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FOOTNOTES

    

    

4 CHAPTER

Reforming Medical
Education: Who Will
Rule Medicine?

 

BY THE END of the nineteenth century, American physicians were still complaining bitterly of their "poverty" and low status in American society. Those who had studied in Europe were especially struck by the low esteem in which American doctors were held compared with their German colleagues. The disparity among physicians' incomes left some well off and some poor. As the New York State Medical Society's journal put it, "There is a handsome income for a few, a competence for the many, and a pittance for the majority." 1

   Most professional spokesmen blamed the relative poverty of doctors on "overcrowding" in the profession. The AMA Journal argued in 1901 that through death and retirement of old doctors and the increase in population, there was "room for nearly 3,300 new doctors each year," but the nation's 160 medical colleges were producing nearly double that number. 2

   To deal with these problems, the medical profession adopted an effective strategy of reform based on scientific medicine and the developing medical sciences. Their plan was to gain control over medical education for the organized profession representing practitioners in alliance with scientific medical faculty. Their measures involved large expenditures for medical education and required a major change in the financing of medical schools. Dependent on outside capital, the profession opened the door to outside influence. The corporate philanthropies that intervened turned the campaign to reform medical education into a struggle for control between private practitioners, on the one hand, and academic doctors and the corporate capitalist class, on the other. The conflict over who would rule medical education, to which we now turn, was fundamentally a question of whose interests the medical care system would serve.


PRACTITIONERS GAIN A FOOTHOLD

   By 1900 the strategy evolved by elite physicians to reduce the number of doctors, increase incomes, and raise the social class base of the profession began to pay off. Medical research, despite its limited financial support, was building public confidence in modern practitioners. Reforms were being pressed in some leading universities, setting a new standard that others would soon be forced to follow. Most states had established medical licensing boards, however varied the standards they imposed. The Illinois Board of Health in particular had begun a crude evaluation of all medical schools in the United States and Canada. Its report published in 1889 shook more than a few of the 179 schools of the regular sect, twenty-six homeopathic, twenty-six eclectic, thirteen miscellaneous, and thirteen schools condemned as "fraudulent." 3

   All these advances did not yet resolve two major obstacles to professional uplift. First, medical schools remained unregulated. In the final quarter of the nineteenth century more than 114 new schools had been founded. 4 The finances of medical schools forced their faculties to oppose the reformers' strategy of promoting scientific medicine to reduce output. Medical schools were for the most part small profit-making enterprises, owned mainly by their faculties. The only commodities they could sell were medical degrees. Dependent for their survival as well as their profits on student fees, the schools continued to pour forth their products. Being proprietary in character but profitable only to the faculty directly involved, they were unable to attract outside capital or operating funds to support expensive teaching and research programs necessary to scientific medical education. Thus, "scientific medicine" was taught at only a few university medical schools, and to a limited extent even in those--except for Johns Hopkins, which was far from the norm.

   The second obstacle to implementing the reform strategy was the organizational disarray of the profession itself. The AMA had failed in its mission. It was by-passed in the last part of the century by specialty societies which formed an alliance in 1888 in the American Congress of Physicians and Surgeons. The American Academy of Medicine and other groups were formed to fill the reform role left vacant by the AMA. Membership in local and state medical societies did not confer membership in the national association, isolating it from the majority of practitioners. By 1900, only 8,400 physicians were members of the AMA. 5 The national leadership, without structural ties to state and local societies, operated within a vacuum. Structurally weak, numerically small, dominated by traditional doctors only half-heartedly committed to scientific medicine, the "voice of the medical profession" seemed to have laryngitis.

   Before the medical profession could secure reforms in medical education, it had to strengthen its own organization. After some stalled attempts at reorganization at the end of the nineteenth century, the reformers won support from state medical societies and completely reorganized the AMA at the 1901 convention in St. Paul. The new organization, which continues to this day, made the local medical society the basic unit of the association. Individual physicians would join a local society. The local society would send representatives to a state society, which in turn would elect delegates to the newly formed house of delegates, the legislative body of the national association. The president of the AMA and a board of trustees were given substantial powers. With the campaign skillfully managed by Dr. George H. Simmons, the reform leader recently appointed secretary of the AMA and editor of its Journal, and with the convention sessions presided over by Dr. Charles A. L. Reed, the reorganization plan was instituted without discussion. 6

   The reorganization created a hierarchical, representative structure. The direct line of authority depended on the strength of the local societies, always the strongholds of professional interests. The new structure gave the state and national organizations stable leadership, which could more effectively coordinate and mobilize resources for the profession's interests. The plan was intended, and succeeded, to federate state societies into the national association and, in the words of the committee on reorganization, "to foster scientific medicine and to make the medical profession a power in the social and political life of the republic." 7

   Doctors with a vision of uniting the profession behind a campaign to elevate it moved from the wings onto center stage. George Simmons invigorated the Journal with the mission of the reform movement. AMA leaders asked physicians around the country to spur legislative reforms, control state licensing boards, and goad medical schools into altering their admission criteria and curricula. The increased effectiveness of the AMA brought support and membership from the many specialists who seemed to have forgotten that they were physicians first and surgeons or gynecologists second. Private practitioners of all types rose to support the coordinated local-state-national vehicle for their common interests. By 1910 some 70,000 doctors were AMA members, more than eight times the membership at the turn of the century.

   Although many rank-and-file physicians were unhappy with the centralized control emanating from the AMA's Chicago offices and with the reform strategy itself, most physicians undoubtedly supported the movement. 8 Most physicians resented the economic and social conditions of the profession, particularly when they realized that things could be better. They understood that competition among physicians for a greater share of the available medical dollars would help only a few and that the interests of every physician were tied to the interests of the profession as a whole.

   The reform leadership, representing a coalition of private practitioners and medical school faculty, articulated the desires of most doctors for financial and social uplift, and offered a viable strategy for achieving them. This coalition controlled the AMA from the end of the nineteenth century until World War I, sharing the association's presidency and jointly implementing its reform strategy. 9


COUNCIL ON MEDICAL EDUCATION

   Once in control of the reorganized AMA, the reformers launched their most effective tool for transforming the profession. In 1904 the AMA replaced its temporary committee on medical education with a permanent Council on Medical Education, headed by the energetic and resourceful Arthur Dean Bevan, a successful surgeon and part-time professor at Rush Medical College in Chicago. The new council was armed with a staff to help it exert "a national influence and control of medical education." 10

   To facilitate that control, it invited state licensing boards to a national conference in 1905 to review the status of medical education and set standards. There the council adopted "an ideal standard to work for in the future"--one that would raise U.S. medical education to the same basis as England, France, and Germany--and "a minimum standard for the time being." The temporary standard was: (1) a preliminary education of four years of high school, (2) a four-year medical course, and (3) passing an examination before a state licensing board. 11

   Bevan urged local and state medical societies to become more active in the reform movement and to see that "the right sort of men" were appointed to the licensing boards. Within two years the state medical societies, under the guidance of the Council on Medical Education, dominated the state boards. Through the influence of the state societies and direct contact by the council, the licensing boards increasingly became agents of the council's plan of action. 12

   The more the state boards cooperated with the council to accept diplomas only from medical schools "in good standing" and to gear their examinations to the curricula of scientific medical schools, the more uncertain was the future of all medical schools except those elite schools already geared to the needs of scientific medicine. Those schools that could tap sufficient resources to provide laboratories, "clinical material," and scientifically trained faculty had a reasonably good prognosis. The graduates of such schools were allowed by the state boards to take their licensing exams, and they had a fairly good chance of passing. There was little incentive for students to attend and pay the fees of unapproved schools and schools whose graduates tended to flunk the licensing examinations. But state boards were not uniformly in the hands of the state medical societies, so the council developed a new tactic to upgrade medical education, dose more schools, and develop a controlling role for itself in the field.

   In 1906 the council inspected every one of the country's 160 medical schools. Each school was personally visited by council secretary Dr. N. P. Colwell or another council member and was rated on the percentage of its graduates who passed the state licensing exams, enforcement of preliminary education requirements, curriculum, laboratory and clinical facilities and instruction, laboratory science faculty, and whether the school was run for a profit. Reports on each school were sent to the state licensing boards, and the percentage of each school's graduates who failed state board examinations was published in the AMA Journal. 13

   In 1907 the council divided medical schools into classes A, B, and C, depending on their ratings. Of the 160 schools inspected, eighty-two were rated as class A medical colleges, forty-six were class B, and thirty-two class C. The impact of the council's report was significant. Fifty schools agreed to require one year each of college physics, chemistry, biology, and a modern language before admission to the medical program. Sensing doom, a number of schools consolidated with other medical schools in their cities, combining facilities and staffs. Other schools realized that they did not have the resources to survive the heightened competition. By 1910 the number of schools had fallen from a high of 166 to 131. 14

   While the practitioner reform leaders were pressing for stiffer standards within medical education, the medical schools themselves were doing their best to survive. The Association of American Medical Colleges (AAMC), representing about a third of all American medical colleges, sought to differentiate its member schools--"the better classes of medical colleges"--from run-of-the-mill schools. They were concerned that rising standards in admission and instruction would bankrupt even the best schools. As the representative of the elite portion of scientific medicine's rear guard--the schools themselves--the AAMC favored cooperation between itself, the Council on Medical Education, and the association of state licensing boards. The AAMC sought uniform minimum standards for all states so that each state's requirements of medical schools would come "up to, but not beyond," the standard recommended by a joint committee of all three bodies. 15

   Although the Council on Medical Education had neither legal powers nor authority within the profession, council chairman Bevan, AMA secretary and Journal editor Simmons, and other professional reformers well understood the role of leadership and the powerful advantage of articulating a strategy consistent with historical forces. Science's time had arrived in medicine: A middle and upper class whose dominance depended on industrialization was receptive to what scientific medicine advocates within the profession offered. State licensing boards, under the influence or in the hands of the medical societies, assured the dominance of scientific schools and the competitive disadvantages of economically weaker schools. The cost of a scientific medical education was shattering the financial arrangements of proprietary medical schools. The council could not order schools closed, but it rallied political allies in the state boards and the forces of the marketplace to wreck the ancien régime.


MONEY FOR MEDICAL EDUCATION: WHO WILL PAY?

   The reforms initiated and pressed by the AMA leadership were clearly having their desired impact. But the profession's power to accomplish its ultimate goals was limited. Scientific medicine was an expensive affair. Nearly all medical schools at the end of the nineteenth century relied for most of their support on students' tuition fees. Most independent medical colleges and many of those nominally associated with universities had no other source of income. Yet the teaching of scientific medicine required expensive laboratory buildings, a teaching hospital and teaching clinic, and equipment. Some of these facilities could be obtained from local men and women of wealth if faculty members had fashionable private practices. Some facilities could be had if the medical school was affiliated with a well-endowed university. However, more than facilities were needed.

   The largest operating expense for a scientific medical school was the faculty to teach the laboratory science courses. A practitioner might be good enough to teach clinical courses, but he usually was not expert enough in physiology, bacteriology, or pathology. The basic medical sciences had to be taught by medical scientists who were specially trained in that area and whose on-going research kept them abreast of developments in their field. These faculty had to devote their full time to teaching and research, and they were the largest operating expense of a turn-of-the-century scientific medical school.

