Stanford University School of Medicine and the Predecessor Schools: An Historical Perspective
Part V. The Stanford Era 1909-

Chapter 33: The Clinical Full-Time System

It was the work of the 19th century to place medical education on a scientific basis, and of the twentieth century to put clinical departments on a full-time or "university" basis. The clinical full-time system of faculty organization played such an important role in raising clinical departments to the university level of scholarship and productivity that a history of its evolution is in order.

Origin of the Full-Time Concept

Before further consideration of the organization and development of the medical faculty at Stanford during the deanship of Dr. Wilbur and after, we should recall that Johns Hopkins, to which Stanford looked as its model, installed the clinical full-time system in 1914.

We have already described briefly (in Chapter 3, pp. 31-35) how Hopkins adopted the system of full-time faculty appointments for the clinical departments of Medicine, Pediatrics and Surgery. Full-time appointments were already the norm for the basic science departments in the few American medical schools with advanced programs, but there was no medical school in the country in which the clinical departments were on the full-time or "university" basis. Hopkins was the first. [1]

It was argued that teaching and particularly clinical research would be greatly enhanced if faculty of the clinical departments were also employed full-time by the university as in German medical schools. Under such a full-time system, clinical faculty would not be permitted to hold outside paid positions, or to engage in private medical practice for personal gain, lest their attention to teaching and research be diverted by external commitments and the prospect of additional income. Any income from private practice incidental to teaching and research would be collected and retained by the medical school.

The conversion of the clinical departments of Medicine, Pediatrics and Surgery at Hopkins to a full-time or "university" basis in 1914 was one of the century's most significant and invigorating innovations with respect to the organization of American medical faculties. It was also one of the most controversial because of (1): its prohibition of private practice for personal gain and (2): its possible undesirable side-effects. "I take it," Osler told Johns Hopkins president Remsen, "the special advantage claimed for the whole-time system is that the Professors will be better able to promote research." But Osler initially feared that the plan might foster "the evolution throughout the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only human interest was research." Years later Osler changed his opinion and endorsed the full-time concept. [2]

The fact that Stanford eventually adopted the clinical full-time system in 1959 makes it relevant at this point to provide additional information on the origin and evolution of the system.

In 1884, while studying at Leipzig in the laboratory of Carl Ludwig, noted German physiologist, William Welch met another visiting American trainee, Frederick Mall. Welch and Mall were so impressed by the success of the German model of full-time clinical appointments in fostering scholarly work that they later played critical roles in introducing the full-time plan into this country.

Circumstances brought Welch and Mall together again in 1893. Welch had by that time become the first Professor of Pathology and Dean at Johns Hopkins Medical School, and Mall was Professor of Anatomy at the University of Chicago. On the invitation of Dean Welch, Mall resigned his post at Chicago and in 1893 became the first Professor of Anatomy at Hopkins. There he and Welch joined in a continuing effort to persuade the Hopkins' faculty to install the full-time system in the clinical departments. [3] [4]

Dr. Barker Acclaims the Clinical Full-Time System

Their cause was significantly advanced by one of their trainees, Dr. Llewellys F. Barker, who left Hopkins in the summer of 1900 to become Professor of Anatomy at Chicago. As a result of his prior association with Professors Welch and Mall, particularly Mall, Barker was convinced of the merits of the clinical full-time concept. When invited to address a Chicago meeting of the Western Alumni of Johns Hopkins University on 28 February 1902, Barker seized the opportunity to discuss the concept in detail. The title of his address was "Medicine and the Universities." [5]

In his comprehensive discourse, published in the journal American Medicine of 5 July 1902, Barker urged extension of the "university" or "full-time" system to the organization and conduct of the main clinical departments of medical schools connected with universities. He declared that a university school of medicine must place emphasis on research as well as on teaching. This could best be accomplished, he argued, by expanding the full-time system of appointment from the preclinical to include the clinical departments. To eliminate the financial incentive for practice, the professors' medical fees should go to the institution. [6]

The following perceptive contemporary critique of Dr. Barker's address is from an editorial in the Journal of the American Medical Association for 18 October 1902: [7]

In a recent and widely noticed address on "Medicine and the Universities" Dr. Lewellys F. Barker, of the University of Chicago, reviews the general progress of medical instruction in this country, and gives his ideas as to its needs. A special weakness of the methods of the present day, in his opinion, is in the fact that the teaching of medicine is not an exclusive life-work of those who are engaged in it, and in this he would include not only instructors in the especially scientific branches, but also those who have the chair of general internal medicine and of surgery as well as of the specialties. The university medical school, he holds, should be like the other departments of the university, with its professors devoting themselves solely to instruction and original work, and in no way dependent on other work or tempted to seek income from outside sources. . .

Daily experience in the practice of medicine has certain advantages and the teacher thus trained is, in our opinion, other things being equal, better qualified, more practical and less purely theoretical than one whose professional duties are confined within medical college and hospital walls. . . .

Dr. Barker's ideal, therefore, seems impracticable in this particular, however admirable it may be in other respects. . .The great expense of carrying out all of Barker's suggestions would be an obstacle to their realization - except it may be in one or two favored places - but that alone would not be the greatest obstacle. The impossibility of isolating the highest medical ability which it should command would be a greater one.

Clearly the idea of full-time appointment of essential faculty in the clinical departments of American medical schools was not original with Barker. He gave credit to Dr. Mall for being the first to advance the idea in this country. He assumed that Mall got the idea from the German system as it operated under his old master, Carl Ludwig. Regardless of how the idea originated, Barker was the first to comprehensively articulate and effectively advocate adoption of the full-time system in the clinical departments of American university medical schools.

Reverend Gates and the Rockefeller Institute

Barker introduced the clinical full-time system to the medical profession at large. Fortunately, he also brought it to the attention of Reverend Frederick Gates, one of the few men who had access to the funds essential to support such a system. Reverend Gates was a Baptist minister and trusted senior adviser on philanthropic programs to the oil magnate, John D. Rockefeller, Sr. Convinced that humanity would benefit if medicine became more scientific, Gates played a crucial role in Mr. Rockefeller's decision to endow the Rockefeller Institute for Medical Research, incorporated in New York City on 14 June 1901.

Dr. Welch was Chairman of the first Board of Directors of the Institute, and his influence with Gates and the Rockefeller organization grew even further when his protégé, Simon Flexner, was appointed first Director of Laboratories at the Institute: [8]

Simon Flexner (1863-1946), an older brother of Abraham Flexner, was born (25 March 1863) in Louisville, Kentucky, and graduated in medicine from the University of Louisville in 1889. One year later he came to Baltimore and entered Dr. Welch's laboratory as a graduate student in pathology. At the end of that year (1891) he was appointed Fellow in Pathology. From that time until 1899 he was connected with both Hopkins Medical School and Hospital, and when Dr. Councilman left in June 1892 to become Shattuck Professor of Pathology at Harvard, Flexner became the right hand man of Dr. Welch in the Hopkins Pathology Department.

In 1895 Flexner was made Associate Professor of Pathology at Hopkins and in 1898 Professor of Pathological Anatomy, a post which he held for one year only, resigning to accept the professorship of Pathology at the University of Pennsylvania. From there he was called in 1903 to organize the Rockefeller Institute for Medical Research in New York City, and he served as Director of that institution until his retirement in 1935.

While at the Institute he guided the work of numerous investigators while he himself continued to contribute to the study of infectious diseases and helped to develop a serum for spinal meningitis in 1907. After that he and his coworkers did fundamental research on the nature, transmission and viral origin of poliomyelitis.

However, it is perhaps not amiss to say that the solid foundations for his success in these endeavors were unquestionably laid during the years when he served under Dr. Welch in Baltimore. [9] [10]

The General Education Board

The Rockefeller Institute, with Simon Flexner at its head, created an environment and prototype for medical research on a scale unprecedented in America, and it served to strengthen the ongoing relationship between the Gates - Rockefeller and Welch - Hopkins alliances. This relationship soon found its further expression in another Rockefeller philanthropy, the General Education Board.

