Seminar # Five
Wednesday, March 24, 1999
Principal Speaker: David Rosner

Universities and Their Medical Schools: The Columbia Experience

Elizabeth V. Robilotti
Columbia College '99

In 1908, Dr. Henry Pritchett, president of the Carnegie Foundation, approached the relatively unknown Abraham Flexner, who had recently published a rather modestly received critique of American university education, in hopes of commissioning him to make a similar study of American medical education. Both Dr. Pritchett and his colleague, Dr. Wallace Buttrick, of the Carnegie Foundation’s General Education Board, believed someone alien to the internal machinations of the medical establishment would best be able to offer a concise criticism of its teaching practices. Although promoted as a complete outsider by Pritchett and Buttrick, Flexner maintained a close association to the medical profession through his brothers -- Jacob, a Louisville pharmacist, and more importantly, Simon Flexner, a physician, who was the first director of the Rockefeller Institute.

From 1908 to 1910 Abraham Flexner traveled throughout the United Stated and Canada evaluating medical schools. His investigation extended beyond the written records of the deans’ offices and questioning of the staff. As Flexner explained in his autobiography, "a stroll through the laboratories disclosed the presence or absence of apparatus, museum specimens, library, and students; and a whiff told the inside story regarding the manner in which anatomy was cultivated."

Flexner published his report on the condition of American medical education in 1910. In the report, he reflected many of the General Education Board’s universal goals, including standardizing professional schools and promoting education --- . Flexner incorporated the GEB’s educational mission into his specific reform proposals. He hoped to regulate medical education and reduce the dramatic inconsistencies in training that characterized the profession at the turn of the century. In addition, Flexner believed his specific prescription for medical education would remedy the over-supply of physicians that Professor Rosner has explained.

Flexner based his ideal medical school model on the example he observed at Johns Hopkins University, in Baltimore. The university was founded in 1876, as a result of an enormous bequest of a local merchant. Johns Hopkins’ seven million-dollar gift expressly called for the establishment of a university and a hospital united by a medical school. From its outset, Hopkins was an atypical medical school because teachers and students pursued academic research and clinical training with equal vigor. The medical school, the university, and the hospital enjoyed a harmonious relationship as a result of each institution’s acceptance of this dual objective. This unified vision of medical education as the pursuit of scientific knowledge saved Hopkins from much of the quibbling that divided other institutions. Flexner’s intimate relationship with Johns Hopkins began in his undergraduate days and his connection to the medical school came through his brother Simon, who began his career as one of William Welch’s proteges. Flexner’s model, as Professor Rosner has pointed out, created a hierarchy in which the interests of the medical school dominated the tripartite relationship among medical school, hospital, and university, in keeping with the Hopkins example.

In assuming that pre-existing independent hospitals and universities could achieve the harmonious relationship that existed among Johns Hopkins’ nascent organizations, Flexner failed to consider the peculiarities of individual institutions and their cultures and political environments. In New York City, for example the disparate ethnic groups flooding into the city established medical facilities to cater to their individual constituencies. New York City hospitals at the end of the nineteen century bore the beneficence and names of the diverse ethnic and religious groups that founded them – Jewish Hospital (Mount Sinai), German Hospital (Lenox Hill), St. Vincent’s (Catholic) St. Luke’s (Episcopal). These individual charity institutions had all the cohesion of independent Greek city-states. Flexner marched into this world with his standardized model to impose order on this chaotic system. As we shall see, it is the unique individual character of the College of Physicians and Surgeons, Presbyterian Hospital and Columbia University within the complex environment of New York City, that rendered Flexner’s ideal impossible to implement on the site of the Highlanders baseball field at Broadway and 168^th street.