   The cost of a scientific medical education was beyond the means of students. "It costs more to educate a medical student," Bevan noted, "than he can pay in the way of fees." 16 The capital investment and operating costs for scientific medical education were also beyond the means of the profession itself. Wealthy physicians might provide a small portion of the capital for a medical college, but the reformers recognized early that most of the capital for scientific medical schools would have to come from outside the profession. 17 States might be persuaded to support state institutions, but most medical schools and universities--and certainly the most elite--were privately controlled. "The public must be taught the necessities and the possibilities of modern medicine," Bevan argued, and philanthropists must be shown that medicine deserves their endowments. 18 Because of the amounts involved, much of the money would have to come from the fortunes of the very wealthiest men and women in America. The medical reformers were well aware of the dangers of help from the outside. "Rich men may injure the cause of medical education," the AMA Journal warned in 1901, unless their giving is directed by the profession itself. 19 With the blessings of the rest of the profession's leadership, Bevan took on the task of getting and guiding endowments for medical colleges. "We must secure for them state aid and private endowment," he told the council's 1907 national conference. "We must start an active, organized propaganda for money for medical education." 20


HELP FROM THE CARNEGIE FOUNDATION

   Impressed with the impact of the council's own survey, Bevan turned to the Carnegie Foundation for the Advancement of Teaching. He sought the foundation's help, not just to replicate the council's own work, but to add to their campaign the foundation's developing prestige and image of "objectivity." Bevan understood the foundation's potential for molding public opinion and providing a credible blueprint for philanthropists to follow while channeling their money into medical education. It was also clear that an agency outside the profession could openly attack medical schools that resisted reorganizing themselves or going out of business without once again splitting medical school faculty off from the reform leadership. At the council's first national conference in 1905, Bevan criticized proprietary medical schools as an obstacle to reform, but he felt compelled by the need for diplomacy to urge leniency because of the "property and professional interest" invested in them. 21

   In 1907 Bevan invited Henry S. Pritchett, president of the Carnegie Foundation for the Advancement of Teaching, to examine the survey materials collected by the council. Meeting at the Chicago Club, Bevan and Pritchett saw eye-to-eye on the value of a Carnegie-sponsored study of medical education. For Bevan the Carnegie study would be the big guns in the campaign for medical education reform. Pritchett was sympathetic to that concern, but mainly in the context of the foundation's program to reform and rationalize the nation's colleges and universities, including its professional schools. 22

   The foundation had been established in 1905 to upgrade the status of college teachers while creating a uniform system of higher education. Out of discussions between Andrew Carnegie and Pritchett emerged a plan to advance teaching by the carrot-and-stick method. The new foundation provided an initial endowment of $10 million to support a retirement program for college teachers. The pensions would be given without any cost to the institution or its individual teachers, but each college must meet the conditions laid down by the foundation. Denominational colleges were not eligible for the pension plan. Religion was, of course, an important moral force, but it would not promote the universality of science; colleges controlled by competing denominations would be more concerned with propagating the faith than with training scientists and engineers. Denominational colleges, hoping to make themselves more attractive to faculty, besieged the foundation with inquiries about how to amend their charters to make themselves eligible for free pensions. In addition, the foundation imposed academic and financial requirements designed to force the poorer colleges to match the academic standards of the better colleges and to make higher education follow a uniform pattern throughout the country. 23

   Thus, Sevan's request for a study of medical schools fit well with the foundation's general program and provided an opportunity for the foundation to move into reforming professional education. Pritchett discussed the proposed study with Charles Eliot, president of Harvard and a trustee of the Carnegie Foundation, Rockefeller's General Education Board, and the Rockefeller Institute for Medical Research. He also talked with Dr. Simon Flexner, director of the Rockefeller Institute. Flexner suggested a director for the study, his brother Abraham. The suggestion meshed well with Pritchett's conception of the study as contributing to the reform of higher education. 24

   Abraham Flexner was a professional educator. He got his bachelor's degree from Johns Hopkins in two years of diligent and hard work. He later founded and ran his own college preparatory school in Louisville and afterwards spent a year in advanced study in education at Harvard. While in Heidelberg in the summer of 1908, Flexner wrote The American College, which, in his own words, "fell quite flat." Late in the summer of 1908 Flexner returned from Europe unemployed and "prepared to do almost anything." Hoping to get a job, Flexner initiated a meeting with Pritchett. They talked about higher education and its problems and found they agreed on the necessity for reform. "When I next saw him," Flexner later recalled, "he asked me whether I would like to make a study of medical schools." Flexner was enthusiastic, "but it occurred to me that Dr. Pritchett was confusing me with my brother Simon at the Rockefeller Institute, and I called his attention to the fact that I was not a medical man and had never had my foot inside a medical school."

   "That is precisely what I want," replied Pritchett. "I think these professional schools should be studied not from the point of view of the practitioner but from the standpoint of the educator. I know your brother, so that I am not laboring under any confusion. This is a layman's job, not a job for a medical man." 25

   A report on medical education by a physician would lack credibility, and it would feed the divisions between practitioners and part-time medical school faculty. Moreover, Pritchett, while certainly not adverse to aiding medical professionals, wanted medical education integrated into a general system of education. A report by an educator sold on the importance of a scientific medical profession would provide both the right perspective and credibility. 26

   At their November 1908 meeting, Pritchett asked the Carnegie Foundation trustees to authorize the study and appropriate the necessary funds. With their approval, Flexner immediately began his study. 27 Bevan directed the reform campaign, Pritchett financed it with Carnegie's money, and Abraham Flexner implemented it.


THE "FLEXNER REPORT"

   A scholarly technician, Flexner began by reading up on the history of medical education in Europe and America. He went to Chicago to discuss the study with George Simmons, secretary of the AMA and editor of its Journal. He also met with Bevan and Colwell, secretary of the Council on Medical Education. He read Colwell's reports on medical schools and found them "creditable and painstaking documents" but "extremely diplomatic."

   Flexner then visited his alma mater, Johns Hopkins, where he met with the medical school's leading faculty members, Drs. Welch, Halsted, Mall, Abel, and Howell. Flexner found Hopkins "a small but ideal medical school embodying in a novel way, adapted to American conditions, the best features of medical education in England, France, and Germany." Hopkins became the living model for Flexner. "Without this pattern in the back of my mind, I could have accomplished little." 28

   Flexner saw his mission as translating the Hopkins medical school into a standard against which to judge all other medical education in the United States. All others paled before this "one bright spot." Flexner's praise of Hopkins grew ecstatic:

It possessed ideals and men who embodied them, and from it have emanated the influences that in a half-century have lifted American medical education from the lowest status to the highest in the civilized world. All honor to Gilman, Welch, Mall, Halsted, and their colleagues and students who hitched their wagon to a star and never flinched! 29

   Flexner visited every one of the 155 medical schools in the United States and Canada. Colwell, of the AMA, went with him to most of them. In nearly all cases, the school administrators and faculty laid bare the facts of their existence—facilities, laboratory equipment, numbers of faculty and their qualifications, numbers of students and their preparation, the curriculum, patients available as teaching material, income from student fees, and endowments. 30

   Even administrators and faculty who knew their schools were deficient in many assets the Council on Medical Education believed important permitted Flexner and Colwell access to facilities, staff, and account books. Many of the schools were run by doctors who were committed to elevating the profession and saw the importance of creating scientific medical schools. Even more persuasive in opening medical schools to inspection was that deans, faculty, and trustees of most medical schools believed that Flexner's visit "would be followed by gifts from Mr. Carnegie to set things right." Whatever fear the medical school deans and faculty had of the consequences of public criticism, they understood that failure to comply with the Carnegie study would result in their rapid demise. The market for medical students was very competitive, and bad publicity would do serious injury. But riskier still were the dynamics of the competitive market. If many competing medical schools that cooperated with the Carnegie study got a large advantage--for example, a new laboratory or an endowment--the financial collapse and demise of the disadvantaged was assured. 31

   Some colleges resisted inspection, but resistance was grounds for suspicion. To the recalcitrant medical schools, Pritchett let it be known that "all colleges and universities, whether supported by taxation or by private endowment, are in truth public service corporations," and, therefore, the foundation, the medical profession, and the public had a right to know about their finances and educational practices. Rather than fear intervention by outsiders, the leading reformers in the profession savored this attitude of the foundation. Not only did this attitude support their campaign, but it recognized medicine as a vital societal function. 32


FLEXNER'S FINDINGS

   Flexner visited the medical schools and wrote his report in the space of eighteen months. His whistle-stop tour and his acerbic comments on what he saw gave him a reputation, even among medical reformers, for being "erratic" and "hasty in judgment." The medical faculty at Harvard were insulted and in return cast aspersions on his ability while the faculties at lesser schools merely bristled. 33

   Not coincidentally, Flexner's criticisms of American medical schools and his recommendations for reform were perfectly consistent with those of the leading medical profession reformers. Flexner attacked medical schools for producing too many doctors, for requiring too little education before admission to medical school, for having inadequate facilities and faculty and providing inadequate training, and for creating a social composition for the medical profession that was inappropriate to its important social role.

   Flexner and Pritchett both attached great importance to medicine's changing role in society. The physician's function in society, traditionally "individual and curative," was rapidly becoming "social and preventive." 34 If "society relies" on doctors for important social functions, then "the interests of the social order" must be considered first in any public policy for reforming the profession. 35 What was wrong with the medical profession from society's point of view?

   Overcrowding was the most serious problem with the profession, according to Pritchett and Flexner. If Germany could thrive with one doctor for every 2,000 inhabitants, then the United States, with an average of one doctor for every 568 persons, suffered from a severe oversupply of physicians. Overcrowding forces professionals into competition with one another, fighting for a relatively inelastic market of patients and encouraging one another to perform unnecessary services to increase their incomes. Overcrowding "decreases the number of well-trained men who can count on the profession for a livelihood," reducing the attractiveness of a medical career to competent men. "The country needs fewer and better doctors," Flexner argued, and "the way to get them better is to produce fewer." 36

   The main reason for the overcrowding of the profession, as well as for its generally low standards, was the prevalence of "commercial" medical schools. Only fifty of the 155 medical colleges were integral parts of universities. The rest, whether independent or nominally affiliated with a university, were in reality run by the medical faculty alone without any outside control. These proprietary schools depended on students' fees, which were divided up among the local practitioners who were lecturers in the school. Many of the faculty fattened their incomes through "the consultations which the loyalty of their former students threw into their hands." Faculty chairs in the commercial schools were bought and sold, sometimes for as much as $3,000. 37

   Commercial medical schools dragged down medical education in its entirety, argued Flexner. Their incomes based entirely on student fees, the schools tended to admit as many students as possible and to reduce their expenses as much as possible. Since lectures were the cheapest form of education--in which the income from student fees went directly to the faculty instead of being invested in buildings, laboratories, or equipment—medical education came to consist almost entirely of lectures until the 1880s. The necessity of laboratory and clinical training for the scientific medical doctor greatly strained the resources of proprietary medical schools. The choice was clear. "The medical profession is an organ differentiated by society for its own highest purposes, not a business to be exploited by individuals according to their own fancy." 38 To assure its public service character, medical schools must be made integral parts of universities.

   The social importance of the medical profession meant not only that medical education should not be left to proprietary organization, but that it should be reserved for those who could afford "a liberal and disinterested educational experience." Proprietary medical schools, with their admission requirements of four years of high school or its "equivalent," attracted "a mass of unprepared youth . . . drawn out of industrial occupations into the study of medicine." Neither "the crude boy" nor "the jaded clerk" were suitable material for a career in medicine. 39 Flexner proposed a minimum two years of college for admission to medical school at a time when only 15 percent of the high school age population was enrolled in high school and only 5 percent of the college age population was enrolled in a college or university. 40

   Consistent with the racism of his period, Flexner argued that "the practice of the Negro doctor would be limited to his own race." However, "self-protection not less than humanity" should encourage white society to support improved training for black physicians: "ten millions of them live in close contact with sixty million whites." In addition, the importance of black physicians in facilitating "the mental and moral improvement" of their race required creating an elite core of scientific black doctors. Applying the formula of "the fewer, the better," Flexner recommended that of seven black medical schools then in existence, only Meharry and Howard be continued. 41

   Flexner also recommended closing the three women's medical colleges. Schools for women alone were unnecessary and inefficient since "medical education is now . . . open to women upon practically the same terms as men." If the number of women medical students was declining, it demonstrated a lack of either "any strong demand for women physicians or any strong ungratified desire on the part of women to enter the profession," or both. Flexner seemed to believe, with most of his peers, that women are seldom equipped for the mental rigors of medicine and, if middle or upper class, women make better patients than doctors. 42

   The very clear consequence was to be an across-the-board reduction in the production of doctors, with especially large reductions in the numbers of poor and working-class young men, blacks, and women entering the medical profession. The social class and status of medicine would be raised, together with the incomes of physicians, to a level appropriate to its role in society. These changes were made necessary, according to Flexner, by the requirements of scientific medicine as well as by medicine's new social role.