The GEB was established in 1902 (incorporated by an Act of Congress on 12 January 1903) for the broad general purpose of promoting "education within the United States without distinction of race, sex or creed." This foundation, liberally endowed by John D. Rockefeller, Sr., seems to have been primarily the brainchild of his son, John D. Rockefeller, Jr., with Gates contributing to the planning. Gates was a Trustee of the GEB from 1902 to 1928 and Chairman from 1907 to 1917. He was doubtless responsible for directing the Board's program into a primary concern with the problems of medical education in America. As a result of this orientation, it was logical that he and the Board looked increasingly to Welch for advice and to the Hopkins school as a model. The Board ultimately became the source of many generous grants in support of clinical full-time programs. [11] [12]

Barker's essay on the clinical full-time system coincided with the founding of the GEB. Gates was greatly impressed by Barker's formulation of the concept as the most effective means of encouraging research and teaching in the clinical departments of medical schools. In a letter to Barker written years later, Gates told him how deeply he had been affected by his discourse on the clinical full-time system and added: "To your ideals as there and elsewhere presented we owe, I suppose, more than to any other factor, our present progress (in medical education)." [13]

Mr. Gates's interest in medical education and his strong advocacy within the GEB for the funding of programs designed to improve medical research and teaching, were also stirred by a chance introduction to Osler's classical Principles and Practice of Medicine, the best text-book in English on the subject at the time. A young medical student whom he had baptized urged Gates to read Osler's book. While reading the book Gates told the president of the University of Chicago that he had "scarcely ever read anything more intensely interesting." In 1902 he told Osler that while studying his book, "the vast possibilities for good lying in this field of research opened up before my imagination and fired my enthusiasm." [14]

Barker Succeeds Osler in 1905

William Osler, Professor of Medicine at Hopkins and the country's most celebrated internist, departed for England in 1905 to become the Regius Professor of Medicine at Oxford. Among the honors announced during the Coronation of King George in June 1911 was a baronetcy for Dr. Osler which carried with it the title of "Sir William." [15]

When Barker left Hopkins in 1900 to become Professor of Anatomy at the University of Chicago it could not have occurred to him, with his limited clinical background, that he would be recalled in 1905 to succeed Professor Osler as Professor of Medicine and Physician-in-Chief to the Hopkins Hospital. One cannot escape the thought that Barker's prominence as advocate of the clinical full-time system was in part responsible for his choice as Osler's successor. [16]

The Carnegie Bulletins

In 1910, while the issue of full-time appointment of clinical faculty continued to be of theoretical interest but impractical of adoption at Johns Hopkins, the Carnegie Foundation published its Bulletin Number Four, Medical Education in the United Sates and Canada, better known as the Flexner Report. This report was based on visits to American and Canadian schools by Abraham Flexner and associates during 1909 and the winter of 1909-10. As we previously pointed out (in Chapter 31), the picture Flexner drew of these schools was dismal indeed except for a few institutions, chief among them being Johns Hopkins, Flexner's shining model, "the one bright spot, despite meager endowment and missing clinics." Bulletin Number Four caused a profound sensation nationally by its pitiless exposures. Many of the medical schools which Flexner had so unsparingly condemned collapsed and by 1927 only eighty of the former 155 schools were operating. The following is a brief resumé. [17]

Abraham Flexner (1866-1959), a younger brother of Simon Flexner, was the sixth of nine children, seven boys and two girls. He was born in Louisville, Kentucky. A graduate of Johns Hopkins University, he taught Latin and Greek in the high school at Louisville, for four years; and for fifteen years in the same city he ran a highly successful preparatory school of his own. Thereafter he studied at Harvard and Berlin.

He then completed the following two medical surveys for the Carnegie Foundation which established his reputation as the foremost American authority on medical education: [18]

  • 1910, "Medical Education in the United States and Canada." Carnegie Foundation Bulletin No. 4 ("The Flexner Report") [19]
  • 1912, "Medical Education in Europe." Carnegie Foundation Bulletin No. 6 [20]

Mr. Gates Consults Abraham Flexner

When Mr. Gates read Bulletin Number Four, he was greatly impressed by Flexner's findings and recommendations and was eager to consult him on matters of immediate concern to the GEB. As a result he was looking forward with some anticipation to Flexner's return late in 1910 from his survey of Medical Education in Europe. We turn now to Flexner's autobiography for his account of the consultation with Mr. Gates. Flexner wrote: [21] [22] [23]

Early in 1911, while I was writing Bulletin Number Six in a rear office of the Carnegie Foundation, Frederick T. Gates, who had been for many years confidentially associated with John D. Rockefeller, invited me to lunch. I recall the occasion with great distinctness. Mr. Gates was a positive and incisive thinker and speaker. He was perhaps the greatest of American philanthropists, for he had imagination, daring, and an intuitive sense of educational strategy. He had no patience with small things. Unless he could foresee an important and large outcome he would dismiss them with the words "retail business." On the other hand, he was never deterred by the magnitude of an enterprise provided he was convinced that it was good in itself and was likely to be productive of good throughout the country. . . .

The luncheon was simple and soon finished. Mr. Gates wasted no time on preliminaries. He said:

"I have read your Bulletin Number Four from beginning to end. It is not only a criticism but a program"

I replied, "it was intended, Mr. Gates, to be both, for you will remember that it contains two maps, one showing the location and number of medical schools in America today; the other showing what, in my judgment, would suffice if medical schools were properly endowed and conducted by a well-trained personnel."

"What would you do," asked Mr. Gates, "if you had a million dollars with which to make a start in the work of reorganizing medical education?"

Without a moment's hesitation, I replied, "I should give it to Dr. Welch."

"Why?"

"With an endowment of four hundred thousand dollars," I answered, "Dr. Welch has created, in so far as it goes, the one ideal medical school in America. Think what he might do if he had a million more. Already the work Dr. Welch and his associates have done in Baltimore is having its effect in reorganizing the personnel of medical schools elsewhere, and we must not forget that but for the Johns Hopkins Medical School there would probably be no Rockefeller Institute for Medical Research in New York today."

"Would President Pritchett of the Carnegie Foundation release you long enough to go to Baltimore to make a detailed study of the situation and report to me?"

"I think he would," I replied.

"Ask him, and if he agrees, go."

Thereupon the luncheon terminated, Dr. Pritchett was extremely happy to realize that Bulletin Number Four might have some practical consequences of importance, and he made it possible for me to spend a period of about three weeks in Baltimore.

Reaching Baltimore, I sought out Dr. Welch and explained to him that there was a possibility of obtaining a million dollars which might go in a lump to the John Hopkins Medical School for additional endowment, and that I wished therefore to make a careful survey of the school and hospital and to get the judgment of the faculty as to the uses to which the income on this sum could be put. Dr. Welch was not excited at the prospect. He never became excited over possibilities, but he had been thinking, though without any hope or expectation, that this particular day might dawn. He said, "I should like to talk with you and Mall and Halsted at dinner tonight. Can you come to the Maryland Club?" After dinner - an excellent dinner, for Dr. Welch knew as much about food as he did about pathology - he explained to his associates the hypothetical question which I had put to him. There was silence for a little while, then Dr. Mall spoke out:

"If," he said, "the school could get a sum of approximately a million dollars, in my judgment, there is only one thing that we ought to do with it - use every penny of its income for the purpose of placing upon a salary basis the heads and assistants in the leading clinical departments, doing for them what the school did for the underlying medical sciences when it was started. That is the great reform which needs now to be carried through."

It must be remembered that at that time prominent men like Osler, Halsted, and Kelly received nominal salaries - a few thousand dollars annually - from the university. They had to make their living by practice. From the demands of practice they snatched what time they could to devote to clinical research and teaching - and they snatched much time, for they all cherished ideals "made in Germany." Despite the handicap under which they worked, they had started a brilliant development in scientific clinical medicine in the United States, but their success was menacing. The Johns Hopkins Hospital was a Mecca to the sick in all sections of the country. Persons who came there had to be looked after, and they sought and expected the services of the heads. The strain upon these men was therefore terrific. Nevertheless, "Halsted had established himself as the greatest surgical thinker America had yet produced," to quote the words of Dr. Carrel. Dr. Osler, by this time Regius Professor at Oxford, had greatly simplified the practice of clinical medicine by showing the uselessness of most drugs and the importance of rest, fresh air, and diet; and Dr. Kelly had, by his skill and knowledge, introduced a new era in the practice of gynecology.

