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Osler Centenary Papers: Osler as medical leader
  1. Donald RJ Singer
  1. Correspondence to Professor Donald RJ Singer; fpm.chandos{at}gmail.com

Abstract

The Canadian physician Sir William Osler is a key figure in the history of modern medicine. He encouraged lifelong learning for doctors, starting with bedside teaching. Contemporary with Old World figures such as Pasteur in Paris and Virchow in Berlin, he played a major role in raising awareness among clinicians of the importance of the scientific basis for the practice of medicine. He championed a rational approach to treatment and did much to encourage avoidance of ‘unnecessary drugging’ by prescribers. He is credited with playing a key role in improving education of medical students and postgraduate education of doctors, with important benefits for the care of hospital patients. He also had a major influence on his medical colleagues through founding and leading medical societies. A century on from his death in December 1919, his specific contributions and how he achieved them are not well known. The aim of this article is to consider the evidence that Osler was an influential medical leader and to reflect on the extent to which the achievements which resulted from his leadership are relevant to modern clinical medicine. Questions of interest include his leadership style, what made for his success as a leader, his medical achievements both in North America and in England, his own insight into leadership and how he was viewed by his peers.

  • medical education & training
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Introduction

Osler was widely recognised as a key medical leader during his lifetime and well into the twentieth century. He encouraged lifelong learning, starting with bedside teaching and supported by a scientific approach to the practice of medicine, to underpin avoiding unnecessary treatments. He was against ‘random polypharmacy’ and did much to reduce the amount of ‘unnecessary drugging’ by prescribers.1 2 He viewed modernising medical student education as his great contribution, suggesting as his own epitaph ‘that I taught medical students in the ward’.2

He was head of distinguished medical departments and professional societies. ‘Never a mere figure-head, he was the moving spirit in many new projects and reforms’3 and ‘when their future success was practically assured, he would arrange that the leadership should be vested in someone’ suitably eminent.3 He politely turned down many senior positions to allow opportunities for others, including for example the presidency of the Royal College of Physicians of London and of the Royal Society of Medicine.

He played a key role in improving both the education of medical students and the postgraduate education of doctors, with, in parallel, important benefits for the organisation of care of hospital patients.2 These actions of Osler led to major changes in medical teaching throughout North America and in medical schools internationally.

Contemporary with Old World figures such as Pasteur in Paris and Virchow in Berlin, he played a major role in raising awareness among clinicians of the importance of the scientific basis for the practice of medicine. He also had a major influence on his medical colleagues through founding, reorganising and leading medical societies.

In December 1919, he died from lung haemorrhage and empyema, complicating bronchopneumonia—a final illness he personally documented in detail, including a note of regret not to be able to be present at his own postmortem.4 A century on from his death, his specific contributions and how he achieved them are now less well known. His name for most now studying or practising medicine largely lives on merely as an eponym for a select range of clinical signs and diseases.

The aims of this article are to consider the evidence that Osler was an influential medical leader and to reflect on the extent to which the achievements which resulted from his leadership are still relevant to modern clinical medicine. Questions of interest include his leadership style, what made for his success as a leader, his medical achievements both in North America and in England, his insight into himself as a leader and how he was viewed by his peers.

Key appointments as medical leader

At the young age of 25 years, after attending the Toronto Medical College for 2 years,2 then further medical training at McGill University in Montreal in Canada and only 2 years of postgraduate study in Europe, Osler was appointed in 1874 to the Chair of the Institutes of Medicine (physiology, pathology and therapeutics) at McGill.2 In 1884 he was invited to take up the chair of clinical medicine at Pennsylvania University in Philadelphia where he remained for 5 years.2 In 1889, he was appointed as chair of medicine in the new medical faculty at Johns Hopkins University and Hospital in Baltimore where he was also appointed physician-in-chief.2 There he made two of his major contributions: developing new approaches to medical education and postgraduate training; and writing his landmark textbook on The Principles and Practice of Medicine.5

