The University of Michigan, an encyclopedic survey ... Wilfred B. Shaw, editor.

Administration and Policies

In the memorandum outlining the functions of the Hospital drawn up by Dr. Abram Sager in 1869, certain fundamental principles were set forth, although it required time for some of them to be realized effectively. Dr. Sager assumed that the University "did not on the one hand design to offer [the Hospital] as a public charity, nor on the other, intend rigidly to restrict its benefits to those who were competent to meet the necessary charge for maintenance." He suggested that "the main object of a hospital … is to utilize for practical instruction all the clinical material that may present itself." With these objectives in view Sager suggested that the Hospital should be kept open throughout the entire year. This was twenty-four years before the University summer session was opened, and thirty-three years before the summer session in medicine was begun in 1902.

No person was to be admitted for treatment except upon his willingness to contribute directly or indirectly to the "main object of the institution." No patients should be admitted who were not willing to be utilized for class instruction.

The general management of the Hospital was to be under the control of the medical faculty, with the patients under the charge of the Hospital staff "consisting of the Professors of the Practical branches of the University." It was also suggested that "the charge for maintenance should be placed at the lowest rates consistent with the avoidance of actual loss." This last provision was for many years a bone of contention between the Regents and the clinical faculty, especially in later years when the cost of hospital care was largely augmented. The Regents insisted that the Hospital be self-supporting; the clinical faculty always maintained that low charges were

necessary to furnish the maximum amount of teaching material. Thus, for many years, the Regents maintained financial control of the Hospital's operations, and the medical faculty exercised immediate supervision over admission of patients and educational policies.

Whether a medical school should own its own hospital or utilize affiliated institutions has been much discussed during the past fifty years. Naturally, every school has defended its own system. To many, the use of a hospital by a medical school without the problems incident to its control appears advantageous. In reality, there always have been difficulties. President Charles W. Eliot observed in his report for the year 1888:

The School [Harvard Medical School] labors under some disadvantage because it has no official influence over the appointments in any hospital. It receives indispensable aid and furtherance from all the principal hospitals and Infirmaries in and about Boston, and it has always been in especially intimate relations with the Massachusetts General Hospital; nevertheless, there is not a single hospital, infirmary, or dispensary over the appointments in which it has the least control. Yet no clinical teacher in a medical school can do his work properly unless he has rightful access to a large hospital or infirmary. When, therefore, a vacancy occurs in some clinical department of teaching in the Medical School, the question before the Governing Board of the University is — not who is the most available man for the place in Boston or elsewhere — but who is the most available man as a teacher among the Boston practitioners already holding cognate hospital appointments given by other Boards of Trustees. (Harrington, p. 1079.)

The principle that the Hospital ought to be self-supporting had much to do with the remarkable success of the Medical School. Charges were to be so fixed that the Hospital was to pay its own way and was to be no financial burden upon the University. It was not possible to carry out this program completely, and after the first few years state appropriations for maintenance supplemented the income from patients for board, medicine, unusual appliances, and special nursing. This state support, first provided in 1877 to enable the Hospital to keep open during the summer term, was continued through the summer of 1918. In 1892 the superintendent stated that his current report included only running expenses, not maintenance or permanent expenses (R.P., 1891-96, p. 104), though just what the difference was between maintenance and running expenses is not clear. Since 1918 the principle of self-support has been followed with a fair degree of consistency, with deficits in one year balanced by increased income in others. Without the rigid adherence to this rule in recent years one can imagine the mounting expense of the present Hospital of some 1,350 beds, with an annual budget, in 1940, of more than two million dollars.

During the period while the new Hospital was in the course of construction and immediately after it was occupied, the question of full-time service on the part of the clinical members of the Hospital staff was under serious — and sometimes heated — discussion. The faculty had voted in June, 1919, that the chairs of surgery and internal medicine should be filled by teachers giving full-time service to the University, with a salary from University funds supplemented by a further amount from the income of the Hospital. The appointment of Dr. Hugh Cabot as Professor of Surgery in 1919, an active advocate of the plan, made certain its adoption at Michigan, even though many members of the medical faculty were doubtful about its desirability or practicability.

In a statement made to the Regents by Dr. Cabot in January, 1920, he defined

full time as "the requirement on the part of members of the Department of Surgery to give their whole time to teaching and to the care of patients at the University Hospital." By this plan, he maintained, teachers would devote their entire time and thought to the work of the Hospital, and the resulting conflict between duty to the University and the support and education of a family would be avoided. He pointed out that the income of a teacher in a clinical service arose from two sources, his work as an instructor and his "market value" as a practitioner of medicine. This fact must be recognized in assessing a proper income for such teachers, or the best men would be unwilling to limit their incomes to the ordinary University professorial salaries. He proposed that while his salary as a teacher should be equivalent to salaries in other departments of instruction, the clinical instructor should also be paid an additional amount from patients' fees, to be collected by the University and allocated in accordance with the importance of his medical and surgical services. The amount of the whole compensation should be fixed so that it would bear some relation to the income he would receive as a practitioner.

