Interview 1
I think, in a way, telling you how I happened to come to the medical school is part of the history of the medical school. As you know, I was born and raised in New York City, and I graduated from high school when I was fifteen. The school system was large enough that it encouraged children to advance by skipping semesters; you could only do this with a good-sized system. For example, I skipped the first semester of first grade because I went to a kindergarten which had good preparation. There was an arrangement in junior high school so that you could go through in two years: a rapid advance program. They could provide a situation where you weren’t quite so out of touch with your age mates. Then, in those days, they had a special high school called Townsend Harris Hall; it was a three year school, and you had to take a competitive exam for admission. Again you could advance at your own pace, so I graduated when I was fifteen.
I wanted to go out of town to college, but my parents were convinced that I was too young. In retrospect, I can see that they were right, though at the time it seemed unreasonable. So I went to the City College of New York. I went there for two reasons; first of all, it was free, and this was the end of the Depression, so money was still tight. Secondly, if you graduated from Townsend Harris Hall, you were automatically accepted. I did quite well for the first two years and made the Dean’s honor roll. I went to see the dean, and he congratulated me. Then he asked what I planned for the future. I told him I was thinking of medical school. I can still remember the man’s response; he said, “Oh, that’s too bad.” I was startled. He said, “We have an awful lot of pre-med students at City College.” What he didn’t say, but what I knew, was that a very high proportion of the students who were pre-med were Jewish. Most medical schools in the country had some kind of quota. That was not a secret. But, I thought it was interesting that he discussed that. (My memory is that he was not Jewish). He said, “Our students in recent years have done very well when they transferred to three schools: Duke, Washington University, and Vanderbilt.” By doing well, he meant a high proportion of them got into medical school. I said Washington University might be the right one for me because my mother has a sister in St. Louis who is married to a physician. I thought if I told them Washington University was the dean’s suggestion, they would accept it. That turned out to be the case.
I didn’t know then whether I’d go to the medical school, or not. I came in the early fall of 1941; I was eighteen years old. It turned out that at Washington University, I got credit for a lot more hours than I had received at City College. On December 7th, that was a Sunday, I remember a discussion with pre-med students; they said they heard a rumor that medical schools were going to expand and people were going to be urged to apply a little earlier. I knew I’d be only three credits shy of graduation, so thought it might be a good idea to apply. Much to my surprise, I was accepted without taking MCATs or having an interview. I know I had good letters; one of them was from Viktor Hamburger. I took both his courses; that was the most intellectually stimulating experience I had in college. And I also got a good letter from the professor of organic chemistry. He was a very different person. But I knew he’d write a good letter.
Only later, when I was familiar with the workings of admission committees, did I piece together what must have happened. By the time my application was complete, the class had been chosen. But someone dropped out at the last minute, so I was accepted immediately. I applied to other schools because my parents were quite emphatic that I return to New York. But the reply from Washington University came very quickly, so I knew that I was accepted even though I went ahead and had the interviews in New York. Somehow, or other, anti-Semitism didn’t seem to be as big a problem here as it was in other places.
The war had just gotten underway. We were five months into the war, and we knew we’d have an accelerated program: very short holidays and no summer vacation, so we could do it all in three years. I had a very good time in medical school. I don’t think I appreciated until many years later how fine the faculty was. I remember Dr. [Ethel] Ronzoni-Bishop in biochemistry; the first summer, biochemistry was all we did. In that course, we were taught by the Coris [Carl and Gerty Cori], by [Herman Moritz] Kalckar, by [Alfred D.] Hershey. Cori was a very good lecturer, but only if you took measures to make sure you could understand him. He had an almost inaudible voice, an accent, and he spoke with very limited facial movement; he didn’t articulate. There were eighty-six students, and I realized to understand him, I’d have to get there early and sit in the front row. When either of them lectured, I made it a point to get there early and sit in the front row. I took copious notes; then I’d go home and read them – a pattern would emerge. Very often, Gerty Cori would, under her breath, correct Carl’s lecture. If I hadn’t been sitting next to her, I couldn’t have heard it.
Kalckar was a man who couldn’t lecture. He talked with his back to the audience, writing formulas on the board, speaking in an accent. He was lecturing to us on very abstract issues about chemical kinetics. After the lecture, we’d go into the labs. But a pattern developed; Ethel Ronzoni would give an interpretation. That would clarify everything he said. She was an excellent teacher. Both Mildred Trotter and Ethel Ronzoni were considered formidable. It took me a little time to realize that this was kind of an exterior. They were very concerned about students and very anxious to help us learn. But they both had this brusque, slightly aggressive, challenging way of talking so that you felt always that they weren’t sure you really measured up. Gerty Cori was not a major person in our curriculum. Ethel Ronzoni and Mildred Trotter were major teachers. I got along fine with both of them, though it took a little time for me to have enough confidence to talk to them.
Another person we had as a teacher was Alfred Hershey. He lectured in biochemistry and bacteriology. Hershey seemed to us to be a prototypical eccentric; he wore sandals in winter, he never wore a tie, and he talked about things we didn’t understand. But, we realized he was a very bright man, and we should try to make an effort to understand him.
[Joseph] Erlanger was a good lecturer. He wasn’t charismatic, but he knew exactly what he wanted to say and made his points in a very organized way. There was a diffidence and reserve. He was very responsive, but not on a personal level. He wanted you to understand the material, but he didn’t seem to want to know the students. Arthur Gilson was not as good a lecturer, but he was friendly, and he had a sense of humor that showed. He didn’t mind a certain amount of kidding back and forth. That was a good course.
In anatomy, [E. V.] Cowdry gave us a few lectures, but Mildred Trotter was the principal teacher. There was another doctor, Cecil Charles, trained in anatomy, who came over and helped in the afternoons. It wasn’t until many years later that I realized what a racially bigoted fellow he was. He had seemed like such a warm, supportive man. Mildred carried the burden of teaching; she was the person who really taught us. Dr. [Robert J.] Terry was still around; he was half blind. He’d come into the teaching lab, a courteous and old-fashioned gentleman. We realized at the anatomical table that he was searching for things by touch.
[Philip A.] Shaffer was dean, so his role in biochemistry was more distant. Many years later, Carl Moore was his doctor, and he called me in consultation. He had developed what we now would call Alzheimer’s disease. He was hospitalized on the 6th floor of Renard, and when he was sick, his racial bigotry worried me because the attendants were largely black. He would say the most terrible things. And I worried that they wouldn’t be able to contain themselves.
By the time I became a sophomore, [Carl] Cori was still head of pharmacology. A lot of the faculty had gone into the army. It was a good course; Cori was an outstanding teacher. Then we had bacteriology with [Jacques] Bronfenbrenner. He was a wonderful man – warm and empathic. He never gave you the feeling that he saw himself as better than anyone else. He had a friendly expression on his face all the time – he had a crinkly-eyed cheerfulness about him. He built the course around the diphtheria bacillus. His idea was to take an organism and help us try to understand one pathogenetic organism. He had done a lot of work on this in Paris. One story was that when he was there, he had been a model for artists and a frequent assignment was to be a model for Jesus. And it wasn’t a bad choice; you could imagine him in that role. He was a wonderful teacher and a wonderful person. Bronfenbrenner gave us most of the lectures, Hershey gave us some, and then there was a man named [Philip] Varney. He was a sort of a tinkerer; he was one of those people who really felt it was a challenge to be sure all the apparatus was working right, the plumbing and electricity were working right. We used to joke about him, because he was more a handyman than a scientist. He was very emphatic. Carl Harford used to give some lecturers. Barry Wood gave some lectures in pharmacology – on sulfa drugs and penicillin.
In pathology, there was R. A. Moore. He was a very interesting man. The characterization that I like the best is that he was the only man who used to wear a wool three piece suit in the middle of a St. Louis summer, with no air conditioning, and would insist that those of us who complained had to adopt a better mental attitude. A lot of the construction done around here was affected by that idea. Years later we had to retrofit the buildings he had constructed. He believed the way to motivate medical students was to keep them on the edge of their seat and not let them relax. Then there was Maggie Smith [Margaret Gladys Smith]. She was a chain smoker; I don’t think I ever saw her without a cigarette between her lips. She would not have put up with a smoke-free environment. She had a tendency to be a little bit shrill and very caustic. But deep down, she had a soft spot for the medical students, but it took time to realize that. She gave pretty good lectures. David Smith gave excellent lectures; he later left for Virginia.
