The folldnc omenta are my personal observations and refleotions,

offered in response to your suggestion when I was in Chioac.0, that: they might

be of interest to you.  In certain instances my point of view may seem remote

in time or space from local and immodiste issues. 1Wtt Is to be exmated at

times from a detached observer. Yur+bermore, this memorandum avoids concliisi ons

or a oontentious attitude.  The many and strong forces moulding tho teaching,

the praotice and the growth of medioine oannot be controlled by argument. and
I want to emphasize the study of foroes rtxther than indulge 5n an advocate's

disregard of forces impropitfous to his claims.  The ob;leot of t'.lese notes

then is to review factors involved In the settlement and definitfon of the

policy of the university of Chicago wjth respeot to medioal eduaation.

xx

The University of Chiaaqo has an explioit, established, and

oontinuinq treference for the advancement of knowledge.  !IarDerJe enerm and

visfon no less than tho need of Amerioan universities f'or the product of such

a policy made the University of Chicago a great jnfluenae.  I sea no evidenae

that the nolicy of the University towards research and scholarship is ohangine;

in a way to lossen thie sinaularly valuable noejtion.

reason even to be13s-m thRt the Univarsity is more sharply Inclined today than
at any time in the past twenty years to anpear radical while aatually re-
affinninp the earlier tradition of complete liberty of flation in choosing

fields of endeavor and methods of action.

"here 38 consjderable

     VJhat 3s true of the whole happens to be oonspiouously true of a

Dart.  'he biolop,loal soiences at Chicago whether by individual departmsnts

or en bloc as a Divjsion have been, and show no evidences of ceasing to he,

more in+.erested in the advancement of knowledge and the training of researoh

man than in the diffusion of knowledge in unddrgraduate courses or the

2.

preparatlon of teachers in the manner of a normal school.

This is not merely

a tradition and a deolared policy.

It is the eapr preference of the

nrofessora and assistants and the objective principally in vlew when buildings

are put ap an? personnel chosen.

Pere are faults and failures in the realiea-

tion of this winciple: but a8 a noliay or intent3on ft must be consjdered of

unanimous acoeptance and of cardinal import.

It is however not an easy,  elastio

and adaptable Dolioy: it may neoessarily be somewhat jealous of its peculiar

interests, inalined to resent additional opportunities as dilutions rather

than real growth, intolerant of oressure or jnterferenae thouqh keen for

optional and easy oonf.aots with othor Cields of IeRrninq.

The preclinical subjects in medicine at Chicago University form Dart

of the division of biological saiences. That is an important fact in two

senses.

It 3s an important fsct in American mediaal  educatjon beoause it is

an exceptional if not unique arrangement and the nucleus of a KreRt and reason-

able hope.

It Is a fact important to the University of Chicaso because unless

definitely repudiated it anchors one half of the rnedioal aourso and muoh more

than one half of the saientifio faoilitles explicitly and irrevocably t.0 the

South Side.

nctmnt*R;e of associating as does Chicago prealinical mdiaine wjth the PhYslcs,

chemistry, mathematics, psycholoay and sooiolo~y of the University.

?$either Yarmrd nor Hopkins, Columbia nor Cornel1 have the

Since

mediclne has immensely to protit from these mbjects, and for otsher reasons,I

take it that no one would dream of uprooting the nrealiniaal departments to

plaae them on the Vest Side.

One more val?ahle reality - clinica3 accommodations have been put on

*

the South Side.

Wmtever ray be one's view regarding the possibility of good

teaahlng withoiit investigative work goSn[: on along sjde,  there can be no doubt

that the most resourceful and eoonomical correlation of cliniad prob3ems with

*

I realize that these subjeats also are in the Didsion of Rio1op;ical Sc5ences.

3.

the med3aal soiences can be acoomplished in the near neighborhood of the men

and maohines of the preclinical departments.

London Finally showed tho most stubborn and the most skeptjcal that scientjfic

faoilities and traininp; outweigh brilljance of teachinE, professional prestige,

and possession of clinical material, in attracting and preparing students  of


medicine.  Rart's,Guy's and the other London hospitals were foraad to add

anatomy, physiology, etc. to their cljnioal means for training dootors, though

it was oheaner and easier to leave them to be tnught elsewhere. The Edinburgh

Universj ty Medical Faculty forged ahead in splte of the brilliant attract5ons

Exnerienoe in Edinburgh and

of th.e extra mural sohools in Edinburgh because as a Univorsity sohool it

possessed more facilities Rnd more ririvileged oontacts wjth the sciences

ancillary to olinical medicine.

