INFANCY, VISIONS AND REALITIES, 1968-1982
illiam M. Fowler, Jr., M.D., became the founding Chair of the Department of Physical Medicine and Rehabilitation, September 1, 1968. 1968 to 1979 was a history of continuous crises, hard days, lean budgets , disappointments and upsets. It was a time of initial optimistic visions confronted by stark reality, but it was also a period of strength from adversity. The old saying of building programs and facilities "from the ground-up" took on real meaning. With a few exceptions, 1979 to 1982 was a period of consolidation and transition.
"I was assigned an office in a small temporary building shared with the Divisions of Cardiology and Pulmonary Medicine. By 1977, the Department of PM&R had been located in four temporary buildings. Since there was very limited space for department offices at the Sacramento Hospital, the Department of Physical Medicine and Rehabilitation remained on the UC Davis campus until 1982. There were no permanent buildings on the UCD campus until 1977. It is rather ironic that I am still in the same office in TB 191 that I had as Department Chair."
The university did not take full ownership of the Sacramento Medical Center until July 1978 when it became the UC Davis Medical Center. The facility was quite inadequate for a teaching hospital, and, in addition, there was a turn over of five hospital directors between 1967 and 1980. Up to 1973, the director and all hospital staff, including Bob Taylor, were employees of the County of Sacramento. The PM&R inpatient unit like all other wards had 4 to 5 beds in each room and was primarily filled with patients awaiting placement in nursing homes. Some had been there as long as two years. The staff consisted of two physical therapists, several therapy aides, a receptionist and a secretary."
"Several days after I arrived, the Chair of the Curriculum Committee told me that I had been appointed to be Chair of the first year medical student 3-week Musculoskeletal Organ System Course. It was to start in two weeks. He also mentioned that only one person in the Anatomy Department was available to teach gross anatomy and histology. Since gross anatomy was my most disliked subject in medical school, I was not impressed." W. M. Fowler, Jr.
Plans for facilities included two permanent academic buildings by 1971 and 1978 and a 350-bed teaching hospital by 1973 on the UC Davis campus. The newly-named Sacramento Medical Center was to remain a county hospital affiliated with the School of Medicine. These plans were dependent on the successful passage of state bond issues and continued federal aid to new medical schools. Unfortunately, for the first time in California, the 1968 bond issue for higher education failed to pass. At about the same time, there was a major reduction in federal aid to new medical schools. In 1970, a second bond issue for the Health Sciences, which would also result in more federal aid, was rejected by the voters, and the university and Sacramento Medical Center budgets were significantly reduced. At this point, the state administration and the UC Board of Regents were openly talking about closing the UCD School of Medicine. The 1972 bond passed, but the promised 50% match of federal funds was deleted by President Nixon. A 1976 proposed state bond issue was then vetoed by Governor Brown. The limited funds available permitted the construction of one of the two proposed campus academic buildings in mid-1977 but required that 30% would have to be occupied by the School of Veterinary Medicine. As a result, department accommodations were only available for the basic science faculty. More temporary buildings were erected, and as many clinical departments as possible were moved to the medical center in Sacramento over a prolonged period of time, although most of their laboratories remained on campus. In 1968, there were 68 faculty from 60 universities and 69 interns and residents. This increased to over 300 faculty and 510 housestaff by 1979. The School of Medicine had affiliations with the Martinez V. A. Medical Center, Sacramento Kaiser Permanente Medical Center, Sacramento Sutter Medical Center, American River Hospital, and the David Grant Medical Center.
The medical student program continued as if there were no problems. The class size was increased from 48 to 52 in 1969 and 100 in 1971. In that year, based on the size of the entering class, the UCD School of Medicine was one of the three largest medical schools in the state. The curriculum was based on organ system core courses, a third-year clerkship program, and extensive elective time during the first, second, and fourth years. In 1972, with formal accreditation, the School of Medicine became the nation's 100th medical school. The last major crises for the medical school related to the medical students and had an impact on medical schools throughout the country. This was the Bakke case in 1977 which became a milestone in the nation-wide struggle over affirmative action.
After the 1970 bond issue defeat, it became obvious to even the most optimistic that the Sacramento Medical Center would be the School of Medicine's teaching hospital. The hospital had become a community medical center in 1968, caring, in theory, for paying patients in addition to welfare and emergency cases. The history of continuous crisis and problems at the medical center equaled those of the medical school.
