Growing Academic Physiatry: The Comparative Impact of Baruch Grants to Harvard Medical School and Columbia College of Physicians and Surgeons. Part I

Abstract

The first recognition by organized medicine of the academic potential of physical medicine and rehabilitation (PM&R) emerged in the 1940s.1 A group of one hundred pioneers proclaimed that they were qualified to practice the specialty of physiatry in 1947, and they met the approval of the American Medical Association (AMA). At that time, the AMA was the physician organization in charge of the board certification process for medical specialties. The American Board of Physical Medicine (ABPM) was established that same year. In 1951, the ABPM was renamed the American Board of Physical Medicine and Rehabilitation (ABPM&R).2 Although the scientific roots of the specialty dated to World War I,3 peer recognition also required scientific validation of a special body of knowledge and practice. Validation efforts on behalf of PM&R were jumpstarted by the Baruch Committee efforts during the years 1944 to 1951.4, 5 Bernard Baruch, noted philanthropist and son of Dr. Simon Baruch, funded a program comprising leaders in organized medicine and physical medicine and rehabilitation to establish the scientific validity of PM&R.2 The remarkable achievements and legacy of the Baruch Committee to the specialty of PM&R are well documented in the literature.2, 6, 7 Fellowships and research training programs were awarded to 12 distinguished university programs. Two of these programs, one at Massachusetts General Hospital (MGH) and Harvard Medical School (HMS) and another at Columbia College of Physicians and Surgeons (CCP&S), provide a basis for comparison and contrast, especially because of the features that led to continuing success for PM&R at CCP&S.5 A recent publication8 illustrates that the MGH/HMS PM&R presence was not sustained after the Baruch period. However, the academic program that finally formed at HMS in 1993 gained stature and continues to flourish in the 21st century. The history of PM&R at MGH reveals some of the reasons for this lack of a sustained presence, prior to and following the initial success of the Baruch awards.9 In contrast, the program at CCP&S led to an academic department almost immediately, a department that has demonstrated both continuity and expansion over the past 70 year. Part I of this series examines the development of the academic department of PM&R at MGH/HMS based on the impact of the Baruch Award. Facilitators/barriers to success are related to a sustained PM&R tradition, academic leadership and institutional resources of facilities, funding, and faculty. Prior to World War I, physical therapy, and later the medical specialty of PM&R, was pioneered by clinicians and scientists in Germany and the United States. A German neurologist and neurosurgeon, Ofrid Foerster, pioneered physical treatments for the care of patients with neurological impairments.3 As a result, German clinicians possessed advanced training in physical treatments for neurologic and orthopedic conditions, in contrast to their American counterparts prior to the war. Historical evidence of the academic roots of physical therapy and PM&R in the United States came later and was evident in Philadelphia and Boston. R. Tait McKenzie was the first professor of physical therapy in the United States in 1907 at the University of Pennsylvania.10, 11 In 1904, two German physicians and physiotherapists at MGH, Max Bohn and Carl H. Bucholz, were placed in charge of a “Medico-Mechanical Department, commonly known as the Zander Room.”9 The room was named after Jonas Zander, a Swiss physician and developer of exercise equipment in the 19th century. Zander had been considered for the Nobel Prize in 1918.12 The Zander Room used highly sophisticated mechanical exercise equipment that was donated to MGH. Both Bohn and Bucholz published authoritative textbooks on physical therapy.13 In 1914, Bucholz published his 6-year experience with 4900 patients and concluded that mechanical exercises, supplemented by other modalities, benefited musculoskeletal and neurological disorders.14 Both Bohn and Bucholz had faculty appointments at Harvard Graduate School of Medicine (HGSM), but both left the United States at the outbreak of war with Germany.9 Unfortunately, the therapy areas were closed, and the status of PM&R remained dormant at MGH for over 20 years (1917-1939). Another physical therapy physician, Frank B. Granger, is listed as an instructor of electrotherapeutics at HGSM in 1917, along with Bucholz, assistant in physical therapeutics.15 The HGSM was regarded as academically as rigorous as its undergraduate school, HMS.16 Granger's clinical and academic credentials at Harvard were established in 1907 and during his tenure in the Department of Physical Therapeutics at Boston City Hospital (BCH), until his death in 1928.17, 18 At that time, BCH was an HMS teaching hospital and when academic and clinical responsibility for Boston City Hospital passed to Boston University in 1973, these laboratories were incorporated into the research programs of the Boston University Department of Medicine faculty. Granger was also an assistant professor of physical therapy at Tufts Medical School in the 1920s and the relationship of teaching hospitals to the medical school is important to appreciate.18, 19 Irrespective of faculty appointment at additional medical schools and affiliated teaching hospitals other than MGH, it did