textbook, published in 1892, The Principles and Practice of Medicine.3 4 As a work, it was remarkably approachable for students and even enjoyable to read.6 The textbook was an instant international success, secondary to Osler’s extensive publications, lectures and educational curriculum vitae.3 6 New editions were published every few years, even posthumously, and available internationally. Criticisms were levelled at Osler’s medicinal nihilism but did nothing to dampen the book’s reputation as a key text in diagnostics.6 7 It bolstered his already strong reputation as a scientist, clinician and educationalist and made up a significant proportion of his income until his death.

Bedside teaching: the signature pedagogy of medical education

Osler was appointed as physician in chief of Johns Hopkins Medical School and professor of medicine in 1889.3 He had been headhunted by John Shaw Billings and William Henry Welch; Welch was also a keen pathologist, having continued his scientific education in Germany and had been influential in supporting the integration of laboratory-based work into American medical education.8 9 Flexner’s biography of Welch notes that Osler’s appointment was unusual as most medical schools were predominantly staffed with local clinicians, but Welch, as cited in Bliss, considered Osler a ‘great acquisition’ on account of his personal characteristics and clinical ability, although their shared education and background in European medical education should not be overlooked.3 10

It is Osler’s teaching at Johns Hopkins, and his unfaltering support of bedside teaching, that is perhaps known more widely than his clinicopathological work and textbook publication (see figure 1). Bedside teaching was not a new phenomenon, having previously been used within the European schools; McGill University, Osler’s alma mater, had itself been modelled on the University of Edinburgh (one of the oldest medical schools in the English-speaking world) and had this pedagogical approach included within the curriculum.11 12 However, for students across the USA, the clinical apprenticeship model wherein students spent increased time working with patients on the ward, was a new addition to the teaching toolkit.3 Osler’s ward rounds could command the attendance of upwards of 30 students, although it was noted that this popularity did potentially dilute the teaching opportunities.3 It may seem surprising then, considering his strong background in microscopic and macroscopic pathology, that Osler has been seen as a key driver to the more holistic, patient-centred model; rare is the lecture that does not include paraphrased versions of ‘listen to your patient, he is telling you the diagnosis’ or ‘to study the phenomenon of disease without books is to sail an uncharted sea, while to study books without patients is not to go to sea at all’.13 Osler never lost his background in naturalism and emphasised that a diagnosis could be determined from direct observation of the patient and not just from under the microscope. Over-reliance on investigations was discouraged and instead used in conjunction with history and examination. The patient was the focus of each encounter, undoubtedly a more patient-centred approach than many paternalistic consultations that remained common throughout the 20th century.

Figure 1

Osler at the bedside. Credit: Osler Library of the History of Medicine, McGill University. William Osler Photo Collection/NLM/NIH.

The clinical method

The shifting paradigm of biomedicine over the 20th and 21st centuries has caused the balance between patient histories and reliance on investigations to become strained. The rise of increasingly specific, sensitive and technologically advanced testing methodologies fixed the patient in a passive role, and less emphasis was placed on history taking or examination. Historians of medical heterodoxy have highlighted that this approach may have contributed to a breakdown in the doctor–patient relationship and an increase in the uptake in complementary medicine.14 15 William Osler’s aphorisms of patient-centred medicine have also been used to highlight instances where physicians were deemed to have neglected their patients with certain diagnoses.16 However, a holistic biopsychosocial model of medicine has increasingly been advocated in medical education and is particularly relevant with the growing prevalence of chronic conditions. Osler recognised that working collaboratively with patients, not just with treatment but also in determining a diagnosis, was therapeutically beneficial.

In the UK, the General Medical Council’s (GMC) undergraduate medical curriculum guidance—Outcomes for Graduates—echoes Osler’s words by being the latest document shifting the idea of best practices in medical education back to one that includes a patient focus.17 Training within general practice (family medicine) has also been influenced by Osler in conjunction with the later work of Michael Balint.18 Recent educational efforts have ensured that students are encouraged to elicit their patients’ ideas, concerns and expectations, but holistic assessment of patient sensitivities were of great importance for Osler—an ideal that existed before its widespread support. It is important to recognise that a direct comparison of Osler’s version of patient-centredness would still look very different to one encountered today; equating modern and historical approaches would be inherently flawed (see figure 2). Thankfully, we have moved on from the days of keeping patients in the dark about terminal diagnoses because, according to Osler’s version, we should not ‘…depress [his] patients in any way whatever’.3

Figure 2

Teaching theatre. Credit: Osler Library of the History of Medicine, McGill University. William Osler Photo Collection/NLM/NIH.

