From the Department of Medicine, University of South Carolina School of Medicine, Columbia, South Carolina.

Presented at grand rounds, Baylor University Medical Center, November 17, 1998.

Corresponding author: Charles S. Bryan, MD, Department of Medicine, University of South Carolina School of Medicine, 2 Medical Park, Suite 502, Columbia, South Carolina 29203 (cbryan@richmed.medpark.sc.edu).

I want to talk about the issue of caring and competence. What is the role of the physician in caring for patients today? But first I briefly review the life of Sir William Osler. Frequently I ask medical students who he was and they say, “He was the father of internal medicine” or “He was the father of medicine.” They have no idea.

OSLER'S LIFE

Sir William Osler (1849–1919) was a Canadian, born in a small town near the wilderness (Figure 1). As the eighth child of a clergyman, he considered going into the ministry himself. Figure 2 shows Osler as a child, and Figure 3 shows him as a young man. Osler got his medical degree at McGill University in Montreal. Afterwards, he traveled in Europe for a couple of years and studied with several great physicians of that era. He then returned to McGill, where he rapidly rose in the academic ranks. In Montreal, he did approximately 1000 autopsies, eschewing the private practice of medicine, and became one of the bright young lights of Canadian medicine, attracting some worldwide attention.

In 1884, Osler was offered the chair of medicine at the University of Pennsylvania (Figure 4)and succeeded William Pepper. There was some controversy as to why this relatively unknown, swarthy young Canadian was given what was probably the most prestigious position in American medicine at the time. He impressed people in Philadelphia as well and in 1888 was offered the first chair of medicine at Johns Hopkins, a new medical school with ample funding in a university that was the first in the country to emphasize graduate medical education. He saw the chance to build a clinic along German lines, as he would do, unfettered by past tradition.

Figure 5 is the enormous 1905 painting The Four Doctors by John Singer Sargent, which hangs in the Welch Library Building at Johns Hopkins. In it are the pathologist William Henry Welch, the great surgeon William Stewart Halsted, Osler, and the gynecologist Howard A. Kelly. The story goes that Halsted, who was a difficult man and somewhat cynical, sort of infuriated Sargent, who in response painted Halsted's portrait with pigments that are supposed to fade with time so that eventually Halsted would no longer be in this picture.

On my bookshelf in Columbia, I keep 5 textbooks of medicine (Figure 6): Sir Thomas Watson's Principles of Practice of Physic, which was the standard through much of the 19th century (Watson was an Englishman); Austin Flint's Practice of Medicine, which was the last great textbook of medicine written by an American physician before Osler (Flint died in 1886); Osler's 1892 textbook; my father's copy of Cecil's textbook; and my medical school copy of Harrison's textbook. Osler was the last person to write single-handedly a major textbook of internal medicine! When he did this, the model for a multiauthored textbook already existed. Indeed, William Pepper had edited a 5-volume system of medicine by American authors in contradistinction to the great German and French multivolume systems of medicine. What would have happened had Osler decided instead to edit a 1-volume, multiauthored textbook, as Cecil was to do later? I think Osler inadvertently conveyed the idea that one person could master all of internal medicine, a paradigm that fell apart in the last half of the 20th century. But for a while we had the construct of the seemingly omniscient generalist physician.

After his textbook was published, Osler became famous. He was known at Hopkins as “the saint,” as characterized by an 1896 cartoon by the great medical illustrator Max Br?del, showing microorganisms fleeing in front of the Osler cyclone, with the Johns Hopkins Hospital and its famous dome in the background (Figure 7). Osler referred to it as “a scandalous canonization.”

To be the best in anything, you have to pay the price. And Osler did. He put off marriage until he was 42 years old, when he married the widow of a Philadelphia surgeon and friend. She was Grace Revere Gross, a granddaughter of Paul Revere, the revolutionary patriot.

Figure 8 shows Osler when he was my age, 56, realizing that he has burned out. He moved to Oxford, where there was no medical school. His new position reduced his income to about a third of what it had been, but he had a wonderful second career in the United Kingdom. He and his wife set up house in a large, rather mansion-like building in Oxford, which became known as “the Open Arms” (Figure 9). English-speaking guests from all over the world came and stayed with the Oslers. And Osler also—in a way that most of us cannot emulate—could say, “Grace, I'm bringing 30 people home for supper tonight.” And indeed Grace's grocer thought she must be running a hotel. I don't think we could get away with that today.