not diminish the primacy of the MGH/HMS relationship. MGH was the oldest and largest teaching hospital of HMS, and the clinical, teaching, and research relationships are described in great detail in Faxon's history.9 Every physician staff member at MGH held a faculty position at HMS and clinical teaching of all undergraduates and most postgraduate students at HMS was carried out by MGH staff.9 Although HMS lacked PM&R leadership at MGH, its major teaching hospital during World War I and beyond, Dr. Granger deserves recognition for his leadership in the military and at BCH. During the war, Granger was recognized by military medicine20 as the leading authority in physical medicine. His study of the organization of British reconstruction (rehabilitation) hospital with Dr. Joel Goldwaith, head of orthopedic surgery for the Army at the invitation of the U.S. Surgeon General is cited in the literature.21 Granger advocated improving the educational credentials of physical therapy technicians (reconstruction aides during the war) and partnered with Marguerite Sanderson at Walter Reed, one of the founders of the American Physical Therapy Association (APTA). She gave credit to Granger for support of her activities during and following the war.20 John Stanley Coulter praised Granger for establishing the respectable place of the specialty during and following the war: “Dr. Granger in 1926, became the first physician specializing in physical therapy to become a member of the Council on Physical Therapy (AMACPT) of the American Medical Association.”22 The AMACPT was the first formal recognition of physical medicine by organized medicine, and its purpose was to validate physical treatments of proven value and to publish its findings in the Journal of the American Medical Association (JAMA).23 Leading Harvard scientists and clinicians appointed to the council were W. B. Cannon, chair of physiology, and W. T. Bovie, formerly of HMS and chair of biophysics at Northwestern.23 Granger and Coulter helped establish organizations to further the clinical, educational, and scientific advancement of physical medicine. The Academy of Physical Therapy (a physician group), formed in 1923, elected Granger as the organization's first president and the American Congress of Physical Therapy (later the American Congress of Rehabilitation Medicine [ACRM]), established in 1925, elected Coulter as the third president. Granger and Coulter's advocacy also contributed to the formation of the Society of Physical Therapy Physicians (later the American Academy of PM&R [AAPM&R]), which attracted the interest of philanthropist Bernard Baruch in the mid-1940s.19 Granger's legacy at BCH in physical therapeutics likely contributed to the development of the first U.S. spinal cord injury inpatient unit in the early 1930s, an effort led by neurosurgeon Donald Munro.24 The care provided there included physical restoration and prevention of bladder and skin complications.25 Although recognition of Granger's contribution is important to the history of PM&R at HMS, there is little evidence that this had any impact on PM&R at MGH. MGH, anticipating the emergence of physical medicine, established a program in 1939 based on an interest expressed by hospital administration.9 Arthur L. Watkins, at age 29, was appointed director of physical therapy. Following his graduation from HMS in 1935, he had spent several years as a neurology resident at MGH. However, he limited his practice primarily to physical medicine, which qualified him for membership in the Society of Physical Therapy Physicians. Mayo Clinic's Frank Krusen listed Watkins as his third resident following the training of Earl Elkins and Robert Bennett in his diaries.26 Although Watkins visited with Krusen in preparation for his role at MGH, his family recollected that he had not trained at the Mayo Clinic (Mary P. Watkins, personal correspondence by email, August 2018). Krusen was no doubt impressed with this young and promising physician early in his career and mentored him. Krusen later invited him to join as a founding member of the ABPM&R in 1947.2 Watkins' publication history must be recognized for its breadth and depth. More than 50 of his articles are still listed on PubMed, but an additional 10 or more, published from 1939 to 1945, are not accessible by this search method. During this early period, Watkins focused on electrophysiology, diagnosis, and prognosis of mostly neurologic disorders. He demonstrated a thorough knowledge of electrophysiology and used electrical techniques for diagnosis and prognosis of peripheral nerves injuries.27 In two publications on median, ulnar, and radial nerve regeneration, he illustrates the value of electrodiagnostic testing with surgical colleagues from the hand clinic at MGH.28, 29 Watkins' expertise was important to the management of the first reported case of replantation of a severed arm in 1962.30 Watkins is pictured examining 13-year-old “Red” Knowles at MGH with the caption “Pain is good news to severed arm boy” (Figure 1). During the early 1940s, Watkins and his colleagues published a series of articles on the underlying mechanism for muscle spasms in poliomyelitis and the electrodiagnostic testing that distinguished anterior horn disease from peripheral nerve injuries. Their work also furthered the scientific understanding of the prognosis and pattern of recovery of these disorders. Watkins also expanded laboratory testing of polio patients.31 These laboratory methods utilized