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Osler Centenary Papers: Would Sir William Osler be a role model for medical trainees and physicians today?
  1. Vivek K Murthy, First author,
  2. Scott M Wright
  1. Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
  1. Correspondence to Dr Scott M Wright, Johns Hopkins University, Baltimore, MD 21224, USA; swright{at}jhmi.edu; Dr Vivek K Murthy; Vivekmurthy{at}jhmi.edu

Abstract

If Sir William Osler were alive and practising as one of our contemporary colleagues, would he be viewed as a role model by medical trainees and other physicians? Recently published literature has sought to define clinical excellence; this characterisation of physician performance establishes a context in which role models in medicine can be appraised. Building on this framework, we present rich anecdotes and quotes from Sir William Osler himself, his colleagues, and his students to consider whether Osler would have been regarded as a role model for clinical excellence today. This paper illustrates convincingly that William Osler indeed personified clinical excellence and would have been appreciated as a consummate role model if he were alive and on a medical school’s faculty today. However, a century has passed since his death, and he is not sufficiently visible today to serve as a role model to modern medical trainees and physicians. Moreover, we speculate that Osler himself would not have wanted to be a role model for today’s trainees, as he emphasised that medicine is best learned from teachers at the bedside—a place where he cannot be. Reanimating Osler through rich stories and inspiring quotes, and translating his example of clinical excellence into modern clinical practice, can remind us all to carry Oslerian virtues with us in our professional work.

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Introduction

Both within and beyond the field of medicine, a role model is defined as ‘a person considered as a standard of excellence for another to emulate’.1 Role models are different from teachers, who aim to impart knowledge or skills to learners through lessons and instruction. Role models are also distinct from mentors, who actively and purposively attempt to support the advancement and success of mentees; mentors and mentees have formal relationships with mutually agreed on goals and expectations. By contrast, a role model might not even know that another individual looks up to her as an inspiring exemplar.

There is no need to personally know, meet, see or otherwise interact with an individual for him or her to serve as an inspiring role model. Role models can be appreciated across great distances, and even over the passage of long periods of time, from their written words or spoken verse. In this perspective piece, we explore whether Sir William Osler would be considered a role model in medicine if he were one of our current contemporaries. Ultimately, a role model in medicine is one who is clinically excellent, unfailingly professional, and a genuinely good person. This was as true in days gone by as it is today—in spite of the remarkable advances in medicine and healthcare since Osler’s time.

Role models have always been influential in medical education. Since the process of learning in medicine is often conceptualised as an apprenticeship, role modelling is a particularly important method through which the complex skills, attitudes, values and ethics of the profession are conveyed.2–5 Part of the reason for this is evident in the discerning quote by Confucius: ‘I hear and I forget. I see and I remember’.6 Hence, this themed issue of Postgraduate Medical Journal celebrating Osler is appropriately focused. We need to remind contemporary physicians of the greatness of Osler and show them how he practised and lived so that they can ‘see’ and ‘remember’ how to emulate him.

Attributes, skills and philosophical approaches establishing Osler as a role model for the ages

Definitionally, role models of clinical excellence must themselves be superb clinically. Clinical excellence is a complex and multifaceted concept. Five qualitative studies seeking to define clinical excellence are among the most thoughtful published literature on the subject.7–11 In these studies, investigators interviewed peer-nominated expert clinicians about their current behaviours, activities and attitudes; from their insights emerges a paradigm for defining clinical excellence that spans several domains: (1) depth of knowledge built through self-directed learning, (2) advanced interpersonal and communication skills, (3) superior clinical judgement refined through feedback and self-analysis, (4) humanism and compassion, (5) enthusiasm for patient care and teaching, and (6) scholarship. These domains, together constructing a portrait of the clinically excellent physician, have been used to inform election criteria for modern master clinician councils at US academic medical centres.12 13

To address the thesis of this paper, we elaborate below on how Osler personified this conception of clinical excellence. In making the case, we highlight attributes of his intellect and personality that make him worthy of having his likeness etched into the Mount Rushmore of medical role models. We also emphasise his tenderness towards the sick and ailing, his generosity towards his patients, colleagues and family, and his warm and unpredictable sense of humour.

