section four D I V I S I O N S, D E PA R T M E N T S, I N S T I T U T E S, AND CENTERS 1 5 5 11. DIVISION OF MEDICINE BY MUZAFFAR AHMAD, CLAUDIA D’ARCANGELO, AND JOHN CLOUGH A good physician knows his patient through and through, and his knowledge is bought dearly. Time, sympathy, and understanding must be lavishly dispensed, but the reward is to be found in that personal bond, which forms the greatest satisfaction of medical practice. —A.C. Ernstene B E G I N N I N G S THE DIV I S I O N OF MED I C I N E HA S PL AY E D AN IM P O R TAN T RO L E IN TH E development of medical practice at The Cleveland Clinic since its opening in 1921. Dr. John Phillips, the only internist among the four founders, was the first chief of the Division of Medicine, then called the Medical Department. He was a true family physician who saw medicine begin to move away from house calls and toward an of fice-based practice during the eight years between 1921 and his untimely death in 1929 at age 50. Nevertheless, he continued to tr eat patients with diverse disorders and make house calls, often spending his entire weekend visiting patients in their homes. Despite his own inclination and experience, Phillips rec o g n i z e d the value of specialization. In 1921, he assigned Henry J. John, M.D., the field of diabetes and supervision of the clinical laboratories. In 1923, he appointed Earl W. Netherton, M.D., head of the Departm e n t of Derma t o l o g y , and in 1929, E. Perry McCullagh, M.D., head of the De p a r tment of Endocrinology. The rest of the staff, like Phillips, practiced general medicine. 1 5 7 1 5 8 / DI V I S I O N S , D E PA RT M E N T S , I N S T I T U T E S , A N D C E N T E R S In September 1930, one and a half years after Phillips’s death (see Chapter 3), Russell L. Haden, M.D., was appointed chief of the Division of Medicine. Formerly a pr ofessor of experimental medi- cine at the University of Kansas School of Medicine, he ap- pr oached medicine in a signifi- cantly diff e rent way. Where a s Phillips had been interested pri- marily in the clinical aspects of disease, Haden was a modern, la b o r a t o r y-oriented medical sci- entist. During his eight years at the Clinic, Phillips published 26 papers, 23 of which were con- Russell L. Haden, M.D., ce r ned with unusual cases or the Chief of Medicine, 1930-1949 diagnosis or treatment of dis- eases. In contrast, Haden’s first five years at the Clinic saw publication of 26 papers, 23 of which we r e descriptions of laboratory innovations or attempts to define the causes or interrelationships of various diseases. Although his inter- ests spanned the entire field of internal medicine, he was a hematol- ogist, and he made many important contributions to the field of blood diseases, most notably the discovery of spherohemolytic ane- mia. However, his enthusiasm for physical therapy combined with the reluctance of most physicians to tackle the problems of arth r i t i c patients resulted in a large ref e r ral practice in rheumatic diseases. Dynamic, brilliant, and possessing impeccable manners, Haden tr eated everyone with equal respect. Renowned as a superb clinician, he impressed patients and physicians alike by the speed at which he ar rived at correct conclusions. Residents coming to Haden’s service did so with appreh e n s i o n because “the chief” demanded high perfo r mance. This challenge usually brought out the best in the young physicians. Haden never seemed to forget small mistakes and frequently reminded the of fender much later. However, he rarely mentioned major error s again because he knew how miserable the trainee felt and that the D I V I S I O N O F M E D I C I N E / 1 5 9 lesson had been learned. Although he never complimented res i - dents for a job well done, they knew when Haden was pleased by the twinkle in his eye and slight smile. Ha d e n ’ s first appointment to the Clinic staff was A. Carlton Er nstene, M.D., as head of the Department of Cardi o re s p i r a t o r y Disease in 1932. Ernstene had been trained in internal medicine and ca r diology on the Harva r d services of Boston City Hospital and se r ved on the Harva r d faculty. His interest in laboratory and clinical res e a r ch made him an excellent choice to direct the new depart- ment. In 1939, H.S. Van Ordstrand, M.D., who had been appointed head of the Section of Pulmonary Disease, joined Erns t e n e . Ga s t ro e n t e ro l o g y , allergy , and physical medicine were added between 1932 and 1937. Then economic restrictions imposed by the Gr eat Depression req u i r ed the staff to devote most of their energy to pr oviding the highest volume of patient care at the lowest cost. The Clinic experienced almost no further growth until World War II. A gradually improving economy brought visions of expansion that were dimmed by the war. Young physician candidates for the st a f f were drafted into military service, along with several members of the Division of Medicine and many residents. The entire Ca rd i o re s p i r a t o r y Department was depleted when Ernstene and Van Or dstrand departed for military service. Fortu n a t e l y , Fay A. LeFevre, M.D., a former fellow, was able to ret u r n to the Clinic to replace them. Immediately after the war, the Clinic experienced a rapid in c r ease in staff as well as further specialization. As a result of mil- it a r y training, many young physicians recognized the value of grou p practice and applied to the Clinic for training. Haden pref e r red to accept those who had served their country and actually took more than his residency program needed. When Haden ret i r ed in 1949, the chairmanship fell on Erns t e n e . Aside from his love of work and clinical abilities, he had little in common with Haden. Meticulous order was his hallmark. He starte d his hospital rounds at 8 A.M. and finished in one hour. He would rapidly complete any brief, unscheduled activities before he ret u r ned to his office, by which time he expected his first patient of the day to have been examined by his resident. He would question the patient closely, recheck much of the physical examination, and make careful and concise notes in a tight, angular, small script. Residents were occasionally heard to comment that Erns t e n e ’ s hand- 1 6 0 / DI V I S I O N S , D E PA RT M E N T S , I N S T I T U T E S , A N D C E N T E R S writing was reminiscent of 60- cycle interf e rence commonly seen on the electroc a r diograms of the time. Although he had a good ba c k g r ound in internal medicine, ca r diology was his field and he had all the attributes of an out- standing clinical card i o l o g i s t . Er nstene was a model of unclut- te r ed, perfectly logical judgment, although he was not a good teacher in the traditional sense. His lectures were excellent because of their superb orga n i z a - tion and precise delivery. Seven new departments were established during Ern s t e n e ’s James Young, M.D., te n u r e as division chairman, and Chairman, Division of Medicine, 2003- the Department of Cardi o re s p i r a - to r y Disease was divided into Clinical Cardiology and Pulmonary Disease. The new departm e n t s w e re Internal Medicine (1949), Pediatrics (1951), Peripheral Vascular Disease (1952), Rheumatic Disease (1952), Hematology (1953), Hypertension (1959), and Pediatric Cardiology (1960). Ho w e v e r , Ernstene discovered that as a physician with a large prac- tice who also served as an officer of several national medical soci- eties, administrative duties were burdensome. He formed a com- mittee to advise and assist him, and this was the beginning of dem- ocratic governance in the Division of Medicine. At the time of Erns t e n e ’ s ret i r ement as chairman in 1965, the Division of Medicine had 28 staff physicians. Expansion continued under the successive chairmanships of Van Ordstrand, Ray A. Van Ommen, M.D., Richard G. Farme r , M.D., and Muzaffar Ahmad, M.D. They were, res p e c t i v e l y , specialists in pulmonary disease, infec- tious disease, gastroe n t e ro l o g y , and pulmonary disease, but each sought a balanced development in the division, and each brought a unique character and style to the job.