The University of Michigan Medical School, 1850-2000 “An Example Worthy of Imitation”

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Howard Markel, MD, PhD The 150th anniversary of the University of Michigan Medical School af- fords occasion for both celebration and reflection, not just in Ann Arbor but THE EARLY YEARS: 1817-1847 throughout the world, as we consider its contributions to medical educa- While Michigan was still a territory of the tion, research, and health care over the past century and a half. This article Northwest Ordinance, a legislative act of explores the medical school’s origins as a frontier medical outpost and de- August 26, 1817, established the Cathol- scribes the vital reforms in medical education implemented in Ann Arbor long epistemiad, or University, of Michiga- before the landmark Flexner Report on Medical Education of 1910. It also nia in Detroit (population, 4000). The depicts how and why the medical school developed as it did and what fea- school, whose mission spanned the pri- tures are distinctive or typical about the school during this period. mary to the university levels, struggled JAMA. 2000;283:915-920 www.jama.com to exist. After the devastating cholera epi- demic of 1832, it closed and sold its prop- of the ill took place primarily in the The petition was referred for further erty for $5000, which was set aside as a home and was largely in the domain of study to a committee chaired by physi- general fund for a future University of female members of a family. Their un- cian and university regent Zina Pitcher, Michigan. It was not until March 1837, derstanding of disease was a blend of a graduate of the Castleton (Vermont) shortly after Michigan was granted state- knowledge picked up from friends, rela- Medical School and Middlebury College hood, that the legislature passed an act tives, occasional interactions with phy- (MD, 1822). After an 8-year career as a to establish the university. After heavy sicians and alternative healers, and per- US Army surgeon, Pitcher settled in De- politicking by at least 4 Michigan settle- sonal experience. The few physicians troit in 1836 to marry and practice medi- ments, the legislature approved a 40- who did practice in Ann Arbor during cine. In an attempt to spur the university acre site donated without cost to the state this period often offered commonly used into establishing a medical department by a group of citizens from Ann Arbor medicinals and humoralism-based in- of its own, he opened a proprietary medi- in which to situate the proposed univer- terventions such as bleeding.3,4 calschoolin1846,whichfailedandclosed sity. This decision was controversial, es- in 1847. In May 1847, however, Pitcher pecially for those living in Detroit, the FOUNDING THE MEDICAL attended the first annual meeting of the major entry point to Michigan because SCHOOL, 1847-1865 American Medical Association in Phila- of its deep-water port. In 1837, Ann Ar- Financial crises and administrative in- delphia, where he was a member of the bor was only 13 years old, a tiny fron- ertia made the establishment of a medi- education committee and learned about tier village with a population of only cal school at the University of Michi- the inadequate level of medical education 2000, including several German immi- gan difficult until January 1847, when across the United States. He soon became grant families and 9 physicians. Native a group of local physicians petitioned the convinced that it was the state’s obliga- Americans still came to town to trade regents. These physicians conducted a goods, and transportation between Ann survey and found that some 70 “Michi- Author Affiliation: Department of Pediatrics and Com- municable Diseases, Department of History, and His- Arbor and other points relied on stage- gan boys” had left the state to study (and torical Center for the Health Sciences, The University coach. Railroad lines to Detroit were not most likely, practice) medicine else- of Michigan Medical School, Ann Arbor. 1,2 Corresponding Author and Reprints: Howard Markel, established until 1839. where. This potential paucity of a new MD, PhD, Historical Center for the Health Sciences, Health care in Michigan during this crop of available physicians, they The University of Michigan Medical School, 100 Simpson Memorial Institute, Box 0725, 102 Ob- period was similar to that of the rest of warned, was bound to have an impact servatory, Ann Arbor, MI 48109-0725 (e-mail: the early frontier United States. The care on the health of the young state.5,6 [email protected]).