Osler's favorite portrait was done in about 1909 by Seymour Thomas (Figure 10). The couple had one child (an earlier child had died in infancy), Revere Osler, who was a quiet, reserved boy, somewhat unlike his father. He was interested in fishing, cabinet making, and other pursuits (Figure 11). He finally became interested in books and got into Oxford University on his second try. He was the love of his father's life. But World War I was going on, and Revere went to the front and was killed by a shell in 1917. This broke Osler's spirit. The forthcoming biography of Osler by Michael Bliss tells that he eventually regained the weight that he had lost after Revere's death and that he did not die of a broken heart.

Osler spent the last years of his life organizing his 7000 volumes of medical history and other material, which he bequeathed to McGill. At the Osler Library of the History of Medicine at McGill University is the Vernon Plaque (Figure 12), flanked to the left by Osler's own writings and to the right by works of Sir Thomas Browne, a 17th-century English physician who struggled with the issue of science vs faith (long before that became so popular). Browne wrote a book called the Religio Medici, which Osler cherished and memorized. Osler's first copy of the Religio Medici lay on his coffin as he rested in the Lady Chapel at Christ Church College, Oxford, on New Year's Day, 1920.

One thing about Osler comes across in everything written about him. It is very hard to convey, but it is a partial answer to the questions “Why is this man so magical?” and “Why is his name so revered?” especially since he left no major discoveries. (He did not receive a Nobel Prize.) Osler did describe a number of clinical conditions—he gave one of the first descriptions of blood platelets, for example—but he didn't give a single innovation to medicine. Being the youngest son in a large family with a philosophical father at the helm and being able to organize his time, he resembled Benjamin Franklin. As William S. Thayer put it: “There was no one like him.” He was a character. He had a wonderful people sense. He touched the lives of just about everyone he interacted with. One of my favorite topics is his approach to time management. He got a lot done and yet touched people.

OSLER ON CARING

My talk this morning is entitled “Osler on caring: the least sentimental and the most helpful.” The basic material is the sixth chapter of my book on Osler, which has become one of my favorite chapters to discuss. I would like to take from T. S. Eliot's “Ash Wednesday” the phrase, “Teach us to care and not to care.” That is a rather cryptic statement. What does it mean? As an undergraduate student, I took the last course of philosophy of religion that the great theologian Paul Tillich taught. Tillich talked about the issue of detachment and involvement. To me this is key in medicine—the extent to which a physician is involved with the patient's care, issues, and being while maintaining a scientific detachment. It's probably important for each of us, ideally while we're in medical school, to figure out our personality type and decide whether our style is to be a caring primary care physician heavily involved in people's lives or to be a detached radiologist or pathologist or what have you. Each of us must address this issue of caring vs not caring or involvement vs detachment in our own way.

Osler considered the ideal of compassion at length. In 1919 he gave his last major address. As president of the Classical Association of Great Britain—the first physician to serve in that capacity—he gave an annual address, which he called “The old humanities and the new science,” anticipating C. P. Snow's comments several decades later. In it, he paraphrased the Hippocratic saying: “The love of humanity associated with the love of the craft—philanthropia and philotechnia, love of humanity, love of technology. The joy of working joined in each one to a true love of his brother. Memorable sentence indeed.” So you have that ideal of combining compassion with technical competence, which is the grail of medicine, something we should all strive for.

These are the issues I would like to deal with: Are health care workers required only to render services within their areas of competence, or are we also required to render compassion? If so, what do we mean by these terms and how can we measure them? And finally, how should we care for ourselves? These are some key issues that affect the lives of all of us.

Compassion

“Show compassion.” A medical student said of Osler that his motto seemed to be to “do the kind thing and do it first.” Another student wrote his mother, “He seems to be the least sentimental and the most helpful man I've ever seen. The most lovable.” Osler worked out for himself a style of caring appropriate for him; all of us need to look at what our own particular style will be. Let us look at 3 examples of Osler's compassion, how he resolved this tension between technical competence and detachment on the one hand and caring on the other.