The two clear leaders of the clinical faculty were Barry Wood and Evarts Graham. Carl Moore was clearly number two in medicine; he was very highly regarded. My beginning thoughts about an academic career were stimulated by Barry Wood. Ken [M. Kenton King] and I have had many conversations about Barry Wood. He was tall, slim, handsome, man. Though he was very young, he grayed early and looked very distinguished. He was a gentleman born. I don’t know what his feelings were, but he treated everybody with courtesy, refinement, and good manners. I don’t think I’ve ever had a better clinical teacher. He could take any kind of problem and turn it into the most interesting, challenging case you can imagine. If you were to present a case to Barry Wood, you knew you were going to strive to do it the best you could. Only in retrospect did I realize his limitations. Because of his personal qualities, style, and accomplishments, he quickly became a leader. The only person who gave him any challenge was Evarts Graham, who had a very different perspective.
Barry had the ability to bring out the very best in people. Everybody wanted to meet his high standard. The trouble with him was that his clinical teaching was not something he took enough pride in; he wanted to be a laboratory scientist. He felt that was the goal for him. He had some training with Hans Zinsser, and he got interested in surface phagocytosis. He was a better than average scientist, but he was not a great scientist. He was a great clinician. He went back to Hopkins, in part because as head of microbiology, in addition to being vice president for health affairs, he’d be free of clinical burdens. Ken went with him as a research fellow and ran his lab.
There was an aristocratic aura about Barry Wood. Carl Moore strove hard all the time; we all admired him, but we didn’t think he was as skillful a teacher as Barry. Things came easily to Barry Wood; Carl Moore had to work at it. Ed Reinhard was Carl Moore’s young assistant. Early on, I seemed to hit it off with Carl; he took a liking to me. I felt much closer to him than I did to Barry, but I realized that Wood had a leadership quality that came from some other source.
Interview 2
Let me say something about Evarts Graham. He was viewed by all medical students, including me, as a towering figure, even more so than Barry Wood or Carl Cori. I don’t know how it came about, but we were very well informed about his national and international role in surgery. He was very tall, imposing, and formal; it was clear that he probably exerted more power and authority in the medical school than any other single figure. And he could be quite an intimidating person. I can remember one time in surgery grand rounds when he got the chart out and found a couple of words misspelled. And we spent the entire time talking about the importance of spelling, the use of language, etc. At the time, I wasn’t sure how to take it, because I’ve always had an interest in language, but it seemed to me that he got a little carried away. He was probably the only member of the faculty who could have gotten away with that kind of a discussion in that kind of setting without having anybody smile or snicker. You didn’t do that with Evarts Graham. It was interesting; he had a reputation for not being the best technical surgeon. But still, he was perceived as a giant. And I guess that was because all the other people in surgery felt that way about him. There is no one here perceived as being of that stature now. But, then the whole culture of medicine has changed since those days.
I would get into discussions with Tom Burford who was a very cynical and critical sort of person, at least that was his facade. But, if you talked to him about Evarts Graham, his attitude changed; he believed there was no greater person. Gene Bricker is another example of someone who felt that way. So, there was this very powerful presence in the school that everybody recognized. He was very rarely crossed by anyone. But I think he was a man of great self discipline, so I don’t think he took advantage of that fact. He knew he was important and used his power in a reasonably constrained way.
Now I want to talk about Helen [Tredway] Graham. She was another one of these very competent-looking and sounding people, well educated at the best schools. People certainly knew she was Evarts Graham’s wife. She was a very well organized teacher, very clear, and gave good lectures. But she didn’t achieve the kind of intimacy and affection Ethel Ronzoni did with students. She was universally respected, but there was always a distance; you had a very formal relationship with her, as opposed to Dr. Trotter and Dr. Ronzoni for whom medical students really felt affection. I don’t think she was a great pharmacologist, but she certainly was a competent one. I don’t think as a medical student I understood the barriers against women in science. I didn’t understand her importance in the department, but I knew that Ollie Lowry was a great admirer.
David Graham, their son, had more of a burden to deal with; we were very good friends. He went two years to another medical school and then came here. Then he went off to have a research fellowship with Harold Wolff, a professor at Cornell who was very interested in psychosomatic medicine and set up a group at Cornell. They were very interested in showing the role of life situations, stresses, to physiological response. Graham came back here at about the time a similar division was being set up here. I may have been as close to Dave as anybody on the faculty because he and I shared common interests. But one of my self-appointed tasks was to try to interpret him to other people, and to try to persuade them that he wasn’t the kind of “nut” that they thought he was. He was so convinced about the importance of psychosomatic medicine that he reached a point where he thought emotional factors were the most important factors in the etiology of disease. He and Bill Grace, another fellow at Cornell, developed and cultivated the idea (not original with them) that each emotional state is correlated with a distinctive physiological state. That doesn’t seem unreasonable. But I thought it was more likely correlated with a physiological state in the brain. So they decided to study attitude; they studied patients with asthma, to work with them on their emotional state just before and during an emotional attack. The problem was to have blind controls. They concluded that when you had that attitude, that would certainly mean that your bronchioles were going to clamp down; this attitude would be different from the attitude that would constrict your blood vessels and raise your blood pressures. He was a very smart guy, and he loved to argue; he was only minimally diplomatic. We used to have endless discussions about the theoretical and practical implications of all this. When there was no space for me, he gave me space in his lab. We decided that maybe the way to test this was to hypnotize people and suggest the specific characteristics of the attitude to them in a trace and test the physiological changes that resulted. The trouble was that neither of us was very good at hypnosis. I thought it was because neither of us really believed in that technique. Because he was here, it seemed to me that I had no logical place on the full-time faculty in this area because Barry Wood felt one full-time person was sufficient.
Sarah Luse was a disciple of Ed Dempsey, an absolutely outspoken woman. She gave the impression that her persona required this outspokenness in any and all circumstances. I don’t know what her motive was, but she acted as if she had to say what was on her mind, regardless of the situation or the consequences. She was a very conscientious teacher and a pioneer in electron microscopy, and she was Ed Dempsey’s champion. She was an important teacher in pathology. We all knew that she was a loyalist with regard to Dempsey. When the school had lots of troubles, she defended him. Because of her temperament and her style, she didn’t mind going to anybody and telling them what she thought. Students were divided about her; some found her challenging style too uncomfortable, but she could be fun if you enjoyed that way of learning. In one pathology course, I remember Sarah Luse would deal with faculty just as though they were 2nd year medical students, asking them to read the slides. She was also very supportive of Paul Lacy because she saw him as Ed Dempsey’s protege.
Eye and ENT were part-time departments, without any full-time faculty. I think an Englishman was recruited to head ENT, but I’m not certain about this. [Joseph H.] Ogura and [Bernard] Becker put these two departments on an entirely different basis with research and innovative surgery. Ogura was an amazing man; he introduced a number of operations that became standard all over the world.
Alexis Hartmann was another one of the senior kitchen cabinet types in the school, along with Graham, Cori, and Wood. He had the same status at Children’s Hospital as Graham had in surgery or Wood in medicine. The hospital was an extension and expression of his personality; he was that dominating. The hospital board was made up of women; whatever he wanted, they did. Until the new hospital was built, it was primarily a department of pediatrics hospital, not a general children’s hospital. This was one of the problems that Phil Dodge was never able to confront in a politically effective way. In his last years, he had trouble because he couldn’t understand that everybody was seeing the hospital in a different light; they wanted it to be a general hospital for children. He would agree with the idea in conversation, but he couldn’t bring himself to translate this into different policies.
Hartmann was a national and international figure in pediatrics, a pioneer in the treatment of diabetes, and an expert on fluid and electrolyte balance. Students learned more about that with him than they did in medicine or surgery. And that’s not surprising because sick kids are so susceptible to dehydration; they can die of that rather than the disease. There used to be a tennis court between Barnes and Children’s Hospitals; the story was that Hartmann had paid for it to be built. He invited Barry Wood to play, and when he lost to him, he never played again. He didn’t like to lose.
Radiology had no formal clerkships, so students had little contact with Sherwood Moore and learned about it mainly from looking at x-ray films. We knew about Moore’s work with Copher, Cole, and Graham on visualizing the gall bladder. Psychiatry was also underdeveloped, and neurology wasn’t a full-fledged department. It didn’t have a clerkship, but it had some connection with medicine. All the patients were housed in medicine beds. I can’t remember just when neurology and psychiatry were combined into one department. But when Eli [Robins] became head in 1963, they separated. Eye and ENT took one week each and we learned how to use the instruments for examinations. For psychiatry, they sent us out to State Hospital to do mental status exams on chronic patients. They didn’t relate it to anything, and we wondered what it was all about. My feeling was that it was so uninteresting and so remote that if somebody had suggested to me that I’d go into the field, I’d have said, not a chance. At that point, I thought of myself as heading for internal medicine.