Osler’s final appointment was to the Regius Chair of Medicine at Oxford University, a role he fulfilled from 1905 until his death in 1919. At that time, Oxford was a preclinical school. The appointment board had as favoured candidate a lecturer in pathology currently on the staff (James Ritchie).3 Osler’s appointment in part arose from a dissenting petition by 134 Oxford medical graduates for ‘a physician representative of medicine in its widest sense’, a role for which Osler was pre-eminently suited. His colleague and cofounder of the Fellowship of Medicine Sir Humphrey Rolleston describes the politics of the appointment in detail.3

Some key achievements arising from Osler’s leadership

Medical student education in North America

Before innovations led by Osler, medical schools in North America typically offered a degree after 2 years of lectures and perhaps demonstrations, little or no experience of laboratory studies or the anatomy dissecting room, and no direct contact with patients.

The McGill Faculty of Medicine where Osler studied was an advanced medical school for its day, following the example of the medical school at the University of Edinburgh. Teaching was longer (4 years rather than 2 years). Students had access to a large library and to museums of anatomy and pathology. There was a strong emphasis on dissection but there were no laboratories and microscopes were not used for teaching. Medical students had to spend at least 12 months observing patients on the wards of Montreal General Hospital and the related obstetrics hospital. As a senior medical student at McGill, Osler experienced the early training benefits of being allowed to be a clerk for patients and a surgical assistant.2

At Johns Hopkins in Baltimore, working with pathologist William Welch, head of surgery William Halsted and head of gynaecology Howard Kelly, Osler was given ‘a free hand’3 to reorganise teaching of undergraduate medical students. He disliked didactic, lecture-based teaching and after 7 years of preparation (1888–1895), inspired by his experience of medical student teaching at McGill, in Britain and Germany, and at Harvard in Boston in the USA, introduced students to ward-based teaching. Osler also encouraged better teaching in core medical sciences—especially pathology and physiology. To allow time for additional training, the medical student course was lengthened to 4 years. A chief early preoccupation was organisation of the outpatient department as source of patients for the wards.6

Osler and his colleagues moved medical student teaching from the lecture theatre to hospital clinics and wards. Under the supervision of directors and assistants, students were allowed to examine patients on the wards and in clinics and were provided access to laboratory equipment.

In their third year, students began bedside learning, through teaching ward rounds and involvement in continuity of care of inpatients and outpatients in four main departments: medicine, surgery, obstetrics and gynaecology.2 Student teaching and involvement in patient care was supervised by new trainee resident doctors. Students recorded clinical histories of new patients and were assigned patients to follow during their time in hospital. This was complemented by teaching on clinical examination and diagnosis and how to perform microscopy.

In their fourth and final year, students undertook clinical clerkships, again supervised by resident staff. In further rotations in key hospital departments, they would be responsible for aspects of care of around six patients. In addition to recording an initial clinical history, they would record progress in patient files, examine patient samples and assist in the care of any wounds. Roles would also include assisting with surgery and attending or helping with postmortem examinations.2

Ward-based experience of patients was complemented by bedside teaching, with Osler himself leading three bedside teaching sessions per week. Students were also expected to contribute to weekly case conferences.

Medical student education at Oxford

Before Osler’s appointment to the Regius Chair of Medicine 1905, Oxford was a preclinical medical school, with clinical training taking place in London medical schools. Osler made major advances in developing Oxford as a clinical school. He improved the laboratories at the Radcliffe Infirmary, where he led student teaching on patients by example, making weekly ward rounds on Sundays coupled with bedside teaching for medical students.7 From notes from these morning clinics, Archibald Malloch recalled that ‘sometimes half-an-hour was spent in merely looking at a patient and in talking over things that could be seen under Sir William’s guidance’. Osler would also personally illustrate a relevant case by use of a microscope on the ward. Malloch, as many others, notes benefiting from Osler’s fondness of epigrams to aid medical memory and on occasion telling of his own mistakes to impress a clinical point.7 Malloch added that ‘only a great teacher will relate where he was at fault’.7

Postgraduate training

The Residency programme

A major innovation both for patient care and postgraduate training encouraged by Osler at Johns Hopkins was introducing the hospital residency programme—a hierarchy of permanent resident staff led by a chief resident.2 Resident staff lived in the hospital administration building. Doctors spent up to 7–8 years as residents. The resident staff assisted heads of clinical departments in managing patients, while learning medicine and how to teach, through teaching and supervising medical students on the wards. This had clear benefits for medical students and postgraduate trainees, as well as for patients—and freed senior staff to develop services and have more time for teaching and research.

