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

UNIVERSITY OF MICHIGAN MEDICAL CENTER

A survey of the Medical Center for the period 1940-70 can only be based on the remarkable and profound increase in medical knowledge and the innovations in patient care which mark this era. Development of new drugs, innovative and sophisticated diagnostic procedures, new concepts of patient care, and revolutionary knowledge from the many fields of research are only part of the great medical advances of this period.

Drugs have become available for the effective control of gonorrhea, syphilis, tuberculosis, and osteomyelitis. Space and facilities formerly set aside for the specific purpose of treating these diseases now have been converted to accomodate other activities. Anticoagulant drugs are widely used in the treatment of thrombo-embolic diseases. Chemotherapeutic agents, used in conjunction with surgical and radiological treatment, have achieved recognition as effective adjuncts in cancer therapy. The development of biological contraceptives and their widespread use have greatly modified the activities of the staff of obstetrics and gynecology. Cortisone, a hormone produced by the adrenal cortex, and ACTH, which stimulates the adrenals to pour out various hormones, have found broad usefulness in medical practice. The tremors of Parkinson's Disease have been controlled by surgical interruption of affected pathways, and more recently by the administration of drugs. The dangers of general anesthesia have been reduced considerably by newly-available agents in various combinations to produce the degree of unconsciousness, relief of pain, and muscular relaxation desirable. The perfection and widespread innoculation of the Salk vaccine have resulted in the virtual disappearance of paralytic poliomyelitis. The use of tranquilizing drugs was developed during this period and still occupies an important place in the treatment of psychiatric disorders.

Many ingenious and sophisticated diagnostic and therapeutic procedures have become available since 1940 and are now in extensive daily use. In the field of cardiovascular disease, angiography has developed and improved to become a safe and valuable means of investigating the nature and extent of disease involving the heart and circulatory system. Disease states which involve the

blood supply to the liver and pancreas and to the vessels which supply the intestinal tract are now explored effectively by injection of the hepatic and epigastric arteries. In renal disease, the physician's ability to map the blood supply to both kidneys in great detail makes possible the recognition of numerous maladies through the use of angiography.

In addition to the broad field of angiography, cardiovascular medicine now has at its disposal electronic instruments which can stop and start cardiac action and replace normal pacemaking impulses when these are defective. The electrocardiograph is now a common procedure in the diagnosis of the existence and location of myocardial infarction. Highly dependable mechanical pumps have been developed which can maintain adequate circulation of the blood when the entire heart is bypassed, making possible direct surgical approach to cardiac defects, congenital and acquired, which incapacitate and threaten the lives of a sizeable number of patients.

The visualization of deep-seated structures is no longer restricted to traditional methods of x-ray examination or those that depend upon bloodstream opacification. Nuclear medicine has made its debut and forged ahead into a position of great importance in the diagnosis of disease. The techniques of organ and tissue scanning have been applied to the brain, the thyroid, the liver, the kidneys, and other organs.

New concepts and practices are now being employed in the treatment of the mentally ill. Pharmacologic preparations which have psychotherapeutic properties are in use, and group therapy is now an accepted psychotherapy as well as that administered on a one-to-one basis. Clinical output has been expanded considerably by the addition of clinical psychologists, social workers, and occupational therapists to the psychiatric team.

Ingenious devices and methods are now being used for some of the more severe types of skeletal fracture, such as metallic splints driven into the marrow cavity of long bones and early nailing of femoral neck fractures. Badly deteriorated joint structures in many instances are replaced with prosthetic devices. The "Pap" test has become routine in the search for early cytologic signs of cancer of the uterus. The specialized radiology technique of mammography has been similarly serviceable in the detection of breast cancer. Renal dialysis serves an ever-increasing number of individuals with extensively

diseased kidneys. The treatment of malignant neoplasms with external radiation has undergone a phenomenal change with the advent and availability of super-voltage generating equipment, which makes it possible to deliver lethal doses of radiation to malignant tumors with far less damage to surrounding normal tissue. Blood transfusion, without which the survival rates of many surgical procedures would be greatly decreased, is today a commonplace procedure. Blood transfusion is also used in nonsurgical situations involving blood loss or failure of adequate blood production.