The first case concerns a young Englishman visiting Montreal on business. Osler met him at the Metropolitan Club in Montreal, where Osler, being a bachelor, frequently took his meals. One day the young Englishman didn't look very well, and Osler asked him what was wrong, attended to him, and diagnosed smallpox. It became obvious that his case was going to be severe, and Osler arranged for him to be seen by the leading internist in Montreal, his mentor, Palmer Howard. Osler got him into the hospital, but the young man went downhill and died. Thereafter, Osler wrote a factual and detailed letter to the young man's parents. Osler described exactly what had happened and what had been done, stated that the young man had gotten the best care, and explained that during his last hours he had frequently spoken of home, had asked Osler to read him a passage from Isaiah that was his mother's favorite, had talked about his mother, and had died peacefully. Osler did not hear anything further for about 30 years. Then at Oxford at a reception, a woman came up and said, “Would you happen to be the same Dr. Osler who took care of my brother?” And he said, “Yes, I remember.” The woman said, “I can't tell you what your letter meant to my mother. She cherished that letter for the rest of her life.” Osler then arranged for a picture of the boy's grave to be sent to the family.

The second case concerns the old men at the almshouse at Ewelme. The Regius Professorship at Oxford had been established by King Henry VIII as an honorific position but the salary was quite low, and so a subsequent king decided to augment it by making this person also the Master at Ewelme. The Master of Ewelme was a classic sinecure. The almshouse, located about 25 miles from Oxford, had been established by Chaucer's granddaughter a few centuries earlier to serve as a nursing home or boarding house for 13 elderly men chosen from the poor of that area. The master didn't have to do anything; other people ran the house. When Osler discovered that he was not only the Regius Professor but also the Master of Ewelme, he, unlike the previous Regius Professors, visited Ewelme regularly, got to know the men quite well, and often spent weekends there (Figure 13). He would take guests there, organize picnics, and require the men to pray for their benefactress. As a result, the morale of the place improved.

A third instance concerns a small boy with whooping cough. One day as Osler was going to graduation ceremonies at Oxford in his full academic regalia, he was stopped by a friend whose son had whooping cough, which then was untreatable. Osler saw that the boy had a more severe bronchitis than usual. Although he was running late, Osler examined the boy and sat at his bedside. The boy's problem was that he wouldn't eat. Osler carefully peeled an orange, broke it into segments, and coated each one with a little bit of sugar. He told the boy that it was magical fruit and that if he would just eat it one piece at a time he would get well. Osler went outside the door then and told the dad, “I'm sorry, Ernest, but when they're this bad off, they seldom make a full recovery.” Osler was told that the little boy thought he was a magical figure in his academic gown. Thereafter, for the next 40 days, Osler went to the infirmary carrying his academic gown, put it on outside the boy's door, and then went in. And the little boy made a steady recovery, regaining his health.

In none of these 3 instances did Osler gush compassion. He didn't say, “Gosh, I really feel for what you're going through.” He wasn't “touchy-feely.” He didn't embrace anyone. But in each case he did something that was beyond the call of duty, helping people in very specific ways. This seemed to be his style. “Do the kind thing and do it first!” Every medical school has faculty members who talk about caring for the patient, yet they are seldom seen taking night call. Osler simply did specific things.

He infrequently talked about compassion.

Medicine arose out of the primal sympathy of man with man; out of the desire to help those in sorrow, need, and sickness. Our fellow creatures cannot be dealt with as man deals in corn and coal; “the human heart by which we live” must control our professional relations. . . . Nothing will sustain you more potently than the power to recognize in your humdrum routine . . . the true poetry of life, the poetry of the commonplace, of the ordinary man, of the plain toil-worn woman, with their loves and their joys, their sorrows and their griefs.

And I cannot stress this point upon the students too strongly: as someone said, “The world is a great show and physicians have a front row seat.” We can best oppose any tendency to melancholy by an active life of unselfish devotion to others. The great psychiatrist Carl Menninger paraphrased this statement many years later by saying, “The best treatment for depression is to go to the other side of the railroad tracks and ask what you can do to make a difference.” Osler went on: “Care more particularly for the individual patient than for the special features of the disease.”

Equanimity

The second aspect is to maintain equanimity. Osler first used the word aequanimitas in an address to a graduating class at the University of Pennsylvania School of Medicine. When he left Penn—as had been the case in Montreal and as later would be the case in Baltimore—Osler was asked to give a speech. In his 4 short years Osler had become the students' most popular professor. Osler indicated to them that there were a lot of things that he could talk about, but of the many virtues he could enumerate, he chose only two: imperturbability and aequanimitas.

