W HOLE-TIME
CLINICAL PROFESSORS

A LETTER TO PRESIDENT REMSEN

JOHNS HOPKINS UNIVERSITY

FROM

WILLIAM OSLER

NOT FOR PUBLICATION
WHOLE-TIME CLINICAL PROFESSORS

Lo the President, Johns Hopkins University

Dear Remsen,

The subject of whole-time clinical teachers, on
which I send you the promised note, is one of great
importance, not only to Universities, but to the pro-
fession and to the public at large. It is a big question,
with two sides. I have tried to see both, as I have
lived both, and as much, perhaps, as any one can appre-
ciate both. Let me thank you, first, for Mr. Flexner’s
Report. As an Angel of Bethesda he has done much
good in troubling our fish-pond, as well as the general
pool. The Report as a whole shows the advantage
of approaching a problem with an unbiased mind, but
there are many mistakes from which a man who knows
the profession from the outside only could not possibly
escape. It is a pity the Report was allowed to go out
in its present form, as his remarks show a very feeble
grasp of the clinical situation at the Johns Hopkins
Hospital ; but this is not surprising, and perhaps is not

This is a family letter, strictly confidential and not for pub-
ication. It is sent only to the President and the Trustees of
the University, the President and Trustees of the Hospital, to
Mr. Abraham Flexner, to Dr. Hurd, Dr. Winford Smith and

Dr. Norton of the Hospital, and to the Professors in the Medical
School. Other copies are not to be had.
4

his fault, since he has not had the necessary training,
nor, from the outside, could he get the knowledge
to understand it. To say, for example, p. 14, as con-
trasted with the instructors in the Laboratory side the
clinical staff has been on the whole less productive and
less devoted is simply not true. I deny the statement

“~~ .4n toto—they have been more productive and quite as

~. devoted. It is singularly unfortunate that he should
not have been able to appreciate the work of the very
men who have done as much, or more, than any others"
to build up the reputation of the school and to advance
the best interests of the profession. To mention, out of
many, only five names—the most stable on the staff !—
Finney, Thayer, Bloodgood, Cushing, and Cullen. It
is not too much to say that these men have done scien-
tific work of a standard equal to that of the highest
of any laboratory men connected with the University ;
and in addition work which in practical import, in the
translation of Science into the Art, no pure laboratory
men could have done. To speak as Mr. Flexner does
(p. 15 of the Report) of these men as blocking the line
and preventing the complete development of a race
or school is perhaps pardonable ignorance, but again it
certainly is not true. Take away the share of the
reputation of the Johns Hopkins Medical School—par-
ticularly in Europe, which knows chiefly the Hospital
Bulletin and the Reports—contributed from the clinical
side, and by the junior staff, and you leave it, in com-
parison, poor indeed! ‘ By their fruits ye shall know
them!’ After showing the treasures of my library, it is
5

my custom to take an intelligent bibliophile to a shelf on
which stand twelve handsomely bound quarto volumes,
and say, ‘But this is my chief treasure—the 500 con-
tributions to scientific medicine from the graduates
of the first eight years of our medical school.’ It is
a splendid record, but much more brilliant from the
clinical than from the laboratory side; and a great part
of the work has been directly inspired by this younger
group of men. In the development of the school it was
a great advantage that the local conditions in the country
were not favorable, as at present—and as they have
been all along on the laboratory side—to the rapid
migration of assistants. It is hard to say which is the
more prevalent on pp. 14 and 15 of the Report—unfair-
ness or ignorance ; but in either case gross injustice is
done to the men who have made the Johns Hopkins
Clinical School.

But I must confine myself to the question, and, I take
it, the special advantage claimed for the whole-time
system is that the Professors will be better able to pro-
mote research. Fruitful research in medicine, which,
by the way, depends entirely on the man, may be done
in private, in Research Institutes, or at the Universities.

Some of the most revolutionary researches of modern
medicine have come from private laboratories, and
when thoroughly trained in methods, there is no reason
why the very best work should not be done by ae
titioners.

The Research Institutes are deueacd to play an |

ever-increasing part. In the Pasteur Institute, Paris,
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6

Ehrlich’s Institute, F rankfurt, the Lister Institute, Lon-
don, the Rockefeller Institute, New York, and the
Carnegie Laboratory, Boston, the most advanced re-
searches are prosecuted; and in the development of
a Hospital side, as at the Pasteur and Rockefeller
Institutes, will be found ample scope for the men who
desire to be whole-time clinical researchers. |

The University Hospital is in a very different position.
The care and cure of patients and the teaching of young
men the art of medicine are functions co-ordinate with
the advancement of knowledge. Provision for all three
must be made in the modern clinic. There is some-
thing very attractive in the parallel between the
problems of the Laboratories and those of the Hospital,
and at first sight it may seem Strange that the sugges-
tion has not been made earlier that men should devote
all their time to the clinics. It is not altogether a new
departure, and it would not be hard to name clinicians—
usually of the quiet studious habit, not built for battle,—
who have been content to work solely at the problems
of disease.

