- Welcome to the Department of Surgery
- UTHSCSA and the Department of Surgery historical timeline, including photos
- Dr. Arthur McFee's history of the Department of Surgery
- Dr. Arthur McFee's history of the Health Science Center
- Dr. Arthur McFee's history of the City of San Antonio in relation
to UTHSCSA and the Dept of Surgery
- July 12, 2004 lecture / presentation by Arthur McFee, MD, Professor Emeritus, UTHSCSA Department of Surgery (very large RealVideo file - 103mb)
- Past Chairs and Faculty
History of the development of UTHSCSA
With gratitude to Arthur S. McFee, MD, Professor Emeritus
UTHSCSA Department of Surgery
There is an adage that states that we should be careful what we wish for as we may get it. In many respects it applies to our school. Another that states that it is easier to start a tradition then to maintain it does not apply. The creation of this school was not easy and its 1st five years and saw a good deal of turmoil. That the community got what it expected was certainly not evident.
San Antonio was founded nearly one hundred twenty years before Galveston and had endured much history by 1881. In that year, the University of Texas was established and concurrently the first University of Texas Medical School was approved and sited by a state wide referendum for Galveston by over 70% of thirty thousand votes cast. Associated with the establishment of this school, the University assumed much responsibility for the John Sealy Hospital as a teaching institution. At that time, Galveston had a medical society, two private medical colleges and had seen the first medical journal in the state (The Galveston Medical Journal - 1866-1871). San Antonio, although growing rapidly, had a number of real basic health issues: lack of a good sewer system, lack of control of tuberculosis, an uncontrolled advent of pulmonary patients coming to the area and no real public health system. It was a frontier town.
The Spanish American and two world wars would pass before effective efforts to establish a medical school here would be mounted. In 1906, Galveston was virtually destroyed by a hurricane and tidal surge which claimed more then 6,000 lives. It is hard not to believe that this event and the ensuing recovery prompted many of the proposals to move the medical school to San Antonio. The activity was sporadic and definitively squashed in 1944. Early in the 1940's, attempts to establish a medical school here began to coalesce, but the road was to prove long and hard. In the mid 1940's the San Antonio Medical Foundation was organized and it gradually assumed the leadership in this activity for the community.
In the 1940's & 1950's many bills were introduced in the Texas Legislature for a variety of public health projects; none were funded. Bills for a San Antonio medical school were introduced 1947 and 1949. The latter was definitively trumped by an offer from Dallas in 1949 to the regents of the University to back a proposal for the University to take over and operate a small private medical college. This school has become the justly famous University of Texas Southwestern Medical School. It was the second University medical school. I am certain that the backing of the city of Dallas was essential to this action since the University did not wish to engage itself in sponsoring or paying for another major hospital. The action effectively moved the chances for San Antonio back by a least a decade.
From the mid 1940's much of the activity to procure a medical school was in the hands of the San Antonio Medical Foundation. Basically, it was a group of visionary, astute individuals, who were also very good businessmen; many were physicians. It is a non profit organization with stated goals of medical, charitable, and educational purposes. The principal spokesman was Dr. John M Smith Jr. a prominent local general practitioner and an experienced medical politician. He was a very vocal proponent for the school and an effective force in national medical politics; he was also a warm and friendly across the street neighbor of ours for more then thirty years. This group quietly acquired farmland northwest of San Antonio, at some distance from the downtown area, when such property was available and cheap.
Between 1920 and 1940, the population of San Antonio had doubled to 400,000; by 1950 it was to increase by another 25% to nearly 500,000. From 1945-1960, many proposals to establish a school were raised and discarded. What was really important and indicative of the vision of the medical foundation, was the process of urban change. A coalescence of forces occurred that made San Antonio a major metropolitan area not only capable of supporting such a venture but actually needing it.
In January 1959 the Bexar county legislative delegation was instructed to introduce a bill in the Texas House to establish a University of Texas Medical School in their county. The bill passed the House and was approved in the senate with a codicil deal that stated, 'An appropriate teaching hospital be located within one mile of the campus of said school'. The proviso was added by a senator from Dallas who anticipated tepid local support and knew that the University wanted no part of maintaining a teaching hospital as it had been obligated to do for many years in Galveston. Thus, after six decades of consideration and fifteen years of active effort, the long and often contentious trek to procuring a school was ended successfully. It was by no means the end of issues.