Osler had an impressive depth of knowledge built through self-directed learning

Role models for clinical excellence have extraordinary clinical knowledge bases, and their commitment to lifelong learning helps them build on this foundation continually. William Osler was renowned in his time for his encyclopaedic knowledge of clinical medicine and pathology. As Physician-in-Chief and Professor of Medicine at The Johns Hopkins Hospital, he was sought after as a medical reference by his students and colleagues. He was often called on for a second opinion for infirm friends, family members, the social and political elite of Baltimore and Washington, DC, and even for medical students and hospital colleagues.14 His lifetime of experiences in pathology and clinical medicine was distilled into his tour de force textbook, The Principles and Practice of Medicine, which garnered international acclaim and is considered one of the greatest medical textbooks ever written.14

Osler’s expansive medical knowledge was the consequence of a legendary work ethic. A room-mate remembered him as being highly disciplined: “[ He was] more regular and systematic than words can say; in fact, it was hardly necessary, living in the house with him, to have a timepiece of one’s own. One could tell the time exactly from his movements from the hour of rising at seven-thirty until he turned out the light at eleven o’clock… He always had a day’s work laid out before the day began.” 15

Osler was “a notorious reader-traveler in vehicles” and “read and wrote constantly – at meals, while dressing, on trains and in carriages, during every free moment on holiday… Even those who understood the rigid regularity of his habits were not sure how Osler got so much done in mere twenty-four-hour days.”14

Osler had impressive interpersonal and communication skills

Clinically excellent role models are distinguished by their advanced interpersonal and communication skills. In his interactions with colleagues, friends and students, Osler demonstrated his genuine ability to connect deeply. A McGill colleague remembered, I have never known anyone who was surrounded by such a distinctive, attracting, personal ‘aura.’16 He cultivated a practice of “giving you all his attention and interest, perhaps taking you by the arm, listening intently, remarking on an encounter years earlier… convincing you that for William Osler at this moment you are the most important person in the world… But if you see him again, you will find he has not forgotten your meeting.”14 In a medical profession fraught with vigorous debate and conflicts of opinion between physicians, Osler also practised diplomacy and congeniality. A patient and friend wrote, Three times in my life I have seen [Osler], when in consultation, smash the attending physician’s diagnosis… but he left the room with his arm about the corrected physician’s neck, and they seemed to be having a delightful time… every physician felt himself safe in Sir William’s hands; he knew that he could by no possibility have a better friend in the profession.” 17

Osler’s kind manner also left an impression on his students, who were struck by his eagerness to remember their names and take an interest in their lives.14 A colleague recalled, “I never knew a man who possessed this capacity for intimacy with his students in any degree measuring up to that possessed of Osler… Once Osler shook his hand, the student had found a friend for life and he knew it.” 18 A colleague who observed Osler on rounds remembered, “Ward visits were an unusual combination of informality and dignity… which was so evident in Dr. Osler’s own personality… his twinkling eye, his quick steps, his frequent quips, his friendliness of manner… all brought into his clinics… a delightful tone of friendly informality. His criticisms… were incisive and unforgettable, but never harsh or unkindly.”14

Osler had superior clinical judgement refined by self-analysis and feedback

Clinically excellent role models demonstrate superior judgement that is honed by thoughtful reflection on the outcomes of their prior clinical decisions. Osler’s keen medical judgement was indeed supported by his humility, thoughtfulness and drive to seek feedback. During his early medical practice in Baltimore, he once misdiagnosed a distended bladder as a pelvic sarcoma; after being corrected by a consulting surgeon, rather than putting the story behind him, Osler incorporated it into his teaching programme.19 He was obsessed with obtaining feedback on his medical decisions. At McGill’s Montreal General Hospital and at The Johns Hopkins Hospital, he eagerly performed as many autopsies as possible, correlating postmortem findings with his patients’ earlier clinical courses. He wrote (precociously, at age 22), ‘To investigate the causes of death, to examine carefully the condition of organs, after such changes have gone on in them as to render existence impossible, and to apply such knowledge to the prevention and treatment of disease is one of the highest objects of the physician’.20 One student remembered, “It was considered a distinct disgrace if a resident failed to get an autopsy… We travelled to the most remote districts… and at great trouble and inconvenience to appeal to the families of patients… All this effort was for Osler.” 14 Indeed, Osler’s hands were dotted with small monuments to his dedication to learning through autopsy; his cutaneous Verruca necrogenica warts were caused by a nodular immune reaction to the tuberculosis bacilli in his cadaveric specimens.21 22

