The Connection: The Shared History of the Johns Hopkins and Vanderbilt Medical Centers

By Gottlieb Christian Friesinger II MD

The Connection traces the remarkable relationship between Johns Hopkins Hospital and Vanderbilt Hospital, beginning in 1919 and continuing to this day. More than 400 faculty members, including five deans/vice chancellors of medical affairs and at least twenty department chairs, moved from Hopkins to Vanderbilt and brought the cutting-edge concepts of Hopkins with them. These methods and approaches transformed Vanderbilt and indeed the American medical center into the modern institution it is today. Friesinger tracks the effects on departments, administration, and the practice of medicine itself while bringing to life many of the distinguished—and colorful—individuals who played parts.

• Language: English
• Publisher: Xlibris US
• Release date: Aug 16, 2022
• ISBN: 9781669841869

Gottlieb Christian Friesinger II MD

Gottlieb Christian Friesinger II (1929–2012) was a leading cardiologist at both Johns Hopkins (1955–1971) and Vanderbilt (1971–2012) medical centers. He was on the board of trustees at Hopkins for nineteen years. The Friesinger Society was founded in 2000, and it endowed a chair in his name in 2005 at Vanderbilt. In 1960, he was the first to successfully use the Kouwenhoven defibrillator. His research activities, primarily funded through the National Institutes of Health (NIH), resulted in more than one hundred original publications in peer-reviewed journals, more than twenty-five chapters in textbooks, and the editing of two books. This account, written with authority and affection, reflects the man himself—brilliant, sensible, and insatiably curious. A lifelong learner here shares his knowledge one more time.

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COPYRIGHT © 2022 BY GOTTLIEB CHRISTIAN FRIESINGER II, MD.

All rights reserved. No part of this book may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the copyright owner.

Cover Credit

The Four Doctors, 1906, by John Singer Sargent (1856–1925); courtesy of The Alan Mason Chesney Medical Archives of The Johns Hopkins Medical Institutions.

Rev. date: 08/11/2022

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CONTENTS

Editor’s Preface

Chapter 1 Medicine in 1900

Chapter 2 Present at Creation: Kirkland, Flexner, Robinson

Chapter 3 Setting the Pattern

Chapter 4 A Perfect Dozen

Chapter 5 War and Peace

Chapter 6 Mid-Century Reset and the Second Wave

Chapter 7 The Third Wave: Specialty Medicine Ascendant

Chapter 8 Fourth Wave: Evolution of the Vanderbilt Academic Health Center

Chapter 9 The Connection Continued: Affiliated Hospitals, Women, and Minorities

Epilogue

Editor’s Preface

As learner and teacher, Gottlieb Christian Bud Friesinger II (1929–2012) spent fifty-five years at the Johns Hopkins and Vanderbilt medical schools, 1955 to 2012, with two years out for service as a regimental surgeon in the marines. His professional life began, auspiciously, at the pinnacle of America’s postwar confidence and success, when medicine’s forward march seemed certain and unambiguous. Salk’s Vaccine Works, Polio is Conquered screamed the headlines on April 12, 1955, the same season when Bud Friesinger got his MD from Hopkins. By the time his career ended the mood was different, and it has not improved since his death. The two locales where he spent that career, Hopkins and Vanderbilt, nurtured and sustained him through a change-filled history, and to those two institutions he returned, as if to family, his full measure of devotion. Friesinger was a great physician-scientist in the Osler tradition, not a solo act. The scores of other doctors who appear in these chapters are witnesses, both to his personal connectedness with them and to the institutional connectedness between Hopkins and Vanderbilt that they all shared—the Connection in the title of this book.

In 2008, many years after he came to Vanderbilt, Friesinger gave an interview to the Hopkins house magazine Hopkins Medicine for an alumni section called Where Are They Now? In it he talked about this book, then in the making. He had retired (officially if not actually) in 2002 from Vanderbilt’s Division of Cardiology, which he had founded on the Hopkins model in the 1970s. One of the projects he thought would keep him busy and, as he told his family, prevent him from becoming a dullard, was a harpsichord kit. He needn’t have worried. In fact, his retirement consisted of forty-hour weeks as a volunteer teacher of Vanderbilt’s cardiology fellows and more hours of service on the medical school admissions committee. When he died in 2012 at eighty-three, he still had not managed to assemble the harpsichord.