One great thing Osler epitomized is to always do more than you are paid to do in whatever capacity you work in. When he was asked to give speeches, he worked on them and said something original. That is why he was later able to put together the collection of essays called Aequanimitas, most of which are addresses, which surely are the most endearing component of what Osler called his “inkpot career.” He wrote a great deal—he thought maybe too much. Aequanimitas became sort of his signature by virtue of this volume.

Osler described imperturbability as “a bodily virtue.” He said some of us have it and some of us don't, but we can all work on it. He said it means

coolness and presence of mind under all circumstances, calmness amid storm, clearness of judgment in moments of grave peril, immobility and impassiveness, or, to use an old and expressive word, phlegm. It is the quality which is most appreciated by the laity though often misunderstood by them. . . . In full development, as we see it in some of our older colleagues, it has the nature of a divine gift. . . . The first essential is to have your nerves well in hand. . . . Educate your nerve centres so that not the slightest dilator or contractor influence shall pass to the vessels of your face under any professional trial.

Consider this true vignette about an orthopedic surgeon in my hometown involving his daughter, who was 2 years behind me in high school and whom I knew. The surgeon was working in an emergency room and 2 girls were brought in, having been in an automobile accident. A woman under the influence of alcohol had run a stop sign and struck their car broadside. (This was before the era of seatbelts.) The orthopedic surgeon saw the first girl, recognized her as his own daughter, felt her pulse, took her vital signs, and said, “She's dead.” He then immediately began to work on the other girl.

I would argue that blocking out your emotion is very relevant if your task is to clamp a bleeding artery or to do something very specific for someone during a crisis, and those who are good at that are going to be able to do trauma surgery, open heart surgery, and other such things very well. Osler said: “From its very nature this precious quality is liable to be misinterpreted and the general accusation of hardness, so often brought against the profession, has here its foundation. Keen sensibility is doubtless a virtue of high order when it does not interfere with steadiness of hand or coolness of nerve.” Osler makes the point very clearly: “Cultivate, then, gentlemen, such a judicious measure of obtuseness as will enable you to meet the exigencies of practice with firmness and courage, without, at the same time, hardening `the human heart by which we live.'”

Osler defined aequanimitas as the mental equivalent to the bodily attribute of imperturbability. He said, “Let me recall . . . that best of men and wisest of rulers, Antoninus Pius [the Roman emperor who took in Marcus Aurelius as his nephew and successor], who as he lay dying, in his home in Lorium in Etruria, summed up the philosophy of life in the watchword `Aequanimitas.'” Thomas McCrae, a disciple of Osler, said, “Many who came in contact with him [Osler] never realized how much anxiety he often felt but rarely displayed over patients.”

Since my Osler book came out, Mark Carr, a graduate student who was doing a PhD thesis in religion, has pointed out to me that Osler's notion of aequanimitas is different from cold detachment. Indeed, it has to be understood in a context of the later Stoic philosophy, of which Marcus Aurelius is emblematic. The early Stoics talked about apatheia, a lack of emotion, whereas the middle Stoics talked about metriopatheia, in which you seek to engage and include emotion after moderating its force. Aequanimitas does not mean stamping out all emotional concern. Osler's notion of aequanimitas is that of metriopatheia. Emotions must not becloud judgment, but care has to be taken not to, as Osler put it himself, harden the human heart.

Touching the lives of others

The third component is to touch the lives of others frequently, which Osler did. His style was not to get into heavy rap sessions. This was incompatible, for better or worse, with his own tightly compartmentalized life. He had the extraordinary power of attracting others. When he walked into a room, the atmosphere suddenly changed. He was charismatic. There are at least a couple of teachable aspects of charisma shown through his life and work. One is touching people frequently, and the second is being a child with children.

Marcia Grad, in her book Charisma: How to Get “That Special Magic,” describes some characteristics of charismatic persons: high energy, sustained vitality, courage, composure (especially under stress), strong sense of self, clear direction, and the determination to succeed. Other qualities include showing an interest in others frequently and regularly, meeting their needs, shining a spotlight on them, putting others at ease, conveying or projecting optimism and joy of living, maintaining good body language and eye contact, listening well, and having a high measure of self-acceptance. Charismatic people are also nonwhiners. These are things that can be worked on.

