Tag Archives: military medicine

William Osler on Military Medicine (2)

In the first of this series, I noted that the beloved William Osler, teacher, writer, philosopher of medicine, had little to say about military medicine in his years at the University of Pennsylvania and Johns Hopkins.

William Osler, Regius Professor of Medicine, Oxford, 1906. http://digital.library.mcgill.ca/osler/fullrecord.php

This changed when Osler, a Canadian citizen, moved to Oxford as the Regius Professor of Medicine in 1905. Always a bibliophile, he began to avidly collect medical antiquities, and he may have dusted off his Latina and perhaps his Greek reading skills. As a result of his collecting and reading, he seems to have become more aware of the role of military doctors in the history of medicine. Among the antiquities, for instance, he cited Dioscorides, an army surgeon in Nero’s time as one of the first “scientific” students of pharmacology. (1)

In 1909, Osler reflected his study of more recent medical history when he mentioned the work of British Royal Navy scurvy pioneer James Lind, and malaria researcher Vandyke Carter of the British Indian Medical Service to highlight their individual contributions to the advancement of medical knowledge.(2)

Up to this point, Osler’s outlook emphasized the work of individuals in their quest to advance medical science. Gradually, however, he began to express appreciation for  the importance of military medical organizations, in what we would today call public health initiatives. Already, in a 1901 essay Medicine in the Nineteenth Century, he had cited the success of the German army in eliminating smallpox from its ranks by vaccination (3). In 1909, he noted the key role of a military organization in eliminating endemic tropical diseases thus:

It was a fortunate thing that the head of the American occupation of Cuba was General Leonard Wood, himself a well-trained physician, and deeply interested in problems of sanitation.  Backed by the military arm it took Dr Gorgas and his colleagues nine months to clear Havana, which had been for centuries a strong hold of [yellow fever].(4)

In 1914, with the outbreak of the Great War, Osler put on the uniform of an Honorary Colonel in the Oxfordshire Regiment, and by August, he was advocating for compulsory vaccination of British troops

Colonel Sir William Osler at Clivedon, site of a Canadian Military Hosptial, of Which He was Chief Physician. http://digital.library.mcgill.ca/osler/fullrecord.php

against typhoid fever. In a letter he prepared for The Times of London late in the month, he cited “the work of French army doctors and of British army surgeons, particularly in India” for “the remarkable reduction in the incidence of typhoid when vaccination is carried out”. In the same letter he wrote “[the] experience of the American Army is of special value, as the disease is so much more prevalent in the United States…” (5) In October, he again cited the success of armies (German, French, American) in virtually eliminating the disease by vaccination. (6)

I’ll conclude this consideration of Sir William Osler’s thoughts on military medicine in my next post.

(1) Cushing, Harvey, The Life of Sir William Olser, Oxford, Clarendon Press, 1925, vol ii, p 122, quotes an Osler letter in which he detailed his exploration of the Vienna Hofbibliothek, where he had a chance to see a fifth Century Dioscordian manuscript; he described this as “one of the great treasures of the library”.

(2) Osler, William, The Nation and the Tropicsan address at the London School of Tropical Medicine, quoted by Cushing, vol ii, pp 192-194, and published in the Lancet, 1909, vol 2, pp 1401-6.

(3) See Osler’s volume Aequinimitas, with Other Addresses to Medical Students, Nurses and Medical Practitioners, available in several printings and editions. The 1905 edition (Blakiston, Philadelphia) cites the elimination of smallpox in the German army by a program of  “efficient revaccination”, pp 251-252.

(4) The Nation and the Tropics, cited above.

(5) Letter to The Times is quoted by Cushing, vol ii, p. 427

(6) Osler, William, Bacilli and Bullets, an address to the Officers and Men in the Camps at Chum. I originally found this in the Osler Library in McGill University, in a volume “The Collected Essays of Sir William Osler” by John P McGovern and Charles G Roland, Editors, The Classics of Medicine Library, Birmingham (Alabama), 1985. This is now available on line: http://archive.org/stream/bacilliandbullet031212mbp#page/n9/mode/2up, accessed 19 October 2012.

