Growing Academic Physiatry: The Impact of the Baruch's Grants on Harvard Medical School and Columbia College of Physicians and Surgeons. Part II.

Abstract

Pioneering physiatrists, funded by the Baruch Awards, established scientific roots at a number of institutions in the early 1940s, but their successes and failures in the short- and long-term differed and warrant comparisons and contrasts. In the second of a two-part series we continue comparisons of the physical medicine and rehabilitation (PM&R) history of Harvard Medical School (HMS) and Massachusetts General Hospital (MGH) with that of the Columbia College of Physicians and Surgeons (CCP&S).1, 2 Part I focused on HMS/MGH, which lacked continuity of its PM&R program despite the Baruch Awards and initial successes. In Part II, we describe the continuity and expansion of the program at CCP&S over many decades, in contrast with HMS/MGH. The evolution of the two programs differed largely because of differences in various factors such as timing of events, institutional culture, leadership, and even geography. Historical timelines for PM&R in the United States often begin in the 20th century, but the field′s beginnings can be traced to the late 19th century, as exemplified in the history of CCP&S. Although it may be difficult to determine the full impact of this early history on the culture of CCP&S, the influence and impact of three physicians, a father and son - the Snows - and of Simon Baruch, need emphasis. Physical medicine physicians were interested in electrotherapeutics beginning in the 1880s in New York City. These physicians were active in hospitals that eventually became part of academic medical centers such as CCP&S. William Benham Snow, Sr. (1860 to 1930) and his son William Benham Snow, Jr. (1895 to 1973) were both prominent physicians during their careers.3 The son was said to have been attracted to physical medicine because of his father. They were in fact in medical practice together, and their mutual connection with electrotherapeutics is implied below in an early description: “William Benham Snow, Jr., MD, who was associated with Presbyterian Hospital and the College of Physicians and Surgeons, and who was from a family long involved in electrotherapeutics.”4 Both were graduates of Columbia University, but they attended different medical schools. By the turn of the 20th century, the senior Snow had become a well-regarded electrotherapist, and he served as president of the Society of Electrotherapists.3, 5 In addition, he published a textbook and edited a journal, both on advanced physical therapeutics. He was an instructor of electrotherapeutics at the New York Hospital and its affiliated postgraduate medical school, institutions that were established in 1883, and incorporated into CCP&S in 1931.6 This was an institutional trend similar to that of other elite medical schools during that era.7, 8 Dr. Ray Lyman Wilbur formally congratulated Dean Willard Cole Rappleye of CCP&S for this affiliation.7 Dr. Wilber later chaired the Baruch Committee that was established by financier Bernard Baruch, son of New York physician and public health advocate Simon Baruch, to promote the specialty of PM&R. Some physicians who specialized in electrotherapy during this period were also skilled in electrodiagnosis. For example, Frank B. Granger, an academic physician at Harvard and Tufts Universities, advanced the field of physical therapeutics and diagnostics with equipment standardization.9 Despite these academic activities by early physiatrists, traditional medicine was skeptical of the therapeutic benefits of electrical treatment, even though some more conventional physicians had expertise in electrodiagnosis and others used radium treatments for cancer. In 1935, Snow, Jr. was named director of physical medicine at CCP&S. He was a charter member of the Society of Physical Therapy Physicians (SPTP), founded in 1938. After several name changes, the organization became the American Academy of Physical Medicine and Rehabilitation (AAPM&R). Although the American Medical Association (AMA) suggested in 1938 that the SPTP consider developing specialty board certification, it would require another 9 years before the American Board of Physical Medicine and Rehabilitation (ABPM&R) was formed and became the official body to approve residency programs. In the 1940s, a foundation for the growth of PM&R was established at CCP&S with a number of developments. CCP&S established a school of occupational therapy in 1941 and shortly thereafter a school of physical therapy. There was a concentration of physiatrists in New York City, which made qualified faculty available to the medical schools.4 During and following World War II, organized medicine recognized PM&R′s contributions to the restoration of the wounded. Philanthropist Bernard Baruch established the Baruch Committee on Physical Medicine in 1943.10 Baruch chose to honor his father, Simon Baruch, a physician, pioneer in hydrotherapy, and former Columbia faculty member, with a grant of $400 000. He later established an endowed chair in his father′s name at the institution (Figure 1).11, 12 Snow, Jr. served on one of the Baruch subcommittees during the 1944 to 1945 period.13 He established a residency program at CCP&S in 1948, following Robert C. Darling′s arrival in 1946 as director