Rx For Rural Health Care
Less than eight months after Dr. Franklin Murphy assumed the duties of dean of the University of Kansas School of Medicine, a measure he conceived, co-authored and energetically championed across the state became a reality. Called the “Rural Health Program for Kansas” – but popularly known as the “Murphy Plan” – it was an innovative initiative without national precedent aimed at alleviating the critical shortage of physicians and other medical personnel then plaguing many rural Kansas communities.
Signed into law by Governor Frank Carlson on February 18, 1949, after passing both houses of the state legislature with nearly unanimous, bipartisan support (one of the few lawmakers to oppose it, incidentally, was an undertaker in private life), the Rural Health Program for Kansas signaled Topeka’s recognition of a serious problem and the resolve to provide some remedies. It also represented a near universal vote of confidence in the KU Medical Center (not to mention in Murphy himself), as well as the dawn of a mutually beneficial partnership between the state and its only MD-granting institution.
At the cost of $4.3 million in appropriated state funds and supplemental federal grants, the Murphy Plan was engineered to be a classic win-win. The KU Medical Center campus in Kansas City, Kansas, would be dramatically enlarged, with a corollary expansion of its health care capabilities. In return, a four-part program would address the state’s rural health care crisis.
The first plank called for the KU School of Medicine to graduate 25 percent more doctors each year (from 80 to 100 annually), plus achieve additional increases in the number of new nurses and medical technicians. Second, the plan created the Rural Preceptor Program, which required fourth-year Medical School students to spend six weeks assisting veteran physicians in rural areas – both to help provide care to patients and, just as importantly, to experience the unique rewards and challenges associated with being a “country doctor.”
Third, the Murphy Plan encouraged newly minted MDs to set up practices in underserved (or, in some cases, entirely unserved) areas by devising a strategy whereby local community residents could provide low-cost office space and medical equipment to prospective physicians. And fourth, the Plan established an elaborate postgraduate and continuing education program, headquartered at the KU Medical Center, to ensure that every Kansas physician and health care provider could keep their skills finely honed and never become “medically isolated.”
Although not a permanent panacea, and in and of itself not capable of stemming the state’s rural population decline, the Murphy Plan nonetheless stands as an ingenious approach by Kansas and the KU School of Medicine that successfully addressed rural health care problems for more than a generation. In its time, the program reaped a whirlwind of praise and inspired more than a few states to follow its example. In the process, the KU Medical Center emerged from the 1950s as a first-class institution and the University’s “greatest single claim to excellence.”
As for the Plan’s longer-term effects, the School of Medicine’s continuing education division thrives to this day, as does the Rural Preceptor program – still considered, by teachers and medical students alike, to be among the most valuable of educational experiences. Perhaps just as significantly, the Murphy Plan enabled the School of Medicine to finally shake its reputation as an insular, somewhat detached, Kansas City-area complex and instead become a full-fledged provider of truly statewide service.
The roots of the 1940s-era rural doctor shortage in Kansas that spurred the Murphy Plan into existence sprang, ironically, from the exact opposite condition a half-century earlier. In the late nineteenth century, Kansas was virtually teeming with a surfeit of physicians, and had medical schools aplenty.
Unfortunately, a goodly number of these practitioners were outright charlatans. Many others had essentially purchased their credentials following an appallingly short course of study at so-called “proprietary” medical schools – some 20 of which, at one time or another, dotted the Kansas and western Missouri landscapes in the decades after the Civil War.
The physicians churned out by these schools – some of which were little more than diploma mills – were often a health hazard themselves. Not until 1901, as Thomas N. Bonner has noted in The Kansas Doctor, did the formation of a medical licensing board enable the state to begin expelling the “army of quacks, irregular doctors, and medicine vendors [that] regularly invaded every town and village of size in Kansas.”
Along with this internal reduction of the Sunflower State’s surplus of self-styled physicians came additional external pressures for reform. In 1910, Carnegie Foundation researcher Abraham Flexner published Medical Education in the United States and Canada, a comprehensive, often-shocking exposé of more than 150 North American medical schools.
In unsparing language, Flexner detailed everything from filthy laboratories and lax entrance requirements to obsolete equipment and pathetically inadequate curricula. Among the worst offenders were the nation’s proprietary medical schools, including two in Kansas – the Kansas Medical College in Topeka (which doubled as Washburn College’s medical department) and the Western Eclectic College of Medicine and Surgery in Kansas City, Kansas. Soon afterwards, both were closed down.