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tion to protect the health of its citizens The board of regents unanimously eningofthemedicalschool,andthemedi- and the best way to reach this goal would adopted Dr Pitcher’s recommenda- calbuilding,modeledafteraGreektemple be to establish a first-rate medical school. tions to establish a medical school and withcolumnsandaportico,wasnotready Such thought was remarkably advanced appropriated $3000 to construct a until the fall of 1850 (FIGURE 2). The fi- for a post-Jacksonian era American and medical building to be opened by the nalcostofthebuildingwasapproximately presages much public health and medi- following autumn. Five professors were $9000, but it boasted several lecture cal education policy making of the late appointed over the next 2 years: Silas rooms, offices for the professors, a chem- 20thcentury.OnJanuary9,1848,Pitcher Douglass (pharmacy and medical ju- istry laboratory, and a room under a submitted the blueprint for the medical risprudence, 1848), Abram Sager domed roof designed for anatomical dis- school to the regents: (physic or medicine, 1848, and obstet- sectionswheneverahumancadavercould rics and the diseases of women and chil- be procured.9,10 The first class consisted If it can be conceded that it is the duty of this Board when circumstances favor that dren, 1850, and the first dean), Moses of 90 matriculants and 5 physicians seek- end, to establish a Medical Department of Gunn (anatomy and surgery, 1849), ing additional training. Unlike many US the university, it may also be seen that we Jonathan Adams Allen, Jr (pathology medical schools at that time, Michigan who have the administration of a splendid and physiology, 1850), and Samuel could claim its own building on a univer- trust are charged with the execution of a Denton (physic, 1850)8 (FIGURE 1). sity campus—as opposed to another lo- high and responsible duty in setting before such Institutions in our organization, Underestimates of construction costs cation or no affiliation at all with a an example worthy of imitation.7 and inclement weather plagued the op- university—and, unlike all other medical colleges in the nation, in having professors whose salaries were entirely paid Figure 1. The University of Michigan Medical School Founding Faculty by the university. The latter meant that students were not required to buy admission tickets directly from professors for the lectures and demonstrations that made up the curriculum.11 Many other schools were owned by busy practition- ers and operated on a for-profit basis, hence the term “proprietary medical school.” Few medical schools were at- tached to a hospital nor did many have aspecificbuildingforlaboratoryexercises or lectures. At most of these institutions during the early- to mid-19th century, medical instruction was deemed by con- temporary observers to be inadequate. At Michigan, admission required evi- dence of “good moral character” and knowledge of Greek and Latin. Few students went to college, but many were graduates of provincial high schools, as was typical for the good medical schools in the nation such as Harvard Medical School in Boston and the College of Phy- sicians and Surgeons in New York. Once in medical school, students attended 4 lectures per day, Monday through Fri- day,withaclinicaldemonstrationonSat- urday mornings, from October to April. Studentswererequiredtorepeatthesame 6-month regimen the following year and to present a thesis on a topic of their choice, which was essentially a review of the literature on a specific topic. University of Michigan medical students, like their peers at other medical

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schools across the nation, were also re- Figure 2. The 1850 University of Michigan Medical School Building quired to serve as apprentice to a “respectable physician” for 3 years before or during the periods between the di- dactic terms in Ann Arbor. This re- quirement served as the principal means of teaching clinical medicine at Michi- gan until 1880. While an apprentice, the student took on a variety of duties rang- ing from hitching the physician’s horse to his buggy and compounding pre- scriptions to holding down a patient un- dergoing an operation without anes- thesia.5(pp1-7) The term “respectable,” as used by the Michigan medical faculty, meant that the precepting physician subscribed to the methods and theo- ries of the “regular” profession as opposed to other popular medical phi- losophies such as homeopathy or eclecticism. Indeed, there existed much Americans and other minority stu- sibilities” of women