Hopkins’ New Age : Famous Med School Enters 2nd Century Proud of Its Heritage

BALTIMORE —  The opening of the Johns Hopkins Hospital in Baltimore 100 years ago in May, and the Hopkins medical school four years later, greatly influenced the way America trains its doctors. Besides setting the standards of medical education, Hopkins researchers also have made remarkable contributions to the practice of medicine in the 20th Century.

The Chief swept into the hospital lobby, handing his hat, coat and books to the waiting crowd, dispensing a cheery greeting and a wave of his hand.

He led them past the outstretched arms of the 10-foot marble Christ and down the long corridor to the first ward. Gathering at a bed, spectators focused their attention on the patient. And on The Chief.

William Osler, a showman with a high forehead and the bold mustache of a pirate, was in his element. He was teaching medical students at the bedside. And he was making history.

For this was Johns Hopkins Hospital around the turn of the century. And Osler was among a small group of physicians who were helping change the way America trained its doctors.

Emphasis on Research, Experience

With the opening of the hospital in 1889 and the Hopkins medical school in 1893, Osler and his colleagues became the first American medical faculty to demand a college degree from incoming students. They also put a new emphasis on research and on learning by experience.

“From the outset, Johns Hopkins embodied a conception of medical education as a field of graduate study, rooted in basic science and hospital medicine, that was eventually to govern all institutions in the country,” wrote sociologist Paul Starr in his Pulitzer Prize-winning book, “The Social Transformation of American Medicine.”

As Hopkins graduates became professors and scientists all over the country and abroad, “they took a major part in shaping the character of medical education and research in the 20th Century,” Starr wrote.

Johns Hopkins Medical Institutions will formally celebrate 100 years of medicine later this week. The U.S. Postal Service plans to issue a $1 Johns Hopkins stamp, and the prestigious Journal of the American Medical Assn. dedicated its June 2 issue to new research from Hopkins.

Influence Far-Reaching

The Hopkins influence on medicine extends beyond medical education. In the last century, researchers there developed the radical mastectomy for breast cancer, built the first renal dialysis apparatus, crystallized insulin and made many other key contributions.

The Hopkins medical school opened its doors at a time when America had some good medical schools, but also many poor ones, medical historian Lester S. King said in a recent interview.

No national standards governed medical education. Just about anybody could get into a medical school somewhere, often without even a high school education. Some diploma mills conferred a degree in less than a year.

Schools had to compete for access to hospitals and clinics where students could get some training with patients. Most schools could not offer much bedside experience.

In general, American medical schools also lacked laboratory facilities and conducted only limited original research. Germany, by contrast, was leading a scientific transformation of medicine that began in the mid-19th Century, fueled by advances in microscopy, chemistry and physiology.

In America, reformers had been pressing for tougher academic standards, noted University of Minnesota medical historian Leonard G. Wilson. The reformers argued that medical students needed a much better background to study medicine effectively at a time of many advances in such areas as surgery, pathology, bacteriology and biology.

But some medical school professors opposed raising entrance standards. It might discourage a natural genius in the art of healing, they said. And a school that raised its requirements risked losing students to less-rigorous institutions--no small consideration at a time when medical schools depended largely on student fees.

Some of the better schools made major academic improvements during the 1870s and ‘80s. And in 1874, one key reformer told the trustees in charge of establishing Hopkins hospital and university that they had a “precious” chance to set up a top-notch school of their own.

“No medical school already organized has anything like your opportunity,” said Charles William Eliot, president of Harvard University.

The Hopkins trustees had some major advantages. Rather than battling entrenched dogma and professors, they could start from scratch. And rather than having to persuade a hospital to let students into wards, they could make the hospital a teaching tool from the beginning.

When it came to opening the medical school, however, they also had a big problem.

As trustees of the estate of Baltimore financier Johns Hopkins, they were in charge of what was then the largest endowment in American history. The $7 million Hopkins left upon his death in 1873 was to be used for establishing the hospital and a university.

But even as the hospital opened its doors in 1889, the financial prospects for opening the medical school were shaky. Income from the railroad stock that made up the university endowment had dried up.

Four wealthy, well-educated daughters of the trustees offered to raise the needed money, provided the school would admit women on equal terms as men. The trustees agreed.

But by December, 1892, the women had raised less than half the $500,000 the school needed. Other medical schools, knowing of the delay, were trying to lure the Hopkins medical faculty away.

Hard Bargain

Finally, Mary Garrett, a member of the women’s committee, offered to donate the balance--for a price. The school would have to admit only students who had a bachelor’s degree, and a reading knowledge of French and German.

The trustees, swallowing hard at requirements they feared might drive away many prospective students, accepted. “It is lucky that we got in as professors,” Osler told a fellow faculty member. “We could never enter as students.”

It was a relief when 18 students, including three women, showed up to form the first class.

