Bellevue

by David Oshinsky

  The expansion of these privileges spoke to a profession in flux. Physicians had rarely charged for services rendered in a hospital because the typical patient lacked the ability to pay. Surely that would change. And what of the relationship between the family doctor and the hospital staff? Was a nurse or an intern expected to carry out his wishes? Who would order the various tests? Or determine when the patient was well enough to be discharged?

  For a public hospital like Bellevue, such questions were moot. There would be no wooing of private patients and no temptation to segregate by class. But the changing landscape of patient care would seriously complicate its role. Though New York’s voluntary hospitals would continue to accept charity cases, the pace already had begun to slow. Meanwhile, private referrals were pouring in. Among the many examples was Mount Sinai, where the number of paying patients would more than triple—from 9 percent to 30 percent—in the years between 1889 and 1909, while charity care languished.

  Public hospitals had no choice but to pick up the slack.

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  Working at Bellevue in the late nineteenth century had marked a man as a fine doctor and an even finer Christian. The surroundings may have been decrepit, the conditions sometimes threatening, but the medical care was as good as one could hope for, given the challenges of the job. Where else, the New York Times had boasted, could “a pauper without a rag to his back…command the services of [giants] like Dr. Austin Flint, Sr., Stephen Smith, and Dr. A. L. Loomis?” And how better for a pauper to repay his debt than by supplying the “clinical material” required for teaching and research?

  For decades, Bellevue had recruited its doctors through a byzantine arrangement with the city’s top medical schools. Changes had occurred—the merger of Bellevue and NYU in 1898; the addition of newly opened Cornell—but the concept of “separate fiefdoms” remained firmly in place. Columbia (P&S) ran the First Medical and Surgical Division at Bellevue; Cornell the Second Division; NYU/Bellevue the Third Division; and “non-affiliated doctors” seeking postgraduate training the Fourth (a much smaller operation). On paper, at least, it seemed to work. Students were trained; research flourished; patients got free care; and the city fulfilled its obligation to the poor.*

  Bellevue had even survived the pen of Abraham Flexner, whose heralded Carnegie Foundation report, Medical Education in the United States and Canada, published in 1910, had portrayed the typical medical school as a wretched diploma mill run by incompetent doctors looking to make a fast buck. While not a physician himself, Flexner had immersed himself in the German model of medical education, which stressed the combination of clinical training and laboratory work. He particularly admired Johns Hopkins, where entering students held college degrees, the medical school was attached to a hospital, and the operating expenses were covered by an endowment, not simply tuition and fees—the very arrangement that had led William Welch to depart Bellevue for Baltimore two decades before.

  Flexner had visited almost every medical school in both countries. “FACTORIES FOR THE MAKING OF IGNORANT DOCTORS,” read the New York Times headline of the scathing report. The good news, said the newspaper, was that New York City “is practically free from the things [Flexner] condemns.” Cornell, P&S, and NYU/Bellevue “are favorably commented upon in the report.” This was mostly true. Of the eleven medical schools in New York State, Flexner had given the highest grades to Cornell and Columbia, with NYU/Bellevue a distant third. Cornell and Columbia required at least two years of college for entering students; NYU accepted high school graduates (soon to be upgraded). Cornell and Columbia admitted fewer applicants and had fair-sized endowments; NYU relied on tuition and fees to cover its costs. What the three schools held in common, however, was their link to the largest public hospital in America.

  The main problem at Bellevue, in Flexner’s view, was the lack of coordination among the separate divisions. There was no mechanism in place to hold them accountable for clinical training and patient care. “The schools skate on thin ice,” he wrote, calling their “lack of unity” a threat to the hospital they served.

