In 1926, the year Harvey Cushing delivered the commencement convocation “Consecration Medici” to students at Jefferson Medical College, the population of the United States was 117,397,000. The population of “neurosurgeons” was fewer than 100, given that it was a scant seven years after the American College of Surgeons recognized neurosurgery as a specialty and six years following the initiation of the first neurosurgical organization, the Society of Neurological Surgeons. The Harvey Cushing Society would not hold its first meeting until 1932, the 75th anniversary of which will be recognized during the 2007 AANS Annual Meeting.
In 1926, workforce issues in medicine, particularly those concerned with training, were very much on the minds of many. To provide the army with neurosurgeons during the First World War, 100 general surgeons were trained as neurosurgeons, though none practiced in the specialty after the war’s 1918 conclusion. A few years earlier, the influential report by Abraham Flexner criticizing medical education in the United States and Canada spurred dramatic reforms in the field following its 1910 release. For his part, Cushing ardently supported the early exposure of medical students to clinical experience. He reportedly said to Flexner that “…it would be infinitely better if the students began their first two years with clinical work and supplemented it by such laboratory exercises as their clinical work indicated the necessity of.”
Cushing also opposed the “full-time plan” for clinical instruction supported by Flexner. Under the plan, instructors would be paid by their universities, which in turn would collect any fees from private patients seen. Of this arrangement Cushing later reminisced:
- On my own part, a term of service limited to 20 years with an academic salary on which a family of children were to be educated and no pension in sight in case of accident or ill health seemed a dubious proposition. I doubted, moreover, whether such an arrangement would in any way activate me and feared, indeed, that it might encourage indolence. If the purpose of the plan was to prevent the attendants in university hospital from exploiting their position for their personal ends, there was just as much reason to fear, human nature being what it is, that hospital superintendents and trustees might be tempted tin a pinch to exploit their salaried professional attendants … And coming of a race of general practitioners, the intimate and confidential relation between doctor and patient — one of the most precious things in medicine — was in my blood and I could not look upon the cold institutional program with any great enthusiasm, much less with any expectation that it would serve to make something out of me that I was not already.
It is the doctor-patient relationship and the idea of devotion to one’s patients and profession with which Cushing is concerned in these remarks to the Jefferson class of 1926 as the workforce of the future.