Institutional Memory

C. Richard Conti, MD, MACC

I recently read an editorial by Chris O’Connor in JACC heart failure on the topic of institutional memory [1]. This stimulated me to think about the current state of institutional memory vs that which we perceived in days gone by. In my case,I am referring to the institutional memory of Johns Hopkins School of Medicine (where I went to medical school) and comparing it to the institutional memory at the University of Florida, College of Medicine, (where I have been for the past 43 years.)What follows are some of my memories of my time at Hopkins.

As a medical student, my f rst contact with a Hopkins faculty person was Professor Allan Graff in. Graff in was a meticulous individual who insisted that we know something about the historical aspects of medicine. This was the start of my learning who the leaders were in medicine, and I am forever grateful to him for starting my jour-ney. Unfortunately, most medical students today rarely learn of the history of medicine, and who is responsible for the state of medicine that they know today.

I don’t think many graduates of UF COM, will have a recollection of COM faculty at the beginning of the COM. As a current faculty member of the Department of Medicine, I see no prominent portraits, memorializing the early faculty and it is highly unlikely that current medical students and house staf f have any knowledge of persons that helped build the medical school. At Hopkins it was a different story. We were constantly reminded of the Prominent Physicians that made Hopkins what it is today. E.g. Osler, Halsted, Kelly, Welsh, Thayer,Rich, Ross and many more.

Second Year

During my second year at Hopkins, several individuals stood out for me. One of them was Abu Pollock, professor of pathology.

As medical students, we were assigned to autopsies, which in those days were much more common than they are today. This is partially related (not totally) to the fact that all the imaging we do today gives us a fairly clear idea of what was wrong with the patient who died.

Another faculty person who stood out was Gilbert Mudge, who was professor and chairman of pharmacology. He later left Hopkins and went on to become Dean of the medical school at Dartmouth.

A third person who stood out was a resident in medicine. The resident physician was Dr. Eugene Braunwald, who assigned us a patient who was hard of hearing. Can you imagine two young medical students trying to get a history from someone whose hearing was impaired. That was my f rst meeting with Dr. Eugene Braunwald and I have never forgotten that meeting.

Third Year

My third year was a very memorable year in that I was very fortunate to be at Hopkins at a time when there were faculty members who had huge international reputations; for example, Nicholson Eastman was head of OB/Gyn, Richard Telinde, and head of Gyn, A.M. Harvey, head of medicine, and Johnny Eager Howard in endocrinology. Others of note included Philip Tumulty in general medicine,Samuel Asper in endocrinology, Lockhard Conley as head of hematology, Tom Hendricks head of gastroenterology, Richard Ross head of cardiology,and several prominent cardiac sur geons including Alfred Blalock, Henry Bahnson, David Sabiston,and Frank Spencer. A future honorary M.D. (Vivien Thomas) was also a teacher of mine, during my dog surgery experience as a third year medical student.

During our medicine experience, we were assigned to Baltimore City Hospital, Mason Lord was Chief Medical Resident. The unique thing about Mason Lord is that even as a medical resident, he would wear a f ower in his lapel. This was a signature of this physician that persisted until the time of his death.

During a sur gical rotation, I had contact with a physician in the general surgery clinic by the name of Ned Brockenbrough. Ned subsequently described the Brockenbrough-Braunwald-Morrow sign seen in hypertrophic cardiomyopathy, then called idiopathic hypertrophic subaortic stenosis.

The OB program was run by Professor Nicholson Eastman, a prominent obstetrician who edited the book, “William’s Obstetrics”. I still have “W illiam’s Obstetrics, 11thEdition” in my library at home.

In pediatrics, we were taught by the new Professor of Pediatrics Dr. Robert Cook. As I remember vividly, he wore what we then called “sweat socks” as if he was playing tennis or other sports while lecturing to the students. I also remember Cook using the word “prodigious” many times during his lectures. At the time, I never f gured out what the word meant. I have since learned that as an adjective it means extraordinary or huge.

Another important memory relates to my future health. In 1958, Professor John Bordley asked for a volunteer to demonstrate the ear nose and throat examination. I was the volunteer, and when Bordley looked in my mouth, he said, “Y ou have some leukoplakia on inside of your cheeks.” and it may be a precancerous lesion. He then asked me if I smoked cigarettes. I answered yes and his comment woke me up to the problems of smoking, so I immediately quit .

