From: AG
Date: 11 March 1946
To: RBF
Comments:
Subject:
It would be sensible to present to the Trustees at their annual meeting this April a frank account of the status of the medical schools in this country. The relation of these schools to biological science, to the preparation of young men for private and group practice, for public health, for psychiatry, and for all forms of teaching and research, makes the medical schools important to the future success of programs in more than one division of the RF.
Furthermore the time is appropriate for such a review. 1946 is the first year in which plans can be made for a future free from the special demands and limitations of war. We know now about where we are. If the condition of institutions where many of our interests in research would be carried out is becoming seriously doubtful, then so is our success in backing their research programs. Moreover our country's capacity to accept world leadership in teaching and research is more important than ever now that that role has become inescapable.
The preference of the RF for aiding research was made explicit in 1928. It was based upon the assumption that most institutions were in sound enough condition to make our grants for research effective. We took it for granted that we could wisely confine ourselves to institutions that guaranteed stability and invited capable younger men to take solid training for predictable careers as teachers and research workers on reasonable salaries. That assumption is valid no longer. The war has removed to a disturbing degree the proper conditions for training, recruitment, stability and productivity of research workers everywhere.
The serious fact is that medical education in the United States is deteriorating and is likely to continue to fail the obligations as well as the opportunities placed before it by post war conditions unless substantial steps are taken to correct these serious changes. I believe we should point this out to the Trustees. The changes are described briefly in the following paragraphs.
From 1930 to 1937 the endowment funds of universities experienced the effect of skipped dividends, reduced mortgage income, reductions in interest and a widespread cessation of gifts for current expenditures.  In effect these losses amounted to 30-40% of the endowment income, though in some cases they were much larger. Academic salaries were cut, plans to complete buildings and staff appointments were paralyzed, full-time positions were "modified" to part-time and normal growth was stunted.  From 1938 to 1941 conditions began to improve but in few if any instances had medical schools recovered from the depression before the war threw everything connected with teaching, advanced training and research into an abnormal state which has lasted five years.
The war years were characterized by poorly prepared students and lowered standards of performance, losses of both junior and senior teachers, accelerated curricula, war work for the remaining and ablest research men, and pressures of all sorts on the faculties. There was a temporary financial relief from some but not all war research contracts. There was the larger tuition income from larger numbers of students and the "prosperity" of solvent but overcrowded hospitals. Unselfishness and sacrifice solved many a problem temporarily, but the acting deans knew that this kind of prosperity was for the war years only.
Now the situation has become truly serious. The students are poorly and hastily trained. There are some 20,000 doctors returning from the services in search of post graduate courses, the most expensive type of training. The Specialty Board certificates which call for one to three years of graduate training have greatly increased in their influence md their demands upon our facilities: this is a permanent and enduring demand. The war stopped the advanced training of our future professors for five years and left the older teachers tired if they had stayed at home and rusty if they had gone abroad. The decade 1945-1955 even without the war was due to see an unusual number of retirements for age in the medical faculties that had been reorganized and re-staffed with GEB funds from 1915 to 1927.  The younger men returning from service require and request larger salaries than they needed three or five years ago. Many have spent their savings while on army salaries. The creation of new medical schools at Seattle, Houston and Winston-Salem (with another projected for Los Angeles) and the addition of the clinical years at Utah and Birmingham further deplete the ranks of available teachers,  and narrow the choice of appointments to posts in the existing schools. Foreign students from South America, the Far East and Europe press for entrance to our laboratories and clinics as never before. The post-war tax-structure and tax burden of potential supporters in the next few years go far to explain the scant reinforcement of university finance from private givers at present.
But the crowning difficulty is this:  the senior men are too overloaded with teaching and administration to do good research without junior colleagues, and stable positions with adequate salaries for junior men are so scarce that the best young men cannot and will not go into teaching and research. In a short time we shall not have the well trained young men available to receive and apply effectively grants for research work. It is no good buying expensive groceries if you ignore the cook's salary.
I believe that for all the reasons listed above, plus the disastrous effects of rapidly rising living costs, we approach a critical deterioration in research and teaching. We shall delude ourselves and waste substantial amounts of RF grants if we expect good research from a few investigators shabbily paid and sadly overworked. We should reconsider our policy of 1928 which assumed institutional solidity and adequate staffs and salaries. Even the Federal Government is now preparing to put large sums into biological and medical research but I question pointedly if the Government will in its enthusiasm for research realize that money is needed in the first place and essentially for living costs and stable futures for those who can do the expected research.
The way for us to keep donors to research (including ourselves) from being disillusioned and embittered in the next ten years is to put some institutions into the position of being able to use research money effectively. This will need a large departure from our 1928 policy and our current credos.
The essential need of our medical schools is money for salaries to reestablish permanent full-time posts for teachers and investigators - senior posts and junior posts - and for helpers, equipment and consumable supplies so that the holders of such jobs can teach and train the next generation for research.  The essential obligation for us is to oppose the approaching deterioration with action - and the example that bold action sets.
What could be done? Select six or seven private medical schools with an eye to their present excellence, to the quality of their recent professional appointments, to their regional influence especially on State medical schools and to the likelihood of their not being aided by other private donors. Make grants to the general endowment funds of each school in the amount of $1,500,000 each on condition that the school secure new gifts totaling $500,000 in cash or valid pledges before December 31, 1947.  This would cost the RF (if seven schools met the conditions) $10,500,000, but the total program would bring to the schools $14,000,000. Each school would have an increase of $2,000,000 in endowment. The effect on the State schools would be stimulating and exemplary. The research grants in the future by NS, MS and IHD would find more capable and efficient use.  Making such an expenditure at a time when our own market values exceed $200,000,000 would not be unreasonable. But most cogent of all it would set a most valuable example to other foundations and to government in correcting the serious losses of the war and it would point to the deepest need of research - the maintenance of stable conditions for finding, training and supporting research men.
A.G.