students. Others rancor and competition between allo- dents long before this was a common protested based on notions of a wom- pathic and homeopathic physicians in practice at other US medical schools. an’s “physical incapacity” to practice the state of Michigan during this pe- During the late 19th century, the aver- medicine. Some went as far as to sug- riod, and the university maintained a age number of women students in each gest creating a separate “Female Medi- separate homeopathic medical college medical class was about 15; there was 1 cal College” to be based in Detroit. Fi- and hospital from 1875 until 1922, one African American per class.13 The first nally, a compromise was struck in the of the few state-run homeopathic medi- African American medical graduate, summer of 1870: women would be ad- cal schools in the nation.2(pp1003-1012) Henry Fitzbutler, graduated in 1872. mitted to the medical school, but courses Saiske Tagei, a Japanese student, gradu- such as anatomy and gynecology would REFORM AND EXPANSION, ated in 1874; Jose Celeso Barbosa was be taught to them separately. Faculty 1866-1891 the first Puerto Rican medical graduate members who had to teach separate ses- In the decades after the Civil War, in 1880; and 2 women from China, Ida sions were paid an additional $500 per Michigan began a steady transforma- Kahn and Mary Stone, received their year, although this was soon declared tion that placed it at the forefront of US medical degrees in 1896.13 “inefficient” by the medical faculty and, medical education. In 1869, Michigan Although it was accomplished, the de- while women continued to be seated established the nation’s first university- cision to admit women to the Univer- separately in the main lecture hall as well owned hospital when a house origi- sity of Michigan was not easily reached as the anatomy laboratory until 1908, all nally built for a professor was con- and provides a context for how revolu- course work was truly coeducational by verted into a hospital. The hospital tionary the university’s admission policy 1871. Amanda Sanford of Auburn, NY, served merely as a home for patients to really was during a period decades be- was the first woman to receive a medi- stay before and after being presented to fore the concept of coeducational edu- cal degree from the University of Michi- the medical students. There were, as cation was introduced at other institu- gan. Dean Abram Sager announced that Victor Vaughan recalled, “no wards and tions. Although women had petitioned autumn that “our experiment had been no operating or dressing rooms, no the regents to matriculate as early as conducted with entire harmony and suc- place where students might receive bed- 1858, it was not until January 1870 that cess.” Alas, the reality was not quite as side instruction.”12 In 1876, a pavilion women were finally accepted as stu- idyllic. As Sanford walked across the hospital with 70 beds was erected for dents. Shortly thereafter, the medical stage of the Ann Arbor Methodist the treatment of patients and clinical school admitted 18 women. At that time, Church in 1871 to receive her di- presentations for medical students. there were fewer than 6 schools in the ploma, with honors, she was “hooted The University of Michigan Medical United States where a woman could ob- and showered with abusive notes from School, as a public institution charged tain a medical education. young male students sitting in the with providing instruction for all of Many members of the all-male fac- church’s balcony.”14-18 Michigan’s citizens, began to routinely ulty worried that some of the subjects Through the mid-1870s, the curricu- accept women, Asians, and African routinely taught might offend the “sen- lum remained lecture-based, except for

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chemistry and anatomical dissection, original research was not considered to Leora unknowingly smokes a cigarette with little practical experience in the care be a part of a professor’s responsibili- tainted with plague bacillus was based of patients. The focus was on the rote ties; instead, the focus was on teach- on a real-life episode in Ann Arbor in memorization of details. Some medical ing, administration, and, if a clinician, which a medical student did the same faculty members in the early 1870s the practice of medicine. Those few US thing in the laboratory of Frederick Novy. hoped to improve the educational stan- medical educators engaged in re- Fortunately, the student survived even dards, but expressed concerns that set- search did so in their spare time and at if the fictional character