   Flexner found that only twenty-three of the country's 155 medical schools required two or more years of college preliminary to medical school. And 132 schools admitted students with a high school education or its "equivalent." The latter would be a tolerable "temporary adjustment" where there were not enough college students to fill the medical school openings, but two years of college provides "the varied and enlarging cultural experience" necessary to a modern physician. 43

   Instruction in biology, chemistry, and physics should be required before the student could enter medical school. The medical college curriculum was to proceed from there. In the first two years the student would study anatomy, physiology, bacteriology, pathology, and pharmacology. With this thorough grounding in the laboratory sciences, the student would spend his or her third and fourth years in supervised clinical study. Only the better medical schools, affiliated with universities and requiring two years preliminary college education, provided the model curriculum. 44

   Flexner's report thus sought to place medical education on a uniform basis consistent with the needs of scientific medicine and to elevate the status of the medical profession to a position consistent with its important social role. This mission required eliminating both proprietary schools and the lower classes, restricting the opportunities of women and blacks to enter the practice of medicine, as well as increasing the preliminary requirements and standardizing the curriculum into a graded, four-year program. Reducing the supply of physicians was no mere by-product of Flexner's program. "The improvement of medical education cannot," he argued, "be resisted on the ground that it will destroy schools and restrict output: that is precisely what is needed." 45

   Flexner's analysis and recommendations were strikingly like those of the leading reformers of his time within the profession. For at least a decade before Flexner's report was published in 1910, medical journals argued that the profession was overcrowded and that improving medical education was the best means of restricting output. "We raise the standard of medical education year by year, yet the mushroom colleges do not go," Frank Lydston complained to his colleagues in 1900. "We have done the best we could to breed competition by manufacturing doctors." 46

   In 1901 the AMA Journal warned that the growth of the medical profession should be stemmed "if the individual members are to find the practice of medicine a lucrative occupation." 47 And in 1905, Council on Medical Education member V. C. Vaughan told the council's first national conference that "the supply quite equals the demand, and for this reason the time is propitious for raising the barrier to admission one notch higher." 48 The argument that medical students should be drawn only from the better classes likewise did not originate with Flexner. 49

   At their 1905 national conference and in the following year, the council had urged a temporary preliminary education requirement of high school graduation and one year each of university physics, chemistry, and biology. The council had also recommended a curriculum of four years, with anatomy, physiology, pathology, pharmacology, and bacteriology in the first two years and supervised clinical study in the last two. 50

   Strict university affiliation had been a cornerstone of the medical education reform movement for at least forty years by the time Flexner published his report. The university affiliations of most nineteenth-century medical colleges provided the medical school with prestige and legitimacy and gave the university credit for having a medical school, but there were few administrative or academic ties. Charles Eliot, when he assumed the presidency of Harvard in 1869, asserted the authority of the university over the medical faculty and turned the medical school over "like a flapjack," in the words of Oliver Wendell Holmes, then a faculty member in the school. Eliot's new regime raised entrance requirements, instituted scientific medical courses, and forced the faculty to submit to the normal university administrative and academic authorities. Eliot hoped to attract an endowment by demonstrating that the medical school was no longer a private venture "for the benefit of a few physicians and surgeons." His plan was successful. Subordination of the medical school to the university became a key plank in the platform of medical education reformers. 51

   The coincidence of Flexner's and the profession's analysis and recommendations could be due to the compelling claims of scientific medicine. That is, any two investigators of the medical profession at that time might have been led to more or less the same conclusions because, within the strategy of developing medical science, the deficiencies of the profession and medical training were obvious. But the relationship of Flexner to the profession was close. His brother was director of the country's leading medical research institute, and he consulted at great length with the AMA leadership throughout his study.

   In fact, it was explicitly understood from the beginning that the Carnegie study would be part of the council's campaign, lending credibility to the council's plans for reforms. Six months before Flexner's report was published, Pritchett, president of the Carnegie Foundation, wrote Bevan:

In all this work of the examination of the medical schools we have been hand in glove with you and your committee. In fact, we have only taken up the matter and gone on with the examination very much as you were doing, except that as an independent agency disconnected from actual practice, we may do certain things which you perhaps may not. When our report comes out, it is going to be ammunition in your hands. 52

   Bevan, anxious to start getting mileage out of the Carnegie study, wanted Flexner and Pritchett to speak at an AMA meeting several months before the report was to be published. Pritchett was concerned that if the conspiracy between the foundation and the AMA was made visible--and especially before publication--the report would lose some credibility, and the foundation's "disinterested" image would be tarnished. "It is desirable," he privately added to Bevan, "to maintain in the meantime a position which does not intimate an immediate connection between our two efforts."

   This sort of deception increased the credibility of the Flexner report, but it was not essential to the transformation underway. It merely helped along the social and economic forces already in motion.


IMPACT OF THE REPORT

   When the Flexner report was published as "Bulletin Number Four," the Carnegie Foundation found itself the object of "more stone-throwing than was to be expected" for its association with the "Medical Trust"--the AMA and its Council on Medical Education. Pritchett was embarrassed by the "somewhat dogmatic appearance" of the report which lent credibility to charges of collusion with the AMA, but Bevan and the AMA felt "very much flattered by such an association." Regardless of how Pritchett felt about the public impugning of the foundation's reputation, neither he nor the foundation backed down from its support for the AMA. 53

   Pritchett did not consider that aligning his foundation with the medical professionals might compromise the foundation's larger objectives. Only in 1913 did he begin to see a conflict developing between the profession's objectives of closing medical schools right and left and the foundation's goals of rationalizing higher education and providing for a professional group to fulfill an important function in society. The council's demand for one year of college preparation for admission to every medical school in the country did not take account of regional differences and especially the relative backwardness of the South. Pritchett feared that the very classification scheme that so impressed him in 1907 was being used to set medical education off from the rest of the school system, rather than gradually pressuring the lower schools to meet the preliminary training needs of the medical schools. He accused the council of disregarding "the educational results which the school system itself can turn out," and he warned that "your power will quickly disappear if you advocate courses which are educationally indefensible." 54

   Pritchett gradually came to realize that the medical profession's interests would lead it to actions that conflicted with the interests that the foundation wanted to further. By 1918 it was clear to Pritchett that the AMA would wreck all medical education for blacks if left to its own devices. Believing in the social importance of black doctors among black people, the Carnegie Foundation was supporting the Meharry medical school while the council was rating it a class B school. Pritchett protested the "grave injustice done to the negro [sic] schools" by the council's de facto policy of not extending to them the same leniency given to white schools in the South. The policies of the zealous AMA reformers were closing medical schools and disrupting the attempts to build a uniform school system, all without regard for the public interest as defined by the leading foundations. Pritchett threatened to call a meeting of his and the Rockefeller foundations, representatives of some licensing boards, and the dozen "stronger medical schools" to force the council to "revise its present classification of medical schools." 55 Within a decade of his cordial meeting with Bevan at the Chicago Club, Pritchett had come to view the council's power in much the way Dr. Frankenstein viewed his own creation.

   Pritchett's dismay at the council's use of its power was undoubtedly made more painful because of the influence exerted by the Carnegie report. It is sometimes forgotten that the report did not create the movement for medical school reform. The movement for scientific medical education had borne its first fruit four decades earlier. Charles Eliot had led the reform of the Harvard medical school beginning in 1870. Also in the seventies the first teaching hospital was founded by an American university in Michigan, state medical licensing boards were reestablished, and the Illinois board had begun a series of influential reports on medical schools. The Council on Medical Education's own survey of medical schools in 1907 was, of course, the model for Flexner's study and had a substantial impact itself. The profession's increasing control of state boards made rapid "progress" possible. 56

   Flexner noted that even before his study was published, great strides had been made in reforming medical education. Medical school programs had been extended to four years, clinical teaching had been added to didactic methods, laboratories were widely available and had been expanded, admission standards had been adopted and were lived up to with varying degrees of commitment, and state boards--the police power behind the reform movement--had been created in most states. The consequences of these changes were admirable. The number of medical schools was declining, he noted, and independent and commercial schools were rapidly giving up the ghost. 57

   Flexner's report thus aided a process already underway. The rate of consolidation and elimination of medical schools was as rapid before the report as after. Between 1904 and 1915 some ninety-two schools closed their doors or merged, forty-four of them in the first six years to 1909 and forty-eight in the second six years to 1915. 58

   Cut off from sources of funding, in part by Flexner's recommendation, the five disapproved medical schools for blacks soon closed. With racism as rampant in white medical schools and medical societies as throughout the rest of the society, medical care for blacks declined even further. In 1910 there was one black doctor for every 2,883 black people in the United States (compared with one physician to every 684 people for the nation as a whole), but by 1942 the ratio had grown further to one black physician for every 3,377 black people. 59 Flexner's attitude toward women in medicine, more extreme than the views of many of his contemporaries, certainly contributed to keeping women at an average of less than 5 percent of all medical graduates from 1900 until World War II. Today women constitute about a fifth of all medical students and blacks about 6 percent, both far less than their proportions in the population but substantially higher than a decade earlier because of the recent struggle for an affirmative action policy in medical school admissions.

   Flexner's report also contributed to eliminating sectarian medical colleges. Scientific schools no longer called themselves "regular." By 1932 Arthur Dean Bevan was able to say appreciatively, "We were, of course, very grateful to Pritchett and to Flexner" for enabling "us to put out of business" the homeopathic and eclectic medical schools in existence in 1910. 60 Flexner's contribution was not as substantial as Bevan remembered: The 31 homeopathic and eclectic schools surviving in 1910 were down a third from their number in 1900. 61

   The report's direct impact on the profession was moderate, but its consequences were indirectly monumental. As Flexner himself pointed out, the report spoke to the public on behalf of the medical reform movement. It helped "educate" the public to accept scientific medicine, and, most important, it "educated" wealthy men and women to channel their philanthropy to support research-oriented scientific medical education. The Flexner report and the Carnegie Foundation's support brought economic and political power into the war as partisans of the "regular" doctors cum-scientific medical men.

   Within a year following the report's publication, the General Education Board entered the fray in earnest. By 1920 the GEB had appropriated nearly $15 million for medical education and by 1929 a total of more than $78 million. By 1938 contributions from all foundations to medical schools exceeded $150 million. 62 The frequently used matching grant policy, requiring the recipient institution to raise an equal sum itself, greatly increased the impact of their funds. Because the foundation grants were conditional on specific reforms in the medical schools, the foundations exerted a major influence. They forced schools to adopt a research orientation, required teaching hospitals to subordinate their autonomy and patient care to the needs and authority of a university medical school, and established salaried clinical professorships.

   The foundations' power was in providing the outside capital for the reform of medical education and the profession itself. As the suppliers of that capital, they were able to dictate terms to the profession. In the earliest years, however, it was the profession that defined the goals and the strategy. The Carnegie Foundation had provided its resources to the leading medical professionals. The Flexner report united the interests of elite practitioners, scientific medical faculty, and the wealthy capitalist class. The report validated the elite professionals and enabled them to speak to philanthropists with a single voice, amplified by the Carnegie Foundation. Without the Carnegie report, the fears of "misdirected generosity," voiced by the AMA Journal in 1901, 63 might have been even more justified than they turned out to be.


THE GENERAL EDUCATION BOARD:
MEDICAL EDUCATION GETS
A DIFFERENT DRUMMER

   While Pritchett was parrying blows from critics and soaking up support from the medical profession reformers, Flexner was sent abroad by the foundation to study European medical schools. Back home in New York in the spring of 1911, while he was writing the report of his personal investigation, he was invited to lunch by Frederick T. Gates.

   As Flexner recalled the momentous meeting years later, Gates complimented him on Bulletin Number Four and asked him, "What would you do if you had a million dollars with which to make a start in reorganizing medical education in the United States?"

   "Without a moment's hesitation" Flexner recommended giving it all to Welch and the Johns Hopkins medical school. Flexner could not have recommended anyone in medicine more dear to Gates' heart. Gates asked Flexner to obtain a leave for a few weeks from the Carnegie Foundation to go to Baltimore as an agent of the General Education Board and report back on his findings at Johns Hopkins. Flexner was delighted and went off to Baltimore assured that the million dollars was available. 64

   In Baltimore Flexner went directly to Welch and explained that the GEB might add a million dollars to the Johns Hopkins medical school endowment and that he was there to study the situation and report back to Gates. Welch arranged a dinner that night at the Maryland Club and invited two of Hopkins' most illustrious medical faculty, Franklin P. Mall, an anatomist who in effect represented the medical science faculty, and William S. Halsted, a surgeon and de facto representative of the clinical faculty.

