Red tape, hurdles, and fences: The evolution of modern medicine

In March 2008 Dr Tcheremenska-Greenhill, associate CEO of the British Columbia Medical Association, delivered the 87th Annual Olser Lecture. Here is her lecture.

VMA and the Osler Lecture
Since 1921 the Vancouver Medical Association has hosted an annual guest lecture in honor of Sir William Osler to celebrate physician leadership and professionalism.

I am deeply honored to have been chosen as the 2008 Osler lecturer for the Vancouver Medical Association. It is inspiring to know that these lectures have been given here every year since 1921, starting just 2 years after Osler’s death.

Allow me to take this opportunity to congratulate you—the members of the Vancouver Medical Association on the great longevity of your association—110 years in existence is worth recognizing and celebrating! The fabric of physician intercollegiality has been challenged over the years with the gradual disappearance of natural gathering places such as the doctor’s lounge in the hospitals. Organizations like this one are essential to our identity as a profession.

The main focus of my talk will be to reflect on how Osler’s work can contribute to the evolution of modern medicine. But before I proceed, I must share with you that while much may have changed since the days Osler practised, there is at least one constant that I have personally experienced. When he moved from McGill to Baltimore and then to Oxford, Osler was given an incredibly warm welcome from the local medical community. I have to thank my colleagues, many of whom are present tonight, for all of their support, which made my recent transition to the Canadian West Coast such a wonderful and positive experience.

While on personal ground, I must add that Osler has always had a special role in my life—he has been an incredible inspiration ever since the days I discovered his legacy as an undergraduate student at our common alma mater, Montreal’s McGill University. Indeed, I was introduced in my first week at McGill to what became my sacred retreat. It’s a lesser known fact that Osler’s entire library, including the books, registry, oak paneling, and furniture, was moved posthumously to the McGill University Medical Library. Sir William and Lady Osler’s ashes actually rest in a niche within the library, behind a sculpted panel, surrounded by his beloved books.

I was privileged to be able to reserve his desk for many hours and settle there to study. And I have to admit that much of that time was actually spent reading books randomly plucked from the richness of Osler’s handpicked collection—the “Bibliotheca Osleriana.” And what an enriching experience that was!

A life well lived
Osler is deservedly one of the most famous, esteemed, and influential physicians in the history of modern medicine. He led a vibrant, energetic, enthusiastic life that was anchored by the commitment to work, the beauty of generosity, and the enjoyment of life and people.

Sir William Osler was born in 1849 in Upper Canada in Bond Head (now Ontario). He started his medical studies at the Toronto School of Medicine (which was a proprietary, or privately owned, institution, not to be confused with the Medical Faculty of the University of Toronto).

Then Osler went to McGill University in Montreal, where he obtained his medical degree, and after some postgraduate training in Europe, he returned to McGill as a professor and began his illustrious career.

In 1884 at the age of 35 he left McGill for Philadelphia and eventually Baltimore, where he became the first chief of staff at Johns Hopkins Hospital and, in partnership with three other physicians, he led the new Johns Hopkins University School of Medicine to become the premier medical educational program of his time. In 1892 he published the first great textbook of modern medicine, The Principles and Practice of Medicine, and also married the love of his life, Lady Grace Osler.

In 1905 they moved to England where he was appointed to the regius chair of medicine at Oxford, which he held until his death in 1919, continuing to publish, lecture, and inspire.

The evolution of modern medicine
In April 1913 Osler delivered a series of six lectures at Yale University, titled “The Evolution of Modern Medicine,” for the Siliman Foundation lecture series.

This series was quite necessary as, in a 50-year span, Osler witnessed revolutionary changes within the practice of medicine as well as the profession itself. He described the series in the preface of the published edition as “an aeroplane flight over the progress of medicine through the ages.”

If Osler were transported to our world today, he would recognize many dimensions as part of his legacy to the medical profession—from the way we educate physicians to the way we approach, diagnose, and treat patients.

There are, however, some things that didn’t quite exist in his time—beyond the obvious such as scientific innovations and technology. He would not have heard of anything even remotely resembling concepts such as rationing, wait list management, health human resource crisis, strategic planning, or return on investment.

In the 18th century, Voltaire said, “Doctors are men who prescribe medicines of which they know little, to cure diseases of which they know less, in human beings of whom they know nothing.” Well, in the years when Osler first became a physician, this was unfortunately still true and, in fact, the evolution of science allowed people to obtain proof about what the prescient French philosopher had only imagined to be true. It had become quite obvious that not only were the so-called “treatments” not helpful, the great majority of them were actually harmful.

At the time, in North America:
• Pneumonia and tuberculosis were robbing families of all social standing of their loved ones regardless of age and general health.
• Lister’s antisepsis techniques were slowly trickling into hospitals and operating rooms.
• Laboratory confirmation of diagnosis was a relative novelty.
• In hospitals, patients slept on straw mattresses or even dirty wooden floors.
• X-rays were making some intriguing claims about aiding diagnosis.
• The only remedy that was shown to work for malaria was quinine.
• Smallpox, despite an available vaccine, remained rampant.
• Many medical schools were “proprietary,” unaffiliated with a college or university and run by one or two doctors whose goal was to make a profit. A degree was typically awarded after only 2 years of study, which did not necessarily involve any laboratory work or anatomical dissection.
• Regulation of the medical profession was almost nonexistent.

Indeed, with Osler’s ardent leader­ship, medicine was revolutionized—diagnosis became possible, diseases were reclassified, and public health was prioritized. Patients were listened to and were examined. They were encouraged to get outdoors and be active as a possible cure for tuberculosis. The therapeutic effect of the physician-patient relationship was recognized.