Facilities needed massive upgrading and services reorganized for clinical teaching purposes. But these needs were not even the primary problem. Negotiations to turn the medical center over to the university in 1971 ended over cost-splitting, and the county gave notice that they would end the affiliation with the university leaving the medical school without any teaching hospital. However, under pressure from state legislators, it was agreed that the university would purchase the hospital for one dollar. Other buildings at the site would also be purchased by the university and the county would subsidize the care for indigent patients. In July 1973, the hospital became the Sacramento Medical Center of the University of California at Davis.
A long and even more complicated story unfolded before the facility finally became the UC Davis Medical Center in 1978. First, in the fall of 1974, the entire North-South wing of the hospital, in which Physical Medicine and Rehabilitation was located, failed to meet state seismic safety standards. This would require the construction of a new building and remodeling older buildings but funding was not available. Second, the 1976 bond issue had failed so a hospital on the Davis campus was no longer an option. Third, massive financial losses were occurring at the Sacramento facility since the county continued to shift financial responsibility to the university to avoid payment of hospital expenses for Medi-Cal and especially for indigent patients. This culminated in the university giving notice to the county that it was going to cancel its contract and vacate the medical center in mid-1978. Again, the state legislature stepped in and forced the county to agree to provide for indigent care.
UC Davis Medical Center then started to have yearly surpluses which, with additional state funds, permitted the construction of a new tower and remodeling of other buildings in 1982. The last major crises occurred in 1981 when the medical center lost its accreditation for two years over a quality of care issue.
"Regardless of all the problems that were to occur, Bob Taylor and my objectives in 1968 for building a Department of Physical Medicine and Rehabilitationat UCD were to develop by 1980:
- A modest sized but high quality comprehensive clinical service.
- Patient service programs in childrens' rehabilitation, neuromuscular diseases, prosthetics/ orthotics, spinal cord injury, and musculoskeletal disorders.
- A small but high quality PM&R resident program.
- Extensive participation in the medical student curriculum.
- A clinical, applied, and basic science research program focused on neuromuscular diseases and muscle and nerve biology.
- Extramural grant and contract support for teaching and training, patient service, and research.
- School of Medicine, campus, local, state, and national recognition in academic PM&R based on the recruitment of faculty with demonstrated or potential academic and clinical excellence.
Retrospectively, this list of objectives represents a mix of naiveté, arrogance, and pathologic optimism. It's amazing how confident youth can be. Even more amazing is that most of the objectives were met, all or in part." W. M. Fowler, Jr.
During the 5-year period that Sacramento County still owned and operated the hospital, PM&R actually did better than the other clinical departments. As part of the hospital's building program, a relatively adequate and well-designed therapy facility had been included. Most of the funds for this unit and a 60-bed rehabilitation ward had come from federal sources with the requirement that the space could not be used for any other purpose for five years.
"Separation of the hospital and the School of Medicine encouraged the good-guy, bad-guy routine. When Bob Taylor, employed by the county, got in trouble with the hospital director, I took the blame. When I got in trouble with the Dean, Bob would say it was his fault. This occurred quite frequently since Bob and I shared the same belief that it was better to humbly beg for forgiveness than to ask for permission. Since there was far less of an administrative bureaucracy then there is today, it was also easier and quicker to get things done." W. M. Fowler, Jr.
It was fortunate that the department obtained as much as it did under the county administration. When the university assumed ownership of the hospital in 1973, there was a huge budget deficit that was not reversed until 1976 requiring significant staff reduction. This was followed by a new hospital director between 1976 and 1980 who tried without success to eliminate the hospital Department of Physical Medicine and Rehabilitation. After 1980, and the fourth director since 1968, there were only a few minor problems and the department was able to increase its staff.
Clinical services developed in parallel with the availability of facilities. By 1970, Occupational Therapy and Speech Sections had been added to the existing Physical Therapy Section and additional staff for the latter. Over the next five years, Sections of Orthotics and Psychology/Social Services were started. Until Jean Zelle retired in 1977, there was a vocational rehabilitation program, and for several years a Rehabilitation Engineering laboratory under the direction of Worden Waring, PhD. Although the therapy services were satisfactory for that period, the ambulatory clinic and inpatient units were inadequate. The latter was rectified when the new hospital tower was completed in 1982. The new tower also permitted the construction of an electrodiagnostic laboratory, which had been located in the clinic. The Ambulatory Clinic with only four examination rooms remained a major problem until the early 1990s.
