Sir William Osler, the Two Cultures, and the Learned Profession

Long, long ago, medicine was regarded as 1 of the 3 learned professions, the others being the law and the church. “They were called the ‘learned professions’,” wrote Kenneth Hudson in The Jargon of the Professions (1978), “because entry to them was restricted to men who had followed a course in the humanities and were accepted as scholars“ (p. 22).1Hudson K. The jargon of the professions. Macmillan, London1978Crossref Google Scholar When the first examination for the membership of the Royal College of Physicians of London was held in April 1859, the written papers included translation exercises in Latin, Greek, French, and German.2Fleming P.R. Manderson W.G. Matthews M.B. et al.Evolution of an examination: M.R.C.P. (U.K.).BMJ. 1974; 2: 99-107Crossref PubMed Scopus (20) Google Scholar According to the College, the languages “were included so candidates could demonstrate that they had a sufficient level of general education and culture, and thus could maintain the dignity and honour of the College.”3MRCP(UK)Development of the exams.https://www.mrcpuk.org/about-mrcpuk/historyDate accessed: August 30, 2023Google Scholar This part of the examination was eventually dropped in 1963. A few years ago, when I told candidates preparing for the membership of the Royal College of Physicians that the examination used to include languages, they looked at me in disbelief. Sir William Osler (1849–1919), with his orotund classical allusions, did more than any other figure to promote the ideal of medicine as a learned profession. (Osler, I find it necessary to add, was the most famous physician in the English-speaking world in the early 20th century.) He did not wear his learning lightly; his displays of erudition were, I suspect, intended to impress rather than inform. Even Michael Bliss, his otherwise sympathetic biographer, wrote of Osler: “In his early forties, the early Hopkins years, Osler broadens his reading, thinking and oratorical reach . . . His style becomes more self-consciously literary, not always to good effect. He indulges his lifelong penchant for quotation, simile and metaphor, burdening some of his reflections to the point where meaning becomes obscure and readers and listeners run away perplexed“ (p. 196).4Bliss M. William Osler: a life in medicine. Oxford University Press, New York1999Google Scholar Several of Osler’s public lectures were collected in a volume entitled Aequanamitas5Osler W. Aequanamitas: with other addresses to medical students, nurses and practitioners of medicine. H.K. Lewis & Co, London1904Google Scholar; they are as dull as ditchwater. A wearisome speaker though he may have been, Osler was much in demand for those prestigious, often eponymous, lectures instituted by the universities and the medical Royal colleges. On May 16, 1919, he gave the presidential address to the annual meeting of the Classical Association in Oxford. The presidency of the association is awarded every other year to distinguished nonclassicists; they have included TS Eliot and Stanley Baldwin. Osler was the first, and so far, only, medical doctor to be awarded this honor. A keen reader of the classics, he was nominated for the presidency by his friend Gilbert Murray, Regius Professor of Greek at Oxford. Osler had a particular interest in the medicine of ancient Greece; he had given a lecture to Murray’s students on “Lessons of Greek Medicine,” and while at Johns Hopkins, he had engaged in an amiable scholarly dispute with his fellow professor, the classicist Basil Gildersleeve.6Bryan C.S. Wise B.K. Briggs W.W. William Osler and Basil Gildersleeve on Plato’s Eryximachus.J Med Biog. 2003; 11: 35-40Crossref Scopus (1) Google Scholar (Their dispute concerned the merits or otherwise of the doctor Eryximachus, a character in Plato’s Symposium.) Osler chose as his theme, “The Old Humanities and the New Science.”7Osler W. The old humanities and the new science.BMJ. 1919; 2: 1-7Crossref PubMed Scopus (25) Google Scholar He picked his subject carefully. At the time, scientists had begun to challenge the preeminence of the classics in English public life and education; Greek and Latin, for example, were still compulsory for entrance to Oxford and Cambridge. Citing “such great medical humanists as Linacre and Caius and Rabelais,” Osler began by reminding his distinguished audience that Thomas Linacre, the founder of the Royal College of Physicians, had taught Greek at Oxford University. Medicine, which combined art and science, was, he argued, “the most progressive of the learned professions.” Osler pleaded for a reconciliation between the humanities and science: “the so-called Humanists have not enough Science, and Science sadly lacks the Humanities.” (This, incidentally, was 40 years before C. P. Snow coined the phrase “The Two Cultures” to describe the chasm between science and the humanities.) He warned that overspecialization was a great risk to science, that it needed the humanities—philosophy in particular—to give it guidance and perspective: “The salvation of science lies in a recognition of a new philosophy—the scientia scientiarum, of which Plato speaks.” It was Osler’s last public address; he died 7 months later. When Osler gave this address, the idea of the learned profession was an