Matinum

Taking Charge of Your Health


– Okay, welcome to the IHPI seminars. Today for our seminar we
have a distinguished speaker, Dr. Joel Howell. He’s an internist and historian and he is the Victor Vaughan Professor of History of Medicine. He’s written widely on the use of medicine and medical technology, examining the social
and contextual factures relevant to its clinical
application and diffusion. And analyzing why American
medicine has become obsessed with the use of medical technology. He has a new book out called
“Medicine at Michigan” and he’s pretty well known
here in the IHPI community. Partly because he’s the former director of the Clinical Scholars Program. And he was the director of
the Clinical Scholars Program when I was a clinical scholar. He recently and in 2013, he received the Nicholas E. Davies Award for activities in the humanities
and history of medicine from the American College of Physicians. And he is gonna talk to us today
about history and medicine, and Michigan, and we’ll
see where that takes us. Thank you. (audience applauding) – Thanks Caroline. I’m proud to say that I was
one of Caroline’s teachers. She’s a superb student (murmurs). So, this talk could also be subtitled policy decisions that
made a medical school. So we’re gonna talk about policy decisions that made this medical school and it’s part of the
bicentennial celebration. The bicentennial ostensibly
was over in 2017. Actually, we have
several choices as to how we could have chosen our bicentennial date. 1817 was the date of the formation of the Catholepistemiad in Detroit. Which was basically a
fancy elementary school. It was renamed the University of Michigan and closed a few years later. But this is the date that we chose to mark the beginning of the
University of Michigan. In 1837 Michigan became a state and the legislature mandated as one of the first acts that there be a university. That it be in Ann Arbor and that one school of the University should
be a medical school. They said there should be three schools. The undergraduate college,
law, and medicine. So this then is the first policy decision that I’m gonna comment on. This was a policy decision that was not an obvious one to make. Medicine in those days was not a particularly
high class endeavor. There were no licensure laws
anywhere in the United States so you literally could
claim to be a physician without having gone to medical school. It was not at all clear
what kind of medicine was going to be created. And it wasn’t clear if you were gonna have a medical school in the state of Michigan why it should be in Ann Arbor. Why not in Detroit? Ann Arbor was a town of 2,000
people out on the frontier. So this was then a policy decision that was by no means obvious or preordained and
we’ll come back later to talk a little bit about what it meant to stay in Ann Arbor. University opened in 1841. Took a while to get the
Medical School going. In 1848 the medical faculty formed and in 1850 the Medical School opened. Who cares? Why should we care about this stuff? I mean, why should you care
about history in general? By the way, thank you all for coming
out on a scuzzy afternoon to hear about this. Well I think there are
a number of reasons why we should care about the history of the policy decisions
made at the Medical School. For one thing, history takes us away
from the dangerous hubris that comes with presentist exceptionalism. And what I mean by that is presentist exceptionalism
says, “we’re special. “Today is wonderful.” Yeah, it is. And so was yesterday and so was the day before that. And have we discovered all
kinds of really cool stuff? Yeah, we have. All right, the x-ray
was discovered in 1895. That was pretty cool too. People thought it was a big deal. Add the discovery of antibiotics
et cetera, et cetera. So there’s a tendency to look
at the history of medicine and to say that we have
somehow achieved the pinnacle. And history has a way of saying, yeah we have achieved the pinnacle but this has been going on for a while. There’s exponential increases
in scientific knowledge. It’s often said that half of all knowledge that we know was created in the last 10
years or something like that. Again, that’s true but it’s been going on for several centuries now. History also helps us appreciate
the process of change. History is not just a series of events. We’re gonna consider a
number of policy decisions and the debates that surrounded them. But we’re also gonna consider
the arguments pro and con. And if we want to change
things going forward then we need to understand not only that things changed in the past but how and why they changed. And to realize that these were choices not just an inevitable progression
to the way we are today. So by demonstrating the
non-inevitability of past decisions, history then liberates us to
be able to make radical change. To realize that these choices
I’m going to tell you about were just that, choices. Means that rather than
seeing them as obvious parts of the path of history we can then look at them as a
choice among different options and look at today’s
choices in the same light. Finally sometimes history
just makes us feel good and that’s nice. I’m gonna tell you some things that are not necessarily
gonna make you feel good. So what are we gonna do? I’m gonna cover about 167
years in the next 45 minutes. So we’ll be moving fast and
we’re gonna leave out a lot. I’m gonna talk about some
of the policy decisions that helped make the Medical School. Drawing in part on this
book that Caroline mentioned that I wrote with my colleague Dea Boster. It’s the first peer reviewed Academic Press history of medicine, history of the University
of Michigan Medical School. And there’s a lot of details about almost everything
I’m gonna say in here. If any of you were in
Internal Medicine Grand Rounds a few weeks or a month or so ago, there’s some overlap between this talk and that talk but I’m willing to bet you don’t remember every word from the talk a couple
months ago if you were there. And there’s some new material. I’m gonna take the long view. I’m mainly gonna talk
about policy decisions that were the big ones. Mostly I’m gonna talk about
