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The Hospital as College

From: The Hospitalist, May 2007

Reflections on William Osler and education in the hospital

by James S. Newman, MD

James S. Newman, MD

The hospital is the only proper college in which to rear a true disciple of Aesculapius.—John Abernethy (1764-1831), surgeon and teacher

With this quote Sir William Osler began his address, “The Hospital as a College?” to the Academy of Medicine in New York in 1903. His second quote for this report was from the famed physician Oliver Wendell Holmes Sr. in 1867:

“The most essential part of a student’s instruction is obtained, as I believe, not in the lecture room, but at the bedside. Nothing seen there is lost: the rhythms of disease are learned by frequent repetition: its unforeseen occurrence stamp themselves indelibly on the memory. Before the student is aware of what he had acquired he has learned the aspects and causes and probable issue of the disease he has seen with his teacher and the proper mode of dealing with them, as far as his master knows.”

Much of what was written is still true: Whether in a teaching institution or making “lonely rounds” we must strive to continue to educate ourselves, our colleagues, and our patients. And what better place to do it than the hospital?

In his report Osler was celebrating a quarter century’s success in education. He demanded a better general education for students, a lengthened period for professional study, and the substitution of theoretical by practical learning. He wanted the student not to learn only from dissecting the sympathetic nervous system but to learn to “take a blood pressure observation” with a kymograph (an instrument used to record the temporal variations of any physiological or muscular process; it consists essentially of a revolving drum, bearing a record sheet on which a stylus travels).

Osler observed that there should be no teaching without a patient for a text: “The whole of medicine is in observation” that the teacher’s art is educating the student’s finger to feel and eyes to see. Give the student good methods and a proper point of view, and experience will do the rest.

A kymograph, which was once used to record the temporal variations of a physiological or muscular process.
A kymograph, which was once used to record the temporal variations of a physiological or muscular process.

Osler expressed confidence that students would keep the hospital physician from slovenliness and improve the care of patients. He was also concerned that “we ask too much of the resident physicians, whose number has not increased in proportion to the enormous amount of work thrust upon them.” Students were the answer, the proto-scut-monkey.

The practicality of working out of a teaching hospital was outlined at length in Osler’s report. The student’s third year should begin with a systematic physical diagnosis course, first in history taking, then in writing reports. Concurrently, a physical examination course should be given several days a week with individual cases assigned to students to follow, and instruction is accessing the literature. Next comes clinical microscopy—an essential in an era where there was often no lab to call upon. In general, medical clinic occurs one day a week when interesting cases are brought from the wards. Of note, committees were appointed to report on every case of pneumonia.

In revamping medical education Osler brought the third-year students to the outpatient clinic and the fourth-year students to the wards. What implication does this have for us as hospitalists?

I have no pretensions about being another Osler (I am barely a Newman on my best days), but still my colleagues and I trudge along in our teaching duties. What education do we really do? I sat down after reading Osler’s paper, stimulated by a tangential question from the esteemed Tom Baudenistel, MD, and decided to see exactly whom we were teaching.

First there are medical students. We are faculty on their first-year selectives, offering a shadow experience. We staff the introduction to physical exam courses in second year. Third-year students rotate on our services, and seniors take our elective as well as taking acting internships on our teaching services. We act as mentors and interest group leaders. There is certainly more to this list. We also spend time teaching NP and PA students.

The internal medicine residents rotate on our hospitalist services, and we staff the general medical services. We interact with them daily when they are on consult services, trying to set a role model. General medicine, geriatric, and hospital medicine fellows rotate through as well.

We also teach the nurses on services and through in-services and daily rounds to cement the working relationship and improve communication. We teach each other. A day rarely goes by without a colleague passing on a tasty medical tidbit. (Of course, for me, a tabla blanca, no shortage of space for pearls). And finally we teach our patients and their families. Every day we do this, and if we don’t then we are missing the point of our profession entirely.

Each party—patient or student—has something to learn from us, but more importantly we have something to learn from them. Osler wrote that “The stimulus of their presence (the student) neutralizes the clinical apathy certain, sooner or later, to beset the man who makes lonely “rounds” with his house physician.”

One hundred years plus later, much of what was written is still true: Whether in a teaching institution or making “lonely rounds” we must strive to continue to educate ourselves, our colleagues, and our patients. And what better place to do it than the hospital? TH

Dr. Newman is the physician editor of The Hospitalist. He’s also consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Bibliography

Osler W (Sir) Aequanimitas. 1945. The Blakiston Company, Philadelphia. p. 311-327.


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