©2012 Thomas L Snyder

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William Osler on Military Medicine

William Osler, MD

William Osler – later, Sir William Osler – is seen by many in the profession as the father of modern medicine. Born (1849) and educated in Canada (University of Toronto and McGill), he matured at McGill (1874 – 1885) and the University of Pennsylvania (1885 – 1889), and reached the apogee of his career as one – along with William Henry Welch (pathology), William Halstead (surgery) and Howard Kelly (Gynecology) –  of the “Founding Four” professors of the Johns Hopkins Medical School (1889 –  1905). In his maturity, Osler, still a Canadian citizen, was invited to become the Regius Professor of Medicine at Oxford (1905 – ), a post he held until his death in 1919. Osler introduced bedside teaching at Johns Hopkins, an innovation at that time. He was accused of being a therapeutic nihilist, when in reality he simply did not use treatments that had no backing in science or in experience. His textbook of medicine, first published in 1892, was very influential; with updates, it continued in publication until 2001. Osler’s humanitarian and scientific ideals are held in very high regard within western medicine to this day. There are Osler Societies throughout the English-speaking world, and in Japan.

I first “met” William Osler while I was researching the history of my (Albany) medical school’s World War I  (Army) Base Hospital No 33. Albany Med stood this unit up after the onset of hostilities in Europe, as did many US medical schools and hospitals, under provisions of the National Defense Act of June 3, 1916. When the outfit set up shop in Portsmouth England in 1918, William Osler, then an honorary Colonel in the Oxfordshire Militia and consultant to many Canadian Army hospitals in England, was on hand at the hospital’s commissioning and personally raised the American flag over the facility.

By this time, with England embroiled in that devastating war, and Osler’s  thought was inevitably dominated by military medicine. But this was not always the case. In fact, according to Osler’s biographer the great physician Harvey Cushing, Osler “hated war”. (1) Certainly the lack of writings on military medicine in his early professional years bespeaks at least of disinterest in the matter.

However, during his years at Penn, he developed friendships with several Army medical leaders, among them the eminent bacteriologist and epidemiologist George M Sternberg. When he became Army Surgeon General, Sternberg established the Army Medical School, and it was he who induced Osler to speak to the first graduating class of the school on “The Army Surgeon”. (2)

In his talk to the five members of the Class of 1894, Osler offered the thought that the isolation experienced by Army Surgeons stationed in remote forts could lead, in a man of independent nature, to a healthy self-reliance, and he named such medical luminaries as Jenner and Koch as men who did their pioneering medical research in isolated settings.  Addressing a strength of military organization, he noted the remarkable success that several armies had enjoyed in public health efforts to prevent diseases like smallpox (through systematic revaccination) and typhoid fever through careful attention to field sanitation.  He closed by emphasizing that these new graduates would have great opportunities to advance medical knowledge; all they had to do was to seize them. This was all pretty academic stuff, and Osler made no mention whatever of the matter of combat casualty care.

Two years later, in a talk  “On the Study of the Fevers of the South”, given at the AMA in Atlanta, Osler pondered war and pestilence. He gave the nod to pestilence:

Humanity has but three great enemies: fever, famine and war; of theses by far the greatest, by far the most terrible, is fever. Gad, the seer of David, estimated aright the relative intensity of these afflictions when he made three days’ pestilence the equivalent of three month’s flight before the enemy, and of three (or seven) years of famine. As far back as history will carry us, in ancient Greece, in ancient Rome, throughout the Middle Ages, down to our own day, the noisome pestilence, in whatsoever form it assumed, has been dreaded justly as the greatest of evils.

 Osler did appreciate recent advances in medicine to reduce the impact of “fever” – cinchona for treatment of (malarial) fever,  vaccination for prevention of diseases, and asepsis in surgery – he celebrated only the work of civilian medical workers in these successes.(3)

Despite the good news in medicine that Osler highlighted at the AMA, he did not report, and may have been unaware that a shift in the cause of soldier deaths was already under way. Nevertheless, the American Civil War bore out his conviction about the impact of pestilence – nearly twice as many men had died of non-combat causes, “pestilence” mostly, than had died of their wounds in that most horrific of armed conflicts. Just five years later, however, in the Franco-Prussian War, the numbers were reversed: about 28,000 Germans died of their wounds while around 12,000 succumbed to infectious diseases. (4) The data for French soldier deaths are more evenly distributed, but the trend was established: as scientific principles of disease prevention became applied, the impact of pestilence upon mortality in armies fairly rapidly declined. We do not know if Osler was aware of this change at the time.

It was only when he moved to England to take up the Regius Professorship of Medicine at Oxford, that military medicine began to enter the great physician’s thinking anew.

Next Post: The Evolving Thought on Military Medicine of Osler as Regius Professor of Medicine at Oxford

(1) Cushing, Harvey, The Life of Sir William Osler, Vol 1 (of 2), Oxford, Clarendon Press, 1925, p 631. Cushing wrote this in his commentary about Osler’s life in Baltimore, during his Johns Hopkins years. Cushing’s magisterial biography is available in many editions, including a one-volume book, published in 1940 and 1946. It is also available in a print-on-demand paperback edition, all from http://www.abebooks.com.

