Physician behavior and bedside manners: the influence of William Osler and The Johns Hopkins School of Medicine.The practice of medicine changes with time as we develop better techniques for diagnosis and improved therapies for treatment. The art of medicine remains constant over the millennia because human nature is unchanging. Patients bring fear, anxiety, and self-pity into the exam room. It has always been the doctor's responsibility to calm their fears and provide hope. The accomplished doctor has a bedside manner that is humane and compassionate, empathetic and supportive.
Students are taught bedside skills, the art of medicine, by our senior, most experienced clinicians. However, in the past 20 years, more of these professors are laboratory scientists, often deficient or unpracticed in their bedside skills. Bernard Lown, the famous Boston cardiologist, wrote in 1996 in his book The Lost Art of Healing (1) how essential bedside behavior is to good medical care. He expressed his concern that important bedside skills are disappearing in our technology-focused practice of medicine.
Several medical schools have recommended a new emphasis on improving professionalism. Jock Murray, former dean of the Dalhousie Medical School, speaking to the American College of Physicians in 2006, commented on the general erosion of professionalism and a growing public cynicism about the profession. He called for a new focus on the three core principles of professionalism: competency, the primacy of patient welfare, and social justice. Professionalism is not an attempt to protect physicians' power and status, he noted, but a call to practice medicine in patients' best interests (2).
No physician has exerted a greater influence on how physicians should behave than Sir William Osler. His essays on the practice of medicine, his leadership in medical organizations, and his personal charisma established a paradigm that has served as a model for physician behavior at the bedside. His textbook of medicine, The Principles and Practice of Medicine, first published in 1892 (3), was the bible of rational medical therapy for 30 years. He was the first chief of medicine at the Johns Hopkins Hospital and Medical School, and his leadership at Johns Hopkins transformed American medical care. He led the effort to bring a scientific approach to the care of the patient. Osler famously said, "The practice of medicine is an art based on science" (4) (Figure).
Osler was a unique personality and practiced at a propitious time in medicine. At the end of the 19th century and the beginning of the 20th century, medicine was evolving from a practice based on superstition and tradition into a rational biological science. His bedside manners were based on Victorian morals and their notion of the duties of a gentleman. But like the technophobe and iPad enthusiast of today, he eagerly embraced scientific medicine as the new hope for tomorrow. How did William Osler and the Johns Hopkins Medical School influence our current bedside behavior?
HIPPOCRATIC THOUGHT ON BEDSIDE MANNER
We begin with the Greeks in the 4th century bc, as does almost everything in Western culture. The Greeks were very specific about physician bedside manners. Included in the Hippocratic corpus is this comment:
The physician ought also to be confidential, very chaste, sober, not a winebibber, and he ought to be fastidious in everything, for this is what the profession demands. He ought to have an appearance and approach that is distinguished. Everything ought to be in moderation, for these things are advantageous, so it is said. Be solicitous in your approach to the patient, not with head thrown back (arrogantly) or hesitantly with lowered glance, but with head inclined slightly as the art demands. He ought to hold his head humbly and evenly; his hair should not be too much smoothed down, nor his beard curled like that of a degenerate youth. Gravity signifies breadth of experience. He should approach the patient with moderate steps, not noisily, gazing calmly at the sick bed. He should endure peacefully the insults of the patients since those suffering from melancholic or frenetic ailments are likely to hurl evil words at physicians (5).
Physicians' manners, dress, bearing, deportment, and conduct were vital and necessary elements of patient care, a tradition that extended from the earliest shamans to the emergence of scientific medicine. The Hippocratic corpus has many references to appropriate conduct and medical etiquette, with several devoted just to physician behavior. The importance of bedside manners was taught by medical scholars for 1500 years, from Hippocrates and Galen to Avicenna and the early Christian monks who began hospital care in the Middle Ages.
MODERN CHANGES AND THE REDEVELOPMENT OF PROFESSIONALISM
In the 17th century, medical practice changed with competition between physicians, surgeons, and apothecaries and the growth of new institutions including infirmaries, clinics, and hospitals. The professional institutions were unconcerned with moral matters, and legal regulation of medical practice was nonexistent. Only personal character served as a guarantor of a physician's conduct. In the 18th century, when civility had fallen to a low point in England, John Gregory reintroduced appropriate physician behavior into the curriculum at Edinburgh.
In 1769, John Gregory of Edinburgh, a friend of David Hume and a member of the Scottish Enlightenment, was teaching that duty and benevolence were the duties of the physician (6). The physician was an educated, superior individual obligated to serve his fellow man. In 1789, conflict broke out at the Manchester Infirmary over medical staff privileges and care for the poor during a typhus epidemic. Thomas Percival, a pupil of John Gregory, was asked by the board of trustees to mediate. In response to this conflict, he wrote Medical Ethics (7). His book was a set of rules on how physicians should behave with patients and their colleagues and is considered the beginning of modern medical ethics. The book is much more a manual of etiquette than a code of ethics.
