Knowledge in the Time of Cholera (37 page)

Still, Hopkins was a newcomer in the world of American higher education. Its transformation from an experiment to
the
model of medical education involved a concerted campaign, carried out through the AMA by bacteriological reformers with ties to Hopkins and access to philanthropic funding. Of key cultural import was the Flexner Report published in 1910.
⁶
In 1904, as part of a general internal reorganization, the AMA established the Council on Medical Education (CME) to reinvigorate its program of educational reforms. Dominated by bacteriologists, the CME decided to carry out an investigation of medical schools, assessing all medical schools in comparison to the laboratory education of Hopkins. Because of the internal resistance to reforms among proprietary school faculty, the CME sought assistance from the Carnegie Foundation to produce an unbiased “outsider” report. The independence of the Carnegie Report, however, was little more than formal window dressing; from the beginning, it was acknowledged that
study
would be done in conjunction with the CME, as the CME would furnish much of the research and data collection (Berliner 1985; Burrow 1963). To conduct the survey, the Carnegie Foundation chose Abraham Flexner, an educational reformer whose brother was Simon Flexner, a Welch student and future director of the RIMR. As a graduate of Johns Hopkins himself and “a great admirer of William Welch” (Duffy 1993, 208), Flexner, like his brother, was firmly entrenched in Welch's network of bacteriologists. He saw Hopkins as the standard by which all other medical schools should be judged, as it “was the first medical school in America of genuine university type, with something approaching adequate endowment, well equipped laboratories conducted by modern teachers, devoting themselves unreservedly to medical investigation and instruction, and with its own hospital, in which the training of physicians and the healing of the sick harmoniously combine” (Flexner 1910, 12). So he went about judging schools according to these criteria.

The report itself was the prototype of the agenda-setting surveys that would become a common tool for reformers throughout the Progressive Era (Wheatley 1988). Flexner assessed medical schools along a number of dimensions: (1) entrance requirements, (2) size and training of faculty, (3) nature and extent of endowment, (4) adequacy of labs and lab teaching personal, and (5) availability of clinical resources and nature of clinical appointments. While each dimension was relevant, Flexner made it explicit that adequate laboratories would trump all other factors. If a school lacked adequate facilities for laboratory science, it was declared inferior. Legitimate medical knowledge was equated with laboratory science, and in turn, medical education should revolve around the lab: “For purposes of convenience, the medical curriculum may be divided into two parts, according as the work is carried on mainly in laboratories or mainly in the hospital; but the distinction is only superficial, for the hospital is itself in the fullest sense a laboratory” (Flexner 1910, 57).

In all Flexner visited 155 medical schools, 32 of which were affiliated with alternative sects (Bordley and Harvey 1976). His conclusions were damning: “It is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate training whatsoever” (Flexner 1910, x). Flexner recommended
increased
entrance standards, a four-year curriculum, and a drastic reduction in the number of medical schools to 31. Overall, the report proposed a wholesale transformation of medical education by which physicians would be trained in the epistemology of the laboratory to become “scientists in terms of treating each new clinical encounter as an exercise in scientific inquiry” (Flexner 1910, 9).

The report garnered much media attention, as it brought to light some egregious inadequacies of many medical schools. And though there was resistance to the report by many schools—F. W. Hamilton, president of Tufts University, argued that Flexner “had adopted certain arbitrary standards as to methods . . . which may be interesting to him but is worthless for anybody else” (quoted in Wheatley 1988, 51)—the AMA made effective use of this public outcry. The CME adopted a recurring system of ranking schools based on Flexner's criteria, ensuring the continued saliency of the report. The CME exerted continuous pressure on medical schools by only recognizing graduates from schools that met these criteria, and later using their influence on licensing boards to essentially legalize these standards. Through this continuous pressure and its later cozy relationship with licensing boards, the CME became, de facto, “a national accrediting agency for medical schools, as an increasing number of states adopted its judgments of unacceptable institutions” (Starr 1982, 121).