"If," argued Mall, "these men have such achievements to their credit and at the same time teach and practice, what might not ultimately be expected if they could devote themselves to their hospital wards precisely as the physiologist and anatomist devote themselves to the laboratory?"

Mall's suggestion was not new to Dr. Welch and Dr. Halsted. It had first been made some years earlier in a speech, entitled "Medicine and the Universities," by Dr. Lewellys F. Barker. . . Mall had convinced Dr. Barker of the importance of academic medicine and, in (his) quiet way, (Barker) had continued his campaign of education during the years which had passed since he came to Baltimore in 1905 (as the replacement for Dr. Osler). The ground was therefore quite ready. (Welch) found that all those engaged in teaching the underlying medical sciences wished to devote every penny of additional income that could be procured to the installation of full-time academic teaching and research in the main clinical branches. Dr. Halsted and some of the younger clinicians were of the same mind. There was a good deal of hesitation among the others, partly because they feared a loss of experience; partly, I suspect, because through the prosperous practice of medicine they had adjusted their lives to a standard which would have to be greatly changed in the event of a thoroughgoing reform.

I have myself often been credited with the authorship of what is called the "full-time scheme," but I am entitled to no credit whatsoever. It did not originate with me and it is not mentioned in either Bulletin Number Four or Number Six. It did not even originate with Mall, but was attributed by him to his old teacher, the great Leipzig physiologist, Ludwig, who one day, so Mall said, remarked to him that sooner or later teaching and research in clinical medicine and surgery would have to be organized on the same basis as teaching and research in anatomy and pathology; both of these had once been in the hands of practicing physicians, and neither had prospered as they should until they commanded the full time and strength of the men engaged in their teaching and cultivation.

I spent three weeks in Baltimore and finally wrote for Mr. Gates a confidential report, in which I pointed out, first, that a thoroughgoing reform could not be accomplished even in one medical school with $1,000,000. The sum required would be hardly less than $1,500,000. I contrasted the conditions that had come about in the laboratories under full-time men and the conditions that existed in the clinics, where part-time men were driven in various directions. I pointed out further that as a matter of fact it was more important for a clinician to enjoy a full-time opportunity to carry on teaching and research, because, simplify his situation as one would, his task was infinitely harder than that of a laboratory man, for the laboratory man could concentrate upon his research and his teaching and command his entire time, dividing it as he pleased. The clinician had to organize a clinic, had to teach students, had often for his research to attend patients, and had in addition to carry on laboratory investigations aiming at the solution of the problems that arose in the clinic. I urged therefore that a sum of approximately $1,500,000 should be given to the Johns Hopkins Medical School for the purpose of reorganizing upon the full-time basis, or, as Dr. Welch preferred to call it "the university basis," the medical, surgical, obstetrical, and pediatric clinics.

Flexner's report to Mr. Gates concerning the visit to Baltimore was enthusiastically received and approved in principle by Mr. Gates and the General Education Board. As the next step in deciding on a joint course of action to be taken by the GEB and Hopkins University, Flexner was requested to return to Baltimore for the purpose of submitting the report to Dr. Welch and his associates. He was authorized to convey to them the "intimation" that money would be available provided that, after due reflection and discussion, the Hopkins faculty and trustees actually wished to undertake the experiment of establishing full-time clinical appointments.

Late in March 1911 Flexner returned to Baltimore and met with Dr. Welch and the University trustees on the evening of his arrival in the city. After a detailed discussion of the issues, Flexner received from them an assurance of their solid support for the reorganization of the clinical faculty on a full-time basis. In the course of the conversation Flexner urged that, if a change to full-time teaching were made, the attendance of the school should be cut down to two hundred fifty students.

Flexner returned to New York by train that night and on the following day prepared a report of the meeting for Mr. Gates. On 2 April 1911 Mr. Gates called Flexner to say: "I have just finished reading your report. I can hardly find words to express my satisfaction and delight. I am more than satisfied. It is a model. I have occasion to read many reports, but when I have read anything like that I cannot recall."

On the basis of Flexner's report, Mr. Gates and the GEB were under the impression as early as April 1911 that Welch and the Hopkins trustees supported the plan to appoint the heads of certain clinical departments on a full-time basis. They further assumed that a request for a grant to fund the experiment would be soon forthcoming from Dr. Welch. Such was not to be the case. Since adoption of the plan was subject to ratification by the faculty, more than a year and a half dragged by before a consensus was reached.

Within the medical faculty the laboratory men unanimously endorsed the plan, but there was a rift among the clinicians over the assignment of income from private practice to the school rather than to the physician. Welch made no effort whatever to push the idea. He saw that every member of the faculty had a copy of the report, and bided his time. He was determined not to alienate those members of the faculty who remained unconverted. As a result, Welch deferred submitting a grant application to the GEB until, as we shall later recount, Flexner prodded him to do so in October of 1913.

Flexner Joins the General Education Board

As to the fortunes of Abraham Flexner, he had by the fall of 1911 completed his commission to evaluate European medical education for the Carnegie Foundation and had prepared a report on the subject. (His report was published by the Foundation in 1912 as Bulletin Number Six.) Also, by this time, his services were no longer needed by the General Education Board as an emissary to Hopkins. He was thus free of commitments (that is, he was unemployed) when, late in 1911, he was approached urgently by John D. Rockefeller, Jr., to undertake an investigation of prostitution in Europe on behalf of the New York Bureau of Social Hygiene.

During Flexner's temporary association with the General Education Board in connection with the Hopkins negotiations he had enjoyed a cordial relationship of mutual respect with the junior Rockefeller who was an important member of the Board. Under the circumstances Flexner felt obliged to accept the difficult assignment that Rockefeller pressed upon him. Early in 1912 he went to Europe and began the study of prostitution in major cities.

In March of 1913, near the completion of the study, Flexner received word in London that Mr. Rockefeller had arranged for him to become a member of the General Education Board.

The news of an invitation to join the GEB was a godsend to Flexner who had been in grave doubt as to what his future employment might be upon completion of the European assignment. Now, upon his return to New York in the spring of 1913, Abraham Flexner embarked upon a new career as a member of the GEB where he served as Assistant Secretary of the Board from 1913 to 1917, as Secretary from 1917 to 1925, and as a Trustee of the Board from 1914 to 1928. [24] [25]

Harvard and Hopkins Apply to the GEB

Upon joining the GEB Flexner renewed his special interest in the Hopkins experiment with the clinical full-time system. In early October 1913 he learned that the Board would take final action later that month on the grant applications it had received thus far.