The first major one, since the initial consideration of a school, had been its site. As might be expected in Texas, at least two contrary views arose: downtown or outside the city. There were vocal adherents on either side. The issue was decided fairly promptly, if not amicably, by the donation to the university from the medical foundation of 100 acres of its land for a site northwest of the city in open territory allowing growth and development. This site, bitterly opposed by advocates of a downtown campus closer to the patients, has proven visionary indeed and has allowed remarkable growth. Our school is the largest health science center in the University system; and still, after nearly 5 decades, has room to grow. The centers in Dallas and Houston, at their inceptions were entirely surrounded by urban development and really could only grow up. Aside from land owned by the University, the foundation still controls some 150 to 200 acres of undeveloped land in the medical center complex. Certainly, for those initially involved, this is a classic case of doing well by doing good. The decision cost the school and hospital the support of one of the major fortunes of the city, and remnants of the split have persisted for some time.
The Robert B Green hospital was built and opened in San Antonio in 1917. It served the charitable medical needs of the community until the early 1950's. It is to be noted that the population of the city increased by 150% in those 30 years and relatively little if anything was done to upgrade the hospital. It closed, probably for fiscal reasons, in the early 1950's and was reopened with some refurbishing in 1955 under the aegis of the Bexar County Hospital district, a brand new taxing and funding agency. It was the first such district in the state. The hospital remains under this administration today, an exclusively Bexar County responsibility, taking a large percent of the annual property tax levied in the county.
The first dean of the school was Dr. Robert C. Berson who came in April 1962 and did little except to establish an office in two rooms of the National Bank of Commerce building and to hire Mary Ann White as his secretary. He is credited with identifying needs and establishing some sort of presence. He was hampered by lack of legislative response or significant funding. His resignation in October 1964 made way for the 2nd, and, to many, the most effective leader this school has ever had. Dr. F. Carter Pannill had been an assistant professor of medicine at the University of Texas Southwestern in Dallas and Assistant Dean for Grants Management. He is credited with getting the buildings built and gathering the initial faculty, starting some five years after the school was created.
Construction on the school and hospital started concurrently in the mid 1960's, the former funded by the state, the latter, by the county. It was one of the few instances in American medical history that a hospital and its associated school had been built together as an architectural unity. Progress was well along by December 1966; more then 30 faculty and some chairs had been recruited, and construction was proceeding apace. In January 1967, a uniquely Texan situation arose. Bexar county voters had enthusiastically endorsed a five million dollar bond issue to build a new teaching hospital. This sum was matched on a 3 to 1 basis by federal Hill-Burton funds. County planners in 1967 realized that, if they owned the hospital, they had to pay for it annually and they had hopelessly underestimated its cost. There were no county funds for it. Officials in the county were allowed to tax $0.75 on each 100 dollars of property value and property values were capped at 25% of the real market value. The obvious solution, to tax for the hospital district at a higher rate of market value (up to 50%), was presented as a general referendum in January 1967 and was overwhelming rejected by the voting public.
The resulting brouhaha involved almost everybody: the archdiocese, the military base commanders, the commissioners, and the citizenry. In March 1967, an appeal was made to the Bexar County legislative delegation to present a resolution to allow the expanded taxation. The bill passed the house and the senate and authorized the county commissioners in Dallas and Bexar County to tax up to 50% of the real market value for hospital district funds. Three courageous county commissioners led by presiding Judge, Blair Reeves and including James Helland and O.E. Wurzbach voted for the raise. Two commissioners opposed the action. Hospital construction could proceed with some guarantee now of annual funding.
In the 1st year of operation, the hospital funded a budget of 16 million dollars and incurred a deficit of 1 million which cost the director his job. This budget has grown to nearly 600 million dollars of which approximately 25% is covered by hospital district taxes.
Over more then three and one half decades, the investment of the San Antonio Medical Foundation of 100 acres of land has provided a handsome return. In 2004, the chamber of commerce cited the school as a major dynamo in a health care industry of 1.5 billion dollars annually. What was undeveloped farm land in the 1950's is now entirely surrounded by San Antonio growing northwest and northeast. Thanks to a good bit of vision space still exists after over 40 years for new projects and expansion.