of research, after the award of the Baruch Fellowships. As the story unfolds, it will be clear that this continuous presence of PM&R at Columbia contrasts with the HMS/MGH gap in leadership from WW I to 1939 (see Table 1). Snow WB, Sr. 1899 Fellow American Electrotherapeutic Society Snow WB, Sr. Instructor 1904 New York Post-Graduate Medical School (NYPGMS)* Bohn M 1904-1917 Bucholz CH 1904-1917 Instructors Harvard Graduate School of Medicine (HGSM)* Snow WB, Sr. (1860-1930) Snow WB, Jr. 1935 Director PM Charter Member Society PM 1938 Snow WB Jr. 1935-1952 Director PM Darling RC 1946-1972 Chair Dept PM&R 1952-1973 Watkins AL Director of Physical Medicine and Rehabilitation 1939-1967 Charter member ABPM&R 1947 Darling RC retires 1973 Downey J Chair 1974 Downey J Chair 1974-1991 Lieberman J Chair 1991 Corcoran P Chair 1993-1996 Frontera W Chair 1996 Lieberman J Chair 1991-2006 Stein J Chair 2008- present Frontera W Chair 1996-2007 Zafonte R Chair 2007- present Robert C. Darling was likely the most accomplished physician scientist in the early history of PM&R. He was a mild-mannered and humble individual who avoided the limelight and seldom ventured into positions of leadership until much later in his career (Figures 1 and 2).15 His scientific contributions, however, were the physiological foundation for therapeutic exercise and interventions for the functional restoration of people with disabilities.16 The breadth and depth of his contributions became obvious to clinicians, for example, as they applied his research on the energy requirements of activities of daily living (ADLs) and ambulation in persons with amputations and spinal cord injury, and the self-care requirements of patients with pulmonary and cardiac disease.17-21 Darling excelled academically at Harvard Medical School, graduating in 1935, and he chose a career interest in chronic illness. His training in internal medicine began on the wards at Bellevue and Goldwater Hospitals16 in 1936 and ended in 1941. His residency combined clinical and research training, and today would be equivalent to an MD/PhD program. He received research mentorship from future Nobel Laureates (in Physiology or Medicine) - Andre Cournand and Dickinson Richards - awarded for their development of cardiac catheterization techniques (Figures 2 and 3). Six of Darling′s early publications (in which he was the first author or a coauthor) were in the Journal of Clinical Investigation.22-24 His original work on energy requirements was based on analyses of blood gases in normal and pulmonary disease. His work led to medical rehabilitation research by physiatric colleagues John Downey, Edward Gordon, Paul Corcoran, and others.17, 20, 25 Upon completion of his training at Columbia, Darling returned to Boston and continued his work in exercise physiology at the Harvard Fatigue Laboratory (HFL). The precise dates of his term at Harvard are unavailable because much of his research was classified due to government contracts during wartime, but Darling did become assistant director of the HFL prior to its closing in 1947. Most of his research from 1940 to 1946 was also classified, and many citations of the HFL are unavailable. In fact, Darling′s file cannot be examined until 2022.26 Darling completed some studies on fitness and nutrition in 1942, in collaboration with Robert E. Johnson, a biochemist at the HFL. A test of physical fitness for strenuous exercise illustrated his interest in using pulse rate as an index of recovery from exercise in normal subjects.27 Additional studies of energy expenditure in arctic climates were published in collaboration with J. Edgar Folk, an environmental physiologist, who cited Darling′s role at the HFL from 1943 to 1947.28 Four areas of research were funded by the Baruch Award to CCP&S: (1) blood gas equilibrium in fever therapy (Edward Gordon); (2) insensible water loss in congestive heart failure (C. J. D′Alton); (3) studies of human perspiration; and (4) circulatory and metabolic changes associated with convalescence.29-31 Darling′s continued interest in temperature regulation and exercise facilitated his collaboration with Gordon during his Baruch fellowship, and with physiatrist John Downey throughout his career.29-34 Heat dissipation due to sweating examined during these years35 led to seminal research on patients with cystic fibrosis. In 1953, Darling and colleagues described the definitive test for cystic fibrosis of the pancreas in children, that is, five-times-normal salt content in sweat (Figure 1).36 Darling served on the Baruch Committee and chaired a committee on fitness that published its report in the Journal of the American Medical Association.37 The HFL was cited for its important contributions during World War II in Tipton′s classic, History of Exercise Physiology: “Despite its brief history (1927-1947), no physiology laboratory in America is more revered than the Harvard Fatigue Laboratory. Described as ‘the first laboratory for the comprehensive study of man’, it was perhaps more influential and effective in promoting scientific and collaborative research in exercise physiology.”38 “Dr. Darling is Associate Professor of Medicine at the College of Physicians and Surgeons and chairman of the physical fitness sub-committee of the Baruch Committee. For the past three years, he has been Director of