He also learned that Welch at Hopkins had not submitted an application, but that an application had been submitted by the following prestigious Harvard committee appointed by Harvard President Lowell: Henry Christian, former Dean and full-time Professor of Medicine located at the Peter Bent Brigham Hospital, chairman; Harvey Cushing, full-time Professor of Surgery also at the Brigham; and Dean Edsall of Harvard Medical School. The Harvard application requested a grant of $ 1. 5 million for the purpose of placing "all of its clinical departments. . .on a satisfactory university basis." The professors were to "devote the major part of their time to school and hospital work, "but they were not to be barred from receiving fees from private patients." [26] [27]

In fact, Flexner had visited Harvard in June 1913 to advise Christian on the Harvard application. Harvard Medical School was no stranger to Flexner. Four years earlier, during his survey of medical education in the United States and Canada, he had measured Harvard against the standard of medical education set by Johns Hopkins and found it wanting, particularly because it had no teaching hospital of its own but relied on private hospitals such as the Peter Bent Brigham and Massachusetts General for teaching beds. He also knew that the provision in the application which allowed senior professors to conduct a limited consultative practice in the hospitals and to keep the fees, was unacceptable. It did not eliminate the profit motive in clinical teaching, an objective central to the effectiveness of the full-time system, according to the standards set by Flexner and the GEB. Instead of advising Christian specifically regarding these important items of concern, Flexner limited his comments to requests for further data about the medical faculty and student body, and promised on leaving that he would discuss matters more fully in the fall. [28] [29]

Following that meeting with Christian, Flexner sent a number of suggestions to Welch and his associates at Hopkins about what they should include in the application they were preparing for submission to the Board. Furthermore, early in October, when Flexner learned that the GEB would take final action later that month on the grant applications it had received, he alerted Welch to the necessity of submitting the Hopkins proposal before that meeting. [30]

In contrast, at no time did Flexner, following his visit with Christian in June 1913, make an effort to communicate about the Harvard application either with Christian or any of his colleagues. It was not until Christian wrote Flexner in late September requesting an opportunity to discuss the Harvard proposal with him again that Flexner finally agreed to meet with Christian at Harvard Medical School in mid-October. [31]

The meeting proved a shock to Dr. Christian. Flexner told him plainly that the Harvard application was not acceptable and that it would have to be totally revised if it was to be seriously considered by the Board. But Flexner did not inform Christian that the Board would make its final decision in the next week on the applications before it, which consisted of the applications from Hopkins and Harvard. Unaware of the deadline, Christian began immediately to revise the Harvard application and was still in the process when the General Education Board met on 23 October 1913 and made its decisions. [32]

Approval of the Hopkins Application by the GEB

The Hopkins application received a quite different treatment from that of Harvard. Thanks to the patience of Dr. Welch and the coaching of Flexner, the entire Hopkins faculty was at last supportive of the clinical full-time plan and, on 21 October 1913, Welch submitted a formal application to the General Education Board for a grant of $1.5 million to support establishment of three clinical full-time appointments. His application included the following succinct description of the objective of the Hopkins full-time plan: [33]

The faculty of the Medical School are fully convinced of the wisdom and necessity of commanding the entire time and devotion of a staff of teachers in the main clinical branches precisely as the school has since its beginning commanded the entire time and devotion of the teachers of the underlying sciences; we are persuaded that the time is ripe for the step in question and we are desirous of undertaking the innovation. Should the General Education Board provide the funds, the departments of medicine, surgery, and pediatrics would be organized on the full-time basis - that is, the professor and his staff consisting of associate professors, associates, assistants, etc. - would hold their posts on the condition that while engaged in the service of the university and hospital they accept no fees for professional services. They would be free to render such service required by humanity or science, but from it they would be expected to derive no pecuniary benefit. Fees charged by the hospital for professional services to private patients, whether within or without the hospital, by members of the full-time staff, such as at present are paid directly to the physician, would be used to promote the objects for the attainment of which this request is made.

The General Education Board acted swiftly. On 23 October 1913, two days after the date of Dr. Welch's application, the Board passed the necessary resolutions making available to Hopkins the sum of $1.5 million to be used to carry out the full-time proposal as set forth in Welch's application of 21 October 1913. [34] [35]

The outcome was predictable. According to the minutes of the Board, the Hopkins application met every criterion that had been set up and was unanimously approved.

Harvard Grant Applications Rejected by the GEB

At its meeting on 23 October 1913 the General Education Board rejected the Harvard application because the improvements it recommended in clinical teaching were not "sufficiently fundamental." Even more irritating to the Harvard grant committee was the added comment that "although a member of the Board had conferred with the committee at Harvard Medical School and indicated that the Board would be interested in a more comprehensive proposal for reorganization, no such proposition had been received." [36]

Once Flexner had embraced the vision of the full-time system as described by Mall he insisted on a literal application of the concept, with the Hopkins program being the model. This doubtless accounted for his negative reaction to Harvard's application to the General Education Board. From Flexner's viewpoint there were several major deficiencies in the Harvard application.

First, it did not convince Flexner, upon whose judgment the GEB relied implicitly, that Drs. Christian and Cushing were already functioning as "full-time clinical faculty devoted primarily to research and teaching, " which was Christian's presumption. Second, the Peter Bent Brigham Hospital was a private hospital and did not, strictly speaking, fulfill the criterion of being a "university hospital," owned and operated by the medical school.

Like Flexner, Christian's goal was to establish all clinical departments on a full-time basis, but they differed on the method to achieve this result. Flexner wished primarily to establish full-time chairs in the major clinical departments; Christian proposed that young assistants in the various clinical departments be placed on a full-time basis with an adequate yearly salary and that the salaries of the professors of pediatrics, gynecology, obstetrics, and psychiatry be increased so that they too could afford to devote themselves full-time to their academic and hospital duties. However, Christian said nothing specifically about clinical full-time appointments in the departments of medicine and surgery. He apparently believed it to be obvious that he and Cushing were already working on such a basis at the Brigham.

Finally, there was an issue that on its face disqualified the Harvard proposal. This was the continuing insistence by the Harvard committee that full-time clinical faculty be permitted, in accordance with Harvard tradition, to see patients and collect fees. Although Christian's proposal forbade members of the clinical departments (professors as well as assistants) to engage in general private practice, it did insist that senior professors have the privilege of seeing a limited number of private patients in the hospital on a consultative basis and of keeping the fees. To the uncompromising Flexner, this policy alone made the Harvard program inconsistent with his conception of the strict clinical full-time system which GEB grants were designed to install. [37]

Christian and the Harvard administration were incensed by the manner in which their application had been handled. They concluded that, given the prior negotiations by the GEB with Welch and the Hopkins school, this first competition sponsored by the Board to advance clinical education by installation of the clinical full-time system was little more than a charade organized by Gates and deftly carried to fruition by Abraham Flexner. [38] [39]

There followed a period of soul searching and despair at Harvard. Two more grant applications were submitted to the GEB during the next two years, both unsuccessful. Finally in 1916 ex-President Eliot of Harvard, a trustee of the GEB since 1908, came forward with a third proposal that was denied on the grounds that the "proposition continues the old order. . . It is questionable whether in this form the full-time scheme could achieve its purpose." [40]

Internal negotiations at Harvard during the immediately ensuing years failed to result in an application acceptable to the General Education Board. The chief deterrent was insistence by Christian and Cushing on the privilege of senior full-time clinical faculty to consult and retain the fees. It was inevitable that applications from Harvard retaining that privilege would be vetoed on arrival by Flexner, who was pointedly excoriated by Dr. Cushing and others of the Harvard faculty for his bureaucratic rigidity and cavalier disregard for their sensibilities. [41]

For an opinion of the Flexnerian doctrine and the Hopkins model from the Harvard viewpoint, and a reminder that Harvard has also made substantial contributions to American medical education, one may consult Medicine at Harvard (1977) by Professors Beecher and Altschule. They concluded, somewhat peevishly: [42]

In the end, it matters very little who achieved leadership in the reform of medical education in this country - Eliot (President of Harvard University), the American Medical Association, or Flexner. The fact is that essential reform did come, and with far-ranging benefit to the medical establishment in this country and in other countries. There is honor enough for many. What is important is that the Eliot reform strengthened medicine and the Flexner reform deformed it. Today's criticism of the shortsightedness of government agencies that spend billions to support research at medical schools and zero to support clinical teaching is not warranted. The blame lies not with these agencies but with the Flexnerian educators who told them what to do. Today's medicine, which many find irrelevant to patients' needs, is the fruit of Flexner's report. This was not the first time, nor will it be the last, that medical educational policy has come under the influence of a well-informed but short-sighted reformer supported by an enthusiastic but deluded lay press.