[Otto Henry] Schwarz in OB-GYN was a remote figure. We had a clerkship. One nice thing was doing a lot of deliveries. As a 3rd year student, you went with a 4th year student to patients’ homes. This was the first opportunity I had to see what poor people had to put up with in housing and medical care. In fact, as part of preventive medicine (which didn’t have a clerkship), we’d go to Kinloch. I was shocked to find people living without running water or inside toilets. The point was to give us a sense of the circumstances our patients were coping with so we’d do a better job taking care of them. In OB you were assigned only to multiparous women; the others were brought into the hospital. We were to maintain telephone contact with the chief resident if we had any problems. But the advice was to listen to the patient and do what she tells you because she knows more than you do. That experience was a lot of fun. These women preferred to give birth at home. In retrospect, we did some terribly insensitive things. For example, the attending thought nothing of letting ten students examine a patient, one after the other. Now I wonder, how come nobody blew the whistle on this?
I was an intern here on the medical service. I applied to other places, but I didn’t think any place else was better than this one. Our teaching faculty was greatly reduced because of the war, and this was true of house officers. So many student dragooned senior medical students into working as interns, so it was natural for me to stay here. You were already familiar with the work. After internship, I went into the army. As a senior medical student, there was a senior medical student from Emory where [Eugene] Stead was head and [Paul] Beeson was his partner. Gene Stead and Barry Wood decided to exchange two assistant residents between their programs for six month rotations. The residents who had that experience all thought it was terrific. The resident who came up here when I was a student was Bernie Holland, and we got to be pretty friendly. He thought I was a pretty good student; he was very interested in psychiatry, especially psychoanalysis, and tried to get me interested. He even bought me books about it. I’d say it’s baloney, and he’s say, no, it’s really very important.
When Stead went to Duke, Bernie was his first chief resident. He was a pioneer in cardiac catheterization after Cournand. He was an eccentric and got interested in psychology and wanted his residents to be interested. So he encouraged every one of them to go into personal analysis with the department of medicine paying. So Holland was the first one to do that. The interesting thing is that after he finished that, he went to Columbia and worked with Rado; then he went back to Emory where he was for many years the chair of psychiatry.
I came back from the army in 1948, and there were a lot of returning veterans; Barry Wood was trying to accommodate everyone, and it was really very crowded. I went to see him, and he said: “I have a funny letter about you. Gene Stead wants to have you on his house staff. Have you communicated with him?” I said no, but I bet that was Bernie Holland’s idea. So, I think I was the only person in those days offered a position on the house staff I’d never applied for in the first place. Barry Wood said I should think about it, and I came back a couple of days later and said no. I said, “I’m very nervous about one thing; Dr. Stead wants the house staff married or single to be on call five nights a week.” Joy and I had just gotten married and we’d been separated for quite a while. It seemed best to stay here. The interesting part of it is the informality in offering a house staff position. That’s not possible now.
The year I stayed on was very important. Because of the crowding, many of us were assigned more time in the outpatient clinic than was customary for 2nd year residents. I began to realize that I just wasn’t enjoying the work. Joy could tell whether I’d been in the clinic or the hospital just by my walk and my expression. So I went to talk to Barry Wood, and I said: “I’m distressed at how I’m not really enjoying my work, and I don’t think the patients are getting very much out of it. I do a careful history and examination, I order some tests, and no one else has any better idea of what to do than I do.” I don’t think in all the time I was here Barry Wood ever went to the outpatient department. So he said, “There’s a new man in psychiatry named George Saslow; his job is to help all the other specialties understand psychiatry.” His answer was to have me talk to Saslow about it. At the time, these patients complaints seemed non-specific; they wouldn’t seem that way today.
I remember student said that when Saslow came, they finally had a good teacher in psychiatry. He had a charismatic quality. He originally had a Ph.D. in physiology, and then he decided he wanted to go to medical school. He told me afterwards that he decided there would be better opportunities in psychiatry for someone his age rather than in continuing with research on red cells. Then he discussed plans to set up another clinic in medicine; we had A, B, C, and he was going to add D. I discussed this with Wood and decided to work with him. Saslow was the most skillful interviewer I’ve ever seen. If I have any skills, it’s from imitating him. I think it was intuitive on his part. We’d talk about his techniques, and it was clear that he didn’t always recognize them until I’d pointed them out. He tried to relate every patients problem to some kind of context: social, familial, economic. He was very skillful at drawing patients out about what was troubling them, what their strengths and weaknesses were, and where the stress was coming from. I tried to pattern myself after him. That was a wonderful experience.
But I had to plan for my 3rd year of medical residency, and I didn’t like what was offered to me here. Someone told me the VA hospital affiliated with Yale was a very good place, so I applied there and was accepted. I had an understanding with Carl Moore that I’d come back after that time. I had a wonderful year, and it was a good experience; I learned a lot of medicine. Bud Loeb had done it a year ahead of me, and he arranged for a small apartment until we moved onto the campus of the VA. They wanted me to stay on as a 4th year resident and get a fellowship at Yale in some subspecialty. I picked hematology only because it was Carl Moore; I had a lot of affection for him, and he liked me. I think I was the only psychiatrist he ever trusted. All the years after that, he’d always call me if he needed a consult. So I got a call from George Saslow saying they’d gotten a grant from the Commonwealth Fund to establish a division of psychosomatic medicine to teach residents in other fields, especially internal medicine, how to approach patients. “I’d like to offer you the first fellowship.” He said he understood that and suggested I think it over and talk to Carl Moore. At that point, I was still thinking of going into practice; there were only six full-time positions in the whole department. I realized hematology didn’t interest me that much, and that what I might learn with Saslow would be much more useful. So I called Carl Moore, and he said I should do what I thought was best. So I came back to work with Saslow in 1950. They paid me $2,000, and I had a wonderful year. It was then that I met Eli Robins who had a fellowship with Ollie Lowry as well as George Winokur.
Interview 3
The next year, they came up with a salary of $4,000; after our savings were exhausted, we just couldn’t make it on any less. That year was structured so that all this time I was spending in psychiatry would count as training. One year would make me eligible for the American Board of Internal Medicine. But then I decided I wanted to be eligible for certification in psychiatry, so I had three years of training in all. I had a wonderful time and really enjoyed it. When that was over, I was appointed as an assistant professor in internal medicine. I had a joint appointment, but I’m not sure just when the assistant professorship came through. At that time, I was helping Saslow in the clinic and doing consultations on the general medical and surgical services. There were psychiatric inpatients at McMillan Hospital. The Board of Neurology and Psychiatry requirements were flexible in those days.
There were a lot of people who were psychoanalytically oriented in those days, and you had to know the language. Even at my most critical, I always told the residents you had to know the language in order to be critical. Saslow had the responsibility for beginning to introduce medical students to patients. So I took a major role in that course. The point of the course was to begin to introduce the medical students to a broader range of issues concerning clinical medicine; Saslow’s most important central concept, which I continue to use today except for the most self-limited disorders, is that you have to think in terms of total context of of patient illness. You have a certain arrogance when you’re young; I used to say I could take any patient off the ward and show some kind of interesting and potentially important contextual perspective. And I could do it.
For me, that was what began to really make clinical medicine much more interesting, and especially outpatient medicine. It gave me something intellectually interesting and challenging to think about when there weren’t any dramatic physical finding or laboratory tests. Until I worked with Saslow, I didn’t have a framework for this understanding. Several things happened in 1955. Barry Wood accepted the offer at Hopkins to head Microbiology. That was a very important watershed for the Department of Medicine and the school. Carl Moore resigned as dean to become head of medicine. That was important for me because he didn’t feel comfortable with psychiatrists, but he always felt comfortable with me. The other important thing was that George Saslow was offered the professorship of psychiatry at MGH because his old friend and colleague Eric Lindemann just be appointed chief of psychiatry at Harvard. George wanted me to come with him, and he arranged for me to go to some meeting in New York and have breakfast with Lindemann. That was a very interesting experience; it completely unhorsed me. Instead of asking me about myself, he spent the entire breakfast grilling me about Saslow, and it was clear he was very nervous about Saslow coming back and competing with him. I came back to St. Louis and said, “George, I’m not going, and if you take my advice, you won’t go either.” So, he didn’t take my advice, and he and Joe Matarazzo who was part of our team went to MGH and had a ghastly two years. It was impossible, and George suffered from psoriasis and had one hell of a flare-up. Fortunately, for him, in 1957, he was offered the chair at Portland, and he and Matarazzo went. The next year, he invited me out there, and I went, but I decided to stay here.
By 1955, 1 was still thinking of going into general internal medical practice. I was close to signing contracts to sublease space, and Herbie Rosenbaum was generous enough to offer me space in his offices at a token rental. Lo and behold, Ed Gildea called me and said that he and Carl Moore had been having discussions and wanted to offer me George Saslow’s position. That would mean I’d have to have a primary appointment in psychiatry. This came out of the blue. So I said, let me think about it. I was hesitating about my professional identity. Then I thought the important thing was to be able to do what I really enjoyed and was good at; the primary or second appointment was less important than that.
