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The Alan Gregg Papers

Memorandum regarding Gregg's visit to the University of Chicago pdf (794,033 Bytes) transcript of pdf
Memorandum regarding Gregg's visit to the University of Chicago
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15 (794,033 Bytes)
1931-10-28 (October 28, 1931)
Gregg, Alan
Original Repository: Rockefeller Archive Center. Rockefeller Foundation Archives
Reproduced with permission of the Rockefeller Foundation.
Medical Subject Headings (MeSH):
Education, Medical
Schools, Medical
Exhibit Category:
Director of Medical Sciences, 1930-1945
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Document Type:
The following comments are my personal observations and reflections, offered in response to your suggestion when I was in Chicago that, they might be of interest to you. In certain instances my point of view may seem remote in time or space from local and immediate issues. That is to be expected at times from a detached observer. Furthermore, this memorandum avoids conclusions or a contentious attitude. The many and strong forces moulding tho teaching, the practice and the growth of medicine cannot be controlled by argument and I want to emphasize the study of forces rather than indulge in an advocate's disregard of forces impropitious to his claims. The object of these notes then is to review factors involved in the settlement and definition of the policy of the University of Chicago with respect to medical education.
The University of Chicago has an explicit, established, and continuing preference for the advancement of knowledge. Harper's energy and vision no less than the need of American universities for the product of such a policy made the University of Chicago a great influence. I see no evidence that the policy of the University towards research and scholarship is changing in a way to lessen this singularly valuable position. There is considerable reason even to believe that the University is more sharply inclined today than at any time in the past twenty years to appear radical while actually reaffirming the earlier tradition of complete liberty of action in choosing fields of endeavor and methods of action.
What is true of the whole happens to be conspicuously true of a part. The biological sciences at Chicago whether by individual departments or en bloc as a Division have been, and show no evidences of ceasing to be, more interested in the advancement of knowledge and the training of research men than in the diffusion of knowledge in undergraduate courses or the preparation of teachers in the manner of a normal school. This is not merely a tradition and a declared policy. It is the eager preference of the professors and assistants and the objective principally in view when buildings are put up and personnel chosen. There are faults and failures in the realization of this principle: but as a policy or intention it must be considered of unanimous acceptance and of cardinal import. It is however not an easy, elastic and adaptable policy: it may necessarily be somewhat jealous of its peculiar interests, inclined to resent additional opportunities as dilutions rather than real growth, intolerant of pressure or interference though keen for optional and easy contacts with other fields of learning.
The preclinical subjects in medicine at Chicago University form part of the division of biological sciences. That is an important fact in two senses. It is an important fact in American medical education because it is an exceptional if not unique arrangement and the nucleus of a great and reasonable hope. It is a fact important to the University of Chicago because unless definitely repudiated it anchors one half of the medical course and much more than one half of the scientific facilities explicitly and irrevocably to the South Side. Neither Harvard nor Hopkins, Columbia nor Cornell have the advantage of associating as does Chicago preclinical medicine with the physics, chemistry, mathematics, psychology and sociology of the University. Since medicine has immensely to profit from these subjects, and for other reasons, I take it that no one would dream of uprooting the preclinical departments to place them on the West Side.
One more palpable reality - clinical accommodations have been put on the South Side. * Whatever may be one's view regarding the possibility of good teaching without investigative work going on along side, there can be no doubt that the most resourceful and economical correlation of clinical problems with the medical sciences can be accomplished in the near neighborhood of the men and machines of the preclinical departments. Experience in Edinburgh and London finally showed tho most stubborn and the most skeptical that scientific facilities and training outweigh brilliance of teaching, professional prestige, and possession of clinical material, in attracting and preparing students of medicine. Bart's, Guy's and the other London hospitals were forced to add anatomy, physiology, etc. to their clinical means for training doctors, though it was cheaper and easier to leave them to be taught elsewhere. The Edinburgh University Medical Faculty forged ahead in spite of the brilliant attractions of the extra mural schools in Edinburgh because as a University school it possessed more facilities and more privileged contacts with the sciences ancillary to clinical medicine.
* I realize that these subjects also are in the Division of Biological Sciences.
