Taking the Med School's Pulse

In the late 1700s Holden Chapel, one of the smallest buildings in the Yard, housed all of the facilities of the Harvard Medical School. With the school's faculty numbering only three, not too many people were concerned about who was in charge.

Today the dean of the Medical School heads a faculty with some 1400 full-time members and an additional 1400 part-time members. Med School faculty predominate on the physician staffs of major Harvard-affiliated teaching hospitals like Beth Israel, Peter Bent Brigham and Massachusetts General, the largest hospital in New England. The dean is ex officio president of the Harvard Medical Center, a council of hospital officials created to coordinate the work of the Harvard-affiliated hospitals. And in addition to the sheer number of people the dean must direct, he plays an important role as a national leader in the medical field, searching for ways to improve U.S. health care.

Into this position in July walked Dr. Daniel C. Tosteson '46, after spending less than two years as dean of the Pritzker School of Medicine at the University of Chicago. introductory conferences, phone calls and dinner meetings here has yet to stop. But if Tosteson's days are packed tight with appointments, he handles them all with equanimity.

An effective doctor must appear confident and self-assured, so a man charged with keeping a community of physicians and medical educators functioning smoothly must be a doctor's doctor; he must show very little hesitation or uncertainty. Tosteson does not speak fast; he takes time to think out what he is saying. Like the office of Dean Rosovsky in the Faculty of Arts and Sciences, Tosteson's office is spacious, and the focus of the room is on the comfortable furniture designed for conversation rather than paper work. Tosteson's desk looks almost insignificant against a back wall.

The dean, who replaced Dr. Robert H. Ebert when he retired this past summer, is very much a product of the system he is now shaping. Tosteson attended Harvard College from 1942 to 1944 without taking an A.B., and graduated from the Medical School in 1949.

He spent most of the '50s working as a research fellow in various labs, starting at the Brookhaven National Laboratory in 1951, and working at different times in Copenhagen, Denmark and Cambridge, England. After 1958 Tosteson quickly worked his way up through the ranks of academic medicine, becoming a professor and chairman of the departments of physiology and pharmacology at the Duke University School of Medicine in 1961. While at Duke he became involved in national research groups and physicians' organizations, and served as chairman of the Association of American Medical Colleges in 1973-74.

After all of these positions and activities, a deanship was a logical next step. In 1975, he accepted the University of Chicago's offer. As Tosteson notes, "The reward for a job well done is another job." But there was still one more job in the offing. When last fall Tosteson accepted President Bok's offer of appointment to his alma mater, Harvard Medical School, the president of the University of Chicago quickly relieved Tosteson of his posts at Chicago, citing "the potential conflicts of interest in Dr. Tosteson's position as dean-designate of the Harvard Medical School and dean and vice president of the medical school" at Chicago. The Chicago Sunday Times administrators were angry because Tosteson had been the subject of their own prolonged recruitment drive. Tosteson says the University of Chicago move simply gave him more time to prepare to come to Harvard.

Tosteson is still involved in talking and listening here, feeling out the Med School's faculty in general terms before he begins to discuss specific programs. But if Tosteson is anything like Ebert, he has plans. Shortly after Ebert became dean of the Medical School in 1965 he began work on setting up the Harvard Community Health Plan, a health maintenance organization that would emphasize primary and preventive care--a progressive shift in emphasis not especially easy to implement, given the Med School's largely conservative faculty. Most analysts of the U.S. health care system view the shift as a definite change for the better. The plan Ebert started now boasts 65,000 Boston-area residents as members.

If innovations for enhancing primary care were a pet project of Ebert, the issue that puts an eager glint in Tosteson's eye is innovation in teaching. Tosteson points out that "the amount of information potentially relevant to the work of a physician, considering the broad spectrum of roles possible, is infinite for all practical purposes." "I take 'teaching' to mean promoting, encouraging and catalyzing learning," he says. "I do not believe that verb means transferring from the mind of the teacher to the mind of the student some bits" of information, he adds.

