From Osler to CanMEDS and Back Again: Guiding Our Future by Looking to Our Past.
An Historical Appraisal of the Medical Expert Role
Abstract
Medical practice is becoming increasingly complex. The modern physician holds many roles in today’s healthcare system. The Royal College of Physicians and Surgeons of Canada has defined the requirements for physicians-in-training in seven key roles, as part of the CanMEDS project. The central, integrating role is that of the medical expert. Are these new roles that have evolved out of the demands of the modern clinical context or have we simply recapitulate the role of a physician in a more contemporary language? I believe the latter to be true and in this essay propose to review the medical expert CanMEDS role from the perspective of Sir William Osler.
Keywords: Sir William Osler, CanMEDS, Medical Expert, Medical History
Introduction
In the early 1990’s the Royal College of Physicians and Surgeons of Canada (RCPSC) initiated the CanMEDS 2000 project.1 According to the RCPSC, their overarching goal was “to ensure that postgraduate specialty training programs are fully responsive to societal needs” by embodying “two fundamental concepts: 1) changing the focus of specialty training from the interests and abilities of providers (supply) to the needs of society (demand), and 2) orienting these programs to consider the needs of individual patients in context of the population at large”.1 The process involved two working groups with input from various stakeholders from across the Country in an effort to design and shape the future of Canadian postgraduate medical education.1 The result of this endeavor was the development of the seven key CanMEDS roles: medical expert, communicator, collaborator, manager, health advocate, scholar and professional.1 In 2005, the CanMEDS roles were reaffirmed, updated and further clarified to reflect current practice.2 In 2015, the RCPSC reviewed the CanMEDS framework anew, largely maintaining the core roles with the exception of redefining the manager role as “leader”, while making strives to align them within a “competency-based approach to medical education”. Our colleagues in family medicine have adopted a similar framework, the CanMEDS – Family Medicine and have also adapted it around a competency-based approach.3,4 In effect, through the CanMEDS roles we have defined what a Canadian physician should be by distilling down to the core values of our profession.
I originally wrote this as I transitioned from my final year of residency to my first year of fellowship. I was also moving from an area of long-standing economic stagnation and resultant financial constraints and cutbacks in healthcare (i.e. New Brunswick) to one that has enjoyed – until only recently – substantial economic prosperity with a resultant financial freedom in healthcare investment (i.e. Alberta). This dichotomy is clearly evident even to the medical tyro. At that time, this lead me to reflect and contemplate what it meant to be a physician and a future specialist in a country that is facing increased healthcare demands with varied means of meeting them. Moreover, there was the added complexity of Alberta’s local healthcare investments being derived from resources that will likely negatively affect the future health of everyone. This latter issue deserves more focused and informed discussion then I am able to provide here. In the years since, I have moved back to New Brunswick and taken on a faculty position as an Interventional Cardiologist and Assistant Professor of Medicine. I have also been more involved in the decision-making around physician education and training, including at the Royal College level.
Modern medicine and its practice is becoming ever more sub-specialized and technology-driven, and perhaps, dependant. Everyday sees the introduction of more novel and expensive medications and interventions aimed at an aging and often sicker patient demographic. As a result, the practicing physician is required not only master a large body of existing knowledge and practices but also to remain current through their distillation and incorporation of new evidence which is evolving – in both breadth and depth – at a remarkable rate. In effect, we are victims of our own success. This is compounded by a healthcare system that has finite, already limited and strained resources, an aging population that is more co-morbid as a result and demands access to the latest innovations and treatments. Not to mention the differing demands and resources of East versus West, North versus South and rural versus urban Canada. Moreover, for our colleagues in family medicine, there is a recent movement toward broadening the definition of primary care and redefining who constitutes a primary care provider,5 even at the risk of recruiting those who may ultimately work counter to our shared scientific progress and understanding as well as societal interests.6 Given these pressures, what is the role of the medical doctor and what is to become of it? There is also the new politicization and indoctrination of CanMEDS 2025 with Critical Social Justice ideology which threatens the central role, medical expert, in favour of social justice. These questions and concerns have led this writer to revisit and reflect on the CanMEDS roles anew and the two overarching concepts that lead to their original development.
