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Tilting at Windmills - Educational Misadventures in the Big Ten (Draft 02-10-06)
David L. Nanney
22. Biology and Medicine
Throughout my career, Medicine has lurked just around the corner, exerting an indirect influence on my career. I now realize how pervasive and powerful that influence has been. My childhood illnesses asthma and osteomyelitis - brought me into early intimate contact with doctors. That contact may have conditioned my response to my mother’s wish for me to become a medical practitioner. My high scores on the Medical Aptitude Test in College, despite my poor scientific background gave me some confidence that I might be able to handle a career in biology, when a profession in the humanities seemed blocked. At Indiana I owed the opportunity to fund a graduate career at all to the glut of pre-med students. In fact, to casual inquiries, I sometimes describe my career as “four decades of teaching genetics to pre-med students”. But medicine has always loomed not just as a
professional link, but as a force shaping the profession of biology. I have mentioned earlier that, at Michigan, the prestigious and powerful Medical School loomed over educational developments in biology as an immovable object.
Perhaps one of my less cogent reasons for leaving Michigan and coming to Illinois was the absence of a medical school on the Urbana/Champaign Campus. But premedical education was the primary task of the biology faculty throughout my career. Training and evaluating students for careers in medicine was the bread and butter of our job. Eventually a medical school was established at UIUC, and I even served on the governing board of the Medical Scholars Program - the PhD-MD program - in its early days. I may be allowed a few comments on the relationship between biology and medicine in implementation of educational programs.
For many years, particularly after the establishment of the land grant universities, the major application of biological information was in agriculture, and many of the students came from the farms and were headed back to the farms. A major demographic revolution of the 20th century involved the urbanization of American society and the evacuation of the farms. Technological advances allowed far fewer workers to farm much larger tracts as agriculture became mechanized and industrialized. The urbanization of America was a challenge to colleges of agriculture, which struggled to maintain their student populations and their economic status in a changing society. I cannot comment from the inside on the struggles for transformation in agricultural colleges, but I could occasionally peek in from the outside. Soon after arriving in Urbana, for example, I visited with a Professor of Agronomy who had just decided he had had enough of Illinois. He was accepting a position as Dean of Agriculture at Oklahoma A&M where life was still simple. He would be happy to deal with wheat and cattle for the rest of his academic life, without engaging the high technology and industrialization emerging at Illinois. I don’t know whether Oklahoma remained bucolic long enough to keep him happy until retirement.
As the agricultural link for biological education diminished, the association of biology and medicine greatly strengthened. The 20th century began with medicine in America still much of a folk trade. Medical schools trained doctors but not very rigorously and not very uniformly. Medical services across the country were insufficient in scale and inadequate in quality. The situation changed about 1910 with the adoption of a national requirement for training of physicians in approved medical colleges with standardized curricula. The nationalization of medical training improved the preparation of medical practitioners in advance of the challenges of World War I and of the great influenza epidemic. Medicine became established more securely as valued learned profession in American society. I don’t know much about the economic status of medical doctors during the Depression Era. We seemed to have enough doctors in Wewoka, Oklahoma, to serve the needs of the middle class, though I doubt that the poor received adequate medical care. I assumed that the doctors were prosperous, but they didn’t live in mansions such as accommodated the oil barons.
The onset of World War II created a demand for medical services on an unprecedented scale. Medical Colleges responded as well as they could, but were not equipped to produce enough doctors to satisfy both civilian and military needs. Not being accepted for military service, I have no experience of the quality of military doctors. One civilian experience might, however, be worth mentioned. As a senior at Oklahoma Baptist University, I drove the Vice President’s car filled with members of the Bison Glee Club from Shawnee, Oklahoma.. The singers were performing Handel’s Messiah at the First Baptist Church in Oklahoma City. Returning home late at night I fell asleep and plunged off a 30 foot embankment. The bruised and cut students were taken to the closest emergency facility, which happened to be at Tinker Air Force Base. One of the girls had a badly lacerated face. The doctor on duty apologized for his lack of training and experience in cosmetic surgery. He had been drafted from civilian life as a gynecologist. I doubt that his training was any more appropriate for battle casualties.
After the war was over medical education entered a new phase. For one thing the numbers of students interested in medicine as a career was greatly augmented, and the funds necessary to acquire a medical education for GIs were provided by the GI Bill of Rights. Medical Schools were unprepared with facilities and staff to train more than a small fraction of the aspirants. The Pre-Med Crunch was the phenomenon that governed educational practices in college departments that taught pre-meds. Courses in Comparative Vertebrate Anatomy and Organic Chemistry requirements for admission to all medical schools, became the gates to a highly desired profession.
