Friday, March 09, 2007

Irish medicine

If it's Friday, it must be time for history of medicine class! Today's lecture was given to the second-year students by Eran Klein, M.D., OHSU neurology resident. Dr. Klein, being himself of Irish ancestry, was eager to discuss 19th-century Irish medicine and to make his case for why Ireland might have been the site for the transition from 19th-century medicine to modern medicine.

Klein began by describing the national characteristics of medicine in France (development of hospitals, use of autopsies, refinement of the physical examination), Britain (decentralized systems of education and health care, entrepreneurialism), and Germany (development of universities, emphasis on laboratory sciences, bedside teaching from Boerhaave). He then set about to show how Irish physicians combined elements from each of these approaches into the precursor of today's medical system.

Exhibit A is Robert Graves (1796-1853), who is best known for his description, in 1835, of what is now called Graves' Disease. Graves (who also described peripheral neuropathy, scleroderma, and pontine hemorrhage) set up a system of "clinical clerks" in Ireland, taking from the Germans the idea of bedside teaching. In his textbook, Clinical lectures on the practice of medicine, Graves laid out a plan that seems nearly identical to our modern methods of clinical exposure in the third and fourth years of medical education.

Exhibit B is William Stokes (1804-1878) who was an early adopter of the French stethoscope, and used the new device to describe several important cardiovascular conditions. Both Stokes and Graves had been educated first in England, and then in medical centers throughout Europe; their particular genius, according to Klein, was to combine the best of these teachings to create a vibrant medical community back home in Ireland.

By the end of the 19th century, Irish medicine was in decline, probably (opines Klein) because the country itself was relatively poor compared to its neighbors. While it is hard to quantify Irish medicine's influence on later developments, four noteworthy students of Irish medicine went on to establish their own spheres of influence: Alfred Stille and William Gibson in Philadelphia, and James Bovell and Campbell P. Howard in Canada (under whom William Osler later studied).

So, as you celebrate St. Patrick's Day this year, make an extra toast to Stokes and Graves, who may very well have been responsible for the quality of the medical care you receive today!

Thursday, March 08, 2007

Bourgery's Atlas

An exciting addition to our collections came over from cataloging today: J.M. Bourgery's Atlas of human anatomy and surgery: the complete coloured plates of 1831-1854 is now available in the History of Medicine Room. (And measuring in at 41 cm. in height, it's hard to miss!)

French anatomist and physician Jean-Baptiste Marc Bourgery (1797-1849) collaborated with illustrator Nicolas Henri Jacob (1782-1871), a student of the French painter Jacques Louis David, to produce this monumental work on anatomy and surgery.

The atlas illustrates descriptive anatomy, surgical anatomy and techniques (exploring in detail nearly all the major operations that were performed during the first half of the 19th century), general anatomy and embryology, pathology, and microscopic anatomy. Jacob's life-size lithographs are considered by some to be unsurpassed by any later anatomical illustration. Interspersed are numerous plates of surgical instruments.

There is something in this work to interest everyone, from surgery on the tongue and jaw to detailed views of the brainstem to disarticulations of the wrist. We began looking through its pages and literally lost track of time, captivated by the sheer artistry of the images and the complexity of the human body (not to mention the primitive nature of mid-19th century surgical techniques).

To enjoy a few images from the book online, see the publishers' blurb on the Taschen web site (the arrows below the included image allow you to scroll through several other digital images).

Wednesday, March 07, 2007

Do you know these people?

OK readers--we need your help in identifying this photograph! A 1977 School of Medicine alumnus has sent this along to us, and we only have a small amount of information to go on in determining the identity of this group.

Our 1977 alum, Dr. CJ Hockett, is from a long line of OHSU grads: his grandfather CT Hockett graduated from Willamette University Medical School in 1904 and his uncle, Asahel J. Hockett, graduated from UOMS in 1929. The family had assumed that this photo, above, was Asahel's class picture--but in comparing it with the official Class of 1929 photo in our collections here, it became clear that this was not a picture of the full class.

The photo is similar to some early group portraits of medical fraternities that we have here, but the individuals are all wearing regalia, as if the photograph coincided with graduation from medical school.

Any ideas? We'd love to solve this mystery....

Tuesday, March 06, 2007

Beginnings of the OHSU Library, or, why the History of Medicine Room has some great stuff

In a meeting I attended today, a question arose as to when the OHSU Library formally began: Was it in 1887, when the school was founded? Surely, a medical school would need to have a library of texts, for instruction and reference--heck, for patients to browse through while waiting for surgery!

But, alas, no library seems to have graced those first halls. Frankly, the school was lucky to have found some halls to inhabit that first year, after the acrimonious break with Willamette University Medical Department. The first catalog does contain a list of textbooks, but the titles were not only not supplied in an institutional library, they weren't even required--the list was just a "guide" to the student! (Incidentally, we have the exact editions of all those original textbooks recommended to the student in 1887, collected in our First Class Collection.)

So, at what point did the faculty settle down and decide on the need for some library facilities? It wasn't until 1893, when the personal libraries of Portland physicians (and brothers-in-law) R.B. Wilson and Rodney Glisan were donated, that the school had a collection of reading material on hand. The collection was dubbed the "R.B. Wilson Library," and remained such until some time after the school relocated (for the last time) up to Marquam Hill.