He recounted to his interviewer how, when he arrived at Hopkins as a student in 1951 from his hometown of Zanesville, Ohio, one of the first things he did was sign up for the history of medicine elective in the Institute for the History of Medicine, founded by William Henry Welch and made famous by Henry Sigerist. While clinical medicine and research were destined to fill his days fully for the next forty years, it was no surprise that he returned to history in his own life’s closing chapter. His little history, as he called this book, was going to be his give-back, and so it took shape not as an autobiography but a historical memoir. Friesinger appears in it, but as narrator and only tangentially as subject. One of the things, perhaps the most important thing, that he gleaned from that old history of medicine course was an insight into the tight coupling, at Hopkins and the schools molded in its likeness, of research and teaching. This, he came to believe, defined the Hopkins philosophy. Research, he later confirmed from a long perspective, can make for a very exciting teacher. And, he might have added, a constantly excited one.

He hoped, in The Connection, to capture a certain atmosphere: the excitement of being at Hopkins during the great post-war years, when he was young and when everything seemed to be advancing at dizzying speed. Fortune provided him the chance then to learn from renowned exemplars of the research-and-teaching philosophy, men like cardiac surgeon Alfred Blalock and eminent diagnostician A. McGehee Harvey. This was mentoring in the truest sense of the word. Now, he remembered in 2008, it is a catchphrase, but then it just happened. Whatever the secret, he learned it well and was soon passing it on to rising generations whose names and stories would fill his pages.

Though he was too modest ever to say it, the research that both grounded and propelled his teaching also shaped his field of cardiology. In 1967, he founded the Hopkins Coronary Care Unit, and a year later the Myocardial Infarction Research Unit in the Johns Hopkins Hospital, the first in a batch of five institutions to receive National Institutes of Health (NIH) awards for then-rare dedicated cardiac care units. At the time Hopkins Medicine proudly spotlighted his career, cardiologist and then Osler Professor of Medicine Mike Weisfeldt was less shy than Friesinger about it: His were the initial efforts to understand acute myocardial infarction. He was responsible for taking the one-year mortality rate from forty to four percent. It’s one of the great miracles of modern medicine. Of the Vanderbilt years (1971 on), then vice chancellor for health affairs Harry R. Jacobson, himself a medical house officer at Hopkins in the early 1970s, amplified: Vanderbilt didn’t have a strong department when Bud came. He really put Vanderbilt in the modern era of cardiology and built the foundation of what is one of the top cardiology programs in the country. Over the years, the accomplishments piled up: 100 peer-reviewed articles, twenty-five textbook chapters, honors from the American College of Physicians and the American College of Cardiology, consultancies for NIH and Rand, a seat as Presidential Counselor on the Hopkins board of trustees for two decades.

Of the memorials that accumulated at his death in 2012, two in particular bear note. John Michael Criley met Friesinger on July 1, 1956, when Friesinger was resident on Osler 2 at Hopkins and when Criley began his first day of internship. Subsequently, they enjoyed a fifty-six-year-long friendship. Criley recalled two incidents to him representative of Friesinger as physician, scientist, and teacher. During that [first] month, he diagnosed bacterial endarteritis complicating patent ductus arteriosus in a febrile young woman with a heart murmur. And from it, he taught: With infinite patience, he convinced me that the murmur was indeed continuous. I doubt that many cardiologists could make that astute diagnosis today [2013] without the help of echocardiographic imaging. And then, in January 1960, Friesinger was summoned to the Hopkins Accident Room (as the ER was then called there) to treat a man with chest pain and whose electrocardiogram revealed ventricular fibrillation. While Intern Victor Marder went to work with twenty minutes of external chest compressions, Friesinger charged up to William Kouwenhoven’s eleventh-floor animal research laboratory to borrow a 200-pound external defibrillator with which, after delivering two counter shocks, he restored a life-sustaining cardiac rhythm. The patient, who had suffered an acute anterior myocardial infarction, lived on for another two years. With a landmark article documenting it in the Journal of the American Medical Association that July, the incident and Friesinger entered the literature.

Criley’s tribute appeared in the Transactions of the American Clinical and Climatological Association, which illustrated the piece with two side-by-side photographs: one of Friesinger in 1956 at Hopkins, the other in 2011 at Vanderbilt. Criley thought the lack of visible aging remarkable and emblematic of his friend’s well-maintained mental acuity. Indeed, Friesinger taught until just a few weeks before his death. Friesinger also liked great music and was particularly fond of Mozart and Bach, which should be another tip-off.

