The Education of American Surgeons and the Rise of Surgical Residencies, 1930–1960

Justin Barr

doi:10.1093/jhmas/jrx058

The Education of American Surgeons and the Rise of Surgical Residencies, 1930–1960

Barr, Justin 2018-02-02 00:00:00 Abstract In the first half of the twentieth century, the training of American surgeons changed from an idiosyncratic, often isolated venture to a standardized, regulated, and mandated regimen in the form of the surgical residency. Over the three critical decades between 1930 and 1960, these residencies developed from an extraordinary, unique opportunity for a few leading practitioners to a widespread, uniform requirement. This article explores the transformation of surgical education in the United States, focusing on the standardization and dissemination of residencies during this key period. Utilizing the archives of professional organizations, it shows how surgical societies initiated and forced reform in the 1930s. It demonstrates the seminal and early role taken by the federal government in the expansion of surgical residencies through incentivized policies and, especially, the growth of the Veterans Administration health system after World War II. Finally, an examination of intra-professional debates over this process illustrates both the deeper struggles to control the nature of surgical training and the importance of residency education in defining the midcentury American surgeon. The education and very definition of the American surgeon changed dramatically between 1890 and 1955. Whereas in the late nineteenth and early twentieth centuries general practitioners performed the majority of operations in the United States, by 1955 formally trained surgeons were assuming that role. Residency – the structured years after medical school that provide the didactic knowledge, practical experience in patient care, research exposure, and mentorship needed to train a specialist – served as the means of surgeons’ education and professionalization. Between the 1930s and 1950s, surgical residency transformed from an uncommon, idiosyncratic experience for elite practitioners to a standardized, mandatory education for all American surgeons. Thereafter, the American public and the medical profession came to define a surgeon as someone who had passed through a rigorous, regulated residency. This article explores the creation and the institutionalization of surgical residencies as they transitioned from rare, ad hoc, and highly variable experiences in the early twentieth century to the ubiquitous, structured, and required education that exists today. It relies heavily on the archives of professional organizations like the American College of Surgeons, American Medical Association, and the heretofore untouched records of the American Board of Surgery, as well as the personal papers of key individuals who led the process. Despite the importance of graduate medical education in creating physicians, caring for patients, and influencing health policy, few scholars have rigorously analyzed its establishment. Kenneth Ludmerer’s recent Let Me Heal is a notable exception, providing a holistic overview of the history of residencies, and Rosemary Stevens’ classic American Medicine and the Public Interest describes their supra-organizational framework in the context of specialization.1 Anthropologists have undertaken ethnographic studies of surgical residency, providing a window into the experience of a trainee, but these appeared in the 1970s, well after the routinization of training.2 Earlier literature tends to focus on the founding of residencies at Johns Hopkins in the late nineteenth century and the social turmoil of the 1960s and 1970s, but this article strongly argues for the importance of the 1930s – 1950s: in these decades, residency spread around country and took its modern form. Following a brief background reviewing surgical training pre-1930, the article evaluates these crucial thirty years in three sections. First, it examines the spread of residency training to community hospitals. In so doing, it moves beyond existing sources that focus on academic institutions. Exploring this shift unveils the compromises necessary to create universal training at institutions unable to produce professorial surgeon-scientists, like shortening the length of training and concentrating on clinical material at the expense of research and basic science. Professional organizations shepherded much of this change. While other sources have emphasized the importance of societies to the identity and function of the medical profession, this analysis demonstrates the specific mechanisms through which they shaped surgery by creating and enforcing criteria.3 Second, the article examines the exponential rise in surgical residencies following the Second World War. While previous sources highlight the growing role of the federal government in the 1960s with Medicare and Medicaid, this section clearly demonstrates its vital importance to residency expansion in the 1940s and 1950s through military policies in World War II, post-war incentives, the GI Bill, and especially the VA Hospital system. These fillips continued the trend of training community practitioners. The third and final section of the paper explores the fierce intra-professional struggles to control the certification process for residency. This portion re-emphasizes the seminal role of surgical organizations and the means they employed to shape their field. Moreover, through these debates it elucidates the importance of residency in defining who was a surgeon in the United States in the middle of the twentieth century. Surgical Training from the 1890s-1930s In the late nineteenth and early twentieth centuries, no universal system existed for creating American surgeons. Elective operations remained rare in the 1800s,4 and few men identified as surgeons.5 As the medical profession began to regularize after the Civil War, apprenticeship provided the vast majority of surgical education.6 Later in the century, some men sought appointments to hospitals for more formalized training, but these house-officerships remained highly variable in quality and exceedingly rare.7 Other physicians – over 13,000 – attended six-to-twelve week post-graduate courses that taught more advanced surgery.8 While in fewer numbers than their medical colleagues, an elite, self-funded group travelled to Europe to pursue advanced schooling.9 Many of these internationally educated surgeons returned home to serve as clinical and professional leaders in American surgery. Finally, a strong element of autodidacticism pervaded the era. “Those of us interested in gynecological surgery literally learned it by operating on our patients,” recalled Franklin Martin, founder of the American College of Surgeons.10 In an effort to elevate the quality of surgical training in the United States, William Halsted created a residency program. Following medical school and a year as a house-officer in New York, Halsted travelled to Germany and Austria to study. He brought back to the United States not only a commitment to scientific, aseptic surgery, but also an appreciation for the Germanic system of training.11 When Halsted became Chief of Surgery at Johns Hopkins, he worked with William Osler, Chief of Medicine, to adopt that system in the United States, establishing what became the prototypical residency in the country.12 Endeavoring “to adopt as closely as feasible the German plan,” Halsted created a pyramidal program that brought residents through a multi-year training regimen focusing on both patient care and research.13 There was no set length of time residents spent in the individualized program, and only a single man rose to the rank of chief resident. Halsted deliberately aimed to “produce not only surgeons but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.”14 He succeeded, as his trainees chaired departments around the country.15 The Hopkins model spread across the United States, with its graduates the most ardent missionaries. Of Halsted’s seventeen chief residents, eleven went on to establish similar residency programs.16 Other surgeons, like longtime friends and chairmen Allen O. Whipple (Columbia) and Evarts Graham (Washington University), never worked directly under Halsted but nonetheless consciously created consonant programs.17 Graham in particular standardized Halsted’s amorphous system into a set-length, graded curriculum where residents earned increased responsibility as they advanced. This graded permutation, widely adopted by the 1920s, was especially important in surgery to ensure that graduates received appropriate operative exposure.18 By the 1920s, surgery residency, either at Hopkins or an analogous program, became required for appointments at major hospitals and research institutions. In the early 1900s, rank-and-file American doctors were just beginning to pursue formal post-graduate training. Medical schools, themselves undergoing reforms catalyzed by the 1910 Flexner Report,19 made no effort to teach students how to operate, viewing such lessons as beyond their purview.20 Internship, a formal year of education in the hospital after medical school, did provide some instruction. In 1900, fewer than fifty percent of American physicians pursued any post-graduate training, but internships became more common such that by 1923 U.S. hospitals offered positions to every graduating doctor.21 Some hospitals created short, one-year residencies following internship that focused on a specific specialty, including surgery.22 As these became more common in the 1920s, the American Medical Association established guidelines to help regulate them. But twelve months severely limited the scope and quality of the training.23 Between rare Halstedian residencies and increasingly-ubiquitous internships, a “topography” of surgeons emerged in America.24 At universities and in a few major cities, surgical leaders like Halsted, the Mayo brothers, and their trainees pioneered new operations, led departments, and formed the vanguard of the field. Performing the bulk of the research, these elite surgeons provided only a tiny sliver of patient care. Most of the U.S. population relied on general practitioners who may have completed a one-year internship and/or pursued post-graduate training courses. While in retrospect the expansion of Halstedian residencies appears the logical solution to preparing surgeons, through the 1930s the proper course remained unclear and undecided by the profession.25 Given the range of operative interventions for most general practitioners – draining abscesses, setting fractures, and maybe appendectomies – the apprenticeship and postgraduate models provided satisfactory instruction and were readily available.26 But as the practice of surgery evolved, so did the needs of the profession. The 1930s – The Decade of Theoretical Change By the 1930s, the practice of surgery had substantially changed, significantly increasing both the breadth and variety of operations. Leaders of the profession, concerned about the quality of surgery being practiced, initiated efforts to expand, evaluate, and certify training opportunities. Demonstrating the power and role of professional organizations, the campaign fundamentally altered surgical residencies, which increasingly focused on educating not elites, but the average, practicing surgeon. Surgery changed dramatically in the early twentieth century, prompting an intense focus on the training paradigm. The nineteenth century advances of anesthesia and asepsis enabled safe practice, and the acceptance of ontological disease models provided the rationale to operate.27 Hospitals grew in number and acceptability, creating a dedicated space to practice.28 Professionalized nurses facilitated pre-, post-, and intraoperative care.29 Surgery grew rapidly. Between 1900 and 1925, the number of surgeries at the University of Pennsylvania Hospital increased from 870 a year to 4180 a year. At New York Hospital, only eighteen percent of in-patients received an operation in 1900, but sixty-nine percent did in 1920.30 Not only the number of surgeries but also the complexity increased as intra-abdominal operations, intricate cancer resections, and other complicated interventions came to characterize a field previously dominated by trauma and minor procedures.31 General practitioners were as excited about the surgical revolution as their academic colleagues. Operations provided them a chance to cure many diseases at a time when the medical armamentarium offered little.32 Of the 2.5 million surgeries in the United States in 1937, general practitioners – not elite surgeons – still performed the vast majority.33 Elite academic surgeons worried about the ability of general practitioners to care for this new surgical patient. In 1933 and 1935, the leaders of the American Surgical Association, the oldest and most prestigious organization in the field, dedicated their presidential addresses to the problem “where fingers replace brains and handicraft outruns science.”34 Tellingly, their concerns centered on doctors’ ability to navigate the physiology and pathology of surgical conditions, not just on technical prowess. This disquietude reflected changes in the theory and practice of surgery as an increasingly physiological focus prompted a shift away from speedy, dramatic performances to slow, meticulous, yet radical operations that exceeded the abilities of internship-trained generalists.35 Leaders of the American Surgical Association simultaneously recognized the scarce opportunities for additional training.36 In 1935, fewer than thirty-five Halsted-style residencies existed in the country, with each graduating a single chief resident: “not a drop in the bucket towards supplying the need for surgeons through the country,” according to Eugene Pool, professor of surgery at Columbia.37 Pool and others in the American Surgical Association brought the problem of surgical training to the fore; over the next two decades, they and their colleagues worked to create a solution. Importantly, the stimulus to improve surgical education came from within the profession; neither government regulation nor popular dissatisfaction nor economic considerations drove this campaign.38 While not motivated exclusively by altruism, leaders firmly believed educational reform would improve patient care. Notably, they hoped additional training would decrease the amount of surgery in America by improving pre-operative diagnosis, teaching judgment, and reducing unnecessary operations.39 By demanding and generating enhanced educational opportunities, surgery was fulfilling its professional responsibilities of self-improvement, quality control, and auto-regulation, and in so doing building faith with the patient population they served.40 Concordantly, Americans' confidence in the superiority of specialists rewarded this effort.41 The American College of Surgeons (ACS) took the lead in reforming surgical education. Franklin Martin originally founded the College to elevate the quality of surgery in the country by demarcating a class of practitioners who had proven themselves competent surgeons.42 Explicitly trying to include community and elite practitioners, the ACS focused on competency, not pedigree, and did not require any specific training regimen or even the exclusive practice of surgery, reflecting the realities facing most practitioners in the early twentieth century. By the 1930s, those realities had changed. Graduate medical education had become more common; surgery had advanced considerably. The American Board of Surgery represented one response to these new conditions. In the 1930s, a group of young academic surgeons led by Evarts Graham grew dissatisfied with the College.43 These so-called Young Turks believed the standards of the College did not adequately define a surgeon, especially given recent advances in intra-abdominal and intra-thoracic operations as well as developments in perioperative management such as sulfa drugs and blood transfusions.44 Moreover, other specialties were already establishing boards, including surgical subspecialties.45 Fearing for both the quality of surgery and its splintering into dozens of fiefdoms, the Young Turks founded the American Board of Surgery in 1937.46 The Board of Surgery demanded three, graded years of residency following internship.47 No arbitrary prescription, this requirement came from the Advisory Board of Medical Specialties and applied to all boards. The format derived from the Mayo Clinic model that Louis Wilson, president of the Advisory Board, developed in Rochester, a connection that highlights the oft-ignored but seminal importance of the Mayo Clinic in the history of graduate medical education in this country.48 Changing standards of medicine and the creation of the Board spurred the American College of Surgeons to adopt and regulate residency training. The College remained committed to improving American surgery and patient outcomes; they viewed reforming surgical education as central to this core mission.49 The ACS also feared irrelevancy following the formation of the Board, concerned that young surgeons seeking board certification would ignore the College and thus diminish its role. As such, the College demanded residency for all Fellows after 1938.50 Now that they required residency, the ACS shouldered the responsibility of inspecting and approving programs.51 The ACS Committee on Graduate Training in Surgery first met in November 193752 and outlined their expectations for residency programs.53 “There are really two problems that confronted us,” noted an internal report. “One was the ideal training for the surgeon and the other was the graduate training which is necessary for every man to have before he can become a member of the American College of Surgeons.”54 Despite having two problems, they sought a single system of training. This decision created tension between elites, who thought standards too low, and community practitioners who felt they were too stringent, but the committee repeatedly rebuffed suggestions to adopt a two-tier system in their effort to preserve professional unity. The College recognized that the AMA already had established criteria and an inspection system in the 1920s and inquired about collaborating.55 The AMA politely declined a joint venture,56 prompting the College to establish their own, separate system.57 Largely adopting the AMA standards, the Committee insisted on 24 months following internship, compromising between AMA and Board requirements.58 However, the Committee deliberately avoided imposing strict, specific criteria.59 Recognizing that conditions and opportunities differed considerably around the country, they insisted “the emphasis should be on standards, not on standardization.”60 There was an ideal that residencies must embrace, but no procrustean checklist for approval. The American College of Surgeons surveyed and inspected each program.61 The ACS already inspected almost every hospital in the United States as part of an initiative dating to 1918 to ensure patients received surgery in safe, modern facilities.62 The residency approval evaluation modeled itself after this system and relied on its infrastructure to expand. A typical visit lasted two to three days and included tours of the physical plant, discussions with faculty and residents, and efforts to evaluate research opportunities and didactic learning. The ACS paid for the entire process.63 Determined to advance surgical education and not just judge that which already existed, the College worked with sub-standard programs, often provisionally approving them as an incentive while helping improve their curricula. The inaugural inspection in 1937 evaluated 270 hospitals, approved eighty-nine (thirty-three percent) fully, forty-six (seventeen percent) provisionally, and rejected 135 (fifty percent).64 The results limned the state of surgical education at that time. Variability characterized the findings: “one of the most striking impressions as a result of this study is the complete lack of a basic standard or uniformity in the methods of graduate training.”65 Both structure and content differed among hospitals, with residencies ranging from one to five years in length.66 Programs varied tremendously in content with some eliding entire disciplines like urology, orthopedics, or thoracic surgery, raising the question of what “general surgery” included.67 The surveyors repeatedly lambasted the lack of basic science, post-mortem examinations, and formal didactic teaching conferences, particularly in community hospitals.68 The College published these results in the 1939 Bulletin of the American College of Surgeons that they freely distributed around the country.69 The publication and distribution cost the College $9,000 in 1938 ($155,000 in 2017 USD) – a monumental expenditure for a non-profit organization in the Great Depression. Such spending highlights the importance the College placed on disseminating both their requirements and a list of the programs that satisfied them.70 Letters from deans of academic institutions like Yale, smaller schools like the College of Medical Evangelists in Loma Linda, California, and the Women’s Medical College of Pennsylvania praised the report and pledged to raise their programs to its standards.71 J. Curran, dean of the Long Island College of Medicine, “believe[d] it to be one of the finest things of the kind I have seen,” a sentiment Dean C. Poynter of the University of Nebraska echoed while adding somewhat wistfully, “I wish it were as easy to get this program started as it is to talk about it. Certainly the movement is in the right direction and out of it should come a generation of very much better trained men than the last generation furnished.”72 The next generation of students and teachers appeared eager for this opportunity. Interns commenced writing the College, querying which hospitals had or would receive approval and basing their residency decisions thereupon. Following the release of the report, over 100 hospitals contacted the College, asking to be inspected in 1940.73 Programs wanted ACS imprimatur to attract more qualified residents, and residents sought out ACS-approved programs to ensure entrance into the College and boards, with all the advantages membership entailed.74 Less cynically, there remained a real commitment to improving the quality of training and a desire among trainees to receive the best education possible. While this era lacks confirmatory data, the benefits of having someone with three years of structured training operate instead of a general practitioner seemed self-evident to contemporaries. As organizations like the American Board of Surgery came to depend on College inspection and approval,75 and as more programs sought certification, the rather generic provisions applied in 1938 gave way to increasingly detailed requirements in 1941, when the College published eleven full pages of specifications.76 This shift signified a notable departure in surgical education, transitioning from highly variable experiences around the country to a more rigid national standard that, ideally, ensured every graduate from an approved program would possess a common set of intellectual and technical abilities, irrespective of whether they came from an academic or community hospital.77 Requirements emphasized excellent faculty to teach not just surgery but also pathology, radiology, and anatomy, buttressed by new attention to physiology, then viewed as the vanguard of surgical research.78 The committee focused on both the quantity and variety of cases residents performed. They also continued to mandate research, which particularly challenged community programs. By 1941, the College had approved 185 hospitals, an impressive achievement, but still not approaching the needs of American patients.79 With the onset of World War II, reform efforts paused. These 1941 standards expose how much surgical residency had changed since its inception at Johns Hopkins. Fundamentally, its underlying purpose had shifted from producing “surgeons of the highest type,” who populated the ranks of research institutions, to training both academicians and especially practicing community surgeons. This move paralleled developments in graduate medical education for other specialties.80 Form followed function. For example, surgery residencies began evolving away from Halsted’s pyramidal construction, which intentionally produced a limited number of surgical professors. While castoffs in the 1910s had adequate training to practice contemporary surgery and sufficient credentials to land work as surgeons, by the 1930s they lacked both. In 1940, Edward Churchill, chair at the prestigious Massachusetts General Hospital, publicly broke with Halsted’s pyramid, commenting that “half a surgical training is about as useful as half a billiard ball.”81 He established a rectangular program that expected everyone accepted as a resident to complete all four years of training, arguing this arrangement would produce desperately needed surgeons in a more collegial environment.82 This was not the first rectangular program,83 and indeed the College had been discussing promoting that arrangement for several years, but its attachment to Harvard and its association with prominent surgeons like