"he nolfoy of the TJnianrsfity or Ch;cawo is tro cine veferenoe to the

aoquirement of knowledge and the training for researoh work.

distinguished departments of meclinical saience under a form of organization

that increases it anything their olaims for sunport to investigative work and

their potentfa1 serviceabiljty to research work in olinioal nroblems.  It now

possesses clinical facjlitjes which by their looation and form of organization

automatloally favor the tyne of aatjvitg to wE.ljch the Univererity is explicitly

oommitted.

undeniable advantage to cliniaal investigation, sinoe the best teaching is

oossjb'le only #here invostication is going on, sinoe no olinics widely separated

from preolinlcal departments are in the best position to do olinioal investiga-

tion and teaohing, the further support of underp;radunte teachinc on the Nest

Sj?e becomes a matter deserving atireful consideration.  And as a foreword to

such consideratjons I would submit tlmt eduoational '1 oKia - the aoundnaas and

aonsistency of' the nlan is fh~ moat 5mnortant oons5derfi+ion of all . It 5s

It possesses

Since close physjcal proximity to the preclinioal branohes  is an

4.

suosr-personal, it is strongw than the interests of 5nstitutions, it may be

temporarlly frustrated but jt will either bedevil and outlive those who over-

ride jt, or operRte autamatioally for tho common good.

     Durlne the pest 15 years there have been a serios of negotiatjons


between the administratJve officers of the Uni~rersity, members  of the Rush

Faculty, and trustees of the Presbyterian Xospital of such variety of declaration

and imulication that mlsrely by seleati-re quotation one can justify almost any

coilrse today. It woiild therefore be better to limit o~irsel~res to the present

m? the future, since there has been shown me a remarkable absence of pettiness

of viewpoint and a perfect willlngness to consider the whole m-oblem anew and

only in terms of the present and the future. And after all I am writing to

one who is ;Toroughly familiar with the events of the aast 1.5 yews, with the

history of Rush, wjth the dersona espeoially conosrned now and in the nast -

all points of lnfnrmktion to which I could add nothinp;. The most convenient

~resen+ation then would be in ihe form of comment u7on the cho-iaes of` decjsions

to be taken by the University of ChiaaKo.

Fjrst - and RS a mattsr of loci0 lt-trgoly (but not without a narallef

in recent history) the Univers?ky can deaide to make no decjsion, or formally

bostnone any dealaratjon of Dolioy.

Such action or delihernte ineckion would

handicap the Trvstses of the Presbyterian Hospital 8.8 regards any building

vlans or endowment camnalgns as long as the postponement of deolaration is in

foroe.

It, would probably have a mixed effect on the Rush teaahing parsonnel,

hearteninp; a few perhaps but making the rest more than ever restless and inclined

to seek Dosts elsewhere,

omelette. Unless accombanied by Krants to Rush for better teaahinp, facilities

It would avoid hreakinp: any eKp;s and it would make no

it would be Internrete? somewbat; hjtt.ar3-y ~t, Ri13h RS a nermiss5on to waste amy.

It would have the advantaps of not reducing the niimber of students  3n the

nreclfnjoal years, and so the Income from tu5tjon fees, nor muah disturb the

sentiment of Rush graduates.

time when a more radical and explicit step must be taken, meanwhile being

likely to develop a hitternetis and resentment that is not yet in play.   I

should think postponement indefensible unless it co~e from complste bewilder-

ment RS to what dourse should be taken.

It would howevc?r in my minion only rlefsr the

KX

Second it has been suggested that the Rush Medical F~culty an6 the

Presbyter3 an Hospital seek to be re1 eased from control from or affiliation

with the University of Chicago and aJqalgamte with I-he med3cal  school of the

Un37reraity of Illinois.

insunorable, this sug~estion descrves mention because it would constitiite a

fusion of schools of similar organization and objeative and both rffithin an

area already rioh in preclinical a8 well as clinlcal facilities. It Is more

than nrobable t?mt the I-ll!nofs Faculty would be favorably dfsposerl but the

nrinojnal objec+ion Ilea in the almost. c?er+ajn um!ll~nfyess of the Rush Faculty

to edvocate or follow such a course. As exmessed to me their Teelinq: would

be strongly against such a proaedure. They dgslike the Dolltical atmosphere

of 1Jnjvsrsity of Illinois appointments, and do not, find any ploasure in severing

connection with the University of C%ioago whlch they would ljke to continue to



serve .

