DAEEACH I».ffiMDEANDUl«i ON THE SCHOOL OF i&;DICi:iI v\ -^"ly^^n ^ise int^eCttpoflettigork CoUege of ^tpsiictans; anti ^urseon£i Hibrarp Digitized by tine Internet Arciiive in 2010 witii funding from Open Knowledge Commons http://www.archive.org/details/memorandumonschoOOdarr MEMORANDUM ON THE SCHOOL OF MEDICINE BY WILLIAM DARRACH Dean of the College of Physicians and Surgeons Columbia University New York, December 13, 1919 y'^T' I. The Objects of the School of Medicine of Columbia Uni- Objects versity shall be: (a) to train men and women to be physicians of the highest type and to develop leaders of medical thought; (b) to test and increase our knowledge of the art and sci- ence of medicine and to foster research; (c) to apply that knowledge to the prevention, cure or alle- viation of human ills. Immediate Essentials Later Develop- ments II. In planning for such a school we must differentiate be- tween that portion of the entire scheme which is essential for the development of a medical school, designed to accommodate a definite, number of students for the degree of M.D., and other portions not essential to this primary purpose, but neces- sary to complete the organization in its fullest possibilities. Such subdivision can be illustrated by two concentric circles. In the smaller circle would be included, besides the school and laboratories, a general hospital and dispensary of sufificient size to supply the clinical material necessary for research and the undergraduate teaching. In the krger circle would be included special hospitals or institute' ir the better development of the special branches. For, present we shall deal only with the smaller circle, leavi' le outlying portion for further consideration. / To institute and carry on such a school of medicine it Need.' / essary to obtain : .. jnd sufficient in amount to accommodate the various build- ings required at present and to allow for future development. The site should be convenient to clinical material and to the various methods of transportation of the city. Buildings to accommodate the various departments of the school, the laboratories, hospital, dispensary and dormitories for the students. These units must be so arranged as to allow the intimate correlation -and coordination of teaching, research and care of the sick so necessary for the full development of Land Buildings 1 Limited Numbers Expansion Quality .each. The school, hospital, dispensary and laboratories are so interdependent that their unity must be realized geographically as well as functionally. Endowment sufficient to make it possible for the University to carry the greatly increased medical school budget involved in the proposed plan of organization. IV. The Medical School 1. The Student Body. Numhers The natural desire on the part of a university is to accommo- date as many properly qualified students as apply to the insti- tution. But in the teaching of medicine it must be accepted that there is a definite limit, beyond which a single unit cannot expand without lowering the quality of the instruction given. When the demand sufficiently exceeds this limit it should be met by duplicating the unit, rather than by crowding the facili- ties. It is believed that today such a limit is reached when a single class reaches 100. It is more difficult to expand in the later clinical years, when facilities depend on hospital bed capacity, than it is in many of the laboratory courses in the first two years. For this i^eason the number admitted to the first two years should not exceed the accommodations of the later years. It should not be taken for granted that a certain percentage of those enter- ing will fail to qualify for advancement, but it should be pos- sible always to carry through to graduation all who are al- lowed to enter if their work is satisfactory. Vacancies will ahvays probably occur and these can be well filled by admit- ting to advanced standing, students from other schools who may prove their fitness by proper tests. Quality The quality of the applicants for admission will naturally improve with the quality of the teaching, and the general reputation of the school. And it should be possible, with a limitation of numbers, to select those who are best qualified for the work. Such a selection must be made with great care. It may soon be necessary to require three instead of the present two years of academic work, which must include a sufficient amount of physics, chemistry, biology, French or German and English. But other methods must also be devised for the determination of a candidate's fitness for the study of medi- cine. His mental and personal qualification may be tested by a psychological examination and his record in his pre-medical work should be taken into account. 2. Officers of Instruction. The success of such an institution will depend more on the character of the teaching body than upon any other one factor. Selecf o The selection and further development, not only of the heads of the departments but also of their associates and assistants, must be matters for the exercise of the greatest care and wisdom. In their selection, the three-fold purpose of the institution — teaching, research and the application of knowledge — must be borne in mind. In making appointments, irrespective of the grade, every attempt should be made to find and obtain the best available man for the position, wherever he may be. After carefully canvassing all possibilities, expert advice should be sought from outside the institution before the decision is made. The character of the teaching personnel will depend also on the opportunities ofl:'ered them. This includes both a proper salary and facilities