While considering the future of healthcare in Canada and what it means and will mean to be a physician in the modern since, I have begun to look more and more to our past. Given our infatuation with the new and a perception that newer means better, looking to the past is becoming a luxury rather than a prerequisite. Support for this statement is evident in the fact that the study of the History of Medicine is not a requirement at any Canadian medical school, and an elective at only some. It is intriguing that upon reviewing the CanMEDS roles and the referenced materials that went into their creation, there appears to be little explicit emphasis on medicines past and the views of those figures who helped shape our present and perhaps could guide our future. Moreover, recent ideological influences from without and within are endeavouring to de-emphasize the importance of Enlightenment values and downplay or erase altogether the important contributions of those who came before us, largely on identitarian grounds. I will confess to the reader that I was a late bloomer when it came to the study of our shared medical history, to my own detriment I might add. I, unfortunately, missed a great opportunity during my undergraduate medical studies at Dalhousie University to learn from some excellent medical historians. That said, their written words echo longer and further than their spoken, and thus I am fortunate to be able to correct this personal deficiency. In an effort toward ongoing self-improvement, when I reflect on the kind of physician I want to be, I am finding my study of medical history to be invaluable.
This essay was originally intended to be the first in a series of essays to review, in turn, each of the CanMEDS roles through the lens of our shared medical history, beginning with the Medical Expert, our central role. To this end, I wish to embody the teachings, aphorisms and advice of Sir William Osler. While there are many historical figures worthy of study, few were as internationally influential and prolific in putting their thoughts to paper on all matters medicine as Osler was. Among his many attributes, Osler was a master physician, bibliophile, humanist and a teacher of medicine. During a year (1896-1897) spent with Osler at the Johns Hopkins Hospital, Dr. Joseph Pratt noted “the influence of Osler was exerted in many ways on the practice of medicine but even more by his character and life than by his teaching or writing”.7 Furthermore, "the mark which always distinguishes the truly great man is that his greatness is more and more appreciated as we move farther away”.7 “Indeed the years have added to his glory”.8 In an effort to be balanced, and to avoid succumbing to the nostalgia of a bygone era it is appropriate to note that although Osler’s role in medicines history is celebrated, some have suggested that his “mythical aura is shadowed” and his “specialness exaggerated”.9 A concise catalogue of his possible short-comings are provided by Bryan.10 Recent efforts are also being made to posthumously cancel him as he does not live up to modern standards when viewed through a presentism lens. That said, attempts at dissecting those qualities that continue to allow Osler to rise above his equally-accomplished contemporaries have been elusive.11 Perhaps this should not be surprising, as it has been noted that “the distinguishing ethos of a man cannot be easily explained or divided in neat subdivisions, for there are nuances, interactions, and subtleties that defy precise analysis”.12 Moreover, great physicians thought him greater.
I am not the first to frame Osler’s views of our profession in a more modern context; however, this writer is aware of no previous efforts at evaluating the CanMEDS roles from this most-Canadian of historical perspectives. Are the CanMEDS roles a novel way of defining a practitioner of medicine or have these principles been defined and laid out for us in the past? I believe the latter is true and aim to convince you the reader as well. I will not be reviewing the CanMEDS roles as they are described by the RCPSC, as this material is readily available and likely familiar to most. Furthermore, this essay will not present Osler’s thoughts and teachings about specific maladies, as our understanding of disease has advanced greatly since his time. Like Osler, it is likely that much of our own modern understanding of disease and its treatment will be destined for the fossil record of medical history. I will do my best to allow Osler to speak for himself, adding my own words only to provide context and continuity. I caution the reader that contained herein is only a selection of Osler’s teachings, chosen by this writer. Others may have chosen differently. Ultimately, you the reader will be the judge of my success.
On the Medical Expert
It can be said with confidence that this is the one role that most would readily identify as central to being a physician. In effect, this is why our service is sought and where our successes lie. The RCPSC defines a medical expert as a physician who integrates all of the CanMEDS roles, applying medical knowledge, clinical skills, and professional values in their provision of high-quality and safe patient-centered care. Arguably, it is also the role that has changed the most in substance since Osler’s time, but has it changed in principle?