And how did Osler successfully lead these massive changes? Examining his legacy, three key elements of success emerge: first, aequanimitas; second, creating a microcosm of success; and third, working in unity within the profession.

Medicine forms a remarkable world-unit for hope
Aequanimitas: Osler’s concept that could be summarized as imperturbability, or working one day at a time through incremental changes but never losing the ultimate objective.

Where everyone saw scarcity, he was able to create the perspective of abundance. Where others saw insurmountable problems, Osler saw elements on which he could build a better future for all. In fact, that was one of his most defining personality traits—while no stranger to stress and depression, his infectious optimism leveraged his humanistic outlook to create innumerable instances of prevailing against odds.

That is exactly what is called, today, “shifting from a culture of scarcity to one of abundance.” Dr Don Berwick, founder of the Institute for Health Improvement, helped mainstream this notion of shifting from a culture of scarcity to one of abundance within health care and has been able to recognize and create powerful examples of abundance at work.

Abundance is a concept completely unrelated to funds or means. Let me give you an example. When we say “elite,” what often comes to mind is the upper class. But the new definition of elite is simply “someone with more of”—more energy, more ability, more education, more passion, and so on. So within medicine, what do we have more of that we can leverage? Where is our until-now-unseen abundance?

What can we do with the immense new opportunities afforded to us by the massive changes in society, science, and technology? The incredible interest patients have in their own care? What can we do with the incredible energy, intelligence, passion, and wisdom of physicians—individually and collectively?

Creating a microcosm of success
Before all business gurus began advocating for the “quick wins” approach to change management, Osler realized the need to implement his ideas, make them work, and demonstrate the success in a way that makes others follow. That was his second element of success.

For example, Osler believed that students need anatomical and lab training and direct exposure to patients. At Johns Hopkins he implemented his beliefs—he established the 3rd- and 4th-year clinical clerkships and the concept of full-time residency programs (which back then lasted from 7 to 8 years and involved living in the “resident” areas within the hospital).

Osler was so effective in demonstrating the success of his approach that he made it easy for Flexner to then use the Johns Hopkins University School of Medicine as the ideal example for all to follow. The Flexner report published in 1910 shook the medical education system to its core and produced the medical training system that we know today.

Unity of the profession
I want to leave you with a final Oslerian thought—the third key element—the importance of unity within the profession.

How do professions ensure that they have a powerful voice? Social scientists agree that the combination of three elements is necessary:
• A quasi-monopoly on their knowledge.
• A special relationship with their patients, the public, and the elites.
• Highly sophisticated collective organizations.

Osler worked tirelessly to advocate for and create unity in the pro­fession. He was very involved in all kinds of medical societies; at one time he was a member in as many as 70 different associations! In 1884 he was elected as the 17th president of the Canadian Medical Association. His presidential address titled, “The Growth of the Profession,” was a sweeping overview of medicine and medical education, a brilliant presentation of challenges and solutions, and an admonishment to colleagues to be present and active in their medical organizations.

I am biased in favor of medical organizations just as Osler was. He said, “No physician has the right to consider himself as belonging to himself; but all ought to regard themselves as belonging to the profession,”[1] and “The chief weakness of the profession lies in its tendency to break into cliques and coteries, the interests of which take precedence over other of wider and more public character. From this a baneful individualism is likely to arise, with every man for himself. A centrifugalising influence against which this [society] is and has been the only enduring protest.”[2]

Out of the three elements identified earlier that allow a profession to yield a powerful professional voice, the third, “highly sophisticated collective organizations,” is the only element that currently faces no massive external contest or competition. We need to continue to leverage it as we have to date.

The evolution of modern medicine today can be perhaps summarized as red tape, hurdles, and fences, and we all wish for a better environment in which to practise our art and science.

I will not describe the challenges of the medical world we live in. You know them as well as I do. But as Dr Jonas Salk, inventor of the original polio vaccine, once said, “I have had dreams and I have had nightmares, but I have conquered my nightmares because of my dreams.”

My dreams include more recognition for quality full-spectrum care. A world where doctors get to be doctors. Where information and technology necessary for patient care is readily available. Where timely booking of referrals and diagnostic tests does not require pleading calls to colleagues and there is no more struggling to find a locum/MD willing to take over a practice either to get time off or to retire. A world where physicians are treated by the system as an asset. Where decision makers are accessible, they have authority, and are locally accountable.

Many changes are afoot and we, as a unified profession, are all going to have to gather yet again our abundant and untapped resources and lead the way. And, to quote Osler again, “Few men have had more favorable opportunities than I have had to gauge the actual conditions in professional private life, in the schools, and in the medical societies, and as I have seen them in the past 20 years I am filled with thankfulness for the present and with hope for the future.”[3]

References

1. Osler W. The functions of a state faculty. Maryland Med J 1897;37;73-77. In: Silverman ME, Murray TJ, Bryan CS (eds). The Quotable Osler. Philadelphia: American College of Physicians; 2003.
2. Cushing H. The Life of Sir William Osler. London: Oxford University Press; 1940.
3. Osler W. Unity, peace and concord. A farewell address to the Medical Profession of the United States, delivered before the Medical and Chirurgical Faculty of the State of Maryland, 1905. In: Osler W. Aequanimitas. 3rd ed. McGraw-Hill Professional; 1932.
Suggested reading
Bliss M. William Osler: A Life in Medicine. New York: Oxford University Press; 1999.
Osler W. The Evolution of Modern Medicine. New Haven: Yale University Press; 1913.

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Dr Tcheremenska-Greenhill completed her MD at Université de Montréal and her family medicine residency at McGill University. She practised as an emergency and family physician in Montreal and then Ottawa, and served for over a decade within local, provincial, and national medical associations. She worked for the CMA from 2004 to 2007 and then moved to BC to assume the newly created role of BCMA associate CEO.