The Harvard Geographic Full-time System

To this day, the clinical departments of most American medical schools are organized, in part at least, in accordance with the Harvard plan which failed to qualify for GEB support. Under this very practical system, also referred to as "geographic full-time," the school or hospital provides the faculty member with rent-free office and laboratory space for conduct of medical practice, teaching and research. In addition, the member usually receives from the institution a pre-determined salary, ranging from full-time to nominal, and is permitted to retain the fees from his or her medical practice. [43]

There are many variations of the geographic plan. It has the advantage of flexibility and cost control. In contrast the strict clinical full-time system requires payment of full salaries from school resources often insufficient for the purpose. Hence the installation of the strict clinical full-time plan generally requires external sources of funds such as gifts and grants. In practice, the faculty of most schools consists of a combination of geographic and full-time clinical appointments.

Installation of the Clinical Full-Time System at Hopkins

The following letter ushered in the clinical full-time system and opened a new era in the organization of American medical faculties: [44]

October 29, 1913
Dr. William H. Welch
Chairman of the Administrative Committee
Johns Hopkins University, Baltimore

Dear Dr. Welch:
At a meeting of the General Education Board, held October 23, 1913, your application on behalf of the Johns Hopkins Medical School was presented for consideration. After full discussion the following resolutions were unanimously passed:

'Resolved, That the General Education Board hereby agrees to appropriate the funds ($1.5 million) necessary to carry out the full-time scheme described in Dr. Welch's letter under date of October 21, 1913, and empowers the Finance Committee to take the necessary steps looking to the execution of this agreement.

'Resolved, That, in view of Dr. Welch's great services to the cause of medical education in America, the fund appropriated as above be called 'The William H. Welch Endowment for Clinical Education and Research.'

With great respect, I am,
Faithfully yours,
(signed) Wallace Buttrick
(Secretary, General Education Board)

At the first meeting of the Advisory Board of the Hopkins Medical Faculty held after the announcement of the gift from the General Education Board, it was recommended to the Hopkins Trustees that the existing heads of the departments of Medicine, Surgery and Pediatrics, namely Drs. Barker, Halsted and Howland, be offered the posts of Professor of Medicine, Surgery and Pediatrics respectively. They were to hold these positions on the new full-time or "university" basis made possible by the gift from the GEB.

The Trustees promptly approved the recommendation and requested Dr. Welch to invite Drs. Barker, Halsted and Howland to accept these professorships on a full-time basis. Drs. Halsted and Howland accepted the appointments, but Dr. Barker, who had so eloquently advocated the full-time system in 1902, regretfully declined the invitation. His personal situation had changed considerably since he replaced Dr. Osler in 1905 and now, at the age of forty-six, he felt the necessity to continue his lucrative medical practice in order to make provision for his family. [45]

Thus from the very outset, the financial deterrent to acceptance of strict clinical full-time appointments was manifest. Mall had foreseen the problem when he applauded Dr. Barker's speech on the full-time system in 1902 but had also warned his friend: "The clinicians will be at you in full force for you are meddling with their pocket book." Anticipating the emergence of a new generation of dedicated clinical scientists who would accept and dignify the full-time clinical role, Mall added, "I am sure we want an entirely different breed of men to fill our practical chairs before the reform can be made." [46]

Filling the position of the first Professor of Medicine at Hopkins to be appointed on a full-time or university basis proved more difficult than expected. Following Dr. Barker's inability to accept the position, it was offered to Dr. William S. Thayer, the next ranking member of the medical department. It turned out, however, that Dr. Thayer also did not wish to accept the position. Finally, Dr. Theodore C. Janeway, Bard Professor of the Practice of Medicine at Columbia University, New York City, was appointed Professor of Medicine at Hopkins, being the first to serve in that position on a university basis. His appointment, which took effect on 1 July 1914, marks the inception of the Hopkins experiment with the clinical full-time plan. [47]

Reorganization of the Hopkins Medical Staff

The Hopkins faculty could now reorganize to incorporate the clinical full-time concept in its operations. One issue which came up for consideration immediately as a result of the adoption of the full-time program, was that of faculty titles in the School of Medicine.

A committee under the chairmanship of Dean J. Whitridge Williams recommended that the Faculty be divided into two Parts: 1, University Staff; 2, Clinical Staff."

The so-called University Staff was "to include all faculty members who give their entire time to the work of their respective departments;" that is, the clinical full-time appointees.

The so-called Clinical Staff was "to consist of such faculty members as are engaged in private practice," and "in order to distinguish them from those on the full university basis the word 'clinical,' unless unnecessary or clearly inappropriate, will be included in each title and precede the main subject, so that the titles will be Professor of Clinical Medicine, Associate in Clinical Surgery, Assistant in Clinical Gynecology, etc." Dr. Barker accepted the post of Professor of Clinical Medicine in the reorganized medical department. This new organizational pattern was approved by all the appropriate boards and was put into effect in the ensuing year (1914-1915). We have seen that the Stanford medical faculty had already adopted a similar plan of organization in 1909. [48]

Full-Time Plan Under Fire

Implementation of the full-time experiment had the effect of further exposing its flaws. Initially, Janeway was pleased with the plan because its generous support facilitated research and enabled him to increase his faculty. Later, money became an issue. He came to resent the restriction on private practice income and voiced a still-familiar theme: "I rebel more and more at earning money for the institution. I am convinced that, if the professor or anyone else sees a private patient, he should receive the fee." Anticipating an evolution to a less restrictive version of the full-time plan he suggested: "If the liberal support of research provided by the whole-time plan could be secured without its limitations, the ends of medical education would be best served." Thus, in spite of the progress he made at Hopkins, Janeway was not happy in his transformation from active New York consultant and teacher to full-time university professor. This was partly because his restriction from private practice created for him a financial hardship and partly because he was no longer entirely in sympathy with the full-time plan. [49] [50]

In 1917 Janeway informed Welch that he intended to resign. Welch knew that this defection would be cited as evidence of the system's failure by those many critics around the country who opposed the clinical full-time plan. After conferring with Abraham Flexner, Welch asked Janeway to delay announcing his resignation. While Welch and the other architects of the plan were formulating a strategy to minimize the adverse effect of his departure, Janeway died of pneumonia in December 1917. His tragic death at the age of 42 temporarily overshadowed the full-time issue. In his memorial address, Welch minimized Janeway's dissatisfaction with the plan and made no mention of his intention to resign. [51] [52]

In addition to the Janeway problem, there was during this period a truly major disruption of academic affairs. On 6 April 1917 the United States declared war on the German Empire and the Central Powers and entered World War I in support of Britain and the Allies. The war ended with the Armistice of 11 November 1918.

In 1914, when Barker declined to accept the clinical full-time professorship of medicine, Welch had offered Dr. William S. Thayer the position and he had refused it. Now, after Janeway's death, Welch again urged Thayer, still next in line in the medical department, to accept the professorship. This he reluctantly agreed to do after completion of his duties during World War 1 as chief medical consultant of the American Expeditionary Forces in France. During his absence on military duty the full-time plan was temporarily in abeyance and the medical department was ably directed by a part-time physician until Thayer could assume the duties of professor in 1919. [53]

Thayer received his M. D. Degree from Harvard in 1889, after which he served as house officer at the Massachusetts General Hospital, one of the Harvard teaching hospitals. He then spent some time in laboratory studies abroad before coming to Hopkins as an assistant resident physician in November 1890. In September 1891, he was appointed resident physician, a post which he held for seven years lengthy residencies being not unusual at Hopkins. Following the residency he joined the Hopkins faculty. [54]

In Professor Thayer's Department there was a number of talented younger scientists. Many of them later became professors of medicine at other institutions and had distinguished careers in academic medicine, a progression presumably attributable in part at least to the environment created by the clinical full-time system. [55]

Prominent among these Hopkins men who seeded other departments of medicine was Dr. Arthur L. Bloomfield who worked in the biological research division (bacteriology) of the Hopkins Department of Medicine. He received an A. B. from Johns Hopkins University in 1907 and M. D. degree in 1911. Also at Johns Hopkins he served as Assistant, Instructor, and Associate in Medicine, 1912-1922, and Associate Professor of Medicine, 1922-1926. Dr. Bloomfield was appointed Professor of Medicine at Stanford University School of Medicine in 1926. [56] [57]

Thayer remained in the full-time medical professorship for only two years and resigned in 1921. During that period, morale in the department eroded. Antagonisms developed that divided the younger men into the so-called research and clinical groups. The clinicians were, for the most part, opposed to the full-time system and created a difficult environment for the research-oriented members who soon departed.