For a while, Dave Graham and I tried to work together. But he realized that he wasn’t going to have as tolerant and supportive a chief as he’d had in Barry Wood, so he went to Wisconsin. So I inherited what was there. By that time, I’d become quite critical of the concept of psychosomatic medicine, so I wasn’t unhappy at the prospect that the Commonwealth Fund grant was offering. So I suggested that we dissolve the division and I would take responsibility for the psychiatric service in the general hospital and run the outpatient clinic. George Winokur decided he would take care of the psychiatric inpatient service. Eli Robins had come in ’49 to do a fellowship with Lowry, and he had to persuade Ed Gildea to give him an appointment in psychiatry. Winokur came in 1951 or ’52 because he needed one more year of general psychiatry residency, and he was planning to go back to the Washington/Baltimore area where he was going to go into psychoanalytic training. After one year, he turned that job down. It was soon after 1955 that Winokur, Robins, and I suddenly realized that we were now in a position to try to shape the department in the direction we thought it should go. We didn’t want a psychoanalytic department, we wanted a broad research effort, and we wanted to put tremendous emphasis on improving the diagnostic system in psychiatry. That agreement came about from four or five years of informal discussions. We’d have lunch together almost every day and share our reading and ideas. This was a crucial experience in the shaping of my career. We came up with a plan and then went to Ed Gildea saying, “This is what we think and this is how we propose to share responsibility. How do you feel about it?” He had eight more years as department head.
Intellectually and philosophically, he agreed with us. He worried about the political implications, but nevertheless he agreed to let us go ahead. So we took the ball and began to run with it. Gildea was very intelligent and very well read in many fields. He was always wringing his hands. He had been a pioneer in biological psychiatry, and that’s the reason he had been selected to head the department. He studied thyroid hormone and its implications for manic depressive illness. His wife, Margaret, was very different from him. His father had been a physician in Colorado; he was educated at Harvard and joined the Yale faculty. But she was to the manor born. On one side, she was from the Crane family; her mother was one of the very first women physicians in Chicago. Her father was Frank [R.] Lillie, who founded the MBL. She had a successful private group practice and was very psychodynamically oriented; she’d had a personal analysis with Jung. She was a very smart and very serious woman; she served as a kind of brake for Dr. Gildea, not letting him go off in a certain direction without having him discuss it. She was a very good teacher; the residents liked her because she was fun. Even if I disagreed with her, it was always interesting to hear how she thought about a case.
Anyhow, we got this go-ahead from Ed Gildea. And even if he had some misgivings, he never took back his authorization. So we went ahead with changing the courses and the clerkship. He would sometimes accept our advice about appointments. He had the burden of trying to have a balanced department. In his heart, he agreed with us 100 percent. Nobody had a better sense of what academic freedom required. He was politically liberal, and he really did feel that people should be permitted to think and write and research wherever their curiosity led them. His drive to have balance made him appoint some second raters; they knew it and didn’t stay. Another factor that helped us was that many psychoanalytically trained psychiatrists came back from the war and couldn’t stand the idea of not collecting fees directly from patients. So we didn’t have to cope with full-time and therefore influential psychoanalysts. We had to put up with the ideas of part-time staff but not in the full-time department. It was a very exciting and heady time. We thought, and it wasn’t totally exaggerated, that maybe if we were lucky and lived long enough, we could really make a dent in American psychiatry. I remember a senior person at the NIMH came to tell Ed what a bad impression his department was getting because of the way Winokur, Robins, and Guze were turning things. For maybe seven or eight years, we had a lot of trouble getting grants from the NIMH if they weren’t for laboratory research.
Interview 4
With regard to grants, I should have remarked that Lee Robins was able to get a foundation grant for her study of juvenile delinquency in the late 1950s. I do know that we had a lot of trouble getting grants to carry out what we would then have called clinical research. There was very little interest in family studies or diagnostic classification at NIMH. That didn’t change until we got into the 1970s. If you’re adaptable, it’s possible to take advantage of a set of circumstances and see something good in them. One of the great things that happened is that we learned to do studies with very small budgets. We involved medical students, psychiatry residents, and junior faculty. We didn’t have many research assistants and computer databases. Everyone was a lot closer to their data, so people really knew what they had done and what answers they’d gotten because they were working with the data themselves all the time. We did follow-up studies and record analyses; we weren’t able to travel, but we did things that were possible. And I think probably in that way, we involved more younger people in our research.
A very good example is Bob Cloninger, (the present department head) who worked with me for two or three summers. We could always find a few hundred dollars, and we began to write papers that people found interesting. Things began to change, and the change has really been tremendous. One of the most striking things is that if you took the two most read psychiatric journals in the U.S., the Archives of General Psychiatry and the American Journal of Psychiatry and read the articles from thirty years ago, you could see the difference in the topics and issues covered today.
I don’t think this change came from just one factor. I think basically the psychoanalytic model had run down, and the introduction of psychopharmacological agents which began in the 1950s gradually made people think this was the way to do research: on how the brain works. And, also, during the 1950s, there was a growing interest in genetics. We were interested in genetics for two reasons: to find out what was transmitted, and because the familial aggregation of illness was one of the standards that Eli and I specifically proposed to validate diagnosis. That is, if you could show that a given condition ran in families, that close relatives had an increased prevalence of that same condition, that was very important evidence in favor of a given diagnosis. There was a growing body of evidence, picking up momentum, that psychoanalytic theory just didn’t have any place to go; if you accepted it, no one knew what would be the next step. To this day, psychoanalytic theory has no place for integrating findings from genetics, neurobiology, or neuropharmacology. It’s not that they deny these things; they just have no way of integrating them into a coherent theory.
One of the things we began to realize is that there were people around the country who felt that they wanted something different and were looking for some place to take the lead. For many years that was a big advantage to us when it came to recruitment. Residents who were looking for something other than psychoanalytic training were always told to go out to St. Louis. We got a lot of interesting residents that way. Many were probably not the very best, but we got also some of the very best. And one of the things that’s happened is that there’s been a steady dropoff in the proportion of American medical graduates opting for psychiatric training. This began about fifteen years ago; about four to five years ago it looked like it was leveling off. But it started turning down again; the last three years, there was a cumulative drop of about 40 percent. The other thing is that there are now many other places that are now providing a somewhat similar perspective to ours. So, an advantage that we had has been eroded by success.
When Eli took the chair in 1963, he was the oldest among the “gang of four,” and he was the most advanced among us. Always, since 1951, we felt we had a plan and a goal. And we felt choosing Ed Gildea’s successor was crucial. We certainly tried to make it clear to everybody that, as far as we were concerned, Eli was the right person. We saw his taking the chair as essential for our program to stay on the rails. We knew there were many other people on the list who wouldn’t be sympathetic to our ideas. Eli was very lively, big, energetic; he ran a three-ring circus himself. He had two labs, one in Renard and one in pharmacology, as well as doing clinical studies. He was involved in all kinds of things at the medical center; he was exuberant and loved parties.
The Robinses did a lot of entertaining. He always had a cheerful kind of manner about him – much smiling and laughter. This was his general persona for the world; there was a general exuberance what he was doing. He played a lot of tennis and liked to come in and stay late. He also worked very hard – on weekends, for example. People who didn’t know him before he got sick can’t imagine what he was like. He was obviously very smart and very serious about psychiatry, improving patient care, and building a scientific foundation for the field. This was a very serious subject for him. When a bright person takes a serious subject on and does well, he’ll have charisma, and Eli certainly did.
His illness came on during his first year as department head, in the fall of 1963. Just a day or two before Kennedy was assassinated, Eli called me and asked if I’d pick him up. He was having trouble with his shoulder and didn’t want to drive. He said he had an aching, painful shoulder and neck; he hadn’t slept well. I assumed it wasn’t anything trivial. This was about ten months after he had begun to have those focal seizures; so we already knew that he had trouble. He worried about these; he was extremely self-conscious about these jerking movements in his right arm. They started out on a small scale and got worse. Bill Landau sent films out all over the country to see if other neurologists could identify the problem – without any luck. When Kennedy was shot, I went up to his office to see if he’d heard, and he had. I remember asking him about his shoulder, and he said it was still troublesome. It was a few days after that when myelitis was diagnosed; he began to have trouble walking. He went into the hospital and then went home. He was home for six or nine months; I went every day to bring him mail and pick it up. I was representing him in the department. It was a very bad time; he had just taken over. The unfortunate thing is that he never went into a complete remission. It’s been downhill all the way. In that sense, he had one of the more unfortunate clinical courses of multiple sclerosis.