Osler was an optimistic person who loved life. The following is a description of Osler by Cushing: “. . . debonair, in a gray frock-coat, top hat, and the inevitable nosegay in his buttonhole, [Osler] passed no unfamiliar spot without a visit and the leaving of a touching or humorous recollection in someone's mind.” Osler was persona, he was personality. This was one reason he became so famous. And he had that wonderful ability to remember names. When he would see someone whom he hadn't seen for years, he wouldn't say, “Gosh, how have you been? How are the wife and family?” He would say, “Marvin, how's that chapter coming along?” or “What happened?” He would just take up where he had left off. He seemed to say that formalities were not really important.

Another thing he did was to keep prestamped postcards handy at all times. He would frequently let people know that he was thinking about them. If someone published an article that he saw, he would send a postcard that might say, “Neat. W. Osler.” Today we can use e-mail for the same purpose. This lets people know, “I'm thinking about you and appreciate you,” and it doesn't require a response. It puts no obligation on the recipient. He gave people frequent compliments, or “golden bricks.”

He spent a lot of time with children who tended to regard him as one of them. It's very important to spend time with children, and he actually seemed to prefer their company to that of adults on many occasions.

Caring for oneself

Care for yourself, Osler wrote. “In no relationship is the physician more often derelict than in his duty to himself.” Sir Thomas Browne had this to say: “How shall we expect charity towards others, when we are uncharitable to ourselves? Charity begins at home, is a voice of the world, yet is every man his own greatest enemy, and as it were, his own executioner.” Browne continued: “I have examined the parts of man, and know upon what tender filaments that Fabric hangs.” How delicate life is for all of us.

Osler was acutely aware of stress and coronary artery disease and said, “In the worry and strain of modern life arterial degeneration is not only very common, but develops often at a relatively early age. For this I believe that the high pressure at which men live, and the habits of working the machine to its maximum capacity, are responsible, rather than excesses in eating or drinking.” Type A personality matters more than your cholesterol, we might now say. “Angeio-sclerosis, creeping on slowly but surely, with no pace perceived, is the Nemesis through which Nature exacts retributive justice for the transgression of her laws . . . too often slitting `the thin-spun life' in the fifth decade, at the very time when success seems assured.”

Osler became concerned about his own health. He wrote about his practice in 1901, by which time it had grown quite lucrative. By then, he was making the modern equivalent of about $500,000 or $600,000, tax-free. He said, “My professional work increased very much this year. I have analyzed it as a matter of interest. There were 780 new patients, of whom 378 came from outside the city . . . representing 31 states.” In the era in which there were no magnetic resonance imaging scanners and so forth, Osler was looked at as sort of the Oracle of Delphi. One went to Osler for “the diagnosis.” So he became very popular, particularly among physicians and “the worried well.” He said, “Much depends on the patient himself, on the life that he has led, the life that he is willing to lead. As William Pepper used to say, `Give me the life of a hare rather than the existence of a tortoise.' Not even a terrible outburst of pain may suffice to check men of this stamp.”

When Osler got the offer to go to Oxford, his wife wrote, “You better accept it at once. . . . Better to go in a steamer than go in a pine box.” And Osler later wrote: “I had 31 years of uninterrupted hard work. William Pepper, my predecessor in Philadelphia, died of angina at 55; John Musser, my successor, of the same disease at 53!” Thus, Osler was very much aware of the stress of medical practice. He said, “Greater sympathy must be felt for a man who started all right and has worked hard . . . but as the rolling years have brought ever-increasing demands on his time, the evening hours found him worn and yet not able to rest. . . . Many good men are ruined by success in practice.” He said, “I am living a `life of the hunted' at present. Infernal nuisance and yet it seems very difficult to limit one's legitimate work.” And so when he had the chance to become Regius Professor, he saw the opportunity to escape.

“Few men lead lives of more devoted self-sacrifice than the family physician, but he may become so completely absorbed in work that leisure is unknown; he has scarce time to eat or sleep, and as Dr. Drummond remarked in one of his poems, `He's the only man I know me, don't get no holiday.'” So to me, Osler speaks to us in medicine, particularly those of us who have been out there a while, in terms of the extent to which we drive ourselves vs the extent to which we keep some part of ourselves separate. I hope that today with more students, including women, going into medicine, we will see medicine become a much gentler, kinder profession, in which this fact will be recognized.

