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no little courage, and although the results have abundantly
justified it, it was then thought that it would greatly limit
the number of students who would apply for admission. The
first class of 17, including three women, entered in the fall
of 1893. When, in the third year, they began to work in the
hospital, first in the dispensary and then in the wards, Osler^s
genius as a medical teacher became more and more evident.
He saw to it that the students came into the closest contact with
the patients in the dispensary, and he organized the hospital
wards so that the fourth-year students took an essential part
in the management of the cases. Although this last had been
the intention since the inception of the hospital, and the main
building had been designed to house 20 senior students, its
practical application met with opposition and presented diffi-
culties, and it was Osier's insistence that threw open the wards
to the students, a fact, the thought of which, I think, always
gives him pleasure.

He did, indeed, put the students into the wards, but he did
not leave them there. He stayed with them, and if ever
medical students got clinical instruction on a university basis,
2



18 Sir William Osler, Baet.

they did. It is not given to me to speak of Osier as a teacher,
for my chapter ends with the beginning of the medical school.
For me, and for others similarly situated, who had been reared
in the expectation of the new order in medical education, the
coming of Osier ushered in the complete realization of long-
deferred hopes. He set for ns a difficnlt goal, and helped and
cheered us on the way by his wise precepts, his kindly, friendly
commendation, his vigorous leadership, and more than all, by
simply being himself.

It is no fault of his that the finished product is no better,
but what good there is in me as a teacher and a physician I owe
to him, and on this, his birthday, I lay it at his feet in grateful
acknowledgment.




1902.



OSLER AS CHIEF OF A MEDICAL CLINIC

By Lewellys F. Bakkek

Internal medicine, like other branches of science, though
making at all times some progress, is subject in its advance to
fits and starts, the result of unusual concatenations of events.
The opening of the medical clinic at The Johns Hopkins
Hospital in 1889 was an opportunity for helping on the science
and art of medicine that might amount to either much or little,
depending upon its seizure. The time corresponded to the flood-
tide of natural science. Biology, physics and chemistry had
participated in the great rise. Medicine, always quick to apply
to its own service the results of investigations in the funda-
mental sciences, had responded by establishing a whole series
of special medical sciences (anatomy, histology, embryology,
physiology, physiological chemistry, pharmacology, pathologi-
cal anatomy and physiology, bacteriology), to be studied and
taught by men who gave up their lives exclusively to their
promotion ; these sciences were to serve as a foundation upon
which a great superstructure of cKnical science and art might
be built. The place to be filled, the professorship of medicine
in The Johns Hopkins University, which carried with it the
appointment as physician-in-chief to The Johns Hopkins Hos-
pital, was in several ways unique, at least as far as medicine
in America was concerned. For, in the first place, according
to the will of Johns Hopkins, the well-endowed hospital was
designed to be an integral part of the medical school of an
endowed university, and funds were provided for salaries for
the leaders of the clinics as well as for the chiefs of other uni-
versity departments, one of the circumstances that, combined
with others, led to the abandonment of the hitherto-prevailing
" proprietary medical schools '^ and to their replacement by
medical schools organized as parts of great universities. In
the second place, The Johns Hopkins University, through the

19



20 Sir William Osler, Bart.

action of its trustees, and of its first president, Daniel C.
Gilman, had been organized, in all its departments, in the
interests of original research as well as of competent instruc-
tion ; with distinguished investigators in the arts department
and with men like Martin and Brooks in biology and physi-
ology, Rowland in physics, Remsen in chemistry, and Welch
in pathology, it was clear that capacity for personal research
and the power to stimulate others to engage in fruitful re-
searches were regarded, along with ability to teach and to<
organize, as essential requirements of the occupants of chairs
in the university. And, in the third place, the trustees of the
hospital, in consultation with the president of the university,
the professor of pathology, and Dtr. John S. Billings of the
surgeon-general's library, had planned and built (out of
income from the endowment), a hospital that, at the time of
its completion, offered better facilities for the organization
and conduct of clinical work than had heretofore been avail-
able in the IJnited States. The ideals cherished in the uni-
versity, the material equipment at the hospital, the oppor-
tunities and possible rewards open to the clinical leaders who
might be appointed, combined to provide unparalleled places
for occupancy. If, then, for these positions clinical men could
be found, who, by native ability and experience, would measure
up to the extraordinary time and the unusual opportunities,
success in the highest sense for the new institution would seem
to be ensured. The chair of medicine is, by common consent,
the most important clinical chair in a university medical
school. For this professorship the university faculty recom-
mended, and the trustees confirmed, the appointment of
Dr. William Osier, then engaged in teaching medicine in the
University of Pennsylvania and in consultation practice in
Philadelphia. A member of a distinguished Canadian family,
trained in medicine first in the University of Toronto and in
McGill University in Montreal, and, later, as a graduate stu-
dent, in the clinics and laboratories of England, France and
Germany, interested and occupied in research and teaching in
histology, physiology, pathology and parasitology as well as in