Churchill provided the credibility necessary for its wide adoption across America.84 Churchill and others similarly shifted the focus of even academically affiliated programs to producing more community practitioners.85 By the start of World War II, the ideal surgery residency differed markedly from that which Halsted had proposed in number of years, breadth of clinical experience, command of basic science, and engagement in original research. A few dozen academic institutions cleaved closely to the original concept of producing surgical professors, but most programs emphasized creating safe, competent clinical surgeons for the community, compromising ideal standards in favor of achievable ones. Despite these efforts, the practice of surgery remained dominated by generalists. Private practice did not require fellowship or residency, so why should a doctor spend the time and expense of an additional two to three years in school? Leaders like Graham and Churchill – not incidentally pioneers in the new field of chest surgery – argued that modern surgery had exceeded the ability of generalists to practice safely; others proffered professional benefits. The experience of World War II demonstrated the importance of both elements. World War II and the Surgical Residency World War II and the years immediately following it profoundly affected surgical training. Federal policies during the war and after promoted board certification. The GI Bill and especially government hospital systems rapidly expanded residency opportunities. This period demonstrates the early and critical role of the Federal government in the establishment of graduate medical education. While World War II ultimately led to the rapid expansion of surgical residencies, the war years themselves undermined efforts from the 1930s. The military effectively conscripted surgeons, eviscerating the faculty at most programs.86 A mandatory abbreviated regimen for graduate medical education called the 9-9-9 system vitiated residencies, diminishing multi-year programs into a few short months.87 In the early years of the war, with its outcome uncertain88 and policies yet undefined, this plan seemed reasonable and met few objections,89 but as the war dragged on choruses of protest arose. The American College of Surgeons came to believe the 9-9-9 scheme “seriously retarded education in the medical and surgical specialties.”90 Evarts Graham, who chaired the National Research Council’s Committee on Surgery during the war, railed against the plan in both professional journals and lay publications like The Saturday Evening Post, pointing out that neither West Point nor the Naval Academy had shortened their curricula, and neither should medicine.91 The plan also shrunk the absolute number of surgical residents by nearly fifty percent, the first decline since Halsted had established his program nearly a half-century earlier (see figure 1). Fig. 1. View largeDownload slide Total number of residents in ACS approved programs during war years88 Fig. 1. View largeDownload slide Total number of residents in ACS approved programs during war years88 While military policies crippled the residency system during the war, they ultimately catalyzed its expansion and acceptance. Recognizing the benefits of fully-trained surgeons, the Armed Forces used board status almost exclusively to identify them.92 The Board actively campaigned for this distinction, appreciating the implications of official, federal imprimatur on the appeal and relevance of board certification.93 Board-certified surgeons enjoyed superior rank, resulting in greater prestige and higher pay than those not certified. Moreover, the military placed them in jobs and locales where they could actually practice surgery rather than being relegated to more general duties like many self-identified surgeons.94 After the war, the federal government continued to demonstrate preference for board-certified physicians by awarding them salaries twenty-five percent higher than their non-boarded colleagues at Veterans Administration hospitals.95 The practical and professional perquisites the military and federal government granted board-certified surgeons combined with a motivation to finish training curtailed by the war led military medical veterans to pursue both the educational and the credentialing benefits of board certification.96 They recognized this path required completion of an approved residency. The AMA demonstrated this desire for graduate medical education through a survey: over eighty percent of uniformed doctors intended to pursue some form of additional schooling after the war; sixty-three percent hoped to obtain board certification.97 Extrapolating from these data, the College anticipated 15,000 postwar students of surgery.98 Before the war, the College had approved roughly 600 positions per year. Accommodating these numbers required substantial effort and financial support that the federal government helped provide. The government greatly facilitated the process by declaring residency eligible for funds under the GI Bill of Benefits,99 a freighted decision that inherently classified the experience as education, not service.100 Before World War II, hospitals reimbursed interns and residents with room and board and, sometimes, a small stipend. Residents covered by the GI Bill received a salary and funding for room and board outside the hospital – a radical change from the monastic, pre-war conditions that challenged poor housestaff and effectively prohibited families. Hospitals also benefitted now that the federal government paid for veterans’ residencies.101 The federal government helped accommodate the deluge of applicants by creating residency positions in both Veterans Administration (VA) and military hospitals. In the initial ACS survey of twenty VA hospitals in 1944, only seven had general surgery departments certified to educate residents, and even then they received only provisional approval.102 By August 1947, the College had accredited fifty-one VA hospitals for 750 surgical residency slots per year – more than all approved civilian positions created between Halsted’s program and the end of the war, illustrating the enormous effect of the government on the postwar expansion of residency.103 Generating programs in VA hospitals corresponded with the concomitant rise of the institutions generally and particularly with the efforts to link them to academic medical centers.104 VA hospitals offered a wealth of clinical material. More importantly, they provided a patient population that residents could treat independently, a category health insurance was slowly eliminating, to the great consternation of the ACS and other leaders.105 However, the lack of female and pediatric patients along with inadequate facilities for basic science and research necessitated partnering of VA hospitals with academic medical centers in order to meet standards.106 These same difficulties bedeviled military hospitals as they sought ACS approval.107 The decisions of the VA, Public Health Service, and military to pursue ACS certification for their residencies underscores the contemporary importance of those standards, as government hospitals had no explicit or legal need to seek approval, being able to set their own licensing policies. The military actually began using the promise of approved residencies to recruit physicians into uniform, highlighting the demand for that training in the 1940s.108 The postwar expansion of residencies resulted not just from the “push” of doctors seeking additional training, but also from a “pull” by hospitals requiring their manpower and expertise. The exponential increase in hospitals partly fostered this need: in 1946, the VA planned to add 60,000 beds to accommodate World War II veterans.109 The Hill-Burton Act of 1946 concurrently drove the construction of thousands of civilian hospitals around the country.110 Both the number and the complexity of patients rose. The range and invasiveness of operations increased, as indications for thoracic and abdominal explorations expanded, and new fields like heart and transplant surgery emerged.111 These new procedures far outstripped the abilities of general practitioners, who often met disastrous results when attempting them.112 Deadly outcomes led to hospitals requiring the completion of approved residencies before obtaining operating privileges, further increasing the demand for residency.113 Perioperative care came to include antibiotics, chemotherapy, and hemodialysis, to name but a few new interventions, all necessitating physician management. Whereas in the 1930s, major hospitals could still function without housestaff, in the postwar years these facilities relied on residents to care for patients. Anticipating both the deluge of returning veterans eager for training and their own rising need for residents, hundreds of civilian hospitals approached the College to request approval for their programs.114 The American College of Surgeons recognized these forces. Many of their leaders had contributed to surgical developments, memorialized in their self-published Fifty Years of Surgical Progress, and realized the post-World War II surgeon needed quality graduate medical education to operate safely and competently.115 The College also wanted to accommodate the flood of returning veterans, partly because they believed that creating training opportunities for them was “the most useful and patriotic activity in which the College could engage.”116 They simultaneously recognized the disparity between the number of residencies sought and the availability of certified positions, and they feared physicians would settle for unapproved programs, dealing “a serious setback to the standards of surgical practice.”117 As such, after issuing a new set of policies in 1945 that mandated three years of residency to match Board prerequisites,118 the College increased postwar inspections as rapidly as logistics permitted. From 1941 to 1945, the number of approved residencies barely budged (514 to 578), but from 1945 to 1950, they nearly doubled (578 to 1129) (see figure 2).119 Fig. 2. View largeDownload slide Increase in ACS approved surgical residency programs, 1940-1960121 Fig. 2. View largeDownload slide Increase in ACS approved surgical residency programs, 1940-1960121 The ACS performed another round of inspections between 1945 and 1947 that provides unique insight into their approval process through examining rejections.120 Over those two years, the College denied approval to 216 general surgery programs. (Notably, rejected residencies did not necessarily close; large numbers of poor training 121opportunities remained available but did not qualify graduates for ACS fellowship or board certification). For all the emphasis on basic science in the printed requirements, the report cited deficiencies in that arena far fewer times (9) than it noted a lack of clinical material (58).122 The high number of withdrawals (78) perhaps explains this discrepancy. However, the disconnect demonstrates the practical prioritization of clinical experience over basic science, again exposing the compromises necessary in rapidly expanding training opportunities. As programs spread from large cities to smaller towns like Teaneck, New Jersey, and Janesville, Wisconsin, hospitals struggled to demonstrate sufficient patient volume or diversity to satisfy the College. They also strained to hire competent faculty, evidenced by the 39 rejections for insufficient staff, reflecting the dearth of individuals in the country with enough training and experience to educate the next generation. The College was not the only organization approving residencies: The AMA continued performing this function separately. However, they had less rigorous standards, reflecting their particular mission. Whereas the College concentrated on raising the quality of surgery, the AMA felt responsible for American medicine more broadly, which in 1945 still consisted mostly of general practitioners. The AMA could not afford to alienate the generalists who comprised the vast majority of their constituency by insisting on stringent requirements for every doctor removing an appendix. Moreover, they recognized that in 1945 an ACS fellow, much less a board-certified surgeon, remained unavailable to most Americans and endeavored to increase the number of clinicians with at least a modicum of operative training. However, in the rush to create spaces for returning veterans, the AMA accredited many programs provisionally without physically inspecting them.123 By 1948, the Association admitted to a backlog of over 550 residencies requiring inspection in addition to another 350 necessitating re-inspection;124 these represented almost half of all AMA-sanctioned programs.125 Many of the hastily certified programs after the war failed their students. Provisionally approved AMA residencies were considered especially dreadful, with the majority still lasting only a single year (after internship).126 The rapid pace of inspection also degraded the ACS process, especially as efforts centered on traditionally weaker community programs.127 Allan Whipple, a Columbia surgeon crucial to the creation of graduate medical education in the 1930s, cautioned that “unless we are careful, this is going to snowball and the distinction of residency training is going to disappear.”128 Whipple clearly envisioned residency as not just a training opportunity but also as a mark of qualification in and of itself, and its postwar adulteration pained him. Like Whipple, the American Board of Surgery grew quite concerned over the quality of many of the residencies established after the war and the implication this had on patient care.129 In 1944, the Board still accepted the College’s list of accredited programs without reservation.130 By the end of 1945, however, they found the inspection process “in a state of confusion which serves to embarrass and interfere with the work…of the Board.”131 They criticized the reliance on surveys over inspections and especially the low quality of instruction and autonomy at many hospitals. The Board’s president, Warfield Firor, similarly expressed the organization’s dissatisfaction with the AMA’s approval process.132 “It was clear to the American Board” of Surgery, remarked Firor, that “too many candidates were coming up to take the examination and failing, obviously not having had adequate training.”133 The Board briefly attempted to run its own inspection service, but cost, impracticality, and redundancy of others’ efforts led to abandonment after a single year.134 Bureaucratic Bickering, Professional Power Plays, and the Creation of a Joint Residency Review Committee By the late 1940s, the American Medical Association, American College of Surgeons, and American Board of Surgery all recognized the pressing need for a joint committee to inspect residencies, evaluate their qualifications, and publish a single list of approved programs. Economically, running three separate systems was not sustainable, particularly with the rapid increase in the number of hospitals. Through 1944, the College spent $1,750,000 ($24.6 million 2017 USD) to support the enterprise and predicted requiring an extra $100,000 ($1.3 million 2017 USD) per year for five years after World War II just to accommodate the surge of applications.135 Hospitals, while anxious for certification to recruit more qualified residents, grew confused over the multiplicity of standards and weary over the seemingly constant inspections by different organizations. Residents who graduated from a program approved by one body but not another found themselves in an awkward, liminal space.136 Yet despite the mutually accepted need for and benefits of a joint committee, the three surgical organizations required nearly twenty years to effect one. This section analyzes the discontinuous efforts to create a single inspection service and how the conflicts among these three societies reveal a deeper struggle for control over the American surgical profession. Serious negotiations for a joint inspection service began after World War II. Despite appeals from the Board, the College and the AMA failed to reach any agreement in the 1930s, when the task remained manageable for individual organizations.137 The postwar expansion of residencies challenged this feasibility, prompting intense negotiations between 1946 and 1950. Despite the universally recognized need for a joint committee, each organization wanted to maintain autonomy and control, complicating the arrangement of even a preliminary gathering, which finally occurred on 21 February 1948.138 “What we would like to do is to have a coordinated effort that would satisfy everyone,” declared Chicago surgeon Arthur Allen, elected chair of the joint committee, who went on to warn ominously: “whether we can bring that about remains to be seen.”139 Further dialogue met considerable obstacles. The AMA accused the College of growing skittish about losing its role in the inspections, changing the language of the preliminary resolution, and scuttling the deal.140 The College believed the AMA not only continued to approve inadequate programs but also sought to exclude the College from the process, leaving a trail of poorly prepared surgeons in its wake.141 Decades-old tensions among the organizations exacerbated the squabbling, and the remainder of 1948 and 1949 saw no real progress. No single organization had the tools necessary to implement a residency review system independently. The AMA had the financial and material resources but lacked credibility in the surgical community. The College had built a powerful reputation among American surgeons and had developed most of the policies used to evaluate programs, but by 1950 the ACS was running out of money. Professionally, it saw itself being slowly eclipsed by the Board. The Board found itself in an awkward position with the promise of future authority but little current power. Post-World War II American medicine moved increasingly toward expecting board certification,142 but in the 1940s and 1950s, board status remained rare outside the elites. In Michigan, for example, board-certified surgeons performed fewer than twenty percent of appendectomies and thirty percent of hernia repairs in 1955.143 “It’s fine to talk about our Boards,” lamented Frederick Coller, former president of the ACS and future first chair of the joint residency review committee, “but they are not the ones doing the majority of our operations.”144 The Board had little ability to cajole surgeons to follow their lead. Moreover, the Board lacked both the infrastructure and the finances to assume control over the residency approval process. Membership paled compared to the AMA and ACS. In 1947, for example, 2904 surgeons were board-certified.145 In comparison, the College boasted 14,750 fellows and the AMA 132,224 members.146 Budgets reflected membership.147 Since no individual society could manage alone, and as all three wanted to maintain control over American surgery, circumstances forced them to work together. On 1 July 1950, after years of contentious negotiations, the AMA, ACS, and ABS agreed to create a tripartite residency review board, dubbed the Conference Committee on Graduate Training in Surgery, and publish a single list of approved programs based on common criteria largely derived from the College’s 1945 requirements.148 Significantly, the Conference Committee mandated three progressive years of residency (following an approved internship), meeting the minimum standards of the Board and College and substantially increasing the one-year the AMA had demanded.149 Convinced a true Conference Committee had finally emerged (and running out of money to function independently), the College ceased its independent inspections later that summer.150 Within months, the agreement fell apart. Five acrimonious years of increasingly shrill debates followed. All parties theoretically accepted the arrangement; arguments erupted over the execution. The Board and College initially grew frustrated with the comparatively poor-quality programs the AMA kept on the list and their powerlessness to remove them.151 Later quarrels focused on who received credit, particularly between the ACS and AMA who were both struggling to remain relevant as the boards rose in importance. A lengthy dispute broke out over stationary and what name(s) would appear on the letterhead.152 Other issues bubbled to the surface over which organization would seat the permanent secretary on the Committee, who would sign the letters of approval, and the like, preventing the Committee from functioning. Superficially, arguing over stationary appears risible given broad agreement on substantive issues. However, this picayune bickering belied a deeper, political disagreement over who controlled American surgery. Vituperative language hinted at the stakes. Decrying the AMA’s backtracking on several negotiated points, Paul Hawley, executive director of the College, confided to Alfred Blalock, his sympathetic colleague and the chair at Johns Hopkins, “I feel about this [situation] much as the country is beginning to feel about Russia, that the time has come to stop appeasement and to take a very firm stand.”153 Comparing the AMA to communist Russia in October of 1950 with McCarthyism and the Korean War raging demonstrates the extent of his fury and the widening gulf between the two organizations. The sense of betrayal among College leaders rippled through meeting minutes.154 Certainly, the College feared a lower standard driven by an AMA that was trying to appease a core membership of general practitioners, but more acutely, they dreaded being eliminated from the conversation. Frustrated by what he saw as perfidy of the AMA and the complicity of the Board, Hawley unsuccessfully campaigned to have his allies elected to the ABS to out maneuver the AMA, a desperate tactic by a leader believing his organization besieged.155 The AMA in turn believed that even if it had modified the structure of the Conference Committee, the overall mission, purpose, and execution remained unchanged, and the College was merely complaining over symbolic gestures.156 The AMA argued that the Conference Committee retained its core features and that if all the College really wanted was an effective approval process, then it should not matter who received the credit. By 1952, the AMA had grown weary of constant conflict, wondering if “it [was] necessary or wise to continue to be so polite and self-effacing” to an organization they saw in decline, and began pursuing independent alternatives by trying to form bipartite committees with the Board, excluding the College entirely.157 They briefly flirted with International College of Surgeons as a substitute for the ACS, but they were forced to retreat from this proposal when both the Board and the American College of Surgeons vehemently opposed it.158 Attempting to exclude the College epitomized the internecine struggle to shape American surgery in the mid-twentieth century. As board certification remained a comparatively rare qualification, the demarcation of who was an acceptable, adequate surgeon hinged on the completion of an approved residency program. Thus controlling the residency approval process provided an opportunity to shape the profession of surgery in one’s image, with the Board representing elite, academic surgery, the College practicing, full-time surgeons, and the AMA general practitioners who operated. Each society fiercely fought for its constituency – and for itself. In 1955, the three organizations came together and agreed on a Conference Committee, eventually dubbed the Residency Review Committee, which has endured. Core elements remained from 1950, with the AMA continuing to inspect programs, and a group of representatives from the AMA, ACS, and ABS meeting to approve or reject them based on criteria that matched requirements needed for board certification. The committee published a single list and mailed a single letter on mutually agreeable stationary. Archival records do not explain the sudden détente: no specific event or personnel changes occurred. Speculatively, as the Board increased in power and prestige, the AMA and the College recognized the need to cooperate to maintain relevancy. Weariness from constant fighting for years likely contributed. That internal medicine recently agreed on a similar format may also have motivated them. The solution reached for surgery in the form of the Residency Review Committee quickly spread to other specialties, serving as a model for residency reform nationally. Conclusion By 1955, the profession had established an effective, regimented, and regularized system for producing new surgeons. The route from medical school graduate to surgeon – with its expectations, challenges, and demands – was clear to both trainees and their teachers. Crucially, the path to become a surgeon had become standardized. Certainly, residencies differed among institutions, with distinctions between academic and community programs remaining starkest. But these differences paled compared to the homogeneity surgical training had achieved in a half-century. Whereas in 1900, few formal educational opportunities for surgery existed in this country, by 1955 the profession had created and implemented a single portal of entry defined by its training. This process unveils several themes. The transition from rare professorial programs to nearly universal residency training reinforces the idea that specialization starts with research demands before extending gradually into clinical practice.159 It also laid bare the compromises in length, original investigation, and overall quality that were necessary to extend this training to the majority of surgeons via community programs. The diffusion of residencies exposes both the power and limitations of professional organizations. Seizing the initiative to reform graduate medical education, these societies expended enormous resources to establish and enforce national standards, which varied per the constituency of each organization. With firm criteria, they tried to improve the quality of American surgery by demanding their members complete a regulated residency. While participation increased in the 1930s, significant expansion ultimately required the power of the federal government in the post-World War II years, whereupon residency training came to define the American surgeon. This standardization created a national cadre of well-trained clinicians with two concrete outcomes. First, although this era lacks confirmatory statistical data, the claims of the participants in these reforms seem valid: namely, that relying on residency training improved the care patients received, from the accuracy of diagnosis, to the technical quality of an operation, to the post-operative care delivered. Second, this broad education catalyzed the dissemination of new, increasingly intricate interventions. Fields like vascular and orthopedic surgery progressively incorporated complicated procedures like anastomosis and osteosynthesis, while entirely new specialties of cardiac and transplant surgery emerged. These changes relied on a population of surgeons who had sufficient training to manage patients both intra- and peri-operatively.160 The rise of residencies created that community. Thus, exploring the history of residency not only details the formalization of surgical training but also, through examining both the battles for professional control and the development of more complex operations, illuminates the history of surgery in America. Acknowledgements The author is grateful to all those who read, commented on, and vastly improved earlier drafts of this paper, especially Dale C. Smith, Kenneth M. Ludmerer, Mary A. Brazelton, Ashley Morgan, John Harley Warner and the two anonymous reviewers at JHMAS. Presentations at Yale University’s Holmes Workshop and Beaumont Lecture Series as well as the American Association for the History of Medicine provided valuable feedback. Archivists crucially availed me of source material, particularly Susan Rishworth and Delores Barber at the American College of Surgeons, Amber Dushman at the American Medical Association, Tom Biester at the American Board of Surgery, Jessica Murphy at Countway Library, and Stephen Logsdon at Becker Medical Library. Funding from the Michael E. DeBakey Fellowship in the history of medicine, Bernard Becker Medical Library travel scholarship, the Josiah Charles Trent Memorial Foundation Grant, and Duke Department of Surgery supported this research. None of this would be possible without my supportive family, who corrected many iterations of this paper over the years. Footnotes 1 Kenneth M. Ludmerer, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (New York: Oxford University Press, 2015). Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971). See also Heather Varughese John, “Practicing Physicians: The Intern and Resident Experience in the Shaping of American Medical Education, 1945-2003,” (PhD diss., Yale University, 2013). 2 Charles L. Bosk, Forgive and Remember: Managing Medical Failure, 2nd ed. (Chicago: University of Chicago Press, 2003 (1979)). Pearl Katz, The Scalpel’s Edge: The Culture of Surgeons (Boston: Allyn and Bacon, 1999). Rachel Prentice, Bodies in Formation: An Ethnography of Anatomy and Surgery Education (Durham: Duke University Press, 2013). 3 See, for example, Delia E. Garvus, Men of Strong Opinion: Identity, Self-Representation, and the Performance of Neurosurgery, 1919-1950) PhD diss, University of Toronto, 2011). 4 In 1880, only 267 operations were performed in Jefferson Hospital; in 1890, there were only 291 surgeries at Charity Hospital in New Orleans. Gert H. Brieger, “A Portrait in Surgery: Surgery in America, 1875-1889,” Surgical Clinics of North America, 67, no. 6 (1987): 1181-1216, p. 1207 for numbers. 5 Samuel Gross, “Surgery,” American Journal of Medical Science LXXI (1876): 431-84, see quote p. 432. 6 William G. Rothstein, American Physicians in the Nineteenth Century: from Sects to Science (Baltimore: Johns Hopkins University Press, 1992). For the role of the Civil War, see Shauna Devine, Learning from the Wounded: The Civil War and the Rise of American Medical Science (Chapel Hill: The University of North Carolina Press, 2014). 7 Ludmerer, Let Me Heal, chapter one. For surgical examples, see J. M. T. Finney, A Surgeon’s Life: The Autobiography of J.M.T. Finney (New York: G.P. Putnam’s Sons, 1940), chapter five. J. Collins Warren, To Work in the Vineyard of Surgery (Cambridge: Harvard University Press, 1958), chapter seven. The first American hospital house officer dedicated to surgery was John Collins Warren, appointed in 1830 for one year at Massachusetts General Hospital. By 1894, twelve surgical house officers served MGH, although the experience did not produce fully trained surgeons, which required additional apprenticeship. Hermes C. Grillo, “To Impart this Art: The Development of Graduate Surgical Education in the United States,” Surgery 125 (1999): 4-5. With the exception of gynecological surgery, men dominated the surgical profession through the years described in the paper. For further discussion, see Regina Morantz-Sanchez, Conduct Unbecoming a Woman: Medicine on Trial in Turn-of-the-Century Brooklyn (New York: Oxford University Press, 1999). 8 J.J. Walsh, “Post-Graduate Medical School and Hospital,” History of Medicine in New York 2 (1919): 573-93. Steven J. Peitzman, “‘Thoroughly Practical’: America’s Polyclinic Medical Schools,” Bulletin of the History of Medicine 54 (1980): 166-87. Ira Rutkow, “The Education, Training, and Specialization of Surgeons: Turn-of-the-Century America and Its Postgraduate Medical Schools,” Annals of Surgery 258 (2013): 1130-6. 9 John Harley Warner, Against the Spirit of System: The French Impulse in Nineteenth Century American Medicine (Princeton: Princeton University Press, 1998). Thomas N. Bonner, American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870-1914 (Lincoln: University of Nebraska Press, 1963). 10 Franklin H. Martin, Fifty Years of Medicine and Surgery: An Autobiographical Sketch (Chicago: The Surgical Publishing Company of Chicago, 1934), quote p. 28; see chapter 7 for his surgical education. 11 W. G. MacCallum, William Stewart Halsted: Surgeon (Baltimore: The Johns Hopkins University Press, 1930). Samuel J. Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957). The fullest picture of the man may be found in George Heuer “Dr. Halstead,” Bulletin of the Johns Hopkins Hospital 90, no. 2, Suppl. (1952): 1-109. Gerald Imber, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (New York: Kaplan, 2010). More recently, Howard A. Markel wrote a history focusing on Halsted’s work with and addiction to cocaine: An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine (New York: Pantheon, 2011). 12 For a discussion of how Halsted built off Osler’s medicine residency, see Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle: Volume I: Early Years, 1867-1893 (Baltimore: The Johns Hopkins University Press, 1943), 161-2. Ludmerer shows how Osler and Halsted melded the American tradition of apprenticeship with the science-based, more didactic Teutonic experience to form a uniquely American training paradigm. See Ludmerer, Let Me Heal, chapter two. 13 William S. Halsted, “The Training of the Surgeon,” in The Surgical Papers of William Stewart Halsted ed. Walter C. Burket (Baltimore: The Johns Hopkins University Press, 1924) vol. II, 528-9. 14 Halsted, “The Training of the Surgeon,” 527. 15 B. Noland Carter, “The Fruition of Halsted’s Concept of Surgical Training,” Surgery 32 (1952): 518-27. 16 A. McGehee Harvey, “The Influence of William Stewart Halsted’s Concepts of Surgical Training,” The Johns Hopkins Medical Journal 148 (1981): 215-36. 17 Ludmerer, Let Me Heal, 56-7. 18 He also enabled residents to spend one to two years free from clinical duties to perform research, a model that quickly expanded to other academic programs and endures today. C. Barber Mueller, Evarts A. Graham: The Life, Lives, and Times of the Surgical Spirit of St. Louis (London: BC Decker, Inc., 2002), 204-9. 19 Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985). 20 Gert H. Brieger, “Surgery,” in The Education of American Physicians: Historical Essays, ed. Ronald L. Numbers (Berkeley: University of California Press, 1980): 175-204. 21 Graduate Medical Education: Report of the Commission on Graduate Medical Education (Chicago: University of Chicago Press, 1940) 31. American Medical Association, A History of the Council on Medical Education and Hospitals of the American Medical Association (Chicago: 1957) 21. Ludmerer, Let Me Heal, chapter four. Some medical schools required internship to obtain the MD degree. 22 Ludmerer, Let Me Heal, chapters three and four. 23 Graduate Medical Education, chapter three. AMA, A History of the Council on Medical Education and Hospitals of the American Medical Association. “Essentials of Approved Residencies and Fellowships,” JAMA 112 (1939): 1386-92. 24 Dale C. Smith, “Appendicitis, Appendectomy, and the Surgeon,” Bulletin of the History of Medicine 70, no. 3 (1996): 414-41, see pp. 416-7. 25 “Committee for Graduate Training for Surgery,” 1936, American College of Surgeons Archives, Chicago, Illinois (hereafter ACS Archives), Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 3, pp. 1-2. 26 For a list of common surgical procedures performed in the 1880s, see Arthur Dean Bevan, “The Study and Teaching and the Practice of Surgery,” Annals of Surgery 98 (1933): 481-94, list p. 482. 27 The literature on anesthesia and germ-free surgery is vast. For an American focus, see, to start: Martin Pernick, A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985) and Thomas P. Gariepy, “The Introduction and Acceptance of Listerian Antisepsis in the United States,” Journal of the History of Medicine and Allied Sciences 49 (1994): 167-206. Peter J. Kernahan, “Franklin Martin and the Standardization of American Surgery,” (PhD diss., University of Minnesota, 2010). 28 Charles E. Rosenberg, Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987); see chapter 6 for the relocation of surgery to hospitals. 29 See Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: Cambridge University Press, 1987) and Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: The Johns Hopkins University Press, 2010) chapter one. The author is grateful to Naomi Rogers for suggesting these sources. 30 Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: The Johns Hopkins University Press, 1995) 57 and 62 (cited in Kernahan, “Franklin Martin and the Standardization of American Surgery,” 44). 31 Between 1880 and 1890, the literature described over 100 new operations. Morris J. Fogelman and Elinor Reinmiller, “1880-1890: A Creative Decade in World Surgery,” American Journal of Surgery 115 (1968): 812-24, cited in Kernahan, “Franklin Martin and the Standardization of American Surgery,” 43. 32 In his classic 1892 textbook, for example, Osler repeatedly addresses the limitations of medicine to cure patients, urging practitioners to call for the surgeon early in the disease process. Michael Bliss, William Osler: A Life in Medicine (Oxford: Oxford University Press, 1999) chapters four and five. 33 Executive Committee Meeting, 14 May 1938, ACS Archives, RG5/SG2/S8/SS07, Box 2, Folder 2, p. 16. 34 Edward W. Archibald, “Higher Degrees in the Profession of Surgery,” Annals of Surgery 102 (1935): 481-96, quote p. 481. Bevan, “The Study and Teaching and the Practice of Surgery.” For the history of the Association, see Mark M. Ravitch, A Century of Surgery: The History of the American Surgical Association (Philadelphia: Lippincott, 1981). 35 Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, CT: Greenwood Press, 1980). Gert Brieger, “From Conservative to Radical Surgery in Late Nineteenth-Century America,” in Christopher Lawrence, ed., Medical Theory, Surgical Practice (New York: Routledge, 1992) 216-31. Thomas Schlich, “‘The Days of Brilliancy are Past,’: Skill, Style and the Changing Rules of Surgical Performance, ca. 1820-1920,” Medical History 59 (2015): 379-403. 36 Allen O. Whipple, “Opportunities for Graduate Teaching of Surgery in Larger Qualified Hospitals,” Annals of Surgery 102 (1935): 516-30. George J. Heuer, “Graduate Teaching of Surgery,” Surgery, Gynecology, and Obstetrics 54 (1932): 729-32. 37 See Pool’s comments in Whipple, “Opportunities for Graduate Teaching of Surgery in Larger Qualified Hospitals,” 527. See also George J. Heuer, “Graduate Teaching of Surgery in University Clinics,” Annals of Surgery 102 (1935): 507-15. 38 At a subsequent American Surgical Association meeting, minutes noted proudly that trained surgeons charged less than the average general practitioner to remove a gallbladder. Minutes of the 74th Meeting of the American Surgical Association, April 1954, National Library of Medicine History of Medicine Division (hereafter NLM Archives), American Surgical Association Collection, Box 1/Folder 8, p. 10. Data reflected practices in Michigan in 1953. 39 “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association,” 21 February 1948, ACS Archives, Conference Committee on Graduate Training in Surgery RG5/SG2/S8/SS03/Box1/Folder 6. 40 Eliot Friedson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (Chicago: University of Chicago Press, 1988). 41 George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (New York: Oxford University Press, 2006) 229. 42 Martin, Fifty Years of Medicine and Surgery. Loyal Davis, Fellowship of Surgeons: A History of the American College of Surgeons (Chicago: American College of Surgeons, 1988). David L. Nahrwold and Peter J. Kernahan, A Century of Surgeons and Surgery: The American College of Surgeons, 1913-2013 (Chicago: American College of Surgeons, 2012). 43 Peter D. Olch, “Evarts A. Graham, the American College of Surgeons, and the American Board of Surgery,” Journal of the History of Medicine and Allied Sciences 27 (1972): 247-61. Mueller, Evarts A. Graham, chapter twelve. Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter seven. 44 For sulfas, see John Lesch, The First Miracle Drugs: How the Sulfa Drugs Transformed Medicine (New York: Oxford University Press, 2007). For blood transfusions see Susan E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth Century America (New York: Oxford University Press, 2008). 45 For concerns of surgery splintering into multiple boards, see Stevens, American Medicine and the Public Interest, 235-242. The Board of Surgery was the fifteenth board formed in the United States. 46 J. Stewart Rodman, History of the American Board of Surgery, 1937-1952 (Philadelphia: J. B. Lippincott Company, 1956). Ward O. Griffin, The American Board of Surgery in the 20th Century (American Board of Surgery unpublished manuscript, 2004). 47 From its inception, the Board emphasized the importance of formal, post-graduate surgical education. See George Whipple’s comments in the minutes from 23 October 1935 as well as 15 February 1936 in “Report of the Subcommittee on ‘Ways and Means of Enlarging Present Faculties for the Training of Surgeons,” American Board of Surgery Archives in Philadelphia, PA (hereafter ABS Archives), Minutes 3-4 April 1937 and 14-15 November 1937. 48 Christopher J. Boes, Timothy R. Long, Steven H. Rose, and W. Bruce Fye, “The Founding of the Mayo School of Graduate Medical Education,” Mayo Clinic Proceedings 90 (2015): 252-263. Jennifer Gunn, “‘The First Adequate Graduate School of Medicine in America,’” Minnesota Medicine 86 (September 2003): 63-68. W. Bruce Fye, Caring for the Heart: Mayo Clinic and the Rise of Specialization (New York: Oxford University Press, 2015), 44-5, 115-8. Stevens, American Medicine and the Public Interest, 212-6 and 245-65. 49 “Conference on the Teaching of Surgery and Surgical Specialties,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 1. George Crile, “Graduate Training for Surgery,” June 1939, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 2. 50 See the 14 May 1938 amendment, “Executive Committee Meeting,” p. 14. 51 Crile, “Graduate Training for Surgery,” 1. 52 The ACS had previously formed a variety of committees to assess and make recommendations on graduate medical education that served as forerunners to the Committee on Graduate Training in Surgery. For a description of those efforts, see George W. Stephenson, American College of Surgeons at 75 (Chicago: American College of Surgeons, 1990), chapter four. George W. Stephenson, “American College of Surgeons and Graduate Education in Surgery: A Chronical of Surgical Advancement,” Bulletin of the American College of Surgeons (Special Edition) vol. 56, no. 5 (1971) 1-57, see pp. 12-31. The committee had four charges: 1) establish minimum standards; 2) ascertain which hospitals were capable of meeting those standards; 3) help establish residencies; 4) provide means of periodic inspection. See “Abstract of Minutes, Meeting of the Committee on Graduate Training in Surgery,” 28 November 1937, ACS Archives, Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 1. 53 A list of initial requirements appears in “Report of Sub-Committee of the Committee on Graduate Training in Surgery,” 11 February 1938, ACS Archives, Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 1. 54 Joint Conference Committees of the American College of Surgeons and the American College of Physicians, 16 October 1938, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7, p. 2. 55 Letter to Olin West from George Crile, 13 June 1936, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. For the official ACS resolution to approach the AMA, see “Abstract of the Board of Regents Meeting,” 10 May 1936, ACS Archives, Graduate Training for Surgery Survey of Hospitals, 1938, RG5/SG2/S8/SS07/Box 2/Folder 1, pp. 3-4, 7. 56 They did not offer a reason for the rejection, although the discordant relationship between the organizations and the respective desires to lead the surgical profession (discussed below) likely contributed. Letter to George Crile from Olin West, 26 June 1937, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 14 February 1937, American Medical Association Archives in Chicago, IL (hereafter AMA Archives), p. 5. 57 “Minutes of the Committee on Graduate Training in Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box1/Folder 3, pp. 5-6. 58 See “Exhibit A to Abstract of Minutes, Committee on Graduate Training for Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box1/Folder 1, pp. 6-7. 59 For opposition to uniformity of surgical GME, see Heuer, “Graduate Teaching in Surgery,” 515. Whipple, “Opportunities for Graduate Teaching of Surgery,” 516, 520-1. Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 18. 60 Quoted in Ludmerer, Let Me Heal, 127. 61 Surveys sought basic quantifiable information like number of residents, number of operations per year, etc. “Survey for Graduate Training for Surgery,” Bernard Becker Medical Library Archives, Washington University School of Medicine (hereafter Becker Archives) Graham Papers, FC003, Box 10, Folder 65. 62 Inspection continues today as part of the Joint Commission. See Nahrwold and Kernahan, A Century of Surgeons and Surgery, chapters two, three, and twelve. Davis, Fellowship of Surgeons, 172-85, 205-22, 379-88. Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter four. 63 Initially, three surgeons employed by the ACS (Melvin Newquist, Melville Manson and Harold Earnheart) performed all the inspections, providing consistency across institutions. In 1938, it cost roughly $22,500 ($388,000 in 2017 USD). Commission on Graduate Medical Education Tentative Budget 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3. (All financial conversions completed through the U.S. Bureau of Labor Statistics online inflation calculator, http://www.bls.gov/data/inflation_calculator.htm.) The ACS also did not publish a list of residencies that failed, so programs had few disincentives to applying for approval. 64 Dallas B. Phemister, “Graduate Training for Surgery: Report of Survey,” 16 October 1938, ACS Archives, Graduate Training for Surgery Survey of Hospitals, RG5/SG2/S8/SS07/Box 2/Folder 2, p. 13. They had wanted to survey 436 hospitals, only reached 374, and only fully evaluated 270. 65 Melville H. Manson, “Report of Survey Graduate Training for Surgery,” 1938?, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 1, p. 20. 66 Of the 297 surgical residents surveyed in 1937, 118 were in one-year programs; sixty-nine were in two-year programs; seventy-one were in three-year programs; twenty-two in four-year programs; and eight in programs lasting five or more years. These lengths reflect years after internship. Programs associated with medical schools tended to be longer. Manson, “Report of Survey,” 7. 67 Ibid., 9-10. 68 Hospitals associated with medical schools (26% of those inspected) produced thirty-eight percent of graduating residents, who generally received superior training. Ibid., 20, 24. 69 Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 28-30. 70 “Commission on Graduate Medical Education Tentative Budget, 1938,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3. 71 “Administrative Board,” 23 April 1939, ACS Archives, Graduate Training for Surgery, RG5/SG2/S8/SS07/Box 2. 72 Ibid. 73 “Meeting Minutes,” 15 October 1939, ACS Archives, Graduate Education Committee RG5/SG2/S8/Box 1/Folder 3, p. 11. See also Phemister, “Graduate Training for Surgery,” p. 12, 32. “Complete Minutes, Executive Committee, 29 July 1939,” ACS Archives, Graduate Education Committee RG5/SG2/S8/Box 1/Folder 3, pp. 43-4. 74 See, for example, the efforts of Methodist Hospital in Houston to ally with neighboring Baylor College of Medicine and the local county hospital explicitly to meet ACS requirements and gain approval. “Annual Reports of the Department of Surgery, Baylor University College of Medicine, 1949-1950,” NLM Archives, DeBakey Collection, Box 9/Folder 43, p. 22. 75 The Board used the ACS list with the exception that they insisted on three years of residency, rather than the two required by the College. Minutes, 7 May 1939, ABS Archives, p. 14. 76 In comparison, the requirements for 1938 occupied a single page. “Minimum Standards Recommended by the Committee on Graduate Training in Surgery,” Manual of Graduate Training in Surgery, 1 October 1941, ACS Archives, pp. 395-406. 77 Ibid., 395. 78 The shift in attention from pathology in the 1930s to physiology in the 1940s as the central basic science for surgeons is striking. See “Minimum Standards, 1941,” 402. 79 The 1938 report approved 135 hospitals producing 380 surgeons a year; the 1939 report approved 179 hospitals producing 580 surgeons a year. Harold Earnheart, “Trends in the Graduate Training for General Surgery and the Surgical Specialties as Related to Hospitals,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 1. For 1941, see “Plans of Graduate Training in Hospitals of the United States and Canada in General Surgery and in the Surgical Specialties as of Oct. 1, 1941,” in “Minimum Requirements, 1941,” 407. 80 Ludmerer, Let Me Heal, chapters four and six. 81 Hermes C. Grillo, “Edward D. Churchill and the ‘Rectangular’ Surgical Residency,” Surgery 136 (2004): 947-52, quote p. 951. 82 Edward D. Churchill, “A Pattern for Graduate Training in Surgery at the Massachusetts General Hospital,” Report to the Trustees from the General Executive Committee, 1939, Francis A. Countway Library of Medicine, Boston, MA (hereafter Countway Archives), Churchill Collection, Box 17, Folder 45. Edward D. Churchill, “Graduate Training in Surgery at the Massachusetts General Hospital,” Harvard Medical Alumni Bulletin 14 (1940): 28-36. Edward D. Churchill, “Report to the General Executive Committee,” 20 December 1961, Countway Archives, Churchill Collection, Box 17, Folder 50. 83 Mayo Clinic, for example, pioneered a rectangular model in the 1920s. Fye, Caring for the Heart, chapters three and four. 84 See, for example, “Joint Conference Committees of the American College of Surgeons and the American College of Physicians.” Melville H. Manson, “Report of Survey of Graduate Training for Surgery,” 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 1, p. 21. “Minutes Committee on Graduate Training for Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 27. Advocates for pyramidal programs remained, arguing that the competition it fostered drove students to achieve more, and that the closer relationship between a chair and his picked chief produced the best academic surgeons. See Mark M. Ravitch, “The Surgical Residency: Then, Now, and Future,” Pharos (1987): 14; and Whipple, “Opportunities for Graduate Teaching of Surgery,” 518. 