As for the KU School of Medicine, which had become a four-year institution beginning in 1905-06, it received its share of disparaging comments from Flexner, but most of the criticism was constructive rather than damning. By 1920, KU was the only institution left standing in Kansas where aspiring doctors could receive medical training.
Mirroring this medical downsizing in Kansas was a national push for “fewer and better doctors.” This, in fact, had been Flexner’s principal goal in writing his bombshell report. And when the dust settled, this is exactly what happened. By the beginning of the second decade of the twentieth century, the combination of Flexner’s exposé, toughened state regulatory and licensing requirements, and reform efforts by the American Medical Association had cut the number of US medical institutions in half. Enrollment figures plummeted accordingly. Whereas, for example, there were more than 25,000 medical students nationwide in 1906, the figure had dropped to less than 14,000 in 1920.
Yet for all the commendable effects these myriad reforms had in shutting down inferior schools, raising admissions and graduation standards at reputable ones, and regularizing curricula, there were some discernible downsides. Chief among these was that a disproportionate number of school closings had occurred in the Midwest and South – regions encompassing younger, less urbanized states with significantly fewer accredited medical schools than, say, the Northeast.
As a result, many would-be doctors were forced to venture far from home to receive their medical education. And once graduated, fewer and fewer were electing to return to their home states. Especially hard hit were rural communities, irrespective of region. Post-Flexner, they became increasingly unable to attract new doctors, most of whom gravitated toward the higher incomes and the well-equipped, well-staffed modern hospitals found in America’s larger cities.
This was particularly the case in Kansas. By the mid-1940s, as doctors began to retire and were not being replaced by new MDs, the state’s health care situation – exacerbated by the concurrent World War II-era population boom – had reached crisis proportions. To grasp the true depth of the problem, consider that in 1906 Kansas had 2,732 practicing physicians for a total population of approximately 1,500,000 residents, a ratio of 1:549 (slightly better than the national average at the time). Forty years later, though, there were only 1,900 doctors practicing in Kansas – a 30 percent decrease – while the population had risen 20 percent to some 1,900,000. Now the ratio was 1:1,000, a figure considerably worse than the national average of 1:760.
Typifying the trend nationwide, Kansans living in rural areas bore the brunt of this physician shortage. By 1948, for instance, only 28 percent of the state’s doctors were considered rural practitioners, and of those, most were aged 50 or older. In fact, according to Bonner, “In more than twenty counties the mean age of practicing doctors was sixty or more.” Even worse, as many as 100 Kansas communities were without a physician altogether, and in some cases, citizens had to travel 25 miles or more just to reach the nearest doctor. Finally, considering that the KU School of Medicine was the only Kansas institution actually graduating new MDs, and then no more than 80 annually – comparatively few of whom were choosing rural practice – the prospects for relief seemed dreadful indeed.
This was the situation, then, faced by 32-year-old Dr. Franklin D. Murphy when, on July 1, 1948, he was elevated from associate professor of medicine to dean of the KU Medical School. Raised in Kansas City and an undergraduate alumnus of the University of Kansas, Murphy certainly possessed an impressive familial and professional pedigree.
His father, Dr. Franklin E. Murphy, had been one of the founding faculty members of the KU School of Medicine. His grandfather, Dr. Hugh Charles Murphy, had once been a “country doctor” in southeast Missouri. Beyond this, Murphy brought both considerable energy and unique perspective to the deanship. He had taken his own MD from the prestigious University of Pennsylvania School of Medicine and, during World War II, worked as top-flight US Army medical researcher. From these experiences, Murphy came to understand, firsthand, exactly why Kansas had the doctor-supply problems it did.
“He saw with his own eyes,” noted a Kansas City Star profile, written three months before he took over as dean, “man after man from the Middle West, providing brains and skill for eastern research institutions, while his own section of the country had been unable to hold them.” To Murphy, who had graduated valedictorian of his 1941 class at Penn, the explanation for this Midwest medical brain drain “became obvious. It was that educational institutions in this region lacked the research facilities and the post-graduate courses necessary to keep these talented men at home.”