(2) Published in a collection entitled Aequanimitas with other Addresses to Medical Students, Nurses and Practitioners of Medicine. H.K.Lewis, London, 1904. The speech is available on-line at http://mcgovern.library.tmc.edu/data/www/html/people/osler/PA1/P25000.htm

(3) Osler, William, The Study of the Fevers of the South, JAMA, Vol XXVI, No. 21, May 23, 1894, pp 999-1004.

(4) The online source Statistics of Wars, Oppressions and Atrocities of the Nineteenth Century (the 1800s), http://necrometrics.com/wars19c.htm, accessed 14 October 2012, cites several authors with general agreement among them.

©2012 Thomas L Snyder

A Step Away From the Past and Into the Present and the Future – An Old Doc’s Look at Health Care Reform

My son James recently sent me a link to a New Yorker article on health care delivery with this question: “Is Kaiser [-Permanente] like the Cheesecake Factory?” He might also have asked, “Is military medicine like the Cheesecake Factory?”

Health Care Reform - Change and Hope

In “Big Med – Restaurant chains have managed to combine quality control, cost control, and innovation. Can health care?”, Boston surgeon and medical writer Atul Gawande tries to apply the lessons he learned, as a result of a meal at a Boston-area Cheesecake Factory, to health care delivery. While noting that the Cheesecake Factory chain has managed – very well – to control both cost and quality while assuring an excellent customer experience, Dr Gawande points out that medicine doesn’t do nearly as well.

According to Dr Gawande, even in the erudite halls of Boston’s vaunted teaching hospitals – presumably models of the best medical care America has to offer – physician approaches to patient care are individualistic – even idiosyncratic; this results in patient complication rates that vary by as much as threefold within the same hospital; and patient / family experiences have historically been almost invariably wretched. While these hospitals may be at the forefront of research and innovation in health care, they don’t seem to be doing a very good job of delivering quality “every day health care” to “every day patients”.

What are the lessons health care could learn from Cheesecake Factory?

The first is a consistent – and consistently good – product. In the restaurant business, consistency means “standardization”, a consistent way of doing the same thing over and over again. My first lesson in medical consistency came during residency: I trained in a Chicago hospital that catered both to “carriage trade” patients and people from a very poor “mile-square” area in the City. In caring for our patients, our attending physicians very early on cautioned us to use the same care procedures for both the very rich and the very poor, because the instant we tried to “customize” our care (either for the rich or for the poor), we risked introducing opportunities for  medical mistakes. Undoubtedly, in medicine just as in the cooking business, you need to apply the individual judgement of a well-trained and experienced professional to each case. But doctors are notoriously a restive group, very protective of their independence. How do you get a “herd of cats” to practice in a consistent manner, even while permitting those individual judgment calls that hone the standardized approach to each individual patient’s needs? Here, I believe, is the first place my Kaiser-Permanente and my military experience becomes instructive. In both Kaiser and the military, practitioners are salaried. Thus, they aren’t competing with each other for patients and for income. I believe this makes for an environment that encourages true collegiality and a sense of “we’re all in this together”. When you combine true collegiality with a strong culture of “best practices”, I think it becomes relatively easier to develop a department-consistent (or even a hospital-consistent) approach to any aspect of medical care delivery. Of course, this takes effective leadership – something both the military and the Kaiser-Permanente model have spent some resources in cultivating.

Another lesson from my experience not necessarily highlighted in Dr Gawande’s piece is the importance of “doctor-based” decision-making. My favorite example comes from northern California Kaiser-Permanente. I was the chief of urology at my Kaiser hospital. At one of our quarterly Chiefs meetings at the Oakland, California headquarters of The Permanente Medical Group, the 13 of us were pondering a question brought to us by the Chief of the 13 Chiefs of Medicine: what should “company policy” be regarding the use of PSA screening for prostate cancer? Then, as now, with the possible exception of one or two very well circumscribed situations, the data are not at all certain. And then, as likely we would now, we argued the pros and cons at some length. Finally, with no consensus forthcoming, we turned in frustration to the representative from “Higher Headquarters” and begged “What do you want us to do?”. The answer was “You are the content experts. When you decide a policy, that shall be the policy of Kaiser-Permanente.” (We’d probably be urged, today, to look for a “best practice” model to follow, subject to change, of course, as experience and research refined our understanding of the medical matter at hand.) What a reassuring message I could bring back to my colleagues, and to my patients! No “bureaucrat” is making health care decisions for you!