As Chief of a Medical Clinic 21

internal medicine, and possessing personal qualities that even
in youth marked him as a potential leader of men, the ap-
pointee entered upon his work with an enthusiasm that was
stimulating, began to organize his department, selecting a
group of young men as assistants, and soon set an example in
practice, teaching and investigation that was contagious. The
office and the man were suited to one another. The time, the
place, and the person formed a happy conjuncture that was to
mean much for internal medicine in America and in the world.
Of the set of brief contributions here published concerning
Professor Osier's work in Baltimore, those dealing with his
practice, his teaching, and his original inquiries are written
by others; the part assigned to me is the preparation of a
memorandum outlining the principles to which he, as the
organizer of a medical clinic, persistently adhered, and the
methods he employed in their practical application. He had
very definite ideas of what a medical clinic should be and he
felt keenly the responsibility of seeing to it that the functions
of the clinic were faithfully performed. For him, the welfare
of the patients who presented themselves in the clinic for
diagnosis and treatment came first ; next, came into considera-
tion how undergraduate and graduate students could best be
taught; and, finally, came solicitude that every opportunity
for contributing to the advance of our knowledge of internal
medicine should be eagerly seized. He took care to promote in
every way possible the material, the scientific, and the moral
interests of all who were associated with him in his work; his
personal advantage concerned him but little, though to anyone
who aimed at such objects and achieved such purposes as he
did, a modicum of profit and a maximum of honor and
prestige were bound to accrue. The principles he fixed upon
and the methods he used to illustrate them were manifoldly
derived. In part they grew out of personal practical experi-
ence, in part they had their origin in other clinics in this
country and in Europe. Men who were familiar with clinical
work and clinicians in the larger centers of America, those
who had " walked the hospitals " of London and Edinburgh,



22 SiE William Oslek, Baet.

those who knew the laboratories and the clinical institutes of
Austria, Germany and Holland, and those who had visited the
clinics conducted by the best internists in France, had no
difficulty in recognizing the sources of certain of the features
of the organization of the medical service in Baltimore. Pro-
fessor Osler^s clinic synthesized diverse elements into a har-
monious whole; it represented a new form, good in itself for
its time, and yet plastic enough to admit of remoulding at
later need. The limits of this article will permit of only brief
comment upon the plan of organization and upon the way it
was managed.

Where activities are complex, be they those of a factory, of a
business office, of a scientific laboratory, or of a medical or
surgical clinic, organization and management are two execu-
tive functions that must be properly exercised, if the work is to
be successful. Organization involves: (1) An investigation
of the conditions that exist and of the requirements of the
whole situation; (2) the planning of a scheme that will meet
the requirements, that will effectively and systematically cor-
relate the activities of the working force, the materials, the
equipment and the working space, so that the functions of the
institution shall be competently, speedily and economically
performed; and (3) the actual installation of the system as
planned. Management, or the art of conducting an establish-
ment after its organization has been devised and initiated,
involves : ( 1 ) The attainment of the results that are aimed at ;
(2) the overcoming of obstacles that are incident to the con-
ditions under which the work has to be done; and (3) the
application of knowledge and skill in the training of the staff,
in the setting up and in the maintaining of standards, in the
providing of suitable incentives, and in the establishing of
right relationships between the leader and the led. The head
of an institution, or of a department, who creates an organiza-
tion that is adequate, and who manages it with skill, demon-
strates his executive capacity.

On Professor Osier's appointment as physician-in-chief to
The Johns Hopkins Hospital in 1888, he found certain con-



As Chief of a Medical Clinic 23

ditions already existing that were to some extent determining,
at least as far as the general organization of the institution was
concerned. The buildings already completed included one for
general administration, with a building on each side of it for
private patients, a long row of public ward buildings behind, a
building for a general out-patient department, a nurses' home,
a pathological laboratory, a general kitchen and a laundry. In
other words, a " general hospital,'' in which medical and surgi-
cal patients (free and pay) were to be received, distributed and
treated, and in which, later on, medical students were to be
taught, had been constructed on the pavilion system. There
was no spatial concentration of the work of the single depart-
ments in separate institutes such as had already developed in
some of the European centers, or, as was later adopted in the
institutes built for psychiatry and pediatrics on the grounds
of The Johns Hopkins Hospital ; on the contrary, to pass from
some of his private patients in Ward B at the southwest corner
of the grounds to some of his public-ward patients at the
northeast corner, the internist and his staff were compelled to
walk through corridors that extended along two sides of a
square containing 14 acres ! As in most general hospitals, the
functions of general superintendency, financing, accounting,
nursing, purveying and housekeeping had been centralized,
and with them the heads of the clinical departments had but
little to do. But, thus relieved of much administrative detail,
the head of the medical department, who was appointed per-
manently and had a continuous service, was to have a large
degree of autonomy in the diagnosis and treatment of patients,
in the selection of his staff, in the character and amount of his
teaching, and in the conduct of research. His staff was to con-
sist (1) of younger men who lived in the hospital and gave
their whole time to the department, and (2) of senior asso-
ciates who lived outside, giving part of their time to the
hospital and part to private practice. The chief of the medical
service was to be paid a salary in order that he might make the
work of the hospital and of the medical school his main occu-
pation and interest, though he was permitted to supplement



