William Osler’s Prescription for Physician Burnout

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Internist William Osler (1849-1919), one of the founders of Johns Hopkins Hospital, is often considered a founding father of modern medical education due to his creation of the first clinical clerkship and residency programs for medical trainees. He is also one of the most quoted physicians. This article about Dr. William Osler is excerpted from Vivek Viswanathan’s paper entitled “William Osler and the Framing of Medical Education Reform in the United States.” You can access the full paper and bibliography here.

“It is not hard,” William Osler once pointed out, “to teach [a medical student] all about the pneumonia…but put him beside a case, and he may not know which lung is involved, and he does not know how to find out.” [1. Osler, “Aequanimitas,” 19-20.]

At Johns Hopkins, Osler maintained, the medical student “does not see the pneumonia case in the amphitheatre from the benches, but he follows it day by day, hour by hour.”[2. Osler, “Aequanimitas,” 21. While Osler once stated that this immersion-based method of instruction was “never attained” in the United States before its implementation at Johns Hopkins University, the Long Island College Hospital in Brooklyn had, in fact, instituted such a program from its founding in 1860. It emphasized in its first announcement of courses: “It is the design, as indicated in the title of the institution, ‘College Hospital,’ to give especial prominence to this, doubtless the best method of teaching.” William Osler, Men and Books, Earl F. Nation, ed. (Durham, NC: Sacrum Press, 1987), 62; Medical Education in Brooklyn: The First Hundred Years, 1860-1960 (Brooklyn, NY: State University of New York, Downstate Medical Center, 1960), 12.] Osler, who developed the concept of medical residency, believed that the “demonstration that the student of medicine has his place in the hospital as part of its machinery” was “by far the greatest work of the Johns Hopkins Hospital.”[3. Osler, “Aequanimitas,” 20-21.] “I desire no other epitaph,” he reflected, “than the statement that I taught medical students in the wards.”[4. Osler, “Aequanimitas,” 20-21.]

In addition to the training of medical students in hospitals, Osler emphasized the “striking” shift toward a scientific curriculum in medical education that had occurred during the last quarter-century.[5. Osler, “An Address on the Importance of Postgraduate Study.”] “It is not making too strong a statement to say that the chemistry and chemical physics of the nineteenth century have revolutionized the world,” Osler said, and he was gratified that medical schools had embraced the new science.[6.William Osler, The Evolution of Modern Medicine (New York: Kaplan Publishing, 2009), 203.] He acknowledged the “debt of the present generation to Germany,” the country that had been at the forefront of medical research and education, with institutions that Osler and his peers used as a model for the Johns Hopkins School of Medicine.[7. Osler, “An Address on the Importance of Postgraduate Study.” For a more nuanced perspective on the influence of the German system on educational reform in the United States, see Thomas Neville Bonner, “The German Model of Training Physicians in the United States, 1870-1914: How Closely Was It Followed?” in Leavitt and Numbers, Sickness & Health in America, 189-199.] Before the scientific focus of Johns Hopkins, Osler said, American medical education too often resembled a “heterogeneous accumulation of isolated half-understood experiences, instead of an orderly sequence, in which the acquired knowledge of laboratories is brought to bear on the problems of disease.”[8. William Osler, The Quotable Osler (Philadelphia, PA: American College of Physicians, 2003), 176.] Osler’s own contribution to combating this trend, one writer later recounted, was “placing the autopsy at the center of [medical] education, performing more than a thousand post-mortems himself and insisting that staff members and students do them regularly” to improve scientific understanding.[9. David Dobbs, “Buried Answers,” New York Times Magazine 24 Apr. 2005.] By the end of the century, Osler could remark on the “rapidity with which the scientific instruction in our medical schools has been brought to a high level” and declare, as he did in London in 1900, that the “lines of intellectual progress are veering strongly” toward the United States.[10. Osler, “Aequanimitas,” 21; Osler, “An Address on the Importance of Postgraduate Study.” Commenting on Osler’s London address, the Providence Medical Journal noted that “even now men report better facilities for the study of surgery in the clinics of Chicago and of Philadelphia than in Vienna.” “Societies,” Providence Medical Journal, Vol. 1: 1900 (Providence, RI: Providence Medical Association, 1900), 152.]