Back to the Cheesecake Factory, Professor Gawande takes notice of the extensive use of computers, with screens at face level throughout the kitchens. These provide the company recipes and serving suggestions, readily accessible throughout all 160 restaurants in the chain. Both the military and Kaiser-Permanente have adopted extensive computer operations throughout their systems. In fact, Kaiser was looking to introduce system-wide computerized health care records and data sharing as early as the late 1980s. Computerized systems permit a secure sharing of medical information – lab test results, radiology images and medical history information – at every hospital and clinic in the system. The value of this is immeasurable in the reduction of unnecessarily duplicated tests and exams, and the easy discussion of such things as Xray images between specialists within the system. When my wife was facing arthroscopic knee surgery recently, her orthopedist just pulled her MRI images up on the screen right there in the exam room and went over them with her and me in detail! With the computerization of health records comes a similar easy collaboration between primary care provider and a specialist or specialists who might be located – at least in the military – half way around the world. The Kaiser organization offers an electronic version of a patient’s health record – on a thumb drive – that he or she can take on vacation, at nominal cost.

The Cheesecake Factory has an active product development establishment that produces an updated menu about every six months. Each of the military services has the equivalent – a research arm which searches for innovations in preventive medicine and the special health requirements of people operating in challenging environments whether that be in submarines, in space, or in the mountains of Afghanistan. The Kaiser-Permanente Division of Research, based in Oakland, California, has published more than 4000 peer-reviewed medical articles in its 50 year history. In 2010, its budget of nearly $100,000 supported more than 50 researchers involved in more than 200 research projects largely but not exclusively oriented to the health of large populations.

Both the military and the Kaiser-Permanente systems of health care offer a feature Dr Gawande doesn’t mention – the regionalization of very specialized care. For example, in northern California, Kaiser-Permanente’s more than 3 million patients receive their cardiac surgery at specialty centers in San Francisco and Santa Clara. Neurosurgical care is centered in Redwood City and in Sacramento.  The military system has similar echelons of care, from clinics to primary care hospitals to specialty hospitals. This regionalization avoids unnecessary duplication of expensive specialty care and equipment, and, as a bonus, assures that super-specialty surgeons and physicians are constantly busy – one determinant of successful outcomes.

Then there is the matter of “size”. The Cheesecake Factory, with its 160 restaurants, experiences economies of scale in purchasing of everything from eggs to refrigerators. The Department of Defense medical establishment is huge – the largest in the country. If if were so oriented, its huge purchasing power could effect amazing savings of scale. One example of Kaiser-Permanente marketplace power comes from some years ago. As the story goes, one domestic insulin manufacturer bought out its competition and then announced a large increase in the price of insulin. Promptly the northern California Kaiser pharmacy operation, as a major purchaser of insulin,  reached out to a large Scandinavian insulin producer and offered to partner with them to bring product to market in the US. This effort was successful, and the price of insulin dropped promptly.

Health care reform, in my view, requires one more thing that was implicit in Dr Gawande’s New Yorker restaurant piece: competition. Even while it was struggling to grow in its early years, the Kaiser-Permanente organization realized that healthy competition is a necessity. From the early 1940s, the Kaiser mantra became something like “unless patients have choices in the care they receive, we will have no opportunity to show how good we really are”. When I was practicing Navy medicine as a General Medical Officer, lo, those many years ago, I remember resenting my patients going to the doctors “downtown”, on the civilian side, for their care. I knew we were giving every bit as good care as the “townies” did, but the knowledge that our patients had a choice kept us all on our toes to do the best we could, even in the”captive” care system that is military care.

There you have it: consistency of medical procedures while encouraging the application of sound judgement; salaried health care providers to eliminate destructive competition and encourage collegiality and unity of approach; doctors- or professionals-driven policy decision-making based on consensus best practices; extensive application of computer technology to record keeping, data sharing and promulgation of consistent practice; regionalization of super-specialized care; scale of economy based on large regional or national systems of organization; and vigorous competition among provider systems.

By way of background, I practiced medicine in all three practice settings: active duty military (Navy, for 3 years), fee for service in a small multispecialty group (5 years), and in the large northern California Kaiser-Permanente Health Care system (20 years). In addition, with 20 years in the Naval Reserve, I had contact and conversations with physicians from around the country who practiced in a variety of settings. These experiences all convince me that a salaried system of care providers virtually eliminates the extra and often unnecessary medical procedures engendered by the fee-for-service model where a physician is paid for each procedure carried out. Fee-for-service puts the emphasis, in my view, on health care providers (the more procedures, the higher the income), rather than their patients and what’s best for them. It’s much more natural for salaried providers to be driven by what’s best for their patients, since salaries are going to be paid whether procedures are performed or not.

©2012 Thomas L Snyder