| WHEN STANFORD'S MEDICAL
SCHOOL MOVED FROM SAN FRANCISCO TO NEW BUILDINGS AND LABORATORIES
ON THE PALO ALTO CAMPUS 40 YEARS AGO, the changes
were far more than physical in nature. The major role of Stanford's
medical school during its first half century in San Francisco was
to train physicians for medical practice. "The
move" gave birth to a new kind of medical school.
Envisioned by Stanford University's president Wallace Sterling and
provost Frederick E. Terman, the reinvented medical school had a research
emphasis encompassing both clinical medicine and the underlying basic
sciences.
The establishment of a full-time clinical research
faculty was one of the major changes brought about by the move.
While heart surgeon Norman Shumway, MD, PhD; radiologist Henry S.
Kaplan, MD; surgeon Roy Cohn, MD; and internist David Rytand, MD,
joined the new campus, many others were unable to make the move.
This made it possible to hire additional research-oriented clinicians,
including surgeon Robert Chase, MD; urologist Thomas Stamey, MD;
pediatrician Norman Kretchmer, MD, PhD; and psychiatrist David Hamburg,
MD.
At the same time, funding became available to hire
a world-class basic sciences faculty in biochemistry, as well as
in genetics, an area relatively new to medical schools. Pioneering
biochemist Arthur Kornberg, MD, arrived from Washington University,
St. Louis, bringing his entire research group, which included Paul
Berg, PhD, and many others. And legendary geneticist
Joshua Lederberg, PhD, who was at the University of Wisconsin, accepted
an offer to head Stanford's new Department of Genetics.
Untied from the ropes of tradition, the medical school,
influenced by its influx of young energetic researchers, swung toward
the union of basic research and medicine. Related departments on
the Stanford campus, such as the departments of biological sciences
and chemistry, were greatly strengthened, and the proximity of the
medical school to the rest of the university furthered collaboration
between medical and other faculty members.
The reinvigorated medical school included a radical
new program for medical students. The idea was to attract students
who wanted to conduct research -- and then give them every opportunity
to do so, including an extra year's time. The five-year program
encouraged students to find their own niches within the broader
campus as well as the medical school, to work alongside researchers
in their laboratories and to seek the best training available in
their areas of interest.
The move's influence is still felt. "As we celebrate
the 40th anniversary of the move, the integration of basic sciences
and medicine remains at the core of Stanford's medical research
and education," says the medical school's current dean, Eugene Bauer,
MD. "The move, and the changes instituted along with it, set the
stage for the dynamic research programs we have today," says Bauer.
Stanford Medicine invites its readers to see
the move through the eyes of faculty and students who took part
in the school's transformation.
Sidney Raffel
BROADENING HORIZONS:
MOVING TO THE
MAIN CAMPUS
Sidney Raffel, ScD, MD, first came to Stanford in
1935 on a one-year fellowship to study poliomyelitis, after completing
a doctorate in immunology at Johns Hopkins University. He continued
on as an assistant instructor at the Stanford medical school, with
time out to complete his own medical degree at the San Francisco
campus in 1942. Eventually he became head of Stanford's Department
of Medical Microbiology and Immunology, serving in that role from
1953 until his retirement in 1976. Raffel's nearly four decades
of teaching in the medical school's basic sciences program bracketed
the move years.
Prior to the move, Stanford medical students spent
their entire first year and a quarter on the Palo Alto campus taking
anatomy, biochemistry, histology, medical microbiology and physiology.
They continued with preclinical studies in San Francisco, attending
classes in pathology, pharmacology and public health/preventive
medicine. During their third year, students spent one month on each
ward, followed by a fourth year of clinical rotations. The students
roomed at boarding houses located in San Francisco at Fillmore and
Sacramento streets.
Like most medical schools of the time, the clinical
faculty taught on a part-time basis and had their own private practices
at the school. Raffel recalls this faculty as being very devoted
-- and against the move. Because their practices were rooted in
San Francisco, the majority were unable to make the transition.
As Raffel looks back, he remembers the days prior to the move as
filled with good spirit. "The medical school classes were quite
cohesive," he remembers, since everyone was taking essentially the
same program. Yet despite missing some aspects of the "old times,"
Raffel strongly supported the move and enjoyed getting to know the
new young investigators.