In America, the American Medical Association (AMA) was founded in response to a crisis over professionalism and professional standards. This crisis was the result of a change in the method of training physicians. The traditional apprentice system for training doctors was displaced when in 1803 Harvard College granted an MD degree. This diploma was soon recognized in Massachusetts as the qualification to practice medicine. In a very short time, there were 40 diploma schools with >1000 graduates a year, and the diploma quickly became the preferred method to qualify as a medical practitioner. The schools had no standard curriculum, and the training was deficient with didactic lectures and little opportunity for the students to participate in patient care (8). The curriculum was completed in just 16 weeks a year with courses repeated over a 3-year program. The early 19th century American attitude of Jacksonian antielitism resulted in the repeal of all medical licensure requirements in every state of the union. There were no requirements to qualify for the practice of medicine, and a rapid decline in the quality of American medical education and the American practitioner followed.
In response to this deterioration of medical practice, Nathan Smith Davis organized in 1846 a convention to establish a national medical organization to improve medical education. This response to the gross unprofessionalism in American medicine was the beginning of the AMA. Isaac Hayes recommended a second convention to meet the following year in Philadelphia to develop excellence in medical training and establish a code of ethics. This convention was successful in adopting a code of ethics modeled on Thomas Percival's Medical Ethics and the writings of the American physician, medical educator, and founding father, Benjamin Rush (9). It became the first official code of ethics for any professional organization. Reform in medical education itself would have to wait for the Flexner Report in 1910.
Before the Civil War, there were many types of medical care in America. These included homeopathy, hydropathy, electric medicine, and botanical healing. The AMA Code of Ethics was meant to exclude practitioners who did not have formal training in a recognized scientific school of medicine. The AMA hoped that by restricting ethical consultation to those trained at scientific-based medical schools, the code would become a weapon to drive the irregular practitioners (homeopaths) out of business. Homeopathy was popular in America, and the homeopaths frequently referred their patients to university physicians. They were an important source of income for many of the academic centers. In a very short period of time, there developed a conflict between practicing physicians and academic physicians over the clause in the code that restricted referrals from homeopathic physicians to members of the AMA (8).
In 1895, the University of Michigan had both a school of medicine and a school of homeopathy. Victor Vaughn, the dean, wanted to merge the schools to save money. In anticipation of objections, Vaughn wrote prominent physicians around the country to solicit their opinions. William Osler responded: "I concur in the suggestion. It is high time that the profession and the public were made aware of the fact that any system of therapeutics does not embrace the whole scope of medicine and surgery. After all, the differences which, in matter of treatment, separate members of the rational school are not greater than those which separate some of us from our homeopathic brethren" (10). Osler expanded on this egalitarian attitude in his 1902 essay "Chauvinism in Medicine" (11). He stated that medicine is progressive because of its scientific basis and its eagerness for improvements. Medical practice is based on four principles: emancipation from priest craft, science, the Hippocratic oath, and the behavior of a gentleman.
Osler was leading a crusade to establish a scientific approach to patient care. It was the beginning of our current evidence-based medicine. If his recognition of the importance of science in medicine was visionary, his attitudes concerning physician behavior were deeply rooted in 19th century Victorian attitudes. If Thomas Percival and the AMA introduced ethics, decorum, and etiquette to American medicine, William Osler and the Johns Hopkins School of Medicine established scientific medicine in this country. When Johns Hopkins was founded, the English philosopher Thomas Henry Huxley gave the principal address on medical education, stressing that medicine was a branch of experimental physiology. Huxley made no reference to morals, religion, or ethical behavior, a deletion that was commented on in the Baltimore papers (12). Johns Hopkins was to shape a new conception of professional competence based on science.
OSLER'S AND CURRENT VIEWS OF PHYSICIAN BEHAVIOR
At the bedside, Osler's attitude was one of noblesse oblige. In his biography of William Osler, Michael Bliss (12) related that Osler was described by his colleague, "Everyone loved the Chief. He was so warm, so friendly, so happy and charming, so funny, so interesting and interested that he enchanted everyone, from patients to his most senior colleagues." But what was the bedside manner of this charming, compassionate, charismatic medical scientist? Bliss reported that he spent only a short time with private patients, coming in and out of the room quickly. While walking on the wards, he sometimes stopped to grasp the toes of a patient. Ward visits were an unusual combination of informality and dignity. The students imitated every Osler gesture: his walk, his expression, and his accents.
Until the 19th century, it was the character and behavior of the physician that convinced patients to have confidence in his advice. Osler and Hopkins changed that; good science became the preeminent requirement. Although he stressed good behavior, he accepted as a given that physicians fit the mold of a Victorian gentlemen. Our concepts of a gentleman have changed with our culture. In Shakespeare's time, a gentleman was a member of the aristocracy, but Osler's gentleman was the Victorian man of breeding and education, which placed the physician on an elevated pedestal of superior rank. Today, I think it would be difficult to define Sir William Osler's physician gentleman. If art reflects reality, we have progressed from the kindly, compassionate Dr. Marcus Welby of the 1970s TV series to the arrogant, self-absorbed, rude, and even hostile Dr. Gregory House of the current TV series House. This is an individual who places science above any consideration of compassion and empathy.
