Alumnus Writes About Family's History at P&S

My first cousin once removed (1), Hermann Theodore Radin, entered P&S in 1898. There were 142 students in his class, but no women. Tuition was $200 per year, perhaps $4,000 to $5,000 in current dollars. Hermann was unusual in having a BA from City College. In the decades leading up to the 1910 Flexner report, the need for medical education reform, including better preliminary preparation, had increasingly been recognized, exemplified by Johns Hopkins' founding in 1893. However, even by 1910, only about half of P&S students had BA degrees, and the college was just moving to require two years of college for admission. Across the country, only 20 percent of schools required two years of college, although some, including Harvard and of course Hopkins, had been requiring a BA for several years (Barzansky 2010).

Abraham Flexner, a professional educator, was asked by the Carnegie Foundation for the Advancement of Teaching (with support and encouragement from the AMA Council on Medical Education) to study U.S. and Canadian medical schools. Not all his conclusions met universal agreement; Sir William Osler was a notable opponent of the idea that medical school teaching should be restricted to full-time faculty (Chambers 2011). But Flexner's influence was dramatic, establishing the model of four years of premedical liberal arts and science education as well as two years of basic science and two of clinical education in medical school. His trenchant analysis (The California Medical College at Oakland "is a disgrace to the state whose laws permit its existence") led to closure of more than half of U.S. medical schools. 

By 1925, according to the P&S Announcement (the annual school catalog), only two to three exceptional students per year could expect to be admitted without a BA degree; the concept of medicine as a learned profession had won out over the "technical apprenticeship" model. Hermann, who had a strong general cultural background (one brother had a PhD in classics, another in anthropology, from Columbia), was said to prefer history, and the music of Richard Wagner, to medicine. He later became a collector of modern prints.

Flexner thought the P&S anatomy facilities rivaled any in the country, and that the clinical experiences at the Sloane Maternity Hospital and Vanderbilt Clinic were excellent. However, clinical teaching in general had the same problems faced by most medical schools, except the few, such as Hopkins, that controlled their own hospitals. Anatomy received enormous attention. The 1900-1901 P&S Announcement describes gross anatomy as including "Demonstrations to sections, 4 a week for each student. Laboratory Work in dissection, 18 to 20 hours a week, for from 3 to 5 periods of 4 weeks each," for the first year, and "lectures combined with demonstrations, 3 a week. Demonstrations to sections, 4 a week for each student for one half the year; 5 a week for each student for one half the year" in the second year. "Demonstrations to sections," including "osteology, syndesmology, myology, peripheral nervous system, and angeiology of the extremities," apparently were sessions using fixed specimens providing a "direct connection with the laboratory course in dissection." These may well have been valuable anatomy learning aids, analogous to 3D computer renderings.

Clinical clerkships, mainly at Roosevelt (then across the street from P&S), were available only to a few students. Clinical instruction began in the third year, with weekly lectures or demonstrations at Vanderbilt, Roosevelt, New York Hospital, attendance at operations and surgical outpatient clinics. These were more frequent in the fourth year.  There was a two-week obstetrical rotation during which students lived in Sloane but clinical clerkships in the modern sense did not yet exist. Dr. Edwards A. Park (P&S 1905) writes of having "substituted" at Roosevelt at the end of his second year as an anesthetist for several weeks, considering himself lucky not to have killed anyone. The hospital boards considered their mission to be primarily care of the indigent sick, and not medical education, even though there was substantial membership overlap with medical school boards. There seems to have been at least some sense that allowing students to "practice" on the poor was unethical. The emphasis on didactic teaching led to the development of outside "quizzes" mentored by P&S professors, with the main aim of preparing students for internship examinations.

In 1906 formal clerkships were established at Vanderbilt Clinic. Between 1910 and 1914, P&S established a close affiliation with Presbyterian Hospital and was able, due to a gift from Edward Harkness, to move to Washington Heights. By 1910, about 1/3 of the senior class could take a two-month clerkship in surgery or medicine at Presbyterian. Class size was reduced by 50 percent in 1918.  

My father, Frederick Theodore (CC 1927, P&S 1931), was in the last class to start on 59th Street. Columbia initiated the "general education" movement in American universities, including the innovative "Contemporary Civilization," and "General Honors" literature and philosophy courses that he took (McCaughey 2003). There were 102 students, including nine women, in the P&S class of 1931. Tuition was about $500. His recollection that, due to the move uptown, the normal two-year gross anatomy curriculum was simply truncated to one year seems to be supported by the bulletin course descriptions. An ophthalmologist, he knew a great deal of general anatomy. There was a 7½-week "ward clinical clerkship" in medicine in the third year and a similar outpatient experience in the fourth year. Obstetrics had a 7.5-week rotation at Sloane "including day and night duty, during which time lodging is furnished by the hospital." There seems to have been no formal neurology "clerkship," but rather a series of "lectures and demonstrations," typically three hours per week. Even in the 1930s students were mainly observers and generally not expected to be on the wards at night. 