The post-move clinical faculty boasted many stars
-- some from the San Francisco campus and many new recruits. Among
those from San Francisco were Shumway, who pioneered numerous aspects
of heart surgery, including the first adult heart transplant in
the United States; surgeon Cohn, who performed many of the first
kidney transplants on the West Coast; and Kaplan, head of radiology,
who worked with physicists in Stanford's Microwave Laboratory to
develop the first linear accelerator for cancer treatment. Faculty
who joined later included many leading clinical researchers -- for
example, Hamburg, whose norepinephrine studies in rhesus monkeys
initiated a new emphasis on the role of neurotransmitters in mental
health, was recruited from the National Institutes of Health to
head psychiatry, and Kretchmer, an expert in intestinal enzymes
of the developing child, was recruited from Cornell to head pediatrics.
While most of the pre-move students had geared their
studies for medical practice, the post-move curriculum attracted
students leaning toward careers in research. In addition to the
focus on laboratory and clinical research, medical students could
now choose from a wide spectrum of university resources. Some students
forged the beginnings of unusual medical careers by combining fields
like anthropology, sociology and primate behavior with their medical
studies. For those who sought it, the post-move medical school experience
had a much broader horizon.
Avram Goldstein
THE NEW CURRICULUM:
FROM CONCEPT TO LEGACY
Avram Goldstein, MD, who was recruited from Harvard
in 1955 as the new head of pharmacology, played an important role
in bringing distinguished basic science and clinical faculty to
Stanford and in scripting the post-move curriculum. "Our first principle,"
he says, "was that Stanford was going to be a completely research-oriented
medical school."
Recalls Goldstein, "The years immediately before
the move were turbulent ... the essential birth pains of a new school."
A new dean, Stanford's chief of pediatrics Robert Alway, MD, was
chosen to lead the move. Alway, a supporter of the plan to create
new departments in the basic sciences, worked closely with Goldstein
and a small group of others to "bring the best people to Stanford
and turn it into a distinguished institution," says Goldstein. "It
was a great challenge -- and fun."
From today's standpoint, Goldstein was given remarkable
latitude in his quest. For example, he recalls recruiting Kornberg
from Washington University in St. Louis on behalf of the new medical
school. Says Goldstein, "We felt that Stanford couldn't have a modern
medical school without a top biochemistry department. We decided
that Arthur Kornberg was the leading biochemist in the country and
that we were going to bring him here. Kornberg said, 'Well we have
a wonderful department here at Washington University,' so I said,
'Fine -- bring them all. We'll give you the space.' " With the successful
recruitment of Kornberg, other nationally known faculty joined the
basic science departments, quickly increasing Stanford's visibility.
Goldstein and others also redesigned the curriculum
to support student involvement in investigative work. The aim of
the new curriculum was to cover the required ground but to remain
flexible enough to maximize opportunity for bright students to do
whatever interested them the most. Therefore, students were allowed
to take a large number of electives. And, contrary to the national
pattern, which was to produce more doctors by reducing the time
spent in medical school, Stanford extended the time from the standard
four years to five.
"Two of the things we wanted to do were revolutionary
at that time," notes Goldstein. "First, we wanted to give students
a home where they could sit down, have a desk, and their lab courses
could come to them -- a fully equipped lab, where they could do
all their lab work except for gross anatomical dissections." The
medical school had moved into the new buildings designed by famed
architect Edward Durrell Stone. The second floor contained the Fleischmann
laboratories, where each student in the first two years had an assigned
place.
The other revolutionary idea, says Goldstein, was
that these labs would offer a site for the informal exchange of
scientific ideas between the faculty and their energetic inquiring
students. In line with creating this atmosphere, the class size
was 64, considerably smaller than the average medical school class,
to give instructors more time with each student.
As the years passed however, students opted out of
the lab classes, and the Fleischmann laboratories
were converted to faculty space. Emphasis in the late 1960s and
1970s moved to arenas such as health policy and delivering medical
care to minority and impoverished patients. Some of the faculty
felt that these new areas were incompatible with a strictly research-oriented
medical school.
The original concepts for the new curriculum "were
grand notions," admits Goldstein. "Whether we ever fully achieved
them, I would have to question -- but to some extent we certainly
did."
Today's Stanford medical school students are an interesting
mix, Goldstein says. While a number of students attend Stanford
with the goal of entering medical practice, most -- about 90 percent
-- spend at least six months involved in a research project. This
emphasis on hands-on laboratory research is the legacy of the post-move
curriculum.
Arthur Kornberg
RESEARCH: THE LIFELINE
OF MEDICINE
In 1959, when Kornberg came to Stanford to create
its Department of Biochemistry, he was at the leading edge of a
revolution -- a new emphasis on the integration of basic sciences
into medical research and education.