The College of Physicians and Surgeons maintained a sporadic relationship with Columbia University from its founding in 1767 until it was integrated into the University in 1891. The medical school operated haphazardly through the eighteenth-century and by 1807 the College of Physicians and Surgeons functioned as a proprietary medical school under the jurisdiction of the New York State Board of Regents. P&S braved the changes of the post-Civil War period by relocating the medical school and adding new facilities. In 1884, through the munificence of the Vanderbilt family, P&S was able to move from it limited location at 23^rd street and fourth avenue to new facilities located at 59^th street between 9^th and 10^th avenues. This move included establishment of the Sloane Clinic for Women and the Vanderbilt Clinic. These were instrumental in providing P&S medical students with clinical access. The new location also situated the medical school adjacent to Roosevelt Hospital, leaving P&S with many options for the future.

By 1891, the president of P&S, James McLane, and the president of Columbia, Seth Low, negotiated a merger that was mutually beneficial to each institution. P&S saw affiliation with Columbia as a means of expanding its clinical and laboratory facilities, while the university believed professional school affiliations were the best way to shed its young men’s finishing school image. Columbia was also better able to finance the new facilities and staff for the medical school because it had access to the resources of the entire university. In addition, the academic structure of the university validated the changes in medical education that P&S wanted to institute.

Dr. Samuel Lambert became Dean of the College of Physicians and Surgeons in 1905. He immediately amended the curriculum to included recitations and seminars, and new courses in practical embryology and experimental surgery. Lambert also instituted more rigorous entrance requirements. Dean Lambert avidly supported expanding the clinical access for medical students. Walsh, in TheHistory of Medicine in New York, argued that the administrators at P&S viewed the declining number of entering students as testament to the increased selectivity of their new requirements. While the medical school interpreted the dropping entrance figures as affirmation of heightened quality, the Trustees of Columbia viewed this phenomenon as an economic problem conditional to a developing university. Was it better to maintain enrollment statistics or sacrifice fees in order to advance educational standards?

A third player in the establishment of the university medical center was the affiliated hospital. By the turn of the century, P&S utilized many hospitals, including St. Luke’s, Presbyterian, Lincoln, and German (now Lenox Hill) for the limited clinical training of its medical students. However, P&S’s location, on Fifty-ninth Street, encouraged participation with Roosevelt Hospital. Dean Lambert, motivated by a belief that clinical exposure made for good medical education, pursued a relationship with Roosevelt Hospital. He believed that the Vanderbilt Clinic was inadequate for the type of cases it provided and the number of students it could accommodate, therefore, he looked to the neighboring Roosevelt Hospital to augment student clinical access.

Roosevelt was one of the most highly regarded hospitals in New York City at the turn of the century. Affiliation with P&S seemed logical for a number of reasons. First, it was located directly across the street from the medical school, which would simplify any agreement, at least geographically. In addition, many of Roosevelt Hospital’s influential physicians had ties to P&S as many of the attending physicians at Roosevelt held professorships at P&S. Finally, the Dean of P&S served as a member of the Roosevelt Board of Trustees. Despite the fact that affiliation between the two institutions seemed imminent, proximity and an existing administrative relationship could not overshadow the ideological rift between P&S and Roosevelt. While both the medical school and the Roosevelt Hospital shared a commitment to the scientific basis of medicine, the hospital was not convinced that admitting medical students to the wards furthered their education. Whereas the staff of P&S saw practical training as essential to complete medical education, Roosevelt, primarily the President of the hospital, Dr. James McLane, viewed the admission of medical students to the wards as abuse of the hospital’s charity obligation to the sick poor.

P&S initiated the affiliation discussion in 1908, when Columbia President, Nicholas Murray Butler, and the Dean of P&S, Samuel Lambert broached the topic with the Trustees of the University. By 1909, the medical school and the hospital passed a joint resolution affirming their commitment to work together. Fortuitously, in 1910, Edward Harkness, a noted philanthropist, offered to endow a new surgical pavilion and laboratories. Harkness’ benevolence was attached to restrictions that he believed would promote the advancement of medical education. These conditions included the amalgamation of Roosevelt and P&S, the admission of clinical clerks to the hospital wards for practical instruction, and the unification of the University and Hospital staffs.