While the report focused public attention on medical education and elevated the cultural cachet of Johns Hopkins, its most lasting significance was in capturing philanthropic attention (Duffy 1993). Much of the reforms were less the result of the Flexner Report and more of the carrot offered by foundations (Stevens 1971). To carry out the proposed reforms—“an enormously expensive affair” (Welch 1920b, 59)—reformers needed copious institutional support. Once again, Rockefeller money was paramount. Gates devoured the Flexner Report, viewing it as a road map for future Rockefeller giving. When he invited the author to lunch to discuss it, Flexner pointed to two maps in his book—one showing the locations of the medical schools he visited, the other showing what the country needed. “ ‘How much would it cost to convert the first map into the second?' Gates asked and Flexner replied, ‘It might cost a billion dollars.' ‘Alright,' Gates announced, ‘we've got the money, come down here and we'll give it to you' ” (quoted in Cher-now 1998, 492). Later, when Gates posed a hypothetical question to Flexner about the best way to invest $1 million in medical science, Flexner replied
that
he would give the money to Welch to do what he liked with it. Gates agreed, further consecrating Welch's vision at Johns Hopkins “as the prototype to be emulated by recipients of Rockefeller money” (Chernow 1998, 492). With Gates support, the Rockefeller philanthropies used the Flexner Report to guide their giving, a policy formally institutionalized when Rockefeller invited Flexner to serve on the foundation's General Education Board (GEB).

In the end, Flexner provided the blueprint; Gates provided the financial resources and incentives to make Flexner's suggestions a reality. Controlling the allocation of Rockefeller funds, Gates and Flexner, in consultation with Welch, were able to choose the winners and losers in medical education. And education reform was the chief mechanism by which doctors established bacteriology as a key piece in the professionalization of medicine. For Flexner and his colleagues, rationalizing medical education meant standardizing it as an education focused on scientific research in the laboratory. Previously, there were many possible routes to becoming a doctor; now there was only one—through the laboratory. Reformers did not have to choose a one-size-fits-all model of education; indeed, many clinicians clamored for a medical educational system with multiple tiers (Ludmerer 1985). But Flexner was insistent; an acceptable medical education needed to look like that of Hopkins. By effectively forcing medical schools to adopt the scientific model of medical education in order to receive philanthropic funding, educational reformers dashed any dreams of diversity in medical training. Doctors were to become scientists. Medicine was to have a single epistemological foundation.

These reforms were realized not by popular fiat among the rank and file of the profession—indeed many clinicians disparaged the reforms—nor by convincing state legislatures to back them. Instead, elite bacteriological reformers built a new model of medical education by convincing a few philanthropies to bankroll their program.

EPISTEMIC CLOSURE

While medical education was central because it socialized future generations into the epistemology of the laboratory, other institutions like hospitals, licensing laws, and boards of health were consolidated as well under the laboratory. This consolidation, along a number of different fronts, was not achieved without struggle. Nevertheless, by 1920, medical reformers
had
achieved epistemic closure by radically remaking the organization of American medicine along the lines of the laboratory. As E. O. Shakespeare imagined with cholera, all diseases would be filtered through the laboratory, which would identify, understand, and then finally eliminate them.

Hospitals and the Full-Time Controversy

During the nineteenth century, the hospital was a marginal institution established to serve the poor (Duffy 1993; Rosen and Rosenberg 1983; Rosenberg 1977, 1987; Rosner 1982; Rothman 1991; Starr 1982). Given the profession's commitment to bedside empiricism, the locus of medical practice was the patient's home. Yet as the new epistemology of the laboratory reallocated the valuation of evidence away from idiosyncratic bedside observations to laboratory tests, doctors increasingly needed access to labs to practice medicine. Because the costs of establishing laboratories were prohibitive for all but the most elite practitioners, hospitals became a central location where doctors could access the services of the lab:
⁷
“There ought to be, there must be laboratory facilities in and directly connected with every modern hospital. It requires no demonstration that rational treatment is not possible without a correct and minute diagnosis” (Jacobi 1897, 114). With the ascendency of the laboratory, hospitals assumed a prominent place in medicine, morphing from locally based charitable institutions, under the control of lay trustees, into large-scale bureaucracies committed to medical science (Duffy 1993: Rosenberg 1987a; Rosner 1982).