As a member of the executive committee that advises
the dean on policies and management, Kornberg helped to set a new
standard for the function of a medical school. "The role would no
longer be simply teaching, or the practice of what's known, but
to acquire new knowledge -- and that would apply to clinical as
well as pre-clinical departments."
Within a few weeks of Kornberg's move to Stanford
from St. Louis, his group was continuing its experimental work.
Since the cold rooms in the new laboratories were not yet working,
the researchers stored their reagents temporarily in refrigerated
trucks. It was a time of excitement, when science proceeded despite
makeshift arrangements. "The essence of the biochemistry department
is to do science, to do something creative," so they started right
away, recalls Kornberg.
The department was unique in that funding and facilities
were shared; there was a communal attitude that still flourishes
today. The four-person faculty laboratories have always been occupied
by researchers from different groups and, says Kornberg, "frequently
projects grew out of this sharing of space and interaction."
In the first decades following the move, the biochemistry
department -- small and close-knit -- focused almost completely
on the duplication and recombination of nucleic
acids. The group studied DNA, RNA and the proteins that bound them.
The enzymes they discovered ignited the genetic revolution, notes
Kornberg, who in 1959 shared the Nobel Prize in Medicine for his
work in synthesizing DNA.
Biochemistry laboratory for medical and graduate
students was taught in the Fleischmann laboratories. Students were
given the same mandate as the faculty: Discover something new. Students
spent five weeks isolating DNA and demonstrating that it was, in
fact, DNA. Or they could isolate an enzyme of their choice and show
the properties that qualified it as an enzyme.
"There was enough latitude there and enough excitement
so that we were all in the laboratory -- the faculty, the students,
the postdocs -- everyone was involved. The students would come back
in the evenings, on the weekends ... ," Kornberg remembers.
But in the mid-60s, when a curriculum revision made
biochemistry lab optional, only four students decided to take it.
Kornberg is philosophical about this, noting that medical students
are not necessarily pointed toward a research career. And yet, in
his autobiography For the Love of Enzymes Kornberg concludes,
"Experience has taught us that research is the lifeline of medicine.
What a wonderful difference it would make if tens of thousands of
physicians could report once in their lifetime how they had reshaped
a fact of medical science!"
Halsted Holman
TOWN-GOWN RELATIONS:
FORGING A PARTNERSHIP
Immunologist Halsted Holman, MD, came from the Rockefeller
Institute for Medical Research to head Stanford's Department of
Medicine prior to the move. He recalls that, despite some initial
worries on both sides, Stanford and Palo Alto physicians played
complementary roles after the move, especially in internal medicine
and pediatrics.
"The clinical side of the new research focus was
specialty medicine. We developed specialty services, which by and
large were not well represented in the community," says Holman.
The town of Palo Alto had a very good health care
system overall, Holman says, "but most of the physicians were not
specialists or, if they did specialty work, it was based purely
on clinical, not biological, training." In the early days, there
was essentially no primary care at Stanford; the Stanford emphasis
on specialty medicine avoided an immediate competition with community
physicians, Holman notes.
"The purpose of the move was to bring the Stanford
medi cal school into what was perceived as the
modern era," states Holman. "Post-move research was a recognition
that biological processes that underlie human disease could be understood."
The move not only placed the medical school in proximity
to other disciplines like biology, psychology and engineering, it
gave the school updated facilities. An emerging source of support
was the National Institutes of Health, which funded not only research
but buildings and laboratories as well.
On the main campus, leasing of land to emerging technology
companies -- the seeding of Silicon Valley -- generated funds and
allowed the school to develop more fully in many ways. The intention
of Sterling, Terman and others was to make Stanford into a complete
university with strong graduate programs, and moving and strengthening
the medical school was part of that picture, says Holman.
Initially, the new hospital was owned and managed
jointly by Stanford and the city of Palo Alto. As a result of this
arrangement, there was split leadership and even duplication of
some departments. These problems were eventually resolved when Stanford
took over ownership of the hospital in 1968, providing certain guarantees
to the community physicians, including representation in hospital
leadership bodies.
Following the move, there were some initial fears,
expressed, for example, by Russell Lee, MD, founder of the town's
Palo Alto Medical Clinic, that there might not be enough patients,
says Holman. Some community physicians worried about being undercut
by their Stanford counterparts. At the medical school, several faculty
members were concerned that community physicians might not cooperate
in teaching activities.
However, Holman feels that for the most part these
fears were unfounded. From his point of view, the Department of
Medicine worked to include community physicians, and as specialty
services within the surrounding area developed, local physicians
were incorporated to a greater degree into the teaching programs.
