Osler loved to practise medicine and we can too!

Dr Myers was selected as the 2006 Osler Orator, Vancouver Medical Association. This is a revised version of his address.

Being a psychiatrist I can’t help but apply some of the basics of my branch of medicine to the task tonight. One of those fundamentals is history taking. If Osler loved to practise medicine, and it certainly seemed as if he did, what can we learn from his background that helps to explain this love? Even though he was born more than 150 years ago, can we pull out any pearls that excite us—especially on those dim days of medical practice when our spirits are flagging and we need some light? I’ve distilled some facts:

• Osler was born 12 July 1849 in a small Ontario town, Bond Head, 40 miles north of Toronto. He was the eighth child of an Anglican minister father and a devoutly religious mother. His parents were emigrants from Wales. They were very hardworking. Willie, as he was then known, and all but two of his brothers were ambitious and became “men of attainment.” His sisters were not expected to have careers outside the home and did not.

• When he was 4 years old, he lost his younger sister, 2-year-old Emma Henrietta. Her death was very hard for his mother but little is written as to how this might have affected Willie.

• He was dark complexioned and handsome. Peers and teachers liked him. He was smart and athletic. He pulled pranks but nothing approaching antisocial characteristics or defects. People commented that he always seemed happy.

• He was planning to enter the ministry, but fortunately for us, he pursued medicine. He had a great love of nature and natural history. He spent a lot of time rambling in the Canadian countryside. This was instrumental in shaping the passion that led him to medicine in 1868.

Osler loved to practise medicine. Why? What’s the genesis of this? What sustained this love of medicine throughout his career?

I believe that virtually all physicians start out loving medicine—all we need to do is look at the faces of first-year medical students each year. We see the wonder and the curiosity in their eyes. When doctors become demoralized and their love of medicine wanes, transiently or permanently, why? How can Osler help us beyond his oft-cited and pithy quote, “Happiness lies in the absorption in some vocation which satisfies the soul?”[1]

He was very disciplined and very organized

Listen to this description by Edward Rogers, a student who lived with Osler in the late 1870s: “…[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. Hours for meals, hours for recreation, hours for every duty were kept with absolute rigidity. He was always deliberate in every movement, never rushing, never hesitating.”[2] Osler went to bed at 10 p.m. and spent the next hour reading nonmedical classics. This became a legendary habit—an hour’s worth of good reading a day—and it gave Osler a base of literary knowledge that was constantly expanding. He smoked cigarettes and cigars but even then, there was some rationale. He smoked during autopsies to counter the odors and to dissolve the poisons thought to be rising from the bodies.

He published his first scientific paper as a medical student in the Canadian Naturalist. His classmates noticed his appetite for hard work. He ate his lunch in the dissecting room so as not to waste time. As a fourth-year medical student, he worked on his thesis for which he won a book prize. He graduated at the age of 22 with both his doctor of medicine and master of surgery.

Viewing Osler’s restraint and sense of order through the lens of the 21st century, it is tempting to label him as a severe obsessive-compulsive. But I know from personal introspection, my colleagueship with physicians, and my clinical practice of looking after doctors, that some of the happiest physicians are the most organized and disciplined. In fact, when doctors are unhappy practising medicine, they make statements like, “I’ve lost my drive, my initiative… I’m disorganized… I’m late for work… I spend too much time with some patients and not enough with others… I’ve lost control.”

Osler read widely outside of medicine

As noted, he read the classics for an hour every evening. He never lost his early interest in natural history. He read and wrote constantly—at meals, while dressing, on trains and in carriages, during every free moment on holiday.

I know physicians who in part attribute their continued love of medicine to their great love of nonmedical reading. These are physicians who devour biographies and other works of nonfiction. These are physicians who read poetry. These are physicians who always have at least one novel on the go. To quote one of my patients, an academic gynecologist, “Fiction takes me away from the demands and pressures of my career. I need that. But it gives back. It replenishes my compassion.” In this technological age—when we are bombarded and seduced by endless e-mail, world news bites 24/7, the sports channel, and reality TV—we can take a lesson from these colleagues.

Osler wrote incessantly

Osler is described as a compulsive writer whose energies were not fully absorbed by his correspondence and scientific papers. Most of his writing was done after work. “He had become as professional as a writer as he was a physician.” [2] In 1891 he signed a book contract with D. Appleton and Company and his textbook The Principles and Practice of Medicine was completed 1 year later. It was over 1000 pages and one of the last textbooks of medicine to be written by a single author.

