Findings of Flexner Report Contested
In May 1909 when Flexner surveyed the Leland Stanford Junior University School of Medicine, Cooper Medical College was being phased out and the Stanford program had not begun. Thus the weight of the Flexner Report's stern criticism of the medical program fell on the Cooper College Faculty. The Report was brought to the attention of the Faculty on 20 June 1910 and Dr. Ophüls was appointed to prepare a statement for President Pritchett of the Carnegie Foundation to be submitted to him by the Dean.
In a firm but courteous letter to President Pritchett Dean Henry Gibbons, on behalf of the Faculty, took exception to certain of the Report's findings. President Pritchett then tartly defended the Report, and concluded with familiar advice on the future of medical education in San Francisco. First the letter from Dean Gibbons to President Pritchett:  
Henry Gibbons, Jr., M D. , Dean
Cooper Medical College
25 July 1910
Henry Pritchett, President
Carnegie Foundation for the Advancement of Teaching
New York, NY
We are in receipt of your Report on Medical Education in the United States and Canada. While in a general way we fully agree with your conclusions and while we expect that your report will accomplish much towards improving Medical Instruction in our country, still we feel bound in justice to ourselves to correct a few errors which have crept into the report so far as our College is concerned. We are aware of the fact that such mistakes may occur taking into account the vast territory covered but we presume that you will gladly receive such corrections as are necessary for your own information.
Your statement in regard to Lane Hospital, that "it has hitherto been conducted as a pay institution" conveys an erroneous idea. It is true that the larger number of patients at the Hospital so far have been private patients, but whatever surplus the Hospital has received from them has always been used for necessary improvements of the Hospital or Medical College, with the particular view of improving the teaching and scientific work in both. Since the establishment of the College no money has every been distributed in the form of dividends to anyone connected with the institution.
We acknowledge that the organization of the Lane Hospital from the teaching point of view is seriously defective. This is easily accounted for in a Hospital where much private work must be done to keep the Institution going. Your report says "The catalogue statement that the Hospital is a teaching Hospital, is hardly sustained by the facts." What this catalogue really says is this (Page 17) "Lane Hospital was designed as a teaching Hospital. It has seventy-five teaching beds which number it is hoped to increase in the near future." We have never claimed it to be a teaching Hospital but have always relied upon the City & County Hospital which was not even mentioned in the Report, as our chief source of clinical instruction.
The statement "records are meager" is not borne out by the facts. There are several teaching services from the College represented in the clinical wards of Lane Hospital. The histories naturally vary a little with the different men, but they are all quite full and complete, stenographers being employed by some clinicians. There is no foundation for the assertion that no surgical rounds are made in the wards.
It is also said that obstetrical work exists only in the form of an out patient department, whereas a small but fully equipped obstetrical ward of six beds for teaching purposes was opened at Lane Hospital on 2 July 1908. In addition there are two free obstetrical beds in Lane Hospital which were given to the Fruit & Flower Mission with the understanding that the patients could be used for teaching purposes. In parts of 1907 and 1908, 194 cases were confined in Lane Hospital. In 1909 there were 167 clinical confinements, in 1910 to July 1, 83. The out patient obstetrical clinic was somewhat small (67 cases in 1909) but well organized. Students are always accompanied by a competent instructor and have ample instruction in external clinic examination. None of our students sees less than six confinements and some many times that number.
You go on to say: "Post mortems are scarce" and in another part of your volume you refer to the inadequacy of the autopsy material at Cooper Medical College. It is true that the number of autopsies at Lane Hospital is comparatively small, but it should have been stated that the College controls good autopsy material at the City and County Hospital. Our Pathological Department has averaged from 199 to 150 autopsies a year for many years and the material has been supplemented from other services at the City & County Hospital and by material obtained at the German and St Luke's Hospitals. We believe that our Pathological Department is especially well equipped for teaching and research.
It should also have been stated in your Report that the Medical Colleges in San Francisco are in an exceptionally fortunate position in controlling the clinical material at the City and County Hospital almost absolutely. The service at this Institution averaging annually over 500 cases, is divided between the Medical Teaching Institutions of San Francisco; and the various colleges appoint the physicians in charge. The main clinical autopsy service of our College has always been at the City & County Hospital where conditions were very satisfactory from a teaching point of view, until it became necessary to remove the old Hospital buildings. While the new $2,000,000 Hospital is being constructed the patients are partly kept in the Hospitals in the City where medical teaching is carried on, and partly in Ingleside Camp Hospital where we now control 100 beds and use them for teaching purposes although with some difficulty on account of the distance and lack of facilities. In the same catalogue that your informant refers to it is stated on page 10: "At the City and County Hospital in San Francisco the College controls 100 beds, averaging about one thousand patients per year. The Hospital facilities will be greatly improved with the erection of the new City and County Hospital which the City of San Francisco is building at an expense of two million dollars."