Osler was humanistic and compassionate

Role models of clinical excellence are unfailingly humanistic and compassionate. Osler was respected by friends and colleagues for his empathy and caring bedside manner. In one revealing account, he was summoned to the bedside of an ailing physician and former student: “Dr. Osler came, a gentle, tender presence, in a huge fur coat, and sat down by Dr. Swan… He talked to him like a sorrowing tender Mother for her little boy, and then he put his arm around him and said, ‘Now Swan I want you to let this good woman here give you some morphia tonight so that you may relax and sleep, for that is what you need… tomorrow I will find a stronger Dr. Swan.” The patient’s nurse remarked, “I will never forget the scene… Dr. Swan… had refused always… to take morphia… [he] slept all night, feeling much stronger and better the next day.” 14

In his medical practice, Osler emphasised the importance of keeping the patient at the centre of his clinical reasoning and care—an ethic immortalised in his famous quote, The good physician treats the disease; the great physician treats the patient who has the disease’. A colleague’s story reveals a surprising Oslerian exercise in empathy: “I went into his office one morning and found him struggling in the effort to pass a stomach-tube upon himself, resulting in the ordinary gagging and retching which such a procedure produces… I said, ‘what in the world are you doing?’ He replied, ‘well, we often pass these on people, and I thought we ought to find out what it feels like ourselves.’ Then he offered to let me try it myself, but I declined.”14 23

Osler’s compassion for vulnerable patients was apparent during his tenure at Montreal General Hospital, where he committed himself to working in a smallpox ward, caring for 81 contagious patients. He tried various therapies to prevent his patients from becoming physically disfigured by smallpox—a risky and heroic endeavour at a time before personal protective equipment and when the disease was widely feared, even by physicians.14 In the course of his work, Osler contracted smallpox himself, but he maintained his poise and good humour: “My attack was a wonderfully light one the pustules numbering sixteen, all told, and of these only two located themselves on my face; so that ‘my beauty has not been consumed away.’” 14

Osler had a contagious enthusiasm for patient care and teaching

Medical role models inspire those around them with their passion for practising and teaching clinical medicine. Osler was famous for his sparkling enthusiasm and was generally regarded as the greatest clinical teacher of his day. A student at the University of Pennsylvania remembered:

His first ward class was an eye-opener. In it he fairly frolicked in enthusiastic delight, and in a few moments had every [student] intensely interested and avid for more. Every new specimen that he came to at autopsy… was to him a treasure… [Osler] was as the lighthearted child who finding a field of daisies shouts his delight so exultingly that all the other children become interested and gleefully shout with him.24

Another student described Osler’s zeal in the autopsy room as he laboured in his pathologist’s smock, flanked by learners: “Osler would examine the groups of organs… in the minutest detail. His joy at finding something new or unusual was quickly shared with and enjoyed by us – I can see him now with his head bent over the table suddenly exclaim ‘hoity-toity… look at this.’” 14

Osler’s brimming excitement made his teaching sessions popular with students, who marvelled at his gentle and entertaining teaching style. One remembered, “I was called up yesterday in Dr. Osler’s clinic to make a diagnosis… They are the nicest things we go to, for Dr. Osler sits on the table and swings his feet, and asks you all sorts of questions you have never heard of before.” 25 Another reminisced, “His questions were so placed that our knowledge was drawn out of us. He made the poorest student feel at ease and a brilliant student was brought to outdo himself… [he] left us feeling that we had not done so badly – even if our knowledge was woefully small.” 14

