by Lewis Thomas
A university, as has been said so many times that there is risk of losing the meaning, is a community of scholars. When its affairs are going well, when its students are acquiring some comprehension of the culture and its faculty are contributing new knowledge to their special fields, and when visiting scholars are streaming in and out of its gates, it runs itself, rather like a large organism. The function of the administration is solely to see that the funds are adequate for its purposes and not overspent, that the air is right, that the grounds are tidy—and then to stay out of its way.
To function in accordance with its design and intentions, a university must be the most decentralized of all institutions.
This is not easy to do, and it is a surprise that it works, by and large, as well as it does. The risk of politics is always there, and there can be nothing so confusing and aimless as academic politics, or, sometimes, so bitter and recriminatory. The remark was once made, attributed to the California politician Jesse Unruh, that the trouble with university politics, the thing that makes it so different and more potentially damaging than the ordinary politics of state government, is that “the stakes are so low.” There is some truth to this. In real life, nothing much is to be gained through the temporary leadership of a committee or ad hoc group out to reform the curriculum or change the parking rules or get rid of the president or whatever. The leader, even if successful, is not likely to emerge from victory with a higher salary or more space for his office or laboratory, and he runs a greater risk of not changing anything or, at the most, acquiring the reputation of a disturber of other people’s peace.
The worst of all jobs is that of the dean. He carries, on paper, the responsibility for the tranquillity, productivity, and prestige of all the chairmen of the departments within his bailiwick, and when things go wrong at the outskirts, in the laboratories of an individual faculty member or the cubicle of a graduate student, the blame is swiftly transported toward the center, past the desks of the senior faculty, past the chairman’s secretary (who is usually the person running the day-to-day affairs of the department), and straight on to the dean.
The actual power of a dean to do anything much is marginal at best and, even at that best, dangerous if he tries to use it. In the major research universities, and especially those with medical schools, the money for running the departments is money generated by the individual faculty members and their students. In good times, this money cascades over the dean’s head, arranges itself in rivulets that flow past the chairman’s office out into the individual budgets of the faculty. In this circumstance, the faculty members are convinced that the university is run by their efforts, is forever in debt to each of them for its sustenance, and owes them a strict and accurate accounting for every dollar of the funds brought in through their efforts. The dean, in this environment, is there in order to serve the professors, and they, in turn, are paid salaries to serve the junior faculty, who actually do the research for which the grants are made, and the students, who help in this work.
The principal usefulness of academic committees is in getting people to know each other. You get to know your colleagues very well indeed when you sit with them for a couple of hours once a week, to talk, say, about the grading of faculty by students. It is possible to learn more about the substance, the inner resources, and the reliability of a man or a woman in this way than by going off on a canoe trip in white water. You learn quickly who is to be trusted and who is to be worried about.
The main function of committees, and the one most likely to affect in an enduring way the quality and future destiny of the university, is the nomination of faculty members for promotion to tenure rank. This is the single area in which the dean can exert real power, since selecting the membership of tenure committees is, in most places, the prerogative of the dean. If he has an idea that Associate Professor Smith would be a likely prospect for a permanent appointment, good for the future name of the university, he can choose a search committee likely to come down on Smith’s side—or at least he can avoid appointing members likely to hold prejudices against Smith or Smith’s field. In some universities, the faculty are aware of the dean’s power in this matter and mistrust him, and therefore insist that the tenure committee must be a standing committee not subject to a change in its membership by the dean’s whim.
The principal task of the administrators—the president, the provost, and the deans—after making sure that the proper systems are in place for keeping track of the money and generating reliable reports to the outside world in accounting for all funds, is to Let Nature Take Its Course. At any rate, this is the main part of the job in an established university with a distinguished name and a good record. Not to meddle is the trick to be learned. The university is perhaps the greatest of all social inventions, a marvel of civilization, a product of collective human wisdom working at its best. A good university doesn’t need to be headed as much as to be given its head, and it is the administrator’s task—not at all an easy one—to see that this happens. The temptations to intervene from the top, to reach in and try to change the way the place works, to arrive at one’s desk each morning with one’s mind filled with exhilarating ideas for revitalizing the whole institution, are temptations of the devil and need resisting with all the strength of the administrator’s character.
Hands off is the safest rule of thumb. The hands of trustees, the state legislature, the alumni, the federal granting bureaucracies, the national professional and educational societies, and most of all the administrators, must be held off, waving wildly from a distance maybe but never touching the mechanism. I would as soon take command of a platoon of scuba divers and swim into a coral reef with the notion of making improvements in its arrangements for living as I would undertake revision in the ecosystem of a university. It needs a lot of leaving alone, and a lot of spontaneous, natural evolution.