George Canby Robinson, scheduled to become dean and professor of medicine at Vanderbilt University, was asked to succeed Thayer during the year beginning July 1, 1921 as acting professor of medicine and physician-in-chief of the Johns Hopkins Hospital. Vanderbilt granted him a leave of absence; its administrators realized that the position would be an excellent preparation for his new duties in Nashville. Dr. Robinson made an outstanding contribution as acting professor for the year 1921-1922 during which he restored morale and recruited new full-time faculty to head the clinical research divisions. He effectively paved the way for the next full-time professor, Warfield Theobald Longcope, who was appointed professor in March 1922 and assumed office in July of that year. He had received his A. B. (1897) and his M. D. (1901) from Johns Hopkins. [58]

By 1921 the full-time plan at Hopkins had met with variable success. In surgery, implementation was no problem. Halsted was already on an essentially full-time basis when the plan was adopted, and because of his deep interest in clinical investigation he engaged in little private practice. In pediatrics, the plan was an outstanding success. The private patients in the hospital were taken care of exclusively by John F. Howland, the professor, with the able assistance of his perennial resident pediatrician, Kenneth Blackfan, who later had a distinguished career as professor of pediatrics at Harvard. [59] [60]

Thus, faculty dissatisfaction with the full-time plan at Hopkins centered in the department of medicine and mainly concerned two issues: the perceived neglect of teaching the art and science of patient care, and the denial of private practice income to the treating physician. As a demonstration project for replication in other institutions, the Hopkins program was closely watched nationally, and with some apprehension, by Frederick Gates and Abraham Flexner.

The General Education Board Supports Installation of the Hopkins Model in Selected Schools

In January 1914, three months after it awarded $ 1.5 million to Johns Hopkins, the General Education Board adopted a resolution which colored the Board's activities in medical education for the next 6 years. It was resolved that: [61]

The Board does not consider it expedient at present to aid medical education except insofar as it concerns the installation of full-time clinical teaching.

By this time Flexner had been added to the staff of the GEB. It is certain that he played a part in drafting this resolution calling for a concentrated effort to improve medical education exclusively by installing clinical full-time faculties in additional schools. Indeed from this time forward the leadership of the Board's experimental "clinical full-time program" was largely in Flexner's hands.

Flexner thus became the chief proponent of the strict full-time system for clinical faculties in American medical schools. He was also essentially in command of the resources of the GEB to support the experiment., it being generally understood that no university could adopt the system without a source of funds to support the added cost. He argued that clinical professors should abandon private practice and devote themselves to teaching and research. He was convinced that private practitioners consistently placed more importance on financial income than on teaching and research and that commercialism and science were opposing goals. He was also of the opinion that a teaching hospital owned and operated by the university was a valuable, if not essential, facility. It was not long before his insistence on strict adherence to these principles gained for him and the GEB the reputation for inflexibility and undue interference in the academic programs of the recipient schools.

Between 1913 and 1919 the Board, always acting on Flexner's advice, awarded over 8 million dollars to schools agreeing to reorganize their clinical faculties on a full-time basis. As well as Johns Hopkins, Washington University (in St. Louis), Yale and the University of Chicago were among those which complied with Flexner's demands for strict adherence to a full-time policy. Harvard, on the other hand, resisted the idea and Flexner turned a deaf ear to its demand for flexibility - leading ex-President Eliot of Harvard, as a trustee of the GEB, to write as follows to the Board in 1917: [62]

The authorities of the Harvard medical school regard the full-time policy as a great improvement in clinical teaching. . . .but they believe that in its most intelligent application it will permit the continued employment as teachers of men who accept private practice as well as hospital practice; and they observe that great improvements in medical treatment have in recent years proceeded from men who were in private practice (and kept their fees). . .

Specifically, the Board pledged itself not to interfere with the domestic management of an institution aided, except as regards its prudential financial management. . .Yet now the Board (is making one system of full-time teaching the condition of a grant.). This condition does not seem to me consistent with what I have always believed the wise and generally acceptable policy of the Board.

The Board, in general agreement with Eliot's critique, reviewed its policy with the following result.

Revised Goals of the General Education Board

The experience of the GEB with the clinical full-time plan during the six-year period from 1913 to 1919 had been a sobering one for the Board. While still strongly adhering to their belief in the adequate development of the clinical departments, they were now ready to concede, as they stated in their annual report for 1919-1920, that "it would be a serious mistake to leap to the conclusion that the full-time plan should be universally employed at this time. Its cost is very great, and while experience thus far sustains the presumption. . . that the system is worth the price, it still remains to be objectively proved that. . . (it is ) so much better that universities generally should move to its adoption. . . . Educational, financial and social conditions are still so uneven that the same type of medical education cannot be realized in all sections of the country. Premature efforts to force the pace unduly might provoke a reaction which may in the end retard progress. . ."

Moreover, the officers conceded, in a far more conciliatory vein than had previously been employed, that "medical schools need many things before they are ready for full-time clinical departments. . . . Premature introduction of the full-time scheme into the clinical branches may therefore result in such unsymmetrical progress as may do more harm rather than good." For the future, said the officers, "the General Education Board can profitably employ its resources. . . in cooperating with progressive intention wherever found." [63]

This major broadening of the conditions under which the GEB would provide funding to a medical school was in sharp contrast with the Board's earlier determination to concern itself only with "the installation of full-time teaching." This new emphasis was due to the growing uneasiness on the part of some of the trustees of the Board, chief among them President Emeritus Eliot of Harvard, that the previous guidelines had been too inflexibly interpreted.

Abraham Flexner and the other Board members, now acknowledging that the impact of Rockefeller philanthropy would be unduly limited if they supported only those schools willing to adopt strict full-time plans, proceeded to approve grant requests from a broad spectrum of private, state and municipal medical schools, even though their professors kept their clinical fees - it being clearly understood, however, that installation of the strict clinical full-time system was favored by the Board wherever practicable. The approach ultimately sanctioned by the GEB, and fully supported by Flexner, wisely admitted of a combination of strict clinical full-time and geographic full-time faculty as a realistic solution to the funding of research-oriented programs - the Hopkins and Harvard models reconciled at last.

Implementation of this revised and eminently successful policy was made possible by generous additional grants from Rockefeller, Sr., to the GEB so that by 1928 it had appropriated over $ 61 million for medical schools, and when the work of the Board was terminated in 1960, the total figure of disbursements to a total of 25 schools stood at $ 94 million. It is interesting to note that during the period from 1928 to 1960 no new schools were added to the Board's list; the additional sums constituted supplementary grants to the institutions originally selected for assistance prior to 1928. [64]

See Table X, General Education's Board Appropriations for Medical Education, 1914-1960, for a list of the grants to the 25 institution involved) [65]

Table X. General Education's Board Appropriations for Medical Education 1914-1960
Albany Medical College$70,000.00
Baylor University120,000.00
Columbia University1,519,666.66
Cornell University8,151,113.01
Duke University300,000.00
Emory University180,000.00
Harvard University1,393,268.64
Howard University587,759.32
Johns Hopkins University11,126,126.41
Meharry Medical College8,673,706.12
State University of Iowa1,231,003.40
Tulane University3,421,155.87
University of Chicago (plus President Hospital)14,505,721.83
University of Cincinnati762,411.00
University of Colorado1,113,000.00
University of Georgia60,000.00
University of Oregon691,679.34
University of Pennsylvania309,675.55
University of Rochester5,813,870.64
University of Virginia956,000.00
University of Wisconsin12,500.00
Vanderbilt University17,560,378.45
Washington University7,283,035.52
Western Reserve University1,365,000.00
Yale University6,876,300.98
Total94,083,372.74

Raymond B. Fosdick, Chairman of the GEB from 1932-1936, remarked as follows on the cumulative effect of the Board's expenditures: [66]

Most of the funds, appropriated over the years, particularly in the earlier period, represented a vast pump-priming operation; they were given on the condition that larger funds be raised from other sources, and it is estimated, with a reasonable degree of accuracy, that something like $600 million, including the Board's grants, were thus added to a purpose which swung the whole movement for improved medical training into top-flight effort. The Board's money, matched many times over by the generosity of scores of citizens like Eastman in Rochester, Rosenwald in Chicago, and Harkness in New York, took the teaching of medicine in the United States from the discreditable position it occupied in 1910 and gave it a status which it shares with only a few other countries in the world.