The policy of the University of Chicago is to give preference to the acquirement of knowledge and the training for research work. It possesses distinguished departments of preclinical science under a form of organization that increases if anything their claims for support to investigative work and their potential serviceability to research work in clinical problems. It now possesses clinical facilities which by their location and form of organization automatically favor the type of activity to which the University is explicitly committed. Since close physical proximity to the preclinical branches is an undeniable advantage to clinical investigation, since the best teaching is possible only where investigation is going on, since no clinics widely separated from preclinical departments are in the best position to do clinical investigation and teaching, the further support of undergraduate teaching on the West Side becomes a matter deserving careful consideration. And as a foreword to such considerations I would submit that educational logic - the soundness and consistency of the plan is the most important consideration of all. It is super-personal, it is stronger than the interests of institutions, it may be temporarily frustrated but it will either bedevil and outlive those who override it, or operate automatically for tho common good.
During the past 15 years there have been a series of negotiations between the administrative officers of the University, members of the Rush Faculty, and trustees of the Presbyterian Hospital of such variety of declaration and implication that merely by selective quotation one can justify almost any course today. It would therefore be better to limit ourselves to the present and the future, since there has been shown me a remarkable absence of pettiness of viewpoint and a perfect willingness to consider the whole problem anew and only in terms of the present and the future. And after all I am writing to one who is thoroughly familiar with the events of the past 1.5 years, with the history of Rush, with the persons especially concerned now and in the past - all points of information to which I could add nothing;. The most convenient presentation then would be in the form of comment upon the choices of` decisions to be taken by the University of Chicago.
First - and as a matter of logic largely (but not without a parallel in recent history) the University can decide to make no decision, or formally postpone any declaration of policy. Such action or deliberate inaction would handicap the Trustees of the Presbyterian Hospital as regards any building plans or endowment campaigns as long as the postponement of declaration is in force. It would probably have a mixed effect on the Rush teaching personnel, heartening; a few perhaps but making the rest more than ever restless and inclined to seek posts elsewhere. It would avoid breaking: any eggs and it would make no omelet. Unless accompanied by grants to Rush for better teaching facilities it would be interpreted somewhat bitterly at Rush as a permission to waste away.
It would have the advantage of not reducing the number of students in the preclinical years, and so the income from tuition fees, nor much disturb the sentiment of Rush graduates. It would however in my opinion only defer the time when a more radical and explicit step must be taken, meanwhile being likely to develop a bitterness and resentment that is not yet in play. I should think postponement indefensible unless it come from complete bewilderment as to what course should be taken.
Second it has been suggested that the Rush Medical Faculty and the Presbyterian Hospital seek to be released from control from or affiliation with the University of Chicago and amalgamate with the medical school of the University of Illinois. Although there are objections which are probably insuperable, this suggestion deserves mention because it would constitute a fusion of schools of similar organization and objective and both within an area already rich in preclinical as well as clinical facilities. It is more than probable that the Illinois Faculty would be favorably disposed but the principal objection lies in the almost certain unwillingness of the Rush Faculty to advocate or follow such a course. As expressed to me their feelings would be strongly against such a procedure. They dislike the political atmosphere of University of Illinois appointments, and do not find any pleasure in severing connection with the University of Chicago which they would like to continue to serve.
The third course mentioned to me lies in the amalgamation of the West Side departments with corresponding departments on the South Side. Such a fusion would involve the continuance of undergraduate teaching at the West Side, not under a separate dean, etc. but under the control, department by department, of chiefs mostly on the South Side but not necessarily so. The chief arguments advanced in favor of this solution are as follows:
1. The administrative problems (in the opinion of representatives of Rush) could be resolved with mutual good will and in a spirit of compromise and conciliation.
2. The variety in the methods of teaching: would be advantageous to the students.
3. The tradition and interests of Rush graduates and faculty would be preserved, and the experience, loyalty and ability of the latter would be utilized.
4. The number of the students would remain adequate for recruitment to preclinical and clinical posts. It would maintain the present income from tuition fees.
5. The plan at Harvard, which this amalgamation resembles, has resulted in a first rate school.
6. The main object of a school of medicine anyway is the preparation for the practice of medicine and the part time teachers at Rush have something peculiar and valuable to contribute to this preparation. This main object must have prior consideration even if the purpose on the South Side is described as the study of medicine on the University level with emphasis on the relation to the biological sciences in promotion of the advancement of knowledge and the training of investigations.