The development of x-ray equipment, which incorporates electronic image and linkage with television monitors, has transfigured a sizeable fraction of the diagnostic service rendered by radiology. It replaces the cumbersome fluoroscopic technique, has eliminated the necessity of working in darkened rooms, and has made fluoroscopic information available by direct observation and, by means of tape recording and replay, to large groups of individuals, including medical students.

The clinical practice of early ambulation of postsurgical patients has been of tremendous importance in reducing fatalities resulting from spontaneous vascular thrombosis and the development of postsurgical pneumonia. New concepts of neonatal and perinatal patient care have revolutionized the handling of the newborn. Abnormalities carrying high mortality risks are now readily recognized, and steps for their correction are available.

These examples cited by no means include the full list of medical innovations which have determined the direction of changes in the Medical Center facilities and operation during the past thirty years. They do, however, indicate the extent to which new-found knowledge, when translated into actual patient care, must inevitably affect all segments of hospital and clinical operation, as well as Medical School content.

Another feature of the 1940-70 era was the sudden and seemingly unlimited availability of federal funds in support of research and education. In the year 1940-41, total funds available for these purposes from outside agencies, both federal and private, amounted to no more than $137,000 a year. Ten years later the figure has risen to better than half a million and in the next five years the $1 million had been reached. In the next fifteen years, available funds for research and education rose to more than $12 million — a flood of financial support. The Medical

School, particularly its preclinical departments, was given virtual carte blanche to devote its major energies to research. The past thirty years have seen a massive invasion of third parties into the time-honored prerogative of physicians in matters of patterns of performance and levels of remuneration. The expansion of Blue Cross-Blue Shield and other forms of repayment coverage have resulted inevitably in considerable dictation by these groups in matters of professional performance and charges. The federal government's program of Medicare and Medicaid has thrown further burdens on the supporting staff of the hospital in matters of the program and financing of patient care. Commercial plans have continued to expand and multiply, further complicating billing procedures for both physician and hospital. The Medical Center has accepted this new impact upon the management of its own affairs, and has modified its planning and performance.

For all aspects of medical care and medical education at the University of Michigan the 1940-70 era represents a period of great expansion both in the matter of physical plant facilities, the student body, the faculty, and the organizational structure of the Medical School and Hospital. Geographical shifting of medical activities from the original site on South University to North University to Catherine Street and ultimately to Ann Street progressed at increasing tempo until, in 1969, the last of the Medical School's holdings on the main campus, "East Medical," was abandoned with the move into the newly completed Medical Science II facility. With this move the development in the 53 acres surrounding the Main Hospital on Ann Street truly became the University of Michigan Medical Center. In terms of area, from 1940 to 1970, the total square footage of buildings available for medical education research and patient care purposes has increased from approximately 950,000 to 2,409,632 square feet. Fifteen new buildings have been constructed and occupied, and, in addition, there has been very extensive remodeling of the Main Hospital to modernize facilities and to accommodate activities entirely unheard of prior to 1940.

During the thirty-year period three new departments of the Medical School have been created, Physical Medicine and Rehabilitation, Anesthesiology, and Human Genetics. Within the Medical School's framework, four new institutes have been established, the Institute of Mental Health Research, the Buhl Institute for Human Genetics Research, the Upjohn Institute for Clinical Pharmacological Research,

and the Holden Institute for Perinatal Care Research. In addition to the appointment of chairmen of the three newly created departments, leadership has changed hands in all of the remaining 17 at least once. There were two such replacement appointments in Dermatology, Ophthalmology, and Otorhinolaryngology during the period, while in the case of Microbiology, Pediatrics, and Postgraduate Medicine there were three. Nine of the newly appointed chairmen came from other schools, 15 from the existing faculty of this institution.