Most practising physicians are not writers. Outside of academic medicine very few publish their observations in scientific journals. And yet, haven’t we all known colleagues whose rich lore of clinical anecdotes we would long to see in print? These are stories emanating from doctors who love to practise medicine. Again one of my patients, an emergency physician, said, “I write almost every day—often no more than a sentence or two, a fragment of a case history, or a diagnostic dilemma. But mostly I write about my feelings… my heavy heart after a code, my suppressed tears counseling a rape victim, my sweet satisfaction when a patient smiles with gratitude and shakes my hand. Pausing like this, reflecting, and putting pen to paper always reminds me of why I became a physician. Reading my journals buoys me up on those bad days, when I wish I was still a bouncer in a nightclub and becoming a doctor was far from my conscious mind.”

Osler loved children

He loved playing with children and seemed to generate magic with them. For them he wrote wonderfully whimsical, loving notes, anecdotes, and memoirs. “With children, Osler had Lewis Carroll’s sensibilities without his peculiarities.”[2] He was playful and child-like well into adulthood and well into his meteoric career. Everyone remembered him as lighthearted, jaunty, breezy. He would dance along humming or whistling.

Not all of us work with children in our branches of medicine. Not all of us want kids, are blessed with children of our own, or have grandchildren. Many of us have sad stories of having missed out on our kids’ early years—those milestone years—because of the demands of our training or practice. But it is a universal truth that the innocence of children can offset even the busiest, the toughest, the worst days of medical practice. We can sustain our love of medicine by consorting with children—whatever form that may take. Some unmarried physicians become big brothers or big sisters. Some childless physicians make phenomenal aunts and uncles. Some older physicians become foster grandparents.

Osler loved teaching

He began postgraduate studies in Europe before returning to be on faculty at McGill in 1874. He was called the Baby Professor. That same year he was invited to give the farewell address to the graduating class. He advised them to keep up their reading, plan to add to medical knowledge, make income a secondary consideration, speak no ill behind colleagues’ backs, and consider becoming teetotalers.

He became the pathologist for Montreal General Hospital, if not the city of Montreal. Students found his classes in pathology and histology mesmerizing. Generations of physicians would use the adjectives infectious and contagious to describe Osler’s enthusiasm. He became faculty registrar in 1877. He remembered the names and faces of all the students and took a personal interest in them, their families, their work, and their mutual friends.

Many of us teach medical students, residents, fellows, and other health professionals. Our students nourish us as much as we nourish them. Trainees are so perceptive. They can tell if we’re working too hard or burning out—our dismissive manner with them and our patients becomes palpable. Conversely, when we’re happy doing what we’re doing, like Osler, they find our attitude catching. Whether we call this the art of medicine or role modeling, they like it. Many even consider entering our branch of medicine. Here’s a quote from a resident patient of mine, speaking about one of his attending physicians who had recently died: “I admired him and he is why I’m in this program. He was brilliant, but that’s not what excited me the most. It was his face. He had the kindest eyes and the warmest smile I’ve ever seen in a physician. He treated his patients, and us, with dignity.”

Osler had mentors

One was Reverend William Arthur Johnson. He was the founder and warden of Trinity College School that Willie attended. Another mentor was Dr James Bovell. He taught at Trinity College and practised medicine in Toronto. His medical library became a place of wonder for young Osler. When Bovell returned to the West Indies, Osler transferred his medical studies from Toronto to McGill in 1870. His third mentor was Dr Palmer Howard, professor at McGill, whom Osler found to be the most scholarly and scientific of his professors.

But the details of his mentor-mentee relationship with these three men are not as important as the message. To sustain our love of medicine we need to have mentors throughout our careers, not just when we’re in training. Likewise when we become mentors ourselves, we can continue to be mentored by others. We know that assigning mentors to our medical students or residents often fails. Somehow it’s not a good fit. It’s almost like courting. Individuals need to find their own mentors. They need to see them in action whether at the bedside or in the OR or giving a lecture or teaching a seminar or reading something they’ve published. Something inside gets sparked.

We can be mentored by physicians younger than us. One such person in my life was Dr Peter. Dr Peter was a UBC graduate who died of AIDS in 1992 at the age of 35. He went public and did a series of interviews for the CBC about living and dying with the disease. The Dr Peter Centre here in Vancouver’s West End is his legacy. Peter had been a medical student of mine. Shortly after he became blind from cytomegalovirus retinitis, I invited him to do a grand rounds for us. That began a 2-year colleagueship that continued until 6 weeks before he died. We did two types of teaching together. First, I interviewed him about his experience in front of different classes of medical students and residents and they asked him questions. Second, I made two videotaped productions with him that I showed at various medical meetings near and far.[3] As he faced the end of his life, he taught me, a man 15 years his senior, about dying with courage, self-respect, and love. That was his gift. He’s in my heart.