The chief arguments advanced against amalgamation were these:
1. The objectives of the clinical teachers at the South Side should not be compromised and differ from those at Rush more widely than the members of the Rush Faculty realizes. Consequently the clashes of opinion, discrepancies in income of personnel, administrative friction, and loss of time in attempting what would be at best a grudging compromise and at worst frank dissension, would be such as to make amalgamation unworkable. Under an amalgamation the character of the teaching at the South Side would be dissipated and diluted.
2. It would be vain to adopt a form of departmental control vested in an individual whose objectives and methods are definitely not shared by colleagues whose age status and independence entitle them to a position of complete equality rather than real (because necessary) subordination. The independence of character and station of the senior staff at Rush and their conscious conviction of their clinical abilities and their expressed disapproval of the teaching, methods on the South Side are elements of potential friction and disagreement.
3. In order to organize at the Presbyterian units of departments along lines desired by South Side professors the budgets of clinical departments would have to be increased considerably. Amalgamation would therefore call for considerable increases in budgetary support from the University. Both sides agree that this would be necessary. The question imposes itself: has the University of Chicago an obligation to support as large a school of medicine as the amalgamation would create and require?
4. The analogy to Harvard is fallacious since there are no full time clinical chiefs at Harvard nor departmental organization control led by any one clinical professor. Furthermore, the Brigham Hospital could not become comparable in clinical facilities to what can be and in part is already realized on the South Side. Nor has Harvard University the chance of establishing an entire medical school in close contact with all the other departments of the University, as has Chicago. This opportunity should not be overlooked and thrown away by amalgamation.
The fourth choice open to the University of Chicago appears to be the discontinuance of undergraduate medical instruction on the West Side* and the organization in its place there of a) a highly effective system of internships and b) a few posts for part time or full time residents. The principal arguments advanced against such a course were:
1. It would be in effect the end of the present tradition of undergraduate teaching at Rush Medical School. There is no doubt of the regret, resentment, and possible bitterness this course would cause among Rush graduates and some of the present Rush teachers, even though such discontinuance has been recently mentioned as the possible policy of the University. It will not be the end of the name nor of the influence of the group at tho West Side.
* It is evidently equitable that the date of discontinuance must be postponed so as to permit graduation of all students already enrolled - i.e. until 1936 or 1937.
2. It would result in such a drop in the number of preclinical students on the South Side as to limit the recruitment of research and teaching personnel there. By reason of reduced income from tuition fees these departments might lose a considerable fraction of support from the University.
3. It is believed by many that the educational practices in some of the South Side clinics are inimical to the real interests of medical education, that full time medicine has failed and that the discontinuance of undergraduate teaching on the West Side would be tantamount to throwing away the most valuable and proven method of making doctors, only to continue a costly, faddish and bankrupt experiment.
4. Many members of the staff at Rush would resign rather than continue when undergraduate teaching is abandoned. Indeed it is probable that before the present classes have finished their courses many Rush staff members will accept positions elsewhere and thus seriously embarrass effective teaching on the West Side in the next five years.
In favor of the discontinuance of undergraduate teaching at Rush and the development of an excellent teaching and research organization through the development of internships and residences of the Presbyterian are the following considerations:
1. The organization methods and purposes of the South Side group are postulated upon the declared policy of the University as regards research and the experimental attitude in education, and are consonant with that policy. It seems clear that the geographical separation of the West Side clinics from the preclinical facilities places those clinics at an inevitable disadvantage as regards research work. In organization methods and purposes the Rush Faculty offers admirable competitive attractions among the other medical schools of America, but differs from them in no significant way.
2. The University cannot in justice to other demands maintain the expenditure inevitable with the changes in equipment an amalgamation would require.