In the early 1960's, San Antonio was a parochial town lacking much medical sophistication. Medical practice was dominated by the general practitioner; referrals were among close friends within given cadres; and board certification was not common. Only a very few decades separated the community from the first major Texas medical practice act (licensure to practice). Practice was unregulated and largely independent. The introduction of a medical school into such a community was no insignificant event. There is no lack of evidence that many individuals in this professional community had worked and schemed diligently for years to achieve the establishment of a medical school. There is also no lack of evidence that what so many had worked for was not what they had expected nor what they got.
Probably the first realization was that faculty recruitment would take place. Members of the medical community would not automatically be appointed to a faculty position with an appropriate title and stipend. Certainly this revelation engendered some righteous indignation. The second concept that came with the school was that of the closed staff hospital (board certification required). It takes very little imagination indeed to envisage the reaction of practitioners upon finding out that they were not even eligible to apply to practice in their new hospital built with a county bond issue, and supported by county taxes and designed to match the architecture of the school. Rapidly, indignation became downright hostility of a very ardent nature.
This situation was not ameliorated at all by the first chair of the combined departments of Medicine and Physiology. Eastern coast, arrogant, bright, brash and thoughtlessly outspoken, he allowed himself to be quoted widely in the press concerning his opinion of charitable services available in San Antonio and the level of health care in general. No opinion that he gave was favorable to the community and each one had an implication that the school would soon correct a real or an imagined flaw. The fact that much of this disparaged care had been given pro-bono by a great number of the readers of the press was lost on him. The fact, as Dr. Pruitt has observed to me, that he may have been right, was lost on the community in general; the talk fostered a considerable amount of hostility and continued unabated for some time.
This same chairperson was a jealous guardian of turf and one of his divisions become a front line for an in-house war. Early, on, by some chance, the Department of Pathology had hired a team of three hematologists which provided, to my mind to and those of all the other surgeons, the best hematological service we have ever seen. Consultants came to the OR on demand and solved problems quickly and definitely. The comparable group in Medicine was largely theoretical, hands off, and on a routine delayed consult basis. We regarded them as useless and incompetent. Another aspect of the matter was that the Department of Medicine held that no one in the Department of Pathology had a right to see clinical patients.
In 1972, a major debacle combined this internecine war within the faculty with the town-grown hostility that has been developing for four years. The regents demanded action, the chairs required some direction and faculty polarization was intense. When all was over, the chair in Medicine was fired, the chair in Pathology was relieved of his post but remained on the faculty, well over one half the members of each department resigned and the dean who had remained loyal to the medicine chair felt he had no choice but to leave. This event, barely 3 years after the school had accepted its first students, was a major and near fatal catastrophe largely of our own making and one from which few institutions could recover. The individual selected by the University to deal with the problem was a huge figure both physically and professionally - a noted Plastic Surgeon from Galveston Dr. Truman Blocker. He owned a massive reputation and physical habitus and projected a great aura of stability. Nevertheless, the result of this disagreement was the perception by the medical community of the school as a competitor for compensated patients; and, thus, a natural enemy. Faculty status was a flat reason to deny hospital privileges anywhere. Four decades have had to pass before much of this feeling eased.
This event also marked a major milestone for the school. In 1972, the school together with the dental school which had been founded in 1969 was denominated a health science center. A nursing school, an Allied Health School and a Faculty of Biomedical Science's (basic) were shortly added; a president, Dr. Frank Harrison was named. Two other presidents have succeeded him, Dr. John Howe, and Dr. Francisco Cigarroa. The purview of the school now extends to the Rio Grande Valley and includes centers for Pediatrics and Cancer patients. Building has added much new administrative and educational space. The hospital also has come into the 21st century and has at least eight satellite clinics. The whole has become the largest Health Science Center in the University of Texas System.
At least two other major storms remained for this school to weather, one was of our own making and one was where our reactions were questionable.
In the fall of 1982 two faculty members, a pediatric neurologist and Dr. Kent Trinkle our Senior Cardio-Thoracic surgeon, each noted anomalies in our Pediatric Intensive Care unit. Children admitted for neurological care with no known pulmonary problems and routine post operative chest patients also without such problems were experiencing a disturbing number of unexplained pulmonary or cardiac arrests requiring major resuscitation.