Postgraduate teaching in London

Osler wished postgraduate teaching in London to include access to ‘the wealth of material at all the hospitals’.7 In 1911, Osler founded and was first president of the Postgraduate Medical Association (PMA), which he and his colleagues set up to promote postgraduate medical education in the UK. When appointed in July 1914 to the University Grants Committee in England, he secured funding for clinical units at teaching hospitals in London.

He was also keen to meet demand for postgraduate civilian medical training after World War I (WW1). To promote these aims, he was a key contributor to the founding in January 1919 of the Inter-Allied Fellowship of Medicine (IAFM),8 becoming its president.9 In October 1919, the IAFM merged with the PMA, Osler becoming the first president of the new organisation, which was called the Fellowship of Medicine and Postgraduate Medical Association.10 This organisation went on to be renamed the Fellowship of Postgraduate Medicine.10 Some 50 general and specialist hospitals were initially affiliated with the Fellowship, which first arranged an Emergency Postgraduate Course. The Fellowship went on to promote sustained postgraduate education, publishing weekly bulletins listing clinics, ward rounds and special lectures and organised further training courses for men and women of all nationalities.8 11

Other contributions to postgraduate medical education

Osler further improved postgraduate education by establishing a system of grand rounds at Johns Hopkins in which expert clinicians discussed complex patients with an audience of trainee staff, senior colleagues and medical students.2 His aims were to improve patient care and provide continuing professional training of doctors. Clinical grand rounds remain a key feature in all major clinical institutions around the world.

Professional and clinical organisations

Osler saw professional and clinical societies as important both in promoting continuing education for clinicians and in improving public health and treatment of disease. His early involvement in public health in Baltimore saw him aiding campaigns for clean water and effective sewage.2 He was instrumental both in founding organisations in North America and in the UK and in actively leading and promoting them.2 Outcomes ranged from cofounding major national organisations, to establishing interest groups and supporting local clinical bodies.

For example, at McGill, Osler set up the first formal journal club, a forum in which clinical papers were discussed to keep staff up to date with medical advances.2 Osler was one of the seven founders of the Association of American Physicians, which they formed in 1885 to advance scientific and practical medicine. Later, at Johns Hopkins, Osler led colleagues in founding a journal club, a medical society and a History of Medicine society, and two journals: the Johns Hopkins Hospital Bulletin and the Johns Hopkins Hospital Reports.2

He was also a member of many local and national clinical organisations and had a special interest in infectious diseases. For example, in the UK, he was a member of the Venereal Commission, was on the Council of the National Association for the Prevention of Consumption and other forms of Tuberculosis and was for 9 years president of the Oxfordshire Association for the Prevention of Tuberculosis.7

An obvious question is what evidence is there for Osler’s contributions as leader towards developing medical societies, as opposed to providing general support for proposals by others. The founding of the Royal Society of Medicine (RSM) provides a good example of his key role as initiator and supporter. Sir John McAlister had attempted to create an academy of medicine in London in 1893 without success and failed again in 1905. Cushing notes McAlister’s proposal was not successful until it received support from Osler.3 In 1907, as a result of Osler’s encouragement,3 18 medical societies were merged to form the RSM. Osler supported the election of its first president (Sir William Church), stressing his added credentials as a ‘good business man’.3 Osler also went on become both president of the RSM’s Clinical Section (1911–1913) and founding president of the History of Medicine section of the RSM (1912–1914).2