Thus, upon assuming the Medical School deanship in the summer of 1948, Franklin Murphy also knew what it would take to reverse this alarming course in Kansas. To educate and then graduate more doctors, the Medical Center complex must be greatly expanded. It needed more buildings and more faculty members. To help Kansas retain those physicians trained at KU, the Med School needed to offer advanced postgraduate and continuing education courses. And to encourage KU-educated doctors to strongly consider practicing in the state’s medically depleted rural communities, some good incentives for them to do so must be offered.
These were all solid ideas. They were also potentially very expensive ones. They were not, however, necessarily new ideas, nor did they spring exclusively from the mind of Murphy. For several years, in fact, the Kansas Medical Society, the State Board of Health, the State Board of Agriculture, the Kansas Farm Bureau, the Kansas State Chamber of Commerce, and virtually every elected representative with a rural constituency had been wrestling with the state’s physician shortage crisis. No one denied the gravity of the situation, and in one form or another, these and other concerned parties had come to many of the same conclusions as Dean Murphy.
Yet strangely enough, the principal stumbling block to change and progress was not a grievous lack of money, as has so often been the case in Kansas history. Indeed, on the contrary, amid a postwar surge of economic prosperity, spurred by high farm prices and rapid industrialization, by 1948 the state’s coffers were so full that the solons in Topeka were actually having trouble figuring out what to spend all the surpluses on.
As Bonner explained, what had been preventing action was the “farm-dominated” Kansas legislature’s “coolness” to the KU Medical Center. Vexed by its close proximity to and association with Kansas City, Missouri, many lawmakers were loath to pour more money into a state-supported institution that, to many, had long been benefiting comparatively few taxpaying Kansans.
Moreover, another strike against the Medical School was the charge that its enthusiasm for training medical specialists (e.g., anesthesiologists and surgeons) in lieu of general practitioners, “seemed to discourage young graduates from country practice.” How could legislators be assured, even if they did authorize expansion of the Medical Center’s facilities, that the state’s rural doctor shortage would be addressed?
This is where Franklin Murphy came in. His solution proposed to harmonize what had previously been considered competing (or at least separate) interests. Convinced that “piecemeal reform” was destined to fail, Murphy presented “a unified plan which [linked] an expanding Medical School to a vastly increased program of postgraduate training and a drive to encourage young doctors to go to the rural areas.” In Bonner’s words, his goal was to make “the legislature and [the] people of Kansas see that these things were all inextricably tied together.”
With KU Chancellor Deane W. Malott’s blessing, Murphy promoted his plan by means of a wide-ranging PR blitz during the remainder of 1948. In addition to meeting with and addressing countless agricultural, commercial and health organizations “in every corner of the state,” the Med School dean called upon a number of friends and contacts he had in the media. The Kansas City Star, with its metropolitan purview that straddled the state line, began running articles explaining – and editorials backing – the Murphy Plan. Many local Kansas papers began a drumbeat of support as well.
Perhaps most effective were pieces spotlighting the tragic experiences of small Kansas towns like Minneola in southwestern Clark County, which had been without a physician for almost five years and had seen many residents die for lack of medical care. This sort of priceless media exposure – coupled with the dean’s corralling of influential state legislators, Board of Regents members and, most importantly, Kansas Republican Governor Frank Carlson – quickly created a “juggernaut of support” for the Murphy Plan that ultimately proved unstoppable.
Mentioning the measure in his annual address to the Kansas legislature, delivered on January 12, 1949, Governor Carlson reaffirmed his own support, pledging to be “wholeheartedly for it.” The Murphy Plan “has been given widespread publicity and has met with enthusiastic approval across the entire state,” the governor noted. And by its passage, he predicted, “we will take a great forward step in the relief of pain and suffering and the saving of human life.”
Originating in the State House of Representatives as House Bill No. 5, the “Rural Health Program for Kansas,” as it was officially called, accordingly met with strong bipartisan approval and sailed through both GOP-controlled chambers. By February 18, the bill had reached Governor Carlson’s desk and on that day, he signed it into law.
The legislation’s centerpiece was its establishment of the University of Kansas Hospitals Building Fund. Financed with $3,862,560 in state monies and $460,000 worth of federal grants, this $4.3 million investment “seemed astronomical given the past parsimonious funding of the Medical Center,” as Lawrence H. Larsen and Nancy J. Hulston observed in their 1992 book The University of Kansas Medical Center: A Pictorial History. (Adjusted for inflation, the amount would equate to roughly $40 million in early twenty-first century terms.)