Despite the enthusiasm of the medical staff for the agreement, Roosevelt officials found Harkness’ conditions unacceptable and refused the offer to establish an exclusive relationship with P&S. While many of the prominent physicians voiced their support for the agreement, "its chief opponent was President McLane". Both P&S and Roosevelt claimed to be dedicated to research and the advancement of scientific medicine, and both institutions invoked their founding charters as indicative of their responsibility to science and the community. However, the differences in the how they achieved this professed commitment indicate their drastically different ideologies. P&S demonstrated its dedication to advancing medical education by amending its curriculum and aggressively pursuing an affiliation agreement that would provide the medical school with access to cutting edge facilities and innovative scientists. Roosevelt, however, did not manifest the same thinking. McLane misinterpreted Lenox’s explicit commitment to scientific medicine of the original charter and only focused on a paternalistic conception of the hospital-patient relationship. Nineteenth-century hospitals were founded under the pretense of the elites taking responsibility to help alleviate the suffering of the poor. To then use these patients for experimentation, or clinical education was considered exploitative and antithetical to the purpose of the hospital. Many circumstances indicated that P&S and Roosevelt would have been ideal partners in the pursuit of advanced medical education, yet, they lacked the essential unity of purpose that would make such an affiliation viable. The failure of the Columbia - Roosevelt affiliation reflects the fact that by the turn of the century, physicians did not monopolize medical education, as they had during the proprietary era. The power was now divided among university trustees, the charity hospital financiers, large philanthropic foundations, and physicians.

1910 marked two key events in medical school – hospital affiliation relationships in New York City.

First, Abraham Flexner’s Report on medical education in America was published. Also, philanthropist Edward Harkness, and P&S Dean Lambert, not dissuaded by the Roosevelt Hospital rejection, pursued an affiliation agreement with Presbyterian Hospital. While Flexner may not have been the catalyst for restructuring medical education at P&S, it is important to explore his P&S specific observations to see how closely any of them were incorporated into the operation of the new medical center.

The Flexner Report provided each institution with specific recommendations for achieving the ideal Hopkins model. Flexner’s initial report specified four "crucial points" for the medical school to consider. These included; accessing a hospital of sufficient size, either through affiliation or construction; incorporating teaching and working facilities into the general organization of fundamental laboratories at the medical school; unifying the medical school faculty and the hospital staff; and, affording professors the freedom to adopt necessary teaching arrangements (i.e. clinical rotations), subject only to concerns for the welfare of patients. Although Flexner’s suggestions did not represent new concepts for the administrators, trustees, and physicians at P&S, his continued input after the publication of his report demonstrates his importance to the reorganization of medical education in the United States.

Flexner’s Columbia specific recommendations were designed to bring P&S closer to the Johns Hopkins ideal. Flexner insisted that Columbia, like Hopkins establish direct ties with a single hospital to satisfy its clinical needs. Flexner offered two means of fulfilling this plan. Columbia could either erect its own independent hospital to serve as its medical school or initiate an exclusive relationship with an existing hospital. Constructing a new hospital was impractical for Columbia. Given that P&S could not support itself with its minimal tuition revenue and reliance on the University endowment to cover its operating costs, Columbia University was not prepared to incur the cost of developing an independent hospital for its medical school. Affiliation seemed to be the only viable option.

Flexner’s also mandated that educational and practical facilities occupy adjoining buildings. This would insure that the hospital and medical school were "closely interwoven in organization and conduct". The contiguity of the medical school’s laboratory and teaching facilities with the wards and operating theaters of the hospital would join research and practice. Flexner believed that Columbia would emerge as an elite medical school.

Although Flexner’s recommendations seem like sound advice in the context Progressive era educational reforms, and the tendency towards standardization, it is important to note that many of the changes that Flexner advocated had been entertained by P&S and Columbia administrators prior to the publication of his report. Rather than view the Flexner Report as criticism, the faculty of P&S regarded it, somewhat contemptuously, as an outsider’s confirmation of their own beliefs about how to modernize medical education.