The founding of the Association of Physicians of Great Britain and Ireland illustrates further aspects of Osler as leader. Recognising the high regard in which Osler was held, Sir Humphrey Rolleston and five colleagues sought and obtained Osler’s support for the founding of a journal of medical research.12 Osler saw two opportunities which were accepted; that the journal, to be called the Quarterly Journal of Medicine (QJM), be published by the Clarendon Press for which he was a delegate; and that an Association of Physicians be formed to oversee the QJM and to provide a professional and scientific organisation for British physicians. The Association first met on 23–24 May 1907 in London and appointed Osler as senior editor of the QJM, a role he continued until his death.12

Osler had several further key clinical roles during WW1. He was a civilian member of War Office committees on medical matters and a frequent source of direct advice for the Director General of Medical Services.7 He supported wounded American and Canadian soldiers, visiting the injured and was active as a consultant to the Heart Hospital for Soldiers3 (in Hampstead, then Colchester). He also encouraged international recruitment of doctors and nurses for field hospitals during WW1. As President of the Fellowship of Medicine, he went on to support retraining opportunities for demobilised doctors from the UK, Canada and America.2

Publishing, books and libraries

Respect for Osler was enhanced by his prolific publications—over 1000 papers on clinical medicine—on topics ranging from haematology (including pioneering work on the role of platelets in thrombus formation), to infectious disease, parasitology, angina pectoris and cancer—and on the history of medicine.2 The greatest impact of his writing was through his textbook on The Principles and Practice of Medicine, first published in 18925 and continued in print for over 80 years after his death, overseen by a series of editors until 2001. Through his books, published lectures and journal articles on the principles and practice of medicine he reached an international audience of health professionals.

Perhaps Osler’s greatest sustained interest outside direct involvement in clinical matters was in books—both as a collector and to encourage learning. He promoted investment in and access to libraries in the USA and in England, took on many roles to support libraries and made large donations of books and journals from his own holdings to expand library collections.2 In North America, Osler, with other physicians and librarians, founded the Association of Medical Librarians, with Osler appointed its president from 1901 to 1904. As an ex-officio Curator of the Bodleian Library in Oxford, he was largely responsible for the innovation of improving underground book storage by setting bookcases on rollers, for setting aside a dedicated room for research into the History of Science and for the creation of a publication on library matters—the Bodleian Quarterly Record.7 He personally approached friends to support fundraising for acquisitions.7 His love of books also led to his being president of the Bibliographical Society from 1913 until his death.7

Osler’s leadership style

Osler, reflecting on fellow Pennsylvania University clinical professor William Pepper, wrote in 1918 that ‘there are two great types of leaders: the one, the great reformer … with aspirations in the van of his generation – lives often in … disputations, … is misunderstood and too often despised and rejected’. The other ‘is the leader who sees ahead of his generation, but has the sense to walk and work with it. … He lives a happier life and is more likely to see the fulfilment of his plans’.3 The latter describes Osler’s own style and remarkable effectiveness as medical leader.

Why was Osler a successful medical leader?

He worked as a professor over a 44-year period in four leading medical universities: three in the New World—McGill in Canada and in the USA, Pennsylvania and Johns Hopkins University; and one in the Old World—Oxford. Wherever Osler worked, he was encouraged and supported in his aspirations, whether within universities and hospitals or in professional organisations. Why should that be so?

His warm personality and many achievements impressed senior staff, as well as students and trainee clinicians, who went on to be his protégés and ambassadors around the world. He was liked by medical and other health professional staff—as well as by his patients (although a flaw for some was that he found it difficult to resist practical jokes, including at the expense of anxious patients).2

He was kind and friendly to students, junior and senior colleagues, nursing and other health staff and patients alike (see figure 1). His peers applauded this trait although, according to Rolleston, it led to some initial criticism from some of the more formal academic Oxford staff.3 However, his critics ‘soon fell victim to the charm of the man and of the wide learning that he carried so lightly’.7 His charm is illustrated by Keen who noted that Osler was able to accuse humanists of ignorance of modern science and fellow scientists of neglecting the humanities, while making and keeping friends in both communities.13

Figure 1

Osler with team at Orthopaedic Hospital. Credit: Wellcome Images L0004895.