electromyography to measure response to stimulation and waveforms and the work of muscle contraction recorded in ergographs. He demonstrated his clinical diagnostic skills by differentiating the paralysis and sensory findings of poliomyelitis from Guillain-Barre Syndrome (GBS).32 This differentiation of polio vs GBS recently had become a topic of controversy in Franklin Delano Roosevelt's diagnosis.21 Watkins' comprehensive 1946 review of physical medicine treatments of neurological disorders documented the use of electrical testing to aid in both diagnosis and management.33 Several of his scholarly papers also reviewed the importance and application of electrophysiology to physical medicine,34, 35 and electrodiagnostic applications in orthopedic conditions.36 “At the present time the Hand Clinic is composed of the Chiefs of Neurosurgery, Orthopedic Surgery, Plastic Surgery and the Department of Physical Medicine and a general surgeon so that the patient has the benefit of varying experiences and opinions. The Department of Physical Medicine has been of inestimable assistance, not only in the rehabilitation of injured hands, but also because it can tell the surgeon whether regeneration or degeneration is taking place in the individual case. This is done by means of electrical tests, a description of which follows.”28 In addition to his skill in electrophysiology, Watkins collaborated with another Baruch Fellow, Thomas Delorme, MD. They published a series of papers and a textbook on the physiology and measurement of strengthening exercises.37, 38 Delorme had developed an interest in methods to strengthen muscles in the lower extremities by studying the injuries of wounded soldiers in World War II. He and Watkins collaborated from 1946 to 1954 on studies of progressive resistive exercises (PREs) for treatment of peripheral nerve injuries and poliomyelitis, rheumatoid and other forms of arthritis, and postoperative hip surgery.39-41 They identified indications for treatment, the physiologic basis of muscle strengthening techniques and the contraindications for use of PREs. Delorme was listed as an instructor in physical medicine with an academic appointment during his fellowship years, and after, from 1946 to 1951.4 Following his Baruch fellowship in physical medicine, Delorme completed training in orthopedic surgery and entered private practice as an orthopedic surgeon before returning to Harvard as a faculty member in the mid-1950s.42 “The first Baruch fellow, Charles S. Wise, completed his three fellowship years and was appointed early in 1948 as director of the Department of Physical Medicine at the George Washington University Hospital and Associate ·Professor of Physical Medicine. The second fellow, Sedgwick Mead, left in January 1948, before completing his third year to become Assistant Professor of Physical Medicine at Washington University School of Medicine, St. Louis. Thomas L. DeLorme, who had received two years of fellowship training at the Massachusetts General Hospital at Harvard Medical School, was appointed as a Baruch fellow from October 1, 1948, to September 30, 1949, to fill out the unexpended period of Dr. Mead's appointment and to finish his own third year of special training in physical medicine. Herbert W. Park, after finishing his year of physiology and biophysics, is concluding his second and third years of clinical training at the Massachusetts General Hospital and will finish September 30, 1949.”4 (p87) Baruch fellowships primarily provided basic research training, and the former Harvard Fatigue Laboratory (HFL) was available to the fellows. It provided perhaps the most effective environment for “promoting scientific and collaborative research in exercise physiology.”43 Walter B. Cannon, MD, and Eugene M. Landis, MD, both chairs of the Department of Physiology at Harvard, participated in the HFL and Charles Wise, MD, the first Baruch Fellow at MGH, was mentored by Landis in basic research.44 Watkins pursued foundational research in fatigue related to neuropsychiatric (today mood disorders) disabilities and utilized PREs, rather than fitness or aerobic training.45, 46 In several papers that summarize the findings of the major research effort of the Baruch Award, Watkins attempts to distinguish the clinical and physiological differences between fatigue in normal individuals compared to patients with neurasthenia.45 These studies illustrate that Watkins was a clinical scientist with superior research design skills acquired during training and through collaborations with physiologists such as Cannon and Landis. Although Watkins was unable to show a physiologic difference in the fatigue manifested by psychoneurotic patients compared to controls, Robert C. Darling praised his methodologic approach to this study. Darling stated the methodologic approach was a “fine example … in experimental research,” specifically in the careful choice of controls, the intelligent use of statistics to answer questions, and the standardization of test procedures.45 Robert C. Darling was assistant director of the famed Harvard Fatigue Laboratory during this period.43 This is high praise for a well-controlled study by the foremost national authority on the testing of the physiologic effects of exercise. Watkins' teaching efforts extended to other disciplines and a series of articles in the New England Journal of Medicine (NEJM) that introduced the new specialty of PM&R to all fields of medicine. He mentored doctoral candidates in