local policy decisions. I’m gonna talk some about
national policy decisions. Policy is like fractals. You know, it’s like the
coastline where there, the wiggles on the coastline as you come closer and closer in you see more and more wiggles. Well policy decisions are the same way. There are big ones and
then if you hone down you can see little and
littler and littler ones. We’re gonna look at the big ones. So one decision was to
put the Medical School, once decision was to form a medical school and to put it in Ann Arbor. Another decision was to make the Medical School
a part of the University. It didn’t have to be this way. Harvard. Columbia. Both pretty good med schools. In those cases the initial faculty were
not part of the University. Here, the faculty were an
integral part of the University. The intellectual and physical
linkage has served us well. Now what does it mean to be
part of the University and to be a medical school faculty? Like the University, the Medical School has two functions. Two primary functions. University, we teach and we do research. These are the primary goals of the school, of the faculty. We decided, and we’ll
talk about the decision, down the road, to deliver patient care as well as part of the mission of following our two primary goals. Now Michigan and the
Medical School opened up at about the same time. As this, some of you may
recognize this picture. This is the Erie Canal. The Erie Canal opened up
in the mid-19th century, ran from Albany to Buffalo. And if you drive across New
York State on the Thruway you’ll go past the Erie Canal. It’s actually quite pretty. And it opened up the Midwest. It provided a water route to come from the Great
Lakes to the East Coast. Remember this is in an
era when there are no trains, there are not
automobiles, et cetera. And it provided for the town of Detroit to start on its path to becoming a major urban metropolis. But the Medical School wasn’t in Detroit. It was in Ann Arbor. And Ann Arbor was a small town. Ann Arbor was a small town. There just weren’t that
many people living here. It was a town of 2,000. And right at the beginning people started to debate whether or not we ought to move the Medical School to Detroit. It opened in 1850, in 1856. At a faculty meeting somebody expressed the opinion
that the “department, it was called the
department in those days, “should be transferred
from its present location “to one where greater
advantages could be enjoyed, “a higher standard of
education be attained, “and consequently a
greater amount of glory “be shed upon the University “and benefit experienced
by the people of Michigan.” So notice what the
touchstone of success is. Its glory for the University and its benefit for
the people of Michigan. So it’s as much a policy decision to keep the Medical School in Ann Arbor as it would be to move it to Detroit. This got voted down. But they kept coming back. As Detroit grew, this is downtown Detroit, Ann Arbor eventually became 14,000. Meantime, Detroit was growing
from 285,000 to 465,000. Big urban metropolis. People kept coming back
over and over again saying we really need to
move the Medical School out of the little provincial country town of Ann Arbor to the booming urban
metropolis of Detroit. It’s an argument that makes some sense. It came to a head in what
is called the Detroit matter that we discuss in the
book in some detail, in which some professors
got fairly virulent at posting it. These are some newspaper clippings. I should mention that when the University was opened Native Americans routinely came to downtown
Ann Arbor to shop. We were out on the frontier, hence the fight song talks
about the champions of the west, and so the Native American
analogies in these headlines are not coincidental or accidental. On the war path again. A professor’s scalp knife attacks the University
Regents without gloves. Ann Arbor and a first
class medical school. He’s saying we can’t have a
first class medical school. Doctors wax warm when the discuss the new hospital matter. And a professor’s defiance. Serious charges preferred
against Doctor Frothingham. He does not deny them but
instead defies the Regents to bounce him. Why is he defying the
Regents to bounce him? ‘Cause Professor Frothingham
went up to Lansing and testified before the state legislature against a funds appropriation that the Medical School had requested. So think about that. A faculty member went
up to Lansing and said to the state legislature,
“You know that money the University’s asking for? “You shouldn’t give it to them.” He defied the Regents to bounce him. So they did, he got fired (laughs) (audience laughs) There’s limits to how far
you could push these things. And that appears to have been the end with the opening of Old Main here. How many people in this
room have seen Old Main? I know at least a hand full, yeah. This was a hospital that opened in 1925 and the debate over moving to Detroit seems to come to an end at least through the 20th century. So this was a policy decision that played out over many decades. But note that the underlying tension the raison d’etre of this debate was the need for patients. Notice that that has not gone away and that continues to be
a matter of policy debates even today. Another policy decision that was important is that the University decided to create a number of
health sciences schools in addition to the Medical School. 1875, a school of dentistry. 1876, a school of pharmacy. 1881, they began teaching
sanitary science. Eventually became the School
of Public Health in 1941. And in 1891, a nursing school. So one of the characteristics
of the University has been to have a plethora of first rate professional
health sciences schools. That has served us well over the years. So let’s circle back. A medical school after, well, all this is the first medical building. Let’s talk about medical
education for a minute or two. Like you to meet some
of the medical student from the mid-19th century. It was a fairly rowdy group. This is a self portrait. The monkey’s up here
because they’re making fun of the theory of evolution which had been promulgated