Student teaching in the Medical Center involves, in addition to candidates for the M.D. degree, numbers of students from the Dental School, the School of Nursing, the College of Pharmacy, the School of Public Health, and other University units. Also, the various preclinical departments have sizeable complements of graduate students, and to a lesser extent this is true in the clinical departments of the Medical School. The Department of Postgraduate Medicine arranges and provides instruction for another sizeable group of individuals. The total undergraduate student body of the Medical School in 1940-41 was 472 compared with 861 in 1970-71. In terms of full-time equivalents, the total teaching load in the Medical School reached 2,564 in 1970-71, when the hospital housestaff and dental, pharmacy, nursing, and postgraduate students are counted. During the war years Medical School teaching was accelerated in order to turn out more physicians in a shorter than normal period of time.

Throughout the 30-year interval 1940-70 the Medical School, responding to insistent demands by the state legislature for greater health manpower output, extended itself to increase the size of entering classes. In order to make this possible the legislature was asked for funds to build the present Outpatient Clinic in order to expand the then existing resources for clinical instruction. This building was occupied in 1952 and the incoming undergraduate medical classes were increased from 165 to 204. It was pointed out at that time by the administration of the Medical School that a second step would be necessary, designed to increase the teaching capacity of the preclinical divisions. In 1958 the first unit of the Medical Science buildings was ready for occupancy. This building, closely adjoining the School of Nursing, with a connecting bridge to the Hospital, provided adequate accommodations for the departments of Pathology, Biological Chemistry, and Pharmacology, all of which, with the Medical School administration, were moved into the new quarters from the old "West Medical Building" on South University

Avenue. The second stage of preclinical resource expansion was accomplished with the completion of Medical Science II in 1969. Into this building, Anatomy, Microbiology, and Physiology were moved from the "East Medical Building" on South University Avenue. The Department of Human Genetics, whose research activities were largely confined to the new Buhl Institute for Human Genetics Research, moved its remaining activities to Medical Science II from one of the very old buildings of the Catherine Street complex, originally constructed in 1910 as the eye and ear ward.

Keeping its faith with the legislature in view of these increased provisions for instruction and research, incoming classes of medical students were increased in size from the 1940 level of 120 to 200, 210, and then 225 with a corresponding increase in the number of degrees granted each year. The largest class ever to be graduated from the University of Michigan Medical School — 202 — received their diplomas in June of 1971. Since it was founded, the Medical School has granted 11,757 M.D. degrees.

The matter of selecting applicants to be admitted has been a large and complicated activity. In addition to its demands for greater physician output, the legislature has made it abundantly clear that the major priorities are to be given to applications of Michigan residents. The Medical School has complied by restricting sharply the number of nonresidents accepted. Nonresident tuition has been increased to match the level established by the large schools in the East. At present, incoming classes of 225 contain no more than 44 nonresident students. Again, in response to legislative and public desires, minority groups, chiefly Black, receive special consideration. Over the years The University of Michigan has maintained an open-door for Blacks and this School, prior to 1960, is said to have graduated more Black physicians than all other American medical schools combined, with the exception of Howard University and Meharry College. Since 1960 the number of incoming Black students per year has risen steadily from 5 to 25, exceeding the goal for Black student enrollment promised by the University-at-large for the year 1975.

With applicants in the neighborhood of 3,000 each year the matter of final selection has become a sizeable operation entrusted to the Admissions Committee of the faculty whose decisions are put into effect by two members of the Dean's administrative staff responsible for student affairs. Presently, computerized methods of handling the

large mass of data involved are being used with great effectiveness.

With the massive expansion of research activity, particularly in the preclinical divisions, enrollment of graduate degree candidates has reached the level of 311.

The most striking measure of Medical School expansion is the increase in faculty size which has occurred since 1940. This increased during the first forty years of the School's existence from five professors and one student assistant demonstrator to a total of 27 individuals, including all ranks. In 1971-72, total faculty size, exclusive of emeriti, clinical appointees, the intern assistant resident group, and the large numbers of technical assistants attached to the Medical Center, reached a total of 578. The bulk of this dramatic increase, 164 to 578, occurred within the 1940-71 period.

The rapidly enlarging body of medical knowledge and the extensive changes in the character of health care delivery, in addition to the increasing size of the undergraduate student body, have been paralleled by comparable redesign of teaching methods and course content. The traditional fully departmentalized curriculum of the 1940 period has been replaced with teaching which is largely oriented to the numerous recently developed units, divisions, and facilities offering patient care rather than to the 20 established departments.