A well-trained, sensible doctor is one of the most valuable assets of a community.13
Modern physicians have a much larger and ever growing armamentarium of proven-effective treatments and interventions. The old adage that I do it this way because my mentor did it this way has largely – and appropriately – given way to; I do it this way because this was shown to be most effective in large randomized placebo-controlled trials. Evidence trumps opinion. Thus, we have sacrificed some of the art for the science in the name of safety and effectiveness. Indeed, with the advent of science- or evidence-based medicine, our modern approach to the treatment of disease and the patients’ afflicted with them has become, for better and for worse, standardized. We wisely have traded predominantly religious ways of knowing for an enlightened, scientific epistemology based on evidence. In this era of statistical significance, there appears to be a tendency to treat toward the mean. Although it may be perceived that science-based medicine (a term I prefer to evidence-based medicine as it more fully capitulates the fact that new data exists in a greater scientific context and understanding developed over time) is a more modern invention, Osler too appreciated the importance of the discoveries of science as it relates to the practice of medicine when he remarked,
The hospital units mint, for current use in the community, the gold wrought by the miners of science.14
Modern science has made to almost everyone of you the present of a few years.15
He also highlights the value of science and its methods when he noted
To the physician particularly a scientific discipline is an incalculable gift, which leavens his whole life, giving exactness to habits of thought and tempering the mind with that judicious faculty of distrust which can alone, amid the uncertainties of practice, make him wise unto salvation.16
Regarding the importance of the scientific method and the data it yields, he noted that there has been
Incalculable benefits to man from the introduction of experimentation into the art of medicine.17
Our work is an incessant collection of evidence, weighing of evidence and judging upon the evidence, and we have to learn early to make large allowances for our own frailty, and still larger for the weaknesses, often involuntary, of our patients.18
He cautioned us regarding anecdotal evidence when he stated
We, the doctors, are so fallible, ever beset with the common fatal facility of reaching conclusions from superficial observations, and constantly misled by the ease with which our minds fall into the ruts of one or two experiences.19
We must collect facts with open-minded watchfulness, unbiased by crotchets or notions; fact on fact, instance on instance, experiment on experiment, facts which fitly joined together by some master who grasps the idea of their relationship may establish a general principle.19
It is only by persistent intelligent study of disease upon a methodical plan of examination that a man gradually learns to correlate his daily lessons with the facts of his previous experience and of that of his fellows, and so acquires clinical wisdom.15
On keeping up-to-date of novel developments, Osler remarked that
We doctors do not “take stock” often enough, and are very apt to carry on our shelves stale, out-of-date goods. The society helps to keep a man “up to the times”, and enables him to refurnish his mental shop with the latest wares.20
The medical journals, the medical societies, the post-graduate schools all help in this good work, and both the physician and the public now appreciate how important it is that physicians should keep well abreast of the times.18
The profession in truth is a sort of guild or brotherhood, any member of which can take up his calling in any part of the world and find brethren whose language and methods and whose aims and ways are identical with his own.21
The difficulty lies often with the individual men who fall into routine and slovenly habits of practice, and who never get more than a superficial smattering of the science and of the art of medicine.18
It is much simpler to buy books than to read them, and easier to read them than to absorb their contents.22
It is astonishing with how little reading a doctor can practice medicine, but it is not astonishing how badly he may do it.15
In our modern era of rapid dissemination and implementation of new knowledge, Osler advised caution when he remarked that
The rate of progress has been too rapid for us to appreciate, and we stand bewildered and, as it were, in a state of intellectual giddiness, when we attempt to obtain a broad, comprehensive view of the subject.23
The history of science teaches us that it takes many years from the announcement of the fact to its full application… it is for the practitioner to make the new facts of science efficient and useful, to translate science into practice… to be exploited prematurely in practice is the common fate of all new scientific facts. Not content to wait for full knowledge, men hastily draw conclusions from imperfect data.18
Surrounded by people who demand certainty… the practitioner too often gets into a habit of mind which resents the thought that opinion, not full knowledge, must be his stay and prop. There is no discredit, though there is at times much discomfort, in this everlasting “perhaps” with which we have to preface so much connected with the practice of our art. It is, as I said, inherent in the subject.20
Gentlemen, if you want a profession in which everything is certain you had better give up medicine.24