85 Churchill, “Report to the General Executive Committee.” See also Ludmerer, Let Me Heal, 174. 86 “Report on War Activities of the College,” 12 December 1943, ACS Archives, Eleanor Grimm Scrapbook, XXIV-A, p. 1. Stephenson, “American College of Surgeons and Graduate Education,” 31. 87 All medical school graduates served a nine-month rotating internship, which included two months of surgery. Thenceforth two-thirds deployed overseas and one-third remained for another nine months of specialty training. After eighteen months, half of the remaining residents shipped overseas and half continued their GME for another nine months before deploying. Of the roughly 60,000 medical men in World War II, approximately 18,000 came through this system. Charles R. Reynolds, “Department of Graduate Training in Surgery,” 1945, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. The War Department technically could not force medical schools to do anything, but it did make them an offer they could not refuse, trading hospital draft exemptions for abbreviated training. Undergraduate medical education also suffered from pressure to abbreviate their curricula. Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999) chapter seven. 88 Data compiled from Phemister, “Report on Graduate Training in Surgery,” 1 and Malcolm T. MacEachern, “The Expanded Program of the American College of Surgeons for Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 9. 89 Allen O. Whipple, “The Chairman’s Annual Report to the American Board of Surgery, 1941-1942,” Countway Archives, Churchill Collection, Box 1, Folder 38. 90 “The 1945 Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 38. See also “Minutes of the Adjourned Meeting of the Committee on Graduate Training in Surgery,” 7 February 1944, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 4, pp. 9-10. The American Board of Surgery shared this belief; see Allen O. Whipple, “Report of the Chairman, 1942-1943,” in Minutes, 12 November 1941, ABS Archives. 91 Evarts A. Graham, “What Kind of Medical Officers Do the Armed Services Want?” Surgery, Gynecology, and Obstetrics 79 (August 1944): 217-9. See also Evarts A. Graham, “Have the Armed Services Crippled Medical Education?,” The Saturday Evening Post (27 January 1945): 34, 39, 41-2. For letters and newspaper clippings from hundreds of physicians opposing the 9-9-9 plan, see Becker Archives, Graham Collection, FC003/Box118/Folder1559. 92 Irvin Abell, “Medicine in the National Defense Program,” October 1940, ACS Archives, Eleanor Grimm Scrapbook, XXIV-A. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29 November 1948, AMA Archives, pp. 11-12. Stevens, American Medicine and the Public Interest, 78. Fellows of the College were upset that fellowship did not count as certification, a transition that poignantly emphasized the rising importance of the specialty boards. They confronted the government in 1946 to no avail. “ACS, ABS, and Surgical Specialties, Summary from the Minutes of Board of Regents Meeting,” 17 December 1946, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 2/Folder 1. “Report of the Washington Conference on October 25, 1946,” Becker Archives, Graham Collection, FC003/Box 130/Folder 50. 93 “Chairman’s Annual Report,” ABS Archives, ABS Minutes, 31 March 1942, pp. 3-4. ABS Minutes 13-14 December 1946, p. 1. Fred W. Rankin, an early Diplomate of the Board and, as of February 1942, the Army’s chief consultant in surgery, campaigned for the Board’s acceptance by the Office of the Surgeon General. 94 See Letter to J. Stewart Rodman from Edward Churchill, 4 January 1946, Countway Archives, Churchill Collection, Box 1/Folder 38 detailing how the Army categorized and used surgeons; Churchill was the Surgical Consultant for the North African and Mediterranean theaters. See also Stevens, American Medicine and the Public Interest, 278-9. 95 Section 8 of Public Law 293 of the 79th Congress gave specialists a twenty-five-percent pay bonus and defined specialist based solely on Board status. 96 For the effect of World War II on specialization, see Stevens, American Medicine and the Public Interest, chapter 14, especially pp. 278-9 and 297-300 and Ludmerer, Let Me Heal, chapters seven and eight. 97 For a precise breakdown by specialty of the first 11,019 returned responses, see “Meeting of the Committee on Postwar Medical Service,” 28 October 1944 in ACS Archives, Department of Graduate Training Collections, RG5/SG2/S8/SS10 Box: Correspondence and Reports, Folder 4, p. 1. For an executive summary of the 21,029 responses, see “Report of the Committee on Postwar Medical Service,” 23 June 1945, ACS Archives, Eleanor Grimm Scrapbook vol. XXIV-A, pp. 68-9. 98 Bowman C. Crowell, “Program of the Graduate Training in Surgery,” 1945, ACS Archives, Department of Graduate Training, Correspondence, and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 3, pp. 1-6. 99 For more on the effect of the GI Bill in post-World War II America, see Glenn C. Altschuler and Stuart A. Blumin, The GI Bill: A New Deal for Veterans (New York: Oxford University Press, 2009). 100 General Omar Bradley made the decision. “Post War Planning: Graduate Education of Physician Veterans Under GI Bill,” AMA Archives, CMEH Series 2.1 Graduate Medical Education, Box 27-14, Folder 1412, pp. 2-4. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 2 December 1945, AMA Archives, p. 8. The tension between education and service reverberates throughout the history of GME. See Ludmerer, Let Me Heal and John, “Practicing Physicians.” 101 Hospitals received $500 per veteran resident per year from the government for “tuition.” “The Program of Graduate Training in Surgery of the American College of Surgeons” Becker Archives, Blair Papers, FC025/Box 10/Folder 62, p. 5. 102 Paul S. Ferguson and Charles R. Reynolds, “Progress Report on Graduate Training in Surgery,” ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 5 103 By 1949, VA hospitals were training 2500 surgical residents a year in 74 locales. “Report of the Department of Graduate Training in Surgery to the Annual Meeting of Fellows of the ACS,” 11 September 1947, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, pp. 2-3. Charles Reynolds, “General Statement of Activities of the Department,” 15 December 1946, ACS Archives, Graduate Training Committee, Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 6. Paul S. Ferguson, “Report of Hospital Surveys in Graduate Training in Surgery,” 1946, ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 2. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 3-4 June 1949, AMA Archives, p. 12. Charles R. Reynolds, “Report of the Department of Graduate Training in Surgery, 1 January 1947 – 1 August, 1947,” 7 September 1947, ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, pp. 3-4. Initially VA programs were separate but affiliated with medical centers; by the late 1950s, VA facilities were included as part of academic residency programs. 104 Robinson E. Adkins, Medical Care of Veterans (Washington D.C.: U.S. Government Printing Office, 1967) chapter ten. Paul B. Magnuson, Ring the Night Bell: The Autobiography of a Surgeon, ed. Finley Peter Dunne, Jr. (Birmingham: University of Alabama Press, 1986 (1960)) chapters eighteen, nineteen, and twenty-one. Letter to Deans of Medical Schools from Paul B. Magnuson, Becker Archives, Barnes Hospital Records, RG009/Box 19/Folder 14. Paul B. Magnuson and William T. Doran, “Plans of Future Medical Cooperation between Teaching Institutions and Veterans Hospitals in Proximity,” Becker Archives, Barnes Hospital Records, RG 009/Box 19/Folder 14. In 1944, only 5 VA hospitals had an association with an academic medical center; by 1946, over 30 affiliations existed (out of 109 facilities). George H. Miller, “Report on the Development of Graduate Training Programs through the Collaboration of Medical Schools with Civilian Hospitals and Government Hospitals,” 15 December 1946, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. 105 John Paul North, “Annual Report of the Surgical Residency and Training Programs and the Surgical Services Veterans Administration Hospitals, Dallas and McKinney Texas, 1956-1957,” ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 1/Folder 4, p. 3. Letter to Superintendent of Mount Carmel Mercy Hospital from Charles R. Reynolds, 27 February 1948, Becker Archives, Graham Collection, FC003/Box 7/Folder 50. See also Meeting Minutes of the Committee on Graduate Training, 22 June 1948, Becker Archives, Graham Collection, FC003/Box 7/Folder 49. Eugene Bricker, Frank Gerbode, and David Habif, “The Effect of Health Insurance Programs on Residency Training in Surgery,” Surgery 32 (1952): 333-40. 106 Malcolm T. MacEachern, “Report on Graduate Training Activities During 1944,” 17 September 1944, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. “Complete Minutes of the Meetings of the Committee on Graduate Training in Surgery,” 6-7 February 1944, p. 4. See, for example, the challenges of Ashburn’s Veterans Hospital in McKinney, Texas, highlighted in “The Surgical Service and its Residency Training Program Second Annual Report: July 1, 1947 to June 30, 1948,” Countway Archives, Churchill Collection, Box 17, Folder 49. 107 The Navy and Public Health Service approached the College and began modifying their programs as early as 1943. The Army postponed their effort until after World War II. “Graduate Training Army General Hospitals and to a Limited Extent in AAF and ASF, 1945,” ACS Archives, Department of Graduate Training, Correspondence and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 3, p. 1. “Minutes of the Board of Regents,” 1 April 1946, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 76. MacEachern, “Report on Graduate Training Activities During 1944,” 1-2. Charles R. Reynolds, “The Training Program,” in “Complete Minutes of the Meeting of the Committee on Graduate Training in Surgery,” 30 November 1945, ACS Archives, Graduate Education Committee Collection, RG5/SG2/S8/Box 2/Folder 5, p. 11. “Meeting at ACS, Abstract of Discussion of 13 February 1945,” ACS Archives, Graduate Training Committee for Surgery, RG5/SG2/S8/SS14/Box 1/Folder 1, pp. 1-4. Ferguson and Reynolds, “Progress Report on Graduate Training in Surgery,” 4-7. “Complete Minutes of the Meeting on Graduate Training in Surgery,” 30 November 1945, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 17. Reynolds, “General Statement of Activities of the Department,” 3. Paul S. Ferguson, “Report to the Board of Regents on the Graduate Training in Surgery,” 1 October 1948, ACS Archives, Graduate Training Committee, Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 1, p. 3. 108 Paul I. Robinson, MC, USA, “Presentation before the Council on Education and Hospitals,” 7 February 1948, Appendix H to “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6-7 February 1948, AMA Archives. Albert E. Cowdrey, The Medics War (Washington DC: Center of Military History, 1987) chapter 1. “Appendix E: Conference with Representatives of the Government Agencies, Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 7-10 June 1951, AMA Archives, p. 5. The History of the Medical Department of the United States Navy, 1945-1955 (Washington DC: U.S. Government Printing Office, 1958) chapters two through five. 109 Administration for Veterans Affairs Annual Report Fiscal Year 1946, Washington DC: Government Printing Office, 1946 (https://www.va.gov/vetdata/docs/FY1946.pdf) accessed 11 August 2017. 110 Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (Baltimore: The Johns Hopkins University Press, 1989) 216-30. It funded 4,678 projects. 111 Nicholas L. Tilney, Transplant: from Myth to Reality (New Haven: Yale University Press, 2003) and David S. Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: The Johns Hopkins University Press, 2013). 112 Michael E. DeBakey, interview with Charles Morrissey, 17 December 1988, NLM Archives, DeBakey Collection, Box 9, Folder 7, p. 7. See also interview with Don Schanche, 16 June 1972, NLM Archives, DeBakey Collection, Box 2, Folder 17, pp. 52-8. Bertram M. Bernheim, A Surgeon’s Domain (New York: W. W. Norton & Company, 1947) chapter 5. 113 Minutes of the 67th American Surgical Association, 25-27 March 1947, NLM Archives, American Surgical Association Collection, Box 1, Folder 8, p. 7. 114 For requests to the ACS to survey their program, see Ferguson, “Report to the Board of Regents on the Graduate Training in Surgery,” p. 4, and Reynolds, “Report of Department of Graduate Training in Surgery, 1 January – 1 August 1947,” p. 5. 115 Loyal Davis, ed., Fifty Years of Surgical Progress, 1905-1955 (Chicago: Franklin H. Martin Memorial Foundation, 1955). 116 “Abstract of the Minutes, Board of Regents Meeting,” 5 May 1944, ACS Archives, Department of Graduate Training, Correspondence and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 1, p. 2. See also Special Bulletin of the American College of Surgeons 30 (1945): 5. 117 “Program of Graduate Training in Surgery,” 6. “Complete Minutes of the Meeting on the Committee on Graduate Training in Surgery, 30 November 1945,” Becker Archives, Blair Papers, FC025/Box 10/Folder 62, exhibit C. Exhibit F is a nine page, single-spaced list of programs to evaluate. 118 “Fundamental Requirements for Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 26-36. 119 In 1946 alone, they surveyed 74 hospitals, approving 206 programs (74 civilian and 132 governmental). Reynolds, “General Statement of Activities of the Department,” p. 2. Ferguson, “Report of Hospital Surveys in Graduate Training in Surgery,” p. 2. George H. Miller and Paul S. Ferguson, “The Graduate Training Division: A General Review for the Year 1949,” ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 1, p. 2. 120 The College did not normally store material on programs it had rejected to avoid embarrassing them, but data from the postwar years did perchance survive. For these data, see the reports contained in “Hospitals Surveyed for Graduate Training in Surgery and Not Approved, January 1 1945 to December 31 1947,” ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 4. 121 Surgery programs included general surgery, otolaryngology, obstetrics and gynecology, neurosurgery, urology, thoracic surgery, and ophthalmology. Data compiled from numerous documents in ACS archives. 122 “Hospitals Surveyed for Graduate Training in Surgery and Not Approved, January 1 1945 to December 31 1947,” passim. 123 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 4-5 October 1947, AMA Archives, p. 13. Moreover, after 1945, the AMA refused to disqualify previously approved hospitals in their effort to accommodate veteran interest. The ACS did remove programs that no longer met their standards, although this rarely amounted to more than a handful in a given year. See “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 2 December 1945, AMA Archives, p. 10. 124 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals, Appendix A: Memo to the Board of Trustees of the American Medical Association, 8 July 1945,” 18-20 June 1948, AMA Archives, pp. 1-3. 125 Before World War II, the AMA had approved 610 hospitals for 5256 residency slots, numbers that nearly doubled to 1017 programs and over 12,000 spots by early 1948. “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association for Discussion of Problems of Mutual Interest,” p. 7. 126 Warfield Firor, “Residency Training in Surgery: Birth, Decay, and Recovery,” Review of Surgery 22 (1965): 153-7. 127 “Program of Graduate Training in Surgery,” p. 3. 128 “Graduate Training Committee Meeting,” 17 October 1948, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 4. 129 Report by J. Stewart Rodman in Minutes of the 66th Meeting of the American Surgical Association, 2-4 April 1946, Becker Archives, Graham Papers, FC003/Box 13/Folder 88, pp. 12-3. 130 Meeting minutes, ABS Archives, 6 May 1944, p. 3. The Boards of Orthopedic Surgery and Otolaryngology also relied on the ACS list of approved programs. 131 “Memorandum Concerning the Evaluation of Standards of Training Acceptable to the American Board of Surgery,” Meeting minutes, ABS Archives, 8 December 1945, p. 1. 132 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29 November 1948, AMA Archives, pp. 12-3. Letter to Oliver Cope from Warfield Firor, 8 August 1947, Countway Archives, Cope Collection, Box 7, Folder 32. 133 Guy A. Caldwell, “Suggestions for the Improvement of Resident Training in the Surgical Specialties and for Better Cooperation of Agencies Concerned in Approval of Training, 18 February 1948, in Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association for Discussion of Problems of Mutual Interest,” 21 February 1948, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 6, p. 21. 134 Letter to Oliver Cope from Warfield Firor, 8 August 1947, Countway Archives, Cope Papers, Box 7, Folder 32. Letter to Oliver Cope from Warfield Firor, 13 September 1948, Countway Archives, Cope Papers, Box 7, Folder 32. Frank Berry, James Barret Brown, John C. Burch, Paul B. Magnuson, Reed M. Nesbit, Wilder Penfield, and Oliver Cope, “Report to the American Surgical Association of the Committee on Graduate Surgical Education,” 1 April 1953, Countway Archives, Churchill Papers, Box 17, Folder 49. See report cards in Cope Papers, Box 7, Folder 53. The documentation for most of the institutions inspected also remains available there. 135 Crowell, “Program of the Graduate Training in Surgery,” 1. “Program of Graduate Training in Surgery,” 6-7. 136 “Minutes of the Meeting of the Committee on Graduate Training in Surgery,” 22 June 1948, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 1. Generally, the ABS would permit a graduate from a program approved by either the ACS or AMA to sit for his boards; the ACS only offered fellowship to those who completed residency in a program from their list. 137 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6 and 9 June, 1937, AMA Archives, p. 3. Malcolm T. MacEachern, “Memorandum to the Administrative Board,” 21 June 1937, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. “Conference for Graduate Training of Surgery, 27 October 1937” Becker Archives, Graham Papers, FC003, Box 8, Folder 55. 138 Letter to George F. Lull (AMA) from Malcolm T. MacEachern (ACS), 3 September 1947, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 5. See also “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 4-5 October 1947, AMA Archives, p. 12. 139 “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association,” pp. 1-2. 140 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 18-20 June 1948, AMA Archives, see Appendix E: Letter to Malcolm T. MacEachern from Donald G. Anderson, 2 July 1948 and “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 16-17 October 1948, AMA Archives, pp. 14-5. 141 “Graduate Training Committee Meeting,” 17 October 1948, 2, 6. The ACS was particularly concerned with keeping high standards for the program. See Malcolm T. MacEachern, “Principles Involved in the Coordination of Field Activities for the American College of Surgeons, the American Medical Association, and the Specialty Boards,” 31 March 1948, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 2/Folder 1, p. 2. 142 Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter seven. Stevens, American Medicine and the Public Interest, chapters 11-15. Weisz, Divide and Conquer, 143. 143 Minutes of the 75th Meeting of the American Surgical Association, 27-29 April 1955, Becker Archives, Blair Papers, FC025/Box 6/Folder 13, pp. 12-3. For more complicated operations like gastric resection, board certified surgeons had a greater role, performing nearly fifty percent of surgeries. 144 Minutes of the 76th Meeting of the American Surgical Association, 11-13 April 1956, Becker Archives, Graham Papers, FC003/Box 13/Folder 88, pp. 12-3. 145 Meeting Minutes, ABS Archives, 14 May 1947, p. 9. 146 Francis D. Moore, “Graduate Surgical Training in the Small Hospital,” Countway Archives, Churchill Collection, Box 17, Folder 49. 147 In 1947, the Board had less than $30,000 in disposable income; the College spent $80,000 on residency approval alone. “Department of Graduate Training in Surgery Financial Program, as of 20 January 1947,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5. Meeting Minutes, ABS Archives, 14 May 1947, p. 11. 148 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 23-24 June 1950, AMA Archives, pp. 6-8, and Appendix B: Minutes of the Conference Committee on Graduate Training in Surgery, AMA Archives, 26 May 1950. “Memorandum from Conference Committee on Graduate Training in Surgery,” 25 July 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 4, pp. 1-2. Some members of the American Board of Surgery, like its president, Firor, believed that the creation of the Board’s inspection service in 1949 drove the AMA and ACS to come to an agreement for fear of losing their roles in the process. While theoretically convincing, no documentation supports this supposition. Letter to Massachusetts Committee from Warfield Firor, 16 August 1949, Countway Archives, Cope Collection, Box 7, Folder 32. 149 For a list of the criteria, see “Appendix B in Minutes of the Meeting of Subcommittee B of the Committee of the American Medical Association and the American College of Surgeons Appointed to Prepare a Preliminary Draft of Standards for Residency Training in Surgery and the Surgical Specialties and to Recommend Procedure for Uniform Listing,” 15 April 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 5. 150 Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 15. Letter to John Modlin, Chief Surgeon at Elis Fischel State Cancer Hospital, from George Miller, 1 December 1950, Becker Archives, Graham Papers, FC003, Box 47, Folder 7. The rapid expansion of hospitals post-World War II exponentially increased expenses. For this same reason, the College had to partner with other organizations in order to sustain its hospital inspection system, forming the Joint Commission that endures today. 151 “Minutes of the Conference Committee on Graduate Training in Surgery,” 26 May 1950, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box2/Folder 22, p. 1. 152 See “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29-30 November 1953, AMA Archives, p. 7 and “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 5-6 February 1954, AMA Archives, pp. 5-7. 153 Letter to Alfred Blalock from Paul R. Hawley, 9 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, p. 1. See also Letter to Arthur W. Allen from Paul R. Hawley, 16 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, p. 1. 154 See, for example, the “Minutes from 27 October 1950,” ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, see especially pp. 306-26. 155 Letter to Warfield M. Firor from Paul R. Hawley, 9 October 1950 and Letter to Paul R. Hawley from Warfield M. Firor, 11 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3. Letter to Arthur W. Allen from Paul R. Hawley, 11 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3. Hawley, Letter to Allen, 16 October 1950. 156 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 8-9 February 1952, AMA Archives, see p. 45 in Appendix B. 157 Ibid. 158 The American surgical profession disdained the International College of Surgeons, believing it a copycat organization for individuals lacking the qualifications or ethics to belong to an American organization. That the AMA turned to the International College reflects either a profound ignorance of surgical politics or egregious disrespect. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6-7 June 1954, AMA Archives, pp. 8-9. Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 49-51. Warren Cole, Chairman’s Report, Meeting Minutes, ABS Archives, 15 April 1952. For more on the ACS/ICS rivalry, see Nahrwold and Kernahan, A Century of Surgeons, 238-9. Davis, Fellowship of Surgeons, 350-5. 159 Weisz, Divide and Conquer, 15 and passim. 160 For the importance of training in the dissemination of arterial repair and osteosynthesis, see, respectively, Justin Barr, “Surgical Repair of the Arteries in War and Peace, 1880-1960,” (PhD diss., Yale University 2015) and Thomas Schlich, Surgery, Science and Industry: A Revolution in Fracture Care, 1950s-1990s (New York: Palgrave, 2002). © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of the History of Medicine and Allied Sciences Oxford University Press http://www.deepdyve.com/lp/oxford-university-press/the-education-of-american-surgeons-and-the-rise-of-surgical-H882w0Zplv

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Publisher: Oxford University Press
Copyright: © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com
ISSN: 0022-5045
eISSN: 1468-4373
DOI: 10.1093/jhmas/jrx058
pmid: 29408971
Publisher site: See Article on Publisher Site

Abstract