During those first years on the Hill, the library was housed in Mackenzie Hall (as was everything else, since it was the only building on campus). When physician and philanthropist Dr. John E. Weeks gave $100,000 to the fund to construct the first library building on Marquam Hill, they tried to rename the library after him, but he humbly deferred and the suggestion was soon forgotten. A plaque commemorating the donation is all that remains.

Now the only library service point in that Old Library, the History of Medicine Room still contains many of the books from that original donation of Wilson and Glisan's libraries. Later donations from alumni, faculty, and other friends of the library have added to those volumes to make the History of Medicine and History of Dentistry Collections that we enjoy today.

Though we may date back only to 1893, we're still the oldest medical school library west of Denver and north of San Francisco! (Johns Hopkins' Welch Medical Library? A toddler, having been born in 1929.... )

Monday, March 05, 2007

Gang of Seven

Q: How many people does it take to fix a broken healthcare system?
A: A Gang of Seven.

About a year ago, Karen Whitaker Knapp, outgoing director of the OHSU Center for Rural Health, sat down with interviewer Dr. Reid "Sam" Connell for our Oral History Project. After talking about the circuitous route that had brought her into a career in healthcare, Knapp fielded this question from Connell:
CONNELL: Karen, you've kind of hit upon a pivotal event that occurred in 1988 and around Joseph, Oregon, with the Enterprise group. I also—and you’ve talked about that a bit, but I've heard another kind of an expression of a group of people that met, and it was called the Gang of Seven.

KNAPP: Oh. [Laughs]

CONNELL: I think something that followed the 1987 Oregon legislative session. Can you tell me, what is the Gang of Seven?
While it may sound like a group of gangsters, the Gang was committed to a very worthy goal. Knapp went on:
Well, this was a group of us who were lobbyists. One of the members, well, actually there were a couple of state officials and a person who was staffed to one of the legislative committees who also participated in this group. But we got together and decided that it was time to have a different healthcare system in Oregon. Sort of a young, ambitious, arrogant way of looking at things. So we all were in some way indebted to an organization or a point of view. We agreed to take our hats off at the door, come in the door, and begin to examine, explore, what an ideal healthcare system would be composed of. And we met weekly for, I think, into the next session, so probably about a year and a half. We probably didn't make it every single week, but that was our goal. And we had some very lively debates. So for people who enjoy health policy, it was great fun to sit down with some of these people who had wonderful minds. I felt like I really didn't measure up to the caliber of the rest of them, but I was very happy to be a part of it.

So we came up with a model that we called the compression model. And we had a sort of a straight line of people who were privately insured on one side, and government-sponsored on the other side, and the uninsured people in the middle, with a gap maybe this big [demonstrates]. So the idea was that you put pressure on both sides, and you bring it together in the middle so that the little gap is only this big, instead of this big.

And recognizing that there are always going to be people that you cannot enroll, even if the resources are available. And I think, like the Canadian health system, recognizes that about five percent of the population never gets enrolled because of their lifestyle. You know, they may be very transient; they may not have access to regular kinds of services. So you have primary care clinics, for safety net clinics, for those people.

We envisioned that not only would we grow the Medicaid program, we'd also grow the employer-sponsored programs. And so part of that would be to require employers to provide health insurance to their employees. And to provide tax credits, particularly for small businesses, to be able to make that leap into providing health coverage. And to support the safety net clinics. And also to change the state Medicaid system in some way that would make it run more efficiently.

So we were quite proud of ourselves. And we pitched this idea to John Kitzhaber and Vera Katz at the Night Deposit Café in Salem. It has since closed. But it used to be quite a hangout for legislators. And John was the Senate President, and Vera was Speaker of the House. So John liked it, and he took it. And he added some of his own elements to it, making it his own. And that was, most especially, the ordered list of services, which hadn't occurred to any of us. That was a whole new idea to us.

But when he introduced the Oregon Health Plan in the '89 session, it included all of those components, including a risk pool for people who are uninsurable, who could not get standard insurance because of preexisting conditions. And that risk pool is still in existence, by the way. It included a mandate for employers to provide health insurance and tax credits. And it raised participation in state Medicaid to 100 percent of the federal poverty level. And completely eliminated categories of coverage that were federally defined, like aid to dependent children, foster children, the elderly and the blind and the disabled. Anyone who was less than 100 percent of the federal poverty level could join the Oregon Health Plan. And they were subject to a restriction of coverage that had to do with the list of paired diagnoses and treatments that the state actually came up with during a series of statewide meetings. So there was a lot of public input to this whole process.

And it all passed. Which was astonishing. Associated Oregon Industries even supported it. And, you know, we were all euphoric. We thought that was probably the best thing that ever happened. But they did put a later implementation date on the employer-mandated insurance. And sure enough, leadership had changed by the time the next legislature came into session, and they repealed that part of it. So there could not be overwhelming success without all—you know, it's like a three-legged stool. You had to have all of the parts working together, or it just couldn't work. Because the idea was to eliminate the cost shift. And if it had actually happened, it would have done that.
Who were the members of this revolutionary group? Knapp could come up with only five of the names: Barney Speight, Dick Grant, Tom Lundberg, Bruce Bishop, and Ed Patterson. The last member of the Gang will apparently remain anonymous pending further investigation...

So, let this be a lesson for the bright-eyed activists out there who might be lamenting the current state of affairs in Oregon, the plight of those who remain uninsured, and the political hurdles that face reform at both local and federal levels. Get six of your friends together, stand ont the backs of giants, and hammer out a compromise--because where there is a will, there can be a way!