important pillar of the status of the English medical brahminate. These men (they were all men) held the presidencies of the Royal colleges, the Regius Chairs at Oxford and Cambridge, and the consulting posts at the great teaching hospitals. Many were Oxbridge graduates, the proud beneficiaries of a “liberal” education in the humanities. This scholarly refinement was critical in the formation of the “medical gentleman,” one who moved easily in the company of the rich, the cultured, and the titled. Outside this enclave, however, doctors were not quite so learned as Osler might have wished. In A. J. Cronin’s 1937 best-selling autobiographical novel, The Citadel,8Cronin A.J. The Citadel. Gollancz, London1937Google Scholar for example, the foot soldiers of general practice are portrayed as poorly trained, low brow, and low status. The situation was even worse in North America, where many doctors were barely literate, let alone learned, as the 1910 Flexner report on medical education documented.9Duffy T.P. The Flexner report—100 years later.Yale J Biol Med. 2011; 84: 269-276PubMed Google Scholar More than a century after Osler’s address, the hegemony exerted by the classics has collapsed, and medicine no longer even claims to be a learned profession. Entrants to medical schools in the United Kingdom and the United States are overwhelmingly those with a preference for science over the humanities. In England, for example, the school examination system forces students to specialize early—usually around the age of 16–when they commence A-level studies of generally only 3 subjects. Nearly all English medical schools require an A-level in chemistry, and many require biology as well, so most applicants are heavily science-focused. In the United States, only 3.7% of medical school entrants in 2020 took their primary degree in the humanities, with nearly two-thirds (60%) majoring in the biologic sciences.10Association of American Medical Colleges. AAMC medical school enrollment survey: 2020 results.https://www.aamc.org/media/9936/downloadDate accessed: August 30, 2023Google Scholar Some attempts have been made to instill a little learning back into medicine. The discipline of the medical humanities, for example, first took root in the 1970s with the Oslerian idea that the arts might enhance the personalities and broaden the outlook of medical students and doctors. The early pioneers threw a lot of stuff into that capacious hold-all, including history, literature, philosophy, and ethics. There was no set curriculum or examinations, and the doctors involved were amateurs, in the old, nonpejorative sense of the word. It is impossible to say if this orphan among medical school subjects achieved anything, other than giving the students a break from cramming facts. For several years, I taught medical students a module called “Literature and Medicine.” Once they had established that there would be no examination, most of my students lost interest; those who stayed were self-selecting. We happy few certainly enjoyed these tutorials, but as to whether it helped my students to become better doctors, I can only speculate. Teaching in the medical humanities now focuses overwhelmingly on 2 themes (neither of which are truly humanities): empathy and narrative medicine. Much has been written extolling empathy in health care, but it has a hollow, self-regarding, even consumerist quality. Meanwhile, the all-conquering narrative medicine is seen by some (including me11O’Mahony S. Against narrative medicine.Perspect Biol Med. 2013; 56: 611-619Crossref PubMed Scopus (16) Google Scholar) as a dressing up in fancy clothes of something good doctors have always done—that is, take a detailed history. Narrative medicine began with the worthy aim of bringing the attention of the doctor back to the patient, but as the moral philosopher Robin Downie wrote, “While this is admirable, it hardly warrants the extensive literature devoted to the analysis of the term ‘narrative’.”12Downie R. Medical humanities: some uses and problems.J R Coll Physicians Edinb. 2016; 46: 288-294Crossref Google Scholar Fifty years on, the medical humanities has become a recognized academic discipline. What began with the modest and laudable aim of softening the adamantine biomolecular and technologic culture of medicine with a little nuance and contemplation has been comprehensively annexed by academics with far loftier ambitions, such as the promotion of social justice. (It is one of the many ironies of the medical humanities that a century ago, the notion of a “liberal” education for doctors was driven by elitism, whereas this new discipline is obsessed with egalitarianism.) These scholars are overwhelmingly nonmedical, with backgrounds in literature, anthropology, sociology, history, philosophy, and the newer modish critical theories. They are interested primarily in research, not teaching. Their culture is arid and inward-looking; the only readers of the work they publish in their niche journals are other academics in the discipline. The unopposed annexation of the medical humanities by this academic cadre is symptomatic of the medical profession’s indifference to the humanities in general. The notion of medicine as a learned profession is an anachronism; it is hard to imagine any of Osler’s contemporary