It seems almost paradoxical then that, while there has been a move to reintegrate the patient at the heart of a medical encounter, the signature pedagogy of hospital-based education—bedside teaching—seems to have become less frequent and more problematic. For William Osler, it was an ideal teaching modality for history taking, examinations, professionalism and communication, and indeed, it still is. Evidence confirms that bedside teaching is enjoyable and positively linked to examination outcomes at both the undergraduate and postgraduate level.19–23 The reasons for the decline in formal bedside teaching in modern education are complex and nuanced. Some articles place blame principally on the constraints of the health service itself (ie, shorter patient stays and sicker patients) and the overwhelming duties and responsibilities placed on all healthcare professions.24 25 The balance between educational opportunities and service provision remains fraught. However, this attribution of failure does not recognise that learning may happen in a clinical environment with more subtlety and without necessarily requiring a formal bedside teaching round. Interestingly, there also seems a perception from learners that patients find being the subject of bedside teaching embarrassing or stressful.24 This contradicts some data that suggest that patients are happy to be involved as case-based discussions, although one must be mindful that being labelled as the ‘interesting patient’ can be both objectifying and dehumanising.23 26 27 Bedside teaching remains a crucial tool for undergraduate and postgraduate education but maybe its approach needs updating; 19th century bedside teaching should not look like 21st century bedside teaching. Whereas Osler’s bedside teaching was a senior-led formal affair, perhaps our modern equivalent should be peer-led or more ad hoc, with access to technology to reduce time pressures. An evolution, or reinvigoration, of this critical tool in clinical education is required as it is too important to lose.19–21

Characteristics of the teacher

Direct comparison of Osler’s medicine or teaching with our own would highlight more differences than similarities. Perhaps then the ultimate thread that runs through Osler’s influence on medical education is more than his culture of patient collaboration, specific teaching methodologies or even just textbooks: it is his sheer passion and enthusiasm for teaching that transcends the senior physician apprenticeship model that existed previously. After his death, Osler was revered by many of his students, whether they were from Canada, the USA or Britain. He was described as warm, charming, supportive and approachable for his students, and his commitment and undeniable interest in teaching was an example for all he worked with.3 Even in his early days as a Professor at McGill, Osler was noted to have an infectious enthusiasm for his subject. Osler’s style was, and still is, the antithesis of the well-practiced methodology of teaching through humiliation. Students were expected to give their best but made to feel at ease with careful questioning and sharing of knowledge.3

Osler’s love of continued learning complemented his passion for teaching. Osler was a bibliophile, dedicated to collecting and reading books from all medical specialties. He was also a keen historian of medicine himself, setting up the Johns Hopkins Medical History Club. Osler’s ‘The Student Life’ recommended that physicians should always be learning and remain a perpetual student.3 His emphasis on continual professional development has never been lost within medicine; undergraduate students are encouraged to develop their skills in independent learning, key throughout the rest of their careers.