While Flexner commented on the inadequacies of P&S, the staffs of the medical school and the university negotiated with Presbyterian Hospital about a possible affiliation. In 1868, James Lenox, heir to the Lenox shipping fortune, issued a letter to members of New York’s distinguished citizenry explaining the need for the Presbyterian community to establish its own hospital. He thought it unseemly that in this multitude of ethnic and religious institutions, the Presbyterian community lacked its own individual institution. Lenox appealed to the paternalist sentiments that inspired much of the upper class benevolence and charity activity at the end of the nineteenth century. He wanted the hospital to serve a more ecumenical purpose than the other institutions throughout the city. This attitude was manifested in the inscription now etched in stone on the Harkness Pavilion, which reads, "Presbyterian Hospital - for the poor of New York without regard to Race, Creed, or Color". Albert Lamb, in his 1955 history of the Columbia-Presbyterian Medical Center claims that "[f]or many years a number of us at Presbyterian repeated the legend that Mr. Lenox had founded the Hospital because one of his colored servants had been denied admission to the existing hospitals". According to an earlier history hospital, Mr. Lenox’s physician and friend, Dr. Oliver White, was summoned to the Lenox house to care for one of Lenox’s highly regarded black servants. After deciding that she needed immediate hospital care, Dr. White was dismayed because the servant was denied admission to all the existing hospitals due to her race. Dr. White hoped " ‘that some day there would be a hospital broad enough to admit patients without regard to color or creed.’" This incident provided the oft perpetuated foundation myth of Presbyterian Hospital.

Although this story may be little more than legend simply passed down over the years at Presbyterian Hospital, it illustrates a commitment to the community and the charitable mission that motivated the early lay trustees. This sentiment influenced the decisions and attitudes of the Presbyterian Managers from the opening of the hospital through its negotiations with Columbia and the College of Physicians and Surgeons. This tradition of lay control -- and lay goals -- was challenged during the Columbia – Presbyterian affiliation process, as the medical school and the university asserted their own prerogatives.

Edward Harkness’ resignation from the Roosevelt Board and subsequent election to the Presbyterian Hospital Managers, in 1910, facilitated the affiliation discussion between P&S and Presbyterian Hospital. On December 19, 1910, six days after joining the Presbyterian Board, Harkness recycled his Roosevelt Hospital offer for the Presbyterian managers. Harkness hoped to erect a new 150 bed surgical facility and offered $1.3 million for its endowment. However, his philanthropy came with restrictions. These conditions ranged from guaranteeing medical students access to clinical wards, to demanding that Presbyterian affiliate only with P&S. The Presbyterian managers believed that affiliation was the best method for each institution to achieve its goals. The medical school, Presbyterian argued, needed the hospital to maintain its clinical teaching standards, while the hospital would "secure for its patients the best medical and surgical talent" by affiliating.

On April 25, 1911, Presbyterian Hospital and Columbia University established a permanent alliance for the purpose of efficiently serving the needs of patients and the community and promoting medical education. Presbyterian and P&S, with the help of the Columbia Trustees, agreed to relocate to a common site and integrate their staffs.

In reality, the relationship between the two institutions, as a result of the 1911 agreement did not amount to much more than an increase in clinical clerkships for medical students. While this minor step in affiliation was achieved with relative ease, the realization of the other goals of the agreement, such as establishing a new joint facility did not proceed with the same success. From 1915 to 1921 Columbia University and Presbyterian Hospital had an acrimonious relationship. This tumultuous period began with failure to exercise a lease deal for the Broadway and 168^th street site, thus jeopardizing the 1911 affiliation agreement. This animosity was eventually resolved, with the approval of a new affiliation agreement in 1921. However, at numerous instances in the interim, the future of a Columbia-Presbyterian relationship seemed on the verge of collapse. The goals of the agreement were left largely unfulfilled as a direct consequence of the personalities involved in the management of each institution. Dean Lambert argues that both Presbyterian and Columbia regarded each other with disdain. The Presbyterian Managers considered Butler an impediment to productive relations, while the Columbia Trustees saw the Managers as trivial.

