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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 University 120,000.00
Columbia University 1,519,666.66
Cornell University 8,151,113.01
Duke University 300,000.00
Emory University 180,000.00
Harvard University 1,393,268.64
Howard University 587,759.32
Johns Hopkins University 11,126,126.41
Meharry Medical College 8,673,706.12
State University of Iowa 1,231,003.40
Tulane University 3,421,155.87
University of Chicago (plus President Hospital) 14,505,721.83
University of Cincinnati 762,411.00
University of Colorado 1,113,000.00
University of Georgia 60,000.00
University of Oregon 691,679.34
University of Pennsylvania 309,675.55
University of Rochester 5,813,870.64
University of Virginia 956,000.00
University of Wisconsin 12,500.00
Vanderbilt University 17,560,378.45
Washington University 7,283,035.52
Western Reserve University 1,365,000.00
Yale University 6,876,300.98
Total 94,083,372.74

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.



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
Total 1958 - 1959 - 1995-1996 -
Medical Schools 79 - 124 -
Medical Students 28 977 - 66 906 -
Salaried Faculty Percent Percent
Basic Sciences 3 845 37 % 16 972 19 %
Clinical Sciences 6 505 63 % 74 479 81 %
Total Salaried Faculty 10 350 100 % 91 451 100 %
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