A few months later, in December, 1920, the Regents adopted a resolution establishing full-time chairs "as soon as the new Hospital building is prepared." In the final event, the plan proved only partly successful. The salaries in the Medical School were criticized by members of the other faculties of the University, while the medical profession in the state was equally critical because of what they felt was a threat to the practice of doctors in local communities throughout the state.

With the opening of the new Hospital, the question was again brought up for consideration, and in February, 1927, the Regents declared full-time service in the Medical School to "comprehend the policy of using the surplus earnings of the full-time departments … for increasing and supplementing expenditures for salaries, supplies, and equipment." Nevertheless, the whole question continued to be a vexing one, and in May, 1929, a committee composed of Regents, members of the medical faculty, and University officers was set up to study and report on the problem. This committee reported informally from time to time, and their consideration eventually led to a resolution on the part of the Regents that on and after July 1, 1932, full time should "cease to be mandatory in the clinical departments" (R.P., 1929-32, p. 868). Within a few years after the passage of this measure, the status of some members who had been serving on a full-time basis had been changed to part time.

The question of part-time service had been affected also by the fact that throughout the early years of the Hospital little or no accommodation was given to private patients. After 1881 patients were those referred to the Hospital from the local communities or by the state. This restriction upon the patients admitted to the Hospital gave rise to the establishment of other hospitals in Ann Arbor. These included a number of private hospitals maintained by members of the University's medical staff. With the coming of Dr. Cabot a few private surgical patients were admitted to the Hospital, and the situation was finally clearly defined in December, 1932, when the Regents approved special provisions on two floors of the surgical wing for the private patients of part-time members of the faculty. In 1939-40, a little more than 41 per cent of the patients were referred by physicians or were University students. A relatively small number (about 3 per cent) were

employees of the Hospital; the remainder were admitted to the Hospital under the various state laws for indigent adults and children.

Hospital superintendents. — When the first little hospital was established on the campus in 1869, John Carrington became janitor or steward (the terms appeared interchangeably), and his wife was matron. He was to prepare the dietary for the hospital patients, keep the fires, and care for the rooms and beds, in return for which he and his family were to "have residence" in the Hospital and receive seventy-five cents per week for each patient. Another couple continued this arrangement for a year or so. After that for a period of some fifteen years, there is no record of a hospital steward, but in 1874 the position of hospital physician was created. It was first held by Dr. Robert J. Peare, denominated by Dr. Sager as "the physician in immediate charge of the inmates." Dr. Alexander C. Maclean was appointed Hospital Surgeon in 1877 and was also designated Hospital Superintendent, with the understanding "that he shall be furnished a room in the building … and also contingent upon his assuming the general control of the work of the matron" (R.P., 1876-81, p. 125).

The increasing number of patients and the difficulties of satisfactory administration under this system led eventually to a series of recommendations by the medical faculty submitted to the Regents in June, 1888. Among other measures, it was suggested: "That the price of board be raised to four dollars per week, … That a competent matron and steward be engaged to conduct the culinary department, … and that the present system of boarding patients … be abolished." In December, 1888, the auditing committee reported that they had selected Joseph Clark as steward of the hospitals at a salary of $1,000. Two and one-half years later he was given the title of Superintendent of the Hospitals, including the Homeopathic Hospital.

On completion of the Catherine Street Hospital group in 1891, a series of new rules and regulations provided that the superintendent should have charge of admitting and discharging patients and should also keep records of patients as well as a property inventory, provide for the patients' diet, hire all servants, collect all moneys from patients, and have oversight of each department of the Hospital (R.P., 1886-91, p. 532).

This was the beginning of a more systematic administrative policy. Clark continued to serve until his death in 1897, when he was succeeded by his son, Harry W. Clark, upon whose resignation in 1900, E. S. Gilmore became superintendent. Gilmore, in turn, was followed in 1908 by Jay B. Draper, who had previously been superintendent of the Pontiac Asylum. Draper was hardworking and conscientious, but apparently had little administrative ability. A rigid policy of making the Hospital "pay its own way," although it resulted in a surplus, gave rise to many complaints and was responsible for a general decline in efficiency and morale.

This condition led to an investigation by a committee of the medical faculty, which reported that in all medical affairs the Hospital should be under the direction of the medical faculty. There had been hospital committees of the medical faculty before the Catherine Street Hospital was built, but their powers were limited, particularly in the matter of finances. As a result, with the approval of the Regents, a new Hospital committee, with extended powers, was created in January, 1912. Dr. Reuben Peterson was made Medical Director, with Dean V. C. Vaughan and Dr. De

Nancrède, Dr. Hewlett, Dr. Canfield, and Dr. Barrett as the other members.