a few years before. I have no idea what the dead cow and the shotgun are doing there. But it was a pretty rowdy bunch. Not a particularly high class bunch. Here are the regulations
for the Medical School. I draw your attention to
regulation number four. Students are expected to maintain order during the several lectures and to avoid all rough sport, the throwing of missiles et cetera. (audience laughs) They appear to be obeying
the rules of late. I have not had missiles
thrown at me lately. (audience chuckles) One of the markers for top
10 school was gross anatomy. And bodies for anatomy
were hard to come by. The demonstrator for the
University of Michigan in his memoirs of this
period recalled that he and I quote, “Found himself
authorized and required “by the great state of Michigan “to buy, steal, “or any other manner “procure subjects for dissection. “The situation was a difficult one “and I shall not go in to details “but suffice it to say that
I supplied the University, “instructed in the dissecting room, “and was chased by the constable “but did not reside “in the governmental palace in Jackson.” For those new to the area, Jackson was and continues to be the site of the state penitentiary. And so what was he doing? He was grave robbing. And he said he followed two simple rules. Keep the people of the
receiving point quiet and good natured by never getting any supplies in Ann Arbor and he sternly forbade his
agents to touch anything but the bodies of friendless paupers for whom no one cared. Was not totally successful. There was a grave robbing scandal. Somebody came across a freshly de-occupied grave, threatened the Medical School
and towns people came out literally to burn down the medical school. Medical students were called out. They winged the Medical School building in order to protect it from
the towns people until things eventually calmed down. So, how we got our bodies was really not always a great story. So, let’s think about another
policy decision that was made. Should the Medical School
teach clinical medicine? People were not so sure. We had other professional schools here and when people brought it up people in the law school said well, we have a law school. We don’t run a court. People in the engineering school said we have an engineering school. We don’t run a railroad. Why should the medical
school run a hospital? And the argument was made in a document to the Regents. The first sentence says,
“The successful practice “of the healing art “involves not only a
knowledge of its abstract “and speculative principles “of the structure and
organization of the human frame “of the theory of disease “and of all that could be
communicated upon by the difficult “and exhaustless subject
of all its departments “by books and by oral instruction. “But also that skill and dexterity “that power to perceive,
to know, to discriminate “which can only be acquired
by experience and observation “at the bedside of the patient.” So note a couple of things here. First of all, this was back
in the days when people could write long sentences. (audience laughs) But secondly, they are
having to make an argument to the Regents as to why they should, why we should have a hospital. So this is a very
important policy decision. It may seem obvious that we should teach. It was not obvious to them at the time. And in fact, when the
University which previously, as in all medical schools, had simply had classroom instruction. But in 1869, we opened up a hospital on
North University Street. This was a converted professors home which was not unusual in the day. And this was the first hospital
to be owned and operated by a university in the United States. It’s a tremendously
important policy decision. It wasn’t obvious. And it served as a path breaker for many, many other medical
schools around the country who subsequently built
their own hospitals. The University of Pennsylvania also claims the first university hospital in the United States. In 1870 they built one. So they claimed they were
the first ones to build one, were the first ones to
own and operate one. We can get over it but we did
it a year before they did. (audience laughs) This was another, this was a different
kind of an institution. Money didn’t play much of
a role in this institution. Patients got their care for free. Doctors were paid by the state. This was the state hospital. This and its predecessors, here we see the hospital that followed. This is the Pavilion Hospital. You see all the students out there wearing their traditional hats. This was a state hospital
run by the state of Michigan and citizens of the state of Michigan came and got their care at the
University hospital for free because it’s their hospital. And we’re their doctors. So this then was the model for healthcare in the
hospital in those days. There was another policy decision at about the same time. Where Michigan stood in the lead. And that was in the decision to allow women to attend medical school. We were the first major medical school to make a policy decision to admit women. We’re not the first medical
school to admit women. Elizabeth Blackwell was admitted to Geneva
Medical College before this. But A, Geneva medical college was not a particularly well known school, it was not really noted and B, that wasn’t
really a policy decision. Elizabeth Blackwell applied, the Dean brought her application
to the all male class. Said, “Look at this. “I got somebody named Elizabeth “who wants to go to medical school here. “What should we do?” And the guys said, “Ah, admit her. “Let her come.” More or less as a joke. But Michigan did it differently. Michigan thought about whether or not we should accept women. Now there was opposition. There were people who pointed things out. For example, every month women become a quasi-envolent. Women’s highest function of course is child rearing. And that makes her incapable of working. Her emotional nature meant that she would lack the
necessary courage and firmness to deal with emergencies. There were all arguments
that were brought up and finally, and this
one continued to be made in to the late 20th century. I’ve got a quote from a chairman of the department of surgery in the 1960s. That going into medicine