As is evident from the preceding, installation of strict clinical full-time systems requires a continuing source of large sums of money. It is equally certain that philanthropy alone cannot endow scientific medicine to the extent commensurate with the national need for research. Only the government can do so.

It is therefore highly significant that the success of collaborative research at the time of American involvement in World War l (6 April 1917 to 11 November 1918) increased governmental interest in the support of medical science, leading Congress in 1930 to pass an act establishing a National Institute of Health. Publication of the act was accompanied by the claim that "scientific research is the most important function of the Federal Government as relates to public health." Thereafter, government grants for medical research and related purposes were increasingly available. [67]

World War II (7 December 1941 to 2 September 1945) further catalyzed support of medical research by the government which has since then become a major source of the outside funds that sustain clinical full-time systems in the nation's medical schools. Another major source of income is faculty practice fees, commonly collected by the school through the operation of a faculty practice plan, and used by the school in the payment of faculty salaries and other expenses - a subject to which we will return when we report on Stanford's adoption of the Hopkins model of the strict full-time system at the time of the school's move to the University campus in 1959.

Commentary

For an informed opinion on the significance of clinical full-time systems we turn to an authority on the subject, Dr. A. McGehee Harvey, Distinguished Service Professor of Medicine, Johns Hopkins University School of Medicine: [68]

No single event has had a more profound effect on medical education and medical practice than the movement to establish full-time (salaried) positions in clinical departments. Out of this emerged the clinical scientist, versed in the bedside practice of medicine and capable of applying the knowledge and techniques of the basic sciences to the study of human disease. He occupied the position of middle man in the medical world - a complete clinician who served to bridge the gap between the practicing physician and the laboratory-based scientist.

Implementation of the Hopkins model of the strict clinical full-time system at a few other schools during the period from 1913 to 1919 revealed that it was an excellent method in so far as it freed faculty from the distractions of private practice so that they could concentrate on research and teaching.. On the other hand it was a very expensive approach. To maintain salaries in clinical departments at a sufficiently high level that faculty would forego the personal and financial rewards of private practice required endowments of a size beyond all but a few medical schools.

Furthermore, the system led initially to intradepartmental conflict at Hopkins between research-oriented and practice-disposed faculty. On a broader plane, the disparagement of medical practice and the collection of medical fees by institutions rather than the treating physicians, were vigorously debated, censured as "fee-splitting " by some, and in general disapproved by the medical profession at large. As a result, the Hopkins system, originally found limited application..

Indeed, so hallowed by the profession was the tradition of fee-for-service paid to the treating physician by the patient, and so great was the anathema attached to the "corporate practice of medicine" as institutional collection of fees was regarded, that the General Education Board's insistence on disallowing private practice for personal gain proved to be the most contentious of the various conditions under which the GEB provided funds for installment of strict full-time plans. This restriction on fee-for-service practice ultimately came to be construed by some of the GEB trustees as an unwarranted interference by private philanthropy in a school's academic prerogatives. It was at this juncture in 1920 that the GEB liberalized its grant requirements, made adoption of the strict clinical full-time system optional, and thereafter employed its funds for the general advancement of medical education rather than exclusively for the purpose of installing strict clinical full-time plans.

Meanwhile, Harvard's "geographic" full-time plan emerged nationally as an alternative to the Hopkins "strict clinical full-time system." The Harvard plan had the advantage of being generally affordable because private practice earnings retained by the faculty served to offset some or all of their salaries. On this account the Harvard version of clinical full-time was widely adopted in the years following World War I. The GEB eventually recognized its validity by awarding Harvard a grant of $1.4 million to strengthen its program.

With respect to the legacy of Welch , Gates and Flexner, their efforts to establish clinical full-time centers of excellence in American medical schools coincided with the drastic reorganization of these institutions then in progress under the impact of the Flexner Report. The most significant contribution of these men and the General Education Board during this revolution in American medicine was to establish research as a major and indispensable component of American medical education, with the strict clinical full-time system (Hopkins model) as the preferred means to this end. These two basic concepts were associated with the following Flexnerian principles which he espoused in the Flexner Report and during his tenure on the General Education Board:

(1) Each medical school should be an integral part of a parent university.

(2) The medical school should have a university teaching hospital.

(3) The university, medical school and teaching hospital should be in the same location (that is, no "divided schools."

(4) The medical staff of the teaching hospital should be members of the medical school faculty regarding which all power of appointment and promotion rests with the university.

(5) The primary faculty in the school should be salaried. (that is, on a strict full-time basis, including the clinical departments).

(6) Research and teaching should be inseparable because the approach of the investigator and the clinician should be the same.

(7) An implied principle, based on Flexner's concern for adjustment of physician output to societal need, is that medical schools should cooperate to that end.

These concepts and principles were largely incorporated into the design of the future academic health center, devoted to medical education, science and service, that was to evolve following World War II as the consummation of the Flexnerian reforms. [69] [70]

As Flexner et al predicted, the research output of American medical schools grew in proportion to the financial support and academic stimulus to scientific endeavors their faculties received After World War II there was a surge in spending by government and private foundations for research and research training in American medical schools. This resulted in a marked increase in the national number of full-time salaried faculty members, and in American institutions leading the world in contributions to medical science - undoubtedly an instance of cause and effect. [71] [72] [73]

Stanford Unites Its Medical School on the Campus in 1959

In accordance with the Flexnerian principle of "no divided schools" Stanford moved its clinical teaching and hospital facilities from San Francisco to join them with the basic sciences in a new medical center on the Stanford Campus in 1959. . Ground breaking ceremonies for the center were held on 11 September 1956, and construction began in June 1967. Dr. Robert Alway, appointed as Acting Dean on 9 March 1957, was installed as Dean on 15 May 1958.

Strict Clinical Full-time Faculty System Adopted

In accordance with another Flexnerian principle, upon the move to the campus the faculty was reorganized in accordance with the Hopkins version of the strict clinical full-time system as follows: [74]

In contrast with previous patterns in the medical school, the faculty is now entirely full-time. After intensive discussion, a Medical Service Plan was developed by the faculty of the clinical departments, in consultation with the dean. This plan has now been in operation for two years. Fees for services rendered to the faculty's private patients (all of whom are also teaching patients) are pooled on a departmental and then on a schoolwide basis. These funds are used to augment faculty salaries to levels which are more nearly competitive with those of other major institutions and for other worthy purposes within the School of Medicine. Income of individual clinical faculty members is no longer directly dependent on volume of private practice; instead, it reflects their total contribution to teaching, research, and administration, as well as in patient care.

Some forty years and multiple revisions of the Medical Service Plan later, the principles of the strict clinical full-time plan (Hopkins version) are still observed at Stanford which is now (in 1997) arguably the foremost research oriented academic health center in the nation.

Abraham Flexner, much vilified for his stubborn insistence on the merits of strict clinical full-time and a salaried faculty, would have felt vindicated by the Stanford success, and by the strong national trend toward full-time salaried appointments in clinical departments as shown in Table X.

In 1958-1959 for the first time, the annual issue of the JAMA devoted to "medical education in the Unites States and Canada" published data on full-time salaried faculty appointments in American medical schools. Data on such appointments are shown in Table X for 1958-1959 and for the year 1995-1996 . During that 37-year period the number of full-time salaried appointments in the clinical departments of American medical schools increased from 6 505 to 74 479, representing an increase of total full-time salaried appointments in clinical departments from 63 % to 81 %. In 1995-1996, the number of full-time salaried faculty in clinical departments (74 479) exceeded the total number of medical students (66 906) in all the nation's medical schools.