Referring to our Dispensary, upon which the College has always looked as one of its best assets, you say, "but the material, though adequate in amount, was not thoroughly used by Cooper Medical College" and underneath, "Date of visit, May 1909." The latter seems to explain the former and also why it is said, "no surgical rounds are made in the wards of the Hospital." Instruction to the students in the Dispensary stops at the end of April, our commencement being in the beginning of May. It was impossible therefore for our visitor by personal inspection to ascertain how the clinical material in the dispensary was used for teaching purposes. We do not wish to imply that improvement could not be made in our dispensary service, we are far from assuming such an attitude, but we are positive that good scientific records are kept in all departments of the dispensary, that the heads and assistants are competent teachers, and that the students have been given full opportunity to avail themselves of the clinical material as well by didactic clinics as by work in small sections in actual contact with the patients as is shown by the enclosed schedule which was rigorously adhered to.
Thus not only has our chief source of clinical material and post mortems been ignored, and the fact that the College was not in session when the visit was made been overlooked, but Cooper Medical College with its Faculty numbering fifty-six of whom twelve were full Professors; its eighty students; its many well supplied laboratories whose apparatus is inventoried at $15,000 although worth more; its several salaried Professors and Instructors who receive $10,000 per annum; and its yearly expenditure of $25,000 for educational purposes is scarcely given credit in the Report for existence.
Copies of this letter have been sent to the Board of Trustees of Leland Stanford, Jr. University; to Pres. D. S. Jordan; to the California State Medical Society; to the American Medical Association; to the Association of American Medical Colleges; and to Mr. Abraham Flexner of Carnegie Foundation for the Advancement of Teaching.
By order of the Faculty of
COOPER MEDICAL COLLEGE
Henry Gibbons, Jr., Dean
President Pritchett's response:
29 August, 1910
Henry Gibbons, Jr., Dean
Cooper Medical College
My dear Sir:
Let me acknowledge your courteous letter of the twenty-fifth of July written on behalf of the faculty of the Cooper Medical College, in which you object to certain expressions in the description of that school as it appeared in the recent Report on Medical Education in the United States and Canada, issued by the Carnegie Foundation. The Foundation is desirous of securing in its reports as great accuracy as possible and welcomes any such courteous statement as that which you and your colleagues have sent. Let me endeavor in the same spirit to point out a little more clearly the standpoint from which the Report was prepared and to give the reasons which make us feel that the report represented the essential facts concerning the school.
Your letter seems to me to some extent to be founded upon a misconception; for the Report does not profess to deal with the Cooper Medical College now passing out of existence, but only to deal with it in so far as it is taken over by Leland Stanford Junior University. This is made clear on page 193 where the institution is described not as "Cooper Medical College" but as "Leland Stanford Junior University School of Medicine on the Cooper Medical College Foundation."
The account of the school which had been prepared was therefore sent to President Jordan some months before its publication for such criticism as he and the officers of the medical department of the university desired to make. He returned it with a few suggestions, all of which were incorporated in the Report as published. After sending the Report in advance to the authorities of the university, we were justified in feeling that they concurred in the statements which were made.
With regard to the detailed statements with which you deal, I venture to make the following replies:
You contend that in describing the Lane Hospital as a pay hospital the report conveys an erroneous impression. I think you have again misunderstood the meaning of the report. It was intended to show that Lane Hospital, just taken over as the main reliance of a university clinical department, could not support that role because, being without adequate endowment, it had to earn its way. Educationally it is immaterial where the profits go; in describing it as a "pay hospital" it was not intended to imply that the profits went into anyone's pockets, but it was simply meant to indicate that the patients could not be used for teaching purposes as they paid for their care. This situation is, as I understood from your letter, the situation as it stands today: and the term "pay hospital" meant nothing more than this.
