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The Founding of the Mayo School of Graduate Medical Education

      Abstract

      The Mayo Foundation for Medical Education and Research (hereafter the Mayo Foundation), the precursor to the Mayo School of Graduate Medical Education, was incorporated in 1915. The Mayo Foundation, which was affiliated with the University of Minnesota Graduate School, aimed to establish a higher standard for training medical specialists. Together, the University of Minnesota and the Mayo Foundation pioneered a graduate medical education program that allowed residents to earn master’s and PhD degrees in clinical medicine and surgery. Unlike elsewhere in the United States, the residency training program was not pyramidal. (In a pyramidal residency program, each training year, some residents are systematically eliminated to reduce the number of more senior trainees.) All those who started the Mayo Foundation residency program had an opportunity to finish depending on their own merits. Louis B. Wilson, the first director of the Mayo Foundation, became a major figure in graduate medical education in the 1920s and 1930s. Although the granting of graduate degrees in medicine and surgery stopped over time, Mayo Clinic ultimately became the largest site of graduate medical education in the world.

      Abbreviations and Acronyms:

      ACGME (Accreditation Council for Graduate Medical Education), MSGME (Mayo School of Graduate Medical Education)
      This article describes the creation of the Mayo Foundation for Medical Education and Research (hereafter the Mayo Foundation), the forerunner of the Mayo School of Graduate Medical Education (MSGME). The Mayo Foundation was incorporated in 1915 (Figure 1).
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Wilson L.B.
      The Mayo Foundation for Medical Education and Research.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
      The original endowment of $1.5 million came from the personal funds of brothers William J. Mayo, MD (1861-1939), and Charles H. Mayo, MD (1865-1939).
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Their father, William Worrall Mayo, MD, started a medical practice in Rochester, MN, in 1864. After graduating from medical school, the 2 brothers returned to work with their father. The Mayo brothers established a thriving surgical practice that eventually became known as Mayo Clinic. The Mayo Foundation was the graduate education link between Mayo Clinic and the University of Minnesota.
      • Stevens R.
      American Medicine and the Public Interest.
      Mayo Clinic pathologist Louis B. Wilson (Figure 2), who became a major figure in American graduate medical education, stated plainly that the purposes of the foundation were “indicated in its title.”
      • Wilson L.B.
      The Mayo Foundation for Medical Education and Research.
      If the words “Medical Education of Specialists” had been in the title, Wilson’s statement would have been more accurate. The Mayo Foundation’s main purpose was to establish a higher standard for training medical specialists.
      • Fye W.B.
      Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
      Figure thumbnail gr1
      Figure 1Logo of the Mayo Foundation for Medical Education and Research.
      By permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN.
      Figure thumbnail gr2
      Figure 2Dr Louis B. Wilson.
      By permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN.
      The Mayo Clinic residency program was not the first in America. Most authors rightfully emphasize the Johns Hopkins Hospital (founded 1889) as the site of origin of the American medical residency, when residency is defined as several years of supervised, progressive, specialized training after graduation from medical school and completion of an internship.
      Commission on Graduate Medical Education
      Graduate Medical Education: Report of the Commission on Graduate Medical Education.
      • Ludmerer K.M.
      Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
      Internist William Osler and surgeon William Halsted established the residency training program at Johns Hopkins on the lines of the system they had observed in Germany.
      • Harvey A.M.
      • Brieger G.H.
      • Abrams S.L.
      • McKusick V.A.
      A Model of Its Kind, Vol. 1: A Centennial History of Medicine at Johns Hopkins.
      Osler’s first resident, Henry Lafleur, began his Hopkins training in 1889. The residency program implemented at Hopkins differed from traditional apprenticeships, attending extramural private medical schools that provided hands-on clinical experience, serving as a house pupil or intern for 1 or 2 years, and European medical study.
      • Ludmerer K.M.
      Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.
      • Ludmerer K.M.
      Learning to Heal: The Development of American Medical Education.
      These 4 educational avenues were pursued by a small percentage of American medical students or medical graduates in the 1800s to supplement their degree-granting medical school training, whereas residency programs increased markedly in number and importance during the decades after 1920.
      • Ludmerer K.M.
      Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.
      Christopher Graham was appointed the first intern at St Mary's Hospital, Rochester, in 1894, and Melvin Millet worked as a “resident physician” at the hospital from 1898 to 1901, before becoming an attending physician.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Clapesattle H.B.
      The Doctors Mayo.
      The first regularly scheduled, yearly interns (Robert Farrish and Jacob Prinzing) began training in 1901.
      • Clapesattle H.B.
      The Doctors Mayo.
      Mayo Clinic
      Physicians of the Mayo Clinic and the Mayo Foundation.
      By 1901, the pyramidal residency at Johns Hopkins was 12 years into development, highlighting its pioneering role in American medicine. (In a pyramidal residency program, each training year, some residents are systematically eliminated to reduce the number of more senior trainees.) The Mayo residency program was innovative in that it was not pyramidal; that is, all those who started the Mayo Foundation residency program had an opportunity to finish depending on their own merits. Furthermore, the Mayo Foundation residency program emphasized the attainment of graduate (ie, master’s and doctor of philosophy [PhD]) degrees in clinical medicine and surgery. Contributions of Mayo Clinic, and those of Louis B. Wilson, to the development of American residency training programs have been overlooked by most historians.
      Commission on Graduate Medical Education
      Graduate Medical Education: Report of the Commission on Graduate Medical Education.
      • Ludmerer K.M.
      Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.
      Rosemary Stevens is a rare exception.
      • Stevens R.
      American Medicine and the Public Interest.
      For example, Kenneth Ludmerer describes a few aspects of Mayo’s residency program, but does not mention the influence of Louis B. Wilson on American graduate medical education.
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.