This reorganization of the hospital was inextricably tied to educational reforms. One of Welch's innovations at Hopkins was to integrate the hospital into medical education. Welch viewed the hospital, and the clinical work that went on there, as an extension of the lab: “The teaching of the clinical subjects should be carried out along the same general lines as those of the laboratory” (Welch 1920b, 127). In his report, Flexner codified this view in establishing standards for medical education, going so far as to define the hospital as a lab itself (Flexner 1910, 57). When he joined Rockefeller's GEB, Flexner sought to extend this Hopkins model to all medical schools by requiring clinicians who taught in medical schools to become full-time faculty, to renounce their private practices, and to focus on research and teaching. From the start, faculty who taught the basic laboratory sciences were hired on a full-time basis, an employment status that spoke to the primacy of research in their identity as scientists. Clinical faculty, however, had a more ambiguous status with ties both to the school and to their own
private
practices. Indeed, hospitals had long served an important role in advancing the careers of local elite doctors (Rosenberg 1987a). Flexner viewed this as a conflict of interest that left clinicians susceptible to the corrupting influence of commercialism and careerism. To remedy this situation, he acquired Rockefeller funding for an experimental clinical full-time program at Hopkins. Satisfied with the results there, he planned to extend the program to all medical schools.

Flexner's full-time program unleashed a powerful backlash among clinicians who saw medicine more as an art than a science. They denounced the program as a bald attempt to bring clinicians under the control of laboratory technicians, worrying that it “might remove them from the beside to the bench” (Maulitz 1979, 92). While many clinicians welcomed the new tools offered by the laboratory, they were hesitant to privilege laboratory knowledge over clinical experience. After all, the bulk of regulars still practiced in ways far removed from the new ideals of biomedical research (Katz 2002, 41). It was alright for the lab to dictate the practices of public health officials, but when it came to the practice of medicine, clinicians were to have the final word. Some cautioned the profession against succumbing to “bacteriomania” (Jacobi 1885, 172). Others, like Alfred L. Loomis (1888b, 70), the president of the New York State Medical Society, warned those who were in haste to elevate “the experimental above the practical” of the fetishization of the laboratory. Allopathic physicians,

cannot safely forsake the rich storehouses of clinical observations that have been gathered by so many master-minds, and withdraw into the recesses of the laboratory; for although in the work of the laboratory we hope to find the solution to many of the problems with which we are now struggling, it must be remembered that the special field of medical investigation is, and ever will be, the study of disease in its activities. (Loomis 1888b, 70)

Noting laboratory science's limited impact on therapeutics, clinicians worried that their pupils would lose perspective in an educational program focused primarily on the laboratory, as they whiled away their precious time “in the labyrinths of Chemistry and Physiology” (Bigelow 1871, 8). William Osler, perhaps the most distinguished clinician in the United States, vehemently opposed the full-time program, lamenting “the evolution through
out
the country of a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only interest was research” (Wheatley 1988, 69).

Pitted against the well-connected and resource-rich network of bacteriologists, clinicians could not compete with the power of Rockefeller's money. Flexner, refusing to bow to pressure, made the full-time program the centerpiece of the GEB's reforms; medical schools that sought Rockefeller money had to pass a litmus test to receive funds. No full-time program, no money. Medical schools were all but required to adopt it to survive. As more and more university hospitals embraced the full-time program and used the funds to build up their infrastructures, hospitals generally became organized according to the epistemology of the laboratory. In the internal allopathic debate over medicine as an art versus medicine as a science, science won. Once again, Rockefeller finances dictated the winners and losers. Local cliques of clinical physicians were replaced with a national network of clinical scientists, shifting the power in the hospitals from local communities to Welch's network of laboratory scientists (Wheatley 1988). And lay trustees, long the governors of hospitals, were elbowed aside as control went to Flexner's physician/scientists (Rosenberg 1987a).