would serve to quote, “Unsex women.” Close quotes. And make them more like men. If they went into medicine. Nonetheless, the Board of Regents took all these arguments
under consideration and in 1870 said they, “Recognize the
right of every resident “of Michigan to the
enjoyment of the privileges “afforded by the University “and they’ll admit anyone
with the requisite literary “and moral qualifications.” As I said, Michigan was a well
known school in those days and this was noted. The New York Times said,
“The University of Michigan “is young and vigorous and
second to non in the land.” The Ann Arbor Argus on the other hand said, “Men should enroll elsewhere. “Women will soon be asking for courses “in basket weaving.” Note which newspaper has survived. (audience laughs) Women were not admitted on equal terms unfortunately. Here you see a classroom. You see the women on this side. You see the men on this side. What you can’t see but what’s
there is there’s a red line that goes down this aisle. And women who tried to cross over the line were driven back with chants
of “red line, red line, red line.” So they had to sit on one
side of the classroom. They were taught anatomy separately. Faculty objected but then
when they were paid extra to teach the extra class
they soon got over it. (audience laughs) Well you could, I mean
you could understand why. It’s just embarrassing
to teach gross anatomy to men and women together. I mean, you know, it’s difficult. First student, woman student to graduate Michigan was Amanda Sanford. I want to point out another early graduate because it think she’s special, Alice Hamilton. Graduated in 1892. Became the first female faculty member at Harvard University. Went on to be a leader in lead paint poisoning, lead
poisoning and smelting and the refining of lead. If you want to talk about dangers of poisoning from lead. There are dangers from paint, there dangers from water, there are even bigger
dangers for the workers who have to deal everyday
with working with lead. And she worked on this issue and was a leader in industrial medicine. She lived long enough to protest both, she was a pacifist. Lived in Hull House
for a while in Chicago. She protested both the First World War and the Vietnam War. Which is really quite a treat. And of course the director of the institute, John Ayanian is the
Alice Hamilton Professor. So that’s women. African Americans. Initially we thought that
African Americans first enrolled in 1870 after the Board of
Regents passed the resolution that I just showed you. But there’s been some interesting research done
recently at the Clements Library. For those of you who don’t know the Clements Library
it’s on South University. It is a wonderful historical library. And an archivist there
named Cheney Schopieray found a letter from William Ryan to his wife. Written on the 1st of November, 1863. 1863 is in the middle of the Civil War. Ann Arbor is a fairly liberal town. This is the same year as the
Emancipation Proclamation. I realize you can’t read this but if we focus in you might be able to read this. What it says is, “The Negro was informed “by one of the faculty that
for the peace and harmony “of the institution “he had better leave.” And so he went looking for what was this all about? Well who was that Negro? The Negro, the African American man was Alpheus W. Tucker. He was the 296th student to join a class that was to total 343. He had studied at preparatory
school in Oberlin, Ohio. He was a dark skinned mixed race man and when he entered the
medical school classroom he was greeted with jeers and chants of “take
him out, take him out.” He eventually left the
University of Michigan for good. And he thought, some thought the objections
actually originated not with the students but with the professor. After he left and I love the curator at
the Clements discovered this, after he left if you look at number 296. It’s hard to see from the back. You can tell that, his
name has been erased. His ink has been erased by and another name has
been written in over it. So we talk about people being being erased from the pages of history, in this case his name was literally erased from the pages of history. He blamed unnamed faculty. Quote “a Negro hating faculty “will soon make Negro hating students.” He noted that the
treatment he had received from other students was more suited to an uneducated than
an educated community. He pointed out that he
was a native of the state but could not attend because from an accident of birth “I am a shade or two darker
than my fellow student.” And so this as he pointed out is in a sense a policy decision that colored men are not admitted here. Tucker went on to Iowa. He graduated in 1865 with
a thesis on yellow fever. He moved to Washington, D.C. He was part of the National
Medical Society of Washington. An integrated group. In 1870, he tried to get
admission to the all white medical society of the
District of Columbia, an affiliate of the
American Medical Association and was turned down explicitly
on the basis of race. He appealed to the AAMA which rejected the plea
for racial integration. And in another policy decision the AMA allowed local groups to forbid black membership up until the 1960s. There was another person
of color in the class. John Rapier, Jr. Same class as Alpheus Tucker. He enrolled claiming
that he was from Jamaica. He was actually from Alabama. And was allowed to stay. He also left before he graduated. Some time in the 1860s attitudes changed and after
the 1870 Regents resolution W. Henry Fitzbutler, who is generally held up as
the first African American graduate of the school, graduated from medical school. Meanwhile the University was
becoming one of a handful of schools leading the
reform in medical education. They lengthened the curriculum. 1877 went from six to nine months. Only two medical schools
had nine month curriculums other than Michigan. Harvard and Penn. In 1880 they went to three years. In 1890 went to four years. Went to embrace the idea
that knowledge changes. In other words that if you
