Osler: Art of Medicine

Osler: The whole art of medicine is in observation.

Paraphrased by William Thayer in his book about Osler.

Osler: The way to learn & practice medicine

Paraphrased by William Thayer (Osler's student at Johns Hopkins):

Observe, record, tabulate and communicate.

Use you five senses. The art of the practice of medicine is to be learned only by experience; 'tis not an inheritance; it cannot be revealed.

Live on the ward. Do not waste the hours of daylight in listening to that which you may read by night.

Memory plays strange pranks on facts. The rocks and fissures and gullies of the mountain-side melt quickly into smooth, blue outlines of the distant panorama. Viewed through the perspective of memory, an unrecorded observation, the vital details long since lost, easily changes its countenance and sinks obediently into the frame fashioned by the fancy of the moment.

Always note and record the unusual. Keep and compare your observations. Communicate or publish short notes on anything that is striking or new.

Do not waste your time in compilations, but when your observations are sufficient, do not let them die with you.

Study them, tabulate them, seek the points of contact which may reveal the underlying law.

Somethings can be learned only by statistical analysis. If you have the good fortune to command a large clinic, remember that one of your chief duties is the tabulation and analysis of the carefully recorded experience.

Osler: Reading and General practitioner

It is astonishing with how little reading a doctor can practise medicine, but it is not astonishing how badly he may do it.

Self-centered, self-taught, he leads a solitary life, and unless his every-day experience is controlled by careful reading, or by the attrition of a medical society it soon ceases to be of the slightest value and becomes a mere accretion of isolated facts without correlation.

Books and Men in Aequanimitas 210-211.

Osler: Value of libraries

It is hard for me to speak of the value of libraries in terms which would not seem exaggerated. Books have been my delight these thirty years, and from them I have received incalculable benefits. To study the phenomena of disease without books is to sail an uncharted sea, while to study books without patients is not go to sea at all.

Osler: Medical Teaching

"Teach [the student] how to observe, give him plenty of facts to observe and the lessons will come out of the facts themselves".

Medical News [New York] 1903 (82):49-53

"Eye cannot see what the mind does not know."

"The whole art of medicine is in observaton, as the motto goes, but to educate the eye to see, the ear to hear and the finger to feel takes time, and to makea beginning to start a man on the right path, is all that we can do. We expect too much from the student and we try to teach too much. Give him good methods and a proper point of view, and all the other things will be added, as his experience grows."

"The Hospital as College" Aequanimitas 315-316.

Osler: Instruments of Learning

Observation plus thinking has given us the vast stores of knowledge we now possess of the structure of the bodies of living creatures in health and disease. There have been two inherent difficulties - to get men to see straight and to get men to think clearly; but in spite of the fraility of the instrument, the method has been one of the most powerful ever placed in the hands of man.

Glasgow Medical Journal 1911(76):321-333.

Osler: About poorly educated physicians

A man cannot become a competent surgeon without a full knowledge of human anatomy and physiology, and the physician without physiology and chemistry flounders along in an aimless fashion, never able to gain any accurate conception of disease, practising a sort of popgun pharmacy, hitting now the malady and again the patient, he himself not knowing which.

Aequanimitas 121. "Teaching and thinking"

Osler: Life long learning

If the license to practise meant that completion of his education how sad it would be for the practitioner, how distressing to his patients! More clearly than any other the physician should illustrate the truth of Plato's saying that education is a life-long process.

Importance of post-graduate study. Lancet 1900;2:73-75.

Mediocrity

“He has lulled himself into a false sense of competence.”

(Don't know the source)

Cricket - Field positions

From Wikipedia

Quote: Strong men

Shallow men believe in luck. Strong men believe in cause and effect.

-Emerson

Literature: Teaching to the Text Message

By ANDY SELSBERG

NY Times, March 19, 2011

I’VE been teaching college freshmen to write the five-paragraph essay and its bully of a cousin, the research paper, for years. But these forms invite font-size manipulation, plagiarism and clichés. We need to set our sights not lower, but shorter.

I don’t expect all my graduates to go on to Twitter-based careers, but learning how to write concisely, to express one key detail succinctly and eloquently, is an incredibly useful skill, and more in tune with most students’ daily chatter, as well as the world’s conversation. The photo caption has never been more vital.