A medical school is an anomaly within a university and works differently, sometimes placing the whole institution at risk for its principles. Medical schools are constantly having hands laid on them, from all sides, hands carrying money or threatening to take money away, other hands twisting the head of this part of the university and turning it in a direction skewed to one side, aimed at immediate service to the community, also aimed in the direction of money, money carrying the guarantee of something tangible delivered quickly in return. This is not the habit of the universities. Not to say that universities do not seek money, they do so day and night, but not, generally, with the promise of a service or a product.
I have lived most of my professional life in one medical school after another, and have a deep affection and admiration for these institutions, but I can see that some things are wrong with them and are beginning to go wronger still. If I were the president of a major university I would not want to take on a medical school, and if it already had one, I would be lying awake nights trying to figure out ways to get rid of it.
At the beginning, having a medical school was no great responsibility for a university, no trouble at all, and nice for the prestige of the whole place. Medical schools were small affairs by today’s standards, a hundred students or fewer per class: two years of basic biomedical science taught by faculty who usually added strength to the university’s resources for scientific research and teaching, and a small and relatively inexpensive clinical faculty for the last two years, most of whom made their own living in private practice and cost the university nothing for their services. The teaching hospitals were autonomous institutions, supported by the local community, managed as separate corporate entities unrelated to the university and maintained either as voluntary or municipal (or county) institutions. Medicine was a solidly respected career, intellectually rewarding if not famous for being lucrative; the applicants for admission were adequate in number to fill the classes, but not much in excess of that number. The medical school was often located in another part of town—sometimes in another, distant part of the state�
�from the rest of the university, which, most of the time, was oblivious to its existence.
The great change began in the years immediately after World War II, with the expansion of extramural research programs of the National Institutes of Health. During the mid-1950s I was a member of what was then referred to as the “Senior Council” of the NIH, the National Advisory Health Council, which reported directly to the Surgeon General of the U.S. Public Health Service and was supposed to set policy. We had the time of our lives. Everything seemed possible. The Congress was fascinated by the possibilities that lay ahead in medical research, and Senator Lister Hill and Congressman John Fogarty were powerful figures who had already started to build their legislative careers on medical science. The medical schools of the country were of a mind to begin expanding their scientific facilities, and there was money all around. Dr. Frederick Stone, executive secretary for the council, was a skilled and ambitious bureaucrat, and Dr. James Shannon, the director of NIH, knew exactly where he wanted NIH to go and how to lead it to its destiny, which involved strengthening the nation’s capacity for medical science by building research into the daily, central, and essential functions of the American medical schools.
In retrospect, it can be seen that the expansion of NIH and the recruitment of medical faculties for implementing the national mission of NIH represented one of the most intelligent and imaginative acts of any government in history, and NIH itself became, principally as the result of Shannon’s sheer force of will and capacity to plan ahead, the greatest research institution on earth. Only one thing went wrong, a mistake no one involved in the early years envisioned: research became more expensive than anyone could have guessed. While NIH selected for excellence and picked the strongest universities and their medical schools for the effort, it became at the same time the accepted idea that every faculty member of every medical school in the country must be a working scientist with a grant from NIH and a laboratory at his disposal. As an inevitable result, the merit system for recruiting and promoting faculty members in the medical schools would henceforth be determined, in large part or in whole, by research productivity and papers published.
With this stimulus, the emergence of the modern medical center, now known at some universities as the Health Sciences Center, or some such term, began. Today, these creations dominate the scene at many universities. They are typically located at or near the edge of the campus, immense structures built around the core of a huge hospital, swarming with clinics, diagnostic laboratories, special buildings for rehabilitation, mental health, retardation, geriatrics, heart disease, cancer, stroke, and any number of other categorical programs that have, at one time or another down the years, caught the interest of one or another congressional committee. The central hospital is usually designated as the “university hospital”; sometimes the university owns it outright, or otherwise has contractual arrangements which give the university the key right to designate its own faculty as members of the hospital’s professional staff, usually with their incomes provided by the hospital.
Most of these new medical centers are of great value to the communities around their doors, and many of them can fairly be regarded as national, even international, resources for the most skilled and specialized health care to be found anywhere. There is no question as to their excellence—indeed, they have had the effect of raising the professional standards for medical and nursing care across the country.
The only question—and now it is a question causing anguish for both medical school and university administrators—concerns their relevance to the university mission. The question did not arise so often in the years when the medical centers were being built, or in the years when there seemed to be plenty of money to meet their costs of upkeep. But now, in the 1980s, with demands for retrenchment in all governmental programs and outcries everywhere against the rising costs of medical care, particularly hospital costs, the relationship between these hospitals and their parent medical schools, and of both to their fiscal guardians, the universities, is becoming increasingly strained and uncomfortable.