Amidst battling philanthropists and aggressive university trustees, the role of the medical school and the medical faculty got lost. Driven by his goal of asserting Columbia’s position as a major research university, Butler and the trustees made many decisions that did not further medical education. It is also evident that Butler and Columbia wanted to dominate the affiliation, while the Presbyterian managers, save newcomer Edward Harkness were reluctant to relinquish exclusive control of the hospital that they enjoyed since its inception. Slight importance was given to the medical school faculty and their input into the organization of the proposed affiliation agreement, until the resolution of the conflict in 1921.

Neglect of the medical faculty’s input during the affiliation discussions was in direct conflict with Flexner’s conception of the ideal medical school. For Flexner, the driving force for affiliation was medical education, thus situating the medical school at the top of the hospital, university, medical school relationship. The Columbia – Presbyterian affiliation did not follow this model as Dean Lambert proclaimed:

Lambert believed the medical faculty constituted the real power in this affiliation process and that only the medical school could unify the interests of the hospital and the university to effectively achieve an agreement. The subjugation of the medical school as an independent party in these debates continued throughout the contentious period leading up to the second affiliation agreement in 1921. For example, in 1918, a Columbia trustee, clarified the University’s perception of the medical school for Lambert:

Dean Lambert persisted in his claim for the independent role of the medical school. While his belief followed Flexner’s prescription, medical school dominance would never be realized in the Columbia-Presbyterian relationship. The interest of medical education would never exceed the competing motivations of Columbia, as a blossoming university and Presbyterian Hospital, as a facility in transition from a charity to profit a hospital.

By 1915, Edward Harkness was desperate to get Columbia University to commit to a joint land location, as specified in the 1911 agreement and suggested by Abraham Flexner. In a series of letters, from August through September, 1915, Edward Harkness implored President Butler to uphold the University’s end of land deal for the Broadway and 168^th street site. Harkness finally concluded that the Hospital would not be able to act on the land option because they had no assurance that Columbia would relocate the medical school to the same site as the hospital. Butler responded by citing a resolution of the Trustees in which they extended the time frame of their obligation to allocate funds for the purchase of the land until 1920. Butler invoked his duty to the other areas of the University as rationale for not funding Columbia’s portion of the land agreement. In a letter to Edward Harkness, Butler stated:

Butler believed the University’s failure in obtaining funds was actually advantageous, as it afforded the University time to consider all its options. The delay allowed Columbia to plan its medical school expansion according to its own design, independent of the wishes of Presbyterian managers and medical school deans. Under the guise of concern for the perceived clinical limitations of a single hospital, Butler suggested that Columbia establish relationships with a variety of institutions. Butler’s dedication to the Morningside Heights campus is reflected in his desire to erect medical school laboratories on the East Field site and establish clinical units at any hospital willing to cooperate. While this plan violated the terms of the 1911 affiliation agreement with Presbyterian Hospital, it reflects President Butler’s primary commitment to Columbia University and unwillingness to bend to the wishes of others.

From 1915 to 1917, Columbia University and Presbyterian Hospital made little progress towards affiliation. Abraham Flexner, now the secretary of the General Education Board, returned to the scene to distribute his "Memorandum on Columbia University and Medical Education." After outlining a history of P&S’s shortcomings, Flexner offered seven points of reorganization. He reiterated the call for relocation, stressed limited enrollment, and cited the need for an individual medical school endowment. In addition, Flexner encouraged P&S to sever all ties with other hospitals so that it could be fully dedicated in spirit and resources to its affiliation with Presbyterian. Flexner’s persistent involvement in structuring an agreement for P&S illustrates the influence of philanthropic organizations, such as the Carnegie Foundation’s General Education Board in revamping medical education.