for work. The former should be adjusted ^^'^''^' to the needs of the individual. For the full-time worker, whe- ther he be in a laboratory or a clinical department, the salar\- should be sufficient to free him from the necessity for outside employment. For the part-time worker whose main income is derived from other sources, the salary need be much less. But all men who are actually engaged in teaching should, if possible, have some financial reward in addition to the honor and respect the position brings. Of more importance than salary for either type of man is the proper arrangement of his work, so that he shall be freed Arrangement from unessential details and useless waste of time. In the end ^'^ Work the opportunity to carry on teaching and research under whole- some conditions is the most eflfective force for bringing into the medical school men of ability and ideals. 3. Organization. The School and hospital should be organized and adminis- Balanced tered so as to include men who are qualified in all three Personnel branches — teaching, research and the application of knowledge to the care of the sick. Each individual need not possess all three qualifications, but all must be represented and balanced throughout the school. There should also be such cooperation and coordination not only within each department but between the different de- partments as will weld them all together into a single well balanced unit. (a) Laboratory Department. The heads of many of these departments have long been on the full-time basis and with no legislation they have volun- Fuff-Th^r^^" tarily refrained from any outside employment. The results Plan in the advancement of knowledge have proved the value of such an arrangement. There must be no curtailment of the fields of investigation in these departments. They must be free to study and develop fnvesdgldon any part of their particular science. At the same time they but Teaching should consider their problems from the standpoint of medi- CoTrehted cine as a whole. They must remember that they are primarily parts of a medical school and a hospital for the sick, lest their teaching lose that vital contact with medicine which is so es- sential to the best development of its art and science. This better cooperation will be greatly aided by the geo- graphical union of the laboratories and the hospital and there- fore with the clinical departments. It can also be helped by including among the lower grades of their personnel, men who are being trained for the clinical departments. By serving a limited time in several of the laboratory branches, the younger men will gain a wider and firmer foundation for their cHnical work. This arrangement has long existed in the Ana- tomical Department and a large percentage of the Surgical personnel are serving, or have served, as demonstrators of anatomy for two to ten years. (b) Clinical Department. The main clinical departments shall be reorganized on the full-time basis, — Medicine and Surgery immediately and Pedi- Full-Time atrics as soon as financial and clinical facilities permit. It is hoped that other departments may later be similarly arranged. At the head of each shall be placed a. man of such training, ability and character that he may assume full responsibility for and the direction of the general policies of the department, the character of the teaching, the hospital service and the nomination of his associates. It shall be his duty to develop a modem clinic of the best type. Before considering further the organization of these de- partments, the following discussion of the ''full-time" plan seems warranted by the existing ambiguity of the term, a? evidenced by the widely divergent plans of organization now in force or planned throughout the country. In the earlier days of medical education, practitioners gave a portion of their time to teaching. At first a student became associated with a practising physician who gradually taught him in all branches of the art. Later schools were formed where physicians concentrated their efforts on one branch of the subject. At another period it was realized that if teachers were to keep abreast of the knowledge of the day and to make any independent advances, it was necessary for them to devote most of their time to investigation and teaching in their own particular branch. This plan of concentrated effort was first adopted in the laboratory branches and for a number of years, the leaders, and most of their assistants, in the department? of Anatomy, Chemistry, Physiology, Pathology and Bacteri- ology, have been men who have completely given up or have never entered the practice of medicine. The results in the betterment of teaching and in the advancement of knowledge have well proved the wisdom and necessity of such an arrange- ment. Lately a similar development has been taking place in the clinical departments. In several medical schools the depart- ments of Medicine, Surgery and Pediatrics are being reorgan- ized on what is spoken of as the "full-time" or "university" basis. It is being widely accepted that such an arrangement is necessary for the best type of teaching, for the most success- ful clinical investigation and for the most skillful care of the sick. The essential principle of this arrangement is that the domi- nating group of men in the main clinical departments must be free to concentrate their energies on their university and hospi- Head of Department Discussion of FuU-Time Plan Apprentice System Schools Full-Time in Laboratory- Department Details of Organization Limitation tal work. There are two main factors which tend to inter- fere with this freedom, no matter how sincere the