Reflecting on Osler’s passion and enthusiasm begs the question of whether such educators are protected within today’s modern health service. The GMC highlights that doctors have a duty to teach, and surveys of attitudes have shown that many clinicians do maintain enthusiasm for teaching throughout their careers.28–30 However, the perception is that this time and enthusiasm is not remunerated appropriately; evidence of teaching turns into a tick-box exercise for Annual Review of Competence Progression (ARCP) or job applications.28 31 This issue is only going to continue with the planned increase in medical student numbers along with rising numbers of trainees overburdened by pressures within the health service. The 2018 National Training Survey showed that finding time to train was worsening and that an increasing number of respondents disagreed/strongly disagreed that training opportunities were rarely lost due to rota gaps.32 A further 2018 report by the GMC, The State of Medical Education and Practice in the UK, noted that 30% of doctors felt that mentoring provided to them had decreased.33 Enthusiasm may not simply be enough. For undergraduate students, recognition of these issues has led to an increase in the numbers of clinical teaching fellowships.34 35 Many go on to study formal qualifications in medical education and, although not a prerequisite by any means for teaching, enables skill improvement and enhanced practice. The development of an educational portfolio, along with evidenced enthusiasm, may strengthen the argument of greater recognition for teaching, and not just research, as an academic focus. The increased clinical burden has caused CPD to become another hurdle to jump, a points-gathering exercise that is not necessarily relevant for practice.36 Osler’s version of continued learning included history, ethics, classics and literature and not just scientific and medical advancement. While this might not do much to counter the argument that it is not relevant for practice, approaching CPD in its own holistic way might encourage engagement as it becomes something of actual interest to the learner in question.

Assessment in medical education

While Osler’s influence on medical education is undeniable, it is worth noting an element of his practice that would be more controversial in 21st century medical education: his denunciation of the formal examination of students. He preferred assessing students over periods of time, calling examinations ‘stumbling blocks…in the pathway of the true student’.3 The background to his comments is found in his approach to continual learning and development, advocating that passing an exam should not be evidence of finality of learning. An approach akin to Osler’s views is that of programmatic assessment, wherein routine information is gathered about a student or trainee’s performance. Osler’s opinions on assessments were controversially aimed at undergraduate medical education. Today’s standards look to a variety of stakeholders in the health service, including patients, other health professionals and regulators, to assure a high quality of education that assures that new graduates are safe to practice. Indeed, it seems then that we are turning towards more examinations rather than fewer being the answer. Within the USA, controversies have ignited over the influence that US Medical Licensing Examination scores have over future careers and whether, rather than stimulating learning, they are instead causing students to burn out and experience mental health crises.37 38 Debate within the UK has focused on the upcoming Medical Licensing Assessment for new graduates starting in 2022/2023 and whether it will promote ‘teaching for the exam’ and an increased examination burden for students.39 40 Medical educationalists can now only ‘watch and wait’ while this assessment is integrated into the undergraduate curriculum. It remains to be seen whether it will have any impact on patient outcomes or on graduates themselves.

Concluding remarks

Overall, Osler’s unhampered enthusiasm, sheer passion and dedication place him as a giant among men in his influence on medical educationalists today. Osler was not the inventor of bedside teaching, but he made it a crucial element of medical education. Neither was he the sole proponent of a patient-centred model, but his collaborative advocacy has resurfaced with the increasing burden of uncertain or chronic diseases. Even the Principles and Practice of Medicine is not a routinely used textbook in modernity, but Osler’s name lives on as a classifier of clinical signs and disease. It was in Aequanimitas, within an address entitled ‘Chauvinism in Medicine’, that Osler advocated a little bit of hero-worship to stimulate ambition and rouse sympathies; indeed, this is more than easy to do when reflecting on his own influence on medical education, but the question is what ambition is stimulated from it. Technology and teaching methodologies have transformed medical education beyond what Osler could ever have imagined; even his own textbook has been replaced by the infinite expanse of the internet. So perhaps our ambition is to reclaim the simplest of Osler’s lessons: to remember to enjoy the processes of both learning and teaching medicine. It is a privilege that both are so ingrained within our profession, but maybe it is this simple message that we are at risk of losing.

Main messages

  • Bedside teaching, while challenged by high patient throughput, clinical supervisor time, and overall declining availability, remains an important teaching modality for history taking, examinations, professionalism and communication.

  • Clinicopathological correlation was key to Osler’s work and modern generations of medics can do well to remember that a good education process is to consider the presentation and pathology closely together.

  • Patient-centred care was a central tenet of Osler’s practice as he often emphasised that a diagnosis could be determined from history taking and direct observation of the patient rather than over-reliance on investigations.

References

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Footnotes

  • Contributors Both authors conceived the outline for this review, drafted and revised the article, and approved the final article for publication.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Commissioned; externally peer reviewed.

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