Although t'lere are objection8 which are probably

X

The third course mentioned to me lies in the amalgmation of tha

Yest Side departments with corresponding departments on tho South Side.

Such

n fusion wonld involve the oontinuance of underEradunte teachinc st the ','{est

Side, not, under a separate dean, eta. but under the aontrol, department by

daoartment, of Chief8 mostly on the South Side but not necessarily SO.

'fie

chief arguments advanced in favor of this solution are as follows:

1.

The administrative nroblems (in the opinion of reoresentatives of Rush)
aould be resolved with mutual good will and In a spirit of compromise
and conciliation.

2.

'i%e variety in the methoas of' teachinp: would ha advantapous  t;o the

students .

3. The tradi+.ion and in+eresta of Rush graduates and facu3ly would be
   preserved, and tho experience, loya!ty and abillty of the latter
    would be utilized.

4. me number of the students would remain adequate for recruitment to

preclinical and clinical ~osts.
income from tuition fees.

It would maintain the present

5.

The plan at liarmrd, whlah this analgamation ree1emb148, has rasulted

3n a f3rst rate school.

6.

The main object of a school of medicine amy Is the preparation for
the practice of medicine and the oart time teachers at Rush have
something peculinr and valuable to contribute to this preparation.
Th3s main ob.ioat must have Drior considarRtion even if the purpose
on t3e South Side is aescribed as tho study of niadioine on the
IJniversity 'level with emphasis on the relation to the biolonical
sciences in oromation of the advancement of knowledge and the  train-
jnp; of investigations.

xx

The chjaf arguments advanced against amalgamation wQrc these:

1.

The objeatives of the cljnical  teRChf?rs at the South Side should not

be compromised and differ from those ~t Rush more widely than the
members of the Rush 9icult.y real?ze. Consequently the clashes of
onlnion, d5scretmnaiea in income of nersonnel, arlmin5strative
friction, and loss of t,ime in attempting what would be at best a
Erudging compromise and at worst frank dissension, would be such
as to make axnalgamation unworkable.
character of the teaohing at the South Side would be d3ssinRted
Find diluted o

Under an amalgamtion the

2. It would be vain to adont a form of departmental control vested in

an indfvjdual whose objeotives and nethods are definitely not
s3arerl by colleagues whose age status and indenendence entitle
them t.o a oosition of complete equallty rather than real (because
necessary) subordination. The independence of character and
station of the senior staW at Rush and t\eir conscious conviation
of' their cllnloal abilities and their expressed dl;sapproval  of the
teachinp, methods on the South Side are elements of potential friction
and disaereemsnt.

3.

In order to organize at the Presbyterian units of departments along
lines desired by South Side profossors the budp;sts of alinical
denartments would have to be increased oonsjderably. Amal~ammtion
wou1.i thsrePore call for nonsjderable increases Jn budqetmy support
from the UnlveraJt,y.  Both sfdeer agree khat this wovlrl be nocessary.
The aiiesf4on imvosee jtse'lf': has the UnIvwsity of Ch.lcrap;o an
obligation to sunport a8 large a soh001 of vedicino as the amalgama-
tion would oreate and require?

4. The analopy t.0 Iiarvard fs fallacious since there are no full time

clinical chisfs at IIRrmrd nor department a1 organfzation control led
by any one olinical professor. Furthermore, the Arigham Hosp3tal
could not become oomparable in cllnical facilities to what can be
.qnd in nsrt is already realized on the South Side.
llnivnrsity ?-he ahance of establishing an entire riedical school in
close contact with all the othar deparkents of the Univorsity, as
has Chiaap;o.  l'his opportunity should not be overlooked and thrown
away by amalgamation.

Nor has FIarvard

xx

The fourth choice open to the University of Chioap;o appears to be

the discontinuance of underr~;radnste medical instruction on the :lest Side* and
the organization in 1t.s ~YRCO there of a) a hirhly effective system of intern-
shins and b) a fw posts for part; 1:ime or tu11 time residents.

The principal

arguments advanced against  such R course were:

?.

It would be in offect the end of the Dresent trarljtion of undergraduate

teach5nr at Rush f,*djcal Sohool.
resentmen+, Rnd nossqble bitterness t'.js course would cause amonp;
!lush qraduates and some of +he DresF)n+ RIJS~ teaohers, even though
such discon+jnuance has been recently msntioned as the possible
Folicy of the IJni~rersity.
the influence of the group at tho Rest Side.

