Internal medicine, the pandemic, and William Osler

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A guest column by the American College of Physicians, exclusive to KevinMD.

National Internal Medicine Day is October 28, 2020.  It’s a time for internists to reflect on the work they do and take pride in being a part of the greater internal medicine community.

Recognizing internal medicine and the work of internists is particularly pertinent in the midst of an ongoing pandemic in which the specialty occupies such a central role. Internists across the spectrum of practice have both stepped-up and stepped-in to manage the novel coronavirus crisis around the world.   This includes those treating patients in primary care and ambulatory settings, hospitalists, critical care/intensivists, and the wide range of subspecialty internists focused on dealing with the infectious, pulmonary, and multiple other clinical manifestations of COVID-19 about which we are rapidly learning.  And the work of internists in public health and the basic and clinical sciences in seeking to protect our society and ultimately control the infection has been essential in our response to the pandemic.

However, as we take a moment during this unique time to think about internal medicine, it’s also helpful to look back in time toward the origin of our specialty to gain a historical perspective around how we approach the work we do and to better understand how the core tenets of the discipline established many years ago prepare us well for the current challenges we are facing.

As most internists know, William Osler is perhaps the most prominent figure in the history of internal medicine, credited with formulating the scientific and analytical approach that characterizes the specialty and defining the attributes considered essential to its practice.  He was born in 1849, and the centenary of his death at age 70 years was just recognized in December 2019.

One of the key aspects of internal medicine that Osler promulgated was the need to be an astute and discerning observer of both health and disease, something that he was particularly masterful in doing and is why at least four clinical findings or conditions bear his name.  He noted that the importance of doing so was to achieve the best possible understanding of normal physiological function and the clinical manifestations and mechanisms of disease so that the best that science has to offer can be applied to preventing disease and treating the ill.  This is one of the hallmarks of internal medicine that has served as a foundational principle of the discipline since its beginning.  And several examples of this, as demonstrated by Osler early in internal medicine’s history, are particularly pertinent for the present day.

Most internists are aware that in his landmark internal medicine textbook, The Principles and Practice of Medicine, Osler commented that “Pneumonia may well be called the friend of the aged. Taken off by it in an acute, short, not often painful illness, the old man escapes those ‘cold gradations of decay’ so distressing to himself and to his friends.”  Underlying this statement was the observation that while many of his patients died with pneumonia, not all of them died of pneumonia.

What is less known is that as early as 1897, Osler recognized that in patients with pneumonia, other factors (for which he used the term “toxaemia”) seemed to frequently lead to dysfunction of multiple organs, including the heart, kidneys, and brain, usually resulting in death.  Additionally, he noted that the findings of toxaemia may develop relatively early in the course of pneumonia, progress rapidly and in a relentless manner, and were often not proportional to the amount of lung disease present.  In fact, he stated in regards to pulmonary infections that “the toxaemia outweighs all of the other elements in the prognosis.”

In retrospect and based on current scientific knowledge, what Osler described over a century ago seems quite consistent with the complex (and incompletely understood) cascade of inflammatory and anti-inflammatory events leading to the progressive development of the acute respiratory distress syndrome and multiple organ system failure associated with hypercytokinemia, now often referred to as a “cytokine storm” that has been such a prominent aspect of the current pandemic.

This was an incredibly prescient clinical observation that is an iconic example of the fundamental approach that internists are taught – to carefully analyze, characterize, and seek to explain the many different facets of the clinical situations they encounter, even if the scientific basis underlying what they are seeing may not be fully understood.  And Osler even extended this emphasis on clinical observation and analysis to himself as a patient during his final illness, seeking to understand how the different pieces of his own disease process fit together.

Osler initially became ill in July 1919 in the midst of the last major pandemic, the H1N1 influenza outbreak that began in 1918.  His description of his own clinical course shows a multiphasic illness with a brief initial bout of fever and cough accompanied by systemic symptoms that resolved over several weeks, followed by a recrudescence in September of that year that ultimately led to a steadily declining course and ultimately his death in December 1919 from complications of treatment of a likely Haemophilus influenzae empyema.

Although the state of medical science at the time of his death does not allow us to know definitively whether Osler was ultimately a victim of the influenza pandemic of his day (which both he and his personal physician felt played a part in his illness), our current understanding of bacterial superinfection as a significant cause of morbidity and mortality in the setting of prior influenza infection in high-risk patients (as was Osler) could certainly fit with his description of his own clinical course.

The importance of these historical examples to our present time is that as internists, we are again being called upon to actively exercise these same observational and analytical skills as we collectively seek to understand, characterize, and manage the new and as yet poorly-defined disease causing our current pandemic.

The ability to do this is a key aspect of our legacy as internists – one that has served the discipline well since Osler’s time and will certainly position us well to confront not only our current medical challenges but also those in the future.  And being able to apply our individual clinical curiosity and collective intellect as a discipline in seeking to improve the health of our patients and society is certainly a reason to be proud to be an internist.

I’m also sure that Osler himself would also be heartened to see how internal medicine has grown and flourished both scientifically and by evolving toward a wonderfully heterogeneous group of physicians truly committed to providing essential care to our broadly diverse patient population in these difficult times.

Happy Internal Medicine Day!

Philip A. Masters is vice-president, Membership and International Programs, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

Image credit: Shutterstock.com

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