Major curricular changes have been to move clinical instruction closer to the date of matriculation, to replace didactic clinical instruction very largely with student clerkships, and to redesign the senior year as one chiefly devoted to elective courses. Two "vertical core" programs, each running for two years in succession, begin at the outset of the freshman year. This form of teaching is designed to involve many segments of the faculty in succession in the presentation of a central or core subject. In order to provide adequate faculty coverage for this program, which makes great demands upon faculty talent, it has been necessary to curtail departmentalized teaching of the traditional sort. To this end the individual presentations of the seven preclinical departments were reduced by 40 percent.

Traditionally, medical instruction at the University of Michigan has been provided entirely within the Ann Arbor city limits and almost exclusively in University classroom buildings and hospitals. Student body expansion calls for clinical educational resources considerably in excess of

those owned and operated by the University. It has been necessary to utilize three nearby core hospitals available to the Medical School. These — St. Joseph Mercy Hospital, Ann Arbor Veteran's Administration Hospital, and the Wayne County General Hospital at Eloise — have become essential parts of the clinical teaching facility. More laterally the Henry Ford Hospital in Detroit has become firmly affiliated with the University and in the years ahead probably will be used to augment learning opportunity for medical students in clinical years. The Medical School is now considering the utilization of a number of community hospitals throughout the state for the clinical instruction of its students.

A plan is now under serious study whereby students with suitable educational backgrounds may elect to combine premedical and medical instruction during college years to avoid some of the duplication of instruction which now exists and to ultimately shorten the time required to earn the degree in medicine.

None of these sweeping changes in the pattern of medical instruction could have been achieved without faculty consent and cooperation. The changes have in no way been forced upon the faculty but rather have resulted from a series of three teaching institutes and ten retreats which have been held since 1958, at which the very complex problems of modern medical education have been subjected to intensive study and deliberation. Based upon study of this type, the faculty has authorized the successive steps which have so extensively altered the pattern of curriculum structure.

The governance of the Medical School has changed materially in keeping with the institution's growth and its increasing complexity. From an organization consisting of a Dean, a Secretary of the Faculty, a three-man Executive Committee made up of departmental chairmen, and a nonmedical Registrar or Recorder, the administrative organization has progressed to a Dean, with six associates and assistants, a six-man Executive Committee of the faculty; and, in addition, a nonmedical Registrar and an Administrative Associate, together with a sizeable clerical staff. The Dean's Advisory Council, made up of the chairmen of the School's 20 departments meets with him at weekly intervals to discuss administrative policy and procedure.

The faculty is extensively involved in Medical School administration as a result of efforts by Dean Hubbard

(1959-70) to accomplish that end. In addition to a number of standing committees on admissions, student promotions, academic affairs, etc., ad hoc committees are extensively used by the Dean and the Executive Committee to study matters of immediate concern and to report their findings and recommendations for Executive Committee action.

The most outstanding change in administration of the total Medical Center occurred on July 1, 1969, following the report of the Fauri Committee appointed by President Hatcher to find a suitable successor to Dr. Albert Kerlikowske, who retired as administrator of the University Hospital on June 30. In its report, which nominated Mr. Edward Connors to be the new administrator of the Hospital, the committee discussed at length the need for change in the administration of the Medical Center. It was their recommendation that the long-range interests of the Medical School and Hospital would best be served by creation of a new position to be known as the Dean-Director of the Medical School and Medical Center. Dean William Hubbard, Jr., was designated by the Regents as the first incumbent of that position. He was succeeded April 1, 1970, by Dr. John Gronvall.

In the administrative framework of the Medical Center, both Hospital and Medical School, student and house staff representation and participation in committee activities, has been firmly established.

As defined by the Regents in September 1958, the Medical Center comprises the Medical School, the University Hospital complex, and the School of Nursing. For the first time, as of 1969, all of these component parts are housed to the north of Ann Street, east of Glen. Activities within the Medical Center, as officially defined, involve relationships with the Dental and Engineering Schools, the Schools of Public Health, Pharmacy, and Social Work, and the University Health Service, as well as several departments within the College of Literature, Science, and the Arts — Psychology in particular.