Memorandum for: Judge E. E. Townes, Chairman, Houston Executive Committee, Baylor University Board of Trustees
Subject: The Current Status of Baylor University College of Medicine in The Texas Medical Center and the Proposed New Jefferson
In a memorandum on The Texas Medical Center, prepared in 1948 at the request of Mr. H. R. Cullen, the late Dr. H. J. Stander,
an outstanding medical educator who was then Professor of Obstetrics and Gynecology of Cornell University Medical College
and Director of the New York Lying-in Hospital, gave the following definition of a Medical Center:
"A 'Medical Center', as this term is used today, connotes an institution designed to offer medical care of the
highest standards in every branch of medicine to the community; to equip and train most adequately young graduates for general
practice or the specialties; to educate and train undergraduate medical students and nurses in a manner consonant with the
highest demands of medical education; and finally, to be in the forefront in medical investigation and fundamental research
in the cause and treatment of disease. It is evident that to attain these ends the medical center must be able to offer adequate
hospital facilities as well as be an intimate part of a first class medical school."
Dr. Stander further stated that these essential requisites could be met in the proposed Texas Medical Center in Houston and
that "the Medical School of Baylor University is uniquely situated in a large and ever growing modern city with a concentration
of industry and finance which should be able, not only to support, but also to develop the Medical School to a point where
it will be among the best of our centers of medical education and research." He emphasized, however, that in order to
achieve these objectives certain broad principles must be followed, including particularly:
1. For every dollar spent in construction at least two dollars should be reserved for endowment to operate the institution.
2. A total bed capacity of about 1200, provided the classes of Baylor University be limited to 80 students per class.
3. The Head of each major department in the Medical School must be the Chief of Service in the affiliated hospital.
4. Establishment of an administrative organization with a joint Board representing the governing board of the medical school
and each of the participating hospitals and responsible for broad policies and under this a Medical Board composed of the
Heads of the major clinical departments as the responsible professional body. The actual administration organization for the
Center should consist of the President of the Joint Board who works closely with the Director of the Hospital and the Dean
of the Medical School.
5. "Geographic unity. The Center cannot function successfully and become one of the outstanding Medical Centers of the
world if it is merely a combination of five or more individual hospitals associated with a medical school. The new Center
cannot be a mere gathering together with the 'neighborhood' of several hospitals. The Center must be planned as one
complete institution, with its several component units (hospitals) fitting as one over-all scheme, so that services such as
X-ray, Out-Patient Department, Pathology and the various Laboratories may serve each unit alike and that there be no need
for duplication of X-ray, etc."
Several other outstanding medical educators, including Dr. Alfred Blalock of The Johns Hopkins University, Dr. Basil McLean
of the University of Rochester, and Dr. Alfred Snoke of Yale University, who have had occasion to visit Houston and observe
the Texas Medical Center development, have submitted reports embodying similar recommendations for the organization and construction
of the Center. All of these men have emphasized the fact that a Medical Center consists essentially of a regular medical school
and its affiliated hospital (or hospitals) with complete organizational integration of their personnel and geographic unity
of their facilities. In his report on The Texas Medical Center, Dr. Blalock placed great emphasis upon these principles stressing
particularly the proper relationship between the medical school and its affiliated teaching hospital. After explaining the
fundamental reasons for these principles and how time and experience had proved their significance in the nation's greatest
medical centers, he emphasized that by "hospital facilities, I do not mean mere association or proximity to a hospital
where medical students may be permitted to drop in and observe the course of patients, but instead a hospital operated and
maintained primarily for the teaching of medical sciences and the investigation of medical problems, and supervised and directed
by appropriate members of the medical school faculty just as absolutely as other faculty members are in complete charge of
their anatomical dissecting rooms or chemical laboratories."