But even Flexner could not persuade the University to follow any outside advice. An anonymous memo generated by Columbia details the shortcomings of Flexner’s plan. The memo ridicules the strict full-time plan under which medical school professors would become salaried employees restricted to their hospital and university duties. Instead, the memo suggests that the medical faculty should be subject to the same regulations as the rest of the University and not restricted from private practice. Throughout the 1910’s the University resisted implementing Carnegie Foundation suggestions.

Relations between the University and Presbyterian Hospital remained tenuous throughout World War I. During this period, Columbia attempted to secure independent affiliations with other hospitals, such as Lenox Hill. The Lenox Hill affiliation was the brainchild of Butler. In 1919 he offered Lenox Hill an agreement strikingly similar to the one held with Presbyterian. However, the affiliation was not to be realized, as Columbia was still bound precariously to Presbyterian through June 1920. More importantly, the Lenox Hill Association vehemently declined affiliation with Columbia as the physicians believed the hospital’s identity would be subsumed by the larger university. Would the same thing happen to Presbyterian if they continued their agreement with Columbia?

Definitive steps towards settling the affiliation debacle and getting on with modernizing medical education in New York City began in December 1919. First, Dr. William Darrach, who succeeded Lambert as Dean of the Medical Faculty, issued a "Memorandum on the School of Medicine" on December 13, 1919. This document built on many of the previous suggestions for the establishment of medical center. However, he suggested a time limit for action, thus forcing the two institutions to make advances. Darrach also suggested that the staff of the Hospital be composed of professors nominated by the University and appointed by the Hospital. According to his plan, the clinical departments would be organized on a full-time basis. Darrach’s full-time plan differed from the rigid model suggested by Flexner, as it was limited in scope. Dr. Darrach argued, "The essential principle of this arrangement is that the dominating group of men in the main clinical departments must be free to concentrate their energies on their University and Hospital work." Private practice and insufficient assistance distracted department heads from their dual task. Dean Darrach designed his full-time plan to alleviate these two problems in the interest of establishing a "more truly university type of clinical teacher." Darrach’s recommendations for the reorganization of the medical school formed the basis for a second affiliation agreement with Presbyterian. His memo also demonstrated that the newly established medical center would be dominated by academic medicine. The strict practitioner was a remnant of a past medical world.

On February 10, 1921 both the Presbyterian Hospital and Columbia University signed a second affiliation agreement. The contract incorporated Darrach’s recommendations. It established a time frame for the purchase of a new site at Broadway and 168^th street and the erection of new buildings and made specific provisions for the departmental appointments. Finally, the agreement left much of the planning of the new medical center to the Joint Administrative Board composed of Presbyterian Managers, Columbia Trustees, and the Dean of the Medical School. Consolidating all the competing interests at the new medical center required a prodigious planning effort. The Joint Administrative Board addressed the task of reconciling university and hospital goals, through the integration of research and clinical facilities, and the construction of a hospital to serve both charity and private patients.

The establishment of the Columbia-Presbyterian Medical Center was an arduous protracted process because of the personalities involved and divergent interests of each constituency. Presbyterian hospital trying to secure the best medical care for its patients and reconcile its conversion from a charity institution to a modern hospital clashed with Columbia University, establishing its supremacy over affiliated institutions. This forced association between contentious partners did not fit the rigid prescription of reformers, like Abraham Flexner. Flexner’s model was tribute to the sovereignty of scientific education, through which he hoped to raise the status of medical schools. In addition, Flexner’s ideal, Johns Hopkins, followed a unique path of development, in which the university constructed a hospital to serve its medical school in a city that lacked competition for such services. Instead, the Columbia-Presbyterian Medical Center emerged from a witches’ brew of competing interests in medical education, philanthropy, university missions, charity and educational reform. Perhaps it is Columbia – Presbyterian’s heterogeneous origin that has enabled the medical center to weather change over the past 70 years and will enable it to confront future affiliation issues, university relationships, the changing doctor-patients roles.