      Graduate Medical Education at Mayo Clinic Before 1915

      The first trainees at St Mary's Hospital worked directly with William J. Mayo and Charles H. Mayo, and some stayed on afterward to assist other physicians in diagnosis.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      In 1905, a system was started to improve graduate medical education in Rochester.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Medical graduates worked in the laboratories as assistants for 1 to 2 years, and subsequently became hospital interns or assistants in medicine or surgery.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Over the next several years, the training system matured. A 3-year training curriculum was instituted in 1912.
      • Wilson L.B.
      Graduate work in medicine in the University of Minnesota.
      Trainees completed 1 year of pathology, 1 year of clinical diagnosis, and finally 1 or more years of either surgery or internal medicine.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      A graduate education committee appointed by William J. Mayo decided to call these trainees “fellows,” the term used for graduate students in Oxford, United Kingdom.
      • Clapesattle H.B.
      The Doctors Mayo.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      Thus, the term fellow used at Mayo Clinic equated to the modern-day “resident,” and “resident” will be used in this article for clarity. Thirty-six residents were following this plan in 1912.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Mayo physician Emil Beckman explained in 1914:We are establishing in the Mayo Clinic some fellowships [residencies] on a three year basis, one year to be spent in pathology, doing autopsy work, fresh tissue diagnosis, and original research work in some subject in surgical pathology under the direction of the head of the laboratory; one year as house surgeon in Saint Mary’s Hospital, spending two months in the dressing rooms, two months in medical service, and eight months in the operating rooms; and the third year to consist of two months work in the dressing rooms on patients that have left the hospital, and ten months in taking histories and examining patients in the clinical departments under the supervision of one of the heads of the clinical staff.

      Beckman EH. Letter to Edmund H. Mensing, M.D. February 16, 1914. Mayo Foundation for Medical Education and Research (1915-1964) file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      The 27 residents at Mayo in 1915, who had completed internship elsewhere, spent 2 years in the laboratories and hospitals and finished with a year of clinical diagnosis.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.

      Beginning of the MSGME: The Mayo Foundation

      Mayo’s early trainees could not receive formal degrees because Mayo Clinic did not have an academic affiliation.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      The University of Minnesota, about 85 miles north of Rochester, was the logical academic partner. William J. Mayo was appointed a regent of the university in 1907, and by the fall of 1914, 8 of 22 Mayo Clinic section heads had graduated from the University of Minnesota Medical School.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      In 1914, the University of Minnesota inaugurated graduate work in various fields of clinical medicine and surgery, in addition to programs that had been offered for some time in the laboratory branches.
      • Wilson L.B.
      Graduate work in medicine in the University of Minnesota.
      The Mayo Clinic staff recognized the desirability of placing its graduate work under university control.
      • Vincent G.E.
      • Lyon E.P.
      • Moore J.E.
      • Litzenberg J.C.
      • Beard R.O.
      The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
      Louis B. Wilson argued in 1915 that if specialist training in medicine was to mean more than brief educational trips to Europe, which some doctors used to justify calling themselves specialists, it must be controlled by the state.

      Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      George Vincent, who became president of the University of Minnesota in 1911, was very interested in graduate medical education.
      • Fye W.B.
      Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      In the Mayo Clinic’s facilities, patient volume, and residency training program, he saw an opportunity to improve medical specialty training in the state by linking the University of Minnesota and the Rochester institution.
      • Fye W.B.
      Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
      The dean of the University of Minnesota Graduate School, Guy Stanton Ford, toured Mayo Clinic and thought it could support a large specialty training program.
      • Fye W.B.
      Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
      Because Mayo Clinic was not a corporate body with which the university could legally enter into a contract, George Vincent suggested in the winter of 1914 that the Mayo brothers form a corporate institution to conduct their education and research, the Mayo Foundation.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      William J. Mayo approved the concept, noting that the foundation “furnishes a reasonable method of taking care of those particular activities which are essentially outside the scope of the clinic itself.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      The scientific and educational work would belong to the foundation, and the business of treating the sick would belong to the clinic.
      • Vincent G.E.
      • Lyon E.P.
      • Moore J.E.
      • Litzenberg J.C.
      • Beard R.O.
      The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
      The Mayo brothers signed the articles of incorporation of the Mayo Foundation on February 8, 1915, and the next day they endowed it with securities amounting to $1.5 million.
      • Clapesattle H.B.
      The Doctors Mayo.
      The general purposes of the corporation were “educational, scientific, medical and surgical, and to establish, maintain, and operate clinical, pathological, medical, and surgical research laboratories.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      One Mayo staff surgeon was concerned that by increasing the number of residents they would train their competition and lose patients. However, William J. Mayo responded that “personally, I don’t fear that at all … I believe we will be able to hold our ground, and furthermore, I am quite sure that former fellows [residents] will scare up more game than they can possibly shoot.”
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      Opposition to the Mayo Foundation arose from some University of Minnesota alumni and faculty members. The main concern was the affiliation of a public university with a private clinic conducted for profit.
      • Vincent G.E.
      • Lyon E.P.
      • Moore J.E.
      • Litzenberg J.C.
      • Beard R.O.
      The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
      Despite this, in May 1915, the executive committee of the University’s Board of Regents recommended to the Board of Regents a 6-year affiliation trial period between Mayo Clinic and the University of Minnesota.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      The executive committee commented further:It is believed that through this policy the University would fulfill a public duty by: (1) providing notable facilities for advanced medical training, (2) standardizing and controlling in the public interest the preparation of medical specialists, (3) fostering medical research not only on a state but on a national basis, (4) furthering the growth of graduate work on the University campus, and (5) increasing the efficiency of undergraduate teaching at the University.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      On June 9, 1915, the Board of Regents entered into an agreement with the founders and trustees of the Mayo Foundation.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      The faculty members of the foundation would be approved by the university.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Vincent G.E.
      • Lyon E.P.
      • Moore J.E.
      • Litzenberg J.C.
      • Beard R.O.
      The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
      The agreement specified that until September 1, 1921, the net income of the endowment funds would remain in the hands of the trustees of the Mayo Foundation. After September 1, 1921, the principal of the funds and all accumulations up to that date would be turned over to the university, but “the place for carrying on the graduate medical instruction and research work with the endowment income shall be Rochester, Minnesota.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      The University of Minnesota, through its graduate school, could now conduct graduate medical education in the Mayo Foundation at Rochester, as well as in its medical school in Minneapolis.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Wilson L.B.
      Twelve years’ experience of the University of Minnesota in Graduate Medical Education.
      The Board of Regents next appointed a committee consisting of the president of the university (George Vincent), dean of the graduate school (Guy Stanton Ford), dean of the medical school (Elias Lyon), 3 University of Minnesota physicians (James Moore, Clarence Jackson, and Jennings Litzenberg), and 3 Mayo Clinic physicians (Louis B. Wilson, William Braasch, and Melvin Henderson).
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      This medical graduate committee managed all the graduate work in medicine, and first met on August 11, 1915, at the Minneapolis Club.