For the individual physician, striving for full knowledge seems – perhaps ironically – more difficult now than it must have in Osler’s time. Osler’s remarks above would serve as well today as an opening salvo at a modern medical conference presenting the latest state-of-the-science of our art as they did when he wrote them over a century ago. For Osler understood that
Facts alone will not be of much service to you unless studied in connection with others and with the phenomena displayed during life.24
A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practicing a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which.25
The art of the practice of medicine is to be learned only by experience; ‘tis not an inheritance; it cannot be revealed. Learn to see, learn to hear, learn to feel, learn to smell, and know that by practice alone can you become expert.24
In taking up the study of disease, you leave the exact and certain for the inexact and doubtful and enter a realm in which to a great extent the certainties are replaced by probabilities.24
On the practice of medicine, Osler advised attention and focus, evident when he remarked
…but as soon as I got interested in medicine I had only the single idea of doing the day’s work faithfully and honestly, as well as I could, and I do believe that if I have had any measure of success at all, it has been solely and wholly in doing the day’s work that was before me just as actively and just as energetically and just as well as was in my power.26
You will not only be better, but happier men, if you endeavour to do your duty day by day, not from self-interest, not from any outside aim however high, but simply because it is right, content to let the reward come when it will.24
The clinician who keeps one eye on his watch while in the wards is rarely successful.27
The load of to-morrow, added to that of yesterday, carried to-day makes the strongest falter.28
The way of life that I preach is a habit to be acquired gradually by long and steady repetition. It is the practice of living for the day only, and for the day’s work, Life in day-tight compartments.28
With respect to diagnosis, diagnostic reasoning and clinical judgment, Osler provides us with much wisdom. This is but a sampling.
To be able to recognize abnormal states, you must bring a full knowledge of the normal situation of the organs, their physical signs, and the characters and composition of the excretions. Without these standards of comparison, you cannot make the first step in the examination of your patient.24
Get the patient in a good light. Use your five senses. We miss more by not seeing than we do by not knowing. Always examine the back. Observe, record, tabulate, communicate.24
One element must always be taken into account in prognosis and that is the personal equation of the patient. No two cases of the same disease are ever alike; the constitution of the person, his individuality, stamps each case with certain peculiarities.24
There is a tendency among young men about hospitals to study the cases, not the patients, and in the interest they take in the disease lose sight of the individual. Strive against this.24
It is so much easier to do a penny-in-the-slot sort of practice, in which each symptom is at once met but its appropriate drug than to make a careful examination and really do study the case systematically.29
Come to the study of the diagnosis of disease with all the modesty at your command. Positiveness and dogmatism are inevitable associates of superficial knowledge in medicine.24
Absolute diagnoses are unsafe, and are made at the expense of the conscience.15
A cocksure diagnoses and a positive prognosis may express the assurance of ignorance.30
You will soon learn, however, in practice, to be satisfied with probabilities.24
He alludes to the threat of early diagnostic closure by stating
Adhesions are the refuge of the diagnostically destitute.15
In this modern era of sophisticated investigations, Osler reminds us to
Listen to the patient, he is telling you the diagnosis.24
The four points of a medical student’s compass are: Inspection, Palpation, Percussion, and Auscultation.15
It is only by methodical examination of every system and organ that we get those comprehensive facts from which we can draw reasonably safe inductions.24
Regarding treatment and the use of medications, Osler remarked that
To modern pharmacy we owe much, and to pharmaceutical methods we shall owe much more in the future.13
The growth of scientific pharmacology, by which we now have many active principles instead of crude drugs, and the discovery of the art of making medicines palatable, have been of enormous aid in rational practice. There is no limit to the possibility of help from the scientific investigation of the properties and action of drugs.31
One of the most striking characteristics of the modern treatment of disease is the return to what used to be called the natural method – diet, exercise, bathing and massage. There probably never has been a period in the history of the profession when the value of diet in the prevention and the cure of disease was more fully recognized… Adults eat far too much.31
Within the past quarter of a century the value of “exercise” in the education of the young has become recognized. The increase in the means of taking wholesome out-of-door exercise is remarkable, and should show in a few years an influence in the reduction of the nervous troubles in young persons. The prophylactic benefit of systematic exercise, taken in moderation by persons of middle age, is very great.31
Patients should have rest, food, fresh air and exercise – the quadrangle of health.15
Imperative drugging – the ordering of medicine in any and every malady – is no longer regarded as the chief function of the doctor.31