Abraham Verghese, one of those senior medical professors who has been concerned about a loss of the art of medicine, addressed the importance of bedside manners in a scene from his book, Cutting for Stone (13). A case was presented at grand rounds where a young man died with a critical emergency. After the housestaff presentation of the case, the surgical professor at the Boston Mecca Hospital stood to read a letter he had received from the patient's mother. The mother wrote that when her son's condition became critical, she was quickly escorted from the room. As she left, she noted how anxious and afraid her son appeared. She described the doctor's lone concern as preparing the patient for surgery; only a nurse held the patient's hand and provided comfort. The professor asked the students and residents what should be the most important responsibility of the surgeon in this situation. No one had an answer except the book's hero, who had read the professor's textbook. He responded that the surgeon should whisper words of comfort into the patient's ear. The story is noteworthy because Verghese recognized that the humanity of the patient is often forgotten and only his disease is considered. It is also incredible that I cannot remember in the past 30 years when the feelings of a patient or the family were seriously discussed at a medical conference.
Another example deserves mention, the movie 50/50 (14). This is a true story written by a Will Reiser, a cancer survivor. After completing Will's evaluation, the oncologist sat down with him to describe his computed tomography scan. The physician started by describing a large tumor on his spine without first preparing him for this devastating diagnosis. Later when Will underwent a complex surgical procedure, the surgeon met the family postoperatively and began with a discussion of the surgical problems she faced before letting the family know that Will was doing well and had a good outcome.
Atul Gawande, an observer of medical behavior and practice, commented:
It is unsettling how little it takes to defeat success in medicine. You come as a professional equipped with expertise and technology. You do not imagine that a mere matter of etiquette could foil you. But the social dimension turns out to be as essential as the scientific matter of how casual you should be, how formal, how reticent, how forthright. Also how apologetic, how self confident, how money minded. In this work against sickness, we begin not with genetic or cellular interactions but with human ones (15).
Osler was the prophet and communicator who brought the importance of scientific medicine to the practicing physician. But his was a generation of noblesse oblige, a generation where it was expected that honorable and generous behavior was the characteristic of rank and education. By not encouraging the teaching of the art of medicine, and by not including a guide to physician behavior in his textbook, he contributed to the slide down that slippery slope of professional behavior to misconduct, offense, and occasional outrage.
(1.) Lown B. The Lost Art of Healing. New York: Ballantine Books, 1996.
(2.) Murray TJ. From 'Marcus Welby' to 'ER': is medicine losing professionalism? [Keynote presentation at the meeting of the American College of Physicians, 2006]. ACP Observer, June 2006.
(3.) Osler W. Principles and Practice of Medicine. New York: Appleton, 1892.
(4.) Silverman M, Murray TJ, Bryan C. The Quotable Osler. Philadelphia: American College of Physicians, 2003.
(5.) Anonymous admonitions of Hippocrates of learning the history of medicine. In Carmichael AG, Ratzan RM, eds. Medicine: A Treasury of Artand Literature. New York: Hugh Lauter Levin Associates, 1991:53-54.
(6.) Maio G. Is etiquette relevant to medical ethics? Ethics and aesthetics in the works of John Gregory (1724-1773). Med Health Care Philos 1999;2(2): 181-187.
(7.) Percival T. Medical Ethics or a Code of Institutes and Precepts Adapted to the Professional Conduct of Physicians and Surgeons. Manchester, England, 1803.
(8.) Baker RB, Caplan AL, Emanuel LL, Latham SR. The American Medical Ethics Revolution--How the AMAys Code of Ethics Has Transformed Physicians' Relationships to Patients, Professionals, and Society. Baltimore, MD: The Johns Hopkins University Press, 1999.
(9.) American Medical Association. Original Code of Medical Ethics of the American Medical Association 1847. Chicago, IL: American Medical Association Press.
(10.) Osler W. Letter from the historical archives of the University of Michigan.
(11.) Hinohara S, Niki H. Osler's A Way of Life and Other Addresses with Commentary and Annotations. Durham, NC: Duke University Press, 2001.
(12.) Bliss M. William Osler: A Life in Medicine. Oxford: Oxford University Press, 1999.
(13.) Verghese A. Cutting for Stone. New York: Alfred A. Knopf, 2009.
(14.) Reiser M; Levine J, director. 50/50 [movie]. Santa Barbara, CA: Mandate Pictures, 2011.
(15.) Gawande A. Better: A Surgeon's Notes on Performance. New York: Metropolitan Books, 2007:81-82.
Barry D. Silverman, MD
From Piedmont Hospital, Atlanta, Georgia.
Presented at the meeting of the American Osler Society, Boston, Massachusetts, May 2008.
Corresponding author: Barry D. Silverman, MD, Mark Silverman Chair of Education, Piedmont Heart Institute, 275 Collier Road, Atlanta, Georgia 30309 (e-mail: firstname.lastname@example.org).