Abstract In the first half of the twentieth century, the training of American surgeons changed from an idiosyncratic, often isolated venture to a standardized, regulated, and mandated regimen in the form of the surgical residency. Over the three critical decades between 1930 and 1960, these residencies developed from an extraordinary, unique opportunity for a few leading practitioners to a widespread, uniform requirement. This article explores the transformation of surgical education in the United States, focusing on the standardization and dissemination of residencies during this key period. Utilizing the archives of professional organizations, it shows how surgical societies initiated and forced reform in the 1930s. It demonstrates the seminal and early role taken by the federal government in the expansion of surgical residencies through incentivized policies and, especially, the growth of the Veterans Administration health system after World War II. Finally, an examination of intra-professional debates over this process illustrates both the deeper struggles to control the nature of surgical training and the importance of residency education in defining the midcentury American surgeon. The education and very definition of the American surgeon changed dramatically between 1890 and 1955. Whereas in the late nineteenth and early twentieth centuries general practitioners performed the majority of operations in the United States, by 1955 formally trained surgeons were assuming that role. Residency – the structured years after medical school that provide the didactic knowledge, practical experience in patient care, research exposure, and mentorship needed to train a specialist – served as the means of surgeons’ education and professionalization. Between the 1930s and 1950s, surgical residency transformed from an uncommon, idiosyncratic experience for elite practitioners to a standardized, mandatory education for all American surgeons. Thereafter, the American public and the medical profession came to define a surgeon as someone who had passed through a rigorous, regulated residency. This article explores the creation and the institutionalization of surgical residencies as they transitioned from rare, ad hoc, and highly variable experiences in the early twentieth century to the ubiquitous, structured, and required education that exists today. It relies heavily on the archives of professional organizations like the American College of Surgeons, American Medical Association, and the heretofore untouched records of the American Board of Surgery, as well as the personal papers of key individuals who led the process. Despite the importance of graduate medical education in creating physicians, caring for patients, and influencing health policy, few scholars have rigorously analyzed its establishment. Kenneth Ludmerer’s recent Let Me Heal is a notable exception, providing a holistic overview of the history of residencies, and Rosemary Stevens’ classic American Medicine and the Public Interest describes their supra-organizational framework in the context of specialization.1 Anthropologists have undertaken ethnographic studies of surgical residency, providing a window into the experience of a trainee, but these appeared in the 1970s, well after the routinization of training.2 Earlier literature tends to focus on the founding of residencies at Johns Hopkins in the late nineteenth century and the social turmoil of the 1960s and 1970s, but this article strongly argues for the importance of the 1930s – 1950s: in these decades, residency spread around country and took its modern form. Following a brief background reviewing surgical training pre-1930, the article evaluates these crucial thirty years in three sections. First, it examines the spread of residency training to community hospitals. In so doing, it moves beyond existing sources that focus on academic institutions. Exploring this shift unveils the compromises necessary to create universal training at institutions unable to produce professorial surgeon-scientists, like shortening the length of training and concentrating on clinical material at the expense of research and basic science. Professional organizations shepherded much of this change. While other sources have emphasized the importance of societies to the identity and function of the medical profession, this analysis demonstrates the specific mechanisms through which they shaped surgery by creating and enforcing criteria.3 Second, the article examines the exponential rise in surgical residencies following the Second World War. While previous sources highlight the growing role of the federal government in the 1960s with Medicare and Medicaid, this section clearly demonstrates its vital importance to residency expansion in the 1940s and 1950s through military policies in World War II, post-war incentives, the GI Bill, and especially the VA Hospital system. These fillips continued the trend of training community practitioners. The third and final section of the paper explores the fierce intra-professional struggles to control the certification process for residency. This portion re-emphasizes the seminal role of surgical organizations and the means they employed to shape their field. Moreover, through these debates it elucidates the importance of residency in defining who was a surgeon in the United States in the middle of the twentieth century. Surgical Training from the 1890s-1930s In the late nineteenth and early twentieth centuries, no universal system existed for creating American surgeons. Elective operations remained rare in the 1800s,4 and few men identified as surgeons.5 As the medical profession began to regularize after the Civil War, apprenticeship provided the vast majority of surgical education.6 Later in the century, some men sought appointments to hospitals for more formalized training, but these house-officerships remained highly variable in quality and exceedingly rare.7 Other physicians – over 13,000 – attended six-to-twelve week post-graduate courses that taught more advanced surgery.8 While in fewer numbers than their medical colleagues, an elite, self-funded group travelled to Europe to pursue advanced schooling.9 Many of these internationally educated surgeons returned home to serve as clinical and professional leaders in American surgery. Finally, a strong element of autodidacticism pervaded the era. “Those of us interested in gynecological surgery literally learned it by operating on our patients,” recalled Franklin Martin, founder of the American College of Surgeons.10 In an effort to elevate the quality of surgical training in the United States, William Halsted created a residency program. Following medical school and a year as a house-officer in New York, Halsted travelled to Germany and Austria to study. He brought back to the United States not only a commitment to scientific, aseptic surgery, but also an appreciation for the Germanic system of training.11 When Halsted became Chief of Surgery at Johns Hopkins, he worked with William Osler, Chief of Medicine, to adopt that system in the United States, establishing what became the prototypical residency in the country.12 Endeavoring “to adopt as closely as feasible the German plan,” Halsted created a pyramidal program that brought residents through a multi-year training regimen focusing on both patient care and research.13 There was no set length of time residents spent in the individualized program, and only a single man rose to the rank of chief resident. Halsted deliberately aimed to “produce not only surgeons but surgeons of the highest type, men who will stimulate the first youths of our country to study surgery and to devote their energies and their lives to raising the standard of surgical science.”14 He succeeded, as his trainees chaired departments around the country.15 The Hopkins model spread across the United States, with its graduates the most ardent missionaries. Of Halsted’s seventeen chief residents, eleven went on to establish similar residency programs.16 Other surgeons, like longtime friends and chairmen Allen O. Whipple (Columbia) and Evarts Graham (Washington University), never worked directly under Halsted but nonetheless consciously created consonant programs.17 Graham in particular standardized Halsted’s amorphous system into a set-length, graded curriculum where residents earned increased responsibility as they advanced. This graded permutation, widely adopted by the 1920s, was especially important in surgery to ensure that graduates received appropriate operative exposure.18 By the 1920s, surgery residency, either at Hopkins or an analogous program, became required for appointments at major hospitals and research institutions. In the early 1900s, rank-and-file American doctors were just beginning to pursue formal post-graduate training. Medical schools, themselves undergoing reforms catalyzed by the 1910 Flexner Report,19 made no effort to teach students how to operate, viewing such lessons as beyond their purview.20 Internship, a formal year of education in the hospital after medical school, did provide some instruction. In 1900, fewer than fifty percent of American physicians pursued any post-graduate training, but internships became more common such that by 1923 U.S. hospitals offered positions to every graduating doctor.21 Some hospitals created short, one-year residencies following internship that focused on a specific specialty, including surgery.22 As these became more common in the 1920s, the American Medical Association established guidelines to help regulate them. But twelve months severely limited the scope and quality of the training.23 Between rare Halstedian residencies and increasingly-ubiquitous internships, a “topography” of surgeons emerged in America.24 At universities and in a few major cities, surgical leaders like Halsted, the Mayo brothers, and their trainees pioneered new operations, led departments, and formed the vanguard of the field. Performing the bulk of the research, these elite surgeons provided only a tiny sliver of patient care. Most of the U.S. population relied on general practitioners who may have completed a one-year internship and/or pursued post-graduate training courses. While in retrospect the expansion of Halstedian residencies appears the logical solution to preparing surgeons, through the 1930s the proper course remained unclear and undecided by the profession.25 Given the range of operative interventions for most general practitioners – draining abscesses, setting fractures, and maybe appendectomies – the apprenticeship and postgraduate models provided satisfactory instruction and were readily available.26 But as the practice of surgery evolved, so did the needs of the profession. The 1930s – The Decade of Theoretical Change By the 1930s, the practice of surgery had substantially changed, significantly increasing both the breadth and variety of operations. Leaders of the profession, concerned about the quality of surgery being practiced, initiated efforts to expand, evaluate, and certify training opportunities. Demonstrating the power and role of professional organizations, the campaign fundamentally altered surgical residencies, which increasingly focused on educating not elites, but the average, practicing surgeon. Surgery changed dramatically in the early twentieth century, prompting an intense focus on the training paradigm. The nineteenth century advances of anesthesia and asepsis enabled safe practice, and the acceptance of ontological disease models provided the rationale to operate.27 Hospitals grew in number and acceptability, creating a dedicated space to practice.28 Professionalized nurses facilitated pre-, post-, and intraoperative care.29 Surgery grew rapidly. Between 1900 and 1925, the number of surgeries at the University of Pennsylvania Hospital increased from 870 a year to 4180 a year. At New York Hospital, only eighteen percent of in-patients received an operation in 1900, but sixty-nine percent did in 1920.30 Not only the number of surgeries but also the complexity increased as intra-abdominal operations, intricate cancer resections, and other complicated interventions came to characterize a field previously dominated by trauma and minor procedures.31 General practitioners were as excited about the surgical revolution as their academic colleagues. Operations provided them a chance to cure many diseases at a time when the medical armamentarium offered little.32 Of the 2.5 million surgeries in the United States in 1937, general practitioners – not elite surgeons – still performed the vast majority.33 Elite academic surgeons worried about the ability of general practitioners to care for this new surgical patient. In 1933 and 1935, the leaders of the American Surgical Association, the oldest and most prestigious organization in the field, dedicated their presidential addresses to the problem “where fingers replace brains and handicraft outruns science.”34 Tellingly, their concerns centered on doctors’ ability to navigate the physiology and pathology of surgical conditions, not just on technical prowess. This disquietude reflected changes in the theory and practice of surgery as an increasingly physiological focus prompted a shift away from speedy, dramatic performances to slow, meticulous, yet radical operations that exceeded the abilities of internship-trained generalists.35 Leaders of the American Surgical Association simultaneously recognized the scarce opportunities for additional training.36 In 1935, fewer than thirty-five Halsted-style residencies existed in the country, with each graduating a single chief resident: “not a drop in the bucket towards supplying the need for surgeons through the country,” according to Eugene Pool, professor of surgery at Columbia.37 Pool and others in the American Surgical Association brought the problem of surgical training to the fore; over the next two decades, they and their colleagues worked to create a solution. Importantly, the stimulus to improve surgical education came from within the profession; neither government regulation nor popular dissatisfaction nor economic considerations drove this campaign.38 While not motivated exclusively by altruism, leaders firmly believed educational reform would improve patient care. Notably, they hoped additional training would decrease the amount of surgery in America by improving pre-operative diagnosis, teaching judgment, and reducing unnecessary operations.39 By demanding and generating enhanced educational opportunities, surgery was fulfilling its professional responsibilities of self-improvement, quality control, and auto-regulation, and in so doing building faith with the patient population they served.40 Concordantly, Americans' confidence in the superiority of specialists rewarded this effort.41 The American College of Surgeons (ACS) took the lead in reforming surgical education. Franklin Martin originally founded the College to elevate the quality of surgery in the country by demarcating a class of practitioners who had proven themselves competent surgeons.42 Explicitly trying to include community and elite practitioners, the ACS focused on competency, not pedigree, and did not require any specific training regimen or even the exclusive practice of surgery, reflecting the realities facing most practitioners in the early twentieth century. By the 1930s, those realities had changed. Graduate medical education had become more common; surgery had advanced considerably. The American Board of Surgery represented one response to these new conditions. In the 1930s, a group of young academic surgeons led by Evarts Graham grew dissatisfied with the College.43 These so-called Young Turks believed the standards of the College did not adequately define a surgeon, especially given recent advances in intra-abdominal and intra-thoracic operations as well as developments in perioperative management such as sulfa drugs and blood transfusions.44 Moreover, other specialties were already establishing boards, including surgical subspecialties.45 Fearing for both the quality of surgery and its splintering into dozens of fiefdoms, the Young Turks founded the American Board of Surgery in 1937.46 The Board of Surgery demanded three, graded years of residency following internship.47 No arbitrary prescription, this requirement came from the Advisory Board of Medical Specialties and applied to all boards. The format derived from the Mayo Clinic model that Louis Wilson, president of the Advisory Board, developed in Rochester, a connection that highlights the oft-ignored but seminal importance of the Mayo Clinic in the history of graduate medical education in this country.48 Changing standards of medicine and the creation of the Board spurred the American College of Surgeons to adopt and regulate residency training. The College remained committed to improving American surgery and patient outcomes; they viewed reforming surgical education as central to this core mission.49 The ACS also feared irrelevancy following the formation of the Board, concerned that young surgeons seeking board certification would ignore the College and thus diminish its role. As such, the College demanded residency for all Fellows after 1938.50 Now that they required residency, the ACS shouldered the responsibility of inspecting and approving programs.51 The ACS Committee on Graduate Training in Surgery first met in November 193752 and outlined their expectations for residency programs.53 “There are really two problems that confronted us,” noted an internal report. “One was the ideal training for the surgeon and the other was the graduate training which is necessary for every man to have before he can become a member of the American College of Surgeons.”54 Despite having two problems, they sought a single system of training. This decision created tension between elites, who thought standards too low, and community practitioners who felt they were too stringent, but the committee repeatedly rebuffed suggestions to adopt a two-tier system in their effort to preserve professional unity. The College recognized that the AMA already had established criteria and an inspection system in the 1920s and inquired about collaborating.55 The AMA politely declined a joint venture,56 prompting the College to establish their own, separate system.57 Largely adopting the AMA standards, the Committee insisted on 24 months following internship, compromising between AMA and Board requirements.58 However, the Committee deliberately avoided imposing strict, specific criteria.59 Recognizing that conditions and opportunities differed considerably around the country, they insisted “the emphasis should be on standards, not on standardization.”60 There was an ideal that residencies must embrace, but no procrustean checklist for approval. The American College of Surgeons surveyed and inspected each program.61 The ACS already inspected almost every hospital in the United States as part of an initiative dating to 1918 to ensure patients received surgery in safe, modern facilities.62 The residency approval evaluation modeled itself after this system and relied on its infrastructure to expand. A typical visit lasted two to three days and included tours of the physical plant, discussions with faculty and residents, and efforts to evaluate research opportunities and didactic learning. The ACS paid for the entire process.63 Determined to advance surgical education and not just judge that which already existed, the College worked with sub-standard programs, often provisionally approving them as an incentive while helping improve their curricula. The inaugural inspection in 1937 evaluated 270 hospitals, approved eighty-nine (thirty-three percent) fully, forty-six (seventeen percent) provisionally, and rejected 135 (fifty percent).64 The results limned the state of surgical education at that time. Variability characterized the findings: “one of the most striking impressions as a result of this study is the complete lack of a basic standard or uniformity in the methods of graduate training.”65 Both structure and content differed among hospitals, with residencies ranging from one to five years in length.66 Programs varied tremendously in content with some eliding entire disciplines like urology, orthopedics, or thoracic surgery, raising the question of what “general surgery” included.67 The surveyors repeatedly lambasted the lack of basic science, post-mortem examinations, and formal didactic teaching conferences, particularly in community hospitals.68 The College published these results in the 1939 Bulletin of the American College of Surgeons that they freely distributed around the country.69 The publication and distribution cost the College $9,000 in 1938 ($155,000 in 2017 USD) – a monumental expenditure for a non-profit organization in the Great Depression. Such spending highlights the importance the College placed on disseminating both their requirements and a list of the programs that satisfied them.70 Letters from deans of academic institutions like Yale, smaller schools like the College of Medical Evangelists in Loma Linda, California, and the Women’s Medical College of Pennsylvania praised the report and pledged to raise their programs to its standards.71 J. Curran, dean of the Long Island College of Medicine, “believe[d] it to be one of the finest things of the kind I have seen,” a sentiment Dean C. Poynter of the University of Nebraska echoed while adding somewhat wistfully, “I wish it were as easy to get this program started as it is to talk about it. Certainly the movement is in the right direction and out of it should come a generation of very much better trained men than the last generation furnished.”72 The next generation of students and teachers appeared eager for this opportunity. Interns commenced writing the College, querying which hospitals had or would receive approval and basing their residency decisions thereupon. Following the release of the report, over 100 hospitals contacted the College, asking to be inspected in 1940.73 Programs wanted ACS imprimatur to attract more qualified residents, and residents sought out ACS-approved programs to ensure entrance into the College and boards, with all the advantages membership entailed.74 Less cynically, there remained a real commitment to improving the quality of training and a desire among trainees to receive the best education possible. While this era lacks confirmatory data, the benefits of having someone with three years of structured training operate instead of a general practitioner seemed self-evident to contemporaries. As organizations like the American Board of Surgery came to depend on College inspection and approval,75 and as more programs sought certification, the rather generic provisions applied in 1938 gave way to increasingly detailed requirements in 1941, when the College published eleven full pages of specifications.76 This shift signified a notable departure in surgical education, transitioning from highly variable experiences around the country to a more rigid national standard that, ideally, ensured every graduate from an approved program would possess a common set of intellectual and technical abilities, irrespective of whether they came from an academic or community hospital.77 Requirements emphasized excellent faculty to teach not just surgery but also pathology, radiology, and anatomy, buttressed by new attention to physiology, then viewed as the vanguard of surgical research.78 The committee focused on both the quantity and variety of cases residents performed. They also continued to mandate research, which particularly challenged community programs. By 1941, the College had approved 185 hospitals, an impressive achievement, but still not approaching the needs of American patients.79 With the onset of World War II, reform efforts paused. These 1941 standards expose how much surgical residency had changed since its inception at Johns Hopkins. Fundamentally, its underlying purpose had shifted from producing “surgeons of the highest type,” who populated the ranks of research institutions, to training both academicians and especially practicing community surgeons. This move paralleled developments in graduate medical education for other specialties.80 Form followed function. For example, surgery residencies began evolving away from Halsted’s pyramidal construction, which intentionally produced a limited number of surgical professors. While castoffs in the 1910s had adequate training to practice contemporary surgery and sufficient credentials to land work as surgeons, by the 1930s they lacked both. In 1940, Edward Churchill, chair at the prestigious Massachusetts General Hospital, publicly broke with Halsted’s pyramid, commenting that “half a surgical training is about as useful as half a billiard ball.”81 He established a rectangular program that expected everyone accepted as a resident to complete all four years of training, arguing this arrangement would produce desperately needed surgeons in a more collegial environment.82 This was not the first rectangular program,83 and indeed the College had been discussing promoting that arrangement for several years, but its attachment to Harvard and its association with prominent surgeons like Churchill provided the credibility necessary for its wide adoption across America.84 Churchill and others similarly shifted the focus of even academically affiliated programs to producing more community practitioners.85 By the start of World War II, the ideal surgery residency differed markedly from that which Halsted had proposed in number of years, breadth of clinical experience, command of basic science, and engagement in original research. A few dozen academic institutions cleaved closely to the original concept of producing surgical professors, but most programs emphasized creating safe, competent clinical surgeons for the