State of Medicine

IN JUNE 1973, hours after his wedding and as friends and family gathered for a celebration, an anxious Terry Brown went to the mailbox in front of his parent’s home in Jasper, Indiana.

He was looking for an overdue piece of mail that could change his future: an acceptance letter from Indiana University School of Medicine. After sifting through a pile of congratulatory cards, Brown came upon it—an envelope from the School of Medicine.

He tore open the seal and removed a single sheet, signed by George Lukemeyer, MD, head of the school’s admissions committee. Brown had been awarded a place at the School of Medicine.

At the Evansville campus.

Looking back—after graduating in 1977 from the School of Medicine and practicing in his hometown as an OB-GYN for 36 years—Brown, MD, cherishes his medical school experience in Evansville. At the time, though, he wasn’t even aware the medical school had a presence in Evansville. He wondered if the offer was real.

“I was just kind of upset,” Brown recalled, “and really sad.”

Without realizing it, Brown was one of 60 students who were part of an experiment trying to answer a key question: Could a medical school deliver training across a statewide network? Fifty years after its official birth, following a 1971 act of the Indiana General Assembly, we know the answer: an emphatic yes.

More than 5,000 IU School of Medicine alumni have spent part or all of their time at one of the eight campuses other than Indianapolis. And, today, roughly 43% of IU’s current medical students receive all of their education at a regional campus.

Each offers a standardized four-year curriculum, but each has their own special area of concentration. They are known for close-knit communities that facilitate learning and early hands-on experience. And they are a key reason IU School of Medicine can lay claim to being the largest medical school, by enrollment, in the United States.

This pipeline of physicians—visionary at its conception—owes its creation to a combination of foresight and some old-fashioned political maneuvering.

In the end, a statewide system under IU’s direction emerged not only as a way to tackle a physician shortage but also as a means to give competing Indiana communities a med school—at least part of one—to call their own.

Over five decades, the evolution of these campuses hasn’t always been smooth. But the structure created by a forward-thinking cast of leaders grew into a stable network—one that’s been copied by peers nationally.

“Indiana was fortunate to have some very smart people back then,” said IU School of Medicine Dean Jay L. Hess, MD, PhD, MHSA, who inherited the statewide campus system upon his arrival in 2013. “They looked across the state and saw areas, particularly rural areas, where there was a need for more, better prepared doctors.”

'THEY KNEW IT WAS BETTER TO SHARE IT'

Before that, in 1958, the structure of IU School of Medicine seemed settled.

Research funding had grown ninefold in the 1950s, helping IU flesh out new departments in psychiatry, biochemistry and pharmacology. The school’s operations were consolidated on an Indianapolis campus transformed by the post-World War II boom. The new Medical Science Building housed lab space­—and eased the strain of a 30-percent enrollment increase.

“They had the plan for research. They had taken care of enrollments and space. The remaining problem left was graduate medical education,” said historian William H. Schneider, author of The Indiana University School of Medicine: A History.

Since the school’s founding, it was perpetually dogged by one question: How many doctors did it need to produce to meet Indiana’s needs? For nearly two decades, Indiana had been unable to forestall a “brain drain.” Increasing class sizes only went so far. The answer, Dean John D. Van Nuys, MD, knew, was more residency slots for graduates.

Indiana wasn’t alone in facing the challenge. A 1959 U.S. Surgeon General report identified a looming physician shortage in a Baby Boom nation. Tucked into the report’s pages was a key recommendation: build more medical schools. For the next decade, that finding inspired Indiana politicians and regional business leaders to brawl over whether to create a second medical school.

IU’s trustees moved to protect their turf. In 1963, they commissioned the consulting firm Booz Allen Hamilton to study medical education in Indiana. A year later, the group released findings sympathetic to the School of Medicine.

With pages of charts, graphs and jargon, it concluded that a second medical school would cost too much money. It would also take a decade to build and staff, as the physician shortage grew worse.

Legislators had been intrigued by the idea of a second medical school. But competing proposals to be the host—from Gary, Evansville, South Bend and Muncie—splintered support inside the Statehouse. Each proposal died swiftly.

As the pile of defeated bills grew over five years, lawmakers came to a consensus: overcoming regional factions required giving each city a small piece of the project. “They knew it was better to share it,” said Ned Lamkin, MD, ’60, who served in the legislature from 1966 until 1982. “I found no real opposition to the idea of sharing it with other communities.”

'THERE WAS MUCH SKEPTICISM'

By the spring of 1965, the School of Medicine had their consultant’s report but no alternative to offer. Newly appointed Dean Glenn W. Irwin Jr., MD, asked Lukemeyer to lead a committee exploring the issue. But it would take time.

Kenneth Penrod, PhD, provost of the IU Medical Center, sketched a potential solution on a sheet of graph paper. Using boxes, arrows and all-caps headings, he drew up how to take the consultant’s findings and grow the school outside Indianapolis. It took on the shape of an hourglass.

It called for students to spend two years at sites outside Indianapolis, where they could learn basic science and get an introduction to clinical medicine. After that, they’d funnel into the Indianapolis campus for additional clinical training. Finally, they’d flow from Indianapolis to expanded residencies across the state.