While this was disturbing, no one in the unit died. At that time, Pediatrics was chaired by a weak interim head. The pediatric intensive care unit was under the direction of single faculty member who attempted to provide care for each patient by himself. The problem continued; and three in-house investigations were carried out through November and December 1982 and January and February 1983 to no particular end or resolution. It was a fairly open secret that one individual in the unit was a focus of suspicion. She was an LVN with an unblemished record of excellent reviews. The last in-house review recommended that the unit be closed and the patients be transferred to the surgical intensive care unit which I directed at the time. This suggestion, on some scrutiny, would have proved to be disastrous. Ultimately the dean and the director of the hospital requested me to form a committee from three departments to oversee the unit and to accept a suggestion to transfer the unit to an all RN one. It was a typical administrative decision, not addressing the basic issue but removing the nurse in question.
The following July a graduating pediatric resident, against violent advice to the contrary, offered the nurse a position in a new private office she was setting up in Kerrville. At the end of August, in that office, catering to well babies for check ups, shots, and routine pediatric problems, there had been three instances of unexplained pulmonary arrest. No such instance had occurred in Kerrville in the previous 50 years. One of these three instances was fatal. In February 1984 the nurse was convicted of injecting babies with muscle relaxants and jailed, where she remains today.
Two years later, in 1985, this nurse was traced to the University Hospital; and a crusade, led by a politically ambitious district attorney and a singularly ill informed San Antonio Express-News writer, crucified the hospital and school. A grand jury was impaneled; the FBI was involved and six months of great distress ensued. No one in the hospital or school was ever indicted, and the oversight committee lasted for the next 10 years.
In the mid 1990's, another school-wide crisis arose. At a time when overall patient income was dropping, the university enforced a regulation that all patient collections hitherto done at a department level be centralized. Such a move is predictably disastrous for individual departments because much is lost to them. At about the same time, a disgruntled former director of our collection service 'blew the whistle' on our school in terms of collections that had been received from the government that were not properly documented.
In the light of current government regulations, any service not documented in a satisfactory form has not been given and thus any such money collected is fraudulently acquired. The school was initially accused of taking some $80,000,000 in this manner. A final figure required us to pay back $17,000,000. This drop, of course raises the legitimacy of the claim in the first place. Much of this problem came from our own arrogance in disdaining clearly defined rules for accepting government money. The burden on the school lasted 5 years and fell significantly on surgery. This action as much as any put us squarely in the realm of any other mundane agency doing business with the government and did away with the last vertiges of 'a new institution enthusiasm'.
In this odyssey of the development of our school, there are many lessons.
- However bitterly opposed, the selection of a site away from the city
center was correct and has allowed much development as the city has
grown. It was a visionary and responsible step.
- However bitterly fought, the enactment of a special taxing agency by
3 very courageous county commissioners was farsighted and has brought
immense benefit to the community in terms of economic growth and
- However good a new institution may be for a community, it cannot be
established well unless the community fully understands what is
involved. We did not do a good job at all of informing San Antonio what
a school would mean or to integrate ourselves with the community in
- However correct one might be in assessing the prior health system in
a community, one cannot malign it publicly and expect the same public to
support the maligner.
- However correct one might be in views as to the allotment of patient
care services to given departments or divisions one cannot ignore the
fact that those who perform well will be asked to do so regardless of
affiliation. There is no law that says a designated practitioner is
best because of his title or department.
- However well-meaning an administrative decision may be in terms of
'protecting' an institution or individuals, the failure to recognize an
issue as with the pediatric intensive care unit nurse for what it was -
suspected child abuse and to act on that fact promptly - will almost
always be found out and cause unbelievable accusations.
- However secure one may feel in one's practice and procedures, one must always be aware of the fact that any single person can destroy the work of many over much time for personal gain. In the case of this school's fine by the government an angry employee, denied a promised pay raise, profited by 15% of the money paid and caused us no end of trouble extending over 5 years.
The foregoing lessons are evident in development in the school. In this ongoing story, there is much that is praiseworthy. There has also been much to learn. The shortcomings have, in my opinion, largely arisen from arrogance and lack of common sense. In spite of those considerations, we have come far.