But we continued to work together, and we divided up Eli’s tasks among us. I’ve paid a lot of attention to this in Eli and have given a lot of thought to individual attributes and how they determine the success or failure with which people cope with serious illness. If you have the right temperamental qualities, you can reduce its impact. Eli was never embarrassed to ask for help; I’d find that very difficult. Everybody was hoping that he was going to recover. I don’t think there was widespread knowledge about his health problems; he worked very hard to hide them. We had dozens of conversations about how he was going to handle a particular meeting; if he was having trouble, he’d call me and leave a signal so I could come over and cover for him. I was glad to do it, but in time people noticed his impairment.
Ken [M. Kenton King] was probably much more aware than I was about how the Executive Faculty and other members of the faculty saw Eli. I strove very hard to avoid discussions with anyone except Ken. But I think I was the first one to realize that Eli wasn’t going into a significant remission and to appreciate the first subtle indications that he was not doing well. Then I began to worry about the department. Eli’s illness was the single thing that kept me from going to Hopkins. I thought that sooner or later, Eli was going to have to step down; increasingly, I realized it would be sooner than later. I was thinking if I took the Hopkins job, and Eli has to step down, the chances are very good that with George Winokur gone, everything we worked for would be down the tubes. Toward the end, I was more aware of how disabled Eli was, and I worried about his embarrassing himself.
I had become vice chancellor in 1971. In 1965, 1 became the first elected representative of the faculty to the Executive Faculty from the Faculty Council. The Faculty Council was formed because, in the early ’60s, at one point it looked as though the school was going adopt a different relationship with Barnes Hospital. At that point, Edgar Queeny and Ed Dempsey were working very closely together. Dempsey thought he was trying to strengthen the medical school, but he totally and disastrously underestimated Queeny’s power and what he was up against. First, they were buddies, and then they were bitter enemies. And then we realized that not only was this going on, but Ed had also gotten himself into a fight with Tom Eliot. So then some of the faculty, among them Carl Harford, got a bunch of us together to talk about it and figure out what we could do to be helpful. So we decided to form a faculty council which the Executive Faculty was very ambivalent about. David Brown withdrew because Carl Cori didn’t like the idea. But he arranged for me to talk with Ed Dempsey so that he could understand what the motivation was – to be helpful. I think I reassured him. Then we thought there should be some representation on the Executive Faculty, to serve as a bridge. And I was the first one elected. Later on, there were three representatives, including one from the part-time faculty.
In the midst of this conflict, J. S. McDonnell decided that it was his role to protect the medical school. Queeny thought he was trying to help everyone; he thought he’d had a meeting of the minds with Dempsey and gradually realized they’d gone off in different direction. He got very angry. So the decision was made to bring in some outside consultants: Joseph Hinsey and John Knowles. They recommended the creation of the vice chancellorship for medical affairs. That position was just beginning to show itself across the country. Robert Moore had gone to Pittsburgh to fill that position. Everybody agreed because everybody thought there should be some kind of a buffer between Dempsey and Queeny on the one hand, and Dempsey and Eliot on the other. And similar problems were solved in a similar way in other places across the country. Carl Moore agreed to serve for one year, to work out a new contract with Barnes Hospital; that was signed in 1964. Sol Sherry was the acting head of medicine, and he recruited Bill Midkiff to help him with the accounting issues. One year was all Carl Moore agreed to, so a committee was formed to pick his successor.
Ken got the idea that I should be the vice chancellor. He was very discrete about it, but people knew. At that point, we were still struggling with the Queeny-Dempsey battle. Carl Cori had an idea: Bill Danforth. He proposed him and persuaded the committee to go along with that choice. The committee realized Ken would be disappointed, so they suggested a new position called “Assistant to the Dean.” I do think they didn’t want to disappoint Ken. The position was “minister without portfolio.” What that means in a parliamentary system is that I was there to do anything to help Ken. We’d meet twice a week in his office to discuss any issues he wanted to bring up.
And then I’d do certain things; for example, he asked me to chair the committee to revise the curriculum. Technically, Paul Lacy was the chairman of the curriculum committee, but he didn’t have the time. So Ken talked to him, and Paul agreed that this would be my responsibility. It took over two years, and the result was the elective 4th year, among other changes. I used to say that I had had at least one face-to-face conversation with half of the full-time faculty during this process, and that I had probably had a minimum of six to eight face-to-face conversations with every department head during this time. There were a lot of politics, and I learned how to negotiate.
When Tom Eliot was stepping down in 1970, Bill Danforth was offered the chancellorship. That was no surprise to me because Tom Eliot had appointed a committee to deal with a faculty report on the future of the University. Bill Danforth was the chairman, and this was a signal that Tom thought he’d be a good choice. One reason he did that is that during the Vietnam war unrest on campus, Bill felt that one of his responsibilities was to roll up his sleeves and help out. I was also on that committee, and it was a very interesting experience; I learned a lot about the University. When it was clear that Bill was going to be the new chancellor, the Executive Faculty appointed a new committee. Again, I know that Ken was now even more anxious for me to become the vice chancellor. And, this time the committee decided that was the thing to do.
I recommended to Bill, to Ken, and later to Ginny [Virginia Weldon] never to give up their clinical training. I felt it was very important. It’s a question of what’s important to you. Psychiatry was important to me. I thought Bill had been a good vice chancellor, and I thought I’d be a different vice chancellor. He had his strengths, and I had mine. We had a cordial, friendly relationship. From time to time, he’d raise the question of whether I should give up psychiatry and become vice chancellor full-time. And I’d always say, if you want a full-time vice chancellor, I’ll resign anytime with no hard feelings. He’d always back away. I never had any doubt in my mind about which position came first. And I think Ken and I, because of our preexisting friendship and long conversations, really had a very common understanding. We respected each other, so there was a very conscious effort not to do anything that might be an embarrassment. We had many disagreements, but not intense cleavages about basic ideas. We never expressed them outside of our office. We had uninhibited discussions, and we always managed some sort of a compromise. We’d take turns winning. It was very harmonious. For me, it worked very well because I did not want to give up psychiatry.
It turned out that working with the powers that be wasn’t so scary. At one point, I even dealt with Edgar Queeny. At one point, he wanted to put pressure on the medical school because he felt the medical school didn’t accept the fact that Barnes Hospital’s financial problems were all due to teaching burden. He pushed for an arrangement that was in the ’64 agreement that turned out to have been completely in the medical school’s advantage, and not in Barnes Hospital’s advantage, financially – because no one anticipated the effect of Medicare. Harry Panhorst was then the president of Barnes Hospital, and he told me Queeny decided to get the medical school’s attention by closing the 3rd floor of clinic. I just refused to accept that. Soon after this happened, and they moved all the furniture, that night a bunch of psychiatry residents moved all the furniture back. Everybody thought I put them up to it, but I didn’t. This was a spontaneous action on their part. What we did was we told the patients to go up to the 5th floor; we’d meet them there and bring them down. We had a problem; I talked to Tom Eliot about this. We weren’t going to see emergencies, but then I realized it was the patients who would suffer. At any rate, I was told that when this happened, Edgar Queeny talked to someone about me with great respect.
Interview 5
I first got to know Ken [King] very well when he returned from Hopkins and, besides setting up his own research lab, was also asked to take on responsibility for the student health service. I was the psychiatric consultant there. We had enough professional reasons to meet and talk about students he had referred to me. That’s where our close friendship began. I have half-teased him over the years that he made a mistake and should have gone into psychiatry. He’s very interested in what psychiatrists are interested in; he’s a keen observer of human behavior. He has an ability, infinitely greater than mine, to report accurately an exchange between several people. Often I’ll start out to describe an interaction, he’ll correct me, and I’ll realize his version correct. One of the things I liked about Ken is that he was always very sympathetic, never condescending about psychiatric problems. When we talked about a student who was in trouble, he never had a bad thing to say; he was always understanding and compassionate. I didn’t have the burden of trying to change his basic attitude toward psychiatric disorders. Some doctors might have been more uncertain about whether they should be wholly sympathetic. With Ken, there was no problem.
When he became dean, he was probably better educated about psychiatry, what the field was all about, and what psychiatric illness might represent than almost any other non-psychiatrist dean in the country. This wasn’t the result of a crash course; his knowledge had evolved over the course of years.
Ken always had a strong interest in medical school administration and how decisions were made; I shared that interest. By that time, we were good friends, and we often met in the cafeteria to discuss our mutual interests. I began to appreciate what I think are his very important strong points: he’s a person of tremendous integrity. I can’t imagine him lying to anyone. He’s discrete. He has a keen ability to size people up. But even if he would comment about somebody’s weaknesses or bad points, there was never any kind of viciousness about it. He always spoke with a kind of sadness and puzzlement that someone behaved that way. He had the senior faculty and department heads well sized-up; all his personal abilities served the school well. When he was associate dean, he had a front row seat to the conflicts between Dempsey and Queeny, and Dempsey and Eliot. We’d often talk about it; he had confidence in my discretion. We agreed that what Ed Dempsey wanted to do for the school was right, but he completely misjudged the political context. He stopped taking in signals, or maybe he was never any good at listening. Finally, the Executive Faculty realized that he was so upset and so angry that he couldn’t function.