I have my father's copy of the 1927 edition of "Cecil's Textbook of Medicine." Typhoid fever, judging both from the space devoted to it and the attention he clearly paid in reading, was still considered an important disease, although the death rate in New York City had declined from 13.5/105 for 1906-1910 to 1.3/105 for 1926-1930 (2). Perhaps Columbia was particularly interested due to the 1915 epidemic among the staff of Sloane Hospital for Women, where "Typhoid Mary" was a cook, with 25 cases and two deaths.  The chapter on epilepsy, by a professor at Columbia, seems antiquated even for the time.

I entered P&S in 1969, but almost immediately dropped out to work in the Fogg Art Museum Conservation Laboratory and become a classical archaeologist, returning in September 1970 to graduate in 1974 (at least three of the 12 art history majors in my college class eventually went to medical school). P&S was very flexible, perhaps in part because of the era's student unrest. At one point P&S students staged a rally to raise bail money for the Black Panther party. The basic science curriculum had just been reduced from four to three semesters; I think we began clerkships in March or April of the second year. Farrish Jenkins, later the Alexander Agassiz Professor of Zoology at Harvard and curator of vertebrate paleontology at the Museum of Comparative Zoology, enlivened his anatomy lectures with comparisons of human and dinosaur gait. My neurology clerkship attending was Bertel Bruun, who also wrote books on bird-watching and antique toy soldiers. I was one of the last students to present to Houston Merritt. The patient had mononeuritis multiplex probably related to diabetes. I remember he asked me for the CSF chloride level. Enrollment had increased starting in the early 1960s with the availability of federal government funding. There were 133 students in the class, including 15 women. Tuition was $2,300.

My daughter, Deborah (Bowdoin 2008), is in the Class of 2014, the second under the "new" curriculum (since the 1970s there had been a return to a somewhat longer basic science curriculum than I experienced). Gross anatomy lasted from early September until Christmas, with two lectures per week, and one non-dissecting session based on modern imaging, with dissection only one afternoon per week. Two teams with four to five students each shared a cadaver, dissecting parts of arms and legs, face, heart, abdomen, and the inguinal region. In the spring there was a ceremony honoring body donors during which students thanked family members. Is gross anatomy now more a rite of passage than subject of instruction? Although the course duration had not changed since the early 1970s, the amount of time devoted to it is substantially reduced. The "Foundations of Clinical Medicine" course deals with ethical issues, patient interactions, and health care policy.

Informal (though real) limitations on some groups of students have of course evaporated. There are 81 women in a class of 167. More than 50 percent of the class of 2014 took time off between college and medical school for activities including Teach for America, the Peace Corps, or research. More attention is being paid to student well-being; support services now include wellness directors, advisory deans, yoga classes, and meditation opportunities. During orientation there was a cruise around Manhattan, a field day, a Broadway night. Tuition is now around $55,000. In contrast, the Consumer Price Index has increased only by about 600 percent since 1970.  

Compared even with my experience there is much more early clinical exposure; starting in the first semester, students attend clerkships at clinics and centers throughout the city, such as at the Callen-Lorde center in Chelsea, which specializes in health care for LGBT populations; the Door, which serves disadvantaged youth; and the private offices and clinics of P&S faculty. In the second semester, in addition to the standard physical diagnosis courses, students meet once per week in small groups with a preceptor to interview a psychiatric patient. Clinical rotations now begin in January of the second year. One major change, at least compared with my experience, is that some students are assigned to specialty services like oncology or stroke, rather than a general internal medicine or neurology service. Emphasis on outpatient experiences such as community medicine may be more important due to the changing economics of medical care. The new P&S curriculum includes several "return to the classroom" breaks during the major clinical year, including student presentations, evidence-based medicine seminars, and discussion of ethical and economic issues. There is strong emphasis on preparation (with scheduled time off) for the national board examinations (which I don't remember anyone taking very seriously, but are now important both for internship placement and the school's relative media "ranking"). After the 12-month Major Clinical Year, students must devote at least four months to a scholarly project, choosing from basic, clinical or translational research; population research or community service; global health research or services; or social sciences, such as bioethics, narrative medicine, or medical education.

The increasing emphasis on clinical as opposed to basic science education to some extent reverses the early 20th century model that replaced the 19th century's apprenticeship system. A new program at Hofstra uses a case-based curriculum to integrate basic science with clinical experience even more intimately, including new approaches such as training incoming students as emergency medical technicians (3). New York University and several other schools are experimenting with a three-year curriculum for selected students; P&S this fall will admit its first students into a new three-year M.D. program for students who have Ph.D.s in biomedical science.