did not.26,27 ting the bar too high would encourage their personal expense. This changed Equally important were the physi- prospective students to apply else- as the nation entered the 20th cen- cians Vaughan hired to teach clinical where where a medical degree might be tury, largely under the influence of the medicine. George Dock, professor of more easily obtained. By 1877, how- German research universities and other medicine from 1891 to 1908, estab- ever, the Michigan faculty could no major academic centers in Europe. lished the clinical clerkship at the uni- longer ignore these problems, and the In 1891, University of Michigan Presi- versity, beginning in 1899, as the basic annual session was increased in length dent James B. Angell named Victor C. form of instruction where students were from 6 to 9 months. In 1880, a new Vaughan dean of the medical school. responsible for providing direct patient 3-year graded course was instituted that Vaughan was one of Michigan’s first doc- care under faculty supervision.28,29 The introduced a sequence of basic science toral graduates (PhD, chemistry, 1876) medical clerkship at the university, simi- courses, followed by pathology and and a member of the last medical class lar to the one inaugurated by William therapeutics, and then clinical work. at Michigan to take the old 2-year cur- Osler at Johns Hopkins in 1895,30,31 be- Similar curriculum changes were be- riculum (MD, 1878). In the decade that came a model for medical schools ing made at Harvard and the Univer- followed, he rose from an instructor to throughout the United States. sity of Pennsylvania School of Medi- professor of physiological chemistry. He In 1891, the clinical departments cine during this period. Finally, in 1890, was also director of the hygienic labora- moved into a new 64-bed university hos- a fourth year of clinical studies became tory, which functioned as the Michigan pital where students could “walk the mandatory. In that same year, Pennsyl- state health laboratory until 1903, one wards” under the supervision of their vania, Harvard, and Columbia adopted of many examples where the medical clinical professors and have a more similar 4-year programs. Moreover, school played an integral part in the meaningful hands-on experience in the Michigan students were now required health of Michigan citizens outside the care of patients.2(pp953-987) The greatest vir- to have completed at least 2 years of col- confines of Ann Arbor.12(pp213-261),22 tue of the hospital was that it was com- lege. Throughout this period, labora- Vaughan recruited a number of ex- pletely under the control of the univer- tory instruction was increasingly em- cellent scientists, such as pharmacolo- sity. Such an organization avoided the phasized so that, as early as 1878, all gist John Jacob Abel and bacteriologist internecine battles between hospital students were required to complete labo- Frederick Novy, who imbued their stu- trustees, politicians, and others over mat- ratory instruction in each scientific sub- dents with the love of discovery and the ters such as clinical appointments or ject offered, with particular emphasis in importance of the biological basis of dis- educational methods that plagued other physiology, anatomy, and chemistry. All ease.23 For example, 2 Michigan stu- medical schools partnered with charity of these changes reflect what was soon dents during this period who went on to hospitals or municipal- or state- to become the gold standard of medi- active research careers included Alice operated facilities. By 1925, the univer- cal education in the United States. The Hamilton (MD, 1893) who became the sity hospital occupied 20 buildings and University of Michigan, along with Co- founder of the field we now call indus- contained more than 500 beds in its lumbia, Harvard, Pennsylvania, and af- trial medicine,24 and Carl J. Wiggers (MD, medicine, pediatrics, surgery, specialty ter its opening in 1893, The Johns Hop- 1906), a pioneer in the modern under- surgery, and dermatology wards. It now kins University School of Medicine, were standing of cardiovascular hemodynam- played a major role in caring for the making fundamental changes to their ics.25 Perhaps the best-known example state’s most indigent citizens, in addi- medical curricula by requiring medical of the research ethos created at Michi- tion to serving as a referral center for students to be active participants al- gan can be found in Sinclair Lewis’s 1925 “difficult cases” and medical student in- most 2 decades before the landmark Pulitzer Prize–winning novel Arrow- struction. As Abraham Flexner noted