Modern Specialist Training: Brainchild of a Cocaine Addict

Few career paths are as challenging as that of a doctor. Worldwide, only the best students of a given year are admitted to a medical school. After several years of rigorous academic training, they face comprehensive examinations.

It’s no coincidence that the Anglo-Saxon term for subsequent specialist training is “residency.” Originally, residents (who were all men) were expected to live in the building where they worked to be always available. Even today, most regularly work night shifts.

However, ensuring the quality of medical care is not the only reason for the strict hierarchy in hospitals. Recent historical research points to other, perhaps less significant but no less interesting, reasons for the structure of modern specialist training.

Genius With an Open Secret

If one could speak of an all-star team in an academic context, the surgical department at Johns Hopkins Hospital in Baltimore would certainly have earned that description in 1895. Joseph Colt Bloodgood (1867-1935), Harvey Cushing (1868-1939), and several other prominent figures were part of this team. Great moments in medicine would soon unfold within this group.

Bloodgood revolutionized bone cancer diagnostics through the skilled use of x-rays, while Cushing became the first to describe the eponymous endocrinological disease and the world’s first neurosurgeon. Another unifying factor among these stars was their mentor, William Stewart Halsted (1852-1922).

In 189src, Halsted became the surgical director of the Johns Hopkins Hospital, having previously held lower-ranking positions due to past drug problems. Two years later, he cofounded the Johns Hopkins School of Medicine with William H. Welch (185src-1934), William Osler (1849-1919), and Howard A. Kelly (1858-1943). As its first professor, Halsted established a structured, hierarchically managed training program, which would last for the next three decades.

Much like moons orbiting planets in a galaxy, less experienced residents in Halsted’s program followed the more experienced ones, systematically advancing toward success.

Among the 17 residents and 55 assistant residents who completed Halsted’s program, two thirds were appointed professors. Halsted’s teaching methods spread worldwide, forming the foundation of residency training in many institutions.

However, according to the laws of nature, Halsted’s own involvement in this system became increasingly unnecessary. In 1895, Halsted was nowhere to be found in Baltimore. For 6 months, the supervisory committee, which had once appointed him for his innovative teaching, considered him missing.

Harvard-trained surgeon and medical historian Paul Friedmann correctly noted, “If Halsted were practicing today, he would probably be summarily fired from his position and lose his license to practice medicine.”

Halsted’s absence in 1895 was not an isolated incident.

Medical historian Howard Markel agrees with Friedmann, writing that during his time as surgical director, Halsted repeatedly attracted attention for his “erratic behavior in the operating room,” “frequent absences from the hospital,” “avoidance of close colleagues when he was walking the wards,” “going home daily at 4:3src PM,” “regularly locking himself in his office for 9src minutes before dinner,” and “curious habit of sending his soiled linen to an exclusive laundry in Paris (which may have sent back more than clean shirts).”

It must have been an open secret to many of Halsted’s contemporaries that he never overcame his drug problems, which plagued him until his death.

The pyramidal structure of his training program, the competitive selection of exceptional residents, and their heavy workload all helped to conceal Halsted’s drug-associated incompetence.

While his all-star team of stars made rounds through the clinic, Halsted dedicated himself to the tasks in his imagined galaxy that he was still capable of performing under the influence of drugs.

Inspiration From the German Empire

Halsted was rarely close to incapacity during his early life, perhaps only during one phase. Born in 1852 as the eldest son of Mary Louisa Haines and the wealthy New York businessman William Mills Halsted, Jr, Halsted was fortunate enough to attend the elite Phillips Academy in Andover, Massachusetts.

In 1869, he began his studies at Yale University, New Haven, Connecticut, where he gained popularity as the captain of the football team and a member of both the baseball and rowing teams. However, his academic performance was below average, and his application to the “Skull and Bones” secret society was rejected.

From 1874, Halsted devoted himself to studying human medicine at Columbia University College of Physicians and Surgeons, New York. Two years later, a burnout prompted him to move to Block Island, Rhode Island, where he hoped to recover his cognitive abilities through fishing and sailing.

To gain some distance from his purely theoretical studies, he applied for a rare internship at Bellevue Hospital in New York. His year of hands-on work likely sparked his intellectual curiosity. In 1877, he graduated as one of the top 1src students.

After 6 months of training under pathologist Welch at New York Hospital, New York, Halsted realized he had exhausted the training opportunities available in his home country. He decided to travel to Europe, where he had the chance to learn from 19 surgical and scientific experts, including Edoardo Bassini (1844-1924), Ernst von Bergmann (1836-19src7), Theodor Billroth (1829-1894), Heinrich Braun (1862-1934), Hans Chiari (1851-1916), Friedrich von Esmarach (1823-19src8), Albert von Kölliker (1817-19src5), Jan Mikulicz-Radecki (185src-19src5), Max Schede (1844-19src2), Adolph Stöhr (1855-1921), Richard von Volkmann (183src-1889), Anton Wölfler (185src-1917), and Emil Zuckerkandl (1849-191src).