This committee, eager to improve conditions, found that their efforts were still limited by the fact that they had no direct control of Hospital finances, which were administered by the Regents. Although friction was bound to result, this system of control worked with fair success until it was given up in 1918. That it worked at all was probably due to the support of Dr. Walter H. Sawyer, chairman of the Regents' Hospital Committee, to whom the Board naturally turned for advice. Then too, any plan of management would have been strained to the breaking point by World War I and the confusion resulting from the enlistment of a great part of the Hospital staff.

A summary of a report made to President Hutchins by the Medical Director in 1915, outlines the general situation of the Hospital at that time. In this report it was pointed out that the reorganization of the Hospital along modern lines was no easy task, since, under nonmedical management, the unsanitary condition of the old building had resulted in many cases of erysipelas, tonsilitis, and bronchial infections among both patients and nurses. This condition had been remedied and the Hospital had been made clean and sanitary, reducing these avoidable diseases to a minimum. One of the best general kitchens in the state had been installed, as well as a bakery, ward serving-rooms, and a nurses' diet kitchen.

The report also stated that the new Interns' Home had obviated the humiliation of losing the best senior students as interns to other hospitals. A Hospital usher who received patients as they entered and saw that they were escorted to the proper departments, also ended many complaints. An increase in the teaching and supervisory staff of the Training School for Nurses made unnecessary the use of outside nurses unless they were employed by the patients. A trained social service worker, first appointed in 1912, also gradually changed the general tone of the Hospital, bringing the patients to feel that the authorities were interested in them as well as in their bodily ills. Moreover, the twenty-four bed Contagious Disease Hospital brought relief from financial loss caused by quarantines arising from the presence of contagious diseases in the wards. Compulsory Wassermann examinations were given free of charge to all Hospital patients.

As a result of these progressive measures, a deficit incurred in the years 1911-14, because of the increased number of patients, became a surplus in 1914-15. The report mentioned many inadequacies in the plant and emphasized the impossibility of making it over into a modern hospital. It also called attention to the need for a new nurses' home. Despite these deficiencies and handicaps, the report concluded that the institution was as good a teaching hospital as existed anywhere in the country. One great advantage in the increase of control on the part of the Hospital committee lay in the knowledge thus acquired by the faculty members of the committee of the difficulties of hospital management.

Superintendent Draper was killed in a streetcar accident on November 13, 1915, and Robert G. Greve, then in the office of the Secretary of the University, was appointed temporary Superintendent of the Hospital. He held the position until 1918. This was a period of peculiar difficulty because of the problems arising from World War I and from the limited number of nurses, especially during the influenza epidemic of 1918. Moreover, the war also placed those connected with the Hospital in a peculiarly embarrassing position, because the faculty, as teachers, were urged to remain at their posts in

order that the Army would be assured an adequate supply of doctors, whereas the War Department naturally welcomed enlistment of highly trained doctors and surgeons in the Army Medical Corps.

When it was evident that war was imminent, this situation was discussed at a meeting of hospital clinicians held in March, 1917. A statement was drawn up by this group pointing out that the Medical School, in its clinical program, differed from other schools, since its staff was never more than sufficient to ensure good medical and surgical care. The staff at that time included forty-one physicians, all of whom were members of the medical faculty, and their teaching duties were necessarily closely interrelated with the care of their patients. A loss of eight men (20 per cent of the staff) was the maximum depletion that could be allowed if the clinical teaching program were still to be maintained. Reduction of the faculty beyond a certain point would either limit the number of admissions to the Hospital, with a corresponding lessening of service to citizens of the state, or else result in inadequate instruction and the lowering of standards in the treatment of patients.

The members of the staff expressed their willingness to do what was best for the country and signified their readiness to serve in the Medical Officers' Reserve Corps, although it was suggested that a plan be devised which would prevent too serious a reduction of the teaching staff. But, as the war progressed, conditions in the Hospital became worse, and eventually the personnel was depleted by nearly 50 per cent.

When the new and greatly enlarged University Hospital became a certainty in 1917, it was evident that the old system, under which a member of the medical faculty served as medical director, was inadequate and that a medical superintendent and director should be secured who could give his whole time to the administration of the Hospital. Dr. Peterson, then absent under an Army commission, accordingly resigned, and Dr. Christopher G. Parnall, of Jackson, Michigan, a graduate of the Department of Medicine and Surgery in 1904, and experienced in hospital executive work and instruction, was made Medical Superintendent and Director in April, 1918, with the expectation that he would give his whole time to the affairs of the Hospital. Somewhat later he was also made Professor of Administrative Medicine.