Flexner Report on Medical Education of smith.26 Lewis consciously modeled Mar- when he inspected the medical school 1910 mandated the reform of US medi- tin Arrowsmith’s medical school, the in 1909 as part of his influential Report cal training.19-21 University of Winnemac, after Michi- on Medical Education, while Michigan gan largely with the help of bacteriolo- was far from a large urban center, “the THE RISE OF SCIENTIFIC gist, Michigan graduate, and popular school is fortunate in the possession of MEDICINE, 1891-1921 writer Paul deKruif (BS, 1912; PhD, its hospital, every case in which can be At Michigan and most other US uni- 1916). Indeed, the climactic scene of the used for purposes of instruction....The versities during the late 19th century, novel where Martin Arrowsmith’s wife thoroughness and continuity with which

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the cases can be used to train the stu- developing a full-time group practice at gan, like every major medical center in dent in technique of modern methods Michigan was both novel and pre- the United States, benefited greatly from go far to offset defects due to limita- scient, his harsh methods of rule did little the postwar boom in industry, transpor- tions in their number and variety.”32 For to advance his most significant admin- tation, and the federal government’s in- medical educators across North America, istrative measures. Professors bitterly volvement in scientific research, medi- 5 medical schools were heralded as the complained about being “terrorized” by cal care, and education. With the advent models to imitate: Johns Hopkins, Har- Cabot and petitioned University of of the Medicare and Medicaid pro- vard, Columbia, Pennsylvania and Michigan President Alexander Ruthven grams in the 1960s, expansion of medi- Michigan.21(p184) in January 1930 for his immediate dis- cal care, education, and research only missal. Refusing to resign voluntarily, the continued. New research and patient care BUILDING THE MODERN board of regents “relieved” Cabot of his buildings were erected during this pe- TEACHING HOSPITAL, duties as dean and chair of surgery “in riod. Enrollment at the medical school 1921-1935 the interests of greater harmony in the increased. Private medical insurance as In 1920, Hugh Cabot was recruited from Medical School” on February 7, 1930.36,37 well as federal and state programs for the Massachusetts General Hospital to be Following Cabot’s departure to the Mayo elderly and the poor ensured that clini- professor of surgery at Michigan and in Clinic, an executive committee of 5, cal facilities and medical care expanded 1921, after Victor Vaughan’s retirement, chaired by bacteriologist Frederick Novy, at an exponential rate. In addition, a the regents named him dean. Cabot had ran the medical school. During this pe- number of landmark medical events oc- ambitions to develop a “full-time” sys- riod, Cabot’s ambitious full-time plan was curred in Ann Arbor, including Cam- temorcooperativemultimemberedprac- dismantled and would not be fully re- eron Haight’s development of a surgical tice of specialists and general physicians solved until well into the 1970s. In 1935, procedure to correct tracheo-esopha- who would offer a “more complete and otolaryngologist Albert C. Furstenberg geal fistula in 1941 and Jerome Conn’s varied service to patients,” reduction of was appointed dean. There were sev- elucidation of primary hyperaldosteron- costs, and the elimination of competi- eral research accomplishments during ism (Conn syndrome) in 1954. tion between private physicians practic- this period that had international ef- ing in the same area. Cabot believed he fects on health, including pediatrician NEW CHALLENGES AND could effect change in a place like Ann David Murray Cowie’s work to develop ADAPTATION, 1971-2000 Arbor because it was not as encumbered iodized salt as a goiter preventive in Under Deans John Gronvall (1970- by tradition and old habits as Boston.33,34 192438 and cardiologist Frank Wilson’s 1983), Peter Ward (interim dean, 1983- Although Michigan boasted a full-time refinement of the electrocardiograph as 1985), Joseph Johnson (1985-1990), system wherein its basic science faculty a diagnostic tool between 1914 and the Giles Bole (1990-1996), A. Lorris Betz was paid directly by the university and, 1940s.39 (interim dean, 1996-1998), Allen S. for the clinical faculty with private prac- Lichter (1999-present), George Zuidema, tices, a combination of funds from the WORLD WAR II AND vice provost for medical affairs (1984- university and the hospital, not every de- POSTWAR EXPANSION, 