In therapeutics we do not so much need new remedies as a fuller knowledge of when and how to use the old ones.32
Lack of systematic personal training in the methods of the recognition of disease leads to the misapplication of remedies, to long courses of treatment when treatment is useless, and so directly to that lack of confidence in our methods which is apt to place us in the eyes of the public on a level with empirics and quacks.15
Remember how much you do not know. Do not pour strange medicines into your patients.15
Do not rashly use every new product of which the peripatetic siren sings. Consider what surprising reactions may occur in the laboratory from the careless mixing of unknown substances.15
The young physician starts life with twenty drugs for each disease, and the old physician ends life with one drug for twenty diseases.24
The battle against poly-pharmacy, or the use of a large number of drugs (of the action of which we know little, yet we put them into bodies of the action of which we know less), has not been fought to a finish.31
The true polypharmacy is the skilful combination of remedies.33
On the value of skepticism and our interaction with the pharmaceutical industry, Osler was forward and frank
We all know only too well the bastard literature which floods the mail, every page of which illustrates the truth of the axiom, the greater the ignorance the greater the dogmatism. Much of it is advertisements of nostrums foisted on the profession by men who trade on the innocent credulity of the regular physician, quite as much as any quack preys on the gullible public… A still more dangerous enemy to the mental virility of the general practitioner, is the “dummer” of the drug house. While many of them are good, sensible fellows, there are others…who will tell you glibly of the virtues of extract of the coccygeal gland in promoting pineal metabolism, and are ready to express the most emphatic opinions on questions about which the greatest masters of our art our doubtful.21
Far too large a section of the treatment of disease is to-day controlled by the big manufacturing pharmacists… The remedy is obvious – give our students a first-hand acquaintance with disease and give them a thorough practical knowledge of the great drugs and we will send out independent, clear-headed, cautious practitioners who will do their own thinking and be no longer at the mercy of a meretricious literature which has sapped our independence.33
The salt of life for him is a judicious scepticism, not the coarse, crude form, but the sober sense of honest doubt.21
You are in this profession as a calling, not as a business; as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed. You must work in the missionary spirit, with a breadth of charity that raises you far above the petty jealousies of life.34
On interacting with patients, Osler has been referred to as the “father of cool detachment”35 largely as a result of his essay Aequanimitas36 and its resultant influence. This has been refuted by Bryan10,37 and based on the body of Osler’s work it appears more likely that Osler valued control rather than absence of ones emotions. Osler’s own words
To serve the art of medicine as it should be served, one must love his fellow man.18
The practitioner of medicine… we are here not to get all we can out of life for ourselves, but to try to make the lives of others happier.38
Kindliness of disposition and gentleness of manners are qualities essential in a practitioner. If they do not exist naturally, they are virtues which must be cultivated if not be assumed.24
As the practice of medicine is not a business and can never be one, the education of the heart – the moral side of the man – must keep pace with the education of the head… After all, the personal equation has most to do with success or failure in medicine, and in the trials of life the fire which strengthens and tempers the metal of one may soften and ruin another.20
The motto of each of you as you undertake the examination and treatment of a case should be “put yourself in his place”. Realize, so far as you can, the mental state of the patient, enter into his feelings… Scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look.39
Dr. Joseph Pratt – turning Osler’s own words unto himself – referred to him as “a specialized generalist and a generalized specialist”.7 On the consultant role, Osler was of two minds
In the bewildering complexity of modern medicine it is a relief to limit the work of a life to a comparatively narrow field which can be thoroughly tilled. To many men there is a feeling of great satisfaction in the mastery of a small department, particularly one in which technical skill is required… Then, as a rule, the specialist is a free man, with leisure or, at any rate, with some leisure; not the slave of the public, with the incessant demands upon him of the general practitioner. He may live a more rational life, and has time to cultivate his mind, and he is able to devote himself to public interests and to the welfare of his professional brethren.40
The restriction of the energies of trained students to narrow fields in science, while not without its faults, has been the most important single factor in the remarkable expansion of our knowledge. Against the disadvantages in a loss of breadth and harmony there is the compensatory benefit of a greater accuracy in the application of knowledge in specialism, as is well illustrated in the cultivation of special branches of practice.31
There are, in truth, no specialties in medicine, since to know fully many of the most important diseases a man must be familiar with their manifestations in many organs.41
However, he appreciated the shortcomings of specialization.