In the concluding remarks of the report, Dr. Blalock again emphasized the important role of the medical school stating "it
must be obvious to you that I feel that the success and the future of the proposed medical center hinges on the emphasis and
the development of the facilities of the associated medical school. Having carefully selected the men to head the facility
of the medical school, they must assume a position in the organization of the center that will ensure the proper development
of their departments. They must have absolute control under trustee supervision of sufficient beds for training and teaching
purposes. One well organized, closely integrated medical school that is actually the foundation upon which the center is organized
is the best assurance of success."
These men are all eminent medical educators. They are recognized authorities in their fields of endeavor and they speak with
the wisdom derived from long experience and diligent study of those problems. They have all pointed out the important role
of the medical school in the center. They recognize only one medical school for the center - the one regular and complete
medical school - Baylor University College of Medicine. No other medical school is mentioned in their reports because their
concept of a medical center both in organization and construction consists simply of a medical school joined with its teaching
hospital units. This concept by its very nature excluded the possibility of more than one medical school. Thus, it is no more
possible to have a medical center with two medical schools than it is to have a wheel with two hubs. To be sure, two medical
schools can exist in two medical centers geographically located in the same area, but each medical school would constitute
the nucleus of its own center.
A review and analysis of certain events which have taken place in the Texas Medical Center during the past few years make
it plain that the wise counsel and recommendations of these prominent medical educators have not been fully appreciated. More
important, however, than the failure to appreciate the significance of this advice is the fact that the current trend of events
may seriously jeopardize the entire future of the Texas Medical Center and of Baylor University College of Medicine.
For a more concise consideration of these events it is desirable to begin with the status of the Texas Medical Center approximately
two years ago. At that time the only constructed institution in the Center was Baylor University College of Medicine and it
was operating under tremendous handicaps for it had no affiliated hospital facilities for which it could assume proper responsibility
and adequate authority in carrying out its clinical teaching program. With few exceptions the various clinical departments
existed only as organizational facets of the College with no clinical services of their own through which they could properly
perform their teaching and research functions. The blueprint for the Center consisted essentially in a "gathering together"
in the neighborhood of a number of proposed hospitals and a so-called Central Outpatient Clinic which was to provide outpatient
service for all the hospitals in the Center and be operated by the Medical Center Board. It was apparent from this concept
of the Center that the Central Outpatient Clinic would be the "Central organization through which all institutions in
the Center will be drawn into the team," and the Board of the Texas Medical Center would build the Clinic and "exercise
general control over it." It was further stated in describing this concept that "the professional men heading the
various departments" will have charge of the work within the Clinic. Thus, it would be the hub of the Center, not the
medical school. Aside from the fact that the concept itself is unsound, the details of operation so far as professional personnel,
channels of authority, and patient management were never clarified. It is obvious that this concept of a Medical Center violated
all the principles and injunctions of Drs. Stander and Blalock and the idea of a Central Outpatient Clinic was simply unthinkable
to the professional people both in the medical school and in the participating hospitals. The conviction that it was an unworkable
scheme generated much opposition and contention. This was the status of the situation when Drs. Basil MacLean and Alfred Snoke
arrived on the scene approximately two years ago.
Those experts in the field of hospitalization and medical education were invited here by the Board of Managers of the Jefferson
Davis Hospital who were activated by a sincere desire to improve the services and teaching facilities of the institution.
Following their survey of the hospital these men recommended an affiliation with Baylor similar to that in effect at some
of the nations leading medical centers. On the basis of these recommendations and the conviction that they were directed toward
the best interests of the hospital in providing improved professional care of patients and in furthering medical knowledge,
the Board of Managers completed the contract with Baylor University formally establishing the affiliation. The expressed approval
of these recommendations by a majority of the members of the staff of the hospital at that time is also significant in reflecting
their desire to serve the best interests of the institution and their spirit of cooperation which greatly facilitated the
reorganization and which his since prevailed.
The importance of this event cannot be overemphasized for it not only provided Baylor with a teaching hospital without which
it could never function successfully but it also created the requisite units for the development of a true Medical Center.