want to understand how to take care of sick people you can’t just go read Hypocrites. Which actually was the idea for some time. And if knowledge is changing made a decision, that we, that our library needs to subscribe to every major medical
journal in the world. And we started doing that about 1870. Which was a decision that
reflects an appreciation for the changing nature
of medical knowledge. And which also, for medical historians, makes this a wonderful
library to come work in. A lot of this new knowledge
was based on germ theory and laboratory science. Because we were a state university we were not dependent
upon tuition payments and thus when we extended our curriculum and wanted to buy new laboratory equipment which is expensive, we could do it. Proprietary private schools could not. Proponents of germ theory when abroad, including my namesake, Victor Vaughan, for whom I share his name, when abroad visited with people like Koch who described the tubercle
bacillus or Pasteur and came back and brought back not only theories but also hardware necessary to do microbiological studies. Now it’s interesting that
not everybody agreed. There was a debate over
what caused tuberculosis. Whether or not it was
an infectious organism or environment or something else. And a University of
Michigan faculty member named Hennig Gibbs did not believe in the germ theory. Argued against the notion that the tubercle bacilli
was the causative agent. He too was driven out of
the University of Michigan but his career seems to have survived because he landed on his feet and became promptly
became health commissioner of the city of Detroit. The point here is that historical change is a process. That just because somebody
demonstrates something doesn’t mean that immediately, it’s easy when you look back at history to think of it as great moments. This happens, boom. This happens, boom. This happens, boom. It’s a process. And so somebody who was actively opposing the
germ theory of disease could continue to practice
medicine at the highest levels. And in the IHPI, the National
Clinicians Scholars class, we talked just this afternoon about similes and another
example of how theories were not immediately accepted. So what should we base
this medical school on? That was not a given. We want to say allopathy, MDs. What many people don’t realize is that for many years the University of Michigan ran along side the allopathic medical school, a homeopathic medial college. Why did we do that? Because the state
legislature said we had to. Because a lot of people in the community believed in homeopathy. And so for many years, there’s another, this is another picture of the homeopathic hospital
at the University of Michigan. So there was a policy
decision made by the state. Eventually allopathic medicine came to win, to dominate. We now have licensure with, for MDs. Not licensure for homeopathic physicians. But this was an important decision. Going back to the allopathic hospital. What’s the point of the hospital? Why do we have a hospital? Well this guy had some
pretty firm ideas about it. This is Albion Walter Hewlett. He was the founding member
of the American Society for Clinical Investigation. And he was very clear that
the purpose of clinical care is to support teaching and research. Remember we started off
with that as the goal of the University. He was right, in 1908,
he’s right up there. The reason we see patients is to support teaching and research. And this manifest itself
in a number of ways. Teaching and research in the hospital. This is the heart station run by a guy names Frank Wilson. A cardiologist to some repute. Who not only did studies of the electrocardiogram
from the heart station but actually had the
entire hospital wired. Electrocardiogram
machine was big and bulky and it’s hard to move around. Patients when they’re sick are often hard to move around. So every single room in the
hospital had wires that ran from the room down to the heart station so that you could take
electrocardiogram that way. We don’t have time to go into the details. Frank Wilson was responsible
for nine of the 12 leads of the electrocardiogram. He worked out AVR, AVL, AVF. And then he worked out
the precordial leads. He defined what is actually right, what we call right and
left bundle branch block. Had a tremendous influence
on cardiology in this country and elsewhere. I’m just gonna briefly go abroad. This will be my first and only slide from abroad. He not only played roles in health policy but he played roles in international foreign policy. This is a picture of Frank
Wilson down in Sao Paulo where our IHPI colleague Michelle Heisler goes on a regular basis to study healthcare. What is Frank Wilson doing there? Well there’s a line of research Sonoma Croff is in the audience, a colleague from Brazil, and I have been doing work
on how the state department sent Frank Wilson down to Brazil in the middle of the Second World War as an instrument of
international foreign policy to try to convince the Brazilians and other South American countries to line up with the United States rather than Germany in
the Second World War. So it’s an interesting example
of healthcare being used not just for medical policy but for international policy. And if you wanna read more about it let me know and I can send you a reference. Wilson also liked to
take pictures of birds. I’m just showing this ’cause
I think it’s a nice picture. This is the Simpson Institute. It opened in 1927. I’m showing it there because there’s some interesting
attitudes towards religion. There was a candidate who applied and was named unsuitable
because of his religion even though a letter writer opined that he had, quote, “None of the more obnoxious
characteristics of the race.” Cyrus Sturgis was brought in to be head of the Simpson Institute with the explicit understanding
that the next year he would become Chair of Medicine. The existing Chair of
Medicine was not informed of this decision. However, when Cyrus Sturgis
moved over to become Chair of Medicine they created a new department, Post Graduate Medicine. And that chair could still be shared. Michigan was becoming nationally known. It’s the model for the medical school in the novel “Arrowsmith”