Research in Physical Medicine at Columbia. Dr. Darling is a graduate of the Harvard Medical School. During the war, he served as assistant director of the Fatigue Laboratory at Harvard, at the same time acting as consultant to the Quartermaster General. In this latter capacity he studied the physical fitness of individual soldiers in a cold climate and participated in trips to the Arctic region for field trials of the Army′s clothing and rations. Dr. Darling is an authority on physical fitness, has written several papers on fitness and exercise and the effects of various diets on the body. He is also the author of numerous confidential reports on work done with the Committee of Medical Research of the Office of Scientific Research and Development.”39 Darling′s mentorship of Gordon and Downey had a strong impact on the direction of future research in the specialty. Gordon may have come under Darling′s influence during the war while Gordon was a major and stationed at the Columbia Aviation Research Laboratory. Darling′s mentorship certainly was influential when Gordon was a resident in PM&R at the ICD. Gordon served as a Baruch Fellow at Columbia after the war from 1948 to 1949. He published several papers with Darling on physical hyperthermia and its effect on energy requirements as reflected in blood gas studies.29-31 It was this early research on the effect of physical exercise on pulmonary and cardiac function that influenced Gordon′s investigative interests in the 1950s. This new area of investigation in rehabilitation medicine was summarized by Gordon in a 1957 paper in which he cited the most recent studies on energy requirements in pulmonary and cardiac diseases and spinal cord injuries.17 Gordon studied ADL requirements in patients with tuberculosis, ambulation in paraplegia, and energy requirements for cardiac patients using a bedpan.18, 19 In the 1960s and 1970s, Gordon used animal models to study the effect of exercise on muscle types with colleagues from Thomas Jefferson′s Department of Rehabilitation Medicine (Figure 4).41, 42 Gordon was a clinical scientist with a clear grasp of the scientific literature to support his research hypotheses. He also mentored faculty with patience and support, much like his mentor Robert Darling. His participation in journal club simplified the basic questions of the merit of an article by three questions. Is it new? Is it true? — So what! Because he served on National Institutes of Health (NIH) study sections, his grasp of exercise physiology research concepts and methods was unquestioned. Darling′s collaboration with John Downey, the physiatrist who succeeded Darling as chair of the department in 1972, extended more than a decade (Figure 5). Their collaboration provided the scientific foundation for understanding temperature regulation during exercise and specifically in conditions such as spinal cord injury. Downey had done basic research on temperature regulation in his postgraduate years in England, and he found a research home with Darling for the following decade. It was during this period that one of the authors (PC) joined their laboratory and observed their work directly. One of the most important contributions to the scientific underpinnings of PM&R was their textbook, The Physiologic Basis for Rehabilitation Medicine, first published in 1971.43 A third edition of the book, with other authors, was published in 2013 (Figure 5).44 From 1956 to 1957, a decade after the creation of the ABPM&R, a series of nine editorials in the American Journal of Physical Medicine and Rehabilitation addressed the future of the specialty.45 Most authorities agreed that workforce needs were the highest priority, especially those in academic medicine. In his commentary, Darling emphasized that “current recruitment of physicians is less than adequate,” and required physiatrists to assume leadership roles earlier in their career, and he emphasized appreciation of team members′ opinions in this new specialty in contrast with traditional acute medical care, in which the doctor was “dictator of the team.”46 Although thrust into a leadership role earlier than anticipated due to shortages, Darling argued that physiatrists should use restraint and practice humility. He believed that the physiatrist must exhibit a statesmanlike approach, with respect of and clear direction for other physicians and their therapy colleagues. Although Darling was one of the foremost scientists of his time and who adhered to strict protocols, he emphasized moderate temperament and equanimity in clinical matters, deferring to team members and physician colleagues when appropriate, since the rehabilitation process required a collaborative approach. Darling proved a visionary during his AAPM&R presidency, a decade following the field′s argument for an increased workforce and status. His 1968 address about planning the future for the specialty offered a proposal for the accumulation of new knowledge through research and better training to provide improved clinical services. He emphasized, “Better services…require that we become better physicians, diagnosticians, and better scientists.”47 The ABPM&R responded by establishing higher standards for training and accreditation of residency programs in the 1970s. Darling identified the need for research in integrated care, urging