24 Sir William Osler, Baet.

his income and clinical experience by private consultations.
The activities of the different clinical departments were to be
correlated partly by the general superintendent of the hospital,
and partly by a medical advisory board that made recommen-
dations to the trustees of the hospital. When Professor Osier
arrived, the buildings, and the general plan of organization
already completed, had to be accepted as they were ; the plans
of his department had to be drawn so as to fit into them.

It was fortunate that The Johns Hopkins Medical School
was not opened until 1893 and that clinical instruction of
undergraduates did not begin until 1895, for six years were
thus available for perfecting the organization of the wards, the
out-patient department, the laboratories, the staff, the records,
the library, the hospital, the medical society, and the care of
patients in the hospital before the function of teaching under-
graduates was added. Courses for post-graduate students
were, it is true, offered during this period, but the number of
candidates was small and the work was not burdensome. With
few patients at first, a small staff, and a limited amount of
post-graduate instruction, leisure was given for making plans
(and for modifying them after small-scale trials in executing
them), for instituting standards, for writing a text-book that
concisely embodied the principles and practice of medicine and
that was destined to have an unprecedented distribution among
physicians and students, and, in general, for establishing tra-
ditions of the better sort in the clinic. With the organization
thus far planned and installed before the students of the
medical school entered upon their clinical work, it was a
relatively easy matter to expand it and to adapt it to the func-
tions of undergraduate instruction when the time for this
arrived.

When the definitive history of Professor Osier's work in
Baltimore is written, many details of his analysis of the func-
tions of the clinic, of his applications of the principle of
division of labor in the cHnic, of his methods of selecting men,
of assigning them to appropriate tasks, and of motivating them
to high endeavor, and of the personal qualities through which



As Chief of a Medical Clinic 25

he exerted that profound and lasting influence upon patients,
students, assistants, and colleagues for which he is so widely
known, must be recorded. The scope of the present memo-
randum will permit mention of only a few of the more out-
standing features of his organization and management, of
those parts that made his clinic so successful a department of
a university teaching hospital as it is known to have been.

One important element of success in the new clinic was the
arrangement for a graded staff, particularly for a graded,
whole-time, resident staff, among the members of which the
responsibilities of the work were divided, not according to a
so-called " military type,'^ but rather in the manner of the
so-called " composite functional type " of organization. The
professor of medicine (physician-in-chief to the hospital),
though giving most of his time to the work of the clinic, lived
outside the hospital, as did the associate professors who
" visited ^^ the wards, the out-patient department, and the
laboratories. The resident physician, the assistant resident
physicians, and the medical internes lived in the hospital and
were in close contact with the work always by day and as far
as was necessary also by night. The resident staff of the clinic
consisted of two parts : (1) A lower resident staff constituted
by the medical internes appointed for a single year, usually on
graduation with high standing from the medical school; and
(2) an upper resident staff made up of the resident physician
and several assistant resident physicians, usually men of excep-
tional promise, men who had already served as hospital internes
and who were willing to enter upon a more or less prolonged
resident service, often of several years' duration, in order to
secure the best possible training for the " higher walks " of
internal medicine. This upper staff was chosen partly from
the lower staff, partly, in order to prevent " inbreeding/'
from members of the resident staffs of hospitals in distant
medical centers. The position of chief resident physician,
which carried with it large responsibilities and opportunities,
was a prize to be won only by men of exceptional ability, ex-
tensive experience, and favorable promise. Thus, those receiv-



26 Sm William Oslee, Baet.

ing it in Professor Osiers time, included Henry A. Laflenr
(1889-1891), William S. Thayer (1891-1898), Thomas B.
Fntcher (1898-1901), Thomas McCrae (1901-1904), and
Eufus I. Cole (1904-1906). The careers of these men during
their terms of service and since illustrate on the one hand the
wisdom of him who selected them, and on the other the growth-
promoting influence of the duties and authority attached to
the office. The assistant residents, even those who did not
later become chief resident physicians, often continued in office
for several years. Such an upper resident staff, supported by
internes and by senior students, besides forming a whole-time
group of enthusiastic young internists for development under
ideal conditions, afforded an excellent working force for carry-
ing on the routine of the wards, laboratories, and out-patient
department: this left the physician-in-chief and his visiting
associates largely free for planning, standardizing, supervising
and controlling the practice in the clinic, for teaching, and for
promoting original inquiries. The historian bent on analyzing
the conditions of achievement in Professor Osler^s clinic will
do well to consider carefully the significance of this upper
resident staff.