   Mall spoke without hesitation: "If the school could get a sum of approximately $1 million, in my judgment there is only one thing that we ought to do with it--use every penny of its income for the purpose of placing upon a salary basis the heads and assistants in the leading clinical departments." That, Mall added, "is the great reform which needs now to be carried through." 65

   Mall's suggestion was the focus of Flexner's report to Gates. Flexner recommended a grant of $1.5 million to reorganize the medical, surgical, obstetrical, and pediatric departments, placing the clinical faculty on a full-time basis. The "full-time plan" would require the clinical faculty, at that time earning roughly $20,000 to $35,000 a year from consultations, to become salaried employees of the medical school and to turn over all their consultation fees to the school. Incomes would thus drop to $10,000 for a department head, still a very high salary for the period, and $2,500 for his assistants.

   Flexner's report, in the same tradition of thoroughness as his Bulletin Number Four and Gates' own reports to Rockefeller nearly two decades earlier, greatly impressed Gates. The recommendation was informally adopted as policy, and, at Gates' request, Flexner returned to Baltimore and personally explained it to Welch and gave him an informal and confidential assurance that a Hopkins application for $1.5 million to institute the reforms would be approved by the GEB. It would be up to Welch to convince his faculty and the university trustees to make the reform, for it was to be the only basis of the GEB's grant. "No pressure was used," Flexner recalled, "no inducement was held out." Just $1.5 million. 66

   When Flexner brought the proposal to the GEB, the full-time plan already had a powerful advocate within the board. Three years earlier Gates had been instrumental in establishing the strict full-time provision for physician-researchers at the Rockefeller Institute's new hospital. 67 With a view to the needs of maintaining and further developing capitalist society, Gates believed the full-time plan would encourage the application of science to medicine and reduce the independence of the medical profession.

   Gates, a director of industry, finance, and philanthropy, believed, as did other men in his position, in the usefulness of science and technology. Science could discover the causes of diseases, and technology could develop the means to prevent or cure disease. But medical science could neither relieve the misery of the world nor make the work force healthier if people could not afford its services. Likewise, the cultural and legitimizing functions of medicine could not be performed if medical services were priced out of the reach of the working population. The financial independence of the medical profession was an obstacle to bringing the benefits of science to the people. "This practice of fixing his own price granted to American physicians by custom," Gates wrote to the other GEB trustees, "is the greatest present American obstruction to the usefulness of the science of medicine. For it confines the benefits of the science too largely to the rich, when it is the rightful inheritance of all the people alike, and the public health requires they have it." 68

   Commercialism was fine in the economic sectors that should be reserved for profit making, but in medicine it violated the needs of capitalist society. The full-time plan was adopted by the GEB as its central policy in medical education to help bring the medical profession to heel and subordinate its practices to the needs of industrial capitalism for fully accessible medical care, or, as board member Jerome D. Greene put it, to abate "commercialism in the medical profession." 69 If the elite, standard-setting medical schools supported by the GEB adopted the fixed-price schedule for medical services, Gates argued, "public sentiment, in no time, will enforce those schedules, if reasonable, not only throughout their cities but other cities and finally the country at large." 70

   The full-time plan played a central role in foundation funding of medical education for the following important decade of development. The new arrangement altered the relationship of the medical profession to university medical schools. And it caused deep divisions between the reform-minded elite practitioners in the medical societies and the Rockefeller philanthropies.


FULL TIME: "GOLD OR GLORY"

   As Flexner himself has pointed out, the full-time plan for clinical faculty was suggested to him by Mall, though it had first been advocated publicly in 1902 by Lewellys F. Barker, a former colleague of Mall's at Baltimore and then a professor of anatomy at Chicago. 71 The earlier origins of the idea can be traced to more obscure beginnings in German medical laboratories, but its introduction to the United States is of interest here.

   The full-time plan was first instituted in the United States in 1893 when the Johns Hopkins medical school opened its doors. Because of the new school's emphasis on research and the widespread experience that local practitioners do little research in the laboratory sciences, the university provided full-time faculty positions in anatomy, physiology, pathology, and pharmacology. The models for the Hopkins reform were the German medical laboratories and universities where Welch and the other Hopkins medical faculty got their scientific training. For some of the new faculty who had previously split their time between private practice and teaching laboratory sciences, the Hopkins plan meant giving up an income of $10,000 a year or more, in return for a salary of $3,000 or $4,000. But the bright young men who were actively recruited were, like Welch and Mall, struggling to survive without private practice. 72 For these men, medicine was science and laboratories, not patients and housecalls.

   Welch himself had never wanted to be a physician. After graduation from Yale, he wanted to be a tutor in Greek, but the prospect of unemployment thwarted his ambition and drove him to follow his father into medicine. His interest in medicine soon bloomed though not with visions of a bedside practice. Welch was "fired in the dissecting and autopsy rooms with the desire to become a professor of pathological anatomy," wrote Simon Flexner, "to study and examine for the rest of his life without having to make his living as a practitioner." The development of scientific medicine in the United States opened to Welch the possibility of a new kind of medical career, and he ambitiously set about building a future for himself in the medical sciences. Returning from his postgraduate medical studies in Europe, Welch, with a little financial help from his friends, founded the first pathology laboratory in the United States at Bellevue Hospital medical school in New York. From there he was invited to Johns Hopkins by president Gilman as one of the first full-time faculty in the laboratory medical sciences and was soon made dean of the distinguished medical school. Welch devoted his life to building the first medical center "empire," seeking favor with philanthropists, initiating reforms in medical education and research, and planning and organizing new programs and institutions. 73

   Franklin Paine Mall, after receiving his medical degree from the University of Michigan in 1883, went to Germany for additional clinical training and came back a dedicated medical scientist. In Ludwig's and other laboratories Mall learned to love science and to appreciate the freedom to study what interested him. In his anatomy laboratory at Johns Hopkins, Mall was an efficient and organized administrator. He knew the investments of all the major universities and foundations and was good at bringing research grants to his laboratory. Mall put great value on original research as part of the training of physicians. If dissertations were required for the M.D. degree, he urged hopefully, "it would stimulate scientific work in the medical schools, would tend to reduce the number of graduates, and would improve the quality of the physician." 74

   It was Ludwig in Germany who put the bug about full-time clinical teaching into Mall's ear. Mall brought it back to Baltimore and Chicago and spread the idea among Barker and other colleagues. Mall saw the struggle over the full-time plan as a contest between the clinical faculty and practicing physicians, on the one hand, and the laboratory science faculty, on the other. Reform practitioners had demanded full-time laboratory faculty for the first two years of basic science in medical school, and now "it falls to us to demand of the last two years of medicine what they demanded of the first two." With a sense of victory occasioned by the GEB's proposal to Hopkins, Mall added that "the day of reckoning is at hand." The lesser salaries of full-time faculty should not deter brilliant men and women from entering the field. As Mall liked to put the issue, a physician must choose "which 'G' to worship--Gold or Glory."

   Other laboratory science faculty had similar motivations. Many were undoubtedly drawn to the medical sciences partly by the field's growing prestige, partly by their interest in the single-minded pursuit possible in a laboratory, and partly for escape from hustling patients and dealing with the mundane business of medical practice.

   To the laboratory scientists, limiting clinicians to their salaries would accomplish several things at once. First, they believed that medicine should be fundamentally a science devoted to finding the bio-physical causes of disease and less an art of bedside diagnosis and hopeful therapies. Second, since the medical sciences prospered most with faculty devoting themselves entirely to research and teaching, it followed in their thinking that clinical instruction would also benefit from the clinical faculty's singular devotion to research and teaching. Third, since the medical school competed with the clinicians' private practice for their time and energy, eliminating private practice would unify and rationalize the organization of the medical school. Clinicians would no longer be responsible to an outside practice. Finally, eliminating clinicians' private practices would unify the material interests of all the faculty in the medical school. Clinical faculty, leaving behind large and fashionable private practices, would derive their incomes and reputations from the same source as the laboratory faculty. From at least the days of Benjamin Rush, practitioners had used their faculty positions in medical schools to build large, prestigious, and very lucrative private practices. The proposed full-time plan would reduce such practices, making the main clinical faculty captives of the medical school, with loyalties no longer divided between personally lucrative consultations and the needs of the school for research and teaching.

   Some practitioners as well as academic doctors were mindful of the need for faculty who would commit themselves mainly to teaching. As early as 1900, the AMA Journal argued that clinical departments should be headed by physicians "who are properly paid and of whom more may be demanded than of those who regard their clinical services merely as a means of rapidly acquiring a large private clientele." 75

   But as news of the Hopkins plan spread, the outrage among private practitioners grew. The AMA appointed a special committee on the reorganization of clinical teaching. Its chairman, Victor Vaughan of Michigan, tried to steer a middle course, rejecting extreme involvement in private practice by clinical faculty while expressing the committee's considerable skepticism of the full-time plan. Vaughan concluded that even if the plan were ideal, it would not be feasible for any but a few medical schools that were well endowed. 76

   Many clinical faculty charged that full-time medical school faculty, based in laboratories and wards, made "poor practitioners" because they were more concerned with research than with patients as suffering human beings. They claimed that without a private practice a physician would lose touch with the real practice of medicine and be a poor example for medical students. William Osier, the renowned professor of medicine at Hopkins who had introduced a number of reforms in clinical teaching, had always been an advocate of "medicine as art" as well as science. He frequently argued with Mall, who conceived of medicine as simply a research science. When Osier left Hopkins for Oxford in 1904, he bitterly conceded to Mall, "Now I go, and you have your way." 77 The initiation of the full-time plan at Hopkins must not have surprised him, and he wrote from England his severe criticisms of the proposed change. Similarly, the highly regarded Society of Clinical Surgery, including such celebrated surgeons as Charles Mayo and George W. Crile, registered their opposition to the plan. Other general and specialty societies joined the chorus. 78

   Practitioner attacks on the full-time plan exposed their ideological, material, and political differences with academic physicians, particularly the laboratory scientists. Although the practitioners' and academics' common interest in promoting scientific medicine had united them at the end of the nineteenth century, differences quickly developed as to just what that meant. Academics differed with practitioners over the relative weight of science and art in medicine, the financial interests of practitioner-clinicians, and who should control medicine.

   Medical scientists and their foundation allies believed that medicine was at its best as an exact science, isolating variables in the laboratory and finding a cure under very precise laboratory conditions. Practitioners, in the business of selling cures to patients, seldom saw the relevance of laboratory controls to treating individuals in the real world. With all their deficiencies, the proprietary schools had, in the words of Rosemary Stevens, "at least been firmly attuned to the average practitioner." 79 The medical ideology implicit in the full-time plan was now driving practitioners and academics apart.

   Whether the practitioners were driven more by their commitment to practice or by consideration for their bank accounts is, of course, a moot question. The issues were so intertwined that it was never clear whether the argument that medicine is an art was simply a ruse to hide pecuniary motives. Clinicians fiercely defended their material interests against the infringements of the full-time plan. Arthur Dean Bevan denounced the plan as "unethical and illegal" because it deprived clinical faculty of their fees. 80

   Finally, the full-time plan exposed a political conflict that grew out of the different material conditions of practitioners and academics. The AMA sought to control medical education as a vehicle for controlling entry into the profession and thereby medical care itself. The scientific medical school faculty, on the other hand, thought that they should control medical care. Medical scientists, remarked a prominent British physiologist in 1914, ought to "remodel the whole system so as to fight disease at its source. . . . Surely it is a time when those who have laid the scientific foundations for the new advances should take counsel together, assume some generalship, and show how the combat is to be waged." 81 The Rockefeller philanthropists clearly sided with the medical scientists and cast their weighty fortune with the armies of academe.

   Behind the passion of the AMA's attacks were the realizations that the position of medical faculty would no longer be a lucrative supplement for private practitioners and that the full-time clinical faculties' main loyalties would be to medical schools and not the organized profession. Elite practitioners would now have to choose either a grand income or a respected teaching and research position. But even more important to the strategy for controlling medical education, the full-time plan, by reducing the clinician's income and monopolizing his loyalties and material interests in the medical school, would cut the clinical faculty off from private practitioners. Instead of linking together the interests of the elite practitioners with those of the medical schools, full-time clinical faculty would help separate the medical schools from the organized private practice profession. The full-time plan would reduce the power of the organized profession, in particular, the AMA and its Council on Medical Education, within the medical schools.