neuropsychiatry and residents in neurology, in addition to the Baruch Fellows. He published 14 articles in the NEJM from 1939 to 1954, about one per year, in a series titled “Medical Progress” that defined new approaches in clinical care and research.47, 48 PM&R was thus represented by a respected spokesman and prolific writer for this new medical specialty.49 From 1939 until 1951, Watkins' clinical and administrative responsibilities paralleled his academic growth in research, publications, and collaboration with other leaders. During World War II, the sections of physical therapy and occupational therapy were incorporated into the Department of Physical Medicine (DPM) at MGH.9 The department in conjunction with three approved physical therapy schools in Boston trained 270 physical therapists, about half of whom entered military service.9 (pp71,72) Watkins was very supportive of the development of physical therapy during his tenure (Mary P. Watkins, personal correspondence by email, August 2018) and Mary E. Nesbitt the first supervisor of physical therapy at MGH achieved national stature and served as president of the APTA (1954-1956), while still at MGH.50 Nesbitt and Watkins were commended during the polio epidemics in the mid-twentieth century for their pivotal role in caring for patients with polio.51 (p2) A rehabilitation hospital clinic (Bay State Rehabilitation Center), supported by the Massachusetts Vocational Rehabilitation Agency, was established adjacent to MGH and was under the direction of Watkins from 1951 to 1958.52 Watkins was named head of the program of PM&R at MGH, and head of the clinic that was described as linked to MGH: “The Rehabilitation Clinic is housed in a separate building with a separate entrance, but is connected with all sections of the Hospital by enclosed corridors. Although closely associated with the Massachusetts General Hospital, physically and functionally, it is an independently administered clinic.”52 Although this unit was linked to the rehabilitation bed service at MGH, no mention of its termination is found in the literature. A physiatrist-led inpatient unit did not exist at MGH when orthopedic surgery assumed leadership after the 1960s, until MGH purchased the Spaulding Hospital in 1984. Few people have been in a better position to assess Arthur Watkins' role than his daughter-in-law, Mary Watkins, an MGH physical therapist who “married the boss's son,” Dr. John Watkins. She describes Arthur Watkins as a quiet man, not given to bombast, who was known and respected as both a clinician and a researcher. Though trained as a neurologist in the late 1930s, he was always known and self-identified as a physiatrist. Watkins enjoyed good relations and mutual respect with the physical therapy staff and served as a mentor to staff therapists and physical therapy students from several local schools serving clinical rotations at MGH. He was proud of Mary Watkins' faculty role at the MGH graduate program in physical therapy, a component of the MGH Institute of Health Professions. Mary Watkins was one of the institute's founders and was honored as the 1985 Ionta Lecture, an annual event. Mary Watkins was not aware of any “turf issues” with the orthopedists. She reported that Arthur Watkins was good friends with some of them, including Marius N. Smith-Peterson, Otto E. Aufranc, and of course Thomas Delorme. In the mid-1960s, as Watkins' inpatient bed service was evolving into a dedicated spinal cord injury unit, health issues required his early retirement, and his protégé, Delorme, served as director of the unit from 1965 to 1968. The unit continued under orthopedic leadership until it moved to Spaulding Rehabilitation Hospital in the 1980s. In 1951, the same year that the Rehabilitation Clinic was established, Watkins was elected president of the American Congress of PM&R (ACPM&R). Eight years later he received the Gold Key Award of the ACPM&R (Figure 2).53 During the years prior to his election as president of the AAPM&R and following he served on many national committees and on the editorial board for the Archives of Physical Medicine and Rehabilitation.55 The early years from 1939 to the 1960s reveal Watkins' remarkable academic, clinical and administrative abilities. These skills led to the growth of clinical and research collaborations with multiple departments and colleagues. Watkins secured support from MGH and outside funding for research and a vocational rehabilitation facility. His national acclaim and the achievement of the highest honors and leadership position in his medical specialty were recognized in the MGH historical documents during his 32-year tenure, from 1935 to 19679 (Mary P. Watkins, personal correspondence by email, August 2018). Watkins published 50 papers in 15 years in his early period, and 14 during the late period, from 1956 to his retirement in 1967. No doubt his own medical conditions, which required early retirement at age 58, were a contributing factor (Mary P. Watkins, personal correspondence by email, August 2018). In the late 1950s and early 1960s, he published several large case series of patients with amputations of the upper and lower extremities.54, 55 The series included 50 bilateral lower extremity amputee patients who were rehabilitated at the Bay State Rehabilitation Clinic (BSRC) from 1951 to 1956.54 MGH's history of the orthopedic department documents a major reorganization in the 1950s. What began as a purely clinical preceptorship with only part-time