by Sinclair Lewis. Sinclair Lewis of course,
the first American to win a Nobel Prize in literature. This is what the campus looked like in 1938. You see the space there where
the new hospital is to go. There’s Old Main. This is the Simpson Institute
we just talked about. This is the Detroit
Observatory which still stands. It is not in Detroit
although the name might make you think that it was. So, some interesting and
important policy decisions after the Second World War. The Federal Government
had not really supported extramural research in a great extent prior to the Second World War. If the Federal Government
wanted research done it would build a lab, it would hire scientists and
they would do their research. However during the War we needed lots of research done. The atomic bomb, radar, penicillin. And a system was developed for the Federal Government
to fund extramural research. And this became in the years immediately after the War something called the National
Institutes of Health or NIH and study sections were developed to distribute the money to researchers through the NIH. So that’s one, that’s a very
important policy decision that often is over looked. They had to make a decision that rather than doing it the old way they were gonna have a new way of supporting research. Now, the universities also
had to make a decision to accept it. Now you may say of course they’re going to accept it. That’s not true. For a couple of reasons, one, they didn’t need it, they thought. I have a letter to the Chair of the Department of Medicine at the University of Michigan from the National Institute of Health. It says, “You know our budget
year is coming to a close “and we have some money left over. “Can you use it? Would you like some?” And the Chair writes back and says, “Nah, we got plenty. We’re doing fine.” (audience chuckles) Different approach. But others opposed federal funding for much more deeply
philosophical reasons. Why? We were just coming off
the Second World War. The atrocities in Germany, the medical experiments
during the Holocaust. They looked at Germany and said This is what happens when
the Federal Government gets involved in doing research. If you let the government run research this is what you get. This is America. We don’t do things that way. And people as prominent
as Lowell Coggeshall, the Dean of the University of Chicago, went to Congress to testify against the idea of federal
support for extramural research. Now a days this is a weird story to tell because we’re so dependent
upon extramural funding. But the point is that there
had to be a decision made to decide to accept those funds which they did. Another important policy decision had to do with healthcare for veterans. After the First World War there were about four million
veterans who needed to have their healthcare needs
looking at, looked after. And we saw the beginning of the Veterans Administration. After the Second World War there were about 16 million and there was even greater need, the Korean War led to still more. And this obviously a picture
of the Ann Arbor VA hospital which was opened on the
18th of October, 1953. 488 beds. Paul Magnus then led a committee that argued that association
of the VA hospitals with medical schools would improve healthcare. Another important policy decision that has done us a lot of good but that you could easily imagine not having that kind of close association. Meanwhile, the Medical School’s
getting bigger and bigger. Lots of other things are happening on a national level some of which are directly
related to Ann Arbor. This of course is John F. Kennedy. He’s standing outside the Union in Ann Arbor. It’s about two in the morning. He’s not yet President. People some times think he came in, did this when he was
President, he was a candidate. And he is proposing among other things the Peace Corps. And you can go there and this is what the door looks like. Well as you know John F.
Kennedy was assassinated in Dallas. It was said that Kennedy was a showhorse but Johnson, Lyndon Johnson who followed him in office was a workhorse. And Johnson set out in part to do what Kennedy did not. To create this great society. And he laid out his plans for
the great society right here. You may recognize this. This is the big house. He came to the University
of Michigan to the stadium and laid out his notion
for a great society that would include healthcare for all, childcare, a number of other things. This was a decision that had almost unmeasurable impact on healthcare facilities
all around the country ’cause Medicare meant that if you were old now you got your healthcare paid for. Rather than somebody having
it to give it to you for free. This increased the importance of money in the system. This led to an increase in
the administrative structure of the system to deal with all this money. And in something on the side that was almost slipped in there without really any debate or serious consideration. There was this new technique
called hemodialysis and not everybody could get hemodialysis. And there was a prominent story in Life Magazine about the panels that would choose who was gonna get dialyzed. I mean you would have, you know, one open slot and do you dialyze the
33 year old mother of two or the 50 year old banker who’s paragon of virtue in the community or the 22 year old unmarried fire fighter? You know, one of them gets
dialyzed, the others don’t. Congress said this is not right and they wrote in to Medicare the idea that chronic
hemodialysis would be a benefit available to all Americans. I don’t have the numbers
off the top of my head but this is one of those policy decisions that has had unexpected and profound effects which is basically everybody gets dialyzed. Maybe that’s a good thing. Maybe there are people
who are getting dialyzed for the money who don’t really, in
who’s interest it is not. This is the entrance to the old hospital. We had open wards that have gone away. People would do their own lab tests, gram stains, cell counts, EKG. Here’s somebody pipetting. All this is now centralized. You can’t do a gram
stain if you wanted to. Why? Well maybe it’s quality control. Maybe it’s money. When I used to do the