To begin with, Ken saw him as a role model. Ed Dempsey was garrulous. He liked to talk. He was very open with Ken about what he was doing. This may have made Ken uneasy on occasion. Things came to a crisis; Dempsey left, and there was a decision made to have a vice chancellor. Ken was appointed as acting dean, and then dean. I think the Executive Faculty made the right decision. Ken’s basic temperament and code made it impossible for him to let his ego interfere with serving the school. I never heard him ever say anything like “I,” or “My position,” or “I arranged that.” He always looked for a different circumlocution to avoid that pronoun.
The discussions we had when Dempsey left encouraged Ken not to look at the medical school as an extension of one’s own personality. As a result, he was ready until the very end of his term, to consult with people. He saw his job as trying to bring to bear all the information and perspectives relevant for getting the best decision. Many people were surprised that Ken was dean for as long as he was. I’d hear people say well, that’s because he didn’t make any tough decisions. What they were really saying was that he didn’t want to go out on a limb and say that his judgment was the best available. Given his modesty and confidence in people, he always believed that a collective judgment was best.
It didn’t take long before everybody came to have confidence in Ken’s integrity and discretion. So everybody felt it was possible to go to the dean, say what you had to say, sometimes unfairly bind his hands by saying “don’t tell anyone,” and knowing that he wouldn’t. He was absolutely trustworthy. There was a steady growth in confidence in Ken as a human being, and for our system, that was crucial. After we got past the point when the Executive Faculty used to review and set all salaries, when the school got too big for that, everybody realized you had to turn these decisions over to the dean. But you had to have confidence that the dean would do his best to be discrete and fair. No other dean enjoyed more confidence concerning fairness and integrity than Ken had.
I’ll give you an example of the kind of thing that used to upset Ken. A search committee would meet to discuss a candidate, and someone would say: “He’s third rate, a turkey.” This used to bother Ken, that we allowed ourselves to be so cruel and peremptory and inconsiderate about someone. I do remember a couple of times we had discussions about whether someone who had won awards and held responsible appointments could really be a turkey. Ken’s distress about that kind of discussion was symptomatic of how he felt. He always treated everybody with the utmost courtesy. The Executive Faculty wasn’t expecting a dean, and wasn’t looking for a dean, who would try to lead the school to some new venture. They wanted somebody who would raise questions, help them get information, help them carry out discussions, and let them made the decision. That’s the Executive Faculty system, and it worked beautifully with Ken. Now I understand that the AAMC has specified that the dean should have more authority for the curriculum than has been tradition here. People who set a criterion like that don’t understand how a good school operates. No good school allows a dean to develop or change a curriculum; that’s something the senior faculty does. That’s the kind of thing that Ken was exceptionally good at: getting people to work toward some kind of consensus. And the reason he was so effective was that people didn’t think he had some sort of secret self-aggrandizement in mind. That was very important. They were willing to give Ken a lot of latitude because they trusted him. Everyone who came to know him well came to trust his good instincts and his superb ability to size people up.
You have to know how to read Ken, because he’s not given to spontaneous candor. You can go to him with an idea that he thinks is a terrible mistake, and, if you don’t know how to read him, you may not read the signals correctly. I learned a lot from talking to him and watching him. One principle which he enunciated repeatedly, and I took on and repeated it, was that we in administration have a responsibility to facilitate the academic and professional work of the school. Our job isn’t to define it, though we might have a role in that, but to see that administration is helping the academic and professional functions of the school. Many a time, he’d get some recommendation about “being tough.” Ken would say, “I don’t want to be tough unless I have no choice. I want to see how I can be helpful.” He didn’t see his role as obstructive. He would always look for some way avoid confrontation. There were times when he was hurt because he felt that people weren’t fair. He’d say, “Some faculty say they want a strong dean. What do you think they mean? It means they want someone to make other people do what they want.” I think that’s exactly right.
He tried to be as generous as he could be with the resources of the school. Every department in the medical school without exception found itself in a situation where most of its money didn’t come from the school; it came from grants or from clinical work, or both. So, the tradition in the school, which I think nobody was prepared to change, was to continue that. When Mike Timpe was our chief financial officer, I began to worry about whether or not we were doing enough long-range financial planning. This was in the early 1980s. I said, “Where are we going? We have to have some long-range vision.” We had this long history of always being in the black, and there always seemed to be enough money to do all the reasonable things. But circumstances were changing rapidly.
There had never been any policy about growth. Department heads were encouraged to be as entrepreneurial as possible, with the confidence that this approach would continue working. Sometime in the late ’70s, Ken and I started a series of dinner meetings with the clinical chiefs be cause there didn’t seem to be enough time to talk about relations with hospitals in faculty meetings. So we’d meet at Whittemore House. I remember that over the course of six months I gave a similar sermon three times. It went like this: “I’ve been vice chancellor long enough to have a sense of where the school is going, and I’m impressed that our expansion into clinical activities is moving at a very rapid pace. And I’m only concerned that I notice that each of you, in direct relationship to the proportion of your department’s income from clinical activities, is more preoccupied with this. I worry that concern about clinical work is going to cross a line, and our academic goals are going to suffer.” I stopped giving it, because they answered: “Sam, do you have other sources of money for us?” My reply was, “Maybe we don’t have to be so big.” I went home that night and said to my wife, “Joe Stalin would have been more popular in that room when I suggested that we didn’t have to grow.” They were irritated with me, and I could see it was self-defeating to continue. I can tell you this; I thought and talked with Ken a lot about it. I concluded that it was going to be impossible to limit growth on a priori grounds. We were going to have to anticipate that external constraints would force us to stop growing. That’s now a national phenomenon. When resources run out, either money or space, or the supply of good people, then growth will stop. So I decided that infinite growth was just too much of the American dream to try to stop it before circumstances did. Now some people, like Dave Kipnis, are determined that we have to prepare for the next stage of tremendous growth. I could even be persuaded that this was reasonable, if people were willing to make some sacrifices in the short run.
The difference between Ken and me as administrators, is that I was concerned that the way we were heading, the dean’s budget would be in deficit, and we couldn’t let that happen. Ken was inclined to be more skeptical about financial projection. I promised the Board of Trustees that wouldn’t happen. The day the medical school is not completely in the black is the day that the way we operate is going to change. They’ve allowed us tremendous latitude; the day they lose confidence in the way we operate is the day they’ll treat us the way they do the Hilltop Campus. It’s one of the few things I take the majority of the credit for is that by insisting that the departments had to keep the dean’s budget in the black. Over several years in the mid-’80s we shifted about 10 million dollars from the dean’s budget to the departmental budgets. This put us in a much stronger financial situation to think clearly about what was going on in the future.
No institution I know can afford not to have long-range financial planning. It’s very hard to have long-range programmatic planning because no dean, no department head, no vice chancellor is smart enough and has a broad enough perspective to know what kinds of things should be supported and what shouldn’t be. So you have to have enough good people and give them enough latitude to make choices. And especially with the NIH and ADAMHA funding, you’re not forced to make all the decisions yourself; there are peers out there who will help you decide whether what these guys want to do is the right thing. There are a lot of mistakes in both directions, but it’s the best system we have. So I thought financial planning was very important because I did not want to see the medical school get into a situation where we had to go hat in hand to anyone. We averted the crisis before it became a problem.
Interview 6
Everybody recognizes that for a long time, medicine has been a field where women have had to struggle to make their way. The pace of change is accelerating, and I think we’re going to see some material differences in the next decade. But, by and large, women have not yet achieved their proportion in the profession within academic medicine. I think there were some understandable reasons for that, most of which had to do with the fact that women lost ground because of taking time out to raise children. In the past, there really wasn’t very much tolerance for that kind of inevitable development in the lives of women faculty members. Gradually, we’ve come to understand that this is something you have to adapt to and make allowances for.
Talking to one’s colleagues, you very rarely encounter explicit sexist attitudes; maybe colleagues in medicine are too smart for that. What you almost always get are comments like: “They haven’t been as productive, or as successful getting grants, or writing papers, or they don’t sit on the proper national committees.” Until fairly recently, that was much more difficult for women. I now think that has turned around to some extent. First of all, there are an increasing number of women on those committees and secondly, the men have come to an understanding that they’ve got to make an effort to change. Psychiatry has traditionally been more receptive to women than almost any other specialty except pediatrics. My knowledge of what’s happened has come from the ADAMHA institutes rather than from the NIH. In my own direct experience with particular women, my evaluation and contacts were not very much shaped by worrying how they should be treated because they were women. I felt they were very able people.
