To see for oneself: Sir William Osler on autopsies, medical education, and economics.

As I was recently reminded by our colleague, Dr. John Fordtran, the term “autopsy” literally means “to see for oneself” from the Ancient Greek autos (oneself) and opsis (to view). Many pioneers in internal medicine, such as Sir William Osler, performed autopsies because they were anxious to see for themselves the internal derangements that might explain their patients' symptoms and death. One of Osler's mentors, James Bovell, stressed that books were very good, but doctors learned medicine by direct observation. Bovell had marked for him a passage from Latham's Clinical Medicine: “It is by your own eyes, and your ears, and your own minds and your own hearts that you must observe and learn and profit” (1). In this spirit of direct observation, Osler repeatedly stressed the importance of bedside teaching and, when treatment failed, careful follow-up postmortem study. William Osler entered the practice of medicine because of a fascination with the natural history of disease and morbid anatomy, but he also clearly believed that medicine was fun (2). Osler performed many autopsies, and while at McGill, he decided to write his thesis on postmortem studies of diseased organs. He pestered another mentor, Palmer Howard, for information and literature, and one day Howard gave him Samuel Wilk's Lectures on Morbid Anatomy. “From that time on,” Osler recalled, “everything was plain sailing” (1). Osler's thesis included the inspiring statement, To investigate the causes of death, to examine carefully the condition of organs, after such changes have gone on in them as to render existence impossible, and to apply such knowledge to the prevention and treatment of disease is one of the highest objects of the physician (1, 2). In his first monograph Osler also quoted Wilks, “Pathology is the basis of all true instruction in Practical Medicine” (3). By all accounts, Osler quickly became one of McGill's most popular professors, and it was his special classes in pathology and histology that students found mesmerizing. It was also known that large consultation fees might not entice him out of town to see a patient, but he would always come for an interesting autopsy. Osler thus became a great morbid anatomist, and his ‘clinics’ in the autopsy room were, if anything, more interesting that those by the bedside (3). Osler also stated, “No more instructive work is possible than carefully demonstrated specimens illustrating disturbance of function and explanatory of the clinical symptoms” (3), and such instruction remains a primary goal of our current morbidity and mortality conferences at Baylor University Medical Center at Dallas. Some have also opined that these clinical-pathologic conferences have brought us all back together in an exciting and collegial atmosphere of learning. Many believe that the study of morphology was the gateway through which Osler attained those high achievements in clinical teaching and practice (3). Unfortunately, however, current trends in medical education jeopardize the use of anatomic pathology in teaching clinical medicine. Today's avalanche of molecular discoveries are crowding the medical curriculum to the point that hard choices have to be made, and traditional anatomic pathology is one of the first things to go. Again we turn to the writings of Osler himself, which carry a timely message: The new pathology, so fascinating and so time-consuming, tends, I fear, to grow away from the old morbid anatomy which was of incalculable advantage to the physician, and it is hard to have the student see enough morbid anatomy which has such an important bearing upon the mental attitude of the growing doctor. It is a subject which one must learn in the medical school, but the time assigned is rarely sufficient to give the student a proper grasp of the subject (4). Osler's “new pathology” primarily referred to discoveries in bacteriology, but today's genomics are also displacing traditional anatomic pathology. Molecular studies, however, cannot replace the teaching value derived from a comparison of anatomic findings and symptoms in order to improve a clinician's acumen. A patient is not simply an amorphous bag of molecules. In addition, many medical schools have eliminated the traditional course in anatomic pathology in favor of focused case-based studies. One effect is that fewer medical students develop a passion for the science of pathology, and currently there are fewer applicants for pathology residencies. Combined with the trend away from autopsy pathology by many practicing pathologists, the result is that fewer clinicians currently have an opportunity to see for themselves what caused their patients' symptoms and death. As I reviewed Osler's biographies and speeches for this editorial I found myself, once again, becoming inspired and enthusiastic about the practice of pathology in particular and medicine in general. The timeliness of many of his statements is eerie, particularly regarding medical economics and the philosophy of medical practice, and, sadly, today's medical students and residents can barely identify Osler (2). In today's world of rapidly advancing molecular discoveries, dwindling financial resources, and heated arguments over medical economics, it is easy to lose sight of the higher principles which led most of us to choose medicine as a career in the first place, and more and more physicians are leaving medicine rather than face this maelstrom. Some of us, however, are finding guidance and a renewed passion for medicine in the words of Sir William Osler, whose courageous and optimistic message remains relevant and continues to instruct and inspire. Osler stated that we should live our lives in “day-tight compartments,” not worrying about past mistakes or future problems, but addressing the work that is directly in front of us. He often quoted Thomas Carlyle, “Your business is not to see what lies dimly at a distance, but to do what lies clearly at hand.” In my opinion, today's preoccupation with economic issues threatens to obscure the altruistic goals of medicine: to relieve suffering and to promote healing. Although we must be good stewards of our limited financial assets, Osler cautioned against what he called the “corroding influence of mammon,” and he had the greatest contempt for the doctor who made financial gain the first object of his work. “Our best protections are high standards and high purpose.” Osler also believed that the hospital would continue to be necessary within every community: What wonder that many fall by the way and need a shelter in which to recruit or to die, a hospital in which there shall be no harsh comments on conduct, but only, so far as is possible, love and peace and rest. Here, we learn to scan gently our brother man, judging not, asking no questions, but meting out to all alike a hospitality worthy of the House of God (Hotel Dieu), and deeming ourselves honored in being allowed to act as its dispensers. Of medicine, Osler warned: “The ancients attempted to make it a science and failed, the moderns, to make it a trade and succeeded.” He went on to add, Engrossed late and soon in professional cares, getting and spending, you may so lay waste your powers that you find, too late, with hearts given away, that there is no place in your habit-stricken souls for those gentler influences which make life worth living. He further warned: “If your hearts desires are for riches, they may be yours; but you will have bartered away the birthright of a noble heritage and falsified the best traditions of an ancient and Honourable Guild.” Today, as we struggle to find our way, the writings of Sir William Osler remain a resource for guidance, inspiration, and renewed commitment to our profession. I believe that through his writings a sense of higher purpose, and yes, fun, can still be found in the practice of medicine.