His students’ affection for him was memorialised in a telling moment: when Osler left his faculty position at McGill in 1884, the entire student body gifted him a gold watch and accompanied him to the train station to bid him farewell.26

Osler was a prolific writer who was committed to scholarship

Role models of clinical excellence seek to advance what is known about patient care and disseminate their new perspectives through scholarship for the benefit of others. At each stage in Osler’s career—during his appointments at Montreal General Hospital, the University of Pennsylvania and The Johns Hopkins Hospital—his tireless work ethic resulted in a prodigious volume of academic output. Osler was a naturalist who was widely recognised for his observational work at the bedside and in autopsy rooms, where he rigorously chronicled and published on the natural history of diseases.14 In the 6 years after his first faculty appointment at Montreal General Hospital, he published ‘case studies, analyses, or lectures on pernicious anemia, Bright’s disease, Hodgkin’s disease, ulcerative endocarditis, tabes, nephritis in pregnancy, aneurysm of the hepatic artery, tubercular meningitis, the histology of tumors, croup, muscular atrophy, fibroid phthisis, the impaction of gallstones, empyema, and more’.14 During his tenure at McGill from 1874 to 1884, he completed and published notes on nearly 1000 autopsies.27

The acclaimed Osler biographer Michael Bliss writes: ‘Most [of Osler’s] writing was done after work was over, and with the practice of years and the habit of meeting deadlines it came to flow easily… on a hot Sunday afternoon in Baltimore when they heard of the death of a former Montreal colleague… In two hours Osler dashed off a five-hundred-word obituary… Professional writers develop such habits’.14 28 Years later, in the 1890s, Osler’s disciplined writing habits culminated in the publication of his classic and pioneering medical textbook, The Principles and Practice of Medicine.

Beyond being clinically excellent, Osler was a good, kind and fun person

Role models in any field are sometimes noticed because of their remarkable personality attributes. Any homage to Osler would be incomplete without emphasising his shimmering energy, his kindness and affection towards friends and family, and his unique sense of humour (see figure 1). Many vivid stories revealing these features of Osler’s personality and temperament are parts of his legacy.

One night, leaving Johns Hopkins and strolling through Baltimore’s lamp-lighted streets, Osler encountered an impoverished woman with a sick child. Moved by their plight, he paid for their coach ride to the hospital and gave them a note suggesting the child was ‘Mrs. Osler’s youngest’ to ensure they would receive good medical care.29

He was devoted to his family and visited them as often as his work duties permitted. His first cousin May Francis described, “He found it difficult to walk in the accepted sense of the term… his nature seemed too buoyant to allow him to place one foot in front of the other as is done by more humdrum individuals. He would dance along humming or whistling.” 14 Reflecting on his afternoon visits, she remembered, “[We] used to watch for him to come home from his lectures… He always came down the street at a swinging pace… He entered the house with a cheerful whistle… [and] clapping hands of joy from the children… Then he would put his hands lightly on the dining room table and vault across its width. To us it seemed a marvelous feat. He was the Fairy Prince.” 14 30

Osler’s light-hearted and sometimes roguish sense of humour stood in interesting contrast to his clinical rigour and seriousness in his academic work. Bliss writes, ‘Nurses did have to be careful when Osler was around… because they could never know what he might say or do in a joking or teasing way… as on the day he saw the stern Miss Nutting approaching and happened to be standing beside… a basket of fruit… and bowled [a grapefruit] down the hall’.14 31 In another instance he barged into the operating room of the stern and irascible surgeon, Dr William Stewart Halsted, and [deposited ] his hat in one of his sterilizers, cane in another, gloves in the third, and asked how things were going…’ Halsted allegedly quipped, “Osler, will you never grow up?”14 32

Is Osler still a role model today?