Meanwhile, during the past ten or fifteen years, the medical schools themselves have undergone a great expansion. Not only has the number of schools in the country increased by 50 percent, the number of medical students in many schools has doubled, or more than doubled. This happened during a period when both the federal government and many state legislatures believed that we were short of doctors, and the schools were paid by capitation, a sort of bounty, for each student added to the entering classes. Now, with the federal cutbacks already launched, including sharp reductions in low-interest student loans, many of the medical schools are barely escaping bankruptcy. As for the students already in the system, and those now planning to enter it, the cost of medical education is becoming so high that only those backed by affluent families can pay their way. The annual tuition alone in the medical schools of private universities is already close to $10,000 for most, and rising above $20,000 in some. The state schools are considerably cheaper, but their costs are also rising steeply.
The universities themselves are now at risk. Step by step, they have assumed—probably without anyone realizing the magnitude of each step—the ultimate control and ultimate responsibility for a large sector of the nation’s health-care system. The annual budget of some medical schools matches or exceeds the operating budget of all the rest of the university. The rosters of tenured faculty and the commitment to graduate and postdoctoral education have become disproportionately greater in many medical schools. And now, with the sure prospect of reductions in the funds flowing from Washington to support the medical schools, it is the universities and the trustees who will have to decide where to make the inevitable cuts. Most universities live chancily from year to year, depending heavily on contributions from their alumni and philanthropic friends, sailing close to the wind. It is not within their conceivable resources to pick up deficits of any size, and the medical school deficits are soon likely to become of great size indeed.
Somehow or other, the medical centers will have to do a better job of sorting out their component parts. The medical school faculties carry responsibilities for teaching, research, and patient care, and are largely dependent on the hospitals for their income. As integral parts of the universities, the medical schools ought not to be in the business of running immense hospitals, any more than the law schools should be running the local court system or the business schools operating the town’s major corporations and banks. The teaching hospitals cannot divorce themselves completely from the medical schools with which they are affiliated, but they should be recognized and supported by society for what they are—complex and costly institutions which are indispensable not only for the local community but for the whole country, some of them indeed for the whole world.
17
RHEUMATOID ARTHRITIS AND MYCOPLASMAS
The greatest difficulty in trying to reason your way scientifically through the problems of human disease is that there are so few solid facts to reason with. It is not a science like physics or even biology, where the data have been accumulating in great mounds and the problem is to sort through them and make the connections on which theory can be based. For most of this century—by far the most productive of technology in the history of medicine—clues have been found through analogies to known disease states in animals, sometimes only vaguely resembling the human disease in question.
In rheumatoid arthritis, the only comparable diseases that occur spontaneously in animals are the infections caused by mycoplasmas. In several species of domestic animals, most persuasively in swine, the joint lesions caused by mycoplasmas are indistinguishable in their microscopic details from those of rheumatoid arthritis in man.
Because of this solitary clue, many attempts have been made in laboratories around the world to cultivate mycoplasma from the joint fluid and tissues in rheumatoid arthritis, with essentially negative results. There are several scatt
ered reports of positive cultures, but my laboratories have been unable to confirm any of these. The problem remains unsettled, although the possibility is by no means excluded by the considerable literature of failed attempts. The mycoplasmas are strange, fastidious creatures, and the growth media required by some of the known species include bizarre, unaccountable nutrients. Just in the last few years, new species of mycoplasma have been found in some of the diseases of plants and insects which have been under close study for a half century or longer. The yellowing death of thousands of Miami’s palm trees is now known to be caused by microorganisms of this kind. It would not be a great surprise, therefore, if a still-unidentified mycoplasma were connected to rheumatoid arthritis in man.
There is another wisp of a clue: the observation that mycoplasmas as a class are peculiarly vulnerable to the action of gold salts. The mechanism of gold’s action is still unexplained, but the fact of its effect is solid. Side by side is the equally solid observation, dating back fifty years, that rheumatoid arthritis is sometimes cured by injections of gold salts; thus far, gold is the only therapy generally recognized to cure this disease, although its use is limited by the frequency and severity of toxic reactions to the metal.
However, the morphologic resemblance to certain animal diseases is, by itself, not much to go by for making up one’s mind, and most of the skilled, responsible investigators of arthritis remain commendably skeptical of its meaning. Meanwhile, a great deal of evidence has accumulated to indicate something gone grossly wrong with the immunologic system in the disease, and rheumatoid arthritis is now listed in some standard textbooks as a disorder of autoimmunity: the standing theory is that antibodies are formed against one’s own tissues and the joint lesions are the outcome of this anomalous event. But this is also an unproved theory, and the field remains wide open for speculation. Hence, by the way, the great number of best-selling paperbacks on how to cure your arthritis by special diets, mineral baths, exercises, meditation, and various combinations of vitamins. It is an unsettled problem.