Founding Section Chiefs and their successors, 1968–1982, were Nancy Pitsch, Mary Lou Stone, and Robert Davison (Physical Therapy); Marilyn McClosky and Mary Lou Burke (Occupational Therapy); Edwina Walcott and Deborah Ross (Speech); Robert Buchanan (Orthotics); Bart Billings, PhD (Psychology); Jean Rode and Jo Mays (Clinic Nursing). The first School of Medicine PM&R Department Manager, Carmen Zinn, also served as the de facto hospital PM&R Department Manager until about 1977. She was succeeded by Vicki Roberts and Jerrie Wright. The first official hospital Department of PM&R Manager, Linda Beaulieu, was recruited in about 1980. The first Clinical Rehabilitation Nurse Specialist was Lynn Macintosh in 1976. Chief Technicians during this period were Charles Peterson, Daryl Zinn, Nancy Ullmann, and the current technician, Ted Abresch.
Patient programs were developed more rapidly than the therapy and other services. By the mid-1970s, regional programs had been started in neuromuscular diseases, sponsored by the Muscular Dystrophy Association, Pediatric Rehabilitation, sponsored by the California Children's Service (child amputee, myelomeningocele, neuromusculoskeletal clinics), as well as, spinal cord injury, adult amputee, and musculoskeletal clinics. As today, there was a greater emphasis on ambulatory patients than on acute inpatient rehabilitation. This was at the time that most other academic PM&R departments emphasized the latter.
The department's teaching and training programs were more extensive then at any time thereafter. Extramural funds from the federal Rehabilitation Service Administration were available and supported a percentage of the residents' salaries; the salary of one non-physician faculty and a secretary; medical student, undergraduate and CME programs, and other training support activities.
The PM&R residency program was started in 1970 -1971, and 19 residents graduated by 1982. The first residents were Thomas Ivers, Harold C. Freedman and Lawrence Janus. Others during this period were Laxman Kewalramani, Paul H. Goodley, James B. Reynolds, Mehendra Nath, Joseph T. Hartzog, Omprakash N. Sureka, Alastair H. McIntosh, Dennis P. Sullivan, Margaret M. Portwood, David W. Ruggles, Gil Won Song, James S. Lieberman, Robert A. Wiemer, Jr., Mark N. Taylor, Susie S. K. Kay, and Gerardo O. Pascual. The low number of residents was primarily due to the lack of qualified applicants through about 1978. Indeed, only about 68% of the funded positions in the country and 45% in California were filled in the mid-1970s. Most of the residents at UCD spent only two years in training since about 75% had come from other medical specialties.
Several of the residents became PM&R faculty; L. Kewalramani, M. M. Portwood, and J. S. Lieberman. Larry Janus established the first community hospital PM&R program in the northern part of the central valley at American River Hospital, Sacramento, in 1972. For a brief period, the department was also responsible for an integrated residency program at the Martinez VA Medical Center.
"The story I would like to relate to you added invaluably to my clinical experience and is as follows: When I became a chief resident, I was in charge of the ward business was slow. There were many empty beds. There wasn't much clinical material for the residents. It seemed to me that there certainly was the need for such treatment, but somehow the patients weren't really getting referred and consults weren't being obtained. Mary Lou Stone was the head of the Physical Therapy Department. When they had rounds, she mentioned that many of her therapists thought many of the patients within the hospital on other services were in need of Physical Medicine and Rehabilitation. We talked and developed a system where a therapist would notify Mary Lou who then subsequently told me about the patient. I would go and review the chart, talk to the resident, and obtain a referral. I would then go and evaluate the patient, discuss the rehabilitation program, and arrange for the transfer of the patient. Business became very brisk in the ward and it was a great clinical experience for me and for all of the residents in PM&R."J.B. Reynolds, 1976
There was extensive involvement in the medical school curriculum. The PM&R and Orthopaedic Surgery Departments were responsible for the first and second year musculoskeletal organ system core courses, and the PM&R Chair was the Co-Chair for both years.
"I only had a few problems with the second year musculoskeletal course, since it primarily included pathology, pharmacology, diagnoses and management. The first year, however, was an experience that I will never forget. The physiology and histology components were not difficult, but the gross anatomy laboratory was a real challenge. There was only one anatomy professor available, so the first thing Bob Taylor and I did was to recruit all three orthopaedic faculty and about five community orthopaedic surgeons. Therefore, each table had two to three instructors. The second action was to assign each table to a single anatomical area, and then, on a rotation basis, have the students at that table teach the rest of the class. The students, of course, loved it since the physician instructors were not interested in nit-picking details and related the material to patient cases. I don't know how much they learned, but I became painfully conversant with Grey's Anatomy Textbook."….W.M. Fowler, Jr.