attending surgeons, became a full-time academic program with full-time faculty during this period. These developments led to acquisition of space, funding, and faculty under the leadership of the chair, Joseph S. Barr.42 Barr recruited Delorme who returned to MGH from private orthopedic practice. He was placed in charge of the spinal cord injury unit in the mid-1950s. The unit's staffing was multidisciplinary, and care was provided by the departments of neurosurgery, orthopedic surgery, urology, internal medicine, and PM&R. Meanwhile, on the Harvard consultation service at Boston City Hospital, physiatrist Donald Munro was gaining international fame with his extensive knowledge and clinical approaches to the diagnosis and treatment of patients with spinal cord injury.24 In 1958, Delorme relinquished his clinical responsibilities at Harvard and moved to full-time research at the Liberty Mutual Rehabilitation Program. He subsequently collaborated with orthopedist Melvin Glimcher, who had succeeded Barr in 1964. They published research together on reimplantation of severed extremities. Glimcher is credited with the development of one of the first neuroprostheses for upper extremity amputees and Delorme is cited for unpublished work with Glimcher.56 The establishment of the DPM in 1939 is documented in the MGH history 1935-1955 edited by Dr. Nathaniel W. Faxon, emeritus director of MGH.9 Faxon was the active director of MGH for 14 years from 1935 to 1949 and in charge when it was decided to create this department after a gap of 22 years (1917-1939). The growth and positive contributions of the DPM and Watkins during World War II, the polio epidemics and establishment of the Bay State Rehabilitation Center (1951-1958) linked to DPM/Watkins bed service are accurately portrayed and documented. Recognition of the Baruch Award for training physical medicine specialists in clinical and research in cooperation with the Department of Physiology at HMS and the first trainee Dr. Wise are cited. The subsequent MGH history 1955-1980 edited by Dr. Benjamin Castleman, distinguished pathologist, assigns authorship of the history of the DPM and Watkins to the Department of Orthopedic Surgery, which absorbed the bed service and clinical direction following Watkins' retirement in 1967. Watkins's extensive publication contributions and national recognition as a PM&R leader are not mentioned. It is implied that a PM&R successor is not sought since the 1955-80 history concludes the discussion of the change in rehabilitation with this statement: “By establishing this department with the concurrence of the Medical School, the hospital affirmed the concept that rehabilitation requires a multidisciplinary effort, which at the MGH, was to be a cooperative enterprise with an orthopedic surgeon serving as quarterback of the team.”42 Academic PM&R at MGH had withered again. For the next 25 year, PM&R leadership shifted to other Boston universities and medical centers. The Spaulding Rehabilitation Hospital opened in 1970, four blocks from the MGH campus, providing a clinical service supported by a broad series of funds and initially in part privately funded. This was just several years after Watkins retired, but it was not until 1993 that PM&R departmental leadership was restored at MGH. It is unclear why PM&R did not survive at MGH after Watkins' spectacular academic contributions and his national and international reputation over a span of 15 years. Was it a failure to recruit qualified academic faculty, due to Watkins' illness and sudden retirement before a successor could be groomed? There were a limited number of academic physiatrists in the Boston area as compared to New York City. The Baruch fellows who trained at MGH may have sought more attractive opportunities in institutions such as Medical College of Virginia (MCV), Washington University, and George Washington University. MGH had comparatively limited facilities and external funding resources compared to other successful Baruch fellowship programs. National Institutes of Health funding for clinically related basic research had increased in the 1960s but would not peak until the 1990s. Federal funding for PM&R research, which began flowing to academic departments in the 1960s and 1970s, was out of phase with changes at MGH.1 So was the arrival of a free-standing rehabilitation facility (Spaulding Hospital) that could have provided additional clinical and research funding. Production and retention of qualified academic faculty continued to be a problem at elite institutions due to rigorous criteria for promotion and low salaries. Clearly the elements of continuity, resources, and timing were out of phase for PM&R at MGH, and its failure to survive was predictable. To Watkins' credit, he had strengthened the physical therapy section, which had achieved national recognition, and this likely paved the way for the development of the Institute of Physical Therapy at MGH. His positive relationships and collaboration with many medical and surgical departments facilitated their continued utilization of rehabilitation services such as physical and occupational therapy (Mary P. Watkins, personal correspondence by email, August 2018). His legacy as a superb clinician, clinical investigator, teacher and pioneer at the largest and oldest teaching hospital affiliated with HMS deserves recognition. The author thanks Mary Watkins, Richard Verville, Stanley Wainapel, and Hilary Siebens for their insights and suggestions.