EKG at two in the morning and read it, I hope accurately, nobody could bill for it. Now it’s done automatically on a machine and somebody sits in front
of rows and rows of EKGs and reads them all usually quite rapidly. Other local policy changes happened when this gentleman showed up in town. This is Bill Kelly. Became Chair of Medicine at the University of Michigan
in 1975 at the age of 35. I like this policy point that he made to the house staff. Kind of, we used to fight about, and not we, I wasn’t a house staff here. But they used to fight about admissions. “If concerned or borderline
patients want to be admitted “admit them. “Don’t question it. “It’s better to admit than
to send the patient home “and find out later a wrong
decision has been made.” Old Main eventually came down. This is a picture of the
old hospital coming down. I looked at this at the time and I look at the picture now and I can’t help but think about what happened. What happened in this room? What happened in that room? Who’s lives were changed? Unaltered. Who lived? Who died? Every one of these rooms could tell a story. And yet they are just kind of unceremoniously being knocked down with a big wrecking ball. And in its place the new hospital that we know sitting up here. And there’s Old Main (mumbles) and the Simpson Institute over here. So here we are. Quickly talked about continuity and change in policy decisions over the last 167 years. What’s old? What’s new? Well some changes that were debated I don’t think are likely to change. The choice to use NIH
funds is solidly in place. We’re not debating whether or
not to take funds from NIH. But the fundamental
basis for understanding health and disease undoubtedly will change. It was homeopathy at one point now it’s genetics. That’s gonna continue to change even more. There’s no reason to think
that the models of disease we have now will forever stay the same. In fact there’s pretty good
reason to think they won’t. And the same goes for the facts that we so authoritatively
present to our students. Those are going to change. We no longer have the sort of overt discrimination on the basis
of race, gender, religion that we used to. We don’t debate whether or not women should be admitted to the Medical School. 56% women last year. But we do have a lot of issues
we need to face in terms of promotions and leadership positions for women and minorities. Size, we’re getting ever bigger. Every decade people boast
about how much bigger we are. Sooner or later if we keep growing we will become coextensive with the entire state of Michigan. At which point we’ll have to stop. Presumably we want to stop
somewhere before then. I’ve asked actually several generation of Deans how you would make a decision when you’re big enough? People have answers to that. They’re based on the
number of patients we need to do this and that. I’m dubious as to whether
we’ll ever hit that point and say you know, we’re big enough. We’re big enough. We don’t need, no we don’t
need to hire more people. So it’s ever growing. The issue of patient care. It wasn’t clear at the beginning that we even should be
engaged in patient care. In 1869 we decided to. And for a long time the
system ran with little money, little administrative staff. It was explicitly clear that the reason we went running a hospital was to have patients that
we could use to teach and to do research. Today the connection of patient care with the academic mission seems a bit more tenuous. It’s not only the case
that many more patients are being seen but it’s the case that money plays a bigger role in decision making. Investing in clinical
space away from Ann Arbor can not help but threaten to erode the connection with the University. Moreover both in Ann Arbor and elsewhere more and more patients are
coming through the system without ever being seen by either medical students or residents. The clinical mission plays
a far more dominant role in decision making than ever before. Leaving observers to ask the same question that was asked in the 19th century. Is this at heart a
clinical delivery system? Or an academic medical school that’s part of a great university? And the answer is of
course that to some extent it must be both. But for while much has changed since 1850 much has remained the same. We still have students that come here to learn how to be skilled doctors. The mechanisms for doing so have changed. Gone from large lectures to small groups. We’ve gone from backpacks filled with textbooks to multimedia electronic documents. But the essential concepts remain the same. And in order to learn
how to be a physician you still have to see patients. You still have to have direct
contacts with patients. Finally I think learning about the history of the Medical School is most important because it’s liberating. Reading the history we learn about how those before us made
consequential choices. The choices I’ve described didn’t have to go the way they did. They did and they made a difference. What to teach. Who to teach. How to teach. Where to teach. People made choices about who to care for. Where to care for them. And what institutions to change. We too are gonna be confronted
with decisions to make in the future. I think realizing that we are not forced to follow past decisions can help us celebrate the opportunity to shape the future. I thank you for your attention. I’d be happy to entertain
questions, arguments, disagreements, whatever. Thank you. (audience applauding) Or we could all go enjoy the reception. Now somebody’s got… – [Audience Member] Can
you say another word about when you were talking about the, sorry. It’s on. Okay, can you say another word about the history of the consideration of moving to Detroit or not. What the, for lack of better
word, competition was there if at all at the time and when one state when hospitals in Detroit how that effected that relationship? – Sure, there was competition in Detroit. The general consensus initially in 1856 there wasn’t really a
whole lot of competition. And after that Detroit was a boom town. It’s, if you’ve been living