  The Flexner Report is considered a watershed document—one that changed the course of medical education in North America. And its release coincided with the efforts of other reformers in the Progressive Era to hold the various professions, including law and medicine, to a higher standard, while protecting society’s most vulnerable groups. New York City would be a major testing ground for reforms involving child labor, worker safety, and stricter health codes. In 1914, it undertook a massive study of its public hospitals, looking, above all, to increase their efficiency—another goal of the Progressive Movement. Running to more than seven hundred pages, the study dissected every imaginable aspect of Bellevue’s operation, from the maternity wards to the morgue, from the high turnover among menial workers (described as “downs and outs” and “periodic drunks”) to the pay grades for drivers of “horse ambulances” and “motor trucks.” There even were statistics showing the amount of food routinely wasted in the dining rooms for doctors (“On one day, 25 pounds of porterhouse steak were returned with the plates”) and for nurses (“89 pounds of steak and chicken were returned, [along] with 55 pounds of Irish stew and veal”).

  The heart of the report, however, addressed patient care. And most troubling, it appeared, was the poor coverage on the wards. The attending physicians from the medical schools were spending too little time at Bellevue—not out of laziness, but because they relied on private patients to earn a decent living. The end result, said the report, was a ripple effect whereby the burden of care had shifted even further to interns and residents “inexperienced in the diagnosing of disease.” A survey of the hospital’s records showed a disturbing pattern of premature patient discharges—some out of ignorance, others because the intern handling the case thought it “uninteresting.” In fact, the report had hit upon a problem that would only grow larger over time: the reliance upon a badly overworked and clearly under-supervised hospital house staff.

  The report had an immediate impact: salaries at Bellevue went up across the board. Menial workers (or “hospital helpers”) saw their meager wages double, from $60 to $120 a year, with free room and board, while the minimum pay for nurses rose to $360. Regarding the medical schools, the city agreed to supplement the salaries of each division chief, a full-time job, which raised the pay to $5,000 a year—a handsome sum in that era, but well below the earnings of an elite faculty member with a private practice on the side. This gap would become painfully clear when four consecutive Columbia physicians turned down the chance to lead the First Division before a fifth agreed to take it on. “Financially, the position would demand considerable sacrifice,” one candidate admitted. New York Hospital not only encouraged its attending physicians to admit their private patients, it also allowed them to charge for their in-hospital services. “This is not allowed at Bellevue,” he said, and “it would mean a [financial] loss greater than I could, in justice to my family, afford.”

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  Between 1915 and 1922, the three medical schools serving Bellevue accepted their first women. It was a progressive move, though hardly a daring one. Johns Hopkins Medical School had been coed since its founding in 1893; Harvard, by contrast, would remain all-male until 1945. But women seeking an internship after graduation were largely out of luck. Though the hospitals in New York City selected their house staffs by competitive examination, the process excluded women, blacks, and, in most cases, Jews.

  Bellevue was the first to break this taboo. With a doctor shortage looming as the nation prepared for World War I, the idea of using female residents to replace the young men joining the armed forces seemed a natural step. Though Bellevue would house these women on the farthest reaches of the property, where “rats of heroic East River dimension came up through the floor at night and playfully scampered across their faces,” the opportunity rarely went begging. “My choices were extremely limited,” recalled Dr. Connie Guion, a 1916 graduate of Cornell Med
ical School. “I could apply to the New York Infirmary for Women and Children, which was run entirely by women, or I could go to Bellevue, which had just begun to take women as interns.” Wanting “the full experience,” Guion chose Bellevue, noting: “I don’t think there was a disease in Osler’s Textbook of Medicine that I didn’t see.”

  By the 1920s, twelve of Bellevue’s ninety-nine interns would be women. They came with medical degrees from Columbia, Cornell, or NYU, recommended in careful prose, free of superlatives, to avoid offending the hospital’s old guard. Words like “acceptable,” “creditable,” and “well-disciplined” dotted the paper. “Her services,” a typical letter ended, “will have no cause for regret.”