The fact that the principal leadership of the community
physicians also believed in building a cooperative relationship
played an important role in the success of Stanford's clinical enterprise
in Palo Alto, Holman emphasizes.
"William Clark, one of the outstanding leaders in
the community at the Palo Alto Clinic, and Charles Armstrong, who
played a similar role at the Menlo Clinic, were very thoughtful
people who strove to have good relations with the medical school
faculty. They were deeply respected by those of us on the academic
side," Holman states. With initiative from both the community physicians
and Stanford medical faculty, town- gown relations
-- a little shaky at first -- became a stable, positive aspect of
medical care in the community.
Student Perspectives
THE EXTRA YEAR:
LEARNING TO THINK
Exams were few; laboratory and research reports,
many. Learning to solve problems by interacting with faculty and
other students was the emphasis of the five-year curriculum; the
medical students had both the time and opportunity to discuss their
work with some of the finest scientific minds in the world.
Reminiscing about what he learned in the biochemistry
class, Irving Weissman, MD, class of 1965, says, "clarity of thought."
His most important lesson was that scientific knowledge grows as
a result of experimental questions asked to clarify central issues
in the field, says Weissman, now on Stanford's medical faculty.
Says research pathologist Sharon Thomsen, MD, class
of 1966: "The research-oriented school taught students not
to be afraid of something they didn't understand but
instead, to pursue the answer." Like many in the five-year medical
school classes, she pursued a career in research and academia. Now
at the University of Texas, Austin, she studies the effects of external
non-ionizing radiation and its application in cancer treatment.
Thomsen's interest in her research field developed
while working alongside mentor Raymond Saunders, PhD, in Stanford's
Department of Pathology. "The research in his laboratory initiated
my interest in the biochemistry, histochemistry and structure of
connective tissues. I expanded this over my years in research into
studies of wound healing, as well as my work on radiation's effects,"
explains Thomsen.
Students had plenty of time each day to pursue their
own interests and, like Thomsen, many chose to work in research
laboratories, where they had the opportunity to learn a variety
of techniques. As medical students, many launched their own research
projects, published and traveled abroad to work in their fields
of interest with leading researchers.
Weissman, who had done biomedical research during
high school, wanted to continue toward a research career in medical
school. At Stanford, he worked with radiologist Kaplan, who gave
Weissman space in his lab and even a part-time lab technician. Every
week Weissman met with his mentor to discuss research papers Kaplan
had written. "He was one of the few who translated scientific discoveries
from the bench to patient care, and he provided a great background
for me." Weissman also had time for an eight-month trip to Oxford
to work in the laboratory of James Gowans. "Gowans had just demonstrated
that lymphocytes -- the cells I wanted to study -- were the cells
that had all the secrets of the immune response."
Another influence was geneticist Lederberg, who "had
become entranced with immunology himself. He gathered around him
some of the world's leading immunologists; we had weekly seminar
sessions to read papers and discuss our work -- and, of course,
being in this five-year school, we had time to do that."
Many students included non-medical topics in their
studies. Robert Erickson, MD, class of 1965, for example, took seminars
in the anthropology department.
Now a pediatrician on the faculty at the University
of Arizona, Tucson, Erickson spent the summer after his first year
of medical school studying how Mayan Indians' medical beliefs affected
their acceptance of a Mexican national medical care program.
"My anthropology training influenced where I ended
up practicing medicine," Erickson says. Erickson's current practice
includes 10 Native American reservations where he sees pediatric
genetic cases; his recent research includes the study of four rare
Athabaskan genetic diseases present in the Navajo and Apache tribes.
AS WELL AS CULTURAL
knowledge and sensitivity, Erickson's work required years of study
in genetics and related areas. Erickson began this study at Stanford,
where he joined the laboratory of Leonard Herzenberg, PhD, and received
two years of training in immunogenetics. Recalls Erickson, "I received
my grounding in scientific research -- Herzenberg taught critical
thinking."
And like fellow alumni Thomsen and Weissman, Erickson
appreciated the support Stanford offered for nascent physician-scientists.
"In the 1960s, Stanford was one of the few medical schools with
role models of physician-scientists in pediatrics," notes Erickson.
"Over the years, I have come to appreciate their importance in my
career choice. I always loved children and knew I wanted to be a
pediatrician -- but I also wanted to be a physician-scientist."
At Stanford, there was tremendous support for this dual role.
Erickson concludes, "A lot of us who were in the
class of 1965 thought we were extremely lucky." SM
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