Paula Clayton was a student, a resident, and a colleague. She was the first woman who went the full academic route and then became a department head of psychiatry in a major medical school. And I recommended her for that position. In all modesty, I think my recommendation was helpful. I was her mentor, and mentoring is very important for both men and women. Paula was a very good student, and we were very pleased when we found out that she was interested in psychiatry. I think she graduated in 1960. Paula married while she was in medical school. She was one of those women physicians who seemed to be fairly comfortable with her male colleagues. She acted as though she took it for granted that she was going to be treated properly. It’s only been on infrequent occasions that she and I have talked about certain occasions where she felt she was handled differently because she was a woman. Early on, she started to work with George Winokur on the inpatient service. Then she collaborated with him and Ted Reich on a very well received book. She took time out to have three children; two sons and a daughter. The thing that’s interesting to me is how we all accommodated to the fact that she was pregnant and would need some time off; the amount of time would vary, but we knew she’d be back. She took for granted that this wasn’t a big issue. Eli [Robins] was department head at the time.
After George left, [Richard] Hudgens took over the inpatient service. Not too many years afterward, he had to go into private practice because he needed to earn more money. I remember asking Paula to take on the inpatient service and the residency; she did want to take on the residency, but she agreed to take on the inpatient service. And I found that I was turning to her more and more. By that time I was also vice chancellor. She really became very important to me and I relied on her to be informed about how things were going. She was here in the department everyday and all day and I wasn’t. Paula was very good at keeping track how individuals in the department were doing; I never was as good at that as she, and I wasn’t here half the time. She did a very good job.
Some years later, I was approached by the University of Minnesota for recommendations for their next department head. I recommended Paula. Much to my delight, they were very receptive – there was no problem in selling her to them. They immediately got in touch with her. Her husband was quite willing to make a move at that time. He and I had talked about this before when I was offered the chair at Hopkins. I talked to her and said if I went, I wanted her to come with me. I asked her how her husband would feel about this. She said I should talk to him, and I did. He said he had recognized that once she got serious about her career, they might have to move. And he said he’d move once, but not twice. The committee was very enthusiastic about her. So they went to Minnesota. I tried to give her advice about what to ask for, and she asked for the right things.
Sad to say, they haven’t delivered on what they promised. I told her I thought she wasn’t being tough enough. I’ve kidded her about being too considerate and too nice. I’m not talking about pounding on the table, because when you have something tough to say, you can say it in a soft voice. She invited me to be a visiting professor the last two summers, and the first year, she had me meet with the dean and other members of the medical school administration. I told them they were running the risk of losing her. And they would have a terrible time replacing her because everybody in the country knows they haven’t delivered on what they promised. No one else will come without iron-clad promises. In addition to this position, because of her accomplishments, and also because she’s a woman, she serves on many boards and has been president of the American Psychopathological Association. She’s very attractive; she gets along with all kinds of people, and she has a good sense of humor. She doesn’t portray herself as perfect; she acknowledges her mistakes and goes on.
Lee Robins’ career had the advantages and disadvantages of being married to Eli. The advantage mostly came from learning a lot about psychiatry without having any medical training herself. She early on saw the outlines of what might happen for her as a sociologist in a clinical department. With four children, she took a lot of time out and didn’t start working full-time until her youngest was ten or so. She started on that basis before Eli got sick. With her, it was a matter of principle not to work full-time because she wanted to feel free to deal with the children if they needed her. Her original study of juvenile delinquents was very well received all over the world, and in a very short time she achieved national and international recognition. The study was very well done and very well described. And this is where being Eli’s spouse was an advantage because her approach was infused with the kind of thinking that we later started to call the “medical model.” Lee, too, is a very responsive, friendly, easy-going person. So I don’t know that I ever had a conversation with her about gender as a problem in the department of psychiatry. I only had a few of those with Paula. For them, it just didn’t seem to be much of a problem. They were first-rate. I’m sure Paula’s salary was comparable to her male colleagues. If Lee had had an MD, she’d have had a higher salary. There are lots of different kinds of Ph.D.s and they get different salaries according to the national market.
Ginny Weldon came to me to ask for advice about going to law school as preparation for a career in administration. I told her that didn’t seem necessary to me, and I offered her a position as my assistant because I needed help at that time. It was quickly apparent that she had a gift for administration, and I began to give her more and more responsibility – mostly in the area of governmental relations. It became clear to me that in a very short time she had achieved national visibility. People would contact her for her opinion. She may very well have been the only M.D. doing this, so she had a real leg up on this. There were other people with law, political science, or business backgrounds; she was unusual because she could interpret medicine for them. She never exploited her medical knowledge; she used it to help others.
Her style was different from Paula’s or Lee’s. Clothes were very important to her. She paid careful attention to her dress and she and was very good at it. More importantly, I discovered that if I asked her to take on some responsibility, I did not have to worry about it. She was very well-organized. She’d plan her strategy and submit an outline for my comments or suggestions. And she’d set to work with very high standards. My usual admonition was: “Keep me posted; I don’t want any surprises.” And she did very well. She and I got along very well from the very beginning. We liked and trusted each other. I tried to help her in every way I could because I liked her very much and thought she was so able. The only problem was that after a while Bill Danforth realized how good she was, and he’d ask her to start doing things for him. That presented a little bit of a problem. I told her to tell him she was too busy, but she’d never do that. Bill particularly wanted her help as his own national role grew. She helped him with a lot of things. And, I had to admit, that in so many of these situations, the medical school stood to gain. She worked harder than she had to because of this situation.
About eight or nine years ago, I restructured the vice chancellor’s operation on paper, and she became the deputy vice chancellor. To use Tom Eliot’s term, she was my alter ego and could speak for me on issues. The only thing I had to be careful about was preparing the budget because this was one of the awkward things that came about from two positions (vice chancellor and dean) and one set of financial officers. We met regularly and talked on the phone all the time. When it was clear that the time to step down was approaching, I began looking for ways to suggest her as my successor and found myself disappointed that there was so much resistance. About ten or twelve years ago, she was offered a position as dean or vice chancellor at a medical school of second rank. I remember saying to her, “I think you can do better. But, if you think you want to be vice president at this point, then I’m willing to resign as vice chancellor. (I had the advantage of being to go back to psychiatry.) And then the school will have a choice: either appoint you or get someone else. But, you have to be prepared to take the other job, or else this will be a fiasco.” She wasn’t prepared to do that.
I tell you this as an indication of how much I respected her and how much I thought she could do the job. I think those who resisted that idea were wrong. I’m not saying that they weren’t operating in good faith when they couched all their comments about her in terms of personal traits and didn’t discuss gender. And I told them so: I said, “I’m not trying to tell you someone else can’t do this job, but I know she can do this job very well.” It didn’t work out, and within my last year as vice chancellor, Mahoney of Monsanto approached me and Bill Danforth about hiring her. The job he offered has proven challenging and exciting for her, but I think she was hurt by her rejection here. She had worked very hard. I think it’s very likely that the school will have a woman department head before the end of the decade.
I see young women coming into psychiatry who, with a little bit of luck, could become leaders in the field. It’s just that they’re so young yet and just getting started. We’ve just hired a senior woman, Barbara Geller, who’s a new appointment in child psychiatry. She is a very serious investigator. I don’t know to what extent her ambitions include administration.
Child psychiatry is a story in itself. Ed Gildea had some contact with the Ittleson Foundation. They wanted child psychiatry to be a separate department. Gildea and Lowry didn’t want that. Lowry understood that the balance between the preclinical and clinical department was very important and very delicate. The foundation was naive about the academic world. They always opted for the worst choice. They reluctantly accepted the worst of all possible worlds.
They said that they wanted the director of child psychiatry to be able to bypass the department head and take the budget straight to the dean. But they accepted that all academic appointment and promotions had to go through the head of the department. They didn’t understand that it would be a rare head of child psychiatry who could get the dean to be very generous with him. Among the things that Ken and I had an agreement about was that I would never see the budget for the department of psychiatry while I was vice chancellor. So I was surprised to see what a small budget child psychiatry had when I became department head. There was nobody who spoke for it. [E. James] Anthony didn’t know anything about American universities. He traveled around the world giving talks and he took his advice when he first came here from the psychoanalysts. And they had no sense of the power structure, or where you go to get things done. He was here for twenty years, largely in isolation. He had a program at Jewish Hospital which was terminated. He had a consultation service at Children’s Hospital which he didn’t do much for. Once, Dr. Alexis Hartmann asked me to come by and talk to him before I was head of the department. He’d known me as a medical student, so he felt he could talk to me. He said, “Have I offended Dr. Anthony?” I said I hadn’t heard anything. “Well,” he said, “we have a consultation liaison service, and I wanted to show the pediatrics department that this was important, so I went to every session. But Dr. Anthony never showed up. Could I have offended him?” So I said, “Now that I know what you’re worried about, I can tell you that isn’t the case.” And I told him about all the other things that Anthony had not gotten involved in.
