Lane LibraryThe 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.
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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]
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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]
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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.