  African Americans faced a tougher climb. Close to 85 percent of the nation’s 1,500 black physicians in these years were graduates of “Negro medical colleges,” Howard (in Washington, D.C.) and Meharry (in Nashville) heading the list. Some Northern medical schools were known for accepting a small number of black men, including Michigan, Northwestern, and Western Reserve. The University of Pennsylvania took in three each year starting in the 1880s—with two of them expected to “fail out” before graduation. And Johns Hopkins, which had led the way in opening doors for women (in return for a $300,000 gift from a feminist donor) would remain an all-white preserve until the 1970s, not surprising given its location in a racially segregated city.

  Roscoe Conkling Giles exemplified the plight of ambitious black doctors in this era. A child prodigy, the son of a Brooklyn minister, Giles had won a full scholarship to attend Cornell University in 1907. Graduating with honors, he became the first African American accepted at Cornell Medical School—and the first to earn a degree. Denied housing and threatened by a gun-wielding student, he graduated on schedule in 1915 and took the competitive examination for a prized Bellevue internship, which had never been offered to a Negro.

  Giles failed the exam. Furious, he accused the hospital of discriminating against him on account of his color, which almost certainly was true. Bellevue officials barely blinked. “In plain English, he was outclassed,” said one, adding that Giles should accept the verdict in a “sportsmanlike manner and not go about claiming that he had a race grievance.”

  Indeed, it would take the political weight of City Hall to get the first African American intern placed at Bellevue. His name was U. Conrad Vincent, and he’d applied after graduating from the University of Pennsylvania Medical School in 1917 because no hospital in Philadelphia would accept him. Applications in those days required a photograph, and that alone doomed Vincent’s chances. But his cause gained an unlikely ally when Mayor John F. Hylan, anxious to court the city’s rapidly growing black vote in future elections, lobbied Bellevue officials to reexamine Vincent’s credentials and test scores, which they did.

  Vincent was accepted, but the progress ended there. Bellevue would award only four other internships to African Americans in the years between 1920 and 1950, though most hospitals, in truth, offered none. Even a medical degree from Columbia, Cornell, or NYU did little good. In 1926, for example, Bellevue rejected two NYU graduates who stood near the top of their class: May Chinn and Aubrey Maynard. Dr. Chinn, an accomplished pianist, was black and female, while the Guyanese-born Dr. Maynard was, in Chinn’s words, a “very, very dark” Negro man who would never be allowed to examine a white female patient. Both took their internships at Harlem Hospital, in a neighborhood undergoing dramatic racial change.

  All four went on to remarkably successful careers. Roscoe Conkling Giles became the first African American to win certification from the prestigious American Board of Surgery and the first to have the word “colored” removed from his title in the AMA’s Official Directory. His success in the white medical world was a source of pride—and some unease—among other black physicians. “Dr. Giles is one of us,” a leading black medical journal declared. “We are proud of him. We are sure that this honor will not be used to lift him away from his constituency but to help to elevate them.”

  Drs. Vincent, Chinn, and Maynard would remain part of the Harlem community—Vincent opening a TB sanitarium that trained a generation of black physicians, Chinn promoting early cancer detection in women, and Maynard specializing in thoracic surgery at Harlem Hospital, where, in 1956, he operated on a visiting young minister who’d been stabbed by a deranged woman while signing books in a local department store. “Days later, when I was well enough to talk with Dr. Aubrey Maynard,” the victim recalled, “…I learned that…the [letter opener] had been touching my aorta, and that my whole chest had to be opened to extract it.”

  Maynard had saved the life of Dr. Martin Luther King, Jr.

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  For Jews, ironically, the problem was reversed. They’d been readily accepted into medical schools and hospital internships throughout the nineteenth century, when their numbers were small and their origins were German. But the mass immigration from Eastern Europe had set off alarm bells at the nation’s leading universities, which were clustered in the regions where these immigrants had settled. Following World War I, Harvard, Yale, Columbia, and Cornell would lead the way in establishing undergraduate quota systems to limit the percentage of Jews, with their medical schools following suit. As Columbia’s dean of students Herbert Hawkes put it: “We have honestly attempted to eliminate the lowest grade of applicant and it turns out that a good many of the low grade men are New York Jews.”