1994), and Gilbert S. Omenn, execu- partment of the medical school sub- 1935-1970 tive vice president for medical affairs and scribed to this plan. Many clinical fac- During Furstenberg’s tenure, 1935- chief executive officer (1997-present), ulty members maintained lucrative pri- 1959, the medical school faculty the medical school has continued to ad- vate practices elsewhere in Ann Arbor doubled in size, from 155 to more than vance medicine and medical education. orDetroit.Indeed,Cabot’sgoalsofimple- 300, and most of the preclinical and In addition to responsive curriculum menting a full-time system for the en- clinical faculties were consolidated in changes over this period, the medical tire faculty led to a series of acrimoni- 1 geographic area. In 1970, when school has been a leader in developing ous debates. The issue, for the clinicians, William Hubbard stepped down as dean minority affairs, affirmative action, and was largely one of money; Cabot’s pro- of the medical school and director of outreach programs for potential and ma- posed system would seriously curtail the medical center, the faculty in- triculated medical students. their incomes.35 cluded 639 active members.40 By the late 1970s, it was clear that the On the positive side of Cabot’s ten- In response to World War II, the medi- university hospital, affectionately known ure as dean was the complete transfor- cal school increased each academic year’s as “Old Main,” was no longer adequate mation of the medical campus, includ- course load to graduate more physi- and it was replaced in 1986. As of 1999, ing the 1925 opening of a new 893-bed cians in 3 rather than 4 years. During the the medical center includes a new, state- university hospital. It was heralded as the war, the medical school formed a mili- of-the-art 848-bed university hospital, a largest and most modern facility of its tary hospital, the 298th General Hospi- large outpatient center, a new medical li- kind in the nation. On the negative side, tal Unit, which attended to more than brary,ahealthmaintenanceorganization, however, was his contentious relation- 40 000 wounded soldiers in the Euro- cancer and geriatrics centers, new labo- ship with the faculty. While his plan for pean theater.41 The University of Michi- ratory buildings, a maternal and child

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health center, and more than 30 com- Acknowledgment: The author is indebted to Robert 20. Reports of the Various Departments of the Bartlett, MD, Richard D. Judge, MD, Joel Howell, MD, Medical School Regarding the Years, 1880-1882. munity-based satellite clinics through- and Allen Lichter, MD; my colleagues, Alexandra Stern, Ann Arbor: University of Michigan Medical School out the state. In 1998, the University of PhD, Janet Tarolli, RN, Carol Shannon, BA, and Chris- Dean’s Papers, Michigan Historical Collections, topher Meehan, BA, at the Historical Center for the Bentley Historical Library, University of Michigan. Michigan Health System recorded ap- Health Sciences; and, above all, Professor Emeritus Ho- Box 72. proximately 1.1 million outpatient vis- race W. Davenport, PhD, DSc, of the University of 21. Ludmerer KM. Learning to Heal: The Develop- its, 33 000 inpatient admissions, and Michigan Medical School. ment of American Medical Education. 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Michigan on the march: The Uni- is all of these people who have made the 18. General Catalogue of Officers and Students of versity of Michigan in World War II. Univ Mich Bent- the University of Michigan, 1837-1911. Ann Arbor: ley Historical Libr Bull. 1995;No. 42. University of Michigan Medical School University of Michigan; 1912. 42. University of Michigan Medical Center. Annual “an example worthy of imitation.” 19. University of Michigan. President’s Report for 1872 Report for 1969-70 [pp 9-10]; Annual Report for [p 12]; President’s Report for 1876 [pp 11-13]; Presi- 1973-74 [pp 1-2]; Annual Report for 1975-1976 [p Funding/Support: Dr Markel is the recipient of a Rob- dent’s Report for 1883 [p 12-13]; President’s Report 2]; Annual Report for 1986 [entire report]; Annual Re- ert Wood Johnson Foundation Physician Faculty Schol- for 1890 [p 90]; President’s Report for 1891 [pp 16, port for 1990; Annual Report for 1998. Ann Arbor: ars Award and the Burroughs-Wellcome Fund 40th 27-29]. Ann Arbor: Michigan Historical Collections, Michigan Historical Collections, Bentley Historical Li- Anniversary History of Medicine Award. Bentley Historical Library, University of Michigan. brary, University of Michigan.

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