There is no doubt. of t4e recret,

It dl.1 not Se the end of' +he nme nor of

*

It is evidently equitable that thc. date of disaontinuance must be postponed

so as to permit graduation of all students already enrolled - 5.e. until
1936 or 1937.

8.

2.

It would result in such a drop in the number of nreclinical  students

on the South Side aa to limit the rearujtment of research and
teaohinq personnel there.
tujtion fees these departments might lose a considerable
fraotion of su~port Prom the Unjversity.

By reason of reduced income  from

3. It is believed by many that the eduoational oraatsces in some of
    the South Side clinios are inimioal to the real interests of
   medical education, that full time medicine has failed and that
   the discontinuanoe of undergraduate teaohing on the Nest Side
   would be tantamount to throwing away the most valuable and
   nroven method of making doctora, only to continue a costly,
    faddish and bankrunt experiment.

4.

!!any members of the stnff at Rush would resign rather than

continue when undersraduste teaching is abandoned.
it is probable that before the present classes have finished
their courses many Rush staff mem5nrs will accept positions
elsewhere and thus seriously embarrass effective teaching on
the Jest Side in the next five years.

Indeed

In favor of the discontinuance of undergraduate teaching at Rush

and the development of an exoellent teaohinR an4 research organization

through the develonment. of intarnshins  and residences af. +he Presbyterian

are the followin[: oonsiderations:

1.

The organization methods and purposes of the South Side group are
postulated upon the declared poliay of the University as regards
research and the exuerimontal attitude in education, and are
oonsonant with that poliay.
separation o? the \'Jest Side clinics from the prealinical
facilitiea plaoes those cllnics at an inevitable disadvantage
as regards research work.  In organization methods and purposes
the Rush Faoulty offers admirable competitive attractions among
the other medical schools of America, but diffnrs from them In
no significant way.

It seem8 clear that the geographjcal

2.

The University cannot in justice to other demands maintain the

expenditure inevitable with the changes in eqiiipment an amalgama-
tion would requjre.

9.

3. l'he creation and administ.ration of a well artioulated system of
   jnternshim and residentahips on the 'Jest Side would continue
    the traditions of Rush Xedical School more effectively than
   would an amalEamation with the South Side. These trarljtiona I
   take to center around the unquestioned value of close personal
   associatjon between a beginner and an exemplary and admired
   mast?r in the praotjce of medicine.
   the Rush group could also organize an intern service at the Cook
   County IIospital the significance and magnitude of the effect'
   upon medicine in Chioago and the Middle West could be larger
    than would be the role of undersraduate teachina.
   of members of the Hush staff in advanced trainin,? and research
   would find adequnte outlet and be B highly valuable contribution
    to thojr fields.*

If, a8 seems qujte feasible,

The jnterest

4.

T'he Unjversity of Ch3cago has a olew-out resgonsibility to train
competent oraatitioners. Now in most Rrguments the things
asserted are true 5n themselves but not true in the sense in
which they are used.
of' the University of Chicago may be interpreted  to mean that the
'raining given must be the same or similar in method to that of
Rush in the past. 'Ms is not. a 1op;ical inference. ?'he method
of undergraduate traininc can be lmnrovad and the Rush group
could supplement it throuRh trainin? for interns and residents.

This assertion regarding the responsibility

xx

Now I would like fo add sorw ohserwt3ons of a p,eneral nature which

I think should be riven weight In the evaliiation of the pros and cons of

methods already mentioned.

It is important to ree;ard tho whole question in terms of 8ucces8ors

as well RS present, incumbents. How will the solution appear to the men you

might call, and to the men your successors might nominal-e?

Tradition8 are

powerful but there can also be a tradition of R willingness to experiment

and dtffer from the mass.
Tranted but nlll a com?romise of teachine; policy attract and hold the best k,,gLtO

on full time or ~3ve their ideas (i fair trial?

You may take an adequate numbor of students  for

*See appendix A for an expansion of this  statement.

If the population of the United States Increases in the next hundred

yews it is Drobable that those enterlq medialne a8 a career will be nilline;

fo train themselves for a 'lonnsr t3me to qat ntRnes more viqorously ComDeted

for than at: present,  That has been the tendency of the past thirty years

and in Europe today proressional oompetitjon is a faator of striking

slgnlf5aance. This mean8 that inetitutions ?or snecjal or advanced training

will be increaeinyly soueht after.

