IT is easy to be clever at the expense of opulence and to jeer at the contrast of the barracks in which Pasteur achieved his wonders, or the rural milk route of Koch, with the palaces and equipment which have grown like mushrooms from the golden fertilizer scattered over our medical schools. Such triviality, however, obscures the accomplishments which have already resulted from this unexampled generosity, and which have placed American medicine upon a footing approaching equality with that of Europe.
Were it helpful, we could mention offhand a dozen important contributions and double that number of names which might have been to our credit without the Rockefeller donations (to mention only one of these agencies), but which probably would not have been — at least at this early stage. And even were this inaccurate, there is little risk in prophesying increased intellectual velocity from the potential energy now accumulating in young men and women who, for the first time in history, are being given that thorough medical education which furnishes the tools for high endeavor. And the nature of medicine, broadly conceived, is such that no school not highly endowed can furnish this.
These admissions are platitudes to the fair-minded. And it may well be that, such splendid accomplishments conceded, wisdom should remain blind to the threatening centre of the cloud with such a golden lining. But in the minds of many who are in touch with medical institutions a feeling of apprehension is being aroused by the progressively increasing dependence of a great educational system upon one or more centrally controlled funds. And since, in our opinion, this apprehension is based on more than the unworthy caution of suspicious natures, we believe that it should be aired in frank discussion instead of being allowed to ferment in the dark corners of vague and irritated criticism. Our remarks of course do not apply to the Rockefeller organizations alone. The General Education Board idea has appealed to other philanthropists; and for this every sensible medical man should be grateful. But the best way to show gratitude, aside from cultivating one’s own garden to the best of one’s ability, is to contribute what one can to the reaping of the healthiest crop from the generous sowing.
It is true that the criticisms to which we refer are often based on differences of conception in which our own judgment inclines us to side with the foundations. And it may also be said that much of this criticism emanates from sources which have failed to obtain some of the money. On the other hand we believe that, if one searches below the surface, the basis for dissatisfaction, often not clearly understood by the critics themselves, may be found in a foreboding that the guidance of medical education is to a considerable extent passing out of the hands of the universities themselves into the hands of a permanent or, at any rate, selfperpetuating body of gentlemen who, by the very force of the established relations, cannot help extending their influence over all the important centres of American education. Though the expressions of this feeling usually take the form of criticisms of the policies of the leaders of this movement, to whose labors American medicine owes a profound debt of gratitude, the heart of the problem lies not so much in a conflict of opinions as in the growth of a situation inevitably created by existing circumstances.
If, as we believe, there is amid the confusion of much trivial, irritated, and reactionary criticism an element that is objective and thoughtful, nothing can be lost and much may be gained by an attempt to formulate this element in order that it may be freely examined. For it would be unintelligent to bury our heads in the golden sand and, for lack of frank discussion, risk the slowing of a forward movement which owes most of its velocity to the group of public-spirited men who have already accomplished so much for our profession. They have devoted laborious and conscientious years to the development of sound medicine — thoughtfully, with study and contemplation. When they hastened the death of some of the obviously inferior schools and formulated policies of progress for the others, they liberated American medicine. They have ridden their lances into many dragons — but also into a number of windmills, The dragons expired and are gratefully forgotten. But the windmills keep on clattering and dulling the lances. We do not want these Saint Georges to become Don Quixotes merely because, as in the classical case, altered conditions are calling for a change of methods.
We may grant — indeed, it seems to us quite self-evident, because of the nature of the relationship — that the purpose of the responsible governing bodies is solely to spend as much as possible of the available funds, as rapidly as is feasible, for the greatest good. It is inevitable that such boards must be besieged by requests for sums far greater than the endowments they administer, a considerable proportion of which could not be granted without unpardonable laxity in the spirit of trusteeship. Ergo, it has been necessary to have on hand one or more individuals who are constantly studying the problems involved in the development of medical institutions and who can give expert opinions in individual instances. Such experts, therefore, must form opinions and — naturally — must adhere to them after they have obtained all the information possible.
Immediately we have a situation. The expert and his board have opinions. They also have money. The universities, too, have opinions; but often no money; never enough. The trustee-experts with the money — in all honesty, we are convinced — disavow the desire to impose their own views upon the organization of the medical schools. But if they do not approve of such organizations, their methods, or intentions, how can they conscientiously give the money? The medical schools, on the other hand, need the money very badly. Often — we know of such cases — their existence may depend upon the control of a hospital, the possession of a laboratory building. They may have convictions of one kind or another, and they may — perhaps wrongly — believe that a certain procedure is peculiarly suited to their traditions, locality, or what not. But the temptation is great to adjust in the direction that will lead to the needed assistance.
We are not leading up to a discussion of the ‘full-time plan.’ Specific differences of opinion do not properly enter our argument. The point is not who is right about this and who about that; but rather: Does the system which was necessary to achieve the indisputable good so far accomplished carry with it into the future an inevitable uniformity of educational methods; does it inevitably diminish local initiative in educational experiment; and does it, or does it not, by all these tokens, by its very uncontrollable evolution, lead to the establishment of a hierarchy of opinion on matters which, of all human endeavors, are the ones for which freedom of development is most necessary?