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, August 11, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      A preliminary announcement of graduate work in medicine by the University of Minnesota and the Mayo Foundation was issued in September 1915.

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      The announcement clarified that “the objects of this graduate work in medicine are the training for medical practice of fully equipped and properly certified specialists and of investigators and possible teachers of medicine.”

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      The training program was for 3 years. Initial appointments were for 1 year, renewable yearly for a period of 3 years if satisfactory progress was made.

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      Entrance was limited to those with a bachelor’s degree or its equivalent, a medical degree from an acceptable institution, and 1 year’s experience as an intern. A thesis was required for those pursuing master’s or Ph.D. degrees (Figure 3), as were final written and oral examinations. The resident chose a major and minor area of focus (typically surgery or medicine for the major and pathology for the minor).

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1918-1919.
      At least one-fourth of the work offered for the degree needed to be in the fundamental laboratory branches, which served as the basis for the proposed clinical specialization.

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      The Mayo Foundation offered residencies in surgery, medicine, pathology, bacteriology, orthopedic surgery, urology and proctology, ophthalmology and otology, rhinology and laryngology, and radiology. Residents were paid $600 in the first year, $750 in the second year, and $1000 in the third year.

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      Figure thumbnail gr3
      Figure 3Master of Science in Medicine degree of Dr Fredrick Willius. Willius received his master’s degree from the University of Minnesota after completing his residency in the Mayo Foundation.
      By permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN.
      By August 1916, there were 71 Mayo Foundation trainees and 36 University of Minnesota trainees.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      All graduate students, working in either institution, were matriculated and registered at the university under the rules of the graduate school.
      • Vincent G.E.
      • Lyon E.P.
      • Moore J.E.
      • Litzenberg J.C.
      • Beard R.O.
      The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
      The first Mayo Foundation graduate degrees were conferred on June 14, 1917, to 4 trainees: Della Drips, MS in Pathology; Dorothy Pettibone, MS in Bacteriology; Francis McMahon, MS in Surgery; and Egerton Crispin, MS in Medicine.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Wilson L.B.
      Graduate work in medicine in the University of Minnesota.
      It is notable that 2 of these 4 were women, but neither of the women was a physician in 1917, unlike the men.
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1918-1919.
      Della Drips had received her undergraduate degree from the University of Wisconsin in 1907, had finished 1 year of medical school at the University of Wisconsin, and subsequently completed her master’s work on the corpus luteum of the marmot in the Mayo Foundation from 1913 to 1917.

      Della G. Drips, 1884-1976, M.D. file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      She graduated from medical school at the University of Minnesota in 1921, completed an internship in New York, and later was a resident in medicine at Mayo Clinic for 30 months.
      Mayo Clinic
      Physicians of the Mayo Clinic and the Mayo Foundation.
      Drips became a consultant in medicine at Mayo in 1924, and retired as an associate professor in 1949. After Dorothy Pettibone received her undergraduate degree from the University of Wisconsin in 1915, she completed her master’s work at Mayo in 1 year.
      University of Minnesota
      The Graduate School. Graduate work in medicine in the Medical School and the Mayo Foundation.
      The Bulletin of the University of Minnesota explained in 1918 that the PhD degree required 3 full years of graduate study, the master’s degree in clinical subjects 2 or 3 years, and the master’s degree in laboratory science 1 year.
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1918-1919.
      The requirement for Mayo Foundation graduate students to graduate from medical school and have done internship was waived for those pursuing degrees in the fundamental laboratory sciences.
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
      Despite this promising start, opposition continued from members of the University Alumni Association and some of Minnesota’s physicians.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      In 1917, a bill was introduced in the Minnesota legislature that would dissolve the affiliation. William J. Mayo defended the affiliation during an address to the legislative assembly in March.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      The Minneapolis Morning Tribune reported what he said:I can’t understand why all this opposition should have aroused over the affiliation with the University. It seems to be the idea of some persons that no one can want to do anything for anybody without having some sinister motive back of it. If we wanted money, we have it. That can’t be the reason for our offer. We want the money to go back to the people who gave it to us … This money belongs to the 2,500,000 people in this state. I don’t care two raps whether the medical profession of the state like[s] the way this money has been offered for use. It wasn’t their money … What better could we do than take young men and help them to become proficient in the profession so as to prevent needless deaths?
      This speech was very influential, and the bill was never released from the legislative committee.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      In September 1917, the Board of Regents signed the final articles making the affiliation permanent, and the funds and income of the Mayo Foundation were transferred to the university.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      • Wilson L.B.
      Twelve years’ experience of the University of Minnesota in Graduate Medical Education.
      Wording was added that after approximately 28 years, the net income could be spent for graduate medical and surgical investigation and research work to be carried on at or directed from the University of Minnesota in Minneapolis, or other places (including Rochester), as “deemed best to effectuate the purposes of the gift and of the donors.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      By 1922, the endowment fund reached $2 million.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      In 1934, Mayo added another half million dollars to the endowment.
      • Clapesattle H.B.
      The Doctors Mayo.

      Influence of Louis B. Wilson, MD, the First Director

      Louis B. Wilson was raised on a small farm in Fayette County, Pennsylvania.

      Program presented by the Mayo Foundation Chapter of Sigma Xi in honor of Dr. Louis Blanchard Wilson. November 8, 1941. Privately printed. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      He graduated from a teachers college in Pennsylvania in 1886. During the early 1890s, he taught biology at Central High School in St Paul, MN, while attending medical school at the University of Minnesota. After receiving his medical degree in 1896, Wilson was appointed assistant professor of pathology and bacteriology at the University of Minnesota. He joined the Mayo staff in 1905, tasked with organizing the laboratories.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      Wilson earned notoriety for highlighting the utility of intraoperative frozen section analysis.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      During World War I, he was field director of the Army Medical Museum

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, May 18, 1918. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      and an acknowledged expert on ballistics.
      • Magath T.B.
      Guns: Louis B. Wilson: ballistics expert and prophet.
      But “at heart he was primarily an educator.”
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      William J. Mayo discerned the need for improved graduate medical education in Rochester, and Louis B. Wilson fulfilled that need.
      • Braasch W.F.
      Early Days in the Mayo Clinic.
      Wilson, who recognized the importance of specialism in medicine, declared in 1915:Medical science has grown since thirty years ago; it has grown so that no one man may know it all. Specialism has become an inevitable necessity and specialism will become more and more divided as time goes on. The training of the specialist is today one of the most difficult problems in medical education.

      Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      He went on to outline the pathways in place for the training of specialists in the early 1900s: European training, postgraduate schools (“most of whose goods are in their show windows”), more reputable medical schools that offered brief courses to medical graduates, and working with an individual engaged in the private practice of that specialty.

      Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Wilson had visited Europe in 1911 to assess the efficacy of graduate medical education, and was not impressed.
      • Wilson L.B.
      Graduate instruction in medicine.
      He observed that most Americans took short trips to Europe and called it specialty training, referring to the experience as “the great European medical quick-lunch counter.”

      Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Men whose limited incomes and involved family relations will permit them only a few months or a year for training for a specialty have, like the hurried businessman, rushed to the European lunch counters, bolted “ready-to-serve” specialties, keeping one hand on their pocketbook and both eyes on the clock and then rushed home again hoping to digest the meal on the return trip. Usually they have regurgitated these meals undigested, rarely have they assimilated them.

      Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Wilson commented that some physicians trained in Vienna for 2 or 3 months, returning with a certificate and “beer breath.”
      • Wilson L.G.
      Medical Revolution in Minnesota: A History of the University of Minnesota Medical School.
      Of note, at least 15,000 Americans took some kind of medical training in Austria-Hungary, Germany, and Switzerland between 1870 and 1914.
      • Bonner T.N.
      American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870-1914.
      Other physicians also criticized these trips to Europe by Americans. Most of the criticism was directed at those without prior internship and practice experience and those who stayed only a short time, partied too much, and/or did not speak the native language.
      • Bonner T.N.
      American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870-1914.
      World War I brought these trips to a halt.
      At the first meeting of the University of Minnesota-Mayo Foundation medical graduate committee on August 11, 1915, it was recommended that Louis B. Wilson be appointed resident director of the Mayo Foundation.

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, August 11, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      At the next meeting, this title was rescinded, and the committee clarified that resident directorship was included in Wilson’s previous duties as chairman of the subcommittee of the Mayo Foundation.

      University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, September 29, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      On October 25, 1917, the office of the director of the Mayo Foundation was finally created, and Louis B. Wilson filled the role.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Wilson was not shy about challenging his faculty members. When several graduate students performed poorly on their oral examinations in 1922, he arranged a 2-hour meeting with 30 faculty members. He stated that “the mass of routine work in the Clinic does not give faculty or fellows [residents] sufficient time during office hours to study cases thoroughly … Neither group are sufficiently in the habit of carefully reading up [on] cases out of office hours.”

      Wilson LB. Confidential resume of faculty discussion on the results of oral examinations of fellows. February 24, 1922. Mayo Foundation Reports I file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      He told them “each member of the faculty must realize more his individual responsibility for personally inspiring, directing and supervising the progress of each fellow [resident] working with him,” and that “the heads of the surgical sections should see to it that the men know the ‘Why’ as well as the ‘How’ of operative procedures.”

      Wilson LB. Confidential resume of faculty discussion on the results of oral examinations of fellows. February 24, 1922. Mayo Foundation Reports I file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Wilson would become a leader in American graduate medical education. He was a member of the American Medical Association’s Council on Medical Education and Hospitals, whose 1920 university graduate medical education recommendations were patterned after the Mayo Foundation.
      • Stevens R.
      American Medicine and the Public Interest.
      • Wilson L.B.
      Report of Committee on Graduate Medical Education.
      Wilson was also a charter member of the National Board of Medical Examiners, president of the Association of American Medical Colleges, and the first president of the Advisory Board for Medical Specialties (hereafter the Advisory Board).
      • Stevens R.
      American Medicine and the Public Interest.

      Program presented by the Mayo Foundation Chapter of Sigma Xi in honor of Dr. Louis Blanchard Wilson. November 8, 1941. Privately printed. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      In 1934, the Advisory Board adopted common standards for the approval of specialty boards.
      • Stevens R.
      American Medicine and the Public Interest.
      The Advisory Board also clarified that specialists should have 3 years of training after internship, mirroring the residency training at Mayo Clinic.
      • Stevens R.
      American Medicine and the Public Interest.
      Wilson felt strongly that “only the men in a specialty [were] competent to say who else should be recognized as competent in that specialty.”

      Wilson LB. Steps leading to the organization of qualifying boards in medical specialties and the Advisory Board for Medical Specialties (unpublished manuscript). June 28, 1939. MHU-0510: Mayo School of Graduate Medical Education. Box 17. File L.B. Wilson reprints. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      He retired as director of the Mayo Foundation in 1937, and died of amyotrophic lateral sclerosis on October 5, 1943,
      • Nelson C.W.
      Dr. Louis B. Wilson, pioneer Mayo scientist and educator.
      leaving his mark on graduate medical education locally and nationally.

      Resident Evaluation

      Faculty members of the Mayo Foundation were given specific instructions on how to grade the residents.

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      The resident’s work was “carefully graded by his immediate chief,” whose duty it was “to determine the student’s [resident’s] ability by daily intercourse with a smaller number of students [residents] rather than by class quizzes and formal examinations.”
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
      Residents were evaluated on a quarterly basis. Faculty members sent grade reports to the director’s office at least 10 days before the end of the quarter. Each report needed to contain a “general grade for work of course,” and at least 1 recommendation or a statement under “general remarks” as to why it was not possible to make a recommendation.

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Initially, the grades ranged from 1 (very good) to 5 (very poor) (Figure 4).
      • Rose S.H.
      • Long T.R.
      • Elliott B.A.
      • Brown M.J.
      A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement.
      Later, an A to E scale was used (Figure 5).

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      If the general grade was below “A,” the reasons why needed to be indicated by lowered grades among the 35 numbered points, or in the general remarks (see Figure 5).

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      • Rose S.H.
      • Long T.R.
      • Elliott B.A.
      • Brown M.J.
      A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement.
      All 6 Accreditation Council for Graduate Medical Education (ACGME) core competencies (introduced in 1999 and still in effect today) were covered in this evaluation process.

      Common program requirements. Accreditation Council for Graduate Medical Education website. www.acgme.org. Accessed September 3, 2014.