Construction began apace, and over the next decade nine new buildings of varying sizes and uses would be erected on the Medical Center’s Kansas City, Kansas, campus. The major structures included Wahl Hall West; the Children’s Rehabilitation Unit; the Student Center; Robinson Hall; the Eleanor Taylor building (serving as a new nurses’ residence); and the Olathe and Delp Pavilions.
Other facilities underwent additions, more than $400,000 was spent on new medical equipment, and the number of faculty hires exploded – going from roughly 300 in 1948 to more than 530 by 1960. Finally, over this same period the Medical School’s yearly operating income quadrupled to almost $10 million while its medical research budgets crossed the $1 million annual threshold.
To hold up KU’s end of the bargain, Murphy set to work quickly as well. In advocating his Plan’s passage, the dean had said that, “It was not easy to tell ‘Bill Jones’ that our facilities permitted us to take only eighty freshmen and he was number eighty-one. Rejecting good potential medical students in the face of the obvious need for more doctors seems to me morally, socially and economically wrong.”
In the fall 1949 semester, less than seven months after the Rural Health Program for Kansas was enacted, the Medical School welcomed its first 100-student class. This represented the promised 25 percent increase over the institution’s previous 80-student limit.
Beyond this, the Medical Center’s expanded facilities allowed for the training, housing and graduation of considerably more nurses, too – from roughly 30 annually to soon well over 50. Similarly enlarged in the ensuing years were classes for a wide variety of other medical professionals, including occupational and physical therapists, dieticians, and laboratory and X-ray technicians.
Meanwhile, Murphy began delivering on the second plank of his namesake Plan. That same fall 1949 semester, he supervised the launch of the Medical School’s Rural Preceptor Program, which was aimed squarely, and immediately, at the heart of Kansas’ rural doctor shortage – especially its dearth of general practitioners. Under this program, fourth-year medical students would be matched up with established physicians – often overworked and understaffed – who were practicing in rural communities (populations 2,500 or less) throughout the Sunflower State.
For six weeks, these students would work closely with, learn from, and assist their host physicians in their day-to-day practices. They would also gain tremendously valuable real-life, hands-on diagnostic and patient-care experience, as well as develop a deep appreciation for both the difficulties and the potential rewards of the small-town “country doctor” life.
Reminiscences are replete with stories of Medical School students delivering their first babies and pronouncing their first deaths while in the Preceptor Program. In between, they were called upon to treat an enormous range of maladies, from stab wounds, heart disease and spider bites, to respiratory infections, terminal cancer and limbs mangled in farm-machinery accidents.
In many ways, this was a far more challenging environment than most would have ever seen in big-city hospitals. (As one former student explained, “When you are perplexed by a cardiovascular problem, you can’t simply consult cardiology. You have to figure it out for yourself.”) Further illustrating the diversity of cases in rural practice – and also the sheer depth of expertise required for it – another program veteran recalled how he once extracted a bean lodged in a little boy’s nose, while a third told of the time he spayed his preceptor’s favorite hunting dog.
Making actual “house calls”; accepting payment (if at all) by cash or barter; sharing families’ joys and sharing in their grief; looking around with pride at having delivered half of a town’s residents; calling people both patient and friend – this was what it meant to be a rural Kansas doctor in the mid-twentieth century.
And for six weeks, the Preceptor Program allowed KU medical students to experience it up close. Granted, upon completing their rotations, some wanted nothing more to do with rural life or with rural practice. Yet for every one of those, there were many others who echoed the sentiments of one alumnus when he spoke of “going to a small town expecting the worst, but [instead] finding the best.”
As Dean Murphy had hoped, thanks to the Preceptor Program, rural practice suddenly became a viable option and a seriously considered career choice for many Medical School graduates. This situation thus dovetailed nicely into the Murphy Plan’s third plank. In conjunction with members of the Kansas Medical Society and the State Board of Health, Murphy helped implement a strategy that would enable underserved – or in some cases, wholly unserved – rural communities to attract and, more importantly, keep newly minted MDs.