Real learning, Tosteson says, involves acquiring the ability "to get at what you need to know when you need to know it." Most important in medical education is development of "the desire, the will to learn," a quality that would once have been called "character."

Tosteson says he believes students and faculty feel uncomfortable thinking about these more abstract aspects of medical education. He admits that building character is a "slightly romantic" side of the school's efforts. He notes, however, that some of the best experiences in medical education occur when students and faculty work closely and learn together, as they must in order to develop this quality in doctors. He complains that the biggest problem in developing effective teaching is the size of the Medical School, which has expanded greatly over the past three decades.

Departing from his generally reserved manner and leaning forward in his chair he explains "I would like to find ways in which we can get smaller groups of students and faculty working together on scholarly projects of genuine educational content in a continuing way." The proposition sounds vague but Tosteson declines, for now, to be more specific.

The issue of teaching quality is sure to come up for discussion at the Med School this fall. Last spring the Med School faculty voted to approve a set of recommendations that a comprehensive program for teaching evaluation be developed, and that the evaluations be used in considering faculty appointments. So far, the faculty members working on the program have mainly worked on field trials of possible evaluation methods, but they plan to meet with Tosteson this fall to discuss possibilities for the broader implementation of the program.

If Tosteson is still feeling out possible changes in the teaching set-up, he has already changed the school's administrative structure to fit his style. He has created four deanships under his direction to handle four specific areas of concern--finance and business, students and alumni, academic programs, and medical services. Ebert's administrative set-up had less structure; when he retired after 12 years as dean, the school's administration had more informal lines of command.

Tosteson has chosen Henry Meadow as his dean for finance and business. Meadow handled the same affairs with a different title under Ebert. The dean for students and alumni, Dr. Daniel Federman, is new to the Med School administration. Tosteson has not yet appointed the deans for academic programs or medical services. The latter will also serve as vice president of the Affiliated Hospitals Center, a group of three Harvard-affiliated teaching hospitals that is building one consolidated facility.

Tosteson, himself, also has a hand in hospital administration. As president of the Harvard Medical Center--really a council of hospital officials--Tosteson hopes better to coordinate the activities of the 13 hospitals affiliated with Harvard. Tosteson says the council, which includes the chairmen of the board of each affiliated hospital, was created in the early '60s for fund-raising purposes, but fell into disuse. Ebert reinvigorated the group three years ago with strong encouragement from President Bok, Tosteson says.

The new dean says he wants to see the center develop educational demonstration projects in the Harvard community "that could inform the current public debate about health policy." Like teaching innovation, the development of demonstration projects seems to be a prime concern for the 52-year-old dean. When he addressed an annual meeting of the American Association of Medical Colleges in 1974, he said, "I propose that the academic medical community move independently to increase the quality and quantity of its efforts in educating the public about health. Each medical center could establish experimental programs in health education in its region."

While Daniel Tosteson the dean tries to get a grip on the school he heads as well as the affiliated hospitals, Tosteson the scientist is trying to keep a hand in scientific research. He is an authority on biological membranes, and although he now has little time to spend in the lab he directs a research team that includes his wife, Magdalena T. Tosteson. Studying red blood cell membranes, the group is exploring possible links between manic depressive disorders and anomalies in individuals' red cell membranes.

Lithium treatment, Tosteson says, is most often used to aid manic depressives. He says that in many manic depressives the red cell membrane has no system for regulating the transport of lithium. Tosteson hopes to examine the chromosomes of manic depressive individuals to see if there is a correlation between the presence of genes for the mental disorder and the presence of genes for the red cell membrane disorder.

But if Tosteson is willing to specify the lines of research he will pursue, he is still quiet on his plans for the Medical School. New deans who have ideas about making changes have to work slowly if they want to succeed at all. Time will show what the dean will accomplish.