      Initially, the evaluators were asked to estimate the number of hours spent per week in practical work, the medical library, and research, but these duty hour questions do not appear on the evaluation forms from the 1920s. The “A” grade was reserved for only the best residents in the foundation, “B” was given to the other good residents, “C” to average or mediocre residents, “D” to weak residents, and “E” to residents who were but little better than complete failure.

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      The Bulletin of the University of Minnesota clarified in 1921 that “work which receives a grade below B will not be counted for graduate credit.”
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
      It was later decided that work that received a C grade was acceptable only if it was in the minor.
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1922-1923.
      The standing of residents with poor grades was discussed at a faculty meeting held at the end of each quarter.

      Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Residents might not be recommended for reappointment, or be asked to resign before the end of their period of appointment.
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
      “Low-grade and mediocre men” were not permitted to continue to fill appointments to the “exclusion of high-grade men.”
      University of Minnesota
      The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
      Figure thumbnail gr4
      Figure 4Mayo Foundation residency evaluation form, 1918.
      By permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN.
      Figure thumbnail gr5
      Figure 5Mayo Foundation residency evaluation form, 1920.
      By permission of the Mayo Historical Unit, Mayo Clinic, Rochester, MN.
      The oral examination committee included faculty members from both the Mayo Foundation and the University of Minnesota. Five things were covered in the oral examinations:(1) The major field with special reference to the candidate’s specialization; (2) The minor field with a reasonably close adherence to the work he offers (especially if it is a master’s examination); (3) The thesis; (4) A reasonable test of the candidate’s working knowledge of supporting subjects relating primarily to his special field and thesis, literature, bibliography, etc.; (5) The history of medicine.

      Ford GS. Examinations of candidates for advanced degrees in medicine—suggestions to examiners. Attachment to minutes of the University of Minnesota-Mayo Foundation medical graduate committee, May 19, 1923. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      Underrepresented Minorities and International Medical Graduates Enrolled in Mayo Clinic Graduate Medical Education

      Data concerning the race of Mayo residents in the early years are limited. In the October 6, 1917, minutes of the University of Minnesota-Mayo Foundation medical graduate committee, the subject of racial consideration in the appointment of residents was “discussed but no formal action was taken.”

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, October 6, 1917. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      The Mayo residency programs were advertised in the Spanish edition of JAMA in 1919.

      Minutes of the Rochester local medical graduate committee, January 4, 1919. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      The Spanish edition of JAMA was an attempt to establish a closer medical relationship between North and Central/South America because their medical students were more likely to go to France and Germany than to the United States for their postgraduate work.

      Editor. A Spanish edition of the Journal of the American Medical Association. JAMA. 1918;71(23):1914.

      Indian physician Nielamber Joshie completed surgical training at Mayo Clinic from 1917 to 1920.
      Mayo Clinic
      Physicians of the Mayo Clinic and the Mayo Foundation.
      The Mayo Foundation medical graduate committee, reflecting contemporary prejudices and practices in American medicine, discussed a strategy in 1925 to avoid “the difficulties of placing private patients under the direct clinical care of physicians of other than the white race or with imperfect usage of the English language.”

      Minutes of the Mayo Foundation section of the medical graduate committee, December 3, 1925. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      Unlike traditional teaching institutions, Mayo’s hospitals treated all individuals as private patients. In May 1927, Louis B. Wilson met with Mayo Clinic executive committee and argued that it was undesirable to exclude “foreigners” from clinical work, and suggested that “undesirable men be eliminated on [their] clinical or other work whether foreigners or American citizens.”

      Wilson LB. Miscellaneous note dated May 25, 1927. MHU-0510: Mayo School of Graduate Medical Education. Box 12. File F (1926-1927). Mayo Foundation Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      By 1937, there were Mayo Clinic graduates living in Argentina, China, India, Japan, Mexico, the Philippines, Puerto Rico, South Africa, Spain, Thailand, and Uruguay, among others.
      Mayo Clinic
      Physicians of the Mayo Clinic and the Mayo Foundation.
      When a black physician expressed interest in the Mayo surgical residency in 1931, the Mayo medical graduate committee stated that “no opportunity could be offered in the Foundation.”

      Minutes of the Mayo Foundation section of the medical graduate committee, April 8, 1931. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      It seems doubtful that there were black residents before the 1950s, as Victor Johnson (director of the Mayo Foundation from 1947 to 1966) noted that he was responsible for the selection of the first black physician for residency training.
      • Johnson V.
      Mayo Clinic: Its Growth and Progress.
      Johnson stated that “I felt all this was sufficiently unusual to warrant taking the matter to the Board of Governors of the Mayo Clinic … they also approved.”
      • Johnson V.
      Mayo Clinic: Its Growth and Progress.
      By the time that Johnson let the trainee know, he had accepted a residency slot in Detroit. Jack Clark was one of the first black residents in the Mayo Foundation (oral surgery 1966-1969, surgery 1974-1975, otorhinolaryngology 1975-1978).

      Jack L. Clark (Otorhinolaryngology M.D.) file. File 55. MHU-0675. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      One of the earliest female black residents at Mayo was Victoria Nichols, who finished her obstetrics and gynecology training in 1975.
      • Johnson V.
      Mayo Clinic: Its Growth and Progress.

      Vicki Nichols views being black, female, a physician. Mayovox 1973;24(13):1, 3. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Summary of the First Decade of Graduate Medical Education in the Mayo Foundation

      During the first 10 years’ work of the Mayo Foundation, the total expenses were $2,194,166.25. Mayo Clinic paid $1,950,283.33, while $243,882.92 came from the Mayo Foundation.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Of 630 total trainees, 61 had done their major work in preclinical fields, 493 graduate students had done their work in clinical fields, and 76 (working in clinical or nonclinical fields) had received their support from institutions other than the Mayo Foundation or Mayo Clinic.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      The periods of residence were 2 to 3 years for about 43% of the graduate students.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      This same percentage stayed for 1 year or less than 1 year. Approximately 9% stayed for 4 years, and approximately 6% trained for 5 years or more.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Some trainees were not candidates for advanced degrees because many had to leave before they had completed their required residence, and a fairly large percentage “failed of recommendation.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Individuals who left the program early, and those who stayed the full time but whose work was not of sufficient quality to justify granting a graduate degree, received a certificate of attendance.

      Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, September 29, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      All trainees who started residency had the opportunity to finish if their work was acceptable to the faculty.
      Mayo Foundation for Medical Education and Research
      Twenty-Fifth Anniversary of the Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota: Commemorative Exercises, Mayo Civic Auditorium, October 23, 1940.
      • Pruitt R.D.
      Each a man for his season.
      There was no pyramiding, defined by Wilson as keeping only half of the residents 2 years and a fourth of them 3 years.
      Mayo Foundation for Medical Education and Research
      Twenty-Fifth Anniversary of the Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota: Commemorative Exercises, Mayo Civic Auditorium, October 23, 1940.
      From 1923 to 1928, the average residency period was 4 years.
      • Wilson L.B.
      Twelve years’ experience of the University of Minnesota in Graduate Medical Education.
      Of the 456 graduate students who left the Mayo Foundation during its first decade, 100 received Master of Science degrees and 6 received PhD degrees.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Each trainee cared for 1000 to 1200 patients/year when on clinical duty, and was “constantly stimulated to make clinical and laboratory investigations in the field of his major subject.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      This graduate training program was designed to combine the best parts of the old apprentice system with the top features of modern graduate education.
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      By the end of a resident’s training, the faculty could intelligently certify “the competency of each candidate to begin the practice of the special field of his major study in a scientific manner without supervision.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Once the residency and research requirements were met, an advanced degree in the clinical fields would be granted if “the members of the faculty would be willing not only to refer patients to them but also even to refer to them members of their own families for diagnosis and treatment.”

      Wilson LB. Notes for talk on “Medicine and Health” in the American Life Seminar, History 232, University Library, Room 12, 4:00 p.m., March 5, 1930. MHU-0601: L.B. Wilson papers. Box 23. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      In 1923, Wilson proudly reported that “Columbia [University] has her plans almost completed for graduate work along lines almost parallel with those here.”

      Wilson LB. Minutes, joint meeting of the Mayo Foundation section of the medical graduate committee and the committee on medical education and research. Suggestions from survey of graduate medical education in the United States. Confidential report to graduate committee of the Mayo Foundation and committee on medical education and research. February 6, 1923. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      In 1930, he reflected that “the University of Minnesota now finds itself accompanied by some eight or ten other universities carrying out similar experiments … the first university after the University of Minnesota to take up this work was the University of Pennsylvania … the last to announce a similar plan is the University of Virginia.”

      Wilson LB. Notes for talk on “Medicine and Health” in the American Life Seminar, History 232, University Library, Room 12, 4:00 p.m., March 5, 1930. MHU-0601: L.B. Wilson papers. Box 23. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      Outsiders had positive reviews of graduate medical education at Mayo Clinic as well. The medical historian Fielding Garrison noted in 1933:The Mayo Foundation has been the great stimulus of oxidation and motor power. Here scientific surgery was for the first time organized and made reliable, while in respect of unique methods of post-graduate training, the clinic has become a Mecca, drawing students from all parts of the country and visitors from all parts of the world.
      • Garrison F.H.
      Contributions of the West to American Medicine.

      Conclusion

      The American medical residency began at the Johns Hopkins Hospital. Developed later, the Mayo residency program differed from that of Hopkins in many ways. The University of Minnesota-Mayo Foundation graduate medical education affiliation emphasized the attainment of graduate degrees. Historian Jennifer Gunn has pointed out that it was the nation’s first 3-year, university-based program to train graduate physicians in specialty practice and medical scientific research, and to grant the Master of Science or PhD degrees in clinical specialties.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
      This particular aspect of residency did not prevail in America in the long run. The primary goal of the Mayo program was to train specialists.
      • Fye W.B.
      Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
      The primary goal of the Hopkins residency was to prepare physicians for careers in academic medicine as clinical investigators and teachers.
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
      This dichotomy was noted when comparing Mayo with its educational partner, the University of Minnesota, as well. Mayo Clinic focused on training specialists first and medical investigators second, with the University of Minnesota Graduate School reversing the order.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
      The Mayo program was rectangular or parallel (all who started had a chance to finish), whereas the Hopkins program was pyramidal (each year some residents were systematically eliminated from the program).
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
      In the Mayo residency program, “each man was given opportunities to work at least three years if he made good … culling was done before rather than after appointment.”
      Mayo Foundation for Medical Education and Research
      Twenty-Fifth Anniversary of the Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota: Commemorative Exercises, Mayo Civic Auditorium, October 23, 1940.
      Mayo pioneered this parallel residency system before World War II, and in the postwar years it would replace the pyramid system so prominent elsewhere in America.
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
      To this day, thoughtful resident selection is one of the most important tasks that a residency program director performs.
      The Mayo Foundation required that its advanced degree graduates be able to practice without supervision by the end of the residency program. Currently, the ACGME has the same requirement, stating that the program director “must verify that the resident has demonstrated sufficient competence to enter practice without direct supervision.”

      Common program requirements. Accreditation Council for Graduate Medical Education website. www.acgme.org. Accessed September 3, 2014.

      The residency evaluation tools used in the early years of the foundation included all 6 ACGME competencies present today.
      • Rose S.H.
      • Long T.R.
      • Elliott B.A.
      • Brown M.J.
      A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement.
      Specialty board certification replaced Master of Science or PhD degrees as proof of competency over time, and the Mayo Clinic training programs adjusted accordingly.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
      The Rochester campus residency training program was renamed the Mayo Graduate School of Medicine in 1964 and the MSGME in 2004. Mayo Clinic ultimately became the largest site of graduate medical education in the world.
      • Ludmerer K.M.
      Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
      The affiliation between the University of Minnesota and Mayo Clinic lasted until 1983, when Mayo became a degree-granting institution.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
      In 1983, the Mayo Foundation endowment fund had reached $5.6 million and was divided under agreement approved by the Board of Regents of the University of Minnesota, with 62.5% ($3.5 million) going to the Mayo Foundation and 37.5% ($2.1 million) going to the University of Minnesota.
      • Gunn J.
      “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.

      Smith M. Mayo endowment fund. Univ Minnesota Brief 1983;13(29):1. University of Minnesota Digital Conservancy website. http://purl.umn.edu/98659. Accessed November 12, 2014.

      Minutes of the University of Minnesota Board of Regents meeting, September 16, 1983. University of Minnesota Digital Conservancy website. http://conservancy.umn.edu/handle/11299/23. Accessed November 12, 2014.