You object in the second place to our statement: "The catalogue statement that the Lane Hospital is a teaching hospital is hardly sustained by the facts" because, as you say, the catalogue does not say that it is a teaching hospital but only that it was designed as a teaching hospital. I am not clear that I entirely understand this argument. The language of the catalogue would unquestionably create in the mind of a prospective student, as it did in ours, the impression that Cooper Medical College had in Lane Hospital a hospital that was the best sort of teaching hospital because it had been designed as such. To argue now that the catalogue description meant only that the school is connected with the Lane Hospital, designed but not used as a teaching hospital, is an argument that I do not entirely understand; and I am inclined to feel that the argument is not exactly that which you had in mind. Certainly the men employed in the Cooper school emphasized strongly the fact that the Lane Hospital belonged to the school, implying at once its teaching value.
With regard to your objection to the statement that the hospital records are meager and uneven, one can only say that this is a question of individual judgment and standards. It still seems to us, from our knowledge of the best institutions in this country, that our description was quite fair; and the information which we had in respect to the school did not depend upon a single visit nor upon the observation of one person alone.
The statement made in the report with regard to post mortems is correct, as it seems to us, so far as present conditions are concerned; and it was only with these that the report undertook to deal, as was made clear in the introduction, page xvi. The same remark applies also to clinical facilities. No reference is made to the old City and County Hospital, for it no longer exists, nor to the new hospital now building, for it is not yet a factor in the situation. The report mentions Lane Hospital only for that is practically all the school now has. The best evidence of the correctness of these statements is furnished by the schedule which you kindly enclosed since this shows that all the clinical and pathological work offered outside amounts to three hours a week, one hour in medicine, one hour in surgery, and one hour in pathology.,
The opinion expressed in the Report concerning the dispensary was based on an examination of the records, equipment, and so forth, and upon inquiries as to how it was used in teaching. The conclusions expressed were endorsed by at least one or two men connected with the school.
With regard to the facilities in obstetrics, I am unable at a distance from the office to make a definite reply. The information was procured from those in the Lane Hospital itself.
Let me say again in conclusion that I appreciate the kindly spirit in which your letter is written; but I am still persuaded, in view of the care which was taken in the preparation of the Report, that the differences to which you call attention are differences rather in point of view than differences in the actual facts. The financial statement which you made at the end of your letter is itself quite full proof that the Cooper Medical College is being maintained on a scale entirely inadequate to the demands of modern medicine. I am quite aware that in this institution and in many similar ones a large measure of devotion has been given which cannot be represented in the income account of the school. Such devotion is sometimes wise, sometimes unwise. But in any case, it is clear that a university school of medicine cannot be sustained upon any such basis as that which you describe.
In view of the kindly letter which you and your colleagues have sent, I cannot close this reply without reference to one other matter which seems to me of supreme importance to medical education in San Francisco, and that is to the regrettable competition brought about by the effort to conduct two medical schools in that city. It will be difficult enough to build up in San Francisco a single school, maintained and conducted upon modern ideals. The effort to conduct two makes the whole future doubtful. Is it not possible for those interested in medical education in San Francisco to come together in one effort worthy of modern medicine and of your great city?
Very sincerely yours,
(Signed: Henry Pritchett.)
We find no reference to President Pritchett's letter in the minutes of the Directors or those of the Faculty of Cooper Medical College, or in the Annual Reports of the President of the University. No doubt, from their viewpoint, there was little more to be said on the subject for, by that time, consolidation was assured. Years later, in his Memoirs, Dr. Ray Lyman Wilbur recalled the correspondence between Dean Gibbons and President Pritchett: 
The survey of medical education in the Unites States, inaugurated by Dr. George H. Simmons of the American Medical Association and its Council on Medical Education, and carried out by Abraham Flexner through the backing of the Carnegie Foundation for the Advancement of Teaching, began the revolution in medical education which is still going on. The report by Flexner on the Cooper Medical College was harsh and in part unjust, but it served to stimulate changes and to further the efforts of those who held that medicine should be a part of the work of a university.
A letter of protest which Dr. Henry Gibbons, Jr., sent to the Carnegie Foundation at the time gives a picture of how the medical education looked to a fine, sympathetic, and honorable dean who was a leader in medical service and in medical education throughout most of his career.
President Pritchett's letter mainly served to expose the wide gulf then existing between the standards of an above-average proprietary institution such as Cooper Medical College, and those required of a modern medical school. President Pritchett also took the opportunity in his letter to reinforce what he considered the "supreme importance" of his agenda for medical education in San Francisco. That is, Stanford should "content itself with the work of the first two years in Palo Alto and cooperate with the state university in all that pertains to the clinical end."