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What Is the Oslerian Tradition?
- Charles S. Bryan, MD
- From the University of South Carolina School of Medicine and Richland Memorial Hospital, Columbia, South Carolina. Requests for Reprints: Charles S. Bryan, MD, Department of Medicine, University of South Carolina School of Medicine, 2 Richland Medical Park, Suite 502, Columbia, SC 29203.
Abstract
Discussants of internal medicine often invoke but seldom define “the Oslerian tradition,” which has many meanings. No definition provides clear insight into the issues now relevant to American internal medicine, primarily because, as William Osler knew, the field itself shows definitional ambivalence. The tradition might be best understood as a virtuous approach to medicine and to life as taught and modeled by Osler. If we understand his philosophy and methods, we will be better prepared to use and pass on (tradere, “to deliver”) something of greater value: the ability to make wise choices that are in society's best interest.
In 1897, William Osler [1] predicted that internal medicine would be the most comprehensive, demanding, and rewarding medical specialty in the 20th century and a superb vocational choice for medical students. That prediction was true for many years. However, in 1978, an academic internist lamented the weakening of the Oslerian tradition in departments of medicine [2]. In 1982, a practicing internist traced the impending “death of the clinician” to departures from Osler's philosophy of medical education [3]. In 1986, a historian asked whether subspecialists and internists are heirs to the Oslerian tradition [4]. The next year's “Black Tuesday” internship matching results indicated that internal medicine was a less popular choice among medical students [5]. Today, various forces and trends, including the structure and financing of health care in the United States, challenge the traditions of internal medicine [6, 7].
To what extent, if any, are today's challenges influenced by departures from the paradigms created by Osler and his contemporaries? Should we revitalize “the Oslerian tradition”? Before we can address these questions, we must review some definitions of “the Oslerian tradition,” consider whether such a tradition is still valuable, and foster a new understanding for today.
Definitions That Apply to Medicine
The Oslerian tradition can be defined in ways that are not mutually exclusive. Some of the previously stated or implied definitions are specific to internal medicine, whereas others apply to medicine in general (Table 1).
The first formal definition of the Oslerian tradition was devised by Sir Geoffrey Keynes: “The influence that Osler's life and personality may have upon the outlook of succeeding generations of medical men when the man himself is gone” [8, 9]. Keynes acknowledged that such influence “is impalpable and elusive and therefore impossible to convey except in words”. Time has diluted the influence of Osler's enthusiasm and energy, his charm and charisma. Today many medical students cannot identify him. Some may reply that he was “the father of internal medicine,” and others simply wonder what the fuss is about.
A second definition is shaped by the hero myth, the epic story of an engaging young Canadian who became the most famous and well-loved physician of American medicine's heroic age, an icon of professionalism. Recently, Wheeler [10] suggested that to “the extent that we live up to the Osler hero-myth, our profession will prosper”. Heroes and hero myths, however, are fragile in today's egalitarian societies [11, 12]. Followers exaggerate claims and forget sacrifices. Technology may have blunted the potential for heroism in medicine, because its practice now involves “sophisticated diagnostic procedures … that would challenge the likes of William Osler” [13].
Perhaps the most familiar definition is Osler's restatement of the Hippocratic ideal of academic humanism in medicine: “the love of humanity associated with the love of his craft!—philanthropia and philotechnia” [2, 14]. Osler reassured a generation of physicians that humanistic ideals might soften the cutting edge of the new science—the phenomenon that a futurist has called “high tech/high touch” [15]. Osler's reputation as “family doctor to the world” is remarkable, because he assumed primary responsibility for few patients, kept his bedside visits short, seldom if ever sermonized about compassion, and took early semi-retirement [16-19]. He understood people, listened well, spoke carefully, used good body language, and projected optimism. Today, we wonder whether compassion can be taught; whether society values broad-based academic humanism for physicians qua physicians; and whether Americans, if forced to choose, want compassionate generalist physicians or prompt, unlimited access to high technology [20, 21].
Definitions Specific to Internal Medicine
The Oslerian tradition offers little if any clear insight into the issues relevant to American internal medicine, primarily because of the discipline's definitional or functional ambivalence [4, 22, 23] (Table 1). Osler and contemporaries such as Francis Delafield and William Pepper formalized a custom whereby certain generalist physicians gained preeminence as consultants as a result of their hard-won reputations. Internal medicine became a specialty within the context of general medicine and previously organized specialties. However, its identity as “an elite form of generalism” was problematic from the beginning [4]. Osler was ambivalent not only about the term “internal medicine” but also about specialization. He said, on the one hand, that “there are in truth, no specialties in medicine,” and, on the other, that “specialism is here, and here to stay” [24, 25]. In 1891, when Index Medicus was but a single slender volume, Pepper observed prophetically:
General medicine and general surgery today are federations of specialties; and the general clinician, even of the broadest gauge, in dealing with obscure and complicated cases, acts but as the leading partner in a medical firm [26].