3. The creation and administration of a well articulated system of internship and residentships on the West Side would continue the traditions of Rush Medical School more effectively than would an amalgamation with the South Side. These traditions I take to center around the unquestioned value of close personal association between a beginner and an exemplary and admired master in the practice of medicine. If, as seems quite feasible, the Rush group could also organize an intern service at the Cook County Hospital the significance and magnitude of the effect upon medicine in Chicago and the Middle West could be larger than would be the role of undergraduate teaching. The interest of members of the Rush staff in advanced training and research would find adequate outlet and be a highly valuable contribution to their fields.*
4. The University of Chicago has a clear-cut responsibility to train competent practitioners. Now in most arguments the things asserted are true in themselves but not true in the sense in which they are used. This assertion regarding the responsibility of the University of Chicago may be interpreted to mean that the training given must be the same or similar in method to that of Rush in the past. This is not a logical inference. The method of undergraduate training can be improved and the Rush group could supplement it through training for interns and residents.
*See appendix A for an expansion of this statement.
Now I would like to add some observations of a general nature which I think should be given weight in the evaluation of the pros and cons of methods already mentioned.
It is important to regard the whole question in terms of successors as well as present incumbents. How will the solution appear to the men you might call, and to the men your successors might nominate? Traditions are powerful but there can also be a tradition of a willingness to experiment and differ from the mass. You may take an adequate number of students for granted but will a compromise of teaching policy attract and hold the best teachers on full time or give their ideas a fair trial?
If the population of the United States increases in the next hundred years it is probable that those entering medicine as a career will be willing to train themselves for a longer time to get places more vigorously competed for than at present. That has been the tendency of the past thirty years and in Europe today professional competition is a factor of striking significance. This means that institutions for special or advanced training will be increasingly sought after. It is not impossible that the medical curriculum will tend to lengthen in any ease the intern experience will become more important. Witness the development of the intern year in the past two decades. In the sense of choice of candidates a fine system of internships and residencies at the West Side would be assured of success, and I would predict a less immediate but very soon equally certain recruitment to the undergraduate training at the South Side. With the development of good schools elsewhere in the Middle Nest, Chicago must choose between doing a peculiar and qualitative service over a wide area or becoming a local school of the ordinary type. Eliot saw the same choice for Harvard in 1909 and advocated differentiation and post graduate developments as the wise course for the non-State University. In "The Federalist" appears the opinion "the ultimate source of faction is property." When the population increases or becomes more highly sorted out property is held with greater tenacity and foresight. The unselfishness and open handed attitude of the Rush Faculty today, almost miraculous to one accustomed to conditions in the Old World, will perhaps not last three more generations: University control will not be so easy then - as it is not now in London, Paris or Rome. The control of beds is a form of property - and ultimately could become a cause of factions, intransigence and stalemate.
Among human institutions none seems more durable, more assured of vitality, more confident of support than universities. Perpetually refreshed by youth they ere equally the object of the solicitude of age. With the care of the sick coming more and more generally throughout the world a tax or insurance-supported affair we can hardly avoid the impression that the modern voluntary hospital can best survive and fulfill a unique purpose by affiliating closely with a University. I would take it for granted that more and more clinical facilities will be given to the University of Chicago and that in twenty five years the West Side beds will be quite superfluous to the needs of the medical faculty. Indeed were the Presbyterian Trustees familiar with the history of European hospitals I am confident they would consider more seriously the ultimate unwisdom of a new building anywhere except the South Side when the time comes for rebuilding. On that site tho system of residents and internes with the added resources of the university would possess unqualified advantages. The free university as a nucleus of self renewing and automatic appeal to the generosity and the reason of future donors is more likely to survive and live a liberal and healthy life than a charitable foundation.
Even with these advantages the future of the faculty of medicine is not at all plain sailing. It will depend more upon the quality of its teaching personnel than anything else. There remains more to be done in increasing the width catholicity and caution in the selection of men for important posts. I venture this somewhat blunt observation because in most universities that I have studied, the confidence and freedom and responsibility given to professors are all possible only on the basis of the most careful selection of those who are accorded such unswerving support and confidence. The full time plan has been too much fathered and too little mothered: after a vigorous and incisive initiative the plan now needs a wise ,patient and solicitously protective attention to the details of a favorable environment. Not that its exponents dare became "precious" or self pitying or parasitic - which is a danger. The school must train good doctors and give good teaching if it is not to be a failure so conspicuous as to preclude the chance of ever starting such a plan again.