   Of course, things were different in the 1910s from the way they had been at the turn of the century. The profession's reform strategy had accomplished much of what it set out to do: It had established scientific medicine as the ascending model of medical practice and education; it had reduced the number of schools considerably and thereby the output of new physicians; and it had secured supportive legislation and licensing laws. But the plan had just begun to work, physicians' incomes and prestige were rising, and the end was not in sight. Medical schools were still considered key to the strategy and to continued control by the organized profession of its own material conditions. And the AMA leadership was not about to let that control slip from its grasp. The profession launched a campaign to discredit and oppose the full-time plan.


SELLING THE FULL-TIME PROPOSAL

   Welch, an astute medical politician, anticipated the furor the plan would provoke. Four years before Mall suggested the idea to Flexner, Welch had called for reforms that would allow clinical department heads to "devote their main energies and time" to teaching and research, "without the necessity of seeking their livelihoods in a busy outside practice and without allowing such practice to become their chief professional occupation." 82

   When the GEB proposed to fund full-time organization of Hopkins' clinical departments, Welch faced the dilemma of mediating the interests of the laboratory science faculty with those of the clinicians. Welch asked the GEB to allow some exceptions to the full-time rule, enabling the university president or "some other responsible authority" to permit some full-time, salaried professors to keep their consulting fees. 83 The board adamantly refused to allow any exceptions.

   The laboratory faculty unanimously endorsed the plan, but, Flexner later recalled, "there was a rift among the clinicians." 84 Within two years Welch won sufficient support from the clinical faculty. Lewellys Barker, the Hopkins professor of medicine who had publicly advocated the full-time plan in 1902, stood in the way of its implementation at Johns Hopkins. He chose "gold" over "glory" and resigned his professorship, agreeing to become a "clinical professor," drawing a small salary from the medical school but being able to devote most of his time to a lucrative private practice. In his place, Theodore Janeway gave up his chair at the College of Physicians and Surgeons and an elite practice in New York to become the first full-time professor of medicine in the United States. William Halsted was named professor of surgery and Charles Howland, professor of pediatrics. In October 1913 Welch formally applied for the grant, accepting the condition that the full-time clinical faculty at all ranks--assistant professor to professor--would "derive no pecuniary benefit" from any professional services they rendered. The board immediately voted its approval and a grant of $1.5 million. 85

   Three months later the GEB decided to devote all its funds in medical education to "the installation of full-time clinical teaching." Flexner had been hired by the board to administer their program in medical education, and he applied himself with his usual energy. 86

   Within a year Welch reported that "the full-time system is a great success" at Hopkins. 87 Halsted and Howland found the system to their liking, but Janeway resigned his position in 1917 to return to private practice in New York. He was dissatisfied with the full-time arrangements, he wrote in a widely publicized journal article, both because "outside engagements" had been a major source of clinical knowledge to him and because he and his family were used to a higher standard of living than he could afford on his salary. It was "unnatural and repugnant to the patient's sense of justice," he said with great sympathy for his patients, "that a consulting physician should not receive the usual fee for such service." 88

   In 1919 even Osier backed off from his opposition. He asked Welch to use his influence to persuade the GEB to "help McGill start up-to-date clinics in medicine and surgery." Osier made it clear that he did not favor the full-time scheme, but he believed it was now necessary at the Canadian school because "new conditions have arisen" which would leave McGill behind the other first-class schools that had instituted full-time teaching in medicine and surgery. 89

   Over the next few years the board voted more than $8 million from its general funds for similar reorganizations on a full-time basis of the medical schools at Washington University at St. Louis, Yale, and the University of Chicago. With the matching grant policy, these funds represented several millions more in support for the reforms. Between 1919 and 1921 Rockefeller, Sr., contributed $45 million to the General Education Board specifically for medical education.

   The first appropriation from this special fund was a grant of $4 million to Vanderbilt University to make the Nashville medical school a model for the South. The GEB considered Nashville its "strategic point" in the South and Vanderbilt the institution that would lead the drive to improve Southern "public health and industrial and agricultural efficiency." 90 By 1960 Vanderbilt, the board's major white university in the South, received a total of $17.5 million from the GEB for medical education. Meharry Medical College, the board's model black medical school and one of only two that Flexner had argued should survive, received less than half the sum given to the white institution. 91 Despite its relative stinginess toward black medical education, the board firmly believed that scientifically trained black doctors were necessary to improve the health of blacks, protect the health of neighboring whites, and provide an elite and "responsible" leadership for the black population. Through its annual grants to Meharry, it exerted substantial control and even instituted full-time teaching in medicine and surgery in the 1930s, with approved white faculty members in charge and a hand-picked white president. 92

   The board used its $45 million to foster, if not force, acceptance of the full-time plan at the major medical schools in the country. But not all the schools were won over as easily as Hopkins.


BOSTON BRAHMINS RESIST

   Harvard staunchly refused to accept the full-time plan. In 1913, while negotiating the details of the Hopkins grant with Welch, the GEB invited the Harvard medical school to apply for a grant to place their clinical departments on a full-time basis. The debt-ridden medical school sought a windfall through subterfuge. The faculty asked for $1.5 million to reorganize all its clinical departments "on a satisfactory university basis." The clinical professors would "devote the major part of their time to school and hospital work," but they could still collect fees from their private patients whom they would see in offices provided by the teaching hospital. This proposal was hardly consistent with the GEB's by then well-known interpretation of full time. 93

   The opposition to the GEB's strict full-time policy was led by two powerful members of the Harvard clinical faculty, Harvey Cushing, a renowned neurosurgeon and chief-of-surgery at Peter Bent Brigham Hospital (a Harvard teaching hospital), and Henry A. Christian, former dean of the medical school. Cushing and Christian, like other members of Harvard's clinical faculty, had lucrative private practices, which they refused to give up. They felt it was enough for the clinical faculty to devote themselves to working in the teaching hospital and "to confine their professional activities within its walls." In return, they wanted to accept fees from "patients who might consult us during hours as we felt justified in setting aside for this purpose." Committed though he was to academic medicine, Cushing even offered his resignation to Harvard president Lowell. But, as Cushing undoubtedly knew, Lowell considered the famous surgeon more important to Harvard's academic reputation than the $1.5 million endowment. 94

   Gates and Flexner continued to press for strict full-time commitments, turning down Harvard's proposals during several years of negotiations. In addition to their ideological commitment to full time, the GEB members had a pragmatic incentive for pushing it as quickly and widely as possible. Harvard and other schools that allowed their medical faculty to keep their consulting fees were raiding the faculties of schools that adhered to the GEB's policy. In 1921 David Edsall, dean of the Harvard medical school, tried to lure Charles Howland, the Johns Hopkins pediatrician, with the same salary he was getting at Hopkins plus consulting fees from private practice. Flexner had to help Hopkins upgrade their facilities as an inducement to keep Howland there. 95

   Harvard was able to resist the full-time plan because of its reputation as a leading scientific medical school and because its clinical faculty were too prominent in Boston's ruling social circles to be easily dismissed. Already by 1900 the Harvard medical faculty boasted that it controlled "probably more clinical material than any other one school in the country." 96 Such powerful medical figures were also physicians to the Boston upper class, and by virtue of their earnings, and many their births, they were themselves members of that very class-conscious city's upper crust. It took such Brahmins to refuse to surrender their consulting fees in the face of the GEB's compelling offer, particularly when the school's accounts were heavily in the red.


FEAR AND TREMBLING IN THE BOARD ROOM

   Meanwhile, Charles Eliot, the illustrious former president of Harvard and a trustee of the GEB, carried the battle into the GEB's board room. Eliot argued that "great improvements in medical treatment have in recent years proceeded from men who were in private practice." 97 Eliot went on to argue not merely for Harvard's latest proposal but for a complete reversal of the full-time policy and the binding contracts imposed by the GEB on universities accepting its beneficence. How could the insistence of the GEB on full time be reconciled with the board's theoretical hands-off policy, he asked rhetorically. Eliot reminded the board that it had pledged itself not to interfere with the running of a recipient institution, "except as regards its prudential financial management." Yet the board was making its strict interpretation of full-time clinical organization the condition of a grant. "This condition does not seem to me consistent with what I have always believed the wise and generally acceptable policy of the board," Eliot diplomatically concluded. 98

   Eliot's arguments fell on receptive ears. The Rockefeller philanthropies were under fire from a range of groups, individuals, and newspapers spanning a considerable portion of the contemporary political spectrum. Ida Tarbell provided fuel for roasting John D. Rockefeller and his financial empire with her "History of the Standard Oil Company," published from 1902 to 1904 in McClure's Magazine. In the latter year, Theodore Roosevelt was elected President on a platform of vacuous promises to bring the trusts to heel. Encouraged by growing popular resentment against the "robber barons" and wishing to channel that resentment through stable political institutions, the Progressive movement won support from the courts as well as the Congress for small reforms and slaps on the wrists of the largest trusts. In 1907 federal Judge Kenesaw Mountain Landis struck Standard Oil of Indiana with an unprecedented $29 million fine for receiving rebates from the Chicago and Alton Railroad. Making its way through the courts was an unprecedented anti-trust suit. On May 15, 1911, the Supreme Court ordered the Standard Oil Trust, then controlling nearly 90 percent of oil refining and sales in the United States, broken up. Neither action slew the Standard Oil empire nor diminished the fortune of John D. Rockefeller and his family. But as part of a growing public attack on Rockefeller and on unrestricted capital accumulation, these attacks were taken seriously by the Rockefellers and their industrial, financial, and philanthropic organizations.

   Hoping to calm the troubled waters of popular hostility and to fuel his engine of social transformation, the Standard Oil billionaire attempted to get a congressional charter for the new Rockefeller Foundation. The proposed charter sparked a veritable firestorm of protest from working-class and Progressive leaders and newspapers. The Los Angeles Record denounced the "gigantic philanthropy by which old Rockefeller expects to squeeze himself, his son, his stall-fed collegians and their camels, laden with tainted money, through 'the eye of the needle.'" Expressing a widespread suspicion of philanthropy, the paper argued that the "monopoly-ridden masses don't want charity under any guise, but justice." The charter bill foundered in Congress for three years and in the end failed to sweep aside the articulated public anger. 99

   The Rockefeller organization found a more receptive mood in Albany and was granted an unrestricted charter by the New York legislature in 1913. But even in New York, anti-Rockefeller Progressive sentiments continued to haunt both the man and his corporate philanthropies. In 1917 State Senator John Boylan introduced a bill to repeal the foundation's charter. Although this attack also failed to stop the Rockefeller philanthropy, it added flack to the assault. What most upset the Rockefeller group about this campaign were the testimony and speeches in support of the bill from Bird S. Coler, a respected Wall Street stockbroker cum-Progressive. 100

   Meanwhile, more specific attacks were being leveled against the Rockefeller and Carnegie foundation programs. The National Education Association (NEA), meeting in St. Paul in 1914, condemned the foundations' education programs for introducing undemocratic controls into the schools. Working-class and Progressive newspapers supported the NEA resolution. The radical organs understood the capitalist class character of the foundation programs in education. The Pittsburgh, Penn., Leader considered the foundation programs so effective "that it is difficult for genuine teachers to make any headway against the class concepts that hold their heads so high in school and college." 101

   The most thoroughgoing indictment, however, followed the "Ludlow Massacre" at the Rockefeller-controlled Colorado Fuel and Iron Company. When workers at the mining operation went on strike in 1914 for union recognition, an eight-hour day, and emancipation from the choking economic, political, and social control of the company over the Ludlow miners and their families, the company brought in armed guards. On April 20 the company's private army together with the state militia shot to death six workers and burned the tents in which the strikers' families were forced to live, cremating two women and eleven children inside them. The Ludlow Massacre shocked an already aroused public and focused anger against the Rockefellers. Labor unions, anarchists, socialists, and radicals organized demonstrations and demanded broad reforms to protect labor. Progressives joined the cry for action, and even conservative newspapers criticized the mining company.