OSLER'S HUMOR

Another way to deal with that stress is to maintain a sense of humor, which I think is an important component of Osler's caring. Osler was not a stand-up comic by any stretch. But he saw the comic side of life and cultivated the ability to be a practical joker, something which was a lot more characteristic of the Victorian era than of ours. Someone said of him, “Never has a man masked so successfully earnestness of purpose and a real love of his fellow men with a glimmering veil of humor. He was most in earnest when he was most in fun.”

Humor for Osler, I believe, was a defense mechanism against stress. George Vaillant, author of the so-called old-boys study at Harvard, showed a hierarchy of defense mechanisms. The people with the best outcomes were those who used the healthiest defense mechanisms: anticipation, sublimation, a sense of humor, and altruism. That seemed to correlate better than how much money a family had or other factors in terms of how one was doing 30 or 40 years after college.

Osler told his students,

The comedy, too, of life will be spread before you, and nobody laughs more often than the doctor at the pranks Puck plays upon the Titanias and Bottoms among his patients. [That of course is a Shakespearean allusion.] The humorous side is really almost as frequently turned towards him as the tragic. Lift up one hand to heaven and thank your stars that they have given you the proper sense to enable you to appreciate the inconceivably droll situations in which we catch our fellow creatures. Unhappily, this is one of the free gifts of the gods, unevenly distributed. . . . Hilarity and good humour, a breezy cheerfulness, a nature “sloping toward the southern side,” as Lowell has it, help enormously both in the study and in the practice of medicine. . . . It is an unpardonable mistake to go about among patients with a long face.

Osler's pranks were a stamp from childhood. He was a practical joker all his life. One time a visiting clergyman came to see his father, and the man and his father had never met. Young Willie came to the door and said, “You have to speak real loud to my dad; he's nearly deaf.” And he goes to his father and says, “You've got a visitor here. He's really deaf. You'll have to speak real loud to him.” Osler then sat back and watched them shout at each other throughout the evening. He would later repeat the prank as an adult. He would send people on wild goose chases. He told a medical student who was going to Philadelphia from Baltimore: “Drop in on my old friends Philip Syng Physick and Shippen, and give them my love.” The poor student looked all day and finally found out that Physick and Shippen had been dead for 30 years. There are many other examples.

An interesting aspect of Osler's humor was his cultivation of an alter ego called Egerton Yorrick Davis, who was allegedly an army surgeon who had practiced medicine among the Caughnawauga Indians in the great Northwest Territory in Canada and had drowned in the Lachine rapids. His body was never discovered. Earlier he had written a manuscript called, “Professional Notes among the Indian Tribes about the Great Slave Lake, North West Territory.” It was never published, but it was probably fairly raucous.

Egerton Yorrick Davis first surfaced in an article on “penis captivis” in the Philadelphia Medical News, in response to the rather pompous Philadelphia obstetrician Theophilus Parvin, who had written a stilted essay on penis captivis or vaginismus. Osler wrote: “The reading of an . . . editorial on forms of vaginismus, has reminded me of a case. . . . When in practice I was called by a gentleman who had gone out to lock up the barn at night and found a maid, who was a very small woman, in bed with a coachman, who was a very large man, and they couldn't get apart.” Osler went on and on about this in great detail. It was taken as a serious letter to the editor and published. He also wrote a letter to the editor about “the baby on the tracks,” in which a woman had gone into labor on a railroad car while she was sitting on the commode and the baby had fallen down the tracks and had nothing to show for it but a small cranial hematoma.

His pranks could have an annoying tinge. He would sign into a hotel and say, “This is Mrs. Osler and I'm Dr. Davis.” How Grace took that we don't know. One time in Boston he was standing on a railroad platform and somebody came up and said, “You must be the famous Dr. Osler.” And he said, “No, I am Dr. Davis. There are my friends Dr. Bigelow and Dr. Ware.” And he made no further comment. These episodes may strike us as being a bit inappropriate today, and maybe some of them were, but again it was his attempt to cultivate a sense of humor. It was also part of his charisma. It reflected the so-called Rabelaisian side of his personality. He would walk away from a death scene whistling and would quote Uncle Toby, a character in Laurence Sterne's book Tristram Shandy, “I whistle that I may not weep.” Others talked about Osler and his peculiar mixture of foolishness and thoughtfulness, which made him such a charming and yet unpredictable, charismatic person.