Osler was a caring physician

Osler’s description of treating a visiting Englishman, a man his own age, on the smallpox ward of Montreal General is revealing: “Around midnight, he [Neville] muttered some prayers and held out his hand which I took… and he said quite plainly ‘Oh thanks.’ These were the last words the poor fellow spoke. He died about an hour later. As the son of a clergyman and knowing well what it is to be ‘a stranger in a strange land’ I performed the last office of Christian friendship I could and read the Commendatory Prayer at his departure.”[2] Osler wrote Neville’s parents a sensitive letter about their son’s death, sparing them the details of the clinical record.

This story and many others in his life are wonderful examples of how his love of medicine included the big picture: that our work as physicians transcends the limits of our science and medical expertise, that the humanness of the doctor-patient interaction is as important as making the correct diagnosis, choosing the right antibiotic, replacing fluids, and removing diseased organs. These gestures—which I call loving and tender—renew and extend our passion as practitioners of medicine.

Here’s a contemporary example of what I mean. This is a piece that I came upon in the American Medical News a few years ago. The article was written by Dr Tennyson Lee, a resident in physical medicine and rehabilitation in Baltimore. It was about his care of his patient Dr M., an internist, who had just died.

“I tried to comb Dr M’s hair down, but the more I combed, the more it fluffed and stood up at the sides of his head. ‘He needed some mousse,’ I thought, just like I needed some now. My hair was much like his, including the cowlick from hell.

“Moments before, I had deflated the cuff and extubated Dr M. Now, I was preparing him for his last goodbye with his wife and son.

“I held down Dr M.’s eyelids for about a minute to keep any of the sclera from showing, and straightened out the covers and blanket of his bed. I opened the window shades and let the new morning light fill the room. Dr M. looked peaceful lying in bed with his eyes shut and the sun warming his face. He looked as if he were in a deep sleep. I cleaned up the clutter and went back to the conference area. Then I led Mrs M. and her son back into the room.”[4]

This was an act of love in the medical setting. I was grateful to the American Medical Association for publishing what many readers would denigrate as “soft,” anecdotal, and not evidence-based.

Osler, despite his stardom, retained humility

When he returned from studies abroad after graduating from medical school, he became a smallpox doctor, a physician in the pest house. This was considered the bottom rung of the medical ladder. In this way he identified with his father, a Christian missionary preaching in the northern wilderness. Like his father, he was paid very little. He used most of the money to order microscopes from Paris for his students. He also ended up developing a mild case of small pox himself. As he wrote in his essay “L’Envoi”[5] in 1905, one of his ideals in life was to cultivate equanimity and composure, and to bear success with humility.

Continuing a love of medicine throughout a long career often includes treating patients from all walks of life. I know a lot of physicians with what they call “carriage trade” practices. However, many are most revitalized by the part-time work they do treating the great unwashed, the most needy, the most medically challenging, and the most marginalized. These are the characters in their practices, the ones who evoke raw emotion, who make them laugh the loudest or make their eyes widen and moisten. These patients give them pause. “I leave my office and drive to my home in Kerrisdale and sit with a glass of merlot and realize how fortunate I am. My own worries seem to pale.” Actually, this physician’s illness is quite serious; I treat him for bipolar disorder. What he means is that he has the psychosocial supports that his patients on the Downtown Eastside don’t have.

Osler was adventuresome and took initiative to meet others

He traveled to Harvard in 1876–1877 and made courtesy calls on the old pillars of the profession. In 1881, he attended the Seventh International Medical Congress in London. Three thousand physicians and scientists gathered there. He described the congress in his report to the Canadian Medical and Surgical Journal: “The sight of the thousands of medical men drawn together for one common purpose, and animated by one spirit… quickened the pulse and roused enthusiasm to a high pitch.” While there he listened to addresses by Virchow, Huxley, and Pasteur. Socializing was very important to him at these meetings.

We do tend to recharge our batteries when we go away to medical meetings. We learn what’s cutting edge in our field and listen to the experts. We enjoy the intellectual stimulation that we often miss if we’re quite isolated in our home setting. We see old friends and sometimes meet new colleagues. We network and brainstorm. We schmooze and socialize in the evenings. We get a short break from our daily responsibilities of work and home. The love of our craft is renewed.

Osler had a happy home life

For many years, he had no love interests. It was stated that medicine was Osler’s mistress. “She tied and bound him.”[2] In 1892, at the age of 43, he married Grace Linzee Revere Gross, who was 37, the widow of the famous surgeon Dr Samuel W. Gross, and a descendant of Boston’s Paul Revere. On their honeymoon they attended the British Medical Association’s meeting at Nottingham. Almost 9 months to the day of their marriage, the Oslers had a son. Sadly, the boy died within days of his birth. “One must take the rough with the smooth,” Osler wrote.[2] Grace became pregnant again and gave birth to another son, Revere, in 1895. They had no other children.

Theirs was a Victorian-era traditional medical marriage. Grace ran the home single-handedly and Willie continued his busy and peripatetic professional life. After they left Johns Hopkins and moved to Oxford in 1905 when Osler became regius professor of medicine there, they entertained a lot. Grace seemed to have as much energy as her husband. They lived comfortably. Olser had a remarkably close relationship with Revere, whom he adored.