Osler was also very effective at networking. For example, he used his Oxford home as a club for visitors from around the world, in year alone entertaining around 1500 guests. He would organise events to introduce protégés to his peers and was an active member of several London clubs, where he would host meetings for local and international medical colleagues and visitors.3

He made efficient use of his time and ‘did not burn the midnight oil’, aided by rationing his non-medical reading, for example avoiding spending unproductive time on ‘modern thrillers’ of his day.3 Nonetheless, he made time to correspond personally with colleagues, junior and senior, to congratulate, encourage and inspire them.3 He had an excellent memory3 but was careful to supplement this by constant note-taking in pocket notebooks.

His wide and frequent medical travels thoughout his life also led to many contacts who were also impressed by the man and the growing evidence of the impact of his leadership on medical education and the science of medical practice. Immediately after graduating as a doctor from McGill, he was already spending 2 years gaining clinical experience at leading medical centres in Europe in London, Berlin and Vienna, acquiring mentors in many institutions.

Osler is consistently described as inspirational. He was supportive of students, juniors and peers, as evidenced by extensive correspondence to recognise success and stimulate projects and activities for those interested in being stimulated.2 MacCallum, who as a medical student was taught by Osler at Johns Hopkins, notes ‘I think he influenced us chiefly by his personal example, since he showed us how well these things could be done, how vast and inviting was the field of the effects of disease with which one might become familiar…’.14 Further insight comes from Sir Clifford Allbutt, who noted that Osler had that ‘wonderful power only possessed by a few great teachers of “inseminating other minds”’.13

He was also generous of spirit—happy to allow and encourage others to adopt leadership roles, including those for which he may himself have been approached as candidate. Joseph Pratt, from his experience of Osler at Johns Hopkins, illustrates this in noting that Osler acted on his belief that ‘we are here not to get all we can out of life for ourselves, but to try to make the lives of others happier’.15

Osler’s achievements were marked by many honours from home and abroad.2 He was awarded many honorary degrees and honorary membership of many international societies. In the UK, his medical achievements led to his being made a fellow of the Royal College of Physicians in 1883. He was made a Fellow of the Royal Society, a mark of high academic excellence, and was awarded a baronetcy in King George V’s 1911 Coronation Honours List for his contributions to the field of medicine.

There are occasional dissenting views on Osler’s impact. Bondy, then Professor of Medicine at Yale, notes that he found it difficult ‘to understand the reverence he inspired and the prolonged recognition’ given to Osler.16 He illustrates his jaundiced view of Osler’s success by stating that ‘the enthusiastic cheering section which developed at Hopkins certainly contributed to keeping his name in the public eye’.14 However even as a sceptic, Bondy accepts that Osler impressed his colleagues at the Medical School at the University of Philadelphia with the quality of his teaching.14 He acknowledges Osler’s major contribution to Hopkins as a revolutionary modern medical school and the great success of his Principles and Practice of Medicine 10 as a dominant text. Bondy also credits Osler as key initiator of many associations of physicians and important promoter of harmony and exchange of ideas within a North American culture dominated by rivalry.14

Osler’s legacy

Osler’s achievements in transforming medical education continue to underpin medical school practice, with bedside learning teaching a mainstay of medical schools around the world.17 His clerkship model is very dependent on effective supervision by resident and senior medical staff. In modern times, concerns about risk to patients have made direct student involvement in patient care no longer the norm. The best clinical teachers continue to allow closely supervised note-taking by students and their limited involvement in ward testing, with, however, ample opportunities for medical students to observe imaging and other investigations and to be present in the operating theatre. Osler’s residency training programmes remain the established method for training junior doctors and case conferences and grand rounds continue to provide key ways to provide continuing professional development of doctors. Many of the major medical organisations he founded or helped to found continue to provide platforms for clinical and academic interaction and support. Perhaps his greatest continued contribution is to have been a key leader in promoting the scientific basis for clinical practice, and within that a rational approach to prescribing.

References

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Footnotes

  • Contributors The author is President of the Fellowship of Postgraduate Medicine for which the Postgraduate Medical Journal and Health Policy and Technology are official publications.

  • 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 Not commissioned; internally peer reviewed.

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