   Congress created, and President Wilson appointed, the Commission on Industrial Relations to investigate the Ludlow affair, relations between capital and labor, and the role of philanthropic foundations in general. The commission, headed by Frank Walsh, exposed much of capital's relations with the working class to examination and criticism and pointed to the important role of foundations in building a superstructure to extend capital's control throughout society. The Walsh Commission subpoenaed the senior and junior Rockefellers, Charles W. Eliot, and Jerome D. Greene to testify about the activities of the Rockefeller Foundation. The commission's final report noted that the Rockefeller and Carnegie foundations' policies are "colored, if not controlled, to conform to the policies" of the country's major corporations, which are themselves controlled by a "small number of wealthy and powerful financiers." 102

   The attacks on Standard Oil and on unrestricted capital accumulation, the hostility to foundations and the Rockefeller programs in particular, and the increased support for radical and socialist working-class movements greatly impressed the men of the Rockefeller philanthropies. Eugene Debs, a revolutionary socialist, rolled up nearly one million votes for President in 1912. In the Rockefeller offices and board rooms at 61 Broadway, the din outside must have sounded at times like the trumpets of Jericho.

   General Education Board member George Foster Peabody, a New York banker, feared the rising tide would force the government to assume all support of educational institutions (robbing the foundations of their power and influence) and would also lead to "economic legislation which shall preclude the acquisition of surplus wealth" (the end of capitalism itself). Peabody preached caution in the face of such challenges. 103

   Charles Eliot feared the outcome of class conflicts, but he believed the best defense were the programs the foundation had already undertaken:

We need not imagine that the process of accumulating great fortunes . . . is going to continue through the coming generations. . . . The evils which I look forward to with dread in the coming years of the Republic are injustice inflicted on those who have by those who have not, and corruption and extravagance in the expenditure of money raised by taxation. Against such evils I know no defense except universal education including the constant inculcation of justice and goodwill. 104

   Gates himself feared possible "confiscation" of wealth, but he had faith in the strength of capitalism to survive. "The recognition of the right to earn and hold surplus wealth marks the dawn of civilization," he noted to himself in 1911. 105

   Gates favored standing fast on the principle of private control of wealth and opposed any special defensive strategies. When Rockefeller Foundation president George Vincent drafted the annual report for 1917, Gates suggested removing a new self-limiting policy statement. Among other points, the new policy precluded the foundation from "supporting propaganda which seek to influence public opinion about the social order and political proposals." Vincent defended the statement on the ground that "the one thing that the opponents of foundations seem most to resent is that attempt to control public opinion." 106 It was hoped that the formal statement denying the charges would be accepted by the public as a verdict of innocence.


FEAR UNDERMINES THE FULL-TIME POLICY

   Board members feared that the full-time contracts would be seen by the public as another example of private capitalist control of essentially public institutions. Visions of more public attacks and restrictive legislation undermined support for the full-time policy within the board. Anson Phelps Stokes, who succeeded Peabody on the board as the voice of caution, counseled against imposing the full-time policy through contracts. "It is not a question of whether we are right or wrong in our opinions," he explained. The full-time plan itself was not an issue. In fact, he thought it was a commendable program.

But it is a question of whether or not we can . . . afford--in view of public opinion and our great wealth as a board--to be imposing, or at least requiring, detailed conditions regarding educational policy in medicine in elaborate contracts which can only be amended with our consent. . . . Personally, I think this policy unwise and fraught with serious dangers. 107

   The "elaborate contracts" were a policy brought by Gates from the American Baptist Education Society to the Rockefeller business dealings and philanthropies. Applied by the GEB to their grants to medical schools, contracts with the recipient universities uniformly included a clause specifying that if the full-time plan "shall, without the consent of the said General Education board, be abandoned, substantially modified or departed from, the said university will, upon demand of said board, return said securities or any securities representing their reinvestment." 108

   Stokes' fear that the contracts would become public knowledge was prophetic. While Eliot, Lowell, and the medical faculty at Harvard could be counted on to keep a gentlemanly silence about their conflict with the GEB, the more volatile president of Columbia, Nicholas Murray Butler, was not adverse to spilling the beans. Under Flexner's hard-nosed leadership, the GEB offered Columbia a substantial grant but only if the university took more decisive control of the medical school, booted out the reigning dean and clinical faculty while instituting the full-time policy, reduced the student enrollment in the medical school, and took more complete control of Presbyterian Hospital as a teaching facility. 109

   After lengthy negotiations between Butler, Flexner, and representatives of the Presbyterian Hospital trustees, Butler rejected the proposals as "so reactionary and so antagonistic to the best interests of the public, of medical education and of Columbia University, that they will not, under any circumstances, be approved by us." 110

   The Presbyterian Hospital trustees, led by philanthropists Edward S. Harkness, W. Sloan, and H. W. deForest, had favored creating a new medical center and had supported all the conditions the GEB was demanding. In 1911 Harkness had given Presbyterian Hospital $1.3 million to encourage them to tighten their bonds with Columbia, giving the medical school exclusive teaching privileges in the hospital and control over Presbyterian's medical staff. 111 Angered at Butler's rejection of the proposals and his support for the existing practitioner faculty, the hospital trustees voted to sever all ties with the Columbia medical school. 112

   Negotiations continued, with Henry Pritchett and the Carnegie Foundation entering the fray in 1919. The Carnegie Foundation joined with the GEB and the Rockefeller Foundation to offer $1 million each toward building a new medical center for Columbia and endowing its faculty. Yet the GEB held out for complete fulfillment of their policy on full time. 113

   Pritchett could see no reason for such obstinacy. "It is quite true," he told Flexner, "that certain of the professors are allowed to take a small consulting practice. . . . That is not 100 percent fulfillment, but I should say that it was comparable to the claims of Ivory Soap to be 99.44 percent pure." 114

   Pritchett was not only uncommitted to complete subordination of the medical faculty through a strict full-time policy. He also, and perhaps more viscerally, feared attacks on the foundations and the recipient universities. "Such a contract binding a university to a fixed policy laid down by the giver of money seems to me a dangerous thing," he complained to Wallace Buttrick, president of the GEB. "If these contracts were made public, I am sure it would bring down on all educational foundations no less than on the universities themselves severe criticism. It seems to me a dangerous policy for those who administer trust funds to adopt." 115

   The standard response of the GEB officers to such criticisms of their full-time plan contracts was that "the policy was proposed to us by the trustees and medical faculty of the university and that the terms of the contract were such as they themselves asked for." 116 According to this fiction, it was Welch who proposed the full-time plan to the GEB. "We have never asked any institution to adopt the plan," Buttrick claimed. "The Hopkins proposal in all particulars came from Doctor Welch." 117 This self-serving posture was supported by carefully worded statements in letters, personal contacts, and even the contracts themselves. Flexner and others orally and confidentially made known the board's requirements, and they were always careful that any written proposals came from the institution. The painstaking, almost nit-picking negotiations with the Columbia medical school faculty, Columbia's president Butler, and trustees of the university belie the GEB's claims that it had "no fixed policy regarding medical education" and that they never attempted to influence the internal policies of universities. 118

   After continued resistance by Harvard and Columbia, public disclosure of the binding contracts, public criticism by the medical profession, and a long history of attacks on corporate philanthropy, the board in 1925 altered its contracts and thus its full-time policy. Eliot had continued his attacks within the board meetings right up to the time of his resignation in 1917, charging the GEB with interfering in the internal affairs of Harvard by demanding full-time organization as the price of an endowment grant. Board member Anson Phelps Stokes carried on the fight to do away with binding contracts and the GEB's narrow definition of full time. 119

 

WINDOW DRESSING: GATES DEFEATED

   Although the public clamor for abolition of foundations, or at least for their severe restriction, had abated with the demise of Progressivism, the entry of the United States in the Great War, and the repression of radical and socialist movements following the war, a majority of the GEB's trustees feared a resurgence of such attacks. "Some day the power of the 'dead hand' will again be the subject of political, if not popular, discussion," warned Thomas Debevoise, legal counsel to the board. 120

   Debevoise prepared the arguments to support the majority of the trustees in their fight with Flexner and Gates. First, it was important for the board not to appear to control recipient institutions. "It will hurt the reputation of the board if it attempts to direct the operation of the objects of its bounty," Debevoise argued. Second, binding contracts were unnecessary to keep the universities in line. "Most of the schools which receive money from the board come back at least a second time, and the possibility of their needing additional help should lend all the inducement necessary to make them follow the ideas of the board." 121

   On February 26, 1925, the board voted, with Gates adamantly dissenting, to authorize a contract with the University of Chicago that required full-time clinical faculty to receive no fees for patients seen in the university's teaching hospitals but allowed them to "continue to engage in the private practice of their professions outside of the university's hospitals." The contract also allowed the university's board of trustees to make "such modifications and changes by the university in future years as educational and scientific experience may . . . justify." 122

   The final defeat for Gates and Flexner came later that year. At the end of September the executive committee of the GEB voted to modify the original contracts with Johns Hopkins, Vanderbilt, Washington (at St. Louis), and Yale universities to allow the boards of trustees to compromise the full-time provision (if they desired). Gates specifically asked to have his negative vote recorded. 123 Gates took his defeat at age seventy-two as a personal attack and a political blunder. Actually, the policy change was a minor one, a question of tactics rather than of strategy.

   The full-time plan was an entering wedge, the first thrust of a continuing struggle by corporate philanthropy to control medical education and medical care--to establish the principle that society's needs, as defined by the corporate class, would prevail over the medical profession's interests. It was the first attempt on a large scale to rationalize medical care in the United States. Gates saw clearly the potential value of academic medicine--doctors subordinated to the university, the university controlled by men and women of wealth, and academic physicians researching the causes of disease and eliminating those causes at their microbiological source. All these relationships and functions would assure that academic doctors, unlike their practitioner colleagues, would serve the needs set before them and not some competing professional interest.

   But in 1925 Gates was a strategist from another era. Although a loyal manager himself, he was a product of early corporate capitalism's rugged individualism, who never adapted to corporate liberalism's trust in the State and other bureaucratic organizations run by professionals and managers. He did not realize how fully academic medicine was already the instrument of foundation and capitalist interests.

   Dependent on outside funding for its capital and operating expenses, medical education could be guided by whoever footed the bill. The GEB and Rockefeller Foundation efforts to institutionalize full-time clinical departments had their effect, even with the resistance and the final defeat of binding contracts. Of the $13 million in medical school operating expenses in 1926, the largest chunk--42 percent--went to salaries of full-time faculty. The Commission on Medical Education reported that in the twelve years since the GEB launched its program with Johns Hopkins, the largest single increase in budgets was "for salaries and other expenses in the clinical divisions, particularly in those schools which have placed the clinical departments on a university basis." 124

   Medical colleges were caught in a bind. Dependent on student fees, they had always been responsive to student demands. By the turn of the century, state licensing boards were requiring at least the rudiments of a scientific medical education. In 1907 the secretary of the Association of American Medical Colleges was able to report that students no longer sought merely the cheapest route to a medical degree. Guided by the demands of state boards, they wanted scientific medical education "and they are willing to pay for it." Every medical college that kept step with "the better schools" found "that the step taken was a profitable one in every way." 125

   The catch was that it took more than student fees to make those changes. Although tuition fees increased to pay for the changes--in 1910, 81 percent of the medical schools charged less than $150 per year whereas in 1925, 85 percent charged more than that in fees—they could not increase beyond the willingness of the middle class to pay them. Nevertheless, by 1927 more than one-third of the annual income of medical schools still came from tuition fees. Income from endowments was, by the mid-1920s, the second largest source of income and meant the difference, for most medical colleges, between making it as a class A school or not making it at all. 126 The influence of the General Education Board and the Rockefeller Foundation was profound.


STATE UNIVERSITIES: PROFESSIONALS,
THE STATE, AND CORPORATE LIBERALISM

   Between 1919 and 1921 Rockefeller, Jr., Flexner, and Gates persuaded the elder Rockefeller to give the General Education Board $45 million to be used for medical education. With the foundation's program of building up several elite private medical schools well underway, Flexner wanted to expand the program to the lesser but still "strategic" schools of the West and the South.