James was a very funny guy. He was very skillful in a superficial way, in social interactions. He was bright and articulate, but he had no stomach for argument or confrontation. His first contacts with us must have been traumatic; he never came back. Before it happened, I told Ed Gildea that I thought this was the wrong appointment. He arranged for me to meet Anthony, and I told him that what I thought child psychiatry needed more than anything else was involvement in Children’s Hospital. I told him that people at the medical school, but especially pediatricians, needed to see psychiatry as an integral part of the operation. He ignored me, 100 percent. Later I heard that some space was being vacated at Children’s, so I rushed over there and proposed that the space be used for the Child Guidance Clinic. I remember a discussion in Eli’s office, with Eli and Anthony, and representatives from Children’s Hospital and the Child Guidance Clinic Board. I made the strongest plea I knew how, and Anthony didn’t want it. His argument was that child psychiatry had to be given an opportunity to develop as an independent entity. He thought pediatrics would stunt it. And I could see the people from Children’s were relieved. They had dozens of other candidates for that space.
Interview 7
James Anthony came from Britain without experience in American universities and especially without experience in American medical schools, which are very different from the British medical school, organizationally. Then he got all his advice from the local psychoanalytic community. And they didn’t know anything either. They were all part-time, they were all relatively marginal in so far as the intellectual life of the department were concerned. what happened is that his natural instincts to be a loner, with the bad advice, resulted in his never having any material impact on child psychiatry and the larger medical community. I used to say that I’ll bet if I had a line-up, most of the full professors at the medical school wouldn’t recognize him. He was very good at getting grants, and he liked to give talks around the world.
James was very self-centered. When I became head of the department, and wanted to take stock of child psychiatry, I was shocked to see how far people were being exploited in his division – that is, the young faculty members, who were being recruited primarily to help Anthony, without any obvious or apparent concern, effort, or program to help them with their own careers. I don’t think patriarchal is the right word; that implies you’re in charge and responsible. I didn’t see any sign of that. Some of these people said, after I interviewed them, that it was the first time anyone had asked then what they wanted to do. I asked them if they had ever applied for a grant of their own? Did Dr. Anthony ever encourage you? Did anyone ever explain to you how important it is to have your own grants if you want to have national stature? The answers were “No.”
They abandoned any opportunity to have child psychiatry on the inpatient service at Children’s Hospital. Because the psychoanalysts still controlled the psychiatric services at Jewish Hospital, they put a child and adolescent unit there. After a few years, they abandoned it because it was failing financially. This was a time when it was hard to fail. It was a sign that James wasn’t paying any attention to it. As I told you, the Ittleson Foundation negotiated the worst arrangement for what they wanted, which was to maximize the independence of child psychiatry. Under their agreement, the head of the division bypassed the head of the department and went directly to the dean. And the dean had no motive to be generous. Anthony didn’t serve on the Executive Faculty, he wasn’t around, he wasn’t a person whose influence on the faculty was something the dean might want to take into consideration. So I was shocked to see how low the salaries were. The dean had no motive to make them any better.
Besides being a loner, Anthony had no stomach for any kind of sparring. He came to one grand rounds, was bruised slightly in a discussion, and never showed up again. A former member of the department, Mark Stewart, used to say when he gave a talk elsewhere: “I don’t mind your interrupting, because where I come from the audience always demands equal time with the speaker.” Anthony could not tolerate this. In his favor, James Anthony was intelligent, scholarly, thoughtful, and serious about his work. But he was a fish out of water. He just didn’t know how to do follow-up studies. By isolating himself, he deprived himself of an opportunity to learn how other people were carrying out similar studies.
When I became head of the department in 1975, I asked James to come by for a talk. I said, “You’ll remember the advice I gave you fifteen years ago to make child psychiatry fully integrated with pediatrics. I see no evidence that you’ve done that. I know a lot of people in child psychiatry think I’m an enemy, but quite the opposite: I think child psychiatry is extremely important, academically underdeveloped, uncultivated as far as research is concerned, and the training program in child psychiatry ignores research and is even antagonistic to it in a covert way. I’d like to see that changed. I’ve looked up the documents, and I see that if the incumbent Ittleson professor agrees, then the division could be reabsorbed. So I’m saying to you that if you agree to regularizing the administrative relationship, I assure you I’ll take seriously my responsibility to help child psychiatry thrive – I’ll help raise money, expand its programs, etc. If you don’t, I’m not going to make you uncomfortable, but I’m not going to help you in any way. I’m not going to hurt you, but I’m not going to help you.” That’s what he preferred. But, as luck would have it, a crisis arose. He had some problems with the state, and he came to me for help. I said, “Remember the discussion we had? If you want me to help, I will, but you know my price.” So he returned with a document requesting that the division of child psychiatry be brought into a regular relationship with the department. He just had no sense of how you solve problems.
When he was two years from retirement, I said: “James, I’m not going to embarrass you in any way, so I’ll let you stay Ittleson Professor until you retire as head of the division at the age of sixty-five.” He thanked me, I think sincerely, because he’d been afraid that I might take his professorship away. Then he told me, he thought he wouldn’t stay in St. Louis after he stepped down. So then I started to see what we could do to work with the people in the division. That was very difficult, because all the psychologists and social workers were in a state of panic. It was uncomfortable to sit down with them because they thought I was going to be ruthless and cruel. I tried to reassure them. I told them I wanted to see what kind of bridges we could build between the division and the rest of the department. And I told them I wanted to move the whole operation into Children’s Hospital. After a year, it became clear that they didn’t want to compromise. So I gave them all a year’s notice. I called each one in separately. I told them I’d help them in any way I could to get a new job, that I had no grudge against anybody. So, in relatively short time, all but one got a new job. They proposed developing a position for an Executive Director of the Child Guidance Clinic. I agreed, and they chose Lee Judy, which was fine with me. He came by to tell me that one of the young social workers had not yet been able to find a position. I said, let’s not tell him this, but if he hasn’t found a position at the end of a year, let’s give him another year. So then one of the other social workers decided to challenge me. They got a lawyer and decided they were going to sue for breach of contract. The young social worker I’d wanted to help was among the litigants. In the end, they all left.
In the meantime, I started looking for another person to head child psychiatry. My first choice was a person named Dan Offord, who at the time was in Toronto. He was one of the most under-appreciated child psychiatrists around. Intellectually, he’s a crackerjack, the equal of Michael Rutter. He’s a little younger and very personable. I tried to recruit him twice. The second time, he had just accepted a chair at McMaster. So then Lee Robins had met Tony [Felton J.] Earls, and she told me about him. So I called him up and asked whether he’d have any interest. And he said he certainly would be interested in coming for a look. First of all, he was very bright and committed to research with interests that overlapped with ours. He wouldn’t be isolated; he’d be welcomed. His temperament and style were such that he’d be very popular. And the fact that he was black was a plus. And I was honest about that. I told him I thought he could have a great career here. And, of course, we’d have to find a position for his wife, Mary. I think she didn’t quite accept the fact that she’d be under the same pressure as everybody else to get grants; she thought, somehow, that the department would bail her out. And I told her that wasn’t going to be possible. But I’m not sure she ever understood that.
They moved out here, and they were welcomed. He was the first black full professor at the School of Medicine. The thing I liked about him so much was that he had exactly the same feeling about the importance of research that the rest of us had. There was nothing put on about it. He’d been educated at Howard and did his residency at Harvard. He had started out to become a neuroscientist, but then he told me that he had one of these confrontations with his own complicated set of goals and decided that going into basic research might be indulging himself in a way that he shouldn’t. He felt that child psychiatry offered him more of an opportunity to give a payback to his community. I think James Anthony liked Tony and approved of that fact that he was black. Anthony himself had suffered racial discrimination in England because he was part [East] Indian.
With the plans for the new Children’s Hospital, I saw the opportunity to accomplish the integration I’d wanted for so long. Then United Way decided to cut us off without any official warning. What they weren’t happy with was that the Child Guidance Clinic [had] just an advisory board, not a real governing board. But they never said that to me, or gave me any kind of written warning. I wrote a very strong letter at that point. I said, “If you come and look at our files, you’ll see that we’re taking care of mostly indigent families.”
After this, we used the money from the sale of the Child Guidance building to make up the deficit. We started inpatient treatment on a pilot basis in the old Children’s Hospital. We still have some financial problems because of the very high Medicaid population and the fact that Medicaid reimbursement is even lower for psychiatry than for other medical services. But the vision I had for integrating training, research, and patient care in child psychiatry with the rest of the department is firmly in place.
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