Despite these ambiguities, internal medicine thrived. Osler and later chairpersons of medicine brought strength and credibility to the construct of the broadly knowledgeable generalist consultant. Eventually, however, new specialties emerged with names that implied functional clarity: family medicine, emergency medicine, and preventive medicine. Meanwhile, the subspecialties of internal medicine spawned new forms of elitism. The Oslerian tradition cannot ease today's tensions between generalist and specialist medicine because these tensions typify its history.
With that in mind, three definitions of the tradition specific to internal medicine can be considered. A common, if largely unwritten, understanding is of “the Oslerian internist,” a person with seemingly encyclopedic knowledge who can provide medical care at any level. As a young man, Osler was advised to “cultivate the whole field” of medicine [27]. His great textbook The Principles and Practice of Medicine [28] showed that he did that. Later generations of internists, inspired by awesome role models and rigorous board examinations, sometimes seemed to pursue a nearly omniscient grail across subspecialty lines. Now this goal is considered unrealistic, unnecessary, and unhealthful for self-esteem [29-31]. Osler would say that “the student tries to learn too much, and we teachers try to teach him too much—neither, perhaps with great success” [32], and that “to master even the smallest specialty requires concentrated effort of years' duration” [33]. He stressed the study of pathophysiology and mastery of skills now known as database management, problem solving, medical informatics, and decision analysis. These skills are essential for internists but are not specific to internal medicine.
A second definition is related to the appropriateness of internal medicine as a career choice. Osler considered the internist to be a “physician proper” in the spirit of Hippocrates and Galen, of Harvey and Sydenham, and of such 19th century predecessors as Sir Thomas Watson and Austin Flint [34]. In 1897, he told members of the New York Academy of Medicine:
I have heard the fear expressed that in this country the sphere of the physician proper is becoming more and more restricted, and perhaps this is true; but I maintain (and I hope to convince you) that the opportunities are still great, that the harvest truly is plenteous, and the labourers scarcely sufficient to meet the demand [1].
He taught that years of preparation to become a well-rounded generalist consultant or “physician proper” could be rewarded by a “cakes and ale” pinnacle of financial prosperity. As time passed, the style of medicine practiced by Osler and his colleagues became largely obsolete [35]. Fellowship programs and subspecialty boards became a direct route to consultant status. The role of the general internist was but one issue of the day [36]. Internal medicine still offers more career options than perhaps any other specialty, but “the Oslerian tradition” does little to reestablish the field's trampled boundaries.
A third interpretation of the Oslerian tradition depends on the institutional importance of departments of medicine traceable, in part, to a descent of chairmen from Osler's lineage. As Burnum phrased it:
Osler begat Henry Christian who begat (Soma) Weiss; and from Weiss—Wilkins, Stead, Janeway, Romano, and Beeson; and from Stead (or with Stead), Warren, Myers, Martin, Hickham, Bogdonoff, McIntosh, and many others [37].
Departments of medicine succeeded beyond Osler's wildest dreams. Osler was actually ambivalent about full-time clinical appointments, warning against
the evolution throughout the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only human interest was research, forgetful of the wider claims of a clinical professor as a trainer of the young, a leader in the multiform activities of the profession, an interpreter of science to his generation, and a counsellor in public and in private of the people, in whose interests after all the school exists [38].
One of Osler's students at Oxford recalled that he often complained “that full-time appointments would lead to clinical training being supplanted by research” and that this prophecy was borne out “in almost every American medical school when the deluge of research grants by the National Institutes of Health started after the Second World War in 1946” [39]. Recently, chairpersons of medicine were told that they had been producing the wrong product for three decades and that departments must be retooled [40]. At a time when academic health centers must redefine their missions [41], the Oslerian tradition does little to assure the continued institutional importance of departments of medicine.
What Is a Tradition?
Does retaining an “Oslerian tradition” help the cause of internal medicine, or have we set up a straw man? “Tradition” ultimately comes from the Latin tradere, “to deliver,” implying a mandate to receive and relinquish something of value [42]. We must begin with one or another tradition even if, in the end, we reject or modify our heritage [43]. In the sense that Osler is emblematic of the organizational period of American internal medicine, “the Oslerian tradition” is essential as a starting point. But in a larger sense, the Osler legacy still ranks among the most popular and well-known expressions of our collective ideals. Why does Osler receive such admiration? The best answer is the sum of his work, influence, and—above all—his character [44]. He exemplifies a desideratum perhaps best captured by Aristotle's definition of happiness: “a complete life (well lived because it is) lived in accordance with (moral) virtue, and accompanied by a moderate possession of (wealth and other) external goods” [45].