intentions of the men may be. These factors are insufficient assistance and the distractions of private practice. By providing the full- time men with sufficient assistance, professional, clerical, tech- nical and menial, he may relieve himself of such unnecessary details as he desires. He must also be protected from the de- mands of private practice. The main purpose is to obtain a more truly university type of clinical teacher. The full-time plan is a means to this end — a method by which it may be obtained. Neither the time element nor the question of fees is, in itself, the essential point, and these must not be con- founded with the primary object. There is apparently but little question in the minds of medical educators as to the wisdom and necessity of this main prin- ciple. There is, however, some doubt and much discussion concerning the details of organization. This is evidenced by the wide variation among the plans now in force and among others suggested. The main difficulty lies in the question of private practice. As a man's value as a clinician increases, the demands made for his services by the public naturally in- crease. If this increasing demand is satisfied he will have less and less time for his university duties. It therefore be- comes necessary for these men to control the amount of pri- vate practice they shall do and the conditions under which it is done. The various so-called full-time plans may be sutfimarized as follows : Summary of Plans Plan 1. No private practice and no outside employment. Plan 2. Private practice at the discretion of the clinician but no fee is paid for such service. Plan 3. As in Plan 2 except that the fee is paid to the Uni- versity. Plan 4. Private practice for fees allowed in such limited amounts that it does not interfere with the thorough, efficient and sincere fulfillment of his academic duties. Plan 5. Unlimited private practice within the hospital. Plan 1 has not been tried. Plan 2 is in effect at the Rocke- feller Hospital and is the plan that will be recommended in this memorandum. Plan 3 is applied at Johns Hopkins. Plan 4 is in effect in several schools. Plan 5 was suggested in 1911 but it is not in eff'ect. From an administrative standpoint Plan 1 would be the Discussion simplest method. The full-time men would limit their clinical °^ ^'^" ^ experience to the wards of the hospital and the dispensary. It seems unwise to deprive the public of these men's services, for patients who are not eligible for the charity wards are at times of great scientitic, educational, or humanitarian interest! Plans 2 and 3, where practice is restricted by removing the pians 2 financial inducement, remove the above objection. The pay- ^^^ ^ ment of the fee to the University, however, is strongly criti- cised by many men and is not entirely satisfactory to some of the men who have been working under that arrangement. Of the two, therefore. Plan 2 seems to be the preferable one. If Plan 4 were used the hospital would place a limited num- pjan 4 ' ber of private rooms with office facilities at the disposal of men working on this basis. These men could then spend a large part of if not all of their time in the school and hospital. This plan, however, cannot be combined with Plan 2 without introducing a discordant element into the situation. The specific plan to be proposed for adoption therefore discards men on the Plan 4 basis. Plan 5 is the one suggested by the Faculty of the College of pj^^^^ 5 Physicians and Surgeons in 1911 but does not meet the re- quirements of today, as with unlimited facilities within the hospital such private practice might well claim the major por- tion of a man's attention. These five variations have all been spoken of as "Full-time" plans. Plans 1, 2 and 4 are consistent with the present statutes of Columbia University as to full time service. The success of any plan will depend on the character of the Character of man in question and the spirit of the school. Any form of ^ ^ t^^" °^ legislation will be unavailing if the wrong men are appointed Importance to these positions. There are manv forms of distraction be- t • \„t.-^ _^ _ _' i^egislation sides private practice, especially in New York City, which might lure a man from proper fulfillment of his academic du- ties. Some definite conception, ho\Yever, is necessary in for- mulating any such reorganization. Specific Plan Proposed. The fundamental principle upon which these departments shall be reorganized is that the control of each main clinical department shall be vested in a director, associated with a differentiated group of men who are devoting all their time to the school and hospital, that they may build up and main- tain a department where the best intensive clincial investiga- tion and scientific research may be carried on with the teach- ing of students and the care of the sick. In order to achieve this end it is believed to be wisest so to organize these departments that the director with all of his associates (those in charge of portions of the hospital service) and as many of his other assistants as he desires and can af- ford, shall be on the basis of Plan 2. They would see private patients at their discretion for scientific, educational, humani- tarian or personal reasons and when they do no fee would be paid for such service. The head of the department shall not only be responsible for the general policies of the whole •department, for the character of the teaching and for the nomi- nation of his associates, but he shall be given every facility to develop a well-rounded, modern clinic, with sufficient clini- cal material in both wards and dispensary, with the specialized