In the East medical education is altogether in the hands of privately endowed institutions of learning. With the exception of some eight or ten schools, medical education in the West and South is in the hands of state universities. The board has found it practicable to cooperate with endowed institutions in developing their medical schools. It has had thus far no experience with state or municipal institutions in this field. It is evident, however, that if Mr. Rockefeller's benefaction is to be made generally effective, cooperation with state and municipal universities is necessary. 127

   It was not long before Flexner brought a concrete proposal to the board to help the University of Iowa build a modern medical center across the river from its small and outmoded facility. The state legislature had dramatically increased its support of the medical school from less than $70,000 in 1912-13 to more than $1 million in 1922-23. But generous though it was to the medical school, the legislature would not appropriate the whole $4.5 million needed to build a new medical center. Assured of continuing support by the governor and the legislature, Flexner proposed that the Rockefeller philanthropies donate $2.5 million, with the state agreeing to raise the remainder from the taxes of the people of Iowa. 128

   When Flexner brought the proposal before the board, Gates prepared an unusually long and passionate speech. The stormy meeting was held over two days at the Rockefeller funds' favorite retreat, Gedney Farms near White Plains. Gates orated for the first half day, his white hair falling in disarray over his forehead, and his necktie twisted out of place by his forceful gestures. 129

   Gates attacked the proposed grant to Iowa because: (1) it was a state university, (2) it was therefore "controlled by the taxpayers," (3) "the taxpayer is not intelligent on the needs and cost of first-class medical education," (4) no attempt was being made "to give Iowa the one supreme and simple thing Iowa needs--viz., illumination of the voter," (5) the indigenous Iowa leadership were incapable of carrying out their ideals of uplifting the medical school, and (6) the proposal was presented by Flexner, whom Gates had grown to despise as an upstart, one of the "bureaucratic officers, usurping the power of the board." 130

   Flexner followed Gates and presented his arguments in favor of supporting Iowa's medical school "in the mildest manner that I could possibly assume." He defended the plan as being practicable and necessary. "We are trying to aid in the development of a country-wide, high grade system of education in the United States. If we confine our cooperation to endowed institutions, we can practically operate only in the East." Flexner's brief, low-keyed presentation suggested the demeanor of a man assured of victory. 131

   That afternoon and the next day board members participated in the discussion. The vote was overwhelmingly in favor of funding the Iowa proposal.

   Gates never forgave Flexner's opposition. "It is amazing," he angrily wrote Flexner. "How could you! You have never squarely met one of my arguments." The issue of not contributing to state universities was a sacred one to Gates. 132

   For Gates, the issue of the board's making gifts to state universities was bound up with his views on the relations between capital and the State and his attitude toward the people generally. Gates did not argue against the existence of state universities. "Indeed, not a few advantages must be conceded them arising out of the fact that they are tax-supported," Gates asserted. "Every taxpayer is told by his annual tax bills that the higher education is not less necessary for a democracy than the district school and the high school at his door; and that all three are equally the inheritance of his children; that the university is not a privilege reserved for religion or leisure or wealth, but belongs equally to every citizen." 133

   Gifts from private wealth, however, would violate the "principle" of taxpayer support for state universities. They are "needless and gratuitous" as well; in 1923 state medical schools received fifteen times more state funds than they got in 1900, a testimonial to the "pride which legislature and people alike take in their universities" as well as to the threefold increase in the states' wealth. 134

   Worse yet, gifts by the Rockefeller philanthropies to state universities would cooperate with the state and federal governments' inheritance taxes, "designed to confiscate between them the whole of very large fortunes." Since the Rockefeller philanthropies were "the only part of the Rockefeller fortune certainly safe," none of their funds should be "thrown into the swollen maw of the confiscatory states." 135


"ENDOW PRIVATE COLLEGES"

   This attitude toward the states had been the official policy of the GEB from 1906 until the 1919 policy statement on the need to expand the medical education program to state-supported medical schools. The board was initially endowed by Rockefeller, Sr., with $1 million in 1902. In 1905 Gates and Junior persuaded the old man to donate another $10 million to allow the board to expand its program. Gates wrote Rockefeller's letter accompanying the gift, saying the funds were to be used "to promote a comprehensive system of higher education in the United States." As a member of the board, Gates proceeded to define what "the founder" intended in "his" letter and gift. Gates emphasized the necessity of forming a rationalized system of stable colleges and universities, "comprehensively and efficiently distributed." 136

   Gates' plan was to build up private institutions in population centers by providing them with substantial endowments. The board should "cooperate with denominational agencies," which then controlled most of the private colleges, but the colleges were not to be aided so long as they remained creatures of any church. All of the Rockefeller-funded colleges and universities, as with the Carnegie Foundation's policy, were to be strictly nonsectarian and nondenominational. In addition, Gates declared, "we must seize the centers of wealth and population." Only they can assure continuing support for universities and colleges, adequate student enrollments, and a mutually supportive relationship between the institution and the local business class. This relationship was necessary "for influence, for usefulness, and for every form of power." 137

   Finally, support by the foundation should usually take the form of contributions to the institutions' endowments rather than yearly appropriations for operating budgets. Gates and Rockefeller learned from their experience with the University of Chicago that supporting a college's operating expenses could easily become like quicksand, consuming the whole energy and fortunes of the foundation. Moreover, Gates laid out four strategic reasons for making endowments the prime work of the GEB. 138

   First, endowments will give universities and colleges financial stability, enabling them to attract a faculty of "great gifts and attainments" without having to pay them high salaries. High-calibre academicians are attracted "not for money but for security, for permanence and continuity of work, for freedom from distraction." The same argument, that people are drawn into academic careers for reasons of security and the undistracted pursuit of research, was applied a few years later to support the demand for full-time clinical faculty. 139

   Second, by providing endowments to carefully selected institutions, the foundation could "preserve and mass our income ... on the strategic points in ever-increasing and cumulative power." It would not be dissipated in smaller amounts on the operating budgets of lesser programs. Third, general endowments given by the GEB would call forth other gifts and personal involvement by the local business class. 140

   Finally, the financial stability of the colleges, the involvement of local capitalists in them, and the continued power and wealth of foundations like the GEB would keep the colleges and universities out of the hands of the people. With sufficient endowments, "no clamor of the masses can embarrass the fearless pursuit and promulgation of truth." This truth, like the colleges themselves, was intended by Gates, as he quoted John Stuart Mill, "to rear up minds and aspirations and faculties above the herd [and] to educate the leisured classes." 141

   The failure of state universities is their financial dependence on the legislature and the populace. "That fact becomes a powerful reason for endowing the private institutions," Gates candidly argued to the board. "If the test should ever come, the power which will act most effectively to preserve the state institutions will be private and denominational colleges and universities amply endowed and holding and teaching truth whatever may be the passions of the hour, and ultimately directing popular opinion into right channels." And, Gates prophesied, guiding the universities will be private foundations, "everywhere numerous and free." They will "so enlighten and direct popular opinion at all times that there can never ensue a conflict between the democracy and its state universities." 142

   Thus, giving endowments to colleges in a system of higher education is like planting "apple trees" in the orchard of capitalism.

I want to see a hundred colleges in this country so planted as to cover the whole land and leave no part destitute, each of them planted in a fruitful soil, each so planted that it shall not be overshadowed by others, each conducted under such auspices as will take care of it, see that it is watered, particularly in its earlier years, see that it is properly fertilized, see that the forces of destruction which always fasten themselves on institutions shall be pruned away. 143


A NEW ROLE FOR THE STATE

   During the period in which Gates' policy against giving to state universities was in force, the GEB, with Gates as chairman until 1917, often contributed to state programs. The board provided the salaries of professors of education at Southern state universities to tour their respective states to urge development of tax-supported high schools. The board paid the U.S. Department of Agriculture for the expenses of agricultural demonstration programs in the South. The campaign against the hookworm in the South and throughout the world was conducted by state and national health departments whose expenses were paid in part by Rockefeller money. 144 But there were two important differences between these programs and the issue of contributing to state university medical schools.

   First, the Rockefeller organization directly controlled all these programs. The GEB named the professors of education and defined their duties. Each professor toured his state "as an officer of the university, laden with its wisdom and moral authority." The high schools that were built because of his efforts were paid for and supported by the state and local governments. Similarly, the GEB found and hired Seaman Knapp to develop the agricultural demonstration program. And, again, "the hookworm work is done in every state under the guise of the State Health Boards, while it is in fact minutely directed by Mr. Rockefeller's staff and paid for with Mr. Rockefeller's money." 145 Clearly Gates and the Rockefeller philanthropies were willing to give money to the State when the State provided legitimating cover for their programs and when they were able to direct the operation.

   Second, higher education differed from other programs. The bulk of Rockefeller's fortune was being used to expand the economic base of society--"employing labor, multiplying the means of subsistence, and enlarging the national wealth." But Gates recognized that other elements of civilization were equally important if the base was to survive. While Rockefeller's industries were "enlarging the national wealth," his philanthropies must stimulate "progress in government and law, in language and literature, in philosophy and science, in art and refinement." And all these "are best promoted by means of the higher education." 146 Thus, the institutions that wrought progress in any one sphere--agriculture, public schools, health--were not so important as the institutions that promoted progress of the whole of civilization.

   Because they are so widely believed to be fundamental to modern society, colleges and universities are more visible and thus more difficult for a single, national private philanthropy to control. Since the GEB and the Rockefeller Foundation could not control the institutions directly, they had to rely on people within each state. For Gates, it was tenuous enough to rely on local business classes to control private colleges. It was unthinkable to yield that control to the people, even through their legislators. It became a sacrosanct principle for Gates not to support state university programs that could not be directly controlled by the foundation.

   As public and governmental attacks on Rockefeller and his philanthropies started to mount, Gates' confidence in the ability of private colleges and foundations to protect private wealth turned to bitter pessimism. "There are too many evidences for my peace of mind," he wrote Rockefeller, Sr., following Judge Landis' anti-trust decision in 1907, "that wherever the voice of the people finds absolutely free expression, that voice is not the voice of reason, of enlightenment, and least of all of a deep-seated sense of right in public things." The people's voice is merely "the voice of reckless greed to lay violent hands on other people's property." 147

   Although all the political, legal, legislative, and public opinion attacks never seriously diminished Rockefeller's wealth, they struck sufficient fear into members of the capitalist class to make them somewhat circumspect in their actions. The GEB members gave up binding contracts and their strict full-time plan, But these "ominous" signs of the times made Gates all the more rigid. He strongly opposed weakening the full-time conditions, and he clung ever more fiercely to his view of the potential evils of the state universities and the importance of "throwing around them in every state a cordon of strong, free, privately endowed colleges and universities." 148

   To Gates, then, the fight within the General Education Board over the appropriation to the state University of Iowa's medical school was a struggle over fundamental principles. Would Rockefeller's fortune be dissipated and, even worse, given over to the enemy? The board answered by overturning the policy established by Gates.