In a note accompanying a memorial concert for Friesinger on November 4, 2012, Alex McLeod (who as a student had also first met Friesinger at Hopkins and then come to Vanderbilt too) recalled a trip he and his wife had made with Friesinger and his wife, Jan, by riverboat from Amsterdam across Europe to the Black Sea. Diligently, Friesinger and McLeod researched every stop on the itinerary ahead of time, and during the journey, Friesinger never went without his little black leather pocket case holding 3 x 5 index cards for note-taking everywhere: We had a terrific time together; pegging the other travelers, reveling in the changing cultures as we progressed, seeing the residual progressive deterioration through communist rule past Vienna, to Budapest, then Belgrade and finally Bucharest. On the way back, they stayed a week in Prague. Each night included a concert, a debriefing dinner at different restaurants, and a walk back to the hotel. McLeod remembered especially how, one night in the Old Town, he and Friesinger happened upon the strains of Eine kleine Nachtmusik and discovered a group of young people, gathered together with their instruments on a side street, joyfully playing Mozart without scores, knowing it as their own. Neither ever forgot, and for years after, back home in Nashville, whenever Friesinger made a dinner reservation for the foursome, he used the moniker Amadeus. Amadeus, in fact, is Gottlieb in Latin.

Though Bud Friesinger and the present editor were at Vanderbilt for some of the same years in the 1970s, some of them in the medical school, there was little reason for our paths to have crossed then, and if they did it was but briefly. This is something that now, many years later, I especially regret. Therefore, I am especially grateful to his children—Alison, Chris (also a cardiologist at Vanderbilt), Kristin, and Gretchen—for affording me the opportunity to meet posthumously a man I would have valued to know more fully in life, and for entrusting me with their father’s little history, which is not so little a history at all.

This is because it tells a story, not of one particular man but of the world that made one particular man into the doctor he was. The best doctors today, whether they recognize it or not, are similarly made throughout their lifetimes: by teachers, students, colleagues, patients, and institutions. Vanderbilt and Hopkins, two of medicine’s greatest, remain bearers today of the tradition that Bud Friesinger credited so much and recalls so warmly in The Connection.

Timothy C. Jacobson

Spring 2020

CHAPTER 1

MEDICINE IN 1900

At the turn of the nineteenth century, a number of social forces intersected that would lay the groundwork for the transformation of American medical education and medicine itself. Higher education was growing more sophisticated. Medical science was beginning to penetrate medical practice as it had not done before. Private philanthropy was stepping forth to finance medical education reform. And expectations were on the rise, slowly at first, for what medicine actually could and should do.

We can get a sense of the early consequences of those forces by listening in on the Johns Hopkins University celebration of its twenty-fifth anniversary in 1901. Among those attending was Charles Eliot, the president of Harvard University and the recipient of an honorary Hopkins degree. Eliot addressed his remarks to Hopkins’ president, Daniel Coit Gilman, and he did not hold back: The twenty-five years just past are the most remarkable twenty-five years in the whole history of the race. He addressed the contributions of Johns Hopkins to higher education in general, and specifically the contributions of the medical school, which admitted its first class in 1893:

President Gilman, your first achievement here, the creation of a school of graduate studies, has lifted every other university in the country in its departments of arts and sciences. I want to testify that the graduate school of Harvard University, started feebly in 1870 and 1871, did not thrive, until the example of Johns Hopkins forced our Faculty to put their strength into the development of our instruction for graduates. I congratulate you on the prodigious advancement of medical teaching, which has resulted from the labors of the Johns Hopkins faculty of medicine.

Nothing is done as it was done twenty-five years ago; the whole social and industrial organization of our country has changed; the whole university organization of our country has changed; but among all the changes there is none greater than that wrought in the development of medical teaching and research; and these men whom you summoned here have led the way. Among the achievements of Johns Hopkins University in the last twenty-five years, let this improvement of medical teaching be counted as one of superb beneficence. The 25 years since Hopkins’ founding had indeed been an extraordinary time in America.

Yet as Eliot suggested, the development of medical education, while less visible, was no less important than any of the other changes, and Johns Hopkins had been the prime mover behind it. Gilman coupled the development of medical teaching and research, a critical relationship to the process that would make America’s medical educational enterprise the envy of the world by the end of the twentieth century. (He might have added that another critical component was making the medical school an integral part of the university.) The changes Eliot spoke of would have meant far less had they been limited to the laboratories and classrooms of Baltimore. The significance of Gilman’s—and Hopkins’—achievement was, as Eliot suggested, not only innovation but also dissemination. The story of the Vanderbilt-Johns Hopkins connection illustrates this, and how those men whom [Gilman] summoned to Baltimore had led the way for the widespread adoption of these ideals at other universities across the country. Nowhere was the connection stronger than with Vanderbilt.