Previously, a significant barrier to rural practice had been an economic one. Upon completing four years of medical school, most young physicians had considerable debts, and were therefore reluctant (or just plain unable) to assume the added burden of setting up a practice from scratch. Renting office space, purchasing expensive diagnostic equipment (such as X-ray machines) and other necessary supplies up front – these were costs that doctors who joined metropolitan hospitals or established practices would not usually have to bear.
Beginning in 1949, though, the Murphy Plan began encouraging individual towns to purchase and fully equip doctor’s offices themselves, then offer to rent them on generous terms to any physician who’d agree to come, live and practice medicine there. Over time, the doctor could eventually own the facilities outright. (Incidentally, thanks to the Preceptor Program, many students had already gained valuable firsthand knowledge of how, from a business standpoint, to successfully operate a rural medical practice.) Initially run out of Dean Murphy’s Medical School office, this program received requests and processed information from small towns all across Kansas, aiming to connect needy communities with willing practitioners.
The results were once again almost immediate. “During 1950 and 1951,” noted Bonner, “seventy-nine physicians began practicing in Kansas towns with a population of 1,500 or less, thus reversing a fifty-year trend.” Furthermore, he added, “The Kansas Medical Society reported in 1951 not only that the Murphy Plan was working but also that in some instances a second doctor had been called to a town that had no doctor at all only a few years before.” (Even the long-suffering town of Minneola now had a doctor – for the first time in nearly six years.)
As related by Murphy himself in a May 26, 1951, article written for the Saturday Evening Post titled “We Need More Doctors” – part of the nationwide call-to-action he was by now helping lead – a typical Kansas success story was the southwestern town of Plains, located in Meade County. Spurred by an initial $25,000 gift from a local resident, the people of Plains collected an additional $10,000 among themselves and proceeded to build an “excellent air-conditioned clinic.” Then, taking advantage of the Murphy Plan’s networking apparatus, the citizens were able to connect with Dr. William H. Burch, who, at the time, was completing his internship at the KU Medical Center. Within a couple weeks, Murphy was pleased to announce in May 1951, Dr. Burch “will [be moving] out to Plains with his wife and two small children. He will rent the office and clinic space for seventy-five dollars a month and purchase the equipment over a ten-year period without interest.”
Throughout the Sunflower State, as Murphy reported in his Saturday Evening Post article, “small clinics and health centers have been popping up faster than new post offices in the hey-day of the New Deal. The towns are getting their doctors, and I think the doctors will stay.” Indeed they did, for by 1957, wrote Bonner, “Kansas could boast that not a single county in the state was without a doctor.”
And what’s more, “there was no community with a population over one thousand which did not have its own physician.” Over this period, too, the median age of practicing Kansas doctors dropped significantly, while the percentage of KU School of Medicine graduates who elected to remain in the state rose – from 33 percent to 55 percent by the end of the 1950s.
Praised for his leadership on rural health care issues, both in Kansas and beyond, Dean Murphy had numerous honors and awards heaped upon him during his three-year tenure at the helm of the KU School of Medicine. In 1949, for example, the Kansas Junior Chamber of Commerce named him “the most outstanding young man” of the year. Then, the United States Junior Chamber of Commerce followed by designating him one of its “ten outstanding young men.” The north-central Kansas town of Mankato (in Jewell County) declared November 17, 1949, to be “Dean Murphy Day,” on which they opened a new self-financed clinic and welcomed a new doctor. And finally, in 1950, Life magazine honored Murphy as one of the year’s most notable examples of “up-and-coming brains and talent.”
By expanding the School of Medicine to educate more physicians, then encouraging students to experience, and possibly go into, rural practice themselves, Dean Murphy and his namesake Plan had certainly made great progress toward alleviating Kansas’ doctor-shortage problems. The capstone, however, had to be an ongoing support mechanism whereby the state’s physicians (rural ones especially) could keep their skills sharp and current. “We are not only going to get you a doctor,” Murphy often told small-town audiences, “but we are going to provide the opportunity for him to maintain his professional excellence on through the years.”
Thus the fourth plank – referred to as the “in-residence program” – involved dramatically expanding the School of Medicine’s postgraduate and continuing education classes, particularly those aimed at general practitioners. The “fear of becoming medically isolated and turning into mere ‘pill rollers,’” Murphy explained, has “deterred many young doctors from taking practices in remote parts of the state.”