Since there was no core PM&R clerkship, it was necessary to offer physical medicine and rehabilitation electives all four years. Direct contact hours for the students was only 20 hours per week in the first and second years and the last year was all electives. The program was very successful, probably due to our exposure to the students in the musculoskeletal courses, and about 75% of each class took a physical medicine and rehabilitation elective at some time. Regular clerkships were also available to medical students from other medical schools.
Other teaching and training programs were elective rotations for neurology, rheumatology, and family practice residents, elective courses for undergraduates, including one in sports medicine, and several CME conferences each year. Most of these programs have disappeared due to the involved faculty leaving or retiring and the ending of federal support for teaching and training programs. The department also established an Office of Nursing and Allied Health Professions, which provided counseling services to undergraduate students and prepared a Program Planning Guide for a School of Allied Health Professions. While the proposed school was not approved by the university due to budget restrictions, the office was successful in moving the Family Nurse Practitioner Program from UC Berkeley to UC Davis.
The department faculty maintained an extensive basic, applied and clinical research program in spite of a heavy clinical and teaching load. Most of the organized research was in muscle and nerve biology, exercise physiology, and neuromuscular disease. A state-of-the-art muscle physiology laboratory was developed with grant and department funds with electrophysiology, histology/histochemistry, biochemical and cell culture components. Extramural grant support of about $150,000 per year was obtained, and about seven papers each year were published.
During much of this period it was as difficult to recruit physician faculty as it had been to find qualified resident candidates. Most of the difficulty was due to the limited number of physiatrists in the country: only 773 in 1969, 1,098 in 1974, and 1,608 in 1979. In California, there were only 85 physiatrists in 1969 and 180 in 1979. The faculty during 1968-1982 included two non-physicians, Jean Zelle and Worden Waring, and ten physiatrists: William M. Fowler, Jr., Robert G. Taylor, Harold M. Sterling, Laxman Kewalramani, James S. Lieberman, Nirmala Nayak, Margaret Portwood, Paul Bach-y-rita (MVAMC), Walter A. Lauvstad, and Floyd D. Bralliar.
"I was Assistant Director, Department of PM&R, Sacramento County Hospital, 1968-1970. A major event at that time was receiving approval of the Rehabilitation Grant which had been submitted to the State of California Department of Rehabilitation. With the funds the department successfully coordinated a combined Muscle Disease Clinic with Neurology; a combined Amputee Clinic with Orthopaedics and a combined Hemophilia Clinic with Pediatrics, in which I served as a Co-Director. This was beginning of the development of the scope of the PM&R Department in terms of personnel and equipment.".…"A full-time EMG and Nerve Conduction Clinic using a two-channel Medic Electrodiagnostic machine and later adding a Tecca 4 machine with multiple stimulation modes. When I first came to Sacramento, Dr. Friend, a physiatrist in private practice, performed EMGs and NC studies in the hospital along with Dr. Taylor."…."I remember when we would function as lab instructors when the medical students were studying the musculoskeletal system MS-102 to observe and to demonstrate the dissection of a cadaver."…."I also remember writing a musculoskeletal handout for the medical students that was an introduction to the terminology, description, and regional physical examination of the affected extremity and joints of common medical complaints of patients that were seen in the PM&R Department."…."I also took over the teaching of a group of freshmen in the teaching of interviewing technique and the interviewing of patients during their first year of medical school. They were eager to learn and to see patients. Later Dr. Taylor and I would select patients with interesting functional problems due to nerve injuries affecting the radial, median, ulnar, and peroneal nerves. The patients would come in on Friday afternoons for their treatments and would be shown to the students."….W.A. Lauvstad
"My first job after residency training was at UCD. During my five years as junior faculty (1978-84), I was introduced to a world of research, publications, administration, and teaching. The confidence acquired working with Drs. Taylor, Fowler, and Lieberman, served me well for my later career. My time at UCD was one of significant professional growth for which I remain grateful."….N.N. Nayak
There were also seven faculty with joint appointments in Physical Medicine and Rehabilitation from the campus departments of Zoology, Animal Sciences, Avian Sciences, Physical Education (now Exercise Sciences) and Veterinary Medicine-Anatomy, as well as multi-departmental research activities with faculty from the medical school's departments of Biochemistry, Pediatrics, Medicine-Endocrinology, and Cardiology. These individuals greatly enriched the departments research programs. In addition, there was clinical and teaching collaboration with the School of Veterinary Medicine, Agriculture, Letters and Science and Engineering. Professor Worden Waring had a major role in the establishment of the Department of Biomedical Engineering and the Biomedical Engineering Graduate Group. Department of PM&R faculty were involved in developing an Electrodiagnostic Service with Veterinary Medicine-Neurology, and were consultants in designing the Physical Therapy Service at the Veterinary Medicine Hospital. For several years there was a Muscle Biology Group that offered an upper division campus course in muscle physiology. The greatest and longest collaboration has been with the Department of Exercise Science in its Exercise Physiology Laboratory.