cooperation between surgical specialties and physiatry. In this way, “the physiatrist contributes his specialized knowledge of function to the operative decisions and the post-operative management.”47 Public administrator and social reformer Mary Switzer′s grasp of this concept facilitated the creation in the 1970s of the Spinal Cord Injury Model Systems program within the National Institute on Disability and Rehabilitation Research (NIDRR), and later similar burn and traumatic brain injury centers and programs. Physiatric sports medicine, and spine and pain programs, developed collaboratively with orthopedic surgery and rehabilitation therapies, also fulfilled Darling′s vision of providing better clinical services and accumulation of new knowledge in PM&R through collaboration. The workforce study by the Graduate Medical Education National Advisory Committee (GMENAC) in the 1980s identified the need to fund undersupplied fields such as physiatry.48 The increased emphasis and funding for resident training by the GMENAC report facilitated an increase in the number and competency of young physiatrists.49 The stage was also set for the realization of research as a major priority of the field, strongly articulated by physiatrist William Fowler, University of California/Davis chair, in his 1980 AAPM&R Presidential Address.50 Darling was a self-effacing scholar with a low organizational profile in PM&R during the 1940 and 1950s, in contrast to Arthur Watkins, who assumed a major leadership role at MGH and had climbed to the top of the specialty by 1951.1, 2 The CCP&S story illustrates the continuity of leadership from William Snow, Jr. to Robert Darling to John Downey from the early 1940s to 1991. These smooth transitions facilitated the successful leadership of James Lieberman (1991 to 2008) and Joel Stein (2008 to the present era). The impressive leadership of Watkins at MGH and Harvard from 1939 to 1967, in contrast, was followed by a gap of over 25 years because of limited institutional resources of space, money, and people in the 1950 and 1960s (Table 1), as described in Part I. Unfortunately, the early 1950s represented a period of resistance by orthopedic surgery to the emergence of PM&R as the leading medical specialty in rehabilitation. Although Krusen51 was successful in enlisting the support of the AMA, Bernard Baruch, and President Dwight Eisenhower to recognize PM&R as the leader in rehabilitation, several leaders in orthopedic surgery were opposed.52 Watkins had a positive relationship with all the surgical specialties at MHG (Mary P. Watkins, personal communication, 2018), but orthopedic surgery required space and hospital resources in 1968. His early retirement in 1967 due to illness left no infrastructure for a successor.2 An orthopedic surgeon assumed leadership of rehabilitation following Watkins' retirement.53 Failure of MGH to recruit a physiatrist successor to Watkins was likely also due to a limited pool of qualified academicians in the 1960s. Physiatrists were in abundance in New York City, so faculty recruitment posed no problem there in comparison with Boston.4 Darling was able to recruit outstanding faculty and mentor them successfully so that the programs in research, education, and patient care continued following his retirement in 1972. In addition, Baruch Committee funding for research at CCP&S extended over 10 years from 1944 to 1954, compared to only 5 years at MGH. The primary New York City programs at New York University (NYU), Cornell, and Columbia also had separate well-established orthopedic hospitals, so space requirements were not a barrier to the development of PM&R at CCP&S. New York City has a historic tradition of large and prominent specialty hospitals devoted to orthopedics (The Hospital for Joint Diseases, now the NYU/Langone Orthopedic Hospital and the Hospital for Special Surgery) and rehabilitation (The Rusk Institute of Rehabilitation at NYU). The Psychiatric Institute and The Neurologic Institute were on the CCP&S campus, each of them housed in a separate free-standing high-rise building. PM&R was allocated an entire floor of the Neurologic Institute for its in-patient unit.54 Space and other resources for PM&R at Columbia were far in excess of those at the MGH campus. Boston′s medical centers, in contrast, tended to be smaller, older, and hemmed in by congested urban neighborhoods, with a tradition of resistance to institutional expansion. Space at MGH was at a premium, and the orthopedic department was eager to take over Watkins′ PM&R beds as this senior physician and leader approached his 1967 retirement without a successor. A few blocks away from MGH, internist Manuel J. Lipson, MD had been both chief operating officer and medical director of Spaulding Rehabilitation Hospital (SRH) beginning in the 1960s.55 Lipson had a dream: to make SRH the host institution for a future Harvard PM&R Department, and his leadership role in this effort was crucial to this effort.1 However, at the time of Watkins retirement in 1967, SRH was not a viable alternative. In contrast, at CCP&S, Darling had been medical director at the ICD Rehabilitation Center from 1952 to 1959, and he directed the 16-bed rehabilitation unit at CCP&S from 1959 to 1997.56 Lengthy hospital stays were the rule for PM&R in the 1960s, but reimbursement rates were low, and