Data are not available to determine how many of the full-time salaried appointees in these clinical departments functioned in the strict academic mode envisioned in the Hopkins model of strict clinical full-time. However, is reasonable to conclude, from the remarkable research productivity of American medical schools at the time, that many of them did..

In retrospect of Flexner's preoccupation with the excessive number of American doctors and medical schools in 1910, it is interesting to note that Table X indicates a similar trend in the period from Stanford Medical School's move to the Campus in 1959 to the present day. During that 37 year interval the number of American medical schools increased from 79 to 124, and the number of medical students more than doubled - with consequences calling for Flexnerian foresight and candor.

Table X. Full-time Salaried Faculty at American Medical Schools 1958-1959 and 1995-1996
Total1958 - 1959-1995-1996-
Medical Schools79-124-
Medical Students28 977-66 906-
Salaried FacultyPercentPercent
Basic Sciences3 84537 %16 97219 %
Clinical Sciences6 50563 %74 47981 %
Total Salaried Faculty10 350100 %91 451100 %

Endnotes

  1. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume II, 1893-1905 (Baltimore: The Johns Hopkins Press, 1958), p.321.Lane Library catalog record
  2. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1558.Lane Library catalog record
  3. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1556.Lane Library catalog record
  4. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume I, Early Years: 1867-1893 (Baltimore: The Johns Hopkins Press, 1943), p.224.Lane Library catalog record
  5. Lewellys F. Barker , "Medicine and the Universities," American Medicine 4, no. 1 (July 5, 1902): 143-147.Lane Library catalog record
  6. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1557.
  7. Editorial, The Journal of the American Medical Association 39, no. 16 (Oct 18, 1902): 989.Lane Library catalog record
  8. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1556-1557.Lane Library catalog record
  9. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume 1, 1867-1893 (Baltimore: The Johns Hopkins Press, 1943), pp.191-192.Lane Library catalog record
  10. The Encyclopedia Americana, International Edition (Danbury, Conn.: Grolier Incorporated, 1983), p. 398.Lane Library catalog record
  11. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp.6-8; p.13; pp.336-339.
  12. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume II, 1893-1905 (Baltimore: The Johns Hopkins Press, 1958), p.322.Lane Library catalog record
  13. Lewellys F. Barker , Time and the Physician (New York: G. P. Putnam's Sons, 1942), p.206.Lane Library catalog record
  14. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1556.Lane Library catalog record
  15. Harvey Cushing , The Life of Sir William Osler (New York: Oxford University Press, 1940), p. 961.Lane Library catalog record
  16. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume I, 1867-1893 (Baltimore: The Johns Hopkins Press, 1943), pp.181-183.Lane Library catalog record
  17. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p.116.
  18. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp.153-154.
  19. Abraham Flexner , "Medical Education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching," Bulletin of Carnegie Foundation for the Advancement of Teaching, Bulletin Number Four (1910): 346 pp.Lane Library catalog record
  20. Abraham Flexner , "Medical Education in Europe: A Report to the Carnegie Foundation for the Advancement of Teaching," Bulletin 0f Carnegie Foundation for the Advancement of Teaching, Bulletin Number Six (1912): 357 pp.Lane Library catalog record
  21. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1558.Lane Library catalog record
  22. Abraham Flexner , I Remember: The Autobiography of Abraham Flexner (New York: Simon and Schuster, 1940), pp.176-184.Lane Library catalog record
  23. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp.155-164.
  24. Abraham Flexner , I Remember: The Autobiography of Abraham Flexner (New York: Simon and Schuster, 1940), pp.185-202.Lane Library catalog record
  25. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp.336-339.
  26. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p. 163.
  27. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), 341-347.Lane Library catalog record
  28. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), 341-347.Lane Library catalog record
  29. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), p. 344.Lane Library catalog record
  30. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), p. 344.Lane Library catalog record
  31. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), p. 344.Lane Library catalog record
  32. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), p. 344.Lane Library catalog record
  33. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 157-158.
  34. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p. 158.
  35. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume III, 1905-1914 (Baltimore: The Johns Hopkins Press, 1963), p. 250-251.Lane Library catalog record
  36. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), 341-347.Lane Library catalog record
  37. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), pp. 342-343.Lane Library catalog record
  38. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), 341-345.Lane Library catalog record
  39. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), p. 345.Lane Library catalog record
  40. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p. 163.
  41. Saul Benison , A. Clifford Barger , and Elin L. Wolfe , Walter B. Cannon: The Life and Times of a Young Scientist (Cambridge, MA: Harvard University Press, 1987), 345-348.Lane Library catalog record
  42. Beecher HK , Altschule MD , Medicine at Harvard: The First Three Hundred Years (Hanover, New Hampshire: The University Press of New England, 1977), pp. 175-184.Lane Library catalog record
  43. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p. 171.
  44. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume III, 1905-1914 (Baltimore: The Johns Hopkins Press, 1963), p. 251.Lane Library catalog record
  45. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume III, 1905-1914 (Baltimore: The Johns Hopkins Press, 1963), pp. 252-256.Lane Library catalog record
  46. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1557.Lane Library catalog record
  47. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume III, 1905-1914 (Baltimore: The Johns Hopkins Press, 1963), pp. 257-260.Lane Library catalog record
  48. Alan M. Chesney , The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle, Volume III, 1905-1914 (Baltimore: The Johns Hopkins Press, 1963), pp. 260-262.Lane Library catalog record
  49. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1559.Lane Library catalog record
  50. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), pp. 153-155.Lane Library catalog record
  51. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1559.Lane Library catalog record
  52. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), pp. 153-155.Lane Library catalog record
  53. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), p. 166.Lane Library catalog record
  54. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), pp. 166-169.Lane Library catalog record
  55. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), pp. 166-169.Lane Library catalog record
  56. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), p. 169.Lane Library catalog record
  57. Stanford University Bulletin: School of Medicine, Annual Announcement, 1928-29 (Stanford University, California: Published by the University, undated), p. 10.Lane Library catalog record
  58. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), pp. 168-172.Lane Library catalog record
  59. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1559.Lane Library catalog record
  60. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), p.186.Lane Library catalog record
  61. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 159-161.
  62. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 163-164.
  63. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 161-163.
  64. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 171-173.
  65. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): p. 328.
  66. Raymond B. Fosdick , Adventure in Giving: The Story of the General Education Board, A Foundation Established by John D. Rockefeller (New York: Harper and Row, Publishers, 1962): pp. 172-173.
  67. "The National Institute of Health: Successor to the hygienic laboratory," Public Health Reports 45 (1930): 1409-1412.Lane Library catalog record
  68. A. McGehee Harvey , Science at the Bedside: Clinical Research in American Medicine, 1905-1945 (Baltimore, Maryland: John Hopkins University Press, 1981), p. 183.Lane Library catalog record
  69. Robert H. Ebert , "Flexner's Model and the Future of Medical Education," Academic Medicine 67, no. 11 (Nov 1992): 737-739.
  70. Lawrence G. Crowley , Stanford Study on the Future of the Academic Medical Center, Vol. 1, Autumn 1990 (Stanford University School of Medicine), Lane Medical Library, Lane Medical Archives. pp. ii.1 - ii.8.
  71. W. Bruce Fye , "The origin of the full-time faculty system," JAMA 265, no. 12 (Mar 27, 1991): 1561.Lane Library catalog record
  72. H. Stanley Bennett , "Research and research training in medical schools in the United States," Journal of Medical Education 37, no. 6 (Jun 1962): 565.Lane Library catalog record
  73. W. Bruce. Fye , "Medical Authorship: Traditions, Trends, and Tribulations," Annals of Internal Medicine 113, no. 4 (Aug 15, 1990): 320.Lane Library catalog record
  74. The Alway Years: 1957-1964 (Published by Stanford University School of Medicine, Undated), p.21.Lane Library catalog record
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