The medical curriculum Hopkins provided was marked not so much by innovation as by combination of features that had appeared in Europe and scattered American schools.

It started with “a clean slate and a bunch of good ideas and good examples,” said medical historian King. Of all the American schools that were trying to improve medical education, “Hopkins went about it with the greatest enthusiasm and effectiveness.”

It was an ambitious enterprise, even apart from requiring a college degree for entry. Few other schools provided well-equipped laboratories in basic science for teachers and students. Hopkins aimed to stress medical research rather than just the passing on of existing knowledge.

The idea was “to give the world men who can not only sail by the old charts, but who can make new and better ones for the use of others,” said John Shaw Billings, a Civil War battlefield surgeon who became a key architect of the medical school curriculum.

Pragmatic Approach

Hopkins also made a policy of learning by doing, both in the laboratory and in the hospital. With Osler as their mentor at the bedside, students took medical histories of patients, performed physical examinations, conducted routine laboratory tests and followed their patients’ course.

As Osler put it, “the student began with the patient, continued with the patient, ended his studies with the patient, using books and lectures as tools, means to an end.”

The school made full-time jobs out of teaching basic science, rather than using local physicians to teach part-time, as most other schools did. The full-time idea, later extended to instructors of medical practice, allowed Hopkins to go outside the local community to lure top-notch faculty members.

Eventually, the school also offered lengthy training in medical specialties to students who had finished the four years of the regular curriculum.

The result of all this was such that in 1901, Harvard’s Eliot congratulated Hopkins University President Daniel Gilman on a “prodigious advancement of medical teaching.”

Among all the changes in the nation of the previous 25 years, Eliot continued, “there is none greater than that wrought in the development of medical teaching and research, and these men whom you, sir, summoned here have led the way.”

Who were those men? Most attention nowadays goes to the Big Four.

The Chief

One was Osler, who had come from Philadelphia to become professor of medicine at the school and physician-in-chief at the hospital. The author of a classic medical text, Osler became one of the nation’s most highly regarded physicians.

Joining him was William Halsted, a shy and excruciatingly meticulous surgeon. He became well-known for such innovations as the radical mastectomy for breast cancer, and his training of other surgeons.

Then there was William Welch, a genial, rotund pathology professor who became a power behind reforms in medical education and stimulated interest in medical philanthropy.

Finally there was Howard Kelly, the gynecological surgeon, who developed and improved that art. He “took pleasure in quick, flashy operating,” one student wrote later. “He’d be in and out of the abdomen almost before you knew it, all the time talking and illustrating what he was doing or about to do.”

Today, Kelly’s operating table serves as a library table, its thick glass top chipped around the edges.

Three Buildings Remain

Of the 17 original hospital buildings, only three remain, hemmed in by the newer boxy homes of the modern hospital and medical school. The old sitting room where Osler wrote his famous textbook is now split into cubicles by blue room dividers, part of an administrative office.

The scene today at Hopkins would astonish the Big Four.

Faint rock music nudges the quiet of a white-walled laboratory as Bert Vogelstein, 39, holds up a dark gray sheet of X-ray film. It shows several series of smudged black lines.

During the days of the Big Four, physicians were just beginning to understand cancer as a disease of abnormal cells. Now, the smudged lines on Vogelstein’s film are helping to explain those abnormalities. They represent an analysis of colon cancer tissue, suggesting that the tumors arose after normal cells lost protection from a gene that suppresses cancer.

In a room crammed with computer terminals, Elliot Fishman, 36, narrates a series of ghostly images. A skull tumbles end over end, revealing its inner detail. A hip bone sways in its pelvic socket like a pendulum. A dark blue liver rotates to reveal patches of cancer that look like popcorn.

Halsted needed a scalpel to peer within patients like this; radiologist Fishman uses sophisticated scanning machines and computer power. The result is three-dimensional images of the body’s interior that can be rotated or manipulated, helping surgeons plan operations well in advance.

New Human Gene on Tape

Victor McKusick, 67, arose shortly after 5 a.m. one recent day at his Baltimore home. He drank some coffee, read the paper, picked up a medical journal article and began to dictate into a small tape recorder. It was time to catalogue a new human gene.

When the Hopkins medical school was founded, the idea of genes was not yet generally accepted, for the work of Austrian monk Gregor Johann Mendel in the 1860s was not yet widely known. Today, McKusick maintains a list of human genes, accessible by computer around the world. The entry he dictated before breakfast that morning was No. 4,584.

But although medicine has advanced greatly since Hopkins began, some things stay the same, noted Hopkins medical historian A. McGehee Harvey.

A committee that reviewed the Hopkins medical curriculum recently endorsed the ideas of learning by doing, and of not only teaching medicine but also emphasizing the importance of creating new knowledge, Harvey said.

“It’s a process of rediscovery,” he said with a smile. “They rediscovered all the principles that were here when the place started.”