The only difficulty in fully achieving the objective, however, was that the fact that these two institutions were situated
several miles apart and experience has shown that until these two units are joined together under one roof or in juxtaposition,
they can never achieve the full fruits of their marriage. It was for this reason that Dr. Basil MacLean in conference with
Mr. H. R. Cullon recommended the construction of a new Jefferson Davis Hospital immediately adjoining Baylor University College
of Medicine and the conversion of the present hospital into a Tuberculosis hospital, with the funds for the proposed new Tuberculosis
hospital to be used along with additional funds for construction of the new Jefferson Davis Hospital. With his characteristic
perspicacity, Mr. Cullen immediately recognized the full significance of this proposal both as a solution to the problems
created by the unworkable and objectionable plans of the proposed Central Outpatient Clinic idea and as a means of renewing
the faltering progress of the Medical Center development. Mr. Cullen's announcement of this proposal was immediately met
with the enthusiastic approval of virtually everyone concerned and steps were taken to secure the authoritative sanctions
of the City and County officials, as well as those in charge of the Tuberculosis hospital program. The additional funds for
construction were to be obtained from the Cullen Foundation and the M.D. Anderson Foundation amounting to about a million
and a half dollars apiece.
Those essential agreements were completed approximately a year ago with a Building Committee established to confer with the
architects in planning the new hospital, but during this time all progress has come to a virtual standstill. An analysis of
the cause of this unfortunate development reveals the fact that the same factors which previously plagued the Medical Center
development have again become operative and stem primarily from the concept of the so-called Central Outpatient Clinic.
Thus, while The Cullen Foundation was willing to provide its funds with virtually no strings attached except, of course, that
the hospital be used as an affiliated teaching hospital of Baylor University College of Medicine, the M.D. Anderson Foundation
(whose members apparently dominate the Medical Center Board) have insisted upon certain qualifications in giving their funds
and have placed those restrictions in the agreement which has been tentatively prepared by the Medical Center Board for deeding
the land to the City County on which the hospital is to be built.
Those provisions which would, and indeed already have, created much objection and even dissension appear in Section IX of
the tentative agreement. They include first "provision for examination and hospitalization of private pay patients"
in addition to "provisions for public charity hospitalization." Second, the appointment of a "separate director"
for the Outpatient Clinic and Pathological Institute upon recommendation of the Administrative Board of the Now Hospital giving
"due consideration to suggestions from the Board of Trustees of the Texas Medical Center." Third, that "arrangements
will be made with medical and educational institutions having school or schools in the Texas Medical Center" and that
the "relations between the Hospital and its services with the schools or school and their or its services will be proper
and equitable as respects all of the institutions concerned." Fourth, the management, control, and operation of the hospital
by (1) a joint board consisting of seven members, three of whom (including the Chairman) would be nominated by the Board of
Trustees of the Texas Medical Center; (2) a "Director of the New Hospital (exclusive of the Outpatient Clinic and Pathological
Institute)"; and (3) a Director of the Outpatient Clinic and Pathological Institute.
It is readily apparent from these provisions that the same fallacious concept of a Medical Center which plagued its earlier
development and reached its climax of frustration in the proposal to build a so-called Central Outpatient Clinic two years
ago has persisted to haunt and frustrate the construction of the new hospital. Why, for example, is there a need to appoint
a separate Director of the Outpatient Clinic and Pathological Institute? The Outpatient Clinic is inherently a part of hospital
and just as much a part of the hospital as the clinical laboratories, the operating room suite, or for that matter, the laundry.