The elements of the Osler marriage that are relevant for us transcend time and changing sex roles and marital expectations. Quite simply, they seemed to really love each other. He cherished and respected her and she admired his commitment to his medical work. They set aside time to be together. They took summer breaks. As older parents, they felt blessed with Revere. They were life partners and shared similar values. Older when they met and fell in love, both had reached a level of maturity that served them well in marriage.

Perhaps one could make an argument for getting married later in life, but this is very rare in medical marriages of today. Medical students and young physicians often marry by their late twenties or early thirties. But second marriages are another story. Many physicians who are divorced and remarried in their late thirties or early fourties report that their happiness is in part due to being much older and wiser.

Osler learned from grief

The greatest loss in Osler’s life was the death of Revere in 1917 while serving in the First World War. He was 21 years old and died after undergoing surgery in Belgium for shrapnel wounds. Michael Bliss’s account of how the Oslers soldiered on after their son’s death is very moving.2 It is heart wrenching and brave. They were comforted by the fact that their dear friend, the famous neurosurgeon Dr Harvey Cushing, attended and was present when Revere died. They had a great sense that everything had been done to save his life and that he had had a decent burial in Flanders. Cushing wrote, “A strange scene—the great-great-grandson of Paul Revere under a British flag, and awaiting him a group of some six or eight American Army medical officers—saddened with thoughts of his father… (Sir William Osler).”[6]

Back in Oxford their life went on. As was said often in those days, they kept the flag flying. Osler busied himself with official duties, consultations, work on his library, and textbook revision. Osler is quoted as saying, “We are taking the only medicines for sorrow—time and hard work.”[2]

As I read about the Oslers grieving Revere, I think of the physicians and their spouses whom I have seen over my 33 years of practice who have lost children. Those of you who have buried a son or daughter will know that pain, its exquisiteness and magnitude, that cries out, “it’s not the natural order of things.” You and my patients and the Oslers teach us that healing is lifelong, a function of time and work, however defined.

But I also know that when physicians lose a child it is life-changing. When doctors return to medical work after the funeral or a leave of absence, their approach to medicine is different. It can be very hard to listen to patients’ complaints that seem prosaic or trivial. It is difficult to attend and to be empathic when you just want to shout out like my patients, “Shut the [expletive] up—you think you got problems—let me tell you what it’s like to lose your 15-year-old son to a drunk driver.” But I also know from my physician patients that their terrible loss, their painful sorrow, and their journey of healing, over time, have made them better physicians; they are more resilient, more enquiring of emotions that accompany their patients’ symptoms, more compassionate and tender. It’s a horrible price to pay, but as one said, “The only way I can find meaning in my daughter’s death—her suicide—is that she hasn’t died in vain and that she lives on inside me and makes me a better doctor.”

Osler was a “doctors’ doctor”

After leaving McGill and being recruited to Philadelphia in 1884, in addition to his academic work, he opened a consulting practice. He was on his way to becoming a “doctors’ doctor.” He did not charge a fee. In 1886, he was called to Cape Cod to treat the wife of William Williams Keen, the dean of American Surgeons in Philadelphia. Neither could save her. Keen wrote to Osler, “You sat with me long into the night listening while I bared my very soul to you. What a comfort you were to me you cannot guess.”[2] This is only one of several stories of how much trust physicians placed in him in their hour of need.

Those of you who treat physicians will know the awesome nature of that work. A privilege, yes, but a big responsibility too. As I’ve reviewed stories of Osler treating other physicians, I think that we can learn from him, irrespective of our branch of medicine and the branch of medicine of our physician-patient. He approached his physician-patients with confidence but not arrogance. One description: “In a room full of discordant elements he entered and saw only his patient and only his patient’s greatest need, and instantly the atmosphere was charged with kindly vitality, everyone felt that the situation was under control, and all were attention. No circumlocution, no meanderings. The moment Sir William gave you was yours.”[2] Another: “Osler’s very presence brought healing… There was healing in his voice.”[2]

I hope that I’ve given you a taste of the ways in which I think Osler’s love of medicine is germane to us, so many years later. His amazing life—how he lived, how he practised medicine, how he taught basic principles, and what he wrote and published—is a gift to us all. I close with a quote, but not from Osler, not by a physician. This is from “Come Sing With Me!” written by Mr Gordon Parks, African American photographer, composer, film director, and writer. Like Osler, he was a giant of a man and he will be revered through the ages.

Hope is the song I have chosen to sing—a deathless song, flowing steadily beside my faith.
Whenever the fist of doubt knocks at my door,
it is powerfully turned away by my hopeful singing.
When things go from bad to worse I still sing my song.
Why not?