      Information sources are unclear as to why these amounts were chosen, but the division may relate to the section of the 1917 agreement that stated that the principal “shall amount to not less than two million dollars.”
      Mayo Clinic
      Sketch of the History of the Mayo Clinic and the Mayo Foundation.
      Of the university’s $2.1 million share, $750,000 went to the endowment of the Mayo Chair in the School of Public Health at the University of Minnesota.

      Smith M. Mayo endowment fund. Univ Minnesota Brief 1983;13(29):1. University of Minnesota Digital Conservancy website. http://purl.umn.edu/98659. Accessed November 12, 2014.

      The Mayo Foundation donated another $125,000 to this chair after the University of Minnesota raised $125,000 in additional funds.

      Smith M. Mayo endowment fund. Univ Minnesota Brief 1983;13(29):1. University of Minnesota Digital Conservancy website. http://purl.umn.edu/98659. Accessed November 12, 2014.

      The Mayo Chair in Public Health was established in 1984.

      School of Public Health. 50 Years: A Legacy and A Vision: University of Minnesota School of Public Health. Minneapolis, MN: University of Minnesota; 1994. University of Minnesota Digital Conservancy website. http://purl.umn.edu/94002. Accessed November 12, 2014.

      The 1983 agreement dividing the $5.6 million between the Mayo Foundation and the University of Minnesota, and signed by the president and the secretary of the University of Minnesota and the vice chairman and the assistant secretary of the Mayo Foundation, stated that “both funds shall continue to be used for the purposes to which the original fund was dedicated—graduate medical and surgical instruction and research, including, with the University’s fund, support of its School of Public Health and, with Mayo’s fund, support of its medical school activities in Rochester … there shall be no restrictions on where the monies from the two funds shall be expended or the manner by which the two institutions shall decide on how to use the income from the funds … Mayo and the University shall have full and exclusive authority over the use of their respective funds.”

      Mayo Brothers Distinguished Fellowship. Subject Files. MHU-0676. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      The Mayo fund was entitled the Mayo Foundation for Medical Education and Research Endowment Fund.

      Mayo Brothers Distinguished Fellowship. Subject Files. MHU-0676. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      In 1996, Mayo Clinic decided to use the fund to support 6 graduate medical education positions.

      Minutes of the Mayo Graduate School of Medicine Education Committee, June 20, 1996. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      These positions were dubbed the Mayo Brothers Distinguished Fellowships. The 6 Mayo Brothers Distinguished Fellowships were first presented in 1997 and continue to be awarded to Mayo’s best residents and fellows yearly for outstanding clinical performance, humanitarian features, and scholarly activity.

      Minutes of the Mayo Graduate School of Medicine Education Committee, June 20, 1996. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      Supplemental Online Material

      References

        • Mayo Clinic
        Sketch of the History of the Mayo Clinic and the Mayo Foundation.
        Saunders, Philadelphia, PA1926
        • Wilson L.B.
        The Mayo Foundation for Medical Education and Research.
        Sigma Xi Q. 1920; 8: 52-54
        • Gunn J.
        “The first adequate graduate school of medicine in America”: a brief history of the University of Minnesota-Mayo Graduate School of Medicine.
        Minn Med. 2003; 86: 63-68
        • Stevens R.
        American Medicine and the Public Interest.
        Updated edition. University of California Press, Berkeley, CA1998
        • Fye W.B.
        Presidential address: the origins and evolution of the Mayo Clinic from 1864 to 1939: a Minnesota family practice becomes an international “medical Mecca.”.
        Bull Hist Med. 2010; 84: 323-357
      1. O’Malley C.D. The History of Medical Education. University of California Press, Berkeley, CA1970
        • Commission on Graduate Medical Education
        Graduate Medical Education: Report of the Commission on Graduate Medical Education.
        University of Chicago Press, Chicago, IL1940
        • Ludmerer K.M.
        Time to Heal: American Medical Education From the Turn of the Century to the Era of Managed Care.
        Oxford University Press, Oxford1999
        • Ludmerer K.M.
        Let Me Heal: The Opportunity to Preserve Excellence in American Medicine.
        Oxford University Press, Oxford2014
        • Harvey A.M.
        • Brieger G.H.
        • Abrams S.L.
        • McKusick V.A.
        A Model of Its Kind, Vol. 1: A Centennial History of Medicine at Johns Hopkins.
        Johns Hopkins University Press, Baltimore, MD1989
        • Ludmerer K.M.
        Learning to Heal: The Development of American Medical Education.
        Basic Books, New York1985
        • Clapesattle H.B.
        The Doctors Mayo.
        University of Minnesota Press, Minneapolis, MN1941
        • Mayo Clinic
        Physicians of the Mayo Clinic and the Mayo Foundation.
        University of Minnesota Press, Minneapolis, MN1937
        • Wilson L.B.
        Graduate work in medicine in the University of Minnesota.
        J Lancet. 1918; 38: 1-5
        • Braasch W.F.
        Early Days in the Mayo Clinic.
        Thomas, Springfield, IL1969
      2. Beckman EH. Letter to Edmund H. Mensing, M.D. February 16, 1914. Mayo Foundation for Medical Education and Research (1915-1964) file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Vincent G.E.
        • Lyon E.P.
        • Moore J.E.
        • Litzenberg J.C.
        • Beard R.O.
        The Medical School of the University of Minnesota and the Mayo Foundation for the Promotion of Medical Education and Research.
        J Lancet. 1915; 35: 135-141
      3. Wilson LB. The Affiliation of the Mayo Foundation with the Graduate Medical School of the University of Minnesota: a Review of Graduate Medical Education and Research. Paper presented at: General Alumni Association of the University of Minnesota, Minneapolis; February 18, 1915. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Wilson L.B.
        Twelve years’ experience of the University of Minnesota in Graduate Medical Education.
        Bull Assoc Am Med Coll. 1928; 3: 210-219
      4. Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, August 11, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      5. University of Minnesota. The Graduate School. Preliminary announcement of graduate work in medicine by the Medical School and the Mayo Foundation. In: Bulletin of the University of Minnesota. General Series No. 32. Minneapolis, MN: University of Minnesota; September 1915, reprinted February 1916.