There is as much reason to have a separate director for the Outpatient Clinic as to have separate directors for every other
phase of the hospital's activities. Why should there be an insistence on private pay patients? Only because this was an
essential part of the original concept of the so-called Central Outpatient Clinic. This provision can only create (it has
already done so) violent objections by the local medical profession and the private hospitals in the city, as well as in the
Center. It is unessential to the educational activities of the hospital and is particularly unnecessary in light of adequate
provisions already available in other hospitals. Why should there be insistence upon arrangements of affiliation between the
hospital and medical schools in the Center? A satisfactory affiliation by means of a formal contract now exists between the
hospital and Baylor University College of Medicine and this provision is obviously directed toward an affiliation with another
medical school. Here again is raised the same old problem which has continuously plagued the Medical Center development --
the problem of two medical schools, Baylor University College of Medicine and the so-called Postgraduate School of Medicine
of the University of Texas. To make matters worse this original plan was based upon the concept that the former would concern
itself with undergraduate teaching and the latter with postgraduate instructions. The fallacy of this plan is based upon the
obsolete concept that undergraduate medical education are independent endeavors requiring separate and different personnel
and facilities. To be sure such a concept once prevailed a quarter of a century ago, but it is now of historical interest
only. Postgraduate Schools of Medicine as separate institutions have long been abandoned. It seems curious that the University
of Texas should still embrace this concept when the trends in medical education have long since passed this point of development.
It is now generally recognized that undergraduate and graduate medical education are inseparable parts of a single program;
they are simply stages in the development of physicians which follow each other in logical sequence. They are interrelated
and interdependent. They require the same teaching staff and facilities and the same structural organization of the institution
providing them. These provisions are all available at Baylor University College of Medicine, and like any other first class
medical institution, it must engage in these activities if it is to maintain the field of medical education.
It is obvious that these provisions written into the tentative agreement for construction of the new Jefferson Davis Hospital
stem from a fallacious concept of a Medical Center -- the original concept that placed emphasis upon the so-called Control
Outpatient Clinic as the hub of the Center rather than the medical school and the now obsolete and factitious notion that
the medical educational program may be separately organized and carried out by two different universities, one of which would
be concerned with undergraduate activities and the other with postgraduate activities. The effort to impose this concept,
which violates all the principles and injunctions of such outstanding medical educators as those mentioned earlier, has produced
a serious conflict of interest which if continued can only lead to further discord and contention. Indeed so much strife and
opposition has now been generated that the whole future of both the Medical Center and Baylor University College of Medicine
is now in serious jeopardy. Because of this contentious situation as well as its own opposition to certain provisions in the
above agreement, the Cullen Foundation is now giving serious consideration to dropping the whole plan of building a new Jefferson
This is a matter of grave concern both for the Medical Center and for Baylor. Such an eventuality would seal the doom of the
Medical Center for a long time -- perhaps in our lifetime -- and it would destroy all hope for the growth and development
of Baylor as a strong and vital medical education institution. To be sure Baylor could limp along under present conditions
but the great disadvantages and handicaps produced by the several miles separation of its hospital would create serious limitations
to its future progress as a first rate institution. Since the Jefferson Davis Hospital is the only hospital that can provide
Baylor with adequate teaching material and it is not possible to move Baylor next to the present hospital, the only hope for
Baylor lies in moving the Jefferson Davis Hospital next to Baylor. In addition, it is recognized that there is a crying need
for a new and enlarged hospital to meet the growing demands of the community which has almost doubled since the present building
This hope can be fulfilled only if certain essential principles which constitute the basis of a Medical Center are closely
followed in its establishment. These principles, are described above and extracted from the Stander and Blalock reports, have
been repeatedly emphasized by many outstanding medical educators. Except for "geographic unity" of the medical school
and the hospital these principles constitute the basis for the present affiliation between Baylor and the Jefferson Davis
Hospital. By simply continuing this agreement all that remains to achieve a great Medical Center and to assure the future
growth and development of Baylor is to construct the new Jefferson Davis Hospital next to the medical school. This is the
key to the solution of our problem.
Michael E. DeBakey, M.D.
Professor of Surgery and Chairman of the Department of Surgery, Baylor University College of Medicine