Specialism is not, however, without many disadvantages. A radical error at the outset is the failure to recognize that the results of specialized observation are at best only partial truths, which require to be correlated with facts obtained by wider study. The various organs, the diseases of which are subdivided for treatment, are not isolated, but complex parts of a complex whole, and every day’s experience brings home the truth of saying, “When one member suffers all the members suffer with it”.24
The incessant concentration of thought upon one subject, however interesting, tethers a man’s mind in a narrow field.21
Seeing the more severe cases, the experience of the consultant is apt to be misleading.30
The dangers do not come to the strong man in a speciality, but to the weak brother who seeks it in an easier field in which specious garrulity and mechanical dexterity may take the place of solid knowledge. All goes well when the man is larger than his speciality and controls it, but when the speciality runs away with the man there is disaster, and a topsy-turvey condition, which in every branch, has done incalculable injury.40
Osler appeared to appreciate the unique difficulties that physicians outside the academic centers faced, evident when he remarked
To you the silent workers of the ranks, in villages and country districts, in the slums of our large cities, in the mining camps and factory towns, in the homes of the rich, and in the hovels of the poor, to you is given the harder task of illustrating with your lives the Hippocratic standards of Learning, of Sagacity, of Humanity, and of Probity. Of learning, that you may apply in your practice the best that is known in our art, and that with the increase in your knowledge there may be an increase in that priceless endowment of sagacity, so that to all, everywhere, skilled succour may come in the hour of need. Of a humanity, that will show in your daily life tenderness and consideration to the weak, infinite pity to the suffering, and broad charity to all. Of a probity, that will make you under all circumstances true to yourselves, true to your high calling, and true to your fellow man.38
Moreover, he advocated respect and admiration for his medical colleagues, particularly his generalist colleagues, evident here
Respect your colleagues. Know that there is no more high-minded body of men than the medical profession.24
I have an enduring faith in the men who do the routine work of our profession. Hard though the conditions may be, approached in the right spirit – the spirit which has animated us from the days of Hippocrates – the practice of medicine affords scope for the exercise of the best faculties of the mind and heart. That the yoke of the general practitioner is often galling cannot be denied, but he has not a monopoly of the worries and trials in the meeting and conquering of which he fights his life battle.42
The cultivated general practitioner. May this be the destiny of a large majority of you! Have no higher ambition! You cannot reach any better position in a community; the family doctor is the man behind the gun, who does our effective work. That his life is hard and exacting; that he is underpaid and overworked; that he has but little time for study and less for recreation – these are the blows that may give finer temper to his steel, and bring out the nobler elements in his character.40
On mastery, self-reflection and improvement Osler offers much. He advised competency as a goal long before we re-discovered its virtues.
…start slowly, take one thing at a time, and do not leave it until you have conquered a few facts regarding it. Learn the lesson of thoroughness at the outset or you are apt not [to] learn it at all.24
Thoroughness is the most difficult habit to acquire, but it is the pearl of great price, worth all the worry and trouble of the search. The dilettante lives an easy, butterfly life, knowing nothing of the toil and labour with which the treasures of knowledge are dug out of the past, or wrung by patient research in the laboratories.40
Begin early to make a threefold category – clear cases, doubtful cases, mistakes. And learn to play the game fair, no self-deception, no shrinking from the truth; mercy and consideration for the other man, but none for yourself, upon whom you have to keep an incessant watch… it is only by getting your cases grouped in this way that you can make any real progress in your post-collegiate education; only in this way can you gain wisdom with experience.40
The artistic sense of perfection in work is another much-to-be-desired quality to be cultivated. No matter how trifling the matter on hand, do it with a feeling that it demands the best that is in you, and when done look it over with a critical eye, not sparing a strict judgment of yourself.38
By far the most dangerous foe we have to fight is apathy – indifference from whatever cause, not from a lack of knowledge, but from carelessness, from absorption in other pursuits, from a contempt bred of self-satisfaction.43
To maintain mental freshness and plasticity requires incessant vigilance; too often, like the dial’s hand, it steals from its figure with no pace perceived except by one’s friends, and they never refer to it. A deep and enduring interest in the manifold problems of medicine, and a human interest in the affairs of our brotherhood – if these do not suffice, nothing will.29
The killing vice of the young doctor is intellectual laziness.20
On knowing your own limits, Osler advised us that
