Rockefeller Foundation Funding and Medical Education in Toronto, Montreal, and Halifax (review)

Marianne Fedunkiw offers a North American perspective on medical education in the first three decades of the twentieth century. She relies on secondary sources for events in the United States, and mainly on archival and printed primary sources for the Canadian story. Her research yields three persuasive conclusions. The first is that in Canada, as is well known about the United States, "medical schools were participating in an age of reform" (p. 131) before the publication of Abraham Flexner's report of 1910 (for which he visited schools in both countries). Second, as a result of the reform of medical education, in Canada as in the United States, the number of schools declined and the "remaining schools improved" (p. 133). Third, and perhaps most important, Fedunkiw finds that in Canada as in the United States, grants from Rockefeller philanthropies, "by changing medical teaching . . . altered the culture of medicine [because] students learned more subjects, with more laboratory time, and in clinical subjects, from pioneering full-time instructors" (p. 142). She documents these conclusions in chapters on the history of medical education in each of the three cities in her title.

Fedunkiw also describes how long-standing relationships between the Rockefellers and prominent employees of their philanthropies and major figures in Canadian politics and business helped to determine how and where to reorganize medical education. William Lyon Mackenzie King, later a prime minister of Canada, worked for Rockefeller business and philanthropic organizations in 1914 to mediate a notoriously brutal coal strike in Ludlow, Colorado. The next year he helped the Rockefellers defend the management of their investment in Ludlow before the United States Commission on Industrial Relations. He was an employee of the Rockefeller Foundation until 1919, when he returned to Canada to become leader of the federal Liberal Party. An uncle of George Vincent, the first professional president of the Rockefeller Foundation, was prominent in Canadian business and civic affairs, including university governance. Yet again, a thorough study of the history of a foundation reveals that its influence was the result of considerably more than clever strategies for awarding grants.

The book has one interpretive and one methodological flaw. The interpretive flaw is that Fedunkiw does not relate reform in medical education to the history of health policy. In every industrial country, philanthropies and governments sharply increased spending for academic medicine in the first three decades of the last century. They did so because they believed that reformed schools, with state-of-the-art research laboratories and teaching hospitals, would produce more-capable physicians and useful knowledge. Policymakers assumed that the institutions of academic medicine would help to improve the effectiveness and efficiency of health services in large geographic regions through linkage with smaller hospitals and private practitioners of medicine. They also believed, along with most public health officials, that new technologies to prevent and cure disease devised in academic medicine would be the most important causes of rising life expectancy. These beliefs turned out to be only partially correct, but the irony of history should not prevent scholars from examining the tenacity with which they were (and in some places still are) held.

Fedunkiw's methodological lapse is the uncritical use of secondary sources about the history of medical education in the United States. She does not distinguish between polemics written mainly from secondary sources and peer-reviewed publications by professional historians. For example, she cites approvingly a book by a disgruntled community physician in support of an argument, with which she seems to agree, that the "full-time system" of employing clinical faculty met its "downfall, because medicine is an art, not a science" (p. 142). The full-time system, in its contemporary form, thrives; so does research in the basic and clinical sciences, and its application to patients in...