Lecture Eleven: The Battle of the Williams, Welch vs. Osler

Two of American medicine's pioneers, and co-founders of Johns Hopkins Medical School, represented a fork in the road.  William Osler, whose scientific humanism pushed back against a healthcare system teetering between commercialism and quackery, created a solution at Hopkins: clinical care, doctors as teachers, patients as teachers, an end to protocols and dogma.  He believed in patient centric care: "If you want to know the diagnosis, ask the patient," he said.  He believed that America was becoming a society of drugging rather than healing.  He believed that nuance and uncertainty were inherent to healthcare, and that there could never be one right answer.  His colleague, William Welch, was a pathologist, a eugenicist, a believer in German medicine, an AMA president.  He did not believe in the importance of patient centered care, rather advocating laboratory medicine that trumped the patient.  He believed in drugs and one-right-answer thinking and he rejected the value of clinical care in education.  He wanted a medical education system run only by full time laboratory faculty, not practicing physicians as Osler had set up at Hopkins.  Welch, in the end, won the day.  Once Osler retired, Welch fired all clinical staff, and imprinted the AMA model upon all of healthcare.  He is indeed the father of American healthcare, but of a healthcare system that embraced eugenics and the medical racial script, that marginalized patients, that created diseases out of numerical norms, and that worked with corporations and drug companies.  If you want to know where our system came from, you only have to understand Welch's victory over Osler.  And if you want to know how to fix the system, you only have to understand and revive Olser.

Transcript

SPEAKER_00 0:00

So let's talk a little about two very prominent doctors at the turn of the century, um, William Osler and William Welch, the two Williams. The um uh the the uh lore is that they were good friends, they were founders of Hopkins, they created the greatest medical school in the country, they believed in science uh as the guiding light to push medicine into the modern age. Um they rejected uh the proliferation of poorly um uh regulated medical schools, the proliferation of terrible doctors. They're both deeply entrenched in the orthodox view. What differentiated them is that William Welch was truly a member of the Orthodox consensus. He believed strongly in the medical racial script, he believed strongly in uh the AMA as the instrument of reform. He believed in a top-down, one right answer approach, dogmatic approach to medicine. He was trained in Germany, he brought German ideas home when he founded Hopkins as a German institution. And one of his first hired was William Osler. William Osler was one of the more famous uh American doctors at the time, again, fully entrenched in orthodoxy, uh, believed in the physical exam, believed in many of the precepts of orthodox medicine, and believed in science. But what their conceptions of science were were diametrically opposed. And it took a little while for Welch, who was a lab rat, a pathologist who studied tissue, to realize that Osler, who was truly a clinical doctor, who went out and saw patients, who was friends with with the whole gamut of uh primary care regular doctors who uh proliferated the Baltimore uh uh region, um, that they had different views of what science was. Uh, William Osler, so excuse me for saying so, but he is my medical hero. He's a lot of our medical heroes. One one of um the recent book I wrote called The Return to Healing, I wrote with another doctor, um, Alan Roth. And we actually met, we were at a table at a conference, and we both started quoting Osler to other people, and and we looked at each other like, who quotes Osler? But we realized we had a lot in common. But Osler was the guy. I mean, he was the most prominent American doctor. Even you go to Hopkins today, his statues are everywhere, he's got halls named after him. Um, but his ideas are are gone, they've been erased completely. So, how did they differ in different uh what were their different philosophies, scientifically and clinically and medically? So let's talk about Osler first. Osler was born in Canada. He he trained as um as a physician, he practiced uh medicine. He did a little research, he dabbled in it, but was certainly never known as a a great researcher. His real skills were in writing about how to practice medicine. His practice of medicine became the textbook of medicine. I own an old copy of it. It's still sometimes quoted in medical schools, even if the ideas are no longer accepted. Um, and he believed that orthodox medicine was and could incorporate the science that was available, the science taught in France, in Germany, and create a vector that was still patient to doctor. That was the big difference. He rejected the entire AMA's idea that the patient is peripheral to the entire medical exam and medical decision-making process. One of his more famous quotes was that if you want to know what's wrong with the patient, ask the patient. In other words, the patient has you have to engage with the patient. All the tests and exams and everything else were not important unless you knew the patient, unless you understood what drove them. Not only medically, but socially, psychologically, and what you could not determine what was going on with the patient or how to fix them unless you understood all that. To him, the exam and the lab testing was peripheral. It was to supplement what you would get from your conversation with the patient. And all the doctors he worked with around Baltimore believed in the same thing. Um, he also rejected medicines as the answer to how to solve uh medical problems. He was still bleeding people and using leeches. Um, he had not crossed the threshold of getting past that, but many of his treatments were herbal and diet and exercise. He believes strongly in lifestyle modification. Um and he he, another one of his famous quotes is that if you have a problem and take a medicine for it, now you have two problems. He also said the young doctor treats each problem with 50 medicines, the older doctor treats uh 