Some have suggested more radical changes. To reduce the burden of student debt, and increase physician numbers, Emanuel and Fuchs (2012) advocate returning the premedical requirement to two years, shortening medical school itself to three years. In addition, the "philosophy" of medical education should be altered to reform the "obsolete image of the ideal physician," encourage group decision-making, practice standardization, and integration of outcomes assessment. Some U.S., as well as most UK and European programs, last six years. However, secondary school education often is a year longer, with narrower focus, than in the U.S. Longer house staff training and compulsory national service in many countries lead to approximately the same elapsed time between secondary school graduation and final qualification. Interestingly, in 1905 the AMA Council on Medical Education had recommended as ideal a five-year pre-medical and medical school program, including one preliminary year of physics, chemistry, and biology, two years of basic science in medical school, and two years in clinical work (Barzansky 2010).

Would abandoning the "Flexner model" of broad liberal and scientific education as a prerequisite make medicine less a learned profession, more a technical skill? Does that matter? Would less time for English literature and world religions at the undergraduate level make it more difficult for physicians to understand the role of medicine in society and act as leaders of "social improvement," including structural reorganization of American medicine, closing racial and socioeconomic gaps in health outcomes, and understanding the socio-economic bases of medical care provision, as well as the forces influencing overall population health status (Berwick and Finkelstein 2010)? Less exposure to research in college and medical school might make it harder for practitioners to understand the results of clinical trials and resist the blandishments of industry. Two Nobel Laureates think reduced time for basic science in medical school curricula, and increasing "irrelevance" of "scientifically oriented faculty in clinical departments," will make it much less likely than in the past for physicians to be inspired to work on fundamental questions (Goldstein and Brown 2012). Since students with broader academic interest or greater financial resources would still obtain BA degrees, a two-tiered system of physicians, and possibly even medical schools, might develop, further complicating a situation in which primary care in many settings already is provided by "physician extenders" (4).

A recent Association of American Medical Colleges/Howard Hughes Medical Institute report (2009) recommended replacing both undergraduate and medical school course requirements with "competencies," as well as revamping  the MCAT, to ensure that physicians possess a "deep understanding" of fundamental biomedical principles. A new Carnegie Foundation report (2010) recommends including language and social science competencies for admission, increasing diversity, early clinical experience, fostering compassion and social responsibility, and integration of pre-medical, medical school, and post-graduate training into a life-long learning process. Other common themes in suggestions for change include financing reform, greater social accountability, better use of technology to reduce the need for memorization, and responsiveness to changes in the health care delivery system and workforce (Skochelak 2010).

A strong argument for requiring broad liberal education for physicians is implicit in Amy Gutmann's "Democratic Education" (1999): "Deliberative democracy" requires for all citizens an education promoting empathy, cross-cultural awareness and respect for diversity, critical thinking skills, and historical knowledge. Physicians, responsible for guiding health care decisions and allocating limited resources both directly and indirectly in an increasingly diverse society, have particular need of these skills. 

Medical school and premedical curricula naturally reflect tensions among scientific, technical, and cultural aspects of medical education. Hans Zinsser (CC 1899, P&S 1903) who had a "classical" education, thought that his generation of physicians were particularly fortunate to have experienced and benefited from the restructuring of American medical education that enhanced the impact of basic science and research on clinical training, and that medical education in general leads to "a balanced education of the mind and of the spirit which, in those strong enough to take it, hardens the intellect and deepens the sympathy for human suffering and misfortune" (5). Continual curriculum redesign suggests that achieving balance is not straightforward.

William H. Theodore is chief of the Clinical Epilepsy Section, Division of Intramural Research, National Institute of Neurological Disorders and Stroke, National Institutes of Health. He lives in Bethesda, Md.

Acknowledgements: The writer acknowledges the help of Paulette Bernd, Lisa Mellman, and especially Alan Schechter (who suggested the article) for providing many helpful comments. Stephen Novak helped the writer access archival materials available through CUMC's Archives & Special Collections.

Notes:

1. He was the oldest son of my father's oldest aunt; my father was the youngest child of her youngest brother, which explains the age difference.
2. Typhoid in the large cities of the United States in 1930. Nineteenth Annual Report. JAMA 1931; 96: 1576-9
3. http://medicine.hofstra.edu/ accessed 10.28.2012
4. Two-tiered systems were common in 19th century Europe. Charles Bovary was an "Officier de Sante," not a physician. Heller R. Officiers de Sante: the Second-Class Doctors of Nineteenth Century France. Medical History 1978, 22:25-43.
5. Zinsser made another interesting observation: "One reads the increasing mass of literature on the origins of the great American fortunes of the 19th century, and one takes bicarbonate of soda. But however one feels about that, one must acknowledge that the pre-eminent position of American medicine today would have been impossible without a certain amount of rich malefaction in the eighties and nineties. Thus, modern American medicine is, in a way, a phoenix arising from the ill-smelling ashes of a big business that is forever gone." Considering the naming of hospitals (and even entire medical schools) for financial firms, it's easy to imagine that profits from more recent questionable business practices have been "laundered" in the same fashion.

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