A pure researcher, as at the clinical hospital of an
Institute, has but two points of contact, the patient and
the laboratory problem; the Director of the Clinic of
a medical school has the student as well ; and whether
it will be to our advantage to cut off his affiliation with
the profession and the public, which he has heretofore

__ (enjoyed, is the question at issue. Conditions to-day

make it impossible to have one man thoroughly charged
at all these points of contact. In a big clinic, as in
7

a Department Store, the importance of the head is not
to be able to conduct each division separately, but to
have sense enough to train, or pick, men who can; men
who know their ‘job’ and who trust a chief, whose saving
gift is in co-ordinating the different departments. So in
a clinic the greater part of the work must be done by
the juniors. To be safe the chief must always have
‘about men who know more than he does of certain
subjects. The most sterile professor may have the most
fruitful laboratory. The two most productive physio-
logical laboratories of the latter half of the last century
were presided over by men who did little or nothing

themselves but suggest and direct. A man at forty, in; ,./ oe

charge of a clinic, who aspires to contribute from all its ¢ :
departments is sure to degenerate into an exploiter «
of other men’s work. An overseer, a director, a teacher,
a commutator, he must make his personality felt in every
corner of the ‘business’, but if he has not a big enough
mind to grasp the art of successful delegation he either
becomes a scientific vampire, sucking the blood of his.
assistants, or the clinic degenerates into a one-sided)
organization for the study of a few problems or for the |
cure of all maladies by some special method.
Problems and patients suffice for the men in charge of
the clinical side of Research Institutes, but only a very
narrow view regards the Director of a University clinic

as chiefly an agent for research. He stands for other %.../, 7, _

things of equal importance. ‘In life, in work, in word,
and in deed he is an exemplar to the young men about
him, students and assistants. ‘ Cabined, cribbed, con-
a AP ;
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8

¢ fined? within the four walls of a hospital, practising the

fugitive and cloistered virtues of a clinical monk, how
shall he, forsooth, train men for a race the dust and
heat of which he knows nothing and—this is a possi-
bility !—cares less? I cannot imagine anything more
subversive to the highest ideal of a clinical school than
to hand over young men who are to be our best prac-
titioners to a group of teachers who are ex officio out of
touch with the conditions under which these young
men will live. The clinical teachers belong to the
fighting line of the profession, whose ambitions and
activities they should share and direct. Do you imagine
for a moment that men whose interests are mainly in

“the research aspects of medicine, and who have no

touch with the rank and file—the men behind the guns
—do you suppose they would get into the arena and
share the struggle of their brethren? A few with
Welch’s broad spirit would—a majority would live lives
apart, with other thoughts and other ways.

As students of the wider problems of social reform
so closely associated with disease, the clinical men
should come into contact with the public, whose foibles
they should know, and whose advisers they should be.
To seclude the ablest men in their respective depart-
ments from this contact would not be possible in the
United States, where the profession lives so much in
the ‘open’; and the attempt would, I believe, defeat
itself. Those best fitted as teachers in the medical
schools, the men with larger outlook, would soon kick
over the traces and leave the positions to the quiet

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9
student-recluses, keen at research, but as little fitted
to train medical students for the hurly-burly of life as
I would be to direct your laboratory.

I cannot bear to think that any successor of mine
should grow up deprived of those delightful associations)
which I enjoyed with the profession and the public.
How barren would I feel my life without these memo-
ries! And a great gap would be left in the education
of a clinical teacher who had not known that inner life
of the public which we meet in our ministry of health.
To some extent seen in hospital work, but not in the
same way, it helps to develop the side of a teacher’s
character very precious in his influence upon young
men.

The danger would be the evolution throughout the

country of a set of clinical prigs, the boundary of whose Ee :
horizon would be the laboratory, and whose only human) +» y

interest was research, forgetful of the wider claims of bn

a clinical professor as a trainer of the young, a leader in ee

the multiform activities of the profession, an interpreter
of science to his generation, and a counsellor in public /-
and in private of the people, in whose interests after all
the school exists. And, remember, what we do to-day
the other schools will try todoto-morrow. Rather than
see the rise ofa caste of clinical Brahmins, I would pre-
fer a return to the French system—still in part effective
—which ensures that each and every professor in a
_ medical school—whether chemist, anatomist, pathologist,
or physiologist—is kept in touch with the profession by
giving him a hospital service! The Trustees of the
IO

Hospital will do well to hesitate before handing over
their magnificent ‘plant’ to a group of men to ‘run’ on
the narrow lines of a Research Institute, and risk the
termination of that close affiliation with the profession
and the public which has made their clinical school the
most potent distributor of scientific medicine in the
United States.