  Hawkes wasn’t alone. College administrators of this era routinely described Jews as “radical,” “pushy,” “asocial,” “unstable,” and “commercially inclined.” Their quota systems were designed to ensure “civility” and “balance” in the student body. And they required no great overhaul, just a tweaking of the application. Where the form had once asked for name, place of birth, a college transcript, and a faculty recommendation or two, it now added categories such as “religion,” “maiden name of mother,” “place of birth of parents,” and a photograph (which helped weed out African Americans as well).

  The quota system proved devilishly effective. At Yale Medical School, the dean had the applications marked with an “H” for Hebrew and “C” for Catholic. His instructions were remarkably precise: “Never admit more than five Jews, take only two Italian Catholics, and take no blacks at all.” According to one detailed study, the percentage of Jewish admissions to Columbia Medical School dropped from 47 percent in 1920 to 19 percent in 1924 to 6 percent by 1940. The same held for Cornell Medical School, which normally took about 80 students each year from a pool of 1,200 applicants—700 of whom were Jewish. With the new system in place, Cornell cut the number of Jewish acceptances to between eight and twelve. As word spread, many Jewish students, knowing the outcome, simply stopped applying to these places. Arthur Kornberg, a graduate of the overwhelmingly Jewish City College of New York and a future Nobel Laureate, recalled his bitterness at the vulgar anti-Semitism he faced. The hardest part, said Kornberg, was learning that an endowed scholarship for a CCNY graduate to attend Columbia Medical School “went begging for nine years because there were no candidates. To this day it rankles me.”

  The harshest quotas were found in the New York City area, where Jewish applicants abounded. On average, a study in the early 1930s concluded, 63 percent of gentile applicants gained admission to a city medical school, as opposed to only 15 percent of Jews. And things would have been even worse had it not been for Dean John Wyckoff of NYU Medical School, who insisted that academic achievement was the best predictor of success in medical school—and beyond. When Wyckoff presented his findings at a conference in 1927, the dean at Columbia sniffed that “many traits” merited attention, such as “the personal side of the man, his ability to get on with other men in his class, and various other things.”

  A look at Columbia’s “preferred” lists for medical internships showed exactly what he meant. One candidate, “standing in the middle third of his class,” had “an attractive personality and is a nice chap to deal with.” A second was “tall, goo
d-looking,” and—better yet—“a graduate of Princeton.” A third, alas, was “a homely chap,” but “very intelligent.” A typical list would contain two or three females (“fine family background…the most desirable type of woman”) and perhaps one or two Jews (“an exceedingly bright, mature, pleasant, and well-rounded boy”).

  Dr. Joe Dancis, a Columbia undergraduate in these years, recalled a conversation he had with a medical school professor there who apparently took a liking to him. Suspecting that Dancis, who was Jewish, might ask him for a recommendation, the professor called him into his office “for a chat, during which he defended the fact that they had a cap on Jews at Columbia…and went on at great lengths to explain that this was an attempt to have a more diverse student body.” Dancis went to medical school at St. Louis University before interning at Bellevue and joining the NYU faculty, where he chaired the Department of Pediatrics for three decades. “I didn’t ask any questions,” he said. “I accepted it as a way of life.”

  Since NYU Medical School had no formal quota system, its average class was more than 50 percent Jewish, providing a refuge for future research giants like Albert Sabin and Jonas Salk—and fodder for critics who sneeringly dubbed it “NY-Jew.” Moreover, because NYU chose so many of its own graduates for internships in the Third Medical and Surgical Division, Bellevue (along with Mount Sinai) became the best option for Jews seeking house staff positions in a time of clubby prejudice and tightly closed doors.