A century has passed since Osler’s death and yet he is still remembered and revered. At McGill, the University of Pennsylvania, Johns Hopkins and Oxford, there are named venues or programmes which remind all who pass through of the illustrious clinician who once ambled through their halls. Organisations like The American Osler Society and The Osler Club of London convene to celebrate and reminisce about prior legends of clinical medicine.33 34

While role models can be appreciated across distance and time, they must also be visible to those who are ready to be influenced. The truth is that for most medical students and residents in 2019, Osler is not regularly considered and is perhaps even unknown; so he is not serving as a role model for most trainees today.

Meanwhile, we suspect that Osler would not want to be a role model for today’s trainees—not merely out of humility, but because of his conviction that medicine is to be learnt from role models at the bedside—a place where he cannot be. Further, Osler advocated for learners to live in the ‘now’, with mindfulness and attention to the tasks at hand and the people around them; he believed this approach would give them the best chance to flourish in the medical profession.

Conclusions

William Osler epitomised and personified clinical excellence. We are confident that he would have been considered a superlative role model today if he were alive and among our contemporaries. However, a century has now passed since his death, and his name has slowly migrated from medicine’s everyday vernacular to bearing silent vigil from plaques, statues and portraits at his alma maters. Osler is not sufficiently visible today to serve as a role model to the global audience of medical trainees and physicians. A free, open-access medical education website called CLOSLER has as its mission to guide us all closer to Osler’.35 Perhaps by conjuring the memory of our greatest clinician and teacher, by reanimating Osler through rich anecdotes and modern reflections on clinical medicine, we can all be reminded to carry Oslerian virtues with us to the bedside.

Key references

  • Bliss M. William Osler: a life in medicine. New York, NY: Oxford University Press, Inc, 1999.

  • Reid EG, The great physician. New York: Oxford University Press, 1931: 136–7.

  • Mylopoulos M, Lohfeld L, Norman GR, et al. Renowned physicians’ perceptions of expert diagnostic practice. Acad Med 2012;87:1413–17.

  • Christmas C, Kravet SJ, Durso SC, et al. Clinical excellence in academia: perspective from masterful academic clinicians. Mayo Clin Proc 2008;83:989–94.

  • CLOSLER: moving us closer to Osler (A Miller Coulson Academy of Clinical Excellence Initiative). http://closler.org [Accessed 25 Mar 2019].

Self assessment questions

  • A role model:

    • Is the same thing as a mentor.

    • Behaves properly when being watched but acts inappropriately when others are not around.

    • Is defined as a ‘person considered as a standard of excellence for another to emulate’.

  • Role models can:

    • Be appreciated across distance and time.

    • Stimulate learners to reflect on the person they hope to become.

    • Only be positive and are not ever negative.

  • Osler, in his professional habits and demeanour,

    • Would not have been respected in our profession if he practised today.

    • Comported to the modern definitions of clinical excellence.

    • Was not viewed as a role model in his own time.

  • William Osler’s seriousness and commitment to his professional work:

    • Made him unlikable to those around him.

    • Resulted in being fired repeatedly so that he had to move regularly from one institution to the next.

    • Came at the expense of developing meaningful personal relationships with patients, colleagues and family.

    • Established him as the consummate role model to be admired even 100 years following his passing.

  • William Osler:

    • Urged trainees to spend as much time as they could learning at the bedside.

    • Understood that talking to patients is key to arriving at the correct diagnosis and to minimising diagnostic error.

    • Was committed to following up on the outcomes of his clinical decisions, including through autopsy, so as to learn and grow.

Answers

  • False, False, True.

  • True, True, False.

  • False, True, False.

  • False, False, False, True.

  • True, True, True.

Acknowledgments

The authors would like to acknowledge Michael Bliss and his acclaimed Osler biography, William Osler: A Life in Medicine, which informed the thinking and content supporting Sir William Osler as a clinically excellent role model.

References

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Footnotes

  • Contributors VM and SW planned the outline and structure of the manuscript. They both researched the relevant materials/sources and wrote the manuscript. Both authors were involved in the critical review and final edits to the manuscript.

  • Funding SW receives support as the Anne Gaines and G Thomas Miller Professor of Medicine through the Johns Hopkins Center for Innovative Medicine.

  • Competing interests None declared.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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