in Southeast Michigan the last several years it’s a little hard to conceptualize but Detroit was one of
the hottest, biggest most rapidly expanding cities in the U.S. I mean the automobile, the assembly line. The city was exploding. And I think the sense was that that there was enough business there that you didn’t need to
worry about the competition. Furthermore, there were certainly
a lot more business there than there was in Ann Arbor. Which at that, you know,
which is going from 2,000 to turn of the century it’s 14,000 15,000 people in the city. That’s a fairly small town. So by comparison there’s a lot, plus you have access to transportation. You have access to money. It’s, I think we might
well have moved there. I didn’t give you blow by blow. The book goes through blow by blow. But this, this comes up every five or 10 years from 1855 til about 1925. Shouldn’t we move to Detroit? Wouldn’t we be better off in Detroit? And that would have
changed the Medical School and the University considerably. If you think about there are
certainly great medical schools that exist in different cities. Some are a long way apart like Cornell. Some are not as far apart like Harvard. But it makes a difference if you’re in a different city than the university. John. – [John] Joel, could you
comment on sort of the… (audience chuckles) Joel, could you comment on the construction of that Old Main Hospital. I think you said it was 1925 and the picture had a few
automobiles parked out front. Was it, how did the growth
of the automobile industry intersect with Ann Arbor
being accessible to people from all over the state and potentially justifying that building of that very large hospital in a relatively small town? – Right. I mean, before the automobile
one of the important things is the railroad. Which decides to come through Ann Arbor. They were considering
going through Dixboro. And Dixboro, Michigan at one
point it was the boom town for Southeast Michigan. But the railroad came through another, what is it, 10 miles south and came through Ann Arbor instead. There’s a lot of money coming
from the auto industry. They start to build the, they go back and forth on the hospital and they actually start to build it before the First World War. And then they ran out of money. And eventually come back and finish building it
and opening it up in 1925. It’s a huge hospital. I think, I don’t want to quote the number of beds. It’s in the book. But it’s quite a large hospital and it’s reflective of the economy and of the notion that this is the state hospital. This is the state of Michigan. If you’re sick in the state of Michigan and you need serious care you come to Ann Arbor. And you don’t get
charged for your services because after all, you know, it’s a university hospital. I know that sounds weird today with all the emphasis
we have on the finances but that’s one of the great policy changes that took place. – [Audience Member] Dr.
Howell, I actually think, kind of, putting sort of both of
those comments together. It doesn’t sound that weird today. I think we continue to
have this tension not over, not necessarily over
where the main hospital is physically located but over what patients are we trying
to attract and serve. And when we have new patient care services what type of patients are we trying to get and where are we getting them from. And I think that there’s there remain extremely diverse
opinions on that topic. And that’s something that’s
going on right now still. – Absolutely, and your
own field of obstetrics. There was considerable
concern early on that we were getting the
wrong kind of patients. The wrong kind of patients
means unwed mothers. And that that would somehow taint the medical students and there were serious
discussions about whether or not we wanted to do that. Similarly today we ask
questions about why are we, why do we want more patients? Why are we opening new hospitals? And the answer that I get is if you do the numbers and you want to train in
a particular specialty you need X number of patients in order to become trained. What that means is we have an awful lot of patients
who have really no contact with the academic side of the hospital. Is that a good thing or a bad thing? That’s the decision we
have to grapple with. – [Audience Member] Thank
you for a great talk, Joel. – Thanks. – So my question is in your studying the
healthcare system’s history have you given any thought about, moving forward for the future, are there any lessons learned and you know, you noted a
couple of policy decisions which were pivotal and for their time, they were ahead of their time. And should we be thinking
about things right now especially in the
current political climate that we may be proud of in the future? – It is, in the historians
code of conduct, it is required that
when asked this question you must quote Yogi Bear, who once said that
“prediction is very difficult, “especially about the future.” (audience member laughs) Yeah, I mean. I don’t know if history
gives me any crystal ball to tell you what’s gonna happen. Let me ask you. What decisions do you
see as the most important that we’re making that might
be the most consequential moving forward? – [Audience Member] Inclusiveness. I think we need to go back in
the direction of inclusiveness and I think we’re not. And I’d apply that to education to inclusiveness in residency programs. Because I think that
our patient population is gonna stay diverse and we need to keep up with that so that they feel like they’re
getting the care from healthcare system that reflects the diversity in the community. – I think that’s, and that
scenario where in some respects we’ve done very well. We were a leader in terms of gender. The story that I told
you about somebodies name being scrubbed out of the pages of history has only been public
for three or four years that we’ve discovered this. And that just blew me away. I mean we talk about
scrubbing people, you know, erasing people from the pages of history. Here we’re doing it literally erasing somebody from
the pages of history. But yeah, I agree. All right. Thank you all very much. (audience applauding)

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