So a few years ago, I started slipping my classes short writing assignments alongside the required papers. Once, I asked them, “Come up with two lines of copy to sell something you’re wearing now on eBay.” The mix of commerce and fashion stirred interest, and despite having 30 students in each class, I could give everyone serious individual attention. For another project, I asked them to describe the essence of the chalkboard in one or two sentences. One student wrote, “A chalkboard is a lot like memory: often jumbled, unorganized and sloppy. Even after it’s erased, there are traces of everything that’s been written on it.”

This was great, but I want to go shorter. Like many who teach, I keep thinking the perfect syllabus is a semester away — with just a few tweaks, and maybe a total pedagogical overhaul. My ideal composition class would include assignments like “Write coherent and original comments for five YouTube videos, quickly telling us why surprised kittens or unconventional wedding dances resonate with millions,” and “Write Amazon reviews, including a bit of summary, insight and analysis, for three canonical works we read this semester (points off for gratuitous modern argot and emoticons).”

The longest assignment could be a cover letter, and even that might be streamlined to a networking e-mail. I’d rather my students master skills like these than proper style for citations.

A lot can be said with a little — the mundane and the extraordinary. Philosophers like Confucius (“Learning without thought is labor lost. Thought without learning is perilous.”) and Nietzsche were kings of the aphorism.

And short isn’t necessarily a shortcut. When you have only a sentence or two, there’s nowhere to hide. I’m not suggesting that colleges eliminate long writing projects from English courses, but maybe we should save them for the second semester. Rewarding concision first will encourage students to be economical and innovative with language. Who knows, we might even start to leave behind text messages and comment threads that our civilization can be proud of.

Andy Selsberg, the editor of “Dear Old Love: Anonymous Notes to Former Crushes, Sweethearts, Husbands, Wives and Ones That Got Away,” teaches English at John Jay College.

Quote: Smell the flowers

I hope that while so many people are out smelling the flowers, someone is taking the time to plant some.
- Herbert Rappaport

Osler: "Aequanimitas" - Student Life...its really about the teachers.

Successful teachers is no longer on a height, pumping knowledge at high pressure into passive receptacles. The new methods have changed all this. He is no longer Sir Oracle...,but he is a senior student anxious to help his juniors...When a simple, earnest spirit animates a college, there is no appreciable interval between the teacher and the taught - both are in the same class, the one a little more advanced than the other. So animated. the student feels that he has joined a family whose honour, whose welfare is his own, and whose interests should be his first consideration.

From p75. Osler by Charles Bryan (Oxford Univ. Press, 1997)

This is quoted from "Aequanimitas" series by Osler. Title: The Student Life.

Photography: "Chimping"

NYTimes

March 17, 2011, 2:59 PM

Excerpts from the article.

Lessons learnt from a private lesson from Tom Bear

So what do you do if there’s too much shadow on one side of the face? A real photographer would hold up a reflector on that side—if there’s an assistant and fancy equipment handy. But in a pinch, Tom uses snow, a sheet from the hotel room, a piece of paper, somebody wearing a white shirt, or even—on our photo-safari lesson—a MacBook laptop, whose silver aluminum body makes a perfect diffuse reflector. “That’s why photographers use Macs,” he joked.* Like any good shutterbug, Tom thinks a lot about light. When he’s taking portraits, the subjects are frequently baffled to see him staring at his own fist in front of his face. What he’s doing is gauging the “wrap”—the degree of light falloff from the brightest side to the darkest side. Some degree of wrap is desirable in a portrait (photographically speaking, about 1.5 stops’ worth); you don’t want to shoot in direct sunlight, where you get squinty eyes and deep black unflattering shadows. On the other hand, you don’t want the face to look completely flat, either.

* Tom says that prints don’t show as much noise and pixels as you see on the computer screen. You might be dissatisfied with the way a photo looks on your computer screen, considering it too “noisy” (has too many color speckles)—but you’ll be surprised at how well it prints. You don’t see that much noise, partly because the ink smooths them out, and partly because people don’t look at prints with their noses pressed right up against them.

* Tom almost always shoots slightly overexposed. You can always tone down the brights in Photoshop later. But if the shot was underexposed, it’s much harder to recover the details that are lost in shadow. “And always overexpose women,” he said. “Overexposing kills wrinkles.”

(Note: Several readers left comments that David Pogue got this overexpose advice backwards. But, all agreed with "overexposing kills wrinkles")

* Tom suggests being careful to avoid “chimping,” a term I’d never heard before. That’s where you get so excited about looking at the playback of your photos on the camera’s screen that you miss the great shots still available around you. (Why is that “chimping?” Because you’re standing there, looking at your playback like an idiot, going, “Ooh! Ooh! Ooh!”)