The question is not: Is the vast benefit accomplished worth the risk? It has been, so far, undoubtedly. But the question is rather, for the thoughtful: Is the great conception in danger of losing effectiveness? And the reply to this query depends upon the answers to a number of further questions. Is there a tendency among medical schools to adjust their organizations and the nature of some of their important appointments by a process of reasoning in which the influence of such adjustment upon prospective donations plays more than a secondary rôle? Have any of the leaders of individual schools put their pride into their pockets, reconsidered their own decisions, and wandered like Henry the Fourth to Canossa to say, ‘Father, I have erred; give me the two millions ’ ? In short, are there growing indications of an influence, well-intended and so far highly beneficial, which is formularizing our medical educational system by a uniform standard and subtly imposing the beliefs — however wise — of a single group?
None of this may be true. But we believe that there is enough truth in it to necessitate frank and friendly discussion; and we believe this discussion to be especially desirable because we are not among those — and there are such — who see in the situation the sinister tentacles of the octopus reaching for power. The situation is much simpler than that, and less dramatic. There is merely a group of conscientious and well-informed gentlemen who have taken over the arduous duties and responsibilities in connection with a fund which they are trusted to spend wisely and without too much delay. They are guided by a capable scholar who has made himself one of the foremost lay students of medical education. They are beset by a clamor of requests which it is their duty to gratify in so far as they properly can do so. Many of these requests are wise, some of them are less wise, others not wise at all. The trustees have wrought mightily by the only method possible when the field was rough, stony, and full of weeds. The situation that has arisen is not of their making — surely, we believe, not desired by them. But if it exists, why not face it before it has done the harm which may not easily be undone?
To all that we have said there are a number of obvious rejoinders. Indeed our discussion might be reasonably regarded as an entirely gratuitous attack upon an undertaking which is unmatched in the magnanimous application of financial resources. We should not care to risk lending support to reactionary obstinacy, inertia, or professional arrogance. But when these and other still smaller human motives for criticism are eliminated, there remain a number of factors in the situation which are causing misgivings in the minds of the thoughtful who hope for still greater results from these undertakings in the future. Foremost among these factors is this inevitable development of a power, superimposed upon the organized educational system of the country, which — however benevolent in its autocracy — must still retain the last word in any question in which its opinions differ from local judgments. If higher education is to develop in a wholesome manner it must be free to follow many paths, to experiment in many directions — if necessary, to make its own mistakes. The universities are the normal guardians of educational progress. Their organizations and their considerable resources in expert opinion and educational experience entitle them to autonomy of decision, both as to policy and as to details of method. Limit them in this regard and the future will inevitably pay for it. Left free, they may commit errors, fall behind, or even remain — for periods — unmindful of their obligations. But in the long run they will make progress, impelled by the varying problems they encounter, or by the enthusiasms of the particular brand of educational progressive who happens to gain local influence. At any rate they will remain individual and independent of guidance by a sort of superacademic general staff.
We know and repeat that none of these tendencies are deliberately intentional; but that they are bound to eventuate we must also endeavor to make clear. That they have begun to develop seems indicated to us by the considerable uniformity of organization already apparent in the clinical departments of almost all the schools that have received support, and by our impression that leaders in many of these schools — wisely, we admit, but none the less significantly — look to the foundations for advice and guidance at least as much as to their own university councils and colleagues.
It behooves us to ask ourselves whether these conditions are inevitable and inherent accompaniments of the foundation idea — in which case they may be accepted as minor evils overshadowed by a great good. But we note that similar developments have been completely avoided in the world-wide activities of the International Health Board, and it would appear to the observer a simple matter to eliminate them completely from the educational programme of the foundations by a relatively slight adjustment to recent changes in the management of medical schools. Largely owing to the activities of the trustees of the larger funds, these medical schools have matured and have become incorporated departments of universities. They are guided by educational wisdom and experience, and can be trusted to apply with studious conscientiousness any funds they may receive. Is it not reasonable to hope that future donations may be determined purely on the basis of demonstrated needs and bestowed for definite purposes, leaving the details of procedure and organization entirely to the governing bodies of the beneficiary institutions? Surely this would be safe in most cases, and would eliminate irritation and the apprehensions we have mentioned from a relationship which should be one purely of gratitude for great benefactions.
We feel neither called upon nor qualified to enlarge upon the remedy. We have endeavored to make a diagnosis. And we have thought it worth attempting because we believe the conception that underlies the return of great private fortunes to public service a very fine one that demands the coöperation of everyone interested in safeguarding its purposes.
There is, of course, still another way of looking at the situation, but one that seems to us unworthy of the magnanimity which pervades the undertaking — to the effect that, after all, the great fund is a free donation, given under conditions which no one but the donors is entitled to determine; and that institutions which apply for assistance cannot expect to dictate the terms of acceptance. This we believe to be a complete misconception of the intentions of the givers, and far removed from the spirit of those who have administered expenditures; moreover, whatever misgivings we may have of the future, a point of view so crude is unjustified by the experience of the past.