50 problems with one medicine. He he said we we as doctors have to teach patients how to avoid the addiction of medicines. He absolutely rejected this direction that the AMA was going and that Welch was going, in that we need to be a society, a medical society where we do a lot of laboratory tests and do a lot and create new medicines and treat people with medicines through a very formulaic script. He did not believe in anything formulaic. He says, if you want to go into a field where there's certainty, do not go into medicine. Again, the whole idea of Welch was there was certainty. There is one right answer. We determined it by lab testing. This became the AMA's modus operandi. He did not, Welch did not believe in that. So Welch was not a member of the AMA ever, from what I could see. I saw one instance where maybe he gave a talk to the AMA because he really was the most famous doctor, nor was he willing to just sit back like a limp rag and let William Welch uh create a German institution at Hopkins. He believed in a different way of educating uh doctors, and he believed that all doctors were going to be different. He believed that um learning the literature of what was out there was important. Um learning the basic science was important, but it was took a back seat to actually talking to patients. So, how did that translate to his role at Hopkins? Because he was actually the clinical director at Hopkins for the time, from the time the school was created until he retired in 1903 when Welch took over that job. His creation of an ideal medical school was not German. He nothing to do with Germans. Uh, was he British, you know, he's a British. He ended up growing up in the British part of Canada and retiring in England itself, where he was knighted by the king. Didn't like the Germans that much. Didn't like German thinking. He felt much like Einstein. He shared Einstein's view that the German view of education was too top-down, too dogmatic, too one-right answer-ish. Well, Osler did not believe in one right answer. He believed that each patient is going to exhibit a disease differently. There's no one way to treat each patient. Each patient was unique in their manifestation of disease, in how you would treat the disease, and in all other aspects of their medical care. So when students came to Hopkins, they dove into clinical medicine. Now, any of you who understand the way medical school works now, this is not the way it is. We are just like uh A.P. Calwell and William Welch and other people in the AMA wanted, when you go to medical school, now you sit in a classroom for two years. You might have some token interactions with patients, but we are basically in the same medical system that the AMA created back in 1900 and that Osler did not appreciate. So when you went to Osler's Hopkins, much over Welch's massive protest, you went out into the community from day one. You were working with primary care doctors in the community, visiting patients, going to their homes, working with these doctors to see how you talk to patients. And then you would go back to the classroom each day or several times a week, work with medical scientists, and discuss the disease processes, the anatomy, the pathophysiology of the patients you saw, of the diseases you saw. So again, the vector for Osler was patient educates the doctor. Doctor then buttresses that education by reading and through these lectures. There was no sit-down time. Osler was very opposed to medical students sitting in a classroom all day and learning from people who he believed were incompetent. Why were they incompetent? Because they didn't practice medicine. You could see in Rosser's writings over and over that if you're not in the trenches practicing medicine, you should not be teaching medical students. He called them clinical prigs. Um, and he believed that they were one of the more dangerous ways medical students could learn because medical students are going to learn from people who were book learned but uh medically ignorant. You could not learn medicine unless you're with patients. That's crucial, and we'll see that. That is a direction we did not take in this country, and that Osler believed was the only way. He said science is subservient to the patient, but science is crucial. He believed in medical science, he believed in research. He simply did not think medical students should be the ones doing the research. He thought that specific medical researchers should be doing the research, and yes, they could teach medical students who had already been uh submerged into patient care. This process occurred for the full three years of the medical school. It wasn't like you had demarcations of you do this one year, this one year, this. This was an ongoing process of this going into the community, learning from doctors, and then coming back to the classroom and learning the pathophysiology. And Osler was wise enough to know you're gonna learn just a little bit in those three years. You're gonna get enough of a taste that you could pursue lifelong learning, which Osler said over and over again that once you stop learning, you stop being a doctor. Osler also created the residency. The residency was that after you finished these three years, you spent anywhere between one and three years working in a hospital or working in doctors' offices and really honing down your skills before you went into the world of practice. So this is a doctor Osler wanted to create, uh a truly modernized um scientific, patient-oriented doctor that was different than the, yeah, the the what they what the AMA would call the quacks out there who had barely any education, and also these German taught doctors who had no patient exposure. Osler was not alone in this belief. Uh one of the one of one of the people who was just as prominent at the time was uh Francis Peabody, who helped run Harvard, who again turned Harvard into a very reputable school with with um with a lot of clinical medicine uh juxtaposed and and immersed in into the uh more so the new sciences they're growing up. And and you know, in creating uh Harvard into the same model, uh it was believed that these two institutions would hurled the nation into a new uh era of medical education where