community, compromising ideal standards in favor of achievable ones. Despite these efforts, the practice of surgery remained dominated by generalists. Private practice did not require fellowship or residency, so why should a doctor spend the time and expense of an additional two to three years in school? Leaders like Graham and Churchill – not incidentally pioneers in the new field of chest surgery – argued that modern surgery had exceeded the ability of generalists to practice safely; others proffered professional benefits. The experience of World War II demonstrated the importance of both elements. World War II and the Surgical Residency World War II and the years immediately following it profoundly affected surgical training. Federal policies during the war and after promoted board certification. The GI Bill and especially government hospital systems rapidly expanded residency opportunities. This period demonstrates the early and critical role of the Federal government in the establishment of graduate medical education. While World War II ultimately led to the rapid expansion of surgical residencies, the war years themselves undermined efforts from the 1930s. The military effectively conscripted surgeons, eviscerating the faculty at most programs.86 A mandatory abbreviated regimen for graduate medical education called the 9-9-9 system vitiated residencies, diminishing multi-year programs into a few short months.87 In the early years of the war, with its outcome uncertain88 and policies yet undefined, this plan seemed reasonable and met few objections,89 but as the war dragged on choruses of protest arose. The American College of Surgeons came to believe the 9-9-9 scheme “seriously retarded education in the medical and surgical specialties.”90 Evarts Graham, who chaired the National Research Council’s Committee on Surgery during the war, railed against the plan in both professional journals and lay publications like The Saturday Evening Post, pointing out that neither West Point nor the Naval Academy had shortened their curricula, and neither should medicine.91 The plan also shrunk the absolute number of surgical residents by nearly fifty percent, the first decline since Halsted had established his program nearly a half-century earlier (see figure 1). Fig. 1. View largeDownload slide Total number of residents in ACS approved programs during war years88 Fig. 1. View largeDownload slide Total number of residents in ACS approved programs during war years88 While military policies crippled the residency system during the war, they ultimately catalyzed its expansion and acceptance. Recognizing the benefits of fully-trained surgeons, the Armed Forces used board status almost exclusively to identify them.92 The Board actively campaigned for this distinction, appreciating the implications of official, federal imprimatur on the appeal and relevance of board certification.93 Board-certified surgeons enjoyed superior rank, resulting in greater prestige and higher pay than those not certified. Moreover, the military placed them in jobs and locales where they could actually practice surgery rather than being relegated to more general duties like many self-identified surgeons.94 After the war, the federal government continued to demonstrate preference for board-certified physicians by awarding them salaries twenty-five percent higher than their non-boarded colleagues at Veterans Administration hospitals.95 The practical and professional perquisites the military and federal government granted board-certified surgeons combined with a motivation to finish training curtailed by the war led military medical veterans to pursue both the educational and the credentialing benefits of board certification.96 They recognized this path required completion of an approved residency. The AMA demonstrated this desire for graduate medical education through a survey: over eighty percent of uniformed doctors intended to pursue some form of additional schooling after the war; sixty-three percent hoped to obtain board certification.97 Extrapolating from these data, the College anticipated 15,000 postwar students of surgery.98 Before the war, the College had approved roughly 600 positions per year. Accommodating these numbers required substantial effort and financial support that the federal government helped provide. The government greatly facilitated the process by declaring residency eligible for funds under the GI Bill of Benefits,99 a freighted decision that inherently classified the experience as education, not service.100 Before World War II, hospitals reimbursed interns and residents with room and board and, sometimes, a small stipend. Residents covered by the GI Bill received a salary and funding for room and board outside the hospital – a radical change from the monastic, pre-war conditions that challenged poor housestaff and effectively prohibited families. Hospitals also benefitted now that the federal government paid for veterans’ residencies.101 The federal government helped accommodate the deluge of applicants by creating residency positions in both Veterans Administration (VA) and military hospitals. In the initial ACS survey of twenty VA hospitals in 1944, only seven had general surgery departments certified to educate residents, and even then they received only provisional approval.102 By August 1947, the College had accredited fifty-one VA hospitals for 750 surgical residency slots per year – more than all approved civilian positions created between Halsted’s program and the end of the war, illustrating the enormous effect of the government on the postwar expansion of residency.103 Generating programs in VA hospitals corresponded with the concomitant rise of the institutions generally and particularly with the efforts to link them to academic medical centers.104 VA hospitals offered a wealth of clinical material. More importantly, they provided a patient population that residents could treat independently, a category health insurance was slowly eliminating, to the great consternation of the ACS and other leaders.105 However, the lack of female and pediatric patients along with inadequate facilities for basic science and research necessitated partnering of VA hospitals with academic medical centers in order to meet standards.106 These same difficulties bedeviled military hospitals as they sought ACS approval.107 The decisions of the VA, Public Health Service, and military to pursue ACS certification for their residencies underscores the contemporary importance of those standards, as government hospitals had no explicit or legal need to seek approval, being able to set their own licensing policies. The military actually began using the promise of approved residencies to recruit physicians into uniform, highlighting the demand for that training in the 1940s.108 The postwar expansion of residencies resulted not just from the “push” of doctors seeking additional training, but also from a “pull” by hospitals requiring their manpower and expertise. The exponential increase in hospitals partly fostered this need: in 1946, the VA planned to add 60,000 beds to accommodate World War II veterans.109 The Hill-Burton Act of 1946 concurrently drove the construction of thousands of civilian hospitals around the country.110 Both the number and the complexity of patients rose. The range and invasiveness of operations increased, as indications for thoracic and abdominal explorations expanded, and new fields like heart and transplant surgery emerged.111 These new procedures far outstripped the abilities of general practitioners, who often met disastrous results when attempting them.112 Deadly outcomes led to hospitals requiring the completion of approved residencies before obtaining operating privileges, further increasing the demand for residency.113 Perioperative care came to include antibiotics, chemotherapy, and hemodialysis, to name but a few new interventions, all necessitating physician management. Whereas in the 1930s, major hospitals could still function without housestaff, in the postwar years these facilities relied on residents to care for patients. Anticipating both the deluge of returning veterans eager for training and their own rising need for residents, hundreds of civilian hospitals approached the College to request approval for their programs.114 The American College of Surgeons recognized these forces. Many of their leaders had contributed to surgical developments, memorialized in their self-published Fifty Years of Surgical Progress, and realized the post-World War II surgeon needed quality graduate medical education to operate safely and competently.115 The College also wanted to accommodate the flood of returning veterans, partly because they believed that creating training opportunities for them was “the most useful and patriotic activity in which the College could engage.”116 They simultaneously recognized the disparity between the number of residencies sought and the availability of certified positions, and they feared physicians would settle for unapproved programs, dealing “a serious setback to the standards of surgical practice.”117 As such, after issuing a new set of policies in 1945 that mandated three years of residency to match Board prerequisites,118 the College increased postwar inspections as rapidly as logistics permitted. From 1941 to 1945, the number of approved residencies barely budged (514 to 578), but from 1945 to 1950, they nearly doubled (578 to 1129) (see figure 2).119 Fig. 2. View largeDownload slide Increase in ACS approved surgical residency programs, 1940-1960121 Fig. 2. View largeDownload slide Increase in ACS approved surgical residency programs, 1940-1960121 The ACS performed another round of inspections between 1945 and 1947 that provides unique insight into their approval process through examining rejections.120 Over those two years, the College denied approval to 216 general surgery programs. (Notably, rejected residencies did not necessarily close; large numbers of poor training 121opportunities remained available but did not qualify graduates for ACS fellowship or board certification). For all the emphasis on basic science in the printed requirements, the report cited deficiencies in that arena far fewer times (9) than it noted a lack of clinical material (58).122 The high number of withdrawals (78) perhaps explains this discrepancy. However, the disconnect demonstrates the practical prioritization of clinical experience over basic science, again exposing the compromises necessary in rapidly expanding training opportunities. As programs spread from large cities to smaller towns like Teaneck, New Jersey, and Janesville, Wisconsin, hospitals struggled to demonstrate sufficient patient volume or diversity to satisfy the College. They also strained to hire competent faculty, evidenced by the 39 rejections for insufficient staff, reflecting the dearth of individuals in the country with enough training and experience to educate the next generation. The College was not the only organization approving residencies: The AMA continued performing this function separately. However, they had less rigorous standards, reflecting their particular mission. Whereas the College concentrated on raising the quality of surgery, the AMA felt responsible for American medicine more broadly, which in 1945 still consisted mostly of general practitioners. The AMA could not afford to alienate the generalists who comprised the vast majority of their constituency by insisting on stringent requirements for every doctor removing an appendix. Moreover, they recognized that in 1945 an ACS fellow, much less a board-certified surgeon, remained unavailable to most Americans and endeavored to increase the number of clinicians with at least a modicum of operative training. However, in the rush to create spaces for returning veterans, the AMA accredited many programs provisionally without physically inspecting them.123 By 1948, the Association admitted to a backlog of over 550 residencies requiring inspection in addition to another 350 necessitating re-inspection;124 these represented almost half of all AMA-sanctioned programs.125 Many of the hastily certified programs after the war failed their students. Provisionally approved AMA residencies were considered especially dreadful, with the majority still lasting only a single year (after internship).126 The rapid pace of inspection also degraded the ACS process, especially as efforts centered on traditionally weaker community programs.127 Allan Whipple, a Columbia surgeon crucial to the creation of graduate medical education in the 1930s, cautioned that “unless we are careful, this is going to snowball and the distinction of residency training is going to disappear.”128 Whipple clearly envisioned residency as not just a training opportunity but also as a mark of qualification in and of itself, and its postwar adulteration pained him. Like Whipple, the American Board of Surgery grew quite concerned over the quality of many of the residencies established after the war and the implication this had on patient care.129 In 1944, the Board still accepted the College’s list of accredited programs without reservation.130 By the end of 1945, however, they found the inspection process “in a state of confusion which serves to embarrass and interfere with the work…of the Board.”131 They criticized the reliance on surveys over inspections and especially the low quality of instruction and autonomy at many hospitals. The Board’s president, Warfield Firor, similarly expressed the organization’s dissatisfaction with the AMA’s approval process.132 “It was clear to the American Board” of Surgery, remarked Firor, that “too many candidates were coming up to take the examination and failing, obviously not having had adequate training.”133 The Board briefly attempted to run its own inspection service, but cost, impracticality, and redundancy of others’ efforts led to abandonment after a single year.134 Bureaucratic Bickering, Professional Power Plays, and the Creation of a Joint Residency Review Committee By the late 1940s, the American Medical Association, American College of Surgeons, and American Board of Surgery all recognized the pressing need for a joint committee to inspect residencies, evaluate their qualifications, and publish a single list of approved programs. Economically, running three separate systems was not sustainable, particularly with the rapid increase in the number of hospitals. Through 1944, the College spent $1,750,000 ($24.6 million 2017 USD) to support the enterprise and predicted requiring an extra $100,000 ($1.3 million 2017 USD) per year for five years after World War II just to accommodate the surge of applications.135 Hospitals, while anxious for certification to recruit more qualified residents, grew confused over the multiplicity of standards and weary over the seemingly constant inspections by different organizations. Residents who graduated from a program approved by one body but not another found themselves in an awkward, liminal space.136 Yet despite the mutually accepted need for and benefits of a joint committee, the three surgical organizations required nearly twenty years to effect one. This section analyzes the discontinuous efforts to create a single inspection service and how the conflicts among these three societies reveal a deeper struggle for control over the American surgical profession. Serious negotiations for a joint inspection service began after World War II. Despite appeals from the Board, the College and the AMA failed to reach any agreement in the 1930s, when the task remained manageable for individual organizations.137 The postwar expansion of residencies challenged this feasibility, prompting intense negotiations between 1946 and 1950. Despite the universally recognized need for a joint committee, each organization wanted to maintain autonomy and control, complicating the arrangement of even a preliminary gathering, which finally occurred on 21 February 1948.138 “What we would like to do is to have a coordinated effort that would satisfy everyone,” declared Chicago surgeon Arthur Allen, elected chair of the joint committee, who went on to warn ominously: “whether we can bring that about remains to be seen.”139 Further dialogue met considerable obstacles. The AMA accused the College of growing skittish about losing its role in the inspections, changing the language of the preliminary resolution, and scuttling the deal.140 The College believed the AMA not only continued to approve inadequate programs but also sought to exclude the College from the process, leaving a trail of poorly prepared surgeons in its wake.141 Decades-old tensions among the organizations exacerbated the squabbling, and the remainder of 1948 and 1949 saw no real progress. No single organization had the tools necessary to implement a residency review system independently. The AMA had the financial and material resources but lacked credibility in the surgical community. The College had built a powerful reputation among American surgeons and had developed most of the policies used to evaluate programs, but by 1950 the ACS was running out of money. Professionally, it saw itself being slowly eclipsed by the Board. The Board found itself in an awkward position with the promise of future authority but little current power. Post-World War II American medicine moved increasingly toward expecting board certification,142 but in the 1940s and 1950s, board status remained rare outside the elites. In Michigan, for example, board-certified surgeons performed fewer than twenty percent of appendectomies and thirty percent of hernia repairs in 1955.143 “It’s fine to talk about our Boards,” lamented Frederick Coller, former president of the ACS and future first chair of the joint residency review committee, “but they are not the ones doing the majority of our operations.”144 The Board had little ability to cajole surgeons to follow their lead. Moreover, the Board lacked both the infrastructure and the finances to assume control over the residency approval process. Membership paled compared to the AMA and ACS. In 1947, for example, 2904 surgeons were board-certified.145 In comparison, the College boasted 14,750 fellows and the AMA 132,224 members.146 Budgets reflected membership.147 Since no individual society could manage alone, and as all three wanted to maintain control over American surgery, circumstances forced them to work together. On 1 July 1950, after years of contentious negotiations, the AMA, ACS, and ABS agreed to create a tripartite residency review board, dubbed the Conference Committee on Graduate Training in Surgery, and publish a single list of approved programs based on common criteria largely derived from the College’s 1945 requirements.148 Significantly, the Conference Committee mandated three progressive years of residency (following an approved internship), meeting the minimum standards of the Board and College and substantially increasing the one-year the AMA had demanded.149 Convinced a true Conference Committee had finally emerged (and running out of money to function independently), the College ceased its independent inspections later that summer.150 Within months, the agreement fell apart. Five acrimonious years of increasingly shrill debates followed. All parties theoretically accepted the arrangement; arguments erupted over the execution. The Board and College initially grew frustrated with the comparatively poor-quality programs the AMA kept on the list and their powerlessness to remove them.151 Later quarrels focused on who received credit, particularly between the ACS and AMA who were both struggling to remain relevant as the boards rose in importance. A lengthy dispute broke out over stationary and what name(s) would appear on the letterhead.152 Other issues bubbled to the surface over which organization would seat the permanent secretary on the Committee, who would sign the letters of approval, and the like, preventing the Committee from functioning. Superficially, arguing over stationary appears risible given broad agreement on substantive issues. However, this picayune bickering belied a deeper, political disagreement over who controlled American surgery. Vituperative language hinted at the stakes. Decrying the AMA’s backtracking on several negotiated points, Paul Hawley, executive director of the College, confided to Alfred Blalock, his sympathetic colleague and the chair at Johns Hopkins, “I feel about this [situation] much as the country is beginning to feel about Russia, that the time has come to stop appeasement and to take a very firm stand.”153 Comparing the AMA to communist Russia in October of 1950 with McCarthyism and the Korean War raging demonstrates the extent of his fury and the widening gulf between the two organizations. The sense of betrayal among College leaders rippled through meeting minutes.154 Certainly, the College feared a lower standard driven by an AMA that was trying to appease a core membership of general practitioners, but more acutely, they dreaded being eliminated from the conversation. Frustrated by what he saw as perfidy of the AMA and the complicity of the Board, Hawley unsuccessfully campaigned to have his allies elected to the ABS to out maneuver the AMA, a desperate tactic by a leader believing his organization besieged.155 The AMA in turn believed that even if it had modified the structure of the Conference Committee, the overall mission, purpose, and execution remained unchanged, and the College was merely complaining over symbolic gestures.156 The AMA argued that the Conference Committee retained its core features and that if all the College really wanted was an effective approval process, then it should not matter who received the credit. By 1952, the AMA had grown weary of constant conflict, wondering if “it [was] necessary or wise to continue to be so polite and self-effacing” to an organization they saw in decline, and began pursuing independent alternatives by trying to form bipartite committees with the Board, excluding the College entirely.157 They briefly flirted with International College of Surgeons as a substitute for the ACS, but they were forced to retreat from this proposal when both the Board and the American College of Surgeons vehemently opposed it.158 Attempting to exclude the College epitomized the internecine struggle to shape American surgery in the mid-twentieth century. As board certification remained a comparatively rare qualification, the demarcation of who was an acceptable, adequate surgeon hinged on the completion of an approved residency program. Thus controlling the residency approval process provided an opportunity to shape the profession of surgery in one’s image, with the Board representing elite, academic surgery, the College practicing, full-time surgeons, and the AMA general practitioners who operated. Each society fiercely fought for its constituency – and for itself. In 1955, the three organizations came together and agreed on a Conference Committee, eventually dubbed the Residency Review Committee, which has endured. Core elements remained from 1950, with the AMA continuing to inspect programs, and a group of representatives from the AMA, ACS, and ABS meeting to approve or reject them based on criteria that matched requirements needed for board certification. The committee published a single list and mailed a single letter on mutually agreeable stationary. Archival records do not explain the sudden détente: no specific event or personnel changes occurred. Speculatively, as the Board increased in power and prestige, the AMA and the College recognized the need to cooperate to maintain relevancy. Weariness from constant fighting for years likely contributed. That internal medicine recently agreed on a similar format may also have motivated them. The solution reached for surgery in the form of the Residency Review Committee quickly spread to other specialties, serving as a model for residency reform nationally. Conclusion By 1955, the profession had established an effective, regimented, and regularized system for producing new surgeons. The route from medical school graduate to surgeon – with its expectations, challenges, and demands – was clear to both trainees and their teachers. Crucially, the path to become a surgeon had become standardized. Certainly, residencies differed among institutions, with distinctions between academic and community programs remaining starkest. But these differences paled compared to the homogeneity surgical training had achieved in a half-century. Whereas in 1900, few formal educational opportunities for surgery existed in this country, by 1955 the profession had created and implemented a single portal of entry defined by its training. This process unveils several themes. The transition from rare professorial programs to nearly universal residency training reinforces the idea that specialization starts with research demands before extending gradually into clinical practice.159 It also laid bare the compromises in length, original investigation, and overall quality that were necessary to extend this training to the majority of surgeons via community programs. The diffusion of residencies exposes both the power and limitations of professional organizations. Seizing the initiative to reform graduate medical education, these societies expended enormous resources to establish and enforce national standards, which varied per the constituency of each organization. With firm criteria, they tried to improve the quality of American surgery by demanding their members complete a regulated residency. While participation increased in the 1930s, significant expansion ultimately required the power of the federal government in the post-World War II years, whereupon residency training came to define the American surgeon. This standardization created a national cadre of well-trained clinicians with two concrete outcomes. First, although this era lacks confirmatory statistical data, the claims of the participants in these reforms seem valid: namely, that relying on residency training improved the care patients received, from the accuracy of diagnosis, to the technical quality of an operation, to the post-operative care delivered. Second, this broad education catalyzed the dissemination of new, increasingly intricate interventions. Fields like vascular and orthopedic surgery progressively incorporated complicated procedures like anastomosis and osteosynthesis, while entirely new specialties of cardiac and transplant surgery emerged. These changes relied on a population of surgeons who had sufficient training to manage patients both intra- and peri-operatively.160 The rise of residencies created that community. Thus, exploring the history of residency not only details the formalization of surgical training but also, through examining both the battles for professional control and the development of more complex operations, illuminates the history of surgery in America. Acknowledgements The author is grateful to all those who read, commented on, and vastly improved earlier drafts of this paper, especially Dale C. Smith, Kenneth M. Ludmerer, Mary A. Brazelton, Ashley Morgan, John Harley Warner and the two anonymous reviewers at JHMAS. Presentations at Yale University’s Holmes Workshop and Beaumont Lecture Series as well as the American Association for the History of Medicine provided valuable feedback. Archivists crucially availed me of source material, particularly Susan Rishworth and Delores Barber at the American College of Surgeons, Amber Dushman at the American Medical Association, Tom Biester at the American Board of Surgery, Jessica Murphy at Countway Library, and Stephen Logsdon at Becker Medical Library. Funding from the Michael E. DeBakey Fellowship in the history of medicine, Bernard Becker Medical Library travel scholarship, the Josiah Charles Trent Memorial Foundation Grant, and Duke Department of Surgery supported this research. None of this would be possible without my supportive family, who corrected many iterations of this paper over the years. Footnotes 1 Kenneth M. Ludmerer, Let Me Heal: The Opportunity to Preserve Excellence in American Medicine (New York: Oxford University Press, 2015). Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971). See also Heather Varughese John, “Practicing Physicians: The Intern and Resident Experience in the Shaping of American Medical Education, 1945-2003,” (PhD diss., Yale University, 2013). 2 Charles L. Bosk, Forgive and Remember: Managing Medical Failure, 2nd ed. (Chicago: University of Chicago Press, 2003 (1979)). Pearl Katz, The Scalpel’s Edge: The Culture of Surgeons (Boston: Allyn and Bacon, 1999). Rachel Prentice, Bodies in Formation: An Ethnography of Anatomy and Surgery Education (Durham: Duke University Press, 2013). 3 See, for example, Delia E. Garvus, Men of Strong Opinion: Identity, Self-Representation, and the Performance of Neurosurgery, 1919-1950) PhD diss, University of Toronto, 2011). 4 In 1880, only 267 operations were performed in Jefferson Hospital; in 1890, there were only 291 surgeries at Charity Hospital in New Orleans. Gert H. Brieger, “A Portrait in Surgery: Surgery in America, 1875-1889,” Surgical Clinics of North America, 67, no. 6 (1987): 1181-1216, p. 1207 for numbers. 5 Samuel Gross, “Surgery,” American Journal of Medical Science LXXI (1876): 431-84, see quote p. 432. 6 William G. Rothstein, American Physicians in the Nineteenth Century: from Sects to Science (Baltimore: Johns Hopkins University Press, 1992). For the role of the Civil War, see Shauna Devine, Learning from the Wounded: The Civil War and the Rise of American Medical Science (Chapel Hill: The University of North Carolina Press, 2014). 7 Ludmerer, Let Me Heal, chapter one. For surgical examples, see J. M. T. Finney, A Surgeon’s Life: The Autobiography of J.M.T. Finney (New York: G.P. Putnam’s Sons, 1940), chapter five. J. Collins Warren, To Work in the Vineyard of Surgery (Cambridge: Harvard University Press, 1958), chapter seven. The first American hospital house officer dedicated to surgery was John Collins Warren, appointed in 1830 for one year at Massachusetts General Hospital. By 1894, twelve surgical house officers served MGH, although the experience did not produce fully trained surgeons, which required additional apprenticeship. Hermes C. Grillo, “To Impart this Art: The Development of Graduate Surgical Education in the United States,” Surgery 125 (1999): 4-5. With the exception of gynecological surgery, men dominated the surgical profession through the years described in the paper. For further discussion, see Regina Morantz-Sanchez, Conduct Unbecoming a Woman: Medicine on Trial in Turn-of-the-Century Brooklyn (New York: Oxford University Press, 1999). 8 J.J. Walsh, “Post-Graduate Medical School and Hospital,” History of Medicine in New York 2 (1919): 573-93. Steven J. Peitzman, “‘Thoroughly Practical’: America’s Polyclinic Medical Schools,” Bulletin of the History of Medicine 54 (1980): 166-87. Ira Rutkow, “The Education, Training, and Specialization of Surgeons: Turn-of-the-Century America and Its Postgraduate Medical Schools,” Annals of Surgery 258 (2013): 1130-6. 9 John Harley Warner, Against the Spirit of System: The French Impulse in Nineteenth Century American Medicine (Princeton: Princeton University Press, 1998). Thomas N. Bonner, American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870-1914 (Lincoln: University of Nebraska Press, 1963). 10 Franklin H. Martin, Fifty Years of Medicine and Surgery: An Autobiographical Sketch (Chicago: The Surgical Publishing Company of Chicago, 1934), quote p. 28; see chapter 7 for his surgical education. 11 W. G. MacCallum, William Stewart Halsted: Surgeon (Baltimore: The Johns Hopkins University Press, 1930). Samuel J. Crowe, Halsted of Johns Hopkins: The Man and His Men (Springfield, IL: Thomas, 1957). The fullest picture of the man may be found in George Heuer “Dr. Halstead,” Bulletin of the Johns Hopkins Hospital 90, no. 2, Suppl. (1952): 1-109. Gerald Imber, Genius on the Edge: The Bizarre Double Life of Dr. William Stewart Halsted (New York: Kaplan, 2010). More recently, Howard A. Markel wrote a history focusing on Halsted’s work with and addiction to cocaine: An Anatomy of Addiction: Sigmund Freud, William Halsted, and the Miracle Drug Cocaine (New York: Pantheon, 2011). 12 For a discussion of how Halsted built off Osler’s medicine residency, see Alan M. Chesney, The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle: Volume I: Early Years, 1867-1893 (Baltimore: The Johns Hopkins University Press, 1943), 161-2. Ludmerer shows how Osler and Halsted melded the American tradition of apprenticeship with the science-based, more didactic Teutonic experience to form a uniquely American training paradigm. See Ludmerer, Let Me Heal, chapter two. 13 William S. Halsted, “The Training of the Surgeon,” in The Surgical Papers of William Stewart Halsted ed. Walter C. Burket (Baltimore: The Johns Hopkins University Press, 1924) vol. II, 528-9. 14 Halsted, “The Training of the Surgeon,” 527. 15 B. Noland Carter, “The Fruition of Halsted’s Concept of Surgical Training,” Surgery 32 (1952): 518-27. 16 A. McGehee Harvey, “The Influence of William Stewart Halsted’s Concepts of Surgical Training,” The Johns Hopkins Medical Journal 148 (1981): 215-36. 17 Ludmerer, Let Me Heal, 56-7. 18 He also enabled residents to spend one to two years free from clinical duties to perform research, a model that quickly expanded to other academic programs and endures today. C. Barber Mueller, Evarts A. Graham: The Life, Lives, and Times of the Surgical Spirit of St. Louis (London: BC Decker, Inc., 2002), 204-9. 19 Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985). 20 Gert H. Brieger, “Surgery,” in The Education of American Physicians: Historical Essays, ed. Ronald L. Numbers (Berkeley: University of California Press, 1980): 175-204. 21 Graduate Medical Education: Report of the Commission on Graduate Medical Education (Chicago: University of Chicago Press, 1940) 31. American Medical Association, A History of the Council on Medical Education and Hospitals of the American Medical Association (Chicago: 1957) 21. Ludmerer, Let Me Heal, chapter four. Some medical schools required internship to obtain the MD degree. 22 Ludmerer, Let Me Heal, chapters three and four. 23 Graduate Medical Education, chapter three. AMA, A History of the Council on Medical Education and Hospitals of the American Medical Association. “Essentials of Approved Residencies and Fellowships,” JAMA 112 (1939): 1386-92. 24 Dale C. Smith, “Appendicitis, Appendectomy, and the Surgeon,” Bulletin of the History of Medicine 70, no. 3 (1996): 414-41, see pp. 416-7. 25 “Committee for Graduate Training for Surgery,” 1936, American College of Surgeons Archives, Chicago, Illinois (hereafter ACS Archives), Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 3, pp. 1-2. 26 For a list of common surgical procedures performed in the 1880s, see Arthur Dean Bevan, “The Study and Teaching and the Practice of Surgery,” Annals of Surgery 98 (1933): 481-94, list p. 482. 27 The literature on anesthesia and germ-free surgery is vast. For an American focus, see, to start: Martin Pernick, A Calculus of Suffering: Pain, Professionalism, and Anesthesia in Nineteenth-Century America (New York: Columbia University Press, 1985) and Thomas P. Gariepy, “The Introduction and Acceptance of Listerian Antisepsis in the United States,” Journal of the History of Medicine and Allied Sciences 49 (1994): 167-206. Peter J. Kernahan, “Franklin Martin and the Standardization of American Surgery,” (PhD diss., University of Minnesota, 2010). 28 Charles E. Rosenberg, Care of Strangers: The Rise of America’s Hospital System (New York: Basic Books, 1987); see chapter 6 for the relocation of surgery to hospitals. 29 See Susan M. Reverby, Ordered to Care: The Dilemma of American Nursing, 1850-1945 (Cambridge: Cambridge University Press, 1987) and Patricia D’Antonio, American Nursing: A History of Knowledge, Authority, and the Meaning of Work (Baltimore: The Johns Hopkins University Press, 2010) chapter one. The author is grateful to Naomi Rogers for suggesting these sources. 30 Joel D. Howell, Technology in the Hospital: Transforming Patient Care in the Early Twentieth Century (Baltimore: The Johns Hopkins University Press, 1995) 57 and 62 (cited in Kernahan, “Franklin Martin and the Standardization of American Surgery,” 44). 31 Between 1880 and 1890, the literature described over 100 new operations. Morris J. Fogelman and Elinor Reinmiller, “1880-1890: A Creative Decade in World Surgery,” American Journal of Surgery 115 (1968): 812-24, cited in Kernahan, “Franklin Martin and the Standardization of American Surgery,” 43. 32 In his classic 1892 textbook, for example, Osler repeatedly addresses the limitations of medicine to cure patients, urging practitioners to call for the surgeon early in the disease process. Michael Bliss, William Osler: A Life in Medicine (Oxford: Oxford University Press, 1999) chapters four and five. 33 Executive Committee Meeting, 14 May 1938, ACS Archives, RG5/SG2/S8/SS07, Box 2, Folder 2, p. 16. 34 Edward W. Archibald, “Higher Degrees in the Profession of Surgery,” Annals of Surgery 102 (1935): 481-96, quote p. 481. Bevan, “The Study and Teaching and the Practice of Surgery.” For the history of the Association, see Mark M. Ravitch, A Century of Surgery: The History of the American Surgical Association (Philadelphia: Lippincott, 1981). 35 Peter C. English, Shock, Physiological Surgery, and George Washington Crile: Medical Innovation in the Progressive Era (Westport, CT: Greenwood Press, 1980). Gert Brieger, “From Conservative to Radical Surgery in Late Nineteenth-Century America,” in Christopher Lawrence, ed., Medical Theory, Surgical Practice (New York: Routledge, 1992) 216-31. Thomas Schlich, “‘The Days of Brilliancy are Past,’: Skill, Style and the Changing Rules of Surgical Performance, ca. 1820-1920,” Medical History 59 (2015): 379-403. 36 Allen O. Whipple, “Opportunities for Graduate Teaching of Surgery in Larger Qualified Hospitals,” Annals of Surgery 102 (1935): 516-30. George J. Heuer, “Graduate Teaching of Surgery,” Surgery, Gynecology, and Obstetrics 54 (1932): 729-32. 37 See Pool’s comments in Whipple, “Opportunities for Graduate Teaching of Surgery in Larger Qualified Hospitals,” 527. See also George J. Heuer, “Graduate Teaching of Surgery in University Clinics,” Annals of Surgery 102 (1935): 507-15. 38 At a subsequent American Surgical Association meeting, minutes noted proudly that trained surgeons charged less than the average general practitioner to remove a gallbladder. Minutes of the 74th Meeting of the American Surgical Association, April 1954, National Library of Medicine History of Medicine Division (hereafter NLM Archives), American Surgical Association Collection, Box 1/Folder 8, p. 10. Data reflected practices in Michigan in 1953. 39 “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association,” 21 February 1948, ACS Archives, Conference Committee on Graduate Training in Surgery RG5/SG2/S8/SS03/Box1/Folder 6. 40 Eliot Friedson, Profession of Medicine: A Study of the Sociology of Applied Knowledge (Chicago: University of Chicago Press, 1988). 41 George Weisz, Divide and Conquer: A Comparative History of Medical Specialization (New York: Oxford University Press, 2006) 229. 42 Martin, Fifty Years of Medicine and Surgery. Loyal Davis, Fellowship of Surgeons: A History of the American College of Surgeons (Chicago: American College of Surgeons, 1988). David L. Nahrwold and Peter J. Kernahan, A Century of Surgeons and Surgery: The American College of Surgeons, 1913-2013 (Chicago: American College of Surgeons, 2012). 43 Peter D. Olch, “Evarts A. Graham, the American College of Surgeons, and the American Board of Surgery,” Journal of the History of Medicine and Allied Sciences 27 (1972): 247-61. Mueller, Evarts A. Graham, chapter twelve. Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter seven. 44 For sulfas, see John Lesch, The First Miracle Drugs: How the Sulfa Drugs Transformed Medicine (New York: Oxford University Press, 2007). For blood transfusions see Susan E. Lederer, Flesh and Blood: Organ Transplantation and Blood Transfusion in Twentieth Century America (New York: Oxford University Press, 2008). 45 For concerns of surgery splintering into multiple boards, see Stevens, American Medicine and the Public Interest, 235-242. The Board of Surgery was the fifteenth board formed in the United States. 46 J. Stewart Rodman, History of the American Board of Surgery, 1937-1952 (Philadelphia: J. B. Lippincott Company, 1956). Ward O. Griffin, The American Board of Surgery in the 20th Century (American Board of Surgery unpublished manuscript, 2004). 47 From its inception, the Board emphasized the importance of formal, post-graduate surgical education. See George Whipple’s comments in the minutes from 23 October 1935 as well as 15 February 1936 in “Report of the Subcommittee on ‘Ways and Means of Enlarging Present Faculties for the Training of Surgeons,” American Board of Surgery Archives in Philadelphia, PA (hereafter ABS Archives), Minutes 3-4 April 1937 and 14-15 November 1937. 48 Christopher J. Boes, Timothy R. Long, Steven H. Rose, and W. Bruce Fye, “The Founding of the Mayo School of Graduate Medical Education,” Mayo Clinic Proceedings 90 (2015): 252-263. Jennifer Gunn, “‘The First Adequate Graduate School of Medicine in America,’” Minnesota Medicine 86 (September 2003): 63-68. W. Bruce Fye, Caring for the Heart: Mayo Clinic and the Rise of Specialization (New York: Oxford University Press, 2015), 44-5, 115-8. Stevens, American Medicine and the Public Interest, 212-6 and 245-65. 49 “Conference on the Teaching of Surgery and Surgical Specialties,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 1. George Crile, “Graduate Training for Surgery,” June 1939, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 2. 50 See the 14 May 1938 amendment, “Executive Committee Meeting,” p. 14. 51 Crile, “Graduate Training for Surgery,” 1. 52 The ACS had previously formed a variety of committees to assess and make recommendations on graduate medical education that served as forerunners to the Committee on Graduate Training in Surgery. For a description of those efforts, see George W. Stephenson, American College of Surgeons at 75 (Chicago: American College of Surgeons, 1990), chapter four. George W. Stephenson, “American College of Surgeons and Graduate Education in Surgery: A Chronical of Surgical Advancement,” Bulletin of the American College of Surgeons (Special Edition) vol. 56, no. 5 (1971) 1-57, see pp. 12-31. The committee had four charges: 1) establish minimum standards; 2) ascertain which hospitals were capable of meeting those standards; 3) help establish residencies; 4) provide means of periodic inspection. See “Abstract of Minutes, Meeting of the Committee on Graduate Training in Surgery,” 28 November 1937, ACS Archives, Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 1. 53 A list of initial requirements appears in “Report of Sub-Committee of the Committee on Graduate Training in Surgery,” 11 February 1938, ACS Archives, Graduate Medical Education, RG5/SG2/S8/Box 1/Folder 1. 54 Joint Conference Committees of the American College of Surgeons and the American College of Physicians, 16 October 1938, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7, p. 2. 55 Letter to Olin West from George Crile, 13 June 1936, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. For the official ACS resolution to approach the AMA, see “Abstract of the Board of Regents Meeting,” 10 May 1936, ACS Archives, Graduate Training for Surgery Survey of Hospitals, 1938, RG5/SG2/S8/SS07/Box 2/Folder 1, pp. 3-4, 7. 56 They did not offer a reason for the rejection, although the discordant relationship between the organizations and the respective desires to lead the surgical profession (discussed below) likely contributed. Letter to George Crile from Olin West, 26 June 1937, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 14 February 1937, American Medical Association Archives in Chicago, IL (hereafter AMA Archives), p. 5. 57 “Minutes of the Committee on Graduate Training in Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box1/Folder 3, pp. 5-6. 58 See “Exhibit A to Abstract of Minutes, Committee on Graduate Training for Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box1/Folder 1, pp. 6-7. 59 For opposition to uniformity of surgical GME, see Heuer, “Graduate Teaching in Surgery,” 515. Whipple, “Opportunities for Graduate Teaching of Surgery,” 516, 520-1. Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 18. 60 Quoted in Ludmerer, Let Me Heal, 127. 61 Surveys sought basic quantifiable information like number of residents, number of operations per year, etc. “Survey for Graduate Training for Surgery,” Bernard Becker Medical Library Archives, Washington University School of Medicine (hereafter Becker Archives) Graham Papers, FC003, Box 10, Folder 65. 62 Inspection continues today as part of the Joint Commission. See Nahrwold and Kernahan, A Century of Surgeons and Surgery, chapters two, three, and twelve. Davis, Fellowship of Surgeons, 172-85, 205-22, 379-88. Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter four. 63 Initially, three surgeons employed by the ACS (Melvin Newquist, Melville Manson and Harold Earnheart) performed all the inspections, providing consistency across institutions. In 1938, it cost roughly $22,500 ($388,000 in 2017 USD). Commission on Graduate Medical Education Tentative Budget 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3. (All financial conversions completed through the U.S. Bureau of Labor Statistics online inflation calculator, http://www.bls.gov/data/inflation_calculator.htm.) The ACS also did not publish a list of residencies that failed, so programs had few disincentives to applying for approval. 64 Dallas B. Phemister, “Graduate Training for Surgery: Report of Survey,” 16 October 1938, ACS Archives, Graduate Training for Surgery Survey of Hospitals, RG5/SG2/S8/SS07/Box 2/Folder 2, p. 13. They had wanted to survey 436 hospitals, only reached 374, and only fully evaluated 270. 65 Melville H. Manson, “Report of Survey Graduate Training for Surgery,” 1938?, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 1, p. 20. 66 Of the 297 surgical residents surveyed in 1937, 118 were in one-year programs; sixty-nine were in two-year programs; seventy-one were in three-year programs; twenty-two in four-year programs; and eight in programs lasting five or more years. These lengths reflect years after internship. Programs associated with medical schools tended to be longer. Manson, “Report of Survey,” 7. 67 Ibid., 9-10. 68 Hospitals associated with medical schools (26% of those inspected) produced thirty-eight percent of graduating residents, who generally received superior training. Ibid., 20, 24. 69 Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 28-30. 70 “Commission on Graduate Medical Education Tentative Budget, 1938,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3. 71 “Administrative Board,” 23 April 1939, ACS Archives, Graduate Training for Surgery, RG5/SG2/S8/SS07/Box 2. 72 Ibid. 73 “Meeting Minutes,” 15 October 1939, ACS Archives, Graduate Education Committee RG5/SG2/S8/Box 1/Folder 3, p. 11. See also Phemister, “Graduate Training for Surgery,” p. 12, 32. “Complete Minutes, Executive Committee, 29 July 1939,” ACS Archives, Graduate Education Committee RG5/SG2/S8/Box 1/Folder 3, pp. 43-4. 74 See, for example, the efforts of Methodist Hospital in Houston to ally with neighboring Baylor College of Medicine and the local county hospital explicitly to meet ACS requirements and gain approval. “Annual Reports of the Department of Surgery, Baylor University College of Medicine, 1949-1950,” NLM Archives, DeBakey Collection, Box 9/Folder 43, p. 22. 75 The Board used the ACS list with the exception that they insisted on three years of residency, rather than the two required by the College. Minutes, 7 May 1939, ABS Archives, p. 14. 76 In comparison, the requirements for 1938 occupied a single page. “Minimum Standards Recommended by the Committee on Graduate Training in Surgery,” Manual of Graduate Training in Surgery, 1 October 1941, ACS Archives, pp. 395-406. 77 Ibid., 395. 78 The shift in attention from pathology in the 1930s to physiology in the 1940s as the central basic science for surgeons is striking. See “Minimum Standards, 1941,” 402. 79 The 1938 report approved 135 hospitals producing 380 surgeons a year; the 1939 report approved 179 hospitals producing 580 surgeons a year. Harold Earnheart, “Trends in the Graduate Training for General Surgery and the Surgical Specialties as Related to Hospitals,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 1. For 1941, see “Plans of Graduate Training in Hospitals of the United States and Canada in General Surgery and in the Surgical Specialties as of Oct. 1, 1941,” in “Minimum Requirements, 1941,” 407. 80 Ludmerer, Let Me Heal, chapters four and six. 81 Hermes C. Grillo, “Edward D. Churchill and the ‘Rectangular’ Surgical Residency,” Surgery 136 (2004): 947-52, quote p. 951. 82 Edward D. Churchill, “A Pattern for Graduate Training in Surgery at the Massachusetts General Hospital,” Report to the Trustees from the General Executive Committee, 1939, Francis A. Countway Library of Medicine, Boston, MA (hereafter Countway Archives), Churchill Collection, Box 17, Folder 45. Edward D. Churchill, “Graduate Training in Surgery at the Massachusetts General Hospital,” Harvard Medical Alumni Bulletin 14 (1940): 28-36. Edward D. Churchill, “Report to the General Executive Committee,” 20 December 1961, Countway Archives, Churchill Collection, Box 17, Folder 50. 83 Mayo Clinic, for example, pioneered a rectangular model in the 1920s. Fye, Caring for the Heart, chapters three and four. 84 See, for example, “Joint Conference Committees of the American College of Surgeons and the American College of Physicians.” Melville H. Manson, “Report of Survey of Graduate Training for Surgery,” 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 1, p. 21. “Minutes Committee on Graduate Training for Surgery,” 28 December 1938, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 1/Folder 3, p. 27. Advocates for pyramidal programs remained, arguing that the competition it fostered drove students to achieve more, and that the closer relationship between a chair and his picked chief produced the best academic surgeons. See Mark M. Ravitch, “The Surgical Residency: Then, Now, and Future,” Pharos (1987): 14; and Whipple, “Opportunities for Graduate Teaching of Surgery,” 518. 85 Churchill, “Report to the General Executive Committee.” See also Ludmerer, Let Me Heal, 174. 