Dog Surgery and Vivien Thomas

Our instructor was Vivien Thomas. Vivien was a black man, who endured much abuse at Hopkins in the 40’s. Hopkins was in a southern town (below the Mason Dixon line) and many of the faculty were opposed to having a black man in such a prestigious position with Dr. Blalock. Vivien performed the f rst subclavian, pulmonary artery anastomosis in a dog. Thomas was with Blalock in the operating room, along with other prominent young sur geons(Cooley and Longmire) when the f rst “Blue Baby”operations was performed. Later in life, Vivien was awarded an Honorary Doctorate of Medicine from Hopkins (the only one ever given up to that time).When I left Hopkins in 1974, the Blalock Clinical Science building had three paintings displayed. One was Alfred Blalock, the other was Vivien Thomas and the third painting was the dog on whom Vivien performed the Blalock-T aussig Shunt. I must say that the TV movie “Something the Lord Made” is quite accurate and consistent with what I remember of the Vivien Thomas story.

Senior Year

During my senior year, my f rst clinical exposure was in medicine at Hopkins. My f rst attending physician was John Eager Howard, and my second attending physician was Ward B. Allan, also a wellknown faculty person whose expertise was related to diseases of the chest. My experience with these two individuals, convinced me that I wanted to train in internal medicine. On the medical wards the student history, because of its completeness, was the off cial history put in the patient’s medical record.

I remember the interns were John Mulholland and Tony Werner. Jack Mulholland subsequently became Chief Resident several years later and eventually became Chief of Medicine at Union Memorial Hospital replacing John Eager Howard.

House Staff that Influenced me as a Senior Medical Student

Mike Criley and O’Neal Humphries clearly had some inf uence on my eventual selection of cardiology, and they subsequently became my teachers in cardiology during my cardiology fellowship, and later as colleagues on the Hopkins faculty.

Mike Criley was an outstanding photographer and also outstanding in the cardiac catheterization laboratory. Most of what I know about congenital heart disease comes from Mike Criley and pediatric cardiologists, Catherine Neill and Richard Roe and occasionally from Helen Taussig. Mike also combined his photographic interests and his angiographic interests and began the study of the physiologic basis of heart sounds and murmurs.

O’Neal Humphries, in contrast, was an expert in pacemakers and general clinical cardiology. O’Neal eventually moved from Hopkins to the University of South Carolina in Columbia, South Carolina where he became Chair of Medicine and eventually Dean of that Medical School. Mike Criley eventually moved from Hopkins and took over as Chief of Cardiology at Harbor General Hospital in Torrance,California, an aff liate of UCLA.

Osler Internship 1960

My internship class consisted of eighteen individuals. I loved the job. We had to take responsibility(ownership) of our patients. This task was somewhat attenuated by the fact that all of us lived very close to the hospital and could walk there within 10 or 12 min, but we still had to get up and go to hospital. All of us took this responsibility very seriously.

In August, 1960 my intern associate was Roger Palmer, who graduated f rst in his class from the University of Florida, the f rst graduating class at that university. Roger also had a very good understanding of physiology and pharmacology (much more than most of us). Roger returned to Florida,where he worked with Thomas Marin, the inventor of Diamox. While at Florida, Roger was one of the f rst to report that the use of beta blockers diminished aortic dissection in patients with that problem.Those observations are still consistent with current treatment of descending thoracic and abdominal aneurysms.

This internship was no walk in the park, but it probably was the most accelerated learning experience of my entire life. During internship, time of f began after rounds on Saturday morning, one of us could have the afternoon and evening of f and the same was true on Sunday morning for the other intern.

At any rate, the internship was something that I really enjoyed and will treasure forever. We all lived near the hospital, (that is no longer the case)and I basically was home for dinner every night, but I was also back in the hospital every night. During my house staf f training there were not as many diagnostic and therapeutic tools as we have now, so we probably spent more time with the patient than what is done in current medical house staf f experiences. It is interesting, as I look at a picture of the house staff, during my internship year, it turns out that three of us, Dean Mason, Robert Frye, and I later became Presidents of the American College of Cardiology.

James Jude

During that internship year, James Jude, who was the Chief Surgical Resident on the Halsted Surgical Service initiated the CPR program and cardiac resuscitation using AC def brillation. Jim Jude eventually left Hopkins after being there for many years and traveled to Miami where he became Chief of Cardiac Surgery for several years thereafter.

Fellowship in Cardiovascular Medicine

After f nishing my medical residency at Hopkins,I began my Cardiology fellowship training in July 1965. My f rst assignment was to work in the surgical dog lab with David Goldfarb, a sur gical resident. David was working in the surgical animal lab using diastolic augmentation as the main therapy for acute myocardial infarction. As far as I can recollect, we never used the device in patients with acute myocardial infarction. But this preliminary work eventually led to the development of the intra-aortic balloon that accomplished the same goal, but more eff ciently. The individual who developed a prototype balloon, at least at Hopkins, was Greg Brown,who was an MD, PhD medical student.