doctors were not dogmatic. They did not all think the same way, they did not follow a script, they did not have one right answer, nor were they um prisoners to what uh Osler would and Peabody would have called constantly changing science. Very much in the Einstein mode of science that science is not something an expert will tell you, but science is something that comes from the bottom up, that it's constantly changing, and that a true scientist, a true doctor, according to Osler, is someone who questions everything. If an expert tells you something, you better question it, you better dig into it. You're not just gonna listen blindly, which was, again, the German idea was to listen blindly to experts and to mimic what they do in a completely formulaic way. So, and that, and that's what Welch believed in. So William Welch was a guy who was trained in Germany as well as America. He was trained as a pathologist, never practiced clinical medicine, did not see patients, didn't think he had to. Why? Because he studied tissues. So, for instance, if someone did a biopsy of the skin or the liver or did surgical biopsy, that those tissue samples would show up in Welch's labs. And without even knowing the patient, Welch could figure out what diagnosis they had and also what treatment they needed. Why see the patient? The patient's just gonna confuse you. Patient's gonna give you this story of this and that and the other thing. But we have the answer right here in the lab. He also believed in the lab of the science of blood labs, blood tests. And some of the pathology back then was also about reading blood tests and interpreting them, again, in the absence of knowing the patient. You could say the same thing about radiology, which was developing at this time, and again was a window into the body where you could see what was going on. Patient was removed. The radiologists, pathologists, um, all these kinds of doctors don't talk to patients, don't see patients, they find the answer out through an objective criteria. That's what Welch believed. And Welch wanted Hopkins to reflect this German-inspired medical education, which which he which did occur in 1903 when Osler decided to retire. What's the first thing Welch did when Osler retired? He fired all the clinical doctors at Hopkins. All the people that the students would go to in the community and work with, they were fired instantaneously. Osler, as we'll see later, protested vehemently from England, but there was nothing he could do. His colleagues disappeared, and they were replaced by research scientists who then taught the medical students at Hopkins the way that the Germans did. Two years in a classroom, one to two years, and that changed over time. It was one and then became two, two years uh in the hospital, essentially. No exposure to the outpatient medical world, no exposure outside the hospital to what doctors were doing, seeing, no exposure to the nuances of medicine. Um it was it was very much an absolutist kind of creed. The the um uh the the other ways in which they differed is through the medical racial script. You don't know much about what Osler thought about race. He didn't write about it. And we could argue that he also fell into the into this pit of the medical racial script because not not during his era, and certainly not during Welch's era, were any African Americans admitted to Hopkins. In fact, none was admitted to Hopkins until the 1960s, uh, because Hopkins really held tight to this the eugenic script. But Welch was part of the progressive movement, he believed deeply in eugenics. Um, Osler did not. Uh, there is no evidence that Osler had any connection to the eugenic movement. He never talked about it, he was not members of any organization. Welch was. And here's the funny thing about it, because again, uh, eugenics is so debunked now, you know, called a pseudoscience, which again is absurd because it was not a pseudoscience at the time. It was the science. Um, but a science that um that Osler and others like him rejected, but a science that was, of course, embraced by most of organized orthodoxy, especially in the AMA. Welch, if you read his biographies, if you read anything about him, they don't mention anything about eugenics. It's it's funny. I I went into the archives at Hopkins and dug through some records, and Welch was deeply involved in eugenics. He was president of several groups, groups from all over the country were writing to him for his support, for his for his endorsement, uh, for his wisdom, for him to write things. I remember looking up at the archivist and saying, My God, this guy is a is a super eugenicist. And the guy said, Yeah, we know. I said, Yeah, but nobody else does. He said, It's the big dark secret of Hopkins. We don't want its founder and its hero to be a eugenicist, so he is not. Again, that part of his legacy was erased, but he was he was. It was almost shocking to see this. Um so he did believe in the medical racial script. He enforced it, he knew it was a unifying, it was a way to unify white doctors, but also to connect uh the Orthodox doctors to the progressive movement because eugenics was, as uh Southern said, the religion of the progressives. So this is what they believed in, this is what they believed science was telling us. Welch um was president of the AMA during the most critical time, 1905, when it was making its changes, he spearheaded uh most of the um uh most of the educational reforms that were going on. He spearheaded the school surveys that Calwell uh set up. Uh he uh was instrumental in changing the structure of the AMA from a very democratic, chaotic organization to the top-down House of Delegates uh uh methodology. Um he all he did all this very quietly. He also was um extremely involved in uh corporate foundations. He worked with the Carnegie Institute, he was president at at several points of the Rockefeller uh Institute in terms of its relationship to medicine. He had he knew Rockefeller and Carnegie well. He he believed that their largesse was the way to save the medical system. He he's the one who brought corporations into medicine. He believed strongly in the pharmaceutical industry, he believed in drugs as the only real way to fix problems, and that the the