And that profession became progressively more desirable. The medical schools still did not have the capacity to train the medical workers demanded by a growing and prosperous population. GIs returning from military service married and inaugurated the post war Baby Boom. The doctors to deliver those babies and provide health care for growing families were in short supply. Short supply equates with long hours and big salaries. Soon the average medical doctor was making more money than state governors and US senators, to say nothing of university professors. And the pressure on the gates to medical school increased. The competition to gain entry to medical school led to the characterization of a “pre-med syndrome”, which included serious anxiety, the blunting of ethical values, an acceptance of short-cuts, and emotional confrontations with the professor. All this pressure built up in lecture classes with hundreds of students, with short-answer or multiple choice tests, and machine grading of exams. Multiple tests were often designed with different correct answers, or different sequences of questions, on different colors of paper. Students were required to sit in alphabetically assigned seats. I once had the problem of monitoring a pair of identical twins, who had seats assigned side by side, but whose hair whorled in opposite directions. I couldn’t decide what to do when the hair whorls shifted from test to test.
The pre-med syndrome involved social issues beyond the undergraduate classroom. Once medicine became accepted as a highly desirable profession questions were raised about equal access. Many medical schools gave admission preference to children of doctors, for example, or recommendations from politically connected sponsors. The uniform medical aptitude tests were imposed in order to provide equitable access to the profession nationally. It was this larger social concern that focused the pressure in the pre-med classroom. The pressure was also felt within the curriculum at large. Should premeds take the physics course designed for physics majors, or the alternate (and terminal) course for general education requirements? Should one dare a 300 level course, which would include graduate students as well as undergrads? Should one drop a course that seemed more difficult than had been expected, on the grounds that an A was improbable? How about signing up for more courses than one expected to finish so that the demanding professor in an optional course could be dropped. What about joining a fraternity that has back files of the exams used in pre-med courses. The gamesmanship associated with the pre-med syndrome rewarded the aggressive externally oriented student, who enjoyed playing “king of the mountain” and was good at it. What it did to the classroom and academic relationships was not always commendable, and might not in fact have put the right king on the top. I once had a discussion with the personnel director of a local health care institution, and asked about the quality of the new physicians who were being hired. She answered that their attitudes were sometimes disturbing. Many weren’t interested in the patients particularly in the fourth kid who walked in with a sore throat in a single morning. They had not yet fully accepted their roles as physicians.
The medical schools were slow to make room for larger classes, and were suspected of deliberately controlling the rate of production of doctors in order to maintain the economic status of the profession. Pressure began to rise at the state and national level to provide more access to training for medical workers. In Illinois the legislature mandated the increase of class sizes at medical schools, and indeed approved a new medical campus at Urbana Champaign. The expenses of instruction could be limited by using local hospitals and clinical centers in other cities for clinical instruction while basic medical sciences biochemistry, physiology and microbiology - could be taught by augmented staff at the University.
An additional rationale for developing a medical school at UIUC came with the concept of a training program for careers in medical research. The Medical Scholars program at Illinois probably provided the nudge to gain approval for a new medical school. Students could choose a PhD program from a large array of specializations law, economics, biochemistry, anthropology, etc. Balancing the medical training with the academic discipline proved to be a challenge. Initially each student in the Medical Scholars program chose an academic sponsor and worked a couple of years within the sponsor’s facilities, enrolling in appropriate courses, and taking on research projects within an ongoing program. Then the students were given clinical experience, either in local hospitals settings or elsewhere in the state. Unfortunately. A large proportion of the students decided not to continue in the clinical program, but remained or returned to a more conventional academic project. The council’s analysis concluded that the socialization of an academic investigator is very different from that of a clinician. The academic is rewarded for independence, for challenging assumptions, for disregarding routines, and for satisfying internal needs. The physician’s calling is one of relationships, of schedules, of sometimes boring but necessary routines. Once one has been received into either culture and made peace with it, the other culture can be very stressful. Our solution in the early days of the program was to require the clinical experience first, in order to continue the flow of physicians.
New buildings for training doctors could be limited by using existing university buildings. This limiting of construction costs was not a trivial consideration. Everything in a medical facility is much more costly to construct that similar accommodations for academics. I was once astonished when reviewing NIH grants by to see that the NIH standard dimensions for bathroom stalls in buildings used by physicians were substantially larger than those required in buildings for academics. In the second half of the 20th century the medical doctors (but not nurses and other health care employees) emerged with very large personal space, as the nobility of a democratic society.