The Oslerian tradition might be best understood as a virtuous approach to medicine and to life as taught, modeled, and recorded by William Osler. This broad definition encompasses the others and contains problem areas vastly beyond the scope of this essay: the nature of virtue, its classifications, its teachability, and its relation to medicine [46, 47]. “Virtue” has become a suspect word, and few of us can name the four cardinal virtues (prudence, justice, temperance, and courage). Moral philosophers, following MacIntyre's lead [48], speak of our era as “after virtue time”. Osler's life and written work, however, reveal many qualities that define him as a “virtuous person,” a person of character who habitually made right choices (Table 2). This definition might be dismissed as a naive success philosophy. Yet, beneath his blithe exterior, Osler was thoughtful but seldom disclosed his deeper feelings, even to his friends, and he articulated the Big Questions—the problems of metaphysics and epistemology, of what happens to us when we die—about as well as anyone [49]. In short, he was and remains a good role model.
Central to Osler was his idealism. Often mischievous, sometimes abrasive, and always aware of his shortcomings, he recognized that “we are only men” yet “we have ideals, which mean much, and they are realizable, which means more” [50-52]. He warned that “the practice of medicine is not a business and can never be one” and added this footnote:
In every age there have been Elijahs ready to give up in despair at the progress of commercialism in the profession. Garth says in 1699 (Dispensary)—
Now sickening Physick hangs her pensive head
And what was once a Science, now's a Trade.
Of medicine, many are of the opinion. that the ancients had endeavored to make it a science and failed, and the moderns to make it a trade and have succeeded. To-day the cry is louder than ever, and in truth there are grounds for alarm; but on the other hand, we can say to these Elijahs that there are more than 7000 left who have not bowed the knee to this Baal [53].
Lest we forget, the definition of professionalism in medicine, as in any occupation, is unclear and ephemeral and must be defended by each generation.
Does remembering Osler in this way address the alleged leadership crisis in internal medicine [54]? Osler's charity, sense of humor, and ability to see all sides of issues made him a poor champion of politically charged issues [55]. His pragmatism has been criticized as short sighted [56], perhaps unfairly because he never claimed to be a visionary and indeed took as a guiding rule Thomas Carlyle's advice, “Our main business is not to see what lies dimly in the distance but to do what lies clearly at hand”. Still, his writings contain suggestions that may be helpful to today's leaders of internal medicine (Table 3). In 1903, Osler observed at the centennial observation of the New Haven Medical Association:
The times have changed, conditions of practice have altered and are changing rapidly, but when such a celebration takes us back to your origin in simpler days and ways, we find that the ideals which inspired them are ours to-day—ideals which are ever old, yet always fresh and new, and we can truly say in Kipling's words:
The men bulk big on the old trail,
our own trail, the out trail,
They're God's own guides on the Long Trail,
the trail that is always new [53].
Today the trail is poorly marked and the destination is uncertain. Stevens [4] reviewed the ambiguities of American internal medicine and suggested that one solution would be to dissolve the field and begin again. She cited four reasons for preserving internal medicine as a specialty: its role as a conscience for the medical profession; its range of perspectives across the complexity of medical care; its ability to relate to other specialties in the public interest; and its historical resilience when challenged by change and uncertainty. Beyond nostalgia, Osler's notion of a “physician proper” somehow captures the essence or soul of medicine. Caring for the soul can be understood as “a continuous process that concerns itself not so much with ‘fixing’ a central flaw as with attending to the small details of everyday life, as well as to major decisions and changes” [57]. Such indeed was Osler's philosophy.
Conclusions
William Osler was elevated to the status of saint by many persons even during his lifetime. Something of a hero worshipper, he was, in turn, worshipped. Nearly every aspect of his life has been analyzed and reanalyzed. He is, as they say in the humanities, “an industry”. But remembering Osler in this way, or asking “what would Osler do were he alive today?” does little good [58]. He was a gifted person from a remarkable family who probably would have succeeded in any field [59]. His legacy has little or no direct bearing on the continued importance of internal medicine. Familiarity with Osler's traits and ideals should, however, help us to make wise choices that are in society's best interest. And, as Somerset Maugham said,
The best homage we can pay to the great figures of the past … is to treat them not with reverence, but with the familiarity we should exercise if they were our contemporaries. Thus, we pay them the highest compliment we can; our familiarity acknowledges that they are alive for us. But when now and then I have come across real goodness I have found reverence rise naturally in my heart [60].
Presented in part at the 23rd annual meeting of the American Osler Society, Louisville, Kentucky, 12 May 1993.
- Copyright ©2004 by the American College of Physicians
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