Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (42 page)

1 1 In 1912, Carrel won the $39,000 Nobel Prize in Physiology or Medicine based on his work on suturing and transplanting blood vessels. He developed an antiseptic technique to sterilize healing tissue, which was very useful during World War I, and collaborated with Charles Lindbergh on a perfusion pump that was the precursor to the bypass machine. In an interesting sidelight, Carrel was brought to Rockefeller from the University of Chicago, by Simon Flexner. Flexner was a Jewish pathologist trained by Welch and one of the scientific directors of the new institute. The two became fast friends. During World War II, Carrel worked with the Vichy government, espoused many of the Nazi beliefs in eugenics, and was thought by many to have been the source of much of the bigotry associated with Lindbergh in later life. Carrel died in disgrace in France in 1944.

CHAPTER THIRTY-TWO
A New Paradigm

FEW NONSCIENTIFIC ISSUES HAVE
stimulated as much heated debate among physicians as the controversy over full time. Should medical professors be full-time salaried employees of the university, restricted in outside earnings, or should they be permitted to earn income above their salaries in private practice? One could easily argue both sides if the issue were only that simple. At Johns Hopkins a new philosophy was gaining a foothold, which further complicated the issue. Tucked quietly under this simple question was the idea that once professors became “full time,” they would be pure scientists, and abandon clinical practice altogether. That was a revolutionary premise which would prove more difficult to sell.

Medicine is a full-time job, and patients think of their doctors as clinicians. They are internists, surgeons, obstetricians, gynecologists, or pediatricians. While medical scientists are correctly perceived as another breed entirely—full time, but different. No patient in his right mind would choose a surgeon to repair his hernia simply because that surgeon had worked in the laboratory to uncover the function of the parathyroid glands. But in 1910 they were the same man, William Stewart Halsted. And he would figure prominently in the struggle.

For the first two decades of its existence, Johns Hopkins was the living embodiment of that gray area. It thrived, and grew, and became famous the world over based on the excellence of its clinician/scientists. When the line was drawn between Mall and Osler, it raised the question of dominance in the academic setting. Who should take the lead in the education of medical students? Should precedence be given to the pure medical scientist or the bedside teacher? At first it was a nonissue. The pure scientists like Mall, Martin, and Abel taught students in the two preclinical years. Halsted, Osler, and Kelly took over as the students were introduced to patients in the last two years of the program.

The lines became somewhat blurred as Halsted, never a great teacher of medical students, gave over much of this responsibility to his assistants, spent less time operating, and more time in the laboratory. Ludwig’s dream of clinical professors devoting all their energies to research struck a chord in Mall, and he became a fierce advocate of the full-time system in its purest form. For the others, led by a relatively quiet Welch, it was a softer and more realistic concept: relieve the clinical professors of the need to engage in private practice to supplement their incomes, and allow them the luxury of teaching, research, and patient care, with the monies earned accruing to the university.

At the opposite pole from Mall was William Osler. The man who chose for his epitaph “He taught medical students” was a staunch defender of the status quo. Osler was outraged by the idea of laboratory scientists teaching medicine to future physicians. He believed his private practice, which he conducted mainly after 2
P.M.,
did not detract from fulfilling his duties. He apologized only for out-of-town consultations, which took him away from the hospital. But these cases, he believed, burnished the Johns Hopkins reputation, as the private practice fostered interaction between the Hopkins staff and important individuals in the community, and established the authority of Hopkins physicians. Halsted was silent.

ABRAHAM FLEXNER WAS
a teacher and school principal in Louisville. He was a Johns Hopkins University graduate and the brother of Simon Flexner, Welch’s former assistant who was now a director of the Rockefeller Institute. In 1908, Abraham Flexner’s interest in educational philosophy brought him to the attention of the Carnegie Foundation for the Advancement of Teaching, where he was charged with preparing a report on the state of medical education in America. The American Medical Association, then a largely impotent organization, had championed the study, which gained importance with the backing of the Carnegie Foundation. Simon Flexner idolized Welch, and the pathologist had no small influence on the thinking of his brother. Two years later, the report found all medical colleges in the United States deficient, with a single exception: The Johns Hopkins School of Medicine. Welch’s dream had become the prototype for proper medical education. The report quoted chapter and verse on the inadequacies of the proprietary medical schools: libraries without books, absence of laboratories, inadequate clinical instruction, lack of research, and the absence of teaching hospitals controlled by the medical school. Only 50 of 155 medical colleges were associated with universities. Only Johns Hopkins and Harvard required a college degree. Cornell required three years of college, 20 other required two years, and 132 medical schools required a high school education, or less.

The death knell had been sounded for proprietary medical schools. The country was scandalized, and the empowered AMA refused to certify schools that were deemed inadequate. More than half of the medical schools in the country were soon shuttered. But the winds of change had preceded the report, and at the better schools, change had already begun. Harvard, the University of Pennsylvania, P&S, and other medical schools associated with universities had already taken heed of the successful Hopkins model and were moving ahead. University-affiliated schools were given the benefit of the doubt and advised to address deficiencies. Some were made to consolidate with
other schools in the community. Everything considered, the landscape was markedly changed for the better.

Critics point out that many necessary, though admittedly marginal, schools were forced to close, including several of the Negro medical colleges.