CARING FOR THE RIGHT REASONS

And finally, care for the right reasons. What do we mean by compassion? Does caring matter for our own self-esteem? Much, of course, has been written about compassion and empathy, but the vocabulary of caring entails a hierarchy of terms: beneficence, which comes from the Latin word meaning “active kindness”; empathy, which means “in feeling” (understanding the patient's feelings); sympathy, which goes a step further, meaning “like-feeling” or “fellow-feeling”; and compassion, which literally means “to suffer with.” Compassion means “taking up your place with the sufferer and suffering with the person.” Osler makes a clear statement about empathy:

The motto of each of you . . . should be “put yourself in his place.” Realize, so far as you can, the mental state of the patient, enter into his feelings . . . scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look. . . . It is a hard matter . . . to tell a patient that he is past all hope. . . . Of the three factors in practice, heart, head, and pocket, to our credit, be it said, the first named is most potent.

And Osler was not always sympathetic. He practiced what we might call “tough love.” There's a story of a woman, who today we would probably say had a somatization disorder, a “yes” to every question during the review of systems. Osler was at her bedside, and she said, “Oh, Dr. Osler, you misjudge me cruelly.” Osler, with a twinkle in his eye, responded: “Madam, I learned early in life never to judge a woman and that rule I have strictly kept. Therefore, I cannot have misjudged you. Good morning.” He left his residents to clean that one up.

Osler did not spend a great deal of time talking to individual patients on rounds. He seemed to sense when each needed special attention. He was efficient. He talked to his students about being able to get out of a room before the so-called “floodgates of talk” opened. That is something we all have to be aware of in practicing medicine because we can be very inefficient, and yet it is important for us to talk to people. We need to pay close attention to body language. I've found, as I'm sure most of you have found, that 2 or 3 minutes sitting at the bedside is probably worth 10 minutes standing at the bedside. Sit down, lean forward, and convey in that window of what Clif Cleaveland calls “a sacred space between the doctor and the patient” that the patient has your undivided attention.

It's important to care from the context of a healthy personality. Aristotle, in The Nicomachean Ethics, wrote about the “pleasure of beneficence.” When we do a good act for someone else, that person then becomes the incarnation of our own goodness, and so we feel better about ourselves and warmly toward our beneficiary. There's a fairy tale about an evil young boy who decided that he wanted to marry the king's daughter and inherit the kingdom. He found out where the king's entourage would be crossing a certain stream and, as they approached, feigned that he was drowning. The king's people saved him, and the king took him under his wing and became attached to him, and sure enough the young man eventually married the king's daughter. An important point, both from the fairy tale and from Aristotle, is that although the recipients of our good deeds become for us the incarnation of our own benevolence, the recipients may not feel the same toward us. Indeed, they may resent us for their having needed our services in the first place. All of us in medicine, at some time or another, have experienced this phenomenon, where a patient actually turns on us and does not reciprocate our warm feelings. It is important to disassociate the outcome of caring from our own self-esteem.

Osler had very high self-esteem, in part because of an accident of birth. He was born on July 12th, which happened to be Orange Day. His parents had planned to name him Walter Farquhar Osler after a Canadian clergyman, but after the Orange Day parade, celebrating the victory of King William III of Orange at the Battle of the Boyne, some rowdy Scots came to the parsonage and told the Reverend Featherstone Osler, “You must name him William.” Thus, instead of being Walter Farquhar Osler, he became just plain William Osler. After that, every July 12th, they would deck their William out in green and orange and put him at the head of the parade. The other children in town thought it was Osler's birthday party that the whole town had come out for. Imagine what that would do for your self-esteem! More important, William was the darling of his mother, which, if Freud is correct, meant that he went through life feeling he could do no wrong. Osler also practiced certain behaviors that can enhance self-esteem, such as adhering to principles, being goal-oriented, living in day-tight compartments, practicing lifelong learning, and accepting self-responsibility and self-awareness.

Looking at this issue of caring for others appropriately and caring for oneself, it's useful to look at the Stoic philosophers famously interpreted by Reinhold Neibuhr in the “serenity prayer” paraphrased in Figure 14, which a colleague of mine calls “a scientific serenity prayer.” If we can control it and act, that's mastery; if we act and can't control it, that's futility. Failure to act when we can control it is surrender. Failure to act when we cannot control it is serenity. It comes down to making a difference when you can.

In summary, we should try to care in ways that are best suited to our own personalities. We should care for ourselves and for others within the context of a healthy personality. We should try to care mainly with deeds and not words. Osler's style was to care very specifically, mainly with deeds—doing the kind thing and doing it first.