   The GEB, including Rockefeller, Jr., and its newer officers were not acting on impulse or out of fear in contributing to state universities. They were impressed by the need to build a rationalized system of medical schools and realized that much of the medical education in the country would necessarily fall to state schools. Furthermore, they trusted the state universities because they understood the strength of institutional structures and the class ties of professionals as forces for "constructive" but conservative social and technological change. Raymond Fosdick, one of the new GEB members and later president of it and the Rockefeller Foundation, explained the board's defeat of Gates' policy: "Gates did not understand the progressive forces which, even as he spoke, were converting the great state universities into the social and scientific laboratories they have become." 149


MODERNIZING THE GEB: GATES DEFEATED AGAIN

   Soon after the board's decision to pursue and develop the Iowa grant, Flexner brought in other requests to fund state-supported medical schools. By the middle of 1921 the board voted to aid four more taxpayer-supported medical schools--at the universities of Cincinnati, Colorado, Georgia, and Oregon--that had accepted the university arrangements that prevailed at Hopkins and the other elite private schools. 150

   After a couple of years of ad hoc decisions, Gates insisted his policy be respected or debated and voted on as policy. "Our funds, and our rules of policy," he declared to the board, "form our legacy to our successors." Exceptions "should be treated as exceptions. It is vital that these successive boards have written policies and the habit of them." 151

   At the end of 1924 the board voted to appointed a committee to recommend a policy on aid to state universities. The GEB committee consisted of Gates; Rockefeller, Jr.; George Vincent, president of the Rockefeller Foundation; James Angell, president of Yale University; Trevor Arnett, a vice-president of the University of Chicago; and Wickliffe Rose, the star director of the Rockefeller Foundation's International Health Commission. The committee met at least twice and presented its report at the end of May 1925. 152

   The two-page report, written by Vincent and Rose, tersely dispensed with Gates' old policy. It noted that the GEB, the Rockefeller Foundation's numerous divisions, the Laura Spelman Rockefeller Memorial Fund, and the International Education Board all had dealt with and financially aided taxpayer-supported universities and other institutions. The report politely acknowledged that in 1906 Gates' policy was "sound," but in 1925 it was clearly "unwise to adopt principles so rigid as to prevent occasional contributions to medical schools whose growth might be of importance in a national system of medical education." With Gates boycotting the meeting and Wallace Buttrick conveniently absenting himself so as not to have to vote against his friend, the board made the de jure policy coincide with the Rockefeller foundations' practice. 153

   The reversals of the full-time contracts and the policy on state universities were too much for Gates to accept. Still fuming in October, he resigned from the GEB executive committee. 154

   The same revision was underway at the Carnegie Foundation, which was unable to join the GEB and the Rockefeller Foundation in aiding the University of Iowa because of opposition from old-timers among its trustees, men like Elihu Root, a corporate lawyer and former Secretary of State. 155 The foundations and individual capitalists had lost their fear of State-run institutions. Indeed, many financiers and industrialists, adherents of the new corporate liberalism, saw great possibilities for stabilizing their markets and profits in cooperation with the State. Sufficient initiative in developing legislation and executive department agencies bore fruit in the creation of regulatory agencies that enabled the most powerful sectors of several industries to control and regulate their industry themselves. Capitalists, corporate managers, and professionals in America were coming to see the State in a new light. Corporate liberalism embraced the State as the guarantor of a stable, profitable economy. 156

   The state universities were no exception. In the years ahead, all the major foundations gladly developed programs at state universities as freely as they used private universities. As with physicians and medical education, the more expensive it became to operate universities, the more the universities--state and private alike--turned to any agency or organization offering money. If money was offered for developing computer sciences, there were long lines of university presidents at the foundation doors explaining how strong their mathematics, statistics, and electrical engineering departments were and how well they worked together in the campus' fledgling program in computer science. Just as with medical schools, a major foundation would fund a few key schools to develop model departments or programs. And soon thereafter other universities would be copying them or refining some problem area in a similar program, hoping to get on the bandwagon of money for research and to attract new faculty. The strategies developed in medical education were refined and applied by numerous foundations in a broad array of programs down through the years.

   This willingness to use state universities and other state organizations came partly from the changed attitude of the business class toward the State, accepting the necessity and value of State intervention in the economy. But foundation officers and trustees had other reasons as well. State universities performed a valuable role by conducting foundation-designed programs at taxpayer expense. Just as the General Education Board had fostered the development of vocationally oriented secondary schools in the South, for which taxpayers picked up the major tab, its provisions for development grants in medical education and other fields committed a university to continue to support the new program once foundation funding was cut off. Gates had always supported this tactic for objectives outside the university, but to Gates the university was too essential an institution to be entrusted to "the people."

   The decisive argument for including state universities in foundation programs, however, was necessity. In 1908 Andrew Carnegie dropped his opposition to including state university faculty in his foundation's retirement plan because in the Midwest and the West, state universities were the dominant institutions of higher education. The same understanding convinced John D. Rockefeller, Jr., and other members of the GEB to support state-run medical schools. If the foundations were to develop a system of higher education, it was necessary to include the predominant type of institution.

   Finally, professionals as a group had demonstrated their value and loyalty to the objectives of the foundations. The foundations' own professional staffs had earned the trust and confidence of their employers--the financiers, industrialists, corporate lawyers, and university presidents who sat on the foundations' boards of trustees. Most staff officers felt trust in their fellow professionals in the field. Gates himself trusted professionals whom he hired and those who worked with his programs although at the end of his career he disagreed sharply with them. Rockefeller, Jr., voted with the board against Gates to rescind full-time binding contracts and to fund state university medical schools; he did so because he believed them important to the very goals of class domination that he shared with Gates. The foundations were not captured by their officers, as Gates asserted. Rather it was the professionals who were captured by the foundations. They did for the foundations what other members of the professional-managerial stratum had already been doing for the same people's industries and financial organizations.

   Whether an economist or medical doctor teaching and doing research in a university or developing and implementing programs in foundations, professionals saw foundations supporting the development of their fields, providing for their livelihoods, promoting expanded opportunities, and rewarding excellence. What could be wrong in cooperating with such foundations? Weren't they, after all, run by such esteemed men as university presidents, corporation directors, and other professionals?

   These were the very relationships and attitudes encouraged by Gates and other self-conscious strategists who built the foundations and gave them purpose and direction. Like the medical schools in Gates' and Flexner's funding strategy, the leading foundations won the flattery of imitation by their weaker brothers and sisters. Gates was indeed the pillar of the General Education Board and the Rockefeller Foundation until his semi-retirement in 1917. Although his successors modified some of his policies and tactics, Gates' goals and strategies seemed inscribed in stone.

   Corporate philanthropies continued to find their mission in making capitalist society work better. Sometimes they tried to make it work more justly, but even then it was because gross injustice leads to movements for radical change. Generally, they have followed the corporate liberal view developed in the Progressive era and later joined by Rockefeller, Jr. His son David, head of the Chase Manhattan Bank, recently summed up this perspective, still popular in business and dominant in foundations:

In view of the emerging demands for revision of the social contract, a passive response on the part of the business community could be dangerous. . . . So it is up to businessmen to make common cause with other reformers--whether in government or on the campus or wherever--to prevent the unwise adoption of extreme and emotional remedies, but on the contrary to initiate necessary reforms that will make it possible for business to continue to function in a new climate. . . . 157

   If the foundations lost their fear of the State, it was not because they had turned aside the objectives or general strategies of people like Gates. They pursued the same goal of rationalizing higher education in general and medical education in particular to make them better serve capitalist society, and like the dominant view within the Rockefeller boards (but unlike Gates' personal view), they adopted corporate liberalism's perspective that the State is a necessary aid in rationalizing industries, markets, and social and educational institutions alike.


SUMMING UP

   The reform of medical education led to a contest over who would control medicine and for what ends. At the end of the nineteenth century laboratory scientists and elite practitioners formed an alliance to promote scientific medicine, revamp the AMA, win licensing legislation, and begin reforming medical education. Abraham Flexner's report for the Carnegie Foundation capped the drive to eliminate proprietary medical schools, the pariahs of all proponents of scientific medicine. Proprietary schools, sensitive to the needs of the average general practitioner, had served the needs of most students going into family practice while their faculty enhanced their incomes with student fees and consultations referred by former students. These commercial schools, however, churned out "too many" doctors, resisted control by medical societies, and were completely inadequate to providing the scientific, research-oriented medical education that was desired by the profession's reform leaders and by capitalist philanthropies.

   Focusing on "commercial" medical schools and their low standards, the Flexner report articulated criticisms of American medical education and a program for reform that unified elite practitioners, medical scientists, and philanthropists. With the rapid decline of proprietary schools in the 1910s, however, the basis of unity evaporated, and more fundamental conflicts emerged.

   The organized medical profession, in particular the AMA, which represented practitioners, wanted to control entry into the profession, assure that the training of physicians upheld the newly established confidence of the public in doctors' technical ability, and ensure that medical schools provided material support and propaganda to continue the dominance of scientific, technological medicine.

   The new academic medical men, especially laboratory scientists, saw the medical centers as their turf. They wanted a greater share of the money spent on medical care, and they wanted, through their medical centers, to control all health care services and facilities. It made sense, they argued, for those who were the source of medical science to direct the resources of the new scientific medical system.

   Foundations, claiming objectivity from their position above interest group squabbles, wanted to rationalize medical care, to create an efficient and unified system that would contribute to the health of the people. To that end, the General Education Board and the Rockefeller Foundation together gave more than $100 million to transform medical education. Like the committed academicians, they believed medical schools were the pivot of an increasingly technological system of medicine.

   The Carnegie Foundation stepped onto center stage before the conflicts between medical scientists and elite practitioners reemerged. Their support for the Council on Medical Education encouraged reform-minded practitioners and science-oriented academics vying for control Flexner's report supported practitioners' insistence on closing down medical colleges and raising the social class base of the profession, and academicians got support for channeling endowment and construction money into medical schools. The capitalist class was encouraged that a medical care system useful to and compatible with its interests was at last at hand. The Carnegie Foundation, under Henry Pritchett's personal guidance, lent its prestige and legitimacy to the profession's own strategy.

   The General Education Board and the Rockefeller Foundation, under Frederick T. Gates' direction, jumped in with a different strategy. Rather than supporting the scheme of the profession's leadership, which sought unity among academics and practitioners, the Rockefeller philanthropies supported the dominance of the medical scientists. Practitioners espoused capitalist values in wanting to make a profit from their professional services qua small business. But Gates and other foundation leaders had in mind a more important political and economic role for medicine, a role that required that health care be organized along the most efficient and productive lines possible under leadership that had demonstrated its support for the interests of the greater capitalist society. Just as the AMA Journal had warned at the turn of the century, there were dangers in letting wealthy capitalists formulate their own philanthropic designs. 158 The GEB's full-time plan attacked the interests of clinicians and the organized profession's ties to the medical faculty.

   The differences in the Carnegie and Rockefeller strategies can be traced to Pritchett and Gates. Pritchett, before organizing the foundation for Andrew Carnegie, had been president of MIT and before that an astronomer for the U.S. Coast and Geodesic Survey. He was a scientist and a professional, and he was concerned about developing and maintaining a sufficient supply of engineers and trained personnel for industrial and government needs. Gates was a former minister and, since the 1890s, a director of industry and finance. Gates' ministerial background probably contributed to his perception of the role of social institutions as an important superstructure for society. His daily experience with business affairs from his perch at the top of the capitalist class gave him a broad perspective on the needs of capital.

   Though these two men were significant in shaping their foundations' policies, the differences between them were not personality differences. They differed on political questions--what will best serve the needs of capitalist society?--and their personal histories are merely sources for understanding how their differing political perspectives developed. Both men and both foundations supported rationalizing medical care. Gates foresaw the problems with the medical profession that Pritchett only later appreciated. Pritchett supported the profession's own plan of action for several years before he became piqued at the narrow concerns of the AMA and Bevan in particular.

   Bevan and other clinicians leading the AMA resented the General Education Board's attack on clinicians' interests. The Rockefeller philanthropies had become "a disturbing influence by dictating the scheme of organization of our medical schools," Bevan wrote to Pritchett. "Their position has become a real menace to sound development." The GEB had been "badly advised by men who are laboratory workers and teachers of anatomy and pathology," he complained. These men regarded "the laboratory as representing the science of medicine, and they rather feel that clinical medicine is not scientific." Bevan argued that in the training of physicians "the controlling influence must lie with the teachers of clinical medicine." 159 But Pritchett had seen the results of leaving medical education to the practitioners' singular concern for their own interests and their disregard of the larger goal of rationalizing education in the society.

   By 1920 the elite practitioners broke off their alliance with the medical academicians and other supporters of rationalized medical care. A plan for compulsory sickness insurance sponsored by the American Association for Labor Legislation--a corporate liberal organization of social reformers, enlightened capitalists, and a few labor leaders--had won the support of a few key men in the AMA beginning in 1915. From the perspective of the time, the efforts to rationalize medicine seemed to physicians and foundation people alike to be leading to the demise of the private practitioner. In 1915 Welch rather condescendingly urged that "every effort ought to be made to rescue this situation," to preserve the "fine" institution of the family doctor. 160 The dour prognosis for private practice medicine was definitely premature.

   As local medical society leaders caught on to "the professional philanthropists" and their attempts to "put something over on us to our detriment," the Progressives within the AMA were denounced. The academics, like Welch who had been elected AMA president in 1909, were by then isolated. By 1920 at least 60 percent of the country's doctors were members of the AMA. 161 With so many physicians joining up to support practitioners' interests, with the academics out of leadership and the Progressives, like Alexander Lambert, in retreat, the conservative leadership of the practitioners prevailed, a reign uninterrupted to this day. 162

   By the time Gates resigned from the General Education Board's executive committee in 1925, the efforts to rationalize medical care had not gotten as far as Gates had hoped. The constraints on his program notwithstanding, Gates' position became the established foundation direction in medicine for half a century.

 

FOOTNOTES

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