It Is not impoasible that the medical

curriculum will tend to lengthen: in any ease tho intern experienoe will

become more fmyortant,

Xitness the development of the intern year in the

yast two deoadea.

In the genae of ohoice of candidates a fine system of

internship8 and residenoies at the Yest Side would be assured of success,

and I would nredlct R less immediate but very soon equally certain recruit-

ment to t%e underKraduate training at the South Side,

of good schools elsewhere in the hAiddle Nest, Chlcngo must choose between

Nith the development

doing a oeouliar and qualitative service over a mdda area or beaming a

looal school of the ordinmy type. Eliot baw the same choice for IIRrv.rd

in 1909 and advoqated diTferentIatjon and post graduate develomenfa as

the wise course for the non-State University.
appears the opinfon "the ultimate soiiroe of fadtion is Property."

In "The Federalist"

i1Jhen the population inoreases or becomes more hip;hly sorted out

propt?rty js hold with greater tenacity and foresight.

open handed attitude of the Rush Faculty today, almost miraculous to one

accustomed to conditions in the Old Xorld, will porha~s not last three more

generatiom:

in London, Paris or Rome.

ultimately aould become a cause of factions, intransfgence and stalemate.

The unselfishness and

University control will not be so easy then - as it is not now

The control of beds is a form of property - and

Am.ong human institutions noneseems more durable, more assured of

vltallty, more confident of support than universities.

by youth t.hey ere equally the object. of the solicitude of age.

of the sick cominR more and more generally throughout the world a tax or insur-

ance-supported a?Pair we can hardly avoid the Impreasjon that the modern

voluntary hoeDit.aY can best swvlve and futfj11 R iinSqi1s nurnose by affjljating

closely with a University.  I would take it for granted  that more and more

clinical facilitjes will be given 1:o the Univsrsity of Chicago and t?mt in

twenty five years the Nest Side beds will be quite superfluous to the needs

of the medical faculty.

the history of European hosp5tals I am confident they would oonsider more

seriously the ultimnte unaisdom of a new building anywhere axcenf. the South Side

when the time comes for rebuildiq.  On that site tho system of residents and

lnternea wrlth the added resources of the university would possess unqualified

advantaqxi.

anneal to the generosity and the :'$ason of f'uture donors is more likely to

survive and live a liberal and healthy life than a charitable foundation.

Perpetually refreshed

     Gith the aaro

Indeed wwe the Presbyterian Trustees familiar dth

The free university as a nucleus of self renewing and automatic

Even with these advantaqes the future of the faculty of medicine is

not al.1 Dlain sailj.ns.

personnel. khnn anyf-5.lfng else.

It will denend more uoon the quality of if-a teaching

There  -erna+na more to be done 5n increas5n~ the

width catholicity and mution in the select3on of men for imnortant posts.

I venture thls somewhat blunt. obssrvation booauae in most uni~virsitias that

I have studied, the confidence and freedom and res?onaibillty E3ven to

wofeasors are all possible only on the basis of - most aareful selection of

those who are aceorded suah unswerving support and confidence. The full

time plan has been too mch fathered and too little mothered:  after a

vigorous and incisive initiative the plan now needs a wise,pRtientl and
solicitously protectjve Rttsntion to the details of a f~vOrAb30 envjroment.

Not that its exponents dare became "nrecious" or self pitying or parasitic -

which 3s a danger.  The sahool must trdn yood doators nnd yive good teaohing

if' it 3s not to be R failure BO oonspiouous a8 to Dreclude the ahanoe of ever

startinc such a Dlan again.

I

Hut there seems to be no reason to fear for the future of thRt phase

of a system of mediaal education which in the alinical years lays emphasfs on


the t.horoue;hly imnlernented study of aa many cases ns oan be thoroughly studied.

I have seen mediaal facultjes whose broduat ma heifer than the teaahine; -

Seaause the inoomlns strident8 were a8 good or better than when +hey graduated.

It is no proof of the value of the teaahiag alone If a eahool has fine or poor

yraduates - one must examine the satual teaching.  It ia for th%t rea8on that

I think confidence can and should be placed in the teaching policy of the cllnics

of the Sou%h Side, It require8 time, continued effort, loyal support, steady

understanding and admitted freedom for admittedly responsjble men to make after

patient trial an established success.

future between aourses whoae relationahips to hiversity polioies and to  CUture

onportunities in medical education I have attempted to present to you.

Rut a deaiaion is nodeaspry in the near

A