86 “Report on War Activities of the College,” 12 December 1943, ACS Archives, Eleanor Grimm Scrapbook, XXIV-A, p. 1. Stephenson, “American College of Surgeons and Graduate Education,” 31. 87 All medical school graduates served a nine-month rotating internship, which included two months of surgery. Thenceforth two-thirds deployed overseas and one-third remained for another nine months of specialty training. After eighteen months, half of the remaining residents shipped overseas and half continued their GME for another nine months before deploying. Of the roughly 60,000 medical men in World War II, approximately 18,000 came through this system. Charles R. Reynolds, “Department of Graduate Training in Surgery,” 1945, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. The War Department technically could not force medical schools to do anything, but it did make them an offer they could not refuse, trading hospital draft exemptions for abbreviated training. Undergraduate medical education also suffered from pressure to abbreviate their curricula. Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care (New York: Oxford University Press, 1999) chapter seven. 88 Data compiled from Phemister, “Report on Graduate Training in Surgery,” 1 and Malcolm T. MacEachern, “The Expanded Program of the American College of Surgeons for Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 9. 89 Allen O. Whipple, “The Chairman’s Annual Report to the American Board of Surgery, 1941-1942,” Countway Archives, Churchill Collection, Box 1, Folder 38. 90 “The 1945 Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 38. See also “Minutes of the Adjourned Meeting of the Committee on Graduate Training in Surgery,” 7 February 1944, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 4, pp. 9-10. The American Board of Surgery shared this belief; see Allen O. Whipple, “Report of the Chairman, 1942-1943,” in Minutes, 12 November 1941, ABS Archives. 91 Evarts A. Graham, “What Kind of Medical Officers Do the Armed Services Want?” Surgery, Gynecology, and Obstetrics 79 (August 1944): 217-9. See also Evarts A. Graham, “Have the Armed Services Crippled Medical Education?,” The Saturday Evening Post (27 January 1945): 34, 39, 41-2. For letters and newspaper clippings from hundreds of physicians opposing the 9-9-9 plan, see Becker Archives, Graham Collection, FC003/Box118/Folder1559. 92 Irvin Abell, “Medicine in the National Defense Program,” October 1940, ACS Archives, Eleanor Grimm Scrapbook, XXIV-A. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29 November 1948, AMA Archives, pp. 11-12. Stevens, American Medicine and the Public Interest, 78. Fellows of the College were upset that fellowship did not count as certification, a transition that poignantly emphasized the rising importance of the specialty boards. They confronted the government in 1946 to no avail. “ACS, ABS, and Surgical Specialties, Summary from the Minutes of Board of Regents Meeting,” 17 December 1946, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 2/Folder 1. “Report of the Washington Conference on October 25, 1946,” Becker Archives, Graham Collection, FC003/Box 130/Folder 50. 93 “Chairman’s Annual Report,” ABS Archives, ABS Minutes, 31 March 1942, pp. 3-4. ABS Minutes 13-14 December 1946, p. 1. Fred W. Rankin, an early Diplomate of the Board and, as of February 1942, the Army’s chief consultant in surgery, campaigned for the Board’s acceptance by the Office of the Surgeon General. 94 See Letter to J. Stewart Rodman from Edward Churchill, 4 January 1946, Countway Archives, Churchill Collection, Box 1/Folder 38 detailing how the Army categorized and used surgeons; Churchill was the Surgical Consultant for the North African and Mediterranean theaters. See also Stevens, American Medicine and the Public Interest, 278-9. 95 Section 8 of Public Law 293 of the 79th Congress gave specialists a twenty-five-percent pay bonus and defined specialist based solely on Board status. 96 For the effect of World War II on specialization, see Stevens, American Medicine and the Public Interest, chapter 14, especially pp. 278-9 and 297-300 and Ludmerer, Let Me Heal, chapters seven and eight. 97 For a precise breakdown by specialty of the first 11,019 returned responses, see “Meeting of the Committee on Postwar Medical Service,” 28 October 1944 in ACS Archives, Department of Graduate Training Collections, RG5/SG2/S8/SS10 Box: Correspondence and Reports, Folder 4, p. 1. For an executive summary of the 21,029 responses, see “Report of the Committee on Postwar Medical Service,” 23 June 1945, ACS Archives, Eleanor Grimm Scrapbook vol. XXIV-A, pp. 68-9. 98 Bowman C. Crowell, “Program of the Graduate Training in Surgery,” 1945, ACS Archives, Department of Graduate Training, Correspondence, and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 3, pp. 1-6. 99 For more on the effect of the GI Bill in post-World War II America, see Glenn C. Altschuler and Stuart A. Blumin, The GI Bill: A New Deal for Veterans (New York: Oxford University Press, 2009). 100 General Omar Bradley made the decision. “Post War Planning: Graduate Education of Physician Veterans Under GI Bill,” AMA Archives, CMEH Series 2.1 Graduate Medical Education, Box 27-14, Folder 1412, pp. 2-4. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 2 December 1945, AMA Archives, p. 8. The tension between education and service reverberates throughout the history of GME. See Ludmerer, Let Me Heal and John, “Practicing Physicians.” 101 Hospitals received $500 per veteran resident per year from the government for “tuition.” “The Program of Graduate Training in Surgery of the American College of Surgeons” Becker Archives, Blair Papers, FC025/Box 10/Folder 62, p. 5. 102 Paul S. Ferguson and Charles R. Reynolds, “Progress Report on Graduate Training in Surgery,” ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 5 103 By 1949, VA hospitals were training 2500 surgical residents a year in 74 locales. “Report of the Department of Graduate Training in Surgery to the Annual Meeting of Fellows of the ACS,” 11 September 1947, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, pp. 2-3. Charles Reynolds, “General Statement of Activities of the Department,” 15 December 1946, ACS Archives, Graduate Training Committee, Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 6. Paul S. Ferguson, “Report of Hospital Surveys in Graduate Training in Surgery,” 1946, ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 2. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 3-4 June 1949, AMA Archives, p. 12. Charles R. Reynolds, “Report of the Department of Graduate Training in Surgery, 1 January 1947 – 1 August, 1947,” 7 September 1947, ACS Archives, Graduate Training Committee Annual Reports to Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, pp. 3-4. Initially VA programs were separate but affiliated with medical centers; by the late 1950s, VA facilities were included as part of academic residency programs. 104 Robinson E. Adkins, Medical Care of Veterans (Washington D.C.: U.S. Government Printing Office, 1967) chapter ten. Paul B. Magnuson, Ring the Night Bell: The Autobiography of a Surgeon, ed. Finley Peter Dunne, Jr. (Birmingham: University of Alabama Press, 1986 (1960)) chapters eighteen, nineteen, and twenty-one. Letter to Deans of Medical Schools from Paul B. Magnuson, Becker Archives, Barnes Hospital Records, RG009/Box 19/Folder 14. Paul B. Magnuson and William T. Doran, “Plans of Future Medical Cooperation between Teaching Institutions and Veterans Hospitals in Proximity,” Becker Archives, Barnes Hospital Records, RG 009/Box 19/Folder 14. In 1944, only 5 VA hospitals had an association with an academic medical center; by 1946, over 30 affiliations existed (out of 109 facilities). George H. Miller, “Report on the Development of Graduate Training Programs through the Collaboration of Medical Schools with Civilian Hospitals and Government Hospitals,” 15 December 1946, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. 105 John Paul North, “Annual Report of the Surgical Residency and Training Programs and the Surgical Services Veterans Administration Hospitals, Dallas and McKinney Texas, 1956-1957,” ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 1/Folder 4, p. 3. Letter to Superintendent of Mount Carmel Mercy Hospital from Charles R. Reynolds, 27 February 1948, Becker Archives, Graham Collection, FC003/Box 7/Folder 50. See also Meeting Minutes of the Committee on Graduate Training, 22 June 1948, Becker Archives, Graham Collection, FC003/Box 7/Folder 49. Eugene Bricker, Frank Gerbode, and David Habif, “The Effect of Health Insurance Programs on Residency Training in Surgery,” Surgery 32 (1952): 333-40. 106 Malcolm T. MacEachern, “Report on Graduate Training Activities During 1944,” 17 September 1944, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 1. “Complete Minutes of the Meetings of the Committee on Graduate Training in Surgery,” 6-7 February 1944, p. 4. See, for example, the challenges of Ashburn’s Veterans Hospital in McKinney, Texas, highlighted in “The Surgical Service and its Residency Training Program Second Annual Report: July 1, 1947 to June 30, 1948,” Countway Archives, Churchill Collection, Box 17, Folder 49. 107 The Navy and Public Health Service approached the College and began modifying their programs as early as 1943. The Army postponed their effort until after World War II. “Graduate Training Army General Hospitals and to a Limited Extent in AAF and ASF, 1945,” ACS Archives, Department of Graduate Training, Correspondence and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 3, p. 1. “Minutes of the Board of Regents,” 1 April 1946, ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 2, p. 76. MacEachern, “Report on Graduate Training Activities During 1944,” 1-2. Charles R. Reynolds, “The Training Program,” in “Complete Minutes of the Meeting of the Committee on Graduate Training in Surgery,” 30 November 1945, ACS Archives, Graduate Education Committee Collection, RG5/SG2/S8/Box 2/Folder 5, p. 11. “Meeting at ACS, Abstract of Discussion of 13 February 1945,” ACS Archives, Graduate Training Committee for Surgery, RG5/SG2/S8/SS14/Box 1/Folder 1, pp. 1-4. Ferguson and Reynolds, “Progress Report on Graduate Training in Surgery,” 4-7. “Complete Minutes of the Meeting on Graduate Training in Surgery,” 30 November 1945, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 17. Reynolds, “General Statement of Activities of the Department,” 3. Paul S. Ferguson, “Report to the Board of Regents on the Graduate Training in Surgery,” 1 October 1948, ACS Archives, Graduate Training Committee, Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 1, p. 3. 108 Paul I. Robinson, MC, USA, “Presentation before the Council on Education and Hospitals,” 7 February 1948, Appendix H to “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6-7 February 1948, AMA Archives. Albert E. Cowdrey, The Medics War (Washington DC: Center of Military History, 1987) chapter 1. “Appendix E: Conference with Representatives of the Government Agencies, Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 7-10 June 1951, AMA Archives, p. 5. The History of the Medical Department of the United States Navy, 1945-1955 (Washington DC: U.S. Government Printing Office, 1958) chapters two through five. 109 Administration for Veterans Affairs Annual Report Fiscal Year 1946, Washington DC: Government Printing Office, 1946 (https://www.va.gov/vetdata/docs/FY1946.pdf) accessed 11 August 2017. 110 Rosemary Stevens, In Sickness and in Wealth: American Hospitals in the Twentieth Century (Baltimore: The Johns Hopkins University Press, 1989) 216-30. It funded 4,678 projects. 111 Nicholas L. Tilney, Transplant: from Myth to Reality (New Haven: Yale University Press, 2003) and David S. Jones, Broken Hearts: The Tangled History of Cardiac Care (Baltimore: The Johns Hopkins University Press, 2013). 112 Michael E. DeBakey, interview with Charles Morrissey, 17 December 1988, NLM Archives, DeBakey Collection, Box 9, Folder 7, p. 7. See also interview with Don Schanche, 16 June 1972, NLM Archives, DeBakey Collection, Box 2, Folder 17, pp. 52-8. Bertram M. Bernheim, A Surgeon’s Domain (New York: W. W. Norton & Company, 1947) chapter 5. 113 Minutes of the 67th American Surgical Association, 25-27 March 1947, NLM Archives, American Surgical Association Collection, Box 1, Folder 8, p. 7. 114 For requests to the ACS to survey their program, see Ferguson, “Report to the Board of Regents on the Graduate Training in Surgery,” p. 4, and Reynolds, “Report of Department of Graduate Training in Surgery, 1 January – 1 August 1947,” p. 5. 115 Loyal Davis, ed., Fifty Years of Surgical Progress, 1905-1955 (Chicago: Franklin H. Martin Memorial Foundation, 1955). 116 “Abstract of the Minutes, Board of Regents Meeting,” 5 May 1944, ACS Archives, Department of Graduate Training, Correspondence and Reports, 1944-1946, RG5/SG2/S8/SS10/Box 1/Folder 1, p. 2. See also Special Bulletin of the American College of Surgeons 30 (1945): 5. 117 “Program of Graduate Training in Surgery,” 6. “Complete Minutes of the Meeting on the Committee on Graduate Training in Surgery, 30 November 1945,” Becker Archives, Blair Papers, FC025/Box 10/Folder 62, exhibit C. Exhibit F is a nine page, single-spaced list of programs to evaluate. 118 “Fundamental Requirements for Graduate Training in Surgery,” Special Bulletin of the American College of Surgeons (September 1945): 26-36. 119 In 1946 alone, they surveyed 74 hospitals, approving 206 programs (74 civilian and 132 governmental). Reynolds, “General Statement of Activities of the Department,” p. 2. Ferguson, “Report of Hospital Surveys in Graduate Training in Surgery,” p. 2. George H. Miller and Paul S. Ferguson, “The Graduate Training Division: A General Review for the Year 1949,” ACS Archives, Graduate Training Committee Annual Reports to the Board of Regents, RG5/SG2/S8/SS09/Box 1/Folder 1, p. 2. 120 The College did not normally store material on programs it had rejected to avoid embarrassing them, but data from the postwar years did perchance survive. For these data, see the reports contained in “Hospitals Surveyed for Graduate Training in Surgery and Not Approved, January 1 1945 to December 31 1947,” ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 4. 121 Surgery programs included general surgery, otolaryngology, obstetrics and gynecology, neurosurgery, urology, thoracic surgery, and ophthalmology. Data compiled from numerous documents in ACS archives. 122 “Hospitals Surveyed for Graduate Training in Surgery and Not Approved, January 1 1945 to December 31 1947,” passim. 123 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 4-5 October 1947, AMA Archives, p. 13. Moreover, after 1945, the AMA refused to disqualify previously approved hospitals in their effort to accommodate veteran interest. The ACS did remove programs that no longer met their standards, although this rarely amounted to more than a handful in a given year. See “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 2 December 1945, AMA Archives, p. 10. 124 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals, Appendix A: Memo to the Board of Trustees of the American Medical Association, 8 July 1945,” 18-20 June 1948, AMA Archives, pp. 1-3. 125 Before World War II, the AMA had approved 610 hospitals for 5256 residency slots, numbers that nearly doubled to 1017 programs and over 12,000 spots by early 1948. “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association for Discussion of Problems of Mutual Interest,” p. 7. 126 Warfield Firor, “Residency Training in Surgery: Birth, Decay, and Recovery,” Review of Surgery 22 (1965): 153-7. 127 “Program of Graduate Training in Surgery,” p. 3. 128 “Graduate Training Committee Meeting,” 17 October 1948, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 4. 129 Report by J. Stewart Rodman in Minutes of the 66th Meeting of the American Surgical Association, 2-4 April 1946, Becker Archives, Graham Papers, FC003/Box 13/Folder 88, pp. 12-3. 130 Meeting minutes, ABS Archives, 6 May 1944, p. 3. The Boards of Orthopedic Surgery and Otolaryngology also relied on the ACS list of approved programs. 131 “Memorandum Concerning the Evaluation of Standards of Training Acceptable to the American Board of Surgery,” Meeting minutes, ABS Archives, 8 December 1945, p. 1. 132 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29 November 1948, AMA Archives, pp. 12-3. Letter to Oliver Cope from Warfield Firor, 8 August 1947, Countway Archives, Cope Collection, Box 7, Folder 32. 133 Guy A. Caldwell, “Suggestions for the Improvement of Resident Training in the Surgical Specialties and for Better Cooperation of Agencies Concerned in Approval of Training, 18 February 1948, in Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association for Discussion of Problems of Mutual Interest,” 21 February 1948, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 6, p. 21. 134 Letter to Oliver Cope from Warfield Firor, 8 August 1947, Countway Archives, Cope Papers, Box 7, Folder 32. Letter to Oliver Cope from Warfield Firor, 13 September 1948, Countway Archives, Cope Papers, Box 7, Folder 32. Frank Berry, James Barret Brown, John C. Burch, Paul B. Magnuson, Reed M. Nesbit, Wilder Penfield, and Oliver Cope, “Report to the American Surgical Association of the Committee on Graduate Surgical Education,” 1 April 1953, Countway Archives, Churchill Papers, Box 17, Folder 49. See report cards in Cope Papers, Box 7, Folder 53. The documentation for most of the institutions inspected also remains available there. 135 Crowell, “Program of the Graduate Training in Surgery,” 1. “Program of Graduate Training in Surgery,” 6-7. 136 “Minutes of the Meeting of the Committee on Graduate Training in Surgery,” 22 June 1948, ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5, p. 1. Generally, the ABS would permit a graduate from a program approved by either the ACS or AMA to sit for his boards; the ACS only offered fellowship to those who completed residency in a program from their list. 137 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6 and 9 June, 1937, AMA Archives, p. 3. Malcolm T. MacEachern, “Memorandum to the Administrative Board,” 21 June 1937, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 7. “Conference for Graduate Training of Surgery, 27 October 1937” Becker Archives, Graham Papers, FC003, Box 8, Folder 55. 138 Letter to George F. Lull (AMA) from Malcolm T. MacEachern (ACS), 3 September 1947, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 5. See also “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 4-5 October 1947, AMA Archives, p. 12. 139 “Joint Meeting of Committee of American College of Surgeons with Executive Committee of Board of Trustees of the American Medical Association,” pp. 1-2. 140 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 18-20 June 1948, AMA Archives, see Appendix E: Letter to Malcolm T. MacEachern from Donald G. Anderson, 2 July 1948 and “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 16-17 October 1948, AMA Archives, pp. 14-5. 141 “Graduate Training Committee Meeting,” 17 October 1948, 2, 6. The ACS was particularly concerned with keeping high standards for the program. See Malcolm T. MacEachern, “Principles Involved in the Coordination of Field Activities for the American College of Surgeons, the American Medical Association, and the Specialty Boards,” 31 March 1948, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box 2/Folder 1, p. 2. 142 Kernahan, “Franklin Martin and the Standardization of American Surgery,” chapter seven. Stevens, American Medicine and the Public Interest, chapters 11-15. Weisz, Divide and Conquer, 143. 143 Minutes of the 75th Meeting of the American Surgical Association, 27-29 April 1955, Becker Archives, Blair Papers, FC025/Box 6/Folder 13, pp. 12-3. For more complicated operations like gastric resection, board certified surgeons had a greater role, performing nearly fifty percent of surgeries. 144 Minutes of the 76th Meeting of the American Surgical Association, 11-13 April 1956, Becker Archives, Graham Papers, FC003/Box 13/Folder 88, pp. 12-3. 145 Meeting Minutes, ABS Archives, 14 May 1947, p. 9. 146 Francis D. Moore, “Graduate Surgical Training in the Small Hospital,” Countway Archives, Churchill Collection, Box 17, Folder 49. 147 In 1947, the Board had less than $30,000 in disposable income; the College spent $80,000 on residency approval alone. “Department of Graduate Training in Surgery Financial Program, as of 20 January 1947,” ACS Archives, Graduate Education Committee, RG5/SG2/S8/Box 2/Folder 5. Meeting Minutes, ABS Archives, 14 May 1947, p. 11. 148 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 23-24 June 1950, AMA Archives, pp. 6-8, and Appendix B: Minutes of the Conference Committee on Graduate Training in Surgery, AMA Archives, 26 May 1950. “Memorandum from Conference Committee on Graduate Training in Surgery,” 25 July 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 4, pp. 1-2. Some members of the American Board of Surgery, like its president, Firor, believed that the creation of the Board’s inspection service in 1949 drove the AMA and ACS to come to an agreement for fear of losing their roles in the process. While theoretically convincing, no documentation supports this supposition. Letter to Massachusetts Committee from Warfield Firor, 16 August 1949, Countway Archives, Cope Collection, Box 7, Folder 32. 149 For a list of the criteria, see “Appendix B in Minutes of the Meeting of Subcommittee B of the Committee of the American Medical Association and the American College of Surgeons Appointed to Prepare a Preliminary Draft of Standards for Residency Training in Surgery and the Surgical Specialties and to Recommend Procedure for Uniform Listing,” 15 April 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 5. 150 Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 15. Letter to John Modlin, Chief Surgeon at Elis Fischel State Cancer Hospital, from George Miller, 1 December 1950, Becker Archives, Graham Papers, FC003, Box 47, Folder 7. The rapid expansion of hospitals post-World War II exponentially increased expenses. For this same reason, the College had to partner with other organizations in order to sustain its hospital inspection system, forming the Joint Commission that endures today. 151 “Minutes of the Conference Committee on Graduate Training in Surgery,” 26 May 1950, ACS Archives, Board of Regents Statements on Education and Specialization, RG5/SG2/S8/SS11/Box2/Folder 22, p. 1. 152 See “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 29-30 November 1953, AMA Archives, p. 7 and “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 5-6 February 1954, AMA Archives, pp. 5-7. 153 Letter to Alfred Blalock from Paul R. Hawley, 9 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, p. 1. See also Letter to Arthur W. Allen from Paul R. Hawley, 16 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, p. 1. 154 See, for example, the “Minutes from 27 October 1950,” ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3, see especially pp. 306-26. 155 Letter to Warfield M. Firor from Paul R. Hawley, 9 October 1950 and Letter to Paul R. Hawley from Warfield M. Firor, 11 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3. Letter to Arthur W. Allen from Paul R. Hawley, 11 October 1950, ACS Archives, Conference Committee on Graduate Training in Surgery, RG5/SG2/S8/SS03/Box 1/Folder 3. Hawley, Letter to Allen, 16 October 1950. 156 “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 8-9 February 1952, AMA Archives, see p. 45 in Appendix B. 157 Ibid. 158 The American surgical profession disdained the International College of Surgeons, believing it a copycat organization for individuals lacking the qualifications or ethics to belong to an American organization. That the AMA turned to the International College reflects either a profound ignorance of surgical politics or egregious disrespect. “Minutes of the Business Meetings of the Council on Medical Education and Hospitals,” 6-7 June 1954, AMA Archives, pp. 8-9. Stephenson, “American College of Surgeons and Graduate Education in Surgery,” 49-51. Warren Cole, Chairman’s Report, Meeting Minutes, ABS Archives, 15 April 1952. For more on the ACS/ICS rivalry, see Nahrwold and Kernahan, A Century of Surgeons, 238-9. Davis, Fellowship of Surgeons, 350-5. 159 Weisz, Divide and Conquer, 15 and passim. 160 For the importance of training in the dissemination of arterial repair and osteosynthesis, see, respectively, Justin Barr, “Surgical Repair of the Arteries in War and Peace, 1880-1960,” (PhD diss., Yale University 2015) and Thomas Schlich, Surgery, Science and Industry: A Revolution in Fracture Care, 1950s-1990s (New York: Palgrave, 2002). © The Author(s) 2018. Published by Oxford University Press. All rights reserved. For permissions, please email: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/about_us/legal/notices)

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The Education of American Surgeons and the Rise of Surgical Residencies, 1930–1960

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The Education of American Surgeons and the Rise of Surgical Residencies, 1930–1960

The Education of American Surgeons and the Rise of Surgical Residencies, 1930–1960

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