In 1919, a 1903 graduate of Johns Hopkins Medical School named G. Canby Robinson became dean of the Vanderbilt Medical School and Hospital, and began reorganizing the institution using the Johns Hopkins model. Thus began a parade of Vanderbilt medical personnel with Johns Hopkins experience, numbering more than 400 by the century’s end. The group included five deans/vice chancellors of medical affairs, at least twenty department chairs, and many key researchers and division heads. This book tells the story of these Hopkins-related people who helped make the Vanderbilt Medical School one of the nation’s premier medical institutions. Through their stories, we can learn a good deal about the evolution of medical education in the twentieth century, perhaps even venture something of its prospects in the twenty-first. To understand their full implication, some context is necessary.

The Nation’s Growth and the Status of Medicine

Between 1850 and 1900, the nation’s population tripled, from 23 million to 76 million. Railroads tied the nation together and made possible a truly continental market. Automobiles soon followed: there were 8,000 in 1900, 4,500,000 in 1929. Technological achievement seemed the order of the day. Education too was energized, its link to economic growth and material prosperity seemingly self-evident. The rise of the idea of professionalism indicated new levels of sophistication and responsibility in numerous walks of life. Medicine, though marginally at first, was one of them.

From where we stand today, it is hard to appreciate the enormous heterogeneity of medicine at the beginning of the twentieth century. It allows no simple characterization. Indeed, it is a stretch to use the word profession in connection with medicine at all. Sociologists define a profession as an occupation that regulates itself through systematic required training and collegial self-discipline and, in exchange for some level of monopoly-like power in the market, professes a commitment to public service. Professionalism implied a commitment to a continuous upgrading of skills and mastery of a changing body of knowledge. Little of this could be said to have characterized American medicine into the early twentieth century. There were pockets of excellence in medical practice and in medical training, but it would be safe to say even the worst of practitioners were no worse than the medical schools that had produced them.

Recognition that education—specifically, public schooling—was key to both individual upward mobility and societal advancement set the foundation. In 1871, a prominent educator stated, the spirit of American institutions is to be looked for in the public schools to a greater degree than anywhere else. In 1870 there were 6.8 million students in public schools; by 1920 the number had increased to 21.6 million students. At the beginning of the Civil War there were only 100 public high schools in the entire country; by 1880, 800; and by the turn of the century, 6,000. Of course, not all elements of society met the ideal; public educational opportunities in the South, particularly in black communities, lagged; yet the commitment to public education was impressive and sustained.

Higher education enjoyed parallel growth. The underlying philosophical principles among colleges and universities varied widely, the spectrum of educational offerings was broad, and the mechanisms of funding were diverse. Many church-supported colleges were established, while other colleges and universities benefited from private philanthropy. States provided funding for a substantial number of universities. Land-grant colleges created following the passage of the Morrill Land Grant College Act of 1862 focused on the development of practical skills and knowledge, such as agriculture and mining, in sharp contrast to the long-established colleges and universities where classical curricula still held sway. While a college education was beyond the reach of the vast majority, the growth of educational opportunities was nonetheless impressive. The number of post-secondary students increased from 52,000 in 1850 to more than 250,000 by the turn of the century. By 1920 the count was 600,000 in more than 1,000 institutions.

In our story, the role of private philanthropy is of particular importance. The pioneer names are still famous. George Peabody, a merchant of Baltimore and London, and arguably America’s first great philanthropist, left his mark on the Peabody Conservatory of Music in Baltimore (now a part of Johns Hopkins University) in 1857 and later on Peabody College for teachers in Nashville (now a part of Vanderbilt University). Peabody was influential in convincing his Quaker friend Johns Hopkins, merchant and railroad owner, to bequeath his $7,000,000 fortune to the Johns Hopkins University and Hospital in 1876. Commodore Cornelius Vanderbilt, founder of the New York Central Railroad and the wealthiest man in America at the time, contributed $1,000,000 to endow a small Methodist institution, Central University, in Nashville. Personalism was important in this early, pre-institutionalized stage of philanthropy. Methodist Bishop Holland McTyeire, whose wife’s cousin was Vanderbilt’s second wife, solicited the gift to the Nashville school, which he contended would help heal the wounds of the Civil War and contribute to strengthening the ties that should exist between all sections of our common country. Vanderbilt stipulated McTyeire be Chairman of the Board of Trust for life. The name of the school was changed to, and remains, Vanderbilt in 1875, but the relationship with the Methodist Church persisted for some time to come. Other institutions owed their founding to similar benefaction, including Stanford (1885) from railroad baron Leland Stanford and his son, and the University of Chicago (1890) endowed by John D. Rockefeller of Standard Oil.

