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an online version of the magazine Fall 2009
Annals of Hopkins

The Imperturbability Club

By Janet Farrar Worthington


In establishing the hospital residency system we know today, William Osler (seated and leaning toward patient) aimed to turn out “master” clinicians.

Like all Hopkins-trained internists, the late and legendary Baltimore physician Benjamin Baker ’27 honed his craft on the Department of Medicine’s Osler Service. Baker, who would go on to treat such luminaries as F. Scott Fitzgerald and Clark Gable, never forgot the ordeal. Sixty years later, recalling his relentless first year as a resident on the service, he recounted, "I was the sole intern on duty 24 hours a day, seven days a week with no time off unless arrangement was made with another of the five interns. I did not take my white suit off from July first to January first."

Living in a white coat, feeling dog-tired, working like you’ve never worked in your life, but being rewarded with a vast amount of knowledge about medicine and knowing that you’re now a lifelong member of a select family of doctors—that’s the Osler Service. And although some major diseases have changed, and interns today enjoy a bit more of a social life, "the spirit of the Osler first year really has never changed," says Charles Wiener, the physician who has directed the residency program for more than a decade.

The hospital residency system as we know it in America was established at Johns Hopkins in the 1890s. William Osler, the first professor of medicine here, adapted it from the German system of postgraduate medical training with the lofty goal of turning out "master" clinicians. Osler structured the residency like a pyramid—lots of interns, fewer assistant residents, and a lone chief resident, who might stay on the job indefinitely (William Thayer, Osler’s second resident, held the post from 1891 to 1898). By the dawn of the 20th century, the Osler Service was recognized as the premier training program in the medical profession. It’s pretty much remained that ever since.

Richard S. Ross, seen here lecturing in the 1960s, became an Osler house officer in the years following World War II. "There was an ethos of being an iron man," he recalls.
The real glory years, though, came right after World War II, when A. McGehee Harvey, the brilliant young new head of the Department of Medicine, graced the cover of Time and the eyes of the world were on Hopkins. Richard S. Ross became an Osler house officer during those years and chief resident in 1953. Ross, who went on to head cardiology here and then become dean of the School of Medicine, was a Harvard man. Already accepted for his residency at Massachusetts General Hospital, he came to Hopkins for a year "just to see how they did things someplace else." He stayed for 60 years.

"I had just gotten out of medical school and really didn’t know anything," Ross recalls. "But coming back onto the Hopkins house staff from the war were people who were maybe four or five years older than me. Those guys were really just one year ahead in training, but they’d had a postgraduate experience in the military, so it was an ideal learning experience." At the time, Ross says, the Osler Service was very small, with 14 interns, a handful of assistant residents, and a tremendous esprit de corps. "There was an ethos of being an iron man who could stay up all night and take care of your patients, and nobody was worried about the hours. We were proud of what we did, and we supported each other."

By the dawn of the 20th century, throughout American medicine, the Osler Service was recognized as the premier training program in the medical profession. It’s pretty much remained that ever since.

That sense of warm-spiritedness has characterized the program from its start. Osler stressed its importance in a letter to the medical board of the hospital: "These young men [yes, they were once only that] come in contact with us at all hours and it is absolutely essential that they should be persons with whom we can work pleasantly. I have suffered so on several occasions from inefficient or ungentlemanly residents foisted upon me...that I would here enter my warmest protest against it."

Former Osler residents still hold dear the bonds they formed toiling together with colleagues. Indeed, Ross and Richard Johns, both revered retired Hopkins faculty now in their 80s, forged a lifelong friendship when they served as fellow Osler residents 60 years ago. And on Fridays, all over the world senior physicians still wear The Tie. Adorned with a plain blue background and shields emblazoned with a favorite Osler expression, Aequanimitas (Latin for Imperturbability), The Tie symbolizes membership in a select club.

For Mark Worthington, now a member of the GI faculty at Hopkins Bayview (and this writer’s husband) it was actually The Tie that led him to the Osler Service for his residency. As a medical student at Vanderbilt in the 1980s, Worthington saw one of his professors, senior cardiologist Gottlieb Friesinger, religiously wearing the neckpiece on Fridays and finally asked him about it. Friesinger, who’d gone through the Osler Service residency 30 years before, responded with such a rave review that Worthington applied.

William Osler pictured here with his Hopkins house staff, 1890-91. By the 1900s, the Osler Service was recognized as the premier training program in the medical profession.
Still, as the practice of medicine changed during the latter half of the 20th century, the Osler Service finally required rethinking. In 1975, it was Victor McKusick, who, as head of Medicine, organized the modern program. Basing his new model on a concept he’d seen at Guy’s Hospital in London, McKusick created four teams or "firms," named after early physicians in the Department of Medicine. For today’s 110 entering residents, each of whom is assigned to one of the teams, these firms form tight teaching units and a home base.

The crux of the residency, however, remains as Osler conceived it: The intern stands as the point of contact between the entire health care team and the patient. Or, as John Stobo, an Osler resident during the late 1960s and head of Medicine from 1985 to 1994, used to say, "They are the Department of Medicine’s chrome bumpers." "The Osler internship experience," Wiener says, "is unique among internal medicine training programs. Putting interns in that situation of responsibility right out of medical school, and then providing them with great mentorship is what creates a Hopkins-trained physician." As they move through the three years of residency, those doctors in turn begin teaching the interns who come behind them.

Today, the role of chief resident has disappeared. Instead, the Osler Service invites four outstanding senior residents who complete a year of fellowship to spend an extra year guiding the residents as an assistant chief of service, or ACS. "The ACSs run the Osler Service," Wiener says. "There are not four other doctors in the country who do what they do."

Roy Ziegelstein, who accepted the hallowed ACS position in 1989 and is now a program director for the internal medicine residency at Johns Hopkins Bayview, recalls that before his Hopkins residency he’d thought of the Osler Service as some sort of rarified club. Today, he believes that reputation is deserved. "Osler residents take care of extremely sick patients," Ziegelstein says, "but they work alongside giants in the field of medicine. Sure, there’s a sense of being in the trenches, but you’re surrounded by people who have the same aspiration to greatness. That’s very unusual, I think, for a residency program—the sense that everyone’s gaze is on the stars."

John Stobo liked to refer to Osler residents as “chrome bumpers”—the point of contact between the entire health care system and the patient.
Peter Kilmarx, who came through the Osler Service in the late 1980s and now heads the epidemiology branch of the division of HIV/AIDS Prevention at the Centers for Disease Control and Prevention in Atlanta, also remembers his group of residents pushing each other to really profound medical knowledge. "One thing I learned is, trust no one," he says. "You can’t say, the lab told me this:

You have to know, and you have to be right."

But just like Ben Baker who preceded him by 60 years, Kilmarx still hasn’t forgotten the all-out fatigue of the experience. One story especially has stayed with him: On Christmas morning in 1990, dog-tired after an all-night rotation at the Hospital, Kilmarx pulled his little red Toyota Tercel over on the side of I-95 to take a catnap on his way home. Awakened by a state trooper knocking at his car window, he recollects, "Here I was in my scrubs and white coat. I looked at him and said, I’m an intern at Hopkins, and I’m just so exhausted." 1

 Take Two Carrots and Call Me in the Morning
 Judgment Day
 Circling the Dome
 Medical Rounds
 Annals of Hopkins
Class Notes
 News from and about graduates.
 Learning Curve
Johns Hopkins Medicine

© The Johns Hopkins University 2009