assistants, professional, clerical and menial, he requires and the necessary laboratories. To carry on efficiently the teaching of two classes of 100 men each, in a clinical department, it is necessary to have a large corps of assistants. Especially is this true as the older lecture method is more and more replaced by recitations, con- ferences and practical work at the bedside, in the laboratories and dispensary. Even if it were advisable to have the entire department on a full-time basis, the expense in certain de- partments would be enormous and the plan therefore imprac- tical. In addition to the group characterized above as under Plan 2, the conduct of hospital, dispensary and school re- quires additional assistance from men giving only part of their time to hospital, dispensary and school. The extent to which they are used should vary with the ideas and plans of the re- spective directors, provided they are not made an essential part of the hospital organization. The salary of the men on the Plan 2 basis should be suffi- cient to make them independent of any private work and that of the director should be enough to allow him to assume the Salaries position in the world that he deserves. The men on a part time basis will require a much smaller salary than that of the full-time men. The head of the department with these associates should form an administrative board, which could relieve him of as much of the administrative details of the hospital and of the teaching as he chose. Unless he is so relieved and protected from the innumerable distractions of departmental matters he will prove sterile as a producer and will soon cease to be the inspiring and stimulating leader so necessary in a depart- ment of this kind. These men should have as much time for constructive thought and productive leisure as the head of a large industrial concern. By such a combination and coordi- nation the department would become a well-rounded unit. which should result in great progress along all three' lines — research, teaching and care of the sick. V. Administration. There should be a large deliberative body to include all teachers who are in charge of courses. There should be a separate legislative body made up of the heads of the departments of Anatomy, Bacteriology, Biologi- cal Chemistry, Neurology, Obstetrics and Gynecology, Pathol- ogy, Pharmacology, Physiology, Practice of Medicine, Pedi- atrics and Surgery. There should be a small adinuiistrative body with whom the Dean could advise as often as was necessary. IV. Hospital and Dispensary. The University Hospital must be in close geographical and functional relation to the medical school. Proximity It must be planned to contain sufficient beds to supply the ^^^^ Hospital clinical material necessary for classes of 100 students. The school should then limit its undergraduate teaching to the Convalescent and Follow- up Facilities Special Hospitals Vanderbilt Clinic University Hospital, except where the dinical material proved insufficient, as for instance at the present time in psychiatry, tuberculosis and infectious diseases. If the student is to have a complete picture of a disease, and of more importance, if the patient is to be properly cared for, a longer stay in the hospital should be planned than is now the custom in most of the New York Hospitals. The de- mand for beds is so great that patients are often discharged as soon as they are able to stand the trip home and before they are really able to resume their home duties. This should be arranged for by providing good convalescent facilities, a good "follow-up system" and by a more generous supply of beds. To satisfy these conditions there should be 200 beds for Medicine, 200 for Surgery and 250 for the other specialties. The number of beds in a general University Hospital which shall be assigned to each of the specialties should be small, as it should aim to satisfy only the demands for undergraduate teaching. It is hoped that later on special hospitals such as the Sloane Hospital for Women, may be obtained adjacent to the Uni- versity Hospital, for each of the specialties. As these become available the beds in the general hospital assigned to that spe- cialty will be released and would be ready to satisfy new de- mands as they will arise. In this way the normal increase will be accommodated for some years to come. It is hoped that the Vanderbilt Clinic will be moved with the school and built on such a scale as to include the outpatient function of that hospital. VII. Summary. The three-fold purposes of the School of Medicine are teach- ing, research and the care of the sick. To attain these there must be : (a) An intimate geographical and functional union with a University Hospital. " (b) Such limitation of numbers of students as will permit the consistent pursuit of a definite policy. Increasing demands may be met by a complete duplication of the whole unit. 10 (c) Reorganization of the main clinical departments on a full-time basis. It is therefore recommended that: (a) An organic affiliation be formed with the Presbyterian Hospital. (b) That sufficient funds be obtained to furnish the neces- sary land, buildings and endowment. This plan represents the best thought of the present time but will naturally be subject to such modifications and changes in future years as larger experience may suggest and justify. 11 COLUMBIA UNIVERSITY This book is due on the date indicated below, or at the expiration of a definite period after the date of borrowing, as provided by the rules of the Library or by special ar- rangement with the Librarian in charge. DATE BORROWED DATE DUE DATE BORROWED DATE DUE asT 1 4 «'' ^ . C28(63S)MS0 D252 cLOQl.Qf