A link from a readers' comments: http://www.luminous-landscape.com/tutorials/expose-right.shtml

Quote: Courage (Mark Twain)

Courage is resistance to fear, mastery of fear - not absence of fear.
- Mark Twain

Quote: Life

Life is just one damned thing after another.

- Elbert Hubbard

Osler: Mentor-Protege relationship

From Osler by Charles Bryant (Oxford Univ. Press, 1997) p. 59 & 62

Origin of Mentor: (Greek legend) Ulysses, king of Ithaca went to Trojan war - leaving behind his wife Penelope and Telemachus under Mentor's care. Telemachus learned practical wisdom from Mentor, that can not be learnt from books.

Mentor-protege relationship can not be forced. The would-be mentor should have competence, character and patience. The would-be protege must show ability, enthusiasm and a willingness to help.

Their personalities should be compatible.

A shared sense of humor is highly desirable, since relationship should be fun.

In general, the story of Mentor-Protege relationship is as follows: The eager young man expresses interest in another's work, formed a bond, and received guidance, focus and affection.

Osler: Quarrels among medical disciplines; Commercialism

1903 Speach to New Haven Medical Association:

Quarrels in medicine seem to make a pretty chapter in the history of medicine. Each generation seems to have had its own.

Quarrel among physicians has existed even in ancient times...

The Coans and the Cnidians, the Arabians and the Galenists, the humoralists and the solidists, the Brunonians and the Broussaisians, the homeopaths and the regulars in different centuries, rent the robe of Aesulapius. But these larger quarrels are becoming less and less intense...

Standard of the profession:

One has only to visit different parts of the country and mignle with the men to appreciate that everywhere good work is being done, everywhere an ernest desire to elevate the standard of education and everywhere the same self-sacrificing devotion on the part of the general practitioner.

Men will tell you that commercialism is rife, that the charlatan and the humbug were never so much in evidence, and that in our ethical standards there has been a steady declension. These Elijahs who are always ready to pour out their complaints, mourning that they are not better than their fathers...But, I am filled with thankfulness for the present and with hope for the future.

Garth in 1699 states the following:

"Now sickening Physick hands her pensive head

And what was once a Science, now's a trade."

Of medicine, many are of the opinion....that ancients has endeavoured to make it a science and failed, and the moderns to make it a trade and have succeeded. To-day the cry is louder than ever, and in truth there are grounds for alarm; but on the other hand, we can say to these Elijahs that there are more than 7,000 left who have nto bowed the knee to this Baal.

p.52-53 Osler by Charles Bryant (Oxford Univ. Press, 1997)

Travel Tips - Spending and tipping during travel

Is There a Right Way to Spend Money When Traveling?
By KEVIN SALWEN
Published: NYTimes March 9, 2011

1. Fix a daily or weekly budget. You may not be able to avoid feeling like a patsy or a skinflint, but a budget of how much to spend, tip or give will create a structure for your own sanity. The goal is to walk that tricky line between helping and having every encounter turn into a negotiation. You’ll never make everyone happy, but at least you’ll have a framework.

2. Overbuy gifts for yourself and others. This is our favorite method of economic development. It helps fuel employment (the most dignified form of money transfer) and it has the residual benefit of having something to bring back home. On a trip to India, we bought a gorgeous hand-woven rug in Jaipur, a piece that we were told took more than four months to make. As our guide, Ashok Verma, later told me in Varanasi, India: “Crafts are the best thing to buy; they have people’s dreams woven into them.”

3. Don’t bargain down price, bargain up quantity. Joan wanted to buy a set of colored stamps with bindi (Indian forehead dots) for her students (she teaches seventh grade). One hundred rupees, the vendor said. No, too expensive, she replied, following cultural norms of bargaining. The negotiation was on. Finally, Joan bought three sets for that same 100 rupees (about $2). The man got his price, she got more stamps. Ms. Honey urges travelers to stop bargaining before they are the only winner. “Let people earn a real wage,” she cautions.

4. Try to be more than a consumer. Local citizens “may be economically poor but they are often culturally rich,” says Harold Goodwin, professor of Responsible Tourism Management at Leeds Metropolitan University in England. So, engage in their culture by getting off the large bus and taking an interest in how they make their living. It’s O.K. to take photos of individuals who capture your interest — but only if you ask first and pay if requested, he adds. The rule is simple, Mr. Goodwin says: “Treat them as you would like to be treated.”