With the success of his report, Abraham Flexner gained considerable influence. He was not a physician, and he was of the firm conviction that medical education should be a laboratory science at the expense of clinical experience. The ball was rolling in the direction of full-time medicine, and Mall, having Flexner’s ear, reinforced the need for that change. As John D. Rockefeller’s wealth grew, Frederick Gates, his point man for philanthropy, focused his efforts on medicine, resulting in the Rockefeller Institute for Medical Research. When Gates asked Flexner what he would do with a million dollars to improve medicine, the response was, “I should give it to Dr. Welch.”

Gates got the idea and sent Flexner to talk to Welch. A dinner was arranged at the Maryland Club, with Halsted and Mall in attendance. Mall saw his moment.

“If the school could get a sum of approximately a million dollars, in my judgment, there is only one thing we ought to do with it—use every penny of its income for the purpose of placing on 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.”

Welch did not jump at the opportunity, and Halsted said little, but the issue was out in the open and the wherewithall to implement it was at hand. By June 1911, the trustees had endorsed Welch’s plan for full-time professors, with fees from practice reverting to the university. The plan required the consent of the medical faculty, which was not quickly forthcoming.

Osler checked in from Oxford. “I did not take away from B a dollar made in practice.” He defended the need to practice medicine.
“Would whole time men have the same influence on the profession at large—I doubt it.” In an open letter to university president Ira Remsen, he angrily took issue with errors in Flexner’s report to Gates and the aspersions cast upon Kelly, who earned hugely and donated a great deal of his income back to his department and his charities. Now the “happy band” were taking sides.

In 1912, Osler wrote that full time would lead to “a faculty of Halsteds. A very good thing for science, but a very bad thing for the profession.”

In January 1913, Remsen resigned for health reasons, and Welch temporarily assumed the position of president of The Johns Hopkins University. Now he was truly in charge, but he stepped lightly. The idea of full time rested on providing adequate income for the professors, which, in turn, would be provided by the Rockefellers’ General Education Board. By October, Welch had a consensus among the governing board of the medical school, and the Rockefellers honored him by naming the fund the William H. Welch Endowment for Clinical Education and Research.

There were two issues that needed to be addressed. First, was the full-time system going to separate the doctors from their patients? Physicians weighed in from everywhere, and the general consensus was that it would insidiously do so. Patients, too, felt uneasy about the fees rightfully earned by their doctors going to the university. Many Hopkins graduates were skeptical of the wisdom of the plan, and some bitterly opposed it. Leading members of the medical faculty, including Kelly and the psychiatrist Adolf Meyer, were unhappy with the decision and felt it was being foisted upon them by outside interests, meaning Gates, Flexner, and the all-powerful Rockefeller company Standard Oil.

The second issue was the need to establish a salary comfortable enough to attract significant individuals to the chairs.

Initially, the new rules would affect pediatrics, medicine, and surgery. For the time being gynecology would be exempt, as would the newly born subspecialties such as urology. John Howland, recently
enlisted as professor of pediatrics, knew what to expect when he accepted the job and offered no resistance. The big surprise was Lewellys Barker. Barker had been primarily a laboratory man. When he replaced Osler in 1905, he was so uninitiated in the art of clinical medicine that he had to be instructed in the bedside techniques of patient examination. But Barker was smart and personable, and found he loved being a doctor. And he loved being in private practice. In the end he refused to give up the lifestyle, and the income, of his private practice and resigned as physician in chief. He took the title of clinical professor and built a thriving practice. Barker’s second in command, William S. Thayer, who had been passed over for the job when Osler left, was offered the full-time position. He, too, declined.

Halsted had more or less cast his lot with the laboratory men, Mall and Welch, but he remained concerned that his residents have the opportunity to become the finest clinical surgeons and teachers of surgery. One of his criteria for choosing a resident was an interest in independent research, but his primary goal had always been creating well-rounded surgeons who would become professors of surgery and spread the gospel of excellence according to William Stewart Halsted.

Halsted sent a series of notes to the trustees to illuminate his thinking. In archive document #1207, in pencil on his personal stationery, Halsted writes:

1. The clinical men tend to deteriorate in certain directions. & the laboratory men are prevented from developing in others.
   

2. The world over the laboratory men are of a higher order than the clinicians; & among the clinicians the physician outranks the surgeon & the surgeon outranks the gynecologist.
   

3. As a rule the more intellectual men & those with the highest ideals select the laboratory branches … The reward for the greater talents & higher achievements should be advance in position & not increase in wealth … I am free from prejudice in trying to take a position in this matter, because it would now make, as far as my income is concerned, very little difference to me whether it (my income) was limited to a $10,000 salary or not. The assurance of such an income, which is perhaps a few thousand dollars less than what I am presently making, would quite compensate for the uncertainty of making so much in the future.
   

The ideal simple life is that which is not enforced.

The simple life is not ideal unless arrived at by voluntary renouncement of luxury.

These last two sentences reflect a philosophy totally unlike the manner in which the 61-year-old Halsted had lived his life. With every financial advantage, Halsted surrounded himself with enormous personal comfort—a grand town house, a country estate, numerous personal employees, closets full of the finest custom-made clothing, and unlimited first-class international travel—all of which would seem anathema to the “simple life.”