The Invention of Bedside Manner
The seventeenth century physician and writer who inspired a tolerant approach
Posted June 8, 2015
We all know what we mean when the speak of ‘bedside manner’. We know who should show it and when – the doctor to their patient in need of care and treatment. The ‘how’ was always trickier. Not all doctors find it easy to adapt their medical knowledge and understanding to a tone – and for that matter language – that patients can comprehend and will accept.
Doubtless, a few physicians always had an intuitive rapport with their patients. But for the rest, it was necessary to invent the bedside manner. As medicine became more technical and complex, doctors needed to be reminded how to relate to their patients.
The man who, perhaps more than any other, had this realization and was responsible for incorporating its lesson into medical training was the Canadian physician William Osler. In 1889, at the age of 40, he moved to the United States to take up a position as chief physician at Johns Hopkins Hospital in Baltimore, MD. There, he was largely responsible for the founding of the now world-renowned Johns Hopkins University School of Medicine.
Osler’s great innovation was to see that students needed to learn not only in the classroom and the dissection laboratory but by coming into contact with real patients. He instituted the idea of the medical residency whereby trainee doctors made up a large proportion of the hospital’s staff. In that way, physicians would learn to recognize illness as it occurred and not in the idealized form in which it was represented in textbooks. They would learn to listen to what the patient was saying – and perhaps also to divine what it was they might be hiding – as well as to examine them physically. The Johns Hopkins Hospital expanded rapidly, and the teaching hospital generally soon became the lynchpin of Western clinical care provision. ‘I desire no other epitaph,’ Osler later wrote, ‘than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.’
But what inspired Osler? In 1905, he was made Regius professor of medicine at Oxford and traveled to England for his inauguration. But perhaps of even greater significance to him on this same trip was that he journeyed to Norwich where he had been invited to attend the unveiling of a statue to one of that city’s greatest figures, another physician, Sir Thomas Browne. The statue was placed to commemorate the 300th anniversary of Browne’s birth.
Osler had been introduced to the writings of Sir Thomas Browne by a friend when he first set out to study medicine. He read Browne’s youthful essay, Religio Medici, written in the 1630s when he had just qualified. Religio Medici means ‘the religion of a doctor’ and is an autobiographical confession of his Christian faith by a man who, because of his medical training and scientific skepticism, feared he might be thought to have no faith at al. It remains one of the most vivid and thought-provoking works of the 17th century, and Osler was deeply influenced by it.
Apart from a judicious and rationalist statement of his faith – ‘I borrow not the rules of my Religion from Rome or Geneva, but the dictates of mine own reason’ – Browne displays a level of tolerance that is admirable enough now, and is simply extraordinary for his period in a Europe set against itself by religious wars. ‘I could never divide my selfe from any man upon the difference of an opinion, or be angry with his judgment for not agreeing with mee in that, from which perhaps within a few dayes I should dissent my selfe,’ he wrote.
In order to complete his training as a physician, Browne left university at Oxford to study in the best European centers, Montpellier in France, Padua in Italy (following in the footsteps of William Harvey, who discovered the circulation of blood) and Leiden in the Netherlands (where Descartes and Rembrandt visited the anatomy theatre). On his travels, he was exposed to unfamiliar tongues, religions, diseases, plants and animals, assimilating and eagerly learning from them all. He also witnessed the aftermath of much conflict – a presage to the civil war that awaited upon his return to England.
But it was surely his patients in Norwich that most stretched Browne’s mind. His major work was not the early Religio Medici or Urn Burial, a late essay meditating on the transience and vanity of human monuments, and the work of his perhaps most admired by writers from Melville to Emily Dickinson. His most successful work in his lifetime was a multi-volume catalogue with the cumbersome title Pseudodoxia Epidemica, and the more helpful subtitle ‘vulgar errors’. Here, Browne gathered 200 such errors – the urban (and rural) myths of the 17th century – and debunked them one by one.
It is the manner of his debunking that is most instructive to us today. For Browne does it with great tolerance, forgiveness and good humor as well as great literary style. His tone is markedly different from many science writers who set out to disabuse the overly credulous today. The 17th century errors seem foolish to us now as no doubt one day our refusal to accept a vaccine or to swallow a homeopathic pill will seem to our successors. For example,
Browne uses a variety of strategies. Considering the popular belief that badgers’ legs are shorter on one side than the other, for example, he encourages his readers to find this idea ‘repugnant to authority, sense and reason’. In other words, scholarly authors do not support it. Actually looking does not support it. And nor does logic – after all, do any other creatures have similar asymmetry? Occasionally, he describes an experiment he has done to refute a silly thing. Apparently, people believed that a dead kingfisher hung from a thread tells which way the wind is blowing. Browne rigs up first one dead kingfisher, but can draw no firm conclusion about its orientation with respect to the wind. So, he hangs up a second bird, and finds that the two point every which way. Therefore, a dead kingfisher is not a good weathervane after all.
Throughout, Browne wants people to think for themselves and to acquire a certain skeptical mindset – what Carl Sagan would later call a baloney detection kit. Undoubtedly, he heard many of these stories while chatting to his patients. He has a vested interest in dispelling those many beliefs that encroach on his area of professional expertise, where charlatans claim that such and such a mineral or herb or animal part has curative powers – that amethyst cures inebriation or that unicorn horn is an antidote to fevers, for example. But when he reckons a ‘vulgar error’, though it be baseless, will not produce actual injury – he discusses the belief that a certain kind of stone held to the belly will ease labor pains – he sees no harm in letting people persist with the custom.
What is most telling in Browne’s catalog of ‘vulgar errors’ is that he has clearly brought his bedside manner to the page. He knows how to tell it straight when a belief is dangerous, but he also knows to lay off when it is something that will do nobody harm. And above all, he remembers always to treat his reader, as he surely treated his patients, as human beings. Impressionable maybe, foolish even, but still always human.
Literary scholars cherish Browne’s writings. But it may come as a surprise to learn that we call use his words. He was one of the most prolific inventors of words at a time when the English language was rapidly expanding. He invented medical words, such as ‘coma’, ‘hallucination’ and ‘expectoration’, as well as ‘medical’ itself. But he also coined many new words which show him at the forefront of an emerging new world of science in which it is important to distinguish the fact from the fabulous – words such as ‘anomalous’, ‘incontrovertible’ and ‘fallaciously’.
Not all of his words gained a permanent foothold in our dictionaries. He also coined the word ‘deuteroscopy’. It means taking a second look. Nobody is more worthy of a second look than Browne himself.