But there seems to be no reason to fear for the future of that phase of a system of medical education which in the clinical years lays emphasis on the thoroughly implemented study of as many cases as can be thoroughly studied. I have seen medical faculties whose product was better than the teaching - because the incoming students were as good or better than when they graduated. It is no proof of the value of the teaching alone if a school has fine or poor graduates - one must examine the actual teaching. It is for that reason that I think confidence can and should be placed in the teaching policy of the clinics of the South Side, It requires time, continued effort, loyal support, steady understanding and admitted freedom for admittedly responsible men to make after patient trial an established success. But a decision is necessary in the near future between courses whose relationships to University policies and to future opportunities in medical education I have attempted to present to you.
Alan Gregg
Oct 28 1931
[NOTE: Handwritten Section]
Appendix A
It is my opinion that the loyalty, experience and character of the leaders at the Presbyterian staff are not greatly appreciated nor most advantageously utilized. They are skilled practitioners of medicine in several of its branches. They know the actual conditions of the practice of medicine. They are men of fine character - the kind of men that the best young aspirants to the practice of medicine need and want to know, not by name or by right but in close and vivid intimacy. The art of dealing with sick human beings is their forte, and close association with pupils is now as it was in the days of the apprentice, the best method of teaching that art of medicine. It cannot be done but by precept and exposition to forty or a hundred students at a time. It can be done by example during a relationship rich in direct experience for small number of selected students.
These could be created at the Presbyterian Hospital two intern services in surgery, two in medicine, and one in some of the specialties such as pediatrics, ophthalmology, otolaryngology, etc. according to the amount of beds available. Each service might well be divided into duty periods of three to four months each in a regular sequence of increasing responsibility. For example the intern in medicine would begin with three months of duty as assistant in the clinical laboratory doing for the whole service in routine clinical laboratory work and taking histories. The next three months he would be in full charge of that laboratory work and perhaps have duties in the outpatient department. The next three months he would have the responsibility for all histories & physical examinations being satisfactorily recorded and perhaps more responsibility than before in the outpatient. Last three months he would be senior intern and have responsibility for the whole service, the work of the interns Junior to him and the direct responsibility to the visiting physician or physicians in charge of the service. Rotating nurses could be consulted if this be desirable. The amount of esprit de corps developed in such a group of really responsible interns is remarkable, as is the amount of experience received an instruction passed on to the incoming juniors. Each day on the visit the whole team of interns making the visit with the chief of the service is the unit ideal in size, quality interest & degree of preparation for learning the practice of medicine. Such a system would immensely improve the care of patients, greatly enlarge the experience of the interns participating, intensify the influence of the teachers, and raise the whole level of teaching at the Presbyterian. No teachers who had experiences small groups of picked interns regard such teaching as uninteresting or unprofitable. No hospital where a fine intern service is establish has ever within my knowledge discontinued it in favor of student wooded desks and mass instruction of undergraduates.
The opportunity that exists to effect such an organization also in Cook County, doubles the number of places to be filled: the combined total of interns receiving thorough training from the excellent teachers of the staff at rush would be not less than sixty and perhaps as high as eighty. The types of experience and example would do more in my opinion to improve medical education in Chicago than anything within the power of the Rush Staff.
For the best in the interns or for highly qualified men coming from internships elsewhere there should be created posts as residents. Here the emphasis should lie on the type of investigative work in medicine which would prepare a man to be consultant in a special field. It seems irrational to suppose that such men as Woodgatt, David, Post, Irons could not find the time to guide the work of residence as well as give their invaluable teaching to the intern services. If the residencies were of two or three years' time, if they were held by selected men, there is no doubt that monies not available to the University of Chicago would be forthcoming in support of the investigative work of such men the room would not be lacking if the undergraduates were no longer crowding for space, and again, as I predict, the quality of work done at the Presbyterian Hospital for his patients and its position in American medicine would take a great step forward.
In the development of a large intern service and a fine arrangement of residentships lies the most rational most significant contribution to the Presbyterian Hospital and the present teaching staff at Rush. It is no reflection upon the Harvard Medical School that the former interns of the Massachusetts General Hospital unanimously declare they learned most in their internship. The school prepared them to profit from the hospital teaching and experience. I am convinced that the finest tool to transmit the high ideals, the valuable experience, the fine character, the needed common sense and the scientific zeal of the staff on the West Side lies at hand in the form of internships and residentships.
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