counterparts giving the presidential address to the Classical Association. (The current holder of the Regius Professorship of Medicine at Oxford, his fellow Canadian, Sir John Bell, is best known for his close links with the pharmaceutical industry and his championing of genomics and digital technology.) What was once a reflection of social status and professional pride is now a matter of personal taste, and a minority one at that. The medical profession is positively suspicious of intellectuals; a passion for running marathons is becoming in doctors, not so bookishness. The culture of the medical schools, the research centers, and the great teaching hospitals is philistine; this anti-intellectualism has, I believe, contributed to a uniformity of thought within the profession. The Newmanian liberal education, which encourages students to question, to think for themselves, is an antidote to such conformity, but as we have seen, very few medical school entrants have had the privilege of such an education. I am not suggesting that we resurrect Osler’s ideal of the learned profession. Although knowledge is never a burden, medical students and doctors don’t need to be classicists or polyglots. Nevertheless, hidden among the show-off quotations and ornate language, Osler’s 1919 lecture contains 2 valuable ideas: first, that medicine needs philosophy, and second, that the humanities could help to humanize medicine. Osler’s scientia scientiarum (or philosophy of science) might give students some insight into the limitations of the paradigm of medicine as an “applied science,” as opposed to a practical art. By “philosophy” I mean the word in its broadest sense—not the desiccated version now on life support in our universities. Most practicing doctors lack the skills to evaluate evidence; many (I would say most) doctor-researchers lack the modesty and doubt that are the hallmarks of the true scientist. A living, vigorous philosophy of science might instill in students a rational, scientific skepticism, the skills to critically appraise research and clinical guidelines, both vastly overproduced, banging loudly on our door, demanding our attention. This philosophy could be a broad tent, providing accommodation too for the sociology of health care; for a rational underpinning to medical ethics; for health economics. In short, this philosophy would give students the intellectual nourishment to sustain them over a career, which, given current demographic trends, might last 50 years or more. Regrettably, there is little appetite among medical educators for such a philosophy. A module on the history of research in the last century, for example, might lead to the contemporary replication crisis in biomedical science, academic medicine’s unhealthy relationship with the pharmaceutical industry, the baleful state of medical publishing, and the hijacking by commercial interests of evidence-based medicine and clinical guidelines. With some notable exceptions (such as the Stanford-based meta-researcher John Ioannidis), medical academics are not especially keen on teaching their students about the grave systemic problems afflicting their own discipline. Medical schools and their research faculties, now so keen on commercial partnerships, are loath to alienate these partners. They see their role as training, not education; they are not in the business of producing skeptics. The new discipline of the medical humanities might have offered a more person-centered approach to medical education and practice, but when it disappeared down an academic cul de sac, a great opportunity was lost. By the “humanities” I do not mean the high-falutin notions of Osler; I most certainly do not mean narrative medicine or empathy. In the medical context, the word “humanities” means a recognition that doctors deal with people, not genomes, or bundles of diagnoses. Death (to take an example close to my heart) is still given scant attention in the medical schools; an early engagement with the inevitable might humanize doctors and dampen biomolecular triumphalism. So too, an exposure to serious, intellectually coherent sociologic critiques of medicine (such as those of Ivan Illich, Thomas McKeown, and Petr Skrabanek) might give students hinterland and perspective. An engagement with these humanities would encourage some humility, an acceptance that medicine’s dominion is limited, that doctors don’t have the answer to all the problems laid at their feet. I suspect my attention might have wandered had I attended one of Osler’s lectures; he was nevertheless a great man. It was he who almost single-handedly dragged clinical teaching out of the lecture hall to the bedside; it was he who established the model for residency training still used today. Sunny of disposition and relentlessly optimistic, Osler didn’t have a mean bone in his body. He saw medicine as a brotherhood and fostered collegiality and professionalism. A generalist who focused his efforts on teaching and the clinical encounter, producing little in the way of original experimental research, he would not today achieve such a preeminent position within the profession. More’s the pity: Our burnt-out, cynical, demoralized, and exhausted profession could do with leaders like Osler.

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