Enjoying the privilege of wide acquaintance with men of very varied capabilities and training, you can, as spectators of their many crochets and of their little weaknesses, avoid placing an undue estimate on your own individual powers and position.41
More perhaps than any other professional man, the doctor has a curious – shall I say morbid? – sensitiveness to (what he regards) personal error. In a way this is right; but it is too often accompanied by a “cocksureness” of opinion which, if encouraged, leads him to so lively a conceit that the mere suggestion of mistake under any circumstances is regarded as a reflection on his honour, a reflection equally resented whether of lay or of professional origin.19
…but I insist for its own sake, and for the sake of what it brings that a due humility should take the place of honour on the list.19
Are the pressures faced by our modern healthcare system really different from those faced by our forebears? Are our current conceptualizations of what constitutes contemporary physicians really modern ideals or have they been there all along? Have we invented something new or simply repackaged something old? I think these ideals have always been there. I confess to the reader that I am not an expert in medical education nor do I claim to know the current state of the science on medical education. Moreover, I have great admiration for a profession that self-reflects and asks itself – can we do better? And then strives toward that end. That said, I do not know whether recent changes in the principals and practice of medicine have been or are necessary or have/will result in better physicians or are they simply change for change’s sake. While I hope the former to be true I wonder about the influence of the latter, particularly in an era where change is ever present, anticipated, accelerating, expected and often sought. It is my conjecture that that many of the current changes being developed and implemented at Canadian medical schools are antithetical to Enlightenment ideas and values and will likely serve to only weaken and devalue our shared calling. Osler had a habit of beginning his speeches and addresses with the salutation, “Fellow Students…”. Implicit in this was the fact that Osler himself identified as a student. Osler recognized the fact that medical school and residency were the beginning of our education as physicians, not the end. In the modern CanMEDS context, we would identify as Scholar, and while the essence remains the same, something is lost, perhaps it is the humility that is implied by the word Student.
In concluding this essay, I leave the reader with some final thoughts from Osler. Here he describes what he feels is the master-word in medicine, perhaps our esprit de corps
I propose to tell you the secret of life as I have seen the game played, and as I have tried to play it myself… Though a little one, the master-word looms large in meaning. It is the open sesame to every portal, the great equalizer in the world, the true philosopher’s stone, which transmutes all the base metal of humanity into gold. The stupid man among you it will make bright, the bright man brilliant, and the brilliant student steady. With the magic word in your heart all things are possible, and without it all study is vanity and vexation. The miracles of life are with it; the blind see by touch, the deaf hear with eyes, the dumb speak with fingers. To the youth it brings hope, to the middle-aged confidence, to the aged repose. True balm of hurt minds, in its presence the heart of the sorrowful is lightened and consoled. It is directly responsible for all advances in medicine during the past twenty-five centuries… Not only has it been the touchstone of progress, but it is the measure of success in every-day life. Not a man before you but is beholden to it for his position here, while he who addresses you has that honour directly in consequence of having had it graven on his heart when he was as you are to-day. And the master-word is Work, a little one, as I have said, but fraught with momentous sequences if you can but write it on the tablets of your hearts, and bind it upon your foreheads.38
Finally, in parting
Never has the outlook for the profession been brighter. Everywhere the physician is better trained and better equipped than he was twenty-five years ago. Disease is understood more thoroughly, studied more carefully and treated more skillfully. The average sum of human suffering has been reduced in a way to make the angels rejoice. Diseases familiar to our fathers and grandfathers have disappeared, the death rate from others is falling to the vanishing point, and public health measures have lessened the sorrows and brightened the lives of millions. The vagaries and whims, lay and medical, may neither have diminished in number nor lessened in their capacity to distress the faint-hearted who do not appreciate that to the end of time people must imagine vain things, but they are dwarfed by comparison with the colossal advance of the past fifty years.21
The times have changed, conditions of practice have altered and are altering 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.38
Acknowledgements
To acknowledge a few, would be to insult many. I will most graciously thank all those who have served as teachers and mentors. I, and I hope they, are better for it. I would like to specifically acknowledge Drs. Peter West and Dylan Taylor who have served as role models of conscientious, patient-centered medicine and a guide on my navigation through this most noble a form of service to others.
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