A second characteristic feature of the medical clinic organ-
ized by Professor Osier was the introduction of more extensive
and more systematic courses of instruction in the practical-
technical methods of gathering data regarding disturbances of
structure and function in the sick than had before been cus-
tomary. The importance of careful history-making and of
accurate physical diagnosis had been, it is true, generally
recognized ; but the machinery of instruction in these forms of
fact-accumulation had been inadequate in the majority of
medical clinics, and one of the first tasks of the new clinic con-
sisted in planning and installing a better organization for this
purpose, and in seeing to it that the example set by all who
participated in the practical work of diagnosis in the clinic
was consistent with the methodological teaching. The most
distinctive advance made in instruction in technique was,
however, the establishment of a systematic course in the appli-



As Chief of a Medical Clinic 27

cation of the laboratory methods of chemistryj physics, and
biology to the study of patients. Students in their third year
of the medical school were not only taught the principles of
these methods, but for two or three afternoons throughout the
year were thoroughly drilled in the practical technique of these
methods, so that, when the course had been completed, each
student had attained to real skill in the use of all the more
important ways of examining clinically the blood, the stomach
Juice, the feces, the urine, and the cerebrospinal fluid. No
medical school has yet devised a perfect system of training,
and the graduates of The Johns Hopkins Medical School,
like those of other schools, doubtless exhibit certain special
defects, but by common consent, they are well-trained in the
methods of gathering clinical facts and especially in the
technical procedures of the clinical laboratory. By many it is
believed that, of the several contributions made by Professor
Osier to the organization of the clinic, the development of the
clinical laboratory and of the thorough education of students
by competent instructors in clinical laboratory work before
entering upon their duties in the medical wards is pre-
ponderant.

A third distinctive mark of the organization in Dr. Osier's
clinic was the arrangement by which each student of the
medical school became for a considerable period a member of
the group that actually did the work of the diagnosis of disease
and of the treatment of patients in the hospital. Thus each
student in his third year, after having had instruction in
history-making and in the elements of physical diagnosis,
assisted, under the supervision and control of instructors, in
recording histories and in making physical examinations in
the out-patient department. More important still, through the
fourth year of the course, each third of the class acted suc-
cessively for three months as '^^ clinical clerks'' in the sta-
tionary medical clinic, giving their whole time to the work of
the medical wards. Thus the medical staff was reinforced
during the entire school year by 30 student assistants, who,
under the eye of the resident staff, took the histories of all new



28 Sir William Osler, Bart.

patientS;, assisted the internes in the making of the first
physical examinations, made all the clinical laboratory tests
on these patients, and accompanied their chief on morning
rounds. At these rounds, the clinical clerk gave orally an
epitome of the findings in the patient, watched the processes of
control examinations used by the professor, and participated
at the bedside in discussions of the pathological-physiological,
pathological-anatomical, and etiological bearings of the case.
He looked up recent articles on the subject and reported them
at later ward rounds, followed the patient to the operating
room if surgical procedure were indicated, watched the effects
of the treatment employed in the case of each patient directly
assigned to him, and kept in touch with him during conva-
lescence at his home after discharge from the hospital, or in
the event of a fatal issue attended the autopsy and the patho-
logical-clinical conference that followed it. The fact that
through all this he was regarded as an integral part of the
working group of the clinic, the knowledge that the anamneses
he registered and the results of laboratory tests he made be-
came a part of the permanent records of the hospital, the feel-
ing of responsibility he had when he realized that the diagnosis
made and the treatment instituted were based in part upon
data accumulated by liim, the personal relationships estab-
lished between student and professor at the hospital and on
delightful Saturday nights at the professor's home at 1 West
Franklin Street-вАФ all this combined to make the time of the
clinical clerkship in Professor Osler^'s clinic a period of rich
experience and of intense stimulation, never to be forgotten
by any pupil who passed through it. Even in the more formal
teaching of the clinic, it was Professor Osier's custom to permit
the clinical clerk to have a share. Thus, at the main teaching
event of the week, the crowded Saturday clinic in the amphi-
theater, where all the students of the third and fourth year,
the whole resident staff, many of the visiting physicians of the
hospital, physicians of the town and medical men from a dis-
tance were assembled, the clinical clerk gave a part of the
clinic; he was always asked to tell the audience briefly (and



As Chief of a Medical Clinic 29

from memor}^ unaided by notes) the main points of the
anamnesis of the patient and was called upon from time to


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Online LibraryMinnie Wright BloggSir William Osler, bart. Brief tributes to his personality, influence and public service → online text (page 2 of 14)