In Dr. Parnall's first annual report, which covered the year ending June 30, 1919, it was pointed out that the University Hospital had become one of the great teaching hospitals of the country. Despite yearly admissions numbering nine thousand and an equally large number of outpatients, there was a long waiting list, especially in the surgical service. The Hospital served, in effect, as an infirmary for the entire state, with patients referred to it from every county — particularly from those without adequate hospital facilities. Dr. Parnall served as Superintendent until 1924. During his term of office he promoted many new ideas in organization and administration and was responsible for the planning and designing of the present Hospital building.

After Dr. Parnall's resignation Mr. Greve again served for a short time as Acting Director prior to the appointment of Dr. Harley A. Haynes, who came to the Hospital after many years' experience as director of the State Hospital at Lapeer. In the course of his tenure many radical changes took place in the policies and administration of the Hospital and in its organization in relationship to the University. Dr. Haynes's institutional experience helped him to keep the Hospital doors open during legislative and financial difficulties, during panics and

war, and aided him in the solution of multiple problems ever present in such an institution.

Shortly after Dr. Haynes was appointed, Dr. Albert C. Kerlikowske ('24m) became Chief Resident Physician and, in 1928, Assistant Medical Director of the Hospital.

Development of intern system. — Throughout the early years of the Hospital, the problem of interns, or house physicians, was never satisfactorily settled. Although essential to the proper conduct of a hospital, for many years they occupied an inferior position and were more or less looked down upon by the hospital chiefs. By 1890, however, it came to be recognized in medical schools that experience was a valuable asset for young doctors before they went into practice.

Thus, although the beginnings were very modest, a system of internship gradually developed. A Hospital physician, later called resident physician, was first appointed in 1874 and doubtless performed many of the functions of an intern. In 1895 both a house physician and a house surgeon were listed in the Announcement. The first interns under that designation, four in number, were listed in the Calendar for 1899-1900 and were given a salary of $125 a year with room and board.

For some years after those first appointments the intern system was far from satisfactorily organized. Some ambitious students in applying for positions as interns secured recommendations to more than one hospital, leaving to their faculty sponsors the duty of explaining their failure to accept appointments in other hospitals to which they had applied. This led, of course, to great confusion.

To meet this situation the medical faculty in 1911 appointed a committee to systematize the entire program. To this committee, composed of Dean Vaughan, Dr. Hewlett, and Dr. Peterson, all requests and recommendations for internships were to be referred. Dr. Peterson in laying the matter before the Council on Medical Education of the American Medical Association reported that the committee felt that a firsthand knowledge of the best hospitals throughout the country should be obtained and that appointments to positions in these hospitals, as well as certification of the students' fitness, should be made. A plan for a fifth clinical year in the medical curriculum at Michigan was considered, but was never put into practice.

The admission of students to internship in the Hospital was thus gradually systematized. The situation was strengthened in 1922 by the passage of a law requiring all medical graduates to serve one year in an accredited hospital before beginning to practice. In 1940 thirty-five interns were on the Hospital staff. They rotated among the various clinical services. There were also approximately forty assistant residents, who served for a second year, and thirty resident physicians, who stayed for a third year.

As the University Hospital expanded and more and more interns were required the question of adequate quarters for them, as well as for the house physicians, became pressing. An old residence, moved to the Hospital site, was made over into an interns' home in 1914 at a cost of $2,500, and three years later an enlargement was authorized, so that the building accommodated fourteen men. The third floor of the Hospital Administration Building was also used, as well as a near-by residence taken over for the purpose. These makeshifts were so unsatisfactory, however, that in 1939, a new building for interns, housing some seventy-five men, was erected at the rear of the main Hospital building.

Medical museums and memorials. — In 1935, largely at the suggestion of Dr. Peterson, it was decided to start a collection of medical and surgical apparatus which had been in use in the Hospital. Cases containing items of interest were placed in the teaching amphitheater and in a small room off the Hospital library. The material thus exhibited includes instruments, splints, stethoscopes, and old X-ray equipment.

To preserve the memory of some of the men whose lives were an inspiration in the organization and development of services within the Hospital, from time to time memorial tablets have been placed on walls within the Hospital. These memorial tablets have thus commemorated the services of Regent Walter H. Sawyer, Albion W. Hewlett, James G. Van Zwaluwenburg, George E. Frothingham, Aldred S. Warthin, A. B. Palmer, and Reuben Peterson.

It would be impossible to enumerate the many generous gifts which the Hospital has received over the years, all expressing the particular interests and desires of the donors. They comprise buildings, research and teaching funds, scholarships and fellowships, as well as small individual gifts, all of which have contributed to the development and growth of the Hospital and its services to thousands of patients.

Reuben Peterson[Died November 25, 1942.]

Wilfred B. Shaw