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Chapter XXXIII. The Clinical Full-Time System

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.

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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]

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