To prevent this outcome, his idea was to invite physicians throughout Kansas (and from anywhere else, for that matter) to come to the 39th and Rainbow campus for several days, or even weeks, at a time for refresher courses. By these, he said, they would be able to keep “in constant touch with new developments in diagnosis and treatment.”
Moreover, for those unable to make the journey to KCK, there would be circuit courses, in which professors from the KU School of Medicine would travel out in teams to various Kansas locales, conducting group seminars on the latest medical techniques.
Here too, success was rapid and remarkable. In 1951, as Bonner has noted, the Medical Center was able to announce that “over 85 percent of the state’s physicians under sixty years of age had attended some course during the preceding year.”
To meet the crush of “students,” soon numbering well into the thousands annually, the Medical School formed a new Department of Postgraduate Education. As a result, by 1953, “Kansas would rank first in the nation” in postgraduate medical training – measured in terms of annual attendance, faculty involvement and the geographical diversity of attendees. Participants hailed from nearly every state in the Union and from eight foreign countries.
By this point, Franklin Murphy was no longer in directly charge of the KU School of Medicine, having become chancellor of the entire University of Kansas in 1951. Continued execution and enhancement of the Murphy Plan thus became the primary responsibility of pharmacology professor Dr. W. Clarke Wescoe, who had succeeded Murphy as dean. The two men were genuine friends and colleagues, and worked closely together on this and other initiatives.
A good indication of their joint success is that, all told, representatives from at least 10 US states (including New York) would eventually contact them, wondering how the “Kansas Plan” might be adapted to address their own rural health care crises. As Wescoe himself noted at the time, “This Rural Health Program has become of major historical interest [and] has literally made the name Kansas synonymous with medical progress across the United States.”
In hindsight, according to KU historian Clifford Griffin, 1948-51 had been “the most stimulating and productive” period in the Medical School’s 50-year history. Thanks to Murphy’s implementation of the Rural Health Program for Kansas – followed by Wescoe’s effective stewardship throughout the 1950s – Bonner was able to characterize the decade itself as one of “momentous change and daring innovation” at 39th and Rainbow.
As Larsen and Hulston have observed, beyond the enlarged campus, the expanded services, the new programs and departments, one of the most significant changes involved the Medical Center’s evolution into a truly “statewide institution.” Once derided and denied substantial funding for its perceived insularity and too-close ties to metropolitan Kansas City, it was now able, at long last, to provide valuable (and much appreciated) service to Kansans across the state.
When first proposed back in the summer of 1948, the Murphy Plan was billed as a means to alleviate a rural doctor-shortage brought on and exacerbated by a multitude of factors, some of which were part of larger commercial and demographic trends that had nothing to do with health care per se. Yet remarkably, perhaps even improbably, the Murphy Plan temporarily reversed these powerful social and economic forces, and then more or less held them in check for some three decades. Indeed, until the 1980s, as Larsen and Hulston have noted, KU could claim “all citizens of Kansas were within twenty minutes of medical help.”
Ultimately, though, the Murphy Plan proved unable to stem the tide permanently. In 1991, for example, out of 105 Kansas counties, only the most urbanized five – Johnson, Sedgwick, Shawnee, Wyandotte and Douglas – were not suffering from any physician shortages. Conversely, that same year, nine counties were considered “underserved,” meaning they only had 33 percent to 37 percent of the doctors needed based on population. And worst of all, an alarming 52 (mainly rural) counties were deemed “critically underserved,” meaning they had less than a third of the doctors they needed.
These conditions have not changed much as Kansas enters the twenty-first century. In fact, as Mary Beth Gentry and Kim Erb noted in Medicine on the Kansas Prairie (published by the KU School of Medicine in 2003),“Today’s [rural] health crisis is more insidious than that faced by Franklin D. Murphy.”
They based this unhappy assessment on the state’s “softening economy, an aging physician population, increasing numbers of uninsured, decreases in federal and insurance reimbursements, skyrocketing [malpractice] insurance premiums, and changing demographics.” In combination, these factors have created a new rural physician shortage in Kansas.
Even without a Murphy Plan to guide it, however, the KU School of Medicine is still playing an important part in addressing the current challenge. Two ongoing legacies of the Murphy Plan – the continuing education division and the Rural Preceptor Program – remain very much in place, annually breathing new life into Dean Murphy’s dictum that a doctor “must be a citizen first, a physician second.”
John H. McCool
Department of History
University of Kansas