On the question of private practice and of fees I can
speak freely. To the enormous value of the outside
work in one’s personal and professional development
I can bear strong testimony. In looking over my
writings for this specific purpose I am surprised to see
how much of my very best material came from this
source. The difficulty is to keep practice within bounds,
but it should not be impossible to frame regulations to
ensure that the major part of the time of the clinical
professors is given to the clinics. Itis not so much con-
sultations in the city, but the long distance calls—which.
alone in my case can I reproach myself as having inter-
rupted my hospital work—that are disturbing. One
cannot do a very large practice if private patients are not
seen until 2p.m., which was my rule. Ina nutshell, the
point at issue is this—After a morning spent in teaching,
in the laboratories, and in seeing the public and private
patients, not all every day, at 2 p.m. should the clinical
professor go home and see patients with their doctors or
should he finish the day in one of his laboratories ?
I maintain that'an able director with a well-organized
staff can do all that should be demanded in four or five
Il

hours daily, and that he is a very much better man as
a teacher and as a worker if he spends the rest of the day

in the service of the profession and the public. I am

speaking only for the subject of medicine ; but before the
school is committed finally to a whole-time policy you
and Judge Harlan, as representatives of the two institu-
tions concerned, would do well to consult the men who
know—two or three selected in each country. And my
opinion is not worth much, as I am naturally biased in
favour of the delightful conditions under which I grew
up, and I am now a clinician, not a laboratory man. It is
not fair to ask Barker and Thayer. In medicine consult
F’, Miller and Krehl in Germany, Chauffard and Widal
in Paris, Hale White and Bradford in England, Dock and
Janeway in the United States—all laboratory clinicians.
Do not be led away by the opinions of the pure labora-
tory men, who have no knowledge of the clinical situation
and its needs. I believe an overwhelming majority of

the plan. Professor F. Miller, who represents the
most advanced thought in medicine in Germany, has

expressed himself strongly against the whole-time t.-;-<“**~
system, as directly prejudicial to the teacher and to the ~“

school.

Against the sin of prosperity, which looms large in
Mr. Flexner’s Report (p. 17), the clinical professor must
battle hard. I was myself believed to be addicted to it;
but you will be interested to know, and I would like the
Trustees of the Hospital to know, that I took out of
Baltimore not one cent of all the fees—none of which

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all the active workers at clinical medicine would oppose -

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came from hospital patients—I received in the sixteen
years of my work. The truth is, there is much misunder-
standing in the minds, and not a little nonsense on the
tongues, of the people about the large fortunes made by
members of the clinical staff. At any rate, let the
University and Hospital always remember with gratitude
the work of one ‘prosperous’ surgeon, whose depart-
ment is so irritatingly misunderstood by Mr. Flexner.
) I do not believe the history of medicine presents a parallel
_to the munificence of our colleague Kelly to his clinic.
Equal in bulk, in quality, and in far-reaching practical
value to the work from any department of the University,
small wonder that his clinic became the Mecca for :
surgeons from all parts of the world, and that his labora- .
tory methods, perfected by Drs. Cullen and Si:
have become general models, while through the inspira-
tion of Mr. Max Brédel a new school of artistic illus-
tration in medical works has developed in the United
States. And, shades of Marion Sims, Goodell and Gail-
lard Thomas! this is the department which the ‘ Angel of
Bethesda’, in the fullness of his ignorance, suggests
should be, if not wiped out, at any rate merged with that
_of Obstetrics!

There are other points which I should like to discuss,
but this letter is already too long. To one I must refer.
If there is to be a New Model and a Self-denying Ordi-
nance, under which the clinical teachers are to live
. laborious days and scorn the delights of the larger life,
let them comein on a University basis. Ifa man’s value
in the open market is to be considered, do not insult him
13

by offering $7,500, as suggested in Alternative Scheme I,
but, as laboratory men, let them be content with salaries
which are thought good enough for men just as good.

We are all for sale, dear Remsen. You and I have
been in the market for years, and have loved to buy and
sell our wares in brains and books—it has been our life.
So with institutions. It is always pleasant to be bought,
when the purchase price does not involve the sacrifice
of an essential—as was the case in that happy purchase
of us by the Women’s Educational Association—but in
Alternative Scheme I we chance the sacrifice of some-
thing that is really vital, the existence of a great clinical
school organically united with the profession and with
the public. These are some of the reasons why I am
' opposed to the plan as likely to spell ruin to the type of
school I have always felt the Hospital should be and
which we tried to make it—a place of refuge for the sick
poor of the city—a place where the best that is known is
taught to a group of the best students—a place where
new thought is materialized in research—a school where
men are encouraged to base the art upon the science of

medicine—a fountain to which teachers in every subject -
would come for inspiration—a place witha hearty welcome |
to every practitioner who seeks help—a consulting centre, ~~

for the whole country in cases of obscurity. Andit may
be said, all these are possible with whole-time clinical pro-
fessors. I doubtit. The ideals would change, and I fear
lest the broad open spirit which has characterized the
school should narrow, as teacher and student chased
each other down the fascinating road of research, forget-
14

ful of those wider interests to which a great hospital
’ must minister. }

Take the money by all means, but use it :—

(1) To reduce the number of students.
(2) To re-arrange the laboratories in accordance with

Alternative Scheme II.

But, lastly and chiefly, divert the ardent souls who wish
to be whole-time clinical professors from the medical
school in which they are not at home to the Research
Institutes to which they properly belong, and in which
they can do their best work.

Believe me, my dear Remsen,
Sincerely yours,
WILLIAM OSLER.

OxFoRD,
September 1, 1911.