One aspect of the growth of such institutions was the growth of graduate-level training. Yale awarded its first PhD in 1861; Harvard its first in 1872. The establishment of Johns Hopkins, as Eliot stated in his 1901 address, gave the graduate-degree movement a unique boost. Hopkins was the first university in the United States founded as a university and that did not grow out of an existing undergraduate college. Graduate degrees required intense seminar and laboratory research experiences under the direction of noted, experienced scholars. The model came from the German universities and first extended to medical education when the Johns Hopkins medical school opened in 1893. This event and the philosophy behind it would dramatically change medical education and set a new standard nationwide. This is the central theme of our story.

It helps here to appreciate the diversity of the medical education system in 1900. The number of medical schools was enormous—160, an increase from 47 in 1860—for a population of 76 million.¹ The number of medical students increased from 11,826 in 1878 to 24,119 in 1900. In the year 2000, there were 72,000 medical students in the United States. Admission standards were spotty; curricula and required length of study or requirements for awarding the MD degree varied. In sharp contrast with what it would later become, medicine then was democratic and pre-professional. Regulation was feeble, and in many settings, nonexistent. The proliferation of schools having different philosophies and educational systems—including homeopathy, osteopathy, Christian Science, and chiropractic—compounded the complexity.

The funding mechanism behind the proliferation of medical schools was largely entrepreneurial and market driven. Proprietary medical schools financed by tuition constituted a sizeable minority of the 160 institutions. Many were established in communities by groups of practitioners who gave a series of lectures and demonstrations, and sometimes a preceptorship. Laboratory courses were scarce on the ground, as were medical libraries. Length of study varied from four to six months a year, and the total duration of medical school was either two or three years. By establishing such schools, physicians added to their prestige locally and enhanced their personal income, since any tuition money not required to run the school went to physicians. While it is tempting in retrospect to denigrate these schools, they filled a legitimate role, even though the lack of uniform standards today seems shocking. It was not unusual for the MD degree to be awarded to virtually every student who stayed for the entire period—and paid the tuition. Most of these schools had no affiliation with a college or university, and with those that did, it was tenuous. Recruiting practices could be aggressive. The Chicago Medical School, which was loosely affiliated with Northwestern, sent out 28,000 brochures to perspective students in 1884. One candidate visiting in 1877 described how he was encouraged to attend a leg amputation (which he did, in a deplorable operating theater) as part of the recruitment effort. The description of the event reads more like a sporting event than a professional demonstration.²

Despite such, educational reform at multiple university-affiliated hospitals was in fact being undertaken, if with modest enough success at first. Harvard is an example. Charles Eliot was a chemist who became president of Harvard in 1869 and vowed to improve its professional schools, particularly medicine. A Bostonian and an 1853 Harvard College graduate, Eliot spent several years in Europe participating in and observing graduate education firsthand. He was an extraordinary force for change, remaking Harvard during his forty-year tenure and stimulating broad changes throughout higher education across the country. Harvard’s story is particularly interesting as it would come to be judged as the nation’s leading medical school during the late twentieth century.

Eliot believed that a scientific underpinning with rigorous academic preparation was critical if medicine was to progress. Students then arrived at Harvard often ill-prepared and followed an esoteric medical curriculum in no particular sequence. Didactic lectures predominated as the principal form of instruction. The total study ran just eight months, and students were graduated if they passed the majority of their oral examinations (written examinations were judged too difficult) and without reference to the examinations they may have failed. As was the case with the many proprietary medical schools throughout the United States, Harvard allowed the faculty to collect fees directly from the students, pay the school expenses, and divide what was left among themselves. The school elected its own dean and was basically independent from Harvard University. In his efforts at reform, Eliot met with considerable success but also great resistance, since the entire medical faculty were elite Boston practitioners who wished to give up neither autonomy nor income. Harvard then had no university hospital (it still doesn’t), and so it could be held hostage by the physicians in the community.

Yet Eliot’s commitment to medical education reform was uncompromising and sustained. Inspired by the British model of medical education, he attended faculty meetings, wrote editorials in medical journals, and withstood enormous pressure from the vested practitioners. Over several years, he developed a core group of medical faculty with training and educational experiences in Europe, who came to support his philosophy. With this group behind him, Eliot made several hard-won gains in his reform efforts. The school’s finances were placed under the control