        • University of Minnesota
        The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1918-1919.
        in: Bulletin of the University of Minnesota. vol. 21. no. 21. University of Minnesota, Minneapolis, MNAugust 3, 1918
      6. Della G. Drips, 1884-1976, M.D. file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • University of Minnesota
        The Graduate School. Graduate work in medicine in the Medical School and the Mayo Foundation.
        in: Bulletin of the University of Minnesota. vol. 19. no. 27. University of Minnesota, Minneapolis, MNAugust 1916
        • University of Minnesota
        The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1921-1922.
        in: Bulletin of the University of Minnesota. vol. 24 no. 23. University of Minnesota, Minneapolis, MNJuly 7, 1921
      7. Willius F.A. Aphorisms of Dr. Charles Horace Mayo, 1865-1939, and Dr. William James Mayo, 1861-1939. Thomas, Springfield, IL1951
      8. Program presented by the Mayo Foundation Chapter of Sigma Xi in honor of Dr. Louis Blanchard Wilson. November 8, 1941. Privately printed. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      9. Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, May 18, 1918. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

        • Magath T.B.
        Guns: Louis B. Wilson: ballistics expert and prophet.
        Mayo Alumnus. 1966; 2: 8-10
        • Wilson L.B.
        Graduate instruction in medicine.
        St. Paul Med J. 1912; 14: 287-295
        • Wilson L.G.
        Medical Revolution in Minnesota: A History of the University of Minnesota Medical School.
        Midewiwin Press, St. Paul, MN1989
        • Bonner T.N.
        American Doctors and German Universities: A Chapter in International Intellectual Relations, 1870-1914.
        University of Nebraska Press, Lincoln1963
      10. Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, September 29, 1915. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      11. Wilson LB. Confidential resume of faculty discussion on the results of oral examinations of fellows. February 24, 1922. Mayo Foundation Reports I file. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Wilson L.B.
        Report of Committee on Graduate Medical Education.
        Am Med Assoc Bull. 1920; 14: 45-49
      12. Wilson LB. Steps leading to the organization of qualifying boards in medical specialties and the Advisory Board for Medical Specialties (unpublished manuscript). June 28, 1939. MHU-0510: Mayo School of Graduate Medical Education. Box 17. File L.B. Wilson reprints. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Nelson C.W.
        Dr. Louis B. Wilson, pioneer Mayo scientist and educator.
        Mayo Clin Proc. 1994; 69: 4
      13. Directions for grading fellows. MHU-0510. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Rose S.H.
        • Long T.R.
        • Elliott B.A.
        • Brown M.J.
        A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement.
        Anesth Analg. 2009; 109: 190-193
      14. Common program requirements. Accreditation Council for Graduate Medical Education website. www.acgme.org. Accessed September 3, 2014.

        • University of Minnesota
        The Graduate School announcement of graduate work in medicine in the Medical School and the Mayo Foundation 1922-1923.
        in: Bulletin of the University of Minnesota. vol. 25. no. 40. University of Minnesota, Minneapolis, MNSeptember 6, 1922
      15. Ford GS. Examinations of candidates for advanced degrees in medicine—suggestions to examiners. Attachment to minutes of the University of Minnesota-Mayo Foundation medical graduate committee, May 19, 1923. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      16. Minutes of the University of Minnesota-Mayo Foundation medical graduate committee, October 6, 1917. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      17. Minutes of the Rochester local medical graduate committee, January 4, 1919. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      18. Editor. A Spanish edition of the Journal of the American Medical Association. JAMA. 1918;71(23):1914.

      19. Minutes of the Mayo Foundation section of the medical graduate committee, December 3, 1925. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

      20. Wilson LB. Miscellaneous note dated May 25, 1927. MHU-0510: Mayo School of Graduate Medical Education. Box 12. File F (1926-1927). Mayo Foundation Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      21. Minutes of the Mayo Foundation section of the medical graduate committee, April 8, 1931. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

        • Johnson V.
        Mayo Clinic: Its Growth and Progress.
        Voyageur Press, Bloomington, MN1984
      22. Jack L. Clark (Otorhinolaryngology M.D.) file. File 55. MHU-0675. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      23. Vicki Nichols views being black, female, a physician. Mayovox 1973;24(13):1, 3. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

        • Mayo Foundation for Medical Education and Research
        Twenty-Fifth Anniversary of the Mayo Foundation for Medical Education and Research, Graduate School, University of Minnesota: Commemorative Exercises, Mayo Civic Auditorium, October 23, 1940.
        Whiting Press, Rochester, MN1941
        • Pruitt R.D.
        Each a man for his season.
        Mayo Alumnus. 1976; 12: 47-53
      24. Wilson LB. Notes for talk on “Medicine and Health” in the American Life Seminar, History 232, University Library, Room 12, 4:00 p.m., March 5, 1930. MHU-0601: L.B. Wilson papers. Box 23. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      25. Wilson LB. Minutes, joint meeting of the Mayo Foundation section of the medical graduate committee and the committee on medical education and research. Suggestions from survey of graduate medical education in the United States. Confidential report to graduate committee of the Mayo Foundation and committee on medical education and research. February 6, 1923. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.

        • Garrison F.H.
        Contributions of the West to American Medicine.
        in: Lectures on the History of Medicine : A Series of Lectures at the Mayo Foundation and the Universities of Minnesota, Wisconsin, Iowa, Northwestern, and the Des Moines Academy of Medicine, 1926-1932. Saunders, Philadelphia, PA1933: 155-185
      26. Smith M. Mayo endowment fund. Univ Minnesota Brief 1983;13(29):1. University of Minnesota Digital Conservancy website. http://purl.umn.edu/98659. Accessed November 12, 2014.

      27. Minutes of the University of Minnesota Board of Regents meeting, September 16, 1983. University of Minnesota Digital Conservancy website. http://conservancy.umn.edu/handle/11299/23. Accessed November 12, 2014.

      28. School of Public Health. 50 Years: A Legacy and A Vision: University of Minnesota School of Public Health. Minneapolis, MN: University of Minnesota; 1994. University of Minnesota Digital Conservancy website. http://purl.umn.edu/94002. Accessed November 12, 2014.

      29. Mayo Brothers Distinguished Fellowship. Subject Files. MHU-0676. Mayo Clinic Archives, Mayo Historical Unit, Mayo Clinic, Rochester, MN.

      30. Minutes of the Mayo Graduate School of Medicine Education Committee, June 20, 1996. Mayo Clinic Archives, Mayo Clinic, Rochester, MN.