Halsted was particularly impressed by the medical training system in the German Empire. Ira Rutkow wrote, “Halsted drew from many sources, but the most important was the collective educational experience of his first visit to Europe in 1878-188src.”

Halsted clearly modeled his residency program for assistants at Johns Hopkins Hospital on the German system. The integration of basic sciences and practical clinical training, the presence of full-time faculty, and the rigorous competition that allowed only the best to succeed were all aspects that Halsted admired.

Addiction: Sword of Damocles

In 188src, Halsted returned to New York. The following 6 years proved to be extraordinarily productive for him. Inspired by his observations at New York Hospital and his experiences in Europe, he began practicing antiseptic surgery. To implement his ideas, Bellevue Hospital, the oldest public hospital in the US, invested $1src,srcsrcsrc in building an operating tent.

Driven by the knowledge he gained during his European travels, Halsted became involved at Bellevue Hospital, Charity Hospital, Roosevelt Hospital, and State Emigrant Hospital on Ward’s Island as an anatomical lecturer. He quickly earned a reputation as an unconventional, energetic, and practical educator, with students consistently achieving outstanding results.

When Halsted’s mother was diagnosed with a life-threatening gallbladder condition in 1882, he promptly performed one of the first cholecystectomies in the United States, operating on her at the family kitchen table.

A few years later, he transfused his own blood into his postpartum moribund sister, saving her life with a subsequent surgical procedure. These and similar actions solidified Halsted’s reputation as a bold and innovative surgeon.

Halsted’s Downfall

Halsted’s downfall began when he encountered a report by Australian ophthalmologist Karl Koller in 1884, which described the anesthetic properties of cocaine. Bold as ever, Halsted encouraged his students and colleagues to test the effects of cocaine on one another, and he participated in the experiments himself.

Over the next 5 years, Halsted published several logically incoherent works. One of these articles, published in 1885 in the New York Medical Journal, raised concerns for Harvey Firestone, a close friend of Halsted, about Halsted’s potential drug problem. Although Firestone arranged a 2-week sea voyage for Halsted to help him curb his cocaine use, Halsted failed to overcome his addiction.

Immediately upon returning to New York, Halsted voluntarily entered drug rehabilitation at the Butler Sanatorium in Providence, Rhode Island. For 7 months, efforts were made to treat Halsted’s cocaine addiction with morphine. Several reports suggest that Halsted never overcame his cocaine addiction and instead developed a morphine dependency during his time in Providence.

Halsted’s addiction, which loomed over his career like a sword of Damocles, would later have had a profound impact on both his professional direction and the development of his residency program.

Halsted’s Weakness

After his release from Butler Sanatorium (now Butler Hospital), a psychiatric hospital in Providence, Rhode Island, in 1886, Halsted’s career prospects in New York had diminished. Many renowned institutions were hesitant to associate with a former drug addict. However, Halsted remained academically competent and well-networked. In Welch’s experimental research group at Johns Hopkins Hospital in Baltimore, Halsted published significant works in the following years.

One of these works was presented at the Harvard Medical School, Boston. Despite a relapse and a temporary return to Butler Hospital, Halsted was appointed in May 1889 as the director of the university outpatient clinic at Johns Hopkins University, the chief surgeon of the surgical department, and associate professor of surgery. A year later, Welch and Osler recommended him for the position of director of surgery.

According to medical historian Thomas Schlick, Halsted’s surgical methods and teaching approach in Baltimore underwent a drastic shift. As a young, energetic surgeon in New York, Halsted had preached speed and pragmatism. Now, he emphasized the importance of a “ conservative, physiological surgical technique” and delegated all teaching responsibilities to his senior assistants.

The slowdown in Halsted’s thinking and actions was so evident that William Mayo (1861-1931), one of the founders of the Mayo Clinic, observed after watching Halsted perform a radical mastectomy, “I have never seen a wound operated at the top while the bottom was already healed.”

Daniel B. Nunn, while a historian of the Halsted Society, noted that “he became a slow, painstaking surgeon who devoted his life to scientific investigation, organization of a surgical residency, development of improved operative techniques, and intense study of surgical problems; in essence, he concentrated on contemplation and reflection rather than the performance of many operations.”

In practice, residents took on most of Halsted’s clinical and didactic duties.

Conclusion

Although Halsted’s drug addiction may not have been the sole reason for his late reorientation, it is undeniable that some of his residents benefited from this shift.

The significant clinical responsibility and high competition faced by Halsted’s residents provided those who reached the top of Halsted’s pyramidal system with an unusually broad and deep clinical experience.

Those who left the program early often did so, then as now, due to the enormous mental and physical strain.

In 1922, Halsted, who as a young surgeon had saved his mother’s life by performing a cholecystectomy on the kitchen table and who, as an older surgeon, had advanced safe and physiological surgical techniques, died due to complications from gallbladder surgery.

One might see another paradox in this, but medical residents around the world will likely forever look back with gratitude and admiration at the achievements of this bold doctor, whose drug addiction significantly shaped the pyramidal structure of modern residency training.

This story was translated from Univadis Germany using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.