But while Osler was proud of his role in, as one physician later wrote, “elevating the status of medical training to the level of a religious ceremony,” he expressed his worry that medical students would view that training as a substitute for the broader education that Osler believed to be as fundamental to the development of a physician.[11. Osler, Evolution of Modern Medicine. The quotation comes from the introduction by Conrad Fischer.] Education “is not a college course, not a medical course, but a life course,” he once said.[12. William Osler, “The Student Life: A Farewell Address to Canadian and American Medical Students,” 1905, in Sir William Osler, 1849-1919, 29.] In his London address, Osler cited the “broad mental outlook and that freedom from the trammels of local prejudice which have ever characterized the true physician.”[13. Osler, “Address on the Importance of Postgraduate Study.”]  He sought to foster this outlook in medical schools because he understood that medical practice, similar to other professional work, “tends to narrow the mind, to limit the point of view, and to put a hallmark on a man of a most unmistakable kind.”[14.William Osler, Counsels and Ideals (Oxford, UK: Henry Frowde, 1905), 61.] Yet his efforts in this area were not as successful. The Commission on Medical Education, chaired by A. Lawrence Lowell, the president of Harvard University, issued its final report in 1932, which cited the “teaching of too many subjects in too great detail [and] the dependence on memory alone…Most medical students in this country are not able at first to pursue medical studies as real graduate students.”[15. Lowell, Final Report of the Commission on Medical Education, 247.] Abraham Flexner recounted in 1925 that the rigidity in medical school instruction that had resulted from his report had “become a fetish, blocking further improvement.”[16. Barbara Barzansky, “The Growth and Divergence of the Basic Sciences,” in Barbara Barzansky and Norman Gevitz, Beyond Flexner: Medical Education in the Twentieth Century (New York: Greenwood Press, 1992), 25.] Osler believed, as he noted in London, that postgraduate study would help remedy the situation.

The inadequacy of the current situation expressed itself, Osler argued, in both clinical practice and in the shape of the profession. Osler believed that medical education should be of practical use, noting that medical schools should provide an “education of such a character that [students] can become sensible practitioners—the destiny of seveneighths of them.”[17. William Osler, Aequanimitas: With other Addresses to Medical Students, Nurses, and Practitioners of Medicine (Philadelphia, PA: P. Blakiston’s Son, 1925), 329.] But he maintained that liberal education was of such use, and he claimed that those physicians who focused only on their craft were guilty of “intellectual idleness” and, because they had not developed their minds, were forever in “ruts.”[18. Osler, “Address on the Importance of Postgraduate Study.”] It is “so much easier,” he noted, “to do a penny-in-the-slot sort of practice, in which each symptom is at once met by its appropriate drug, than to make a careful examination and to really study the case systematically.”[19. Osler, “Address on the Importance of Postgraduate Study.”] Even well-trained physicians, he noted, will tend to observe only “partial truths” and therefore should undertake to open their minds to new experience.[20. William Osler, “Remarks on Specialism,” Boston Medical and Surgical Journal vol. 126, no. 19 (May 1982): 457.] For example, he encouraged medical educators to “train the mind of the student into the habit of looking at things from the historical standpoint,” and he recommended that every student travel, which “not only widens the vision and gives certainties in place of vague surmises, but…enables him to appreciate better the failings and successes of his own line of work.”[21. Osler, “The Student Life.”] Osler would not have agreed with Harvard University physician Frederick Shattuck’s observation that “our ignorance has compelled us to treat the patient rather than the disease.”[22. Frederick C. Shattuck, “Specialism in Medicine,” Journal of the American Medical Association vol. 35 (September 1900): 725.] Because “no two individuals react alike and behave alike under the abnormal conditions which we know as disease,” Osler wrote, treating the patient was not only acceptable but essential, and only the physician with an outlook of the sort developed by a liberal education could provide skillful clinical care.[23. Sherwin Nuland, The Uncertain Art: Thoughts on a Life in Medicine (New York: Random House, 2008), introduction.]

Such an education, Osler believed, not only improved day-to-day medical practice but strengthened the medical profession. Osler, in counseling medical students to “divide your attention between books and men,” offered advice to the would-be physicians in his audience. “Nothing will sustain you more potently than the power to recognize in your humdrum routine, as perhaps it may be thought, the true poetry of life,” he said, “the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their grief.”[24. Osler, “The Student Life.”] His worry that physicians would not possess the aptitude, the “mental freshness and plasticity,” for looking anew at the commonplace has continued to the present day in the form of the dwindling number of general practitioners.[25. Osler, “Address on the Importance of Postgraduate Study”; Robert Pear, “Shortage of Doctors an Obstacle to Obama Goals,” New York Times 26 Apr. 2009.] Meanwhile, though physicians such as Atul Gawande and Jerome Groopman have acquired a public following, no physician has replaced Osler as the polymath intellectual of the profession, his advice on living a good life quoted by figures ranging from Dale Carnegie to Robert Rubin.[26. Both Carnegie and Rubin cited the influence that an address that Osler delivered at Yale University on April 20, 1913, entitled “A Way of Life,” had on their own thinking. Dale Carnegie, How to Win Friends and Influence People (New York: Pocket, 2004), 5; Robert E. Rubin, In an Uncertain World: Tough Choices from Wall Street to Washington (New York: Random House, 2004), 55.] But Osler was not one for pessimism, criticizing those “dour dyspeptics in mind and morals who sit idly croaking like ravens.”[27. William Osler, The Student Life and Other Essays (Freeport, NY: Books for Libraries Press, 1931), 70.] In London, he had expressed his confidence in the future of American medicine, and he marveled at the transformation of the American medical school. “We are lucky to get in as professors,” he once told William Welch, the dean of the Johns Hopkins School of Medicine. “I am sure that neither you nor I could get in as students.”[28. Rene J. Dubos, “The Growing Up of American Medicine,” New York Times Book Review 4 Jul. 1954.]