5. Let others earn a living by helping. In American airports and hotels I never get help with my luggage; wheeled bags roll, don’t they? But overseas, I’ve learned to relax and let someone else carry my suitcase. It’s a rational way for local residents to feed their families, and certain people have turned luggage-carrying into an art: when we were leaving the Varanasi train station, a man offered to carry our bags, then stacked both my and Joan’s roller suitcases on his head for our 200-yard walk.

6. Don’t give to panhandlers. Handouts send a multitude of wrong messages about dependency and the value of work. Plus, handouts encourage more begging, often by children (an awful alternative to school). Long-term change never starts with a quarter or even $10 stuck into someone else’s palm. Still, even Ms. Honey concedes she breaks down sometimes. “I tend to give to women and children because they are the most vulnerable.”

7. Instead, buy stuff on the street. The hawker’s life is a tough one, always a fight against weather, traffic and crime. So if you want to help, buy more than you usually might. Granted, I acted counter to this by not buying that T-shirt from the boy in Palmyra, but, as I think about it now, what would it have harmed if I had? Since then, I’ve purchased boiled eggs, bagged water, toys, even a novel. (I politely said no on the kitchen strainer.) Why not bolster that small-business spirit?

8. Sample local food. Tourists in the developing world often eat at a limited number of hotels or restaurants deemed safe by guidebooks. There’s logic to that, especially where food-borne illness is concerned. But you’d be missing out on part of the reason you travel in the first place.

“Buy food and beverages from local producers, taste the locally produced foods and enjoy this as part of your holiday experience,” Mr. Goodwin says. For instance, you haven’t really tasted a banana if you’ve never had one grown for immediate consumption (compared with ones modified for export and sold blemish-free in United States supermarkets). Peels help keep the fruit safe, as does boiling in the case of a cup of local tea. The winners are the farmers, who often are at the bottom of the economic pyramid.

Kevin Salwen and his daughter, Hannah, are the authors of “The Power of Half: One Family’s Decision to Stop Taking and Start Giving Back.”

A version of this article appeared in print on March 13, 2011, on page TR3 of the New York edition.

Quote: Osler - Importance of medical societies

p.50

The daily round of a busy practitioner tends to develop an egoism of a most intense kind, to which there is no antidote. The few set-backs are forgotten. The mistakes are often buried, and ten years of successful work tends to make a man touchy, dogmatic, intolerant of correction and abominably self-centered. To this mental attitude the medical society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms.

From Osler by Charles Bryan, Oxford Univ. Press, Oxford. 1997.

Online Software: Photo editing

Collected from an article on NYTimes (Mar 10, 2011)
photofunia.com

photo505.com

aviary.com
pixlr.com
splashup.com
citrify.com
taaz.com (makeup)
bighugelabs.com

Regional Bias in Rate of CABG surgery!

Data Watch
NEJM March 9, 2011
Dartmouth Atlas: Surgery rates for preference-sensitive conditions depends largely on where patients live and the clinicians they see.

Coronary artery bypass surgery (CABG) per 1,000 Medicare beneficiaries among hospital referral regions (2003-07)The colors on the map represent the rates of CABG surgery per 1,000 Medicare beneficiaries in each HRR. Rates are adjusted for age, sex and race. The highest rate, 8.9 procedures per 1,000 beneficiaries, was seen in McAllen, Texas. The lowest rate, 1.9 procedures per 1,000, was seen in Pueblo, Colorado. In other words, patients in the McAllen HRR were more than four times more likely than patients in the Pueblo HRR to undergo CABG during 2003-07. The national average rate of CABG was 4.6 per 1,000. The greatest variation within a single HRR was seen in Denver, where the rate of CABG surgery ranged from less than 2 per 1,000 beneficiaries in the Steamboat Springs, Colorado HSA to more than 7 per 1,000 in the McCook, Nebraska HSA.
Source: Improving Patient Decision-Making in Health Care: A 2011 Dartmouth Atlas Report Highlighting Minnesota

Quote: Osler - Find a calling, Stages of life

From Osler by Charles Bryan (Oxford Univ Press 1997)

p.32

Age specific developmental tasks:

(According to Carl Jung,...later by Erik Erikson)

21-35: Stage of identity

35-55: Stage of generativity

>55: Stage of consolidation

p.33

Osler to gradulating nursing students 1891:

...And happy life shall be yours, because busy and useful; having been initiated into the great secret - that happiness lies in the absorption in some vocation which satisfies the soul;that we are here to add what we can to, not to get what we can from, life.