Following that 3 month experience, I spent the next 20 months working of f and on in the cardiac catheterization laboratory. The major imaging done in those days was done in the cardiac catheterization laboratory.

Most of the coronary angiography was done as a research tool at Hopkins, and many of the patients were admitted to a research ward known as Osler Five. Thus, investigation of coronary artery disease patients were done on a research protocol, since revascularization with surgery or percutaneous intervention did not exist. As a result of our early experience with coronary angiography, Gottlieb Christian (Bud) Friesinger, published a landmark paper on the natural history of patients based on their coronary angiographic f ndings.

Coronary Artery Bypass Graft

Coronary artery bypass grafting did not begin at Hopkins until 1969, after René G. Favaloro initiated this procedure at the Cleveland Clinic on May 9th1967. I had the pleasure of meeting Dr. Favoloro at the American Heart Association annual conference in Dallas (as a young faculty cardiologist, I rode a bus to the meeting venue with him) and later in Buenos Aires, as a slightly older cardiologist as well as an invited faculty, at a conference in his honor. Before his death, I received an autographed copy of his book “the Challenging Dream of Heart Surgery, from the Pampas to Cleveland”, this book was written in 1992. He died on July 29th2000.

Cardiac Transplantation at Hopkins

The f rst cardiac transplant at Hopkins (99thin the world) was a patient of mine and was transplanted by Harvey Bender and Vincent Gott. The patient survived the operation but died 4 weeks later, probably of acute rejection since the immunology of rejection had not yet been f gured out.

Chief Medical Residents at Hopkins

Phillip Tumulty:Sometime during in my senior year, I got to know Dr. Phillip Tumulty, who was thought of by the medical students, house staff, and faculty as an outstanding internist/clinician. Phil Tumulty was my wife Ruth’s physician after she underwent emergency lumbar disc surgery, and she will never forget him.

Samuel Asper:Sam was an endocrinologist,who became president of the American college of Medicine. I received my F ACP during his tenure as president. Sam became Dean of the American University of Beirut. He also was temporary Department of Medicine chair when Dr. A.M.Harvery had his heart attack.

Victor McK usick:1951-52 Chair of Medicine,Osler Professor, Father of Human genetics.

Richard S. Ross:50’s Chief of Cardiology and Professor, later Dean and Vice President of Hopkins Medicine.

Leighton E. Cluff:Professor and chief ID, Hopkins,Professor and Chair of Medicine UF-President Robert Wood Johnson Foundation.

Henry Wagner:Professor of Medicine and Chair of Nuclear Medicine Hopkins.

Frank Iber:1959-60 Professor and chief of Hepatology Hopkins.

Joseph Johnson:1960-61, Professor and chief ID UF, Chair of Medicine, Beauman Gray, Dean U Michigan.

Charles C J Car penter:1961-62, Professor and Chair of Medicine, Case Western Reserve.

Gottlieb Christian Friesinger:1962-63, Professor and Chief of Cardiology, Vanderbilt.

John Mullholland:1965-66, Professor and Chair of Medicine, Union Memorial Hospital succeeding John Eager Howard.

C. Richard Conti:1967-68, Professor and Chief of Cardiology, UF, President American College of Cardiology, Editor in chief Clinical Cardiology,ACCEL and CVIA.

Others, trained by AM Harvey who were not Chief Residents but were members of his medical staff:

Richard Johns:1950’s - Professor at Hopkins and Chair of Biomedical engineering.

Lockhard Conley:Professor of medicine and chief of hematology.

Thomas Hendrix:Professor and chief of Gastroenterology.

Albert Owens:Professor and chief of Oncology.

Gordon Walker:Professor and Chief of Nephrology.

Mason Lord:Private practitioner and former Chief Resident at BCH during my third year at Hopkins.

John Eager Howard:Endocrinologist and inventor of the Howard Test.

Conclusion

Perhaps the dif ference in the recognition of our colleagues at each school of medicine, by student s and house staff, is related to the duration of the existence of the Schools, e.g. Hopkins existed for＞100 years and changed the teaching and practice of medicine, and UF COM existed since 1956.However, I do not think that is the only reason for the difference. It may also be related to the time each faculty member spent at the particular institution, e.g. many faculty stayed at Hopkins for their entire career., e.g. Halsted. Harvey, Tumulty,Conley, Hendricks, Johns, Owens, Howard, Ross,Wagner, Walker. That may change in the future as the UF COM ages, but it may not, since both places have changed ( possibly related to new diagnostic tests and new treatments) in the past few years. Only time will tell.