there were few lucrative physiatric procedures to enhance hospital revenue. Hospital managers were reluctant to invest capital in new rehabilitation facilities, which were seen as “loss leaders.” while orthopedic services, by contrast, were viewed as “cash cows.” At Tufts, a Hill-Burton grant funded construction of the 35-bed Rehabilitation Institute in the 1950s, but until the Prospective Payment System provided funding in the 1980s, money for any new PM&R facilities or programs required an “angel.” At CCP&S, generous donors had been supporting PM&R since the Baruch era, while in Boston, however, the first major donors for PM&R did not emerge until the 1990s.1 The Tufts and Boston University PM&R departments both had been very successful in attracting federal research and Model Systems grants (with generous overhead to the host institutions). It was not lost on HMS/MGH that its institutions, lacking PM&R departments and programs, were unable to compete for these funds (Paul J. Corcoran, personal communication, 2018). The 1980s managed care revolution incentivized shorter acute stays and rewarded hospitals for early discharges. SRH was able to accept “sicker and quicker” referrals, thus helping MGH to thrive under managed care. MGH acquired ownership of SRH, with heightened interest in its new subsidiary. In the 1960s, New York City was richly endowed with academic physiatrists and PM&R programs. Faculty could be recruited from among graduates of its six medical schools and their PM&R residency programs. In contrast, Boston, and indeed the entire six-state New England region, could count only a few dozen physiatrists in the 1960s. The residency programs at Tufts and Boston University had difficulty recruiting candidates, and their few graduates were quickly absorbed into clinical practice opportunities. Watkins was nationally known as a clinical leader, but he lacked the resources to mount a PM&R residency program. In contrast, Darling′s reputation was built on basic research, and his successors have continued that focus. His research funding and laboratory endured after his retirement for the benefit of younger academicians. Furthermore, other leaders such as John Downey, Stanley Myers, George Traugh, Erwin Gonzales, Joanne Borg-Stein, and current department chairs Joel Stein (Columbia), Matthew Bartels (Montefiore/Einstein), and Joseph Herrera (Mount Sinai) were products of this program. Although creation of an independent department of PM&R at HMS/MGH was rejected as premature in 1980, the NIH endorsement of rehabilitation science in 1990 and the evolution of the new chair in neurology to advocate for PM&R colleagues as clinical scientists set the stage for success at last.1, 57 The collaboration of physicians from different specialties facilitated the recruitment of Paul Corcoran, former chair at Tufts with a proven track record in clinical investigation and education, to serve as first chair at Harvard/MGH.1 Just as Boston and New York City are culturally different, the Harvard/MGH and CCP&S cultures also differ; and these differences help explain in part the trajectories of the two PM&R departments. A tired old joke encapsulates the two cultures: A New York lady, visiting Boston, asks “Where do you get your hats?” Her Boston hostess replies: “My dear, we have our hats!”58 NYC celebrates its bigness, while Boston is small in a number of ways. Even with the inclusion of Cambridge, the area and population of the Boston area are one-tenth that of NYC. Both city and state government, all three medical schools, and a dozen hospitals, all lie within a compact zone only 3 miles across. NYC′s scores of hospitals and six medical schools are scattered over an area of almost 500 square miles. Despite these cultural and geographic differences, HMS/MGH and CCP&S were interconnected by personnel exchanges: Darling graduated from HMS in 1935 and went to CCP&S for residency and fellowship. He returned to Boston during the War years for classified research at the HFL and then went back to CCP&S in 1945 to lead PM&R efforts for the next 27 years. In 1968, Darling recruited Corcoran and mentored him until he moved to Boston in 1972, eventually becoming the founding chairman of HMS′s PM&R Department.1, 59 Corcoran recruited Joel Stein from the CCP&S residency program to join the HMS faculty, and Stein returned to CCP&S to chair the department in 2008. The uninterrupted growth and success of the PM&R program at CCP&S over three decades, initially stimulated by the Baruch Awards in the 1940s, were due to faculty and facility resources and leadership, but other factors as well. These included timing of events, institutional culture, and even geography. Because the HMS/MGH′s PM&R program lacked a continuous supply of essential elements over a similar period, it flagged despite the initial funding through the Baruch Awards. Over decades, however, both academic programs have expanded and are thriving. We are indebted to Paul Corcoran (June 8, 1932 to November 21, 2019) for his contributions to Part I and Part II of this series. The authors invite the readers, along with Dr. Corcoran′s family, to celebrate his life and gifts to physiatry and to the history of our specialty. The author thanks Akin Beckley, Hilary Siebens, Richard Verville, and Stanley Wainapel for their insights and suggestions.