By March 1966, Lukemeyer’s committee had reached a similar conclusion: a centralized setup solely in Indianapolis should be “abandoned.” Testifying before a state legislative committee that spring, Irwin dubbed this new direction the “Indiana Plan.”

Ball State officials called it “unwieldy.” Editorial writers in Gary said it was a “faulty prescription.” The South Bend Tribune shrewdly observed it spared legislators political peril, but was “not the same thing as political responsibility.”

That fall, Penrod and Irwin outlined how such a system could work in an almost clairvoyant paper published in the Journal of Medical Education. Aside from laying out the framework of the Indiana Plan, it foresaw how distance would stop being a barrier to learning: high-speed computers, online instruction and remote computer terminals “consisting of both an electric typewriter and a cathode ray screen.” This they saw at a time when simple computers filled entire rooms.

In 1967, Lamkin drafted a bill calling for the legislature to spend $2.5 million to pay for residency expansion and a telecommunications network. It also tasked the School of Medicine with overseeing the creation of this statewide medical education system. To help, the federal Bureau of Health Manpower awarded the university a $22 million grant to create a “statewide medical education program” over five years.

Early in 1968, Irwin wrote IU President Elvis J. Stahr to say the main campus couldn’t absorb more students. The time had come to place a “limited number” elsewhere in Indiana. Quickly, the school made plans for teaching first-year students outside Indianapolis.

Lukemeyer, and another administrator, were tasked with negotiating agreements with universities around the state. At first, Purdue and Notre Dame were reluctant. But they struck deals after it was agreed medical students would also be admitted to graduate programs at the host schools. Over the next two years, a handful of students in South Bend and West Lafayette began proving the concept.

“There was much skepticism,” Lukemeyer said later. “But we did show that you could provide a reasonable educational experience in multiple areas in a decentralized way.”

'EVERYONE TASTED BLOOD IN THE WATER'

Undaunted, regional leaders mounted a final push for their own schools in 1969.

Lamkin had proposed creating a Medical Education Authority to look at expansion. But there were concerns from opponents who feared an influential political bloc from northern Indiana, led by a top GOP fundraiser, would steer a second school to South Bend.

“Everyone tasted blood in the water,” Robert Davies, a political advisor to Gov. Ed Whitcomb, recalled in The Serendipitous Creation of the Indiana Statewide Medical Education System. “It was like a school of sharks, and it was disintegrating the legislative process.”

Whitcomb was being pinched politically. His choice was crossing the fundraiser or alienating the other communities around the state.

He found an ally in Beurt SerVaas, an Indianapolis Republican, who had become convinced a second medical school was unnecessary, and offered up a system of “satellite community medical schools.” It was largely a carbon copy of Penrod’s hourglass.

Assured that the statewide plan would work, Whitcomb appointed SerVaas as chairman of a state medical commission that held meetings around the state in potential host cities for a second school. Convening the group, however, was merely window dressing used to resolve a legislative impasse over funding the regional system. When its work was done, the commission supported a program identical to what the School of Medicine already designed.

In 1971, the legislature passed a law to create and fund the network. It formally handed the job to the School of Medicine, mandating it have centers up and running by 1972. Dean Steven C. Beering, MD, who had arrived in 1969, used additional federal money to start the job.

'WE ARE NOW FULLY REALIZING THEIR VISION'

When Brown and nine classmates arrived in Evansville in 1973, they didn’t discuss their unique situation. Many hailed from the area, and were happy to have a year living at home for free. “I didn’t care,” Brown said, “as long as I got my degree.”

Four days a week, Brown and the others reported to the University of Evansville for classes in the back of its student union, which had space set aside for anatomy and histology labs. On Fridays, he carpooled in a classmate’s Chevrolet Chevelle to what’s now known as University of Southern Indiana for lectures. The schedule flipped in the second semester—with four days on the USI campus taking microbiology, physiology and other labs.

Brown recalls that the facilities were meager. “What I can remember of a library is a bookshelf.” His initial disappointment aside, Brown is thankful he was assigned to a regional campus.

Studying at Evansville didn’t allow him to hide. He had to engage–with the material, his classmates and faculty. When he arrived in Indianapolis, he brought with him an asset few peers possessed—a voice.

“It matured us,” he said. “We didn’t just need to learn the material, but we had to develop confidence in ourselves and our knowledge.”

The close-knit atmosphere of the regional campuses still exists today. It is even influencing the design of a new addition to the Indianapolis campus, which is being crafted to create more intimate learning communities.

In the future, Hess expects the flow of students between the different campuses to be more common, as will the sharing of faculty expertise and research collaborations. New buildings have opened recently in Bloomington and Evansville. Others are likely to follow.

And Hess is very careful to remind people that these are no longer “satellite” campuses. There is one IU School of Medicine, with a common curriculum and the state as its campus.

Fifty years after its creation, Hess looks at the statewide campus its founders drew up and thinks they would be pleased. “We are at the point where we are fully realizing their vision,” he said. “And it was a really good one.”