research on drugs should be occurring in American medical institutions along with the pharmaceutical industry and along with corporate foundations. Welch has the library at Hopkins Medical Schools named the Welch Library, his statues clutter the place, and in some ways justifiably. I I can't think of anyone who is more uh instrumental in changing the AMA into the instrument of medical reform that created the medical system we know today, with all the the baggage that came with it, with it with the medical racial script, with the with uh uh diminution of clinical medicine, um with with pushing the patient to the periphery, all that, which a lot of which had been percolating in the AMA during this time, um, was consolidated into a potent force of progressive reform by William Welch. But the reason I bring this up is because, again, orthodoxy was not one thing. To the AMA, it should be. There should be everyone under the same roof speaking the same language, the language of science which is incontrovertible and which came from experts who were basically lab people. They will tell you what's right and wrong, that tests can be uh created to to demonstrate that there's one right answer. Um, that was the Welch AMA method, but that was not orthodoxy. Orthodoxy was many things. Many, many Orthodox doctors never sat in a classroom, never learned this science. They simply had experience, what was called empiric medicine. They they and their colleagues, they like to go to conferences. A lot of them like to go to the AMA and to local medical societies so they could discuss with their colleagues, read some articles, but the bulk of what they did was based on their experience and what their colleagues told them their experience was. That's called empiric medicine. It means, yeah, I mean, the guy that the experts might say X, but we're not saying X when we practice medicine. We're seeing Y. X doesn't seem to exist, and so they're gonna practice Y. That was the Osler mold, really, and the idea that there were a lot of Orthodox doctors at this time who only were empirical. That's all they did. Osler didn't like that. Osler believed that you had to have your empirical exposure through patient contact and through working with colleagues, and you had to add to that readings, critical readings about what was going on in science. Critical meaning you're not just gonna take them uh and believe them because someone said they're true. You're going to read them in the context. Of your experience, and you're gonna see if you believe they're true. You may even decide to do your own research based on your own experience and come up with other alternatives. He he certainly Osler certainly was not opposed to research. He just did not think what we call bench researchers, people who are delving into basic sciences that are apart from the human being, should be the ones teaching medical students and or should be the ones prominent in the medical fields. Osler believed strongly in primary care and generalized medicine and doctors who knew everything, a lot about everything, versus Welch, who believed in specialization. There's a doctor for lungs, doctor for the heart, doctor who does laboratory work, all those doctors, you know, are focused on one area of the body and are told how to take care of that one area of the body by experts who are come out of institutions like Hopkins, Harvard, etc. So this fight that occurred was almost a fight that was futile in terms of the Osler world. Because in the Osler camp were a lot of doctors who Osler himself disparaged, a lot of these poorly trained doctors who did not want schools to be turned into research institutions. A lot of people not in the Osler camp were leaders of these proprietary medical schools that charged steep tuition and basically gave uh people a license just for paying that tuition. Um, Osler detested these people too, but because so many Orthodox doctors um were united under the rubric of progressivism and the medical racial script, and ultimately gravitated to the AMA when they started offering more and when progressive licensing requirements came. The progressives were much more uh tuned to Welch's message than Osler's. Osler's message was nuanced. It was it differed from person to person, it couldn't be put under a single label. Um, and many poor doctors also were the same, although they were not followers of Osler, but they also rejected the Welch view of things. So the corporate foundations did not want to work with people like that. They wanted to work with someone who had a very clear message, a message similar to what they believed in, who believed in using uh the medical system to create a corporate behumuth that would uh be a research institution, drug manufacturer, all that stuff, and believed, as progressives did, that everything was top-down, that there should be a small group of people telling everyone else what to do. That was not Osler. That was Welch. And so when we look at what happened with the Flexner report, which is what we're gonna talk about next, which no one heard of, which but was instrumental in changing our healthcare system to this AMA model. When we look at that, uh Osler was erased. And he could have statues and lecture halls all day, but nothing that he said. And if you just for fun, you could go online and just look up Osler quotes and see what the man said. The quotes are priceless. Um, and and you could see that my God, everything he's saying is not the way medicine is practiced or taught today, um, whereas whereas with Welch it is. So that's where we are we are by about 1910. Osler's gone. He's writing nasty letters from England saying, how dare you do this to my institution? Welch is deep in the trenches, working with corporate entities, working with pharmaceutical companies, working with the AMA, working with state licensing boards, working with progressive reformers. And guess who's gonna win? Um so that this is the turning point. Like Fischbein said, this is when the AMA reached its adulthood by rejecting William Osler and embracing William Welch. The Battle of the Williams ended in 1903 and definitively ended in 1911 when the Flexner Report was released, when it was embraced, and when it changed everything.