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Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990.

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Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.

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The General Examination

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Osler and the Case Study

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William Osler, author of the first modern textbook of medicine in 1892, was responsible for the modern emphasis of learning medicine at the bedside. Osler placed the student at the bedside and kept him on the wards. His instructions were to learn by studying the individual patient, advocating what he called the natural method of teaching, in which the student "begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end."

Born in Canada in 1849, Osler graduated in medicine from McGill University in 1872 at age 23 and went abroad for 2 years. In London, he made original observations on blood platelets; in Berlin, he attended Virchow's autopsies; and in Vienna, he studied under Rokitansky. Osler returned to Montreal in 1874 at age 25 and joined the faculty of McGill University in Toronto, where he remained for 10 years. His work in this decade was primarily in pathology. He performed 786 autopsies as pathologist of the Montreal General Hospital, about 100 cases a year for 8 years. In 1884, at age 35, Osler accepted the Chair of Clinical Medicine at the University of Pennsylvania where he remained for 5 years, shifting his emphasis to the ward. He moved to Baltimore in 1889 at age 39 to accept the Chair of Medicine at the Johns Hopkins Hospital, and within a year began work on his textbook.

The remarkable feature of The Principles and Practice of Medicine (Osler, 1892) is that he is its sole author and that it is based largely on his own clinical and morphologic observations. The two works cited more than any other book are the Montreal General Hospital Pathological Reports and the Bible, to which there are many allusions. In 1905 Osler left America to begin work as Regius Professor of Medicine at Oxford University, England. A year after the death of his only son in World War I, Osler died in 1919.

His own writings demonstrate the importance he placed on study of the single patient. Before his textbook appeared in 1892, Osler had already published over 200 brief reports of single clinical or necropsy cases. He believed that in each patient, "there is something to be found out; and in each case, however trivial, there is something novel." Osler recognized that theoretical teaching in medicine is inadequate, that the student must learn at the bedside.

It is not hard, for example, to teach him all about the disease pneumonia, how it prevails in the winter and spring, how fatal it always has been, all about the germ, all about the change which the disease causes in the lungs and in the heart—he may become learned, deeply learned on the subject—but put him beside a case, and, he may not know which lung is involved, as he does not know how to find out, and if he did find out, he might be in doubt whether to put an ice bag or a poultice on the affected side, whether to bleed or to give opium, whether to give a dose of medicine every hour or none at all, and he may not have the faintest notion whether the signs look ominous or favourable.He does not see the pneumonia case in the amphitheater from the benches, but he follows it day by day, hour by hour; he has his time arranged that he can follow it; he sees and studies similar cases, and the disease itself becomes his chief teacher, and he knows its phases and variations as depicted in the living; he learns under skilled direction when to act and when to refrain; he learns insensibly principles of medicine, and he possibly escapes a nickle-in-the-slot attitude of mind, which has been the curse of the physician in the treatment of disease. (Osler, 1985)

Osler believed that the art of medicine was observation and that it is an art difficult to acquire. He wrote:

Let not your conceptions of the manifestations of disease come from words heard in the lecture room or read from the book. See, and then reason and compare and control. But first see. No two eyes see the same thing. No two mirrors give forth the same reflection. Let the ward be your slave and not your master. Live in the ward. (Osler, 1985)

Osler emphasized that the quality of observation is not always proportionate to the quantity of cases observed, that acquisition of experience and knowledge is not dependent on a large hospital and a large number of cases. He stressed the study of single patients.

Each case has its lesson—a lesson that may be but is not always, learnt, for clinical wisdom is not the equivalent of experience. A man who may have seen 500 cases of pneumonia may not have the understanding of the disease which comes with an intelligent study of a score of cases, so different are knowledge and wisdom, which, as the poet truly says, "far from being one, have ofttimes no connexion." (Osler, 1985)

References

  1. Osler W. The principles and practice of medicine. New York: D. Appleton, 1892.
  2. Osler W. Counsels and ideas and selected aphorisms. Birmingham: Classics of Medicine Library, 1985.
Copyright © 1990, Butterworth Publishers, a division of Reed Publishing.
Bookshelf ID: NBK453PMID: 21250273
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