In 1968, there were two physiatrists in the UCD Department of PM&R, one therapy service, and five to six staff. There was only one community physiatrist in all of inland Northern California, and UC Davis Medical Center was developing the only comprehensive rehabilitation facility in the area. By the early 1980s, there were six department physiatrists, five therapy services, and over fifty staff. The number of community physiatrists had increased to about fifteen, and hospital rehabilitation departments had been established in Sacramento (American River, Kaiser Permanente-Sacramento and South Sacramento), San Joaquin County (French Camp), Chico and Redding. Many of the community physiatrists were graduates of the UCD PM&R residency program and held clinical volunteer faculty appointments in the department. Most of the community hospital departments had been established in collaboration with the UCD Department of Physical Medicine and Rehabilitation.
Dean Tupper resigned in June 1979, and the second Dean of the School of Medicine, Hibbard E. Williams, M.D., started in September 1980. Dr. Fowler resigned as Founding Chair of the Department of Physical Medicine and Rehabilitation in June 1982. The journey to adulthood had only begun.
nbsp; "My time at UC Davis in 1974 was possibly the most important year of my career. I was accepted conditionally and had to sign a stipulation acknowledging that any manipulation, acupuncture or other "infraction" would summarily end my residency. A few months later, I went into Bill's office and told him that there was a man in the clinic in intense pain. He told me to help him. I told him I couldn't; I'd signed a paper. He got it out and, while tearing it up, told me that was when I arrived. The rest of the year was carte blanche. He trusted me with full freedom, he, Bob Taylor, Laxman Kevalramani and Mel Sterling. I could write a book in tribute to them for what was accomplished that year, including the discovery of a new diagnosis and its cure. God bless them all."….P.H. Goodley, 1974
"Bill Fowler helped me to learn how to organize information that was coming from multiple sources and people. The myelomeningocele clinic was quite different than straightforward medical thinking. We needed to gather information from patient, family, therapists, social workers, doctors and other sources. We were interested in the whole patient. We were interested in improving function. This experience was so beneficial in helping me to learn how to deal with team conferences in many different types of rehab units where I have consulted over the 19 years." O.K. Hunter, 1985
"Bill Fowler the Man. Bill Fowler is the reason why I am a physiatrist, period. I will never forget the experience I had when, as a 4th year student, I rotated on the consult service with Bill. Always the caring curmudgeon, I was so impressed with him that it turned me from a junior orthopod into a physiatrist. I have never, ever, regretted that decision and try to be a roll-model for the students that come to work with me. I am happy to say that the UCD tradition of mentoring by way of example is alive and well, and that a future generation of physiatrists will (at the very least indirectly) benefit from Bill's example to me those years ago."A.J. Margherita, 1989
"My first encounter with Bill Fowler was when I was inquiring of him about research projects. He was quite abrupt. He told me he "didn't really know who the hell I was," said he was too busy and told me to talk to Bob Taylor. Of course, Bill later became my primary mentor and basically created my career for me. I then went to Bob Taylor who was an absolute sweetheart, took me under his wings, gave me a few projects to get started on, and then subsequently died."G.T. Carter, 1990
"Our other fearless leader, the lovable Bill Fowler, when totally exacerbated by the occasional lunacy of a patient's inability to make an appropriate personal health care decision for him or herself would mutter, "it's enough to make a republican out of you!" I'm sure he also thought this to himself at faculty meetings and the like, as well. Again, as an acting intern I was in awe as one of the founding fathers of UCD Rehab was conducting an MDA clinic. After we all crowded into one of those hot, tiny, exam rooms, the maestro got bombarded from the patient's parents with endless questions. After about the fourth or fifth question, our learned mentor waved his right hand up high and pointed with his index finger to the sky and said, "one clinic visit, one question." Then he proceeded to depart from the room, but as he was leaving he turned back to the patient and family and said, "naw, just joking, ask the resident the rest of your questions, I'm sure he can answer them." Two other fond memories also surround Dr. Fowler. His unbelievable crab feeds and the MDA dinner roast, arranged by Greg Carter and Dave Kilmer. The MDA dinner roast was hilarious. My sides hurt for hours after the meal."W.S. Rosen, 1992.