Background
Historically, all internists were generalists who provided comprehensive, continuous care to patients with a variety of health problems. Some also subspecialized in particular areas of interest. The Johns Hopkins Department of Medicine, with its Oslerian tradition of excellence, has long been a leader in providing training for this type of physician. In the latter part of the 20th century, however, with the very rapid growth of physician subspecialization, there emerged a need to reinforce the high quality training of the general internist. Responding to this need, the Department of Medicine, under the leadership of Dr. Victor McKusick, the Chairman of the Department, and Dr. Philip Tumulty, the renowned clinician and model of excellence in general internal medicine, created the Division of General Internal Medicine in 1977. They established the Division to help maintain the tradition of the general internist; to identify that tradition as a specialty in its own right; to strengthen the connections that unified the Department of Medicine; to establish a home for the academic general internist; and to promote excellence in practice, teaching, and research relevant to general internal medicine.
Early Years
The Division began as a small cohesive unit under Dr. Tumulty's leadership. Dr. Tumulty was nationally recognized as master clinician and teacher, and was the David P. Carver Professor of Medicine. He served on the faculty for nearly 50 years, heading the Department of Medicine's inpatient and outpatient services for 17 years. Known as an unequaled diagnostician and a champion of the humanistic approach to medicine, Dr. Tumulty focused his scholarship on the study of the natural history of disease. The author of many clinical papers on infectious diseases, he also wrote The Effective Clinician, His Methods and Approaches to Diagnosis and Care. In honor of his excellent teaching, research, and patient care, he received many awards and much recognition, including election to the Association of American Physicians. Before his death in 1989, Dr. Tumulty was honored by colleagues and patients who established the Tumulty Endowment Fund for the support of internal medicine, an area Dr. Tumulty felt important in an age of increasing specialization.
Dr. Craig Smith, a former Assistant Chief of Service, who had advocated for creating the Division, was named Associate Director. Together, Drs. Tumulty and Smith sought to build a division of outstanding general internists on the full-time faculty, who would teach, care for patients, conduct clinical research, and serve as role models for students and housestaff.
Primary faculty recruited to the Division in the early years included Drs. Diane Becker, Laura Mumford, Tom Pearson, Brent Petty, and Lora Wilder. The Division was also the home for the four Assistant Chiefs of Service of the four Firms of the Department of Medicine.
One of the most important developments in the Division’s first year was the creation of the fellowship training program in internal medicine. Drs. Tumulty and Smith secured funding from the Kaiser Family Foundation for two fellows per year for two years. According to Dr. Smith, this was a seminal event in the history of the Division. It gave the Division money, credibility, and the means to attract young talent. Early post-doctoral fellows recruited to the Division included Drs. Lawrence Klein and Steve McPhee (1978) and Dr. Richard Moore (1980). These individuals established a strong multidisciplinary collegium—a hallmark of the Division to this day.
With Dr. Tumulty's retirement from full-time faculty duties, Dr. McKusick appointed Dr. Smith to the Division Director post. The Division began to grow in number of faculty and staff and to develop its clinical, teaching, and research activities. In addition to its own practice, the Division took responsibility for the University Health Service and the Department’s general medicine consultation service. The Division had also become the home for two important grants: 1) the Robert Wood Johnson Grant to establish a model practice for faculty and house staff practice in general internal medicine and 2) the National Institutes of Health (NIH) Preventive Cardiology Award, under the stewardship of Dr. Thomas Pearson, which brought initial scientific recognition to the Division. Recruitment of new faculty and fellows was underway, and Drs. Smith and David Levine—then a joint faculty member, with a primary appointment in the School of Public Health—recruited Dr. Earl Steinberg to develop and head a program in Health Policy and Technology Assessment. They also recruited GIM fellows to Dr. Levine’s NIH training grant in Behavioral Aspects of Heart and Vascular Diseases, which has been continuously funded since 1976.
The fellowship class of 1982 included four young physician scholars who went on to become nationally recognized leaders: Dr. Richard Allman (now Professor of Geriatrics at UAB), Dr. Linda Fried (now Professor and Director of Geriatrics at Johns Hopkins and a member of the Institute of Medicine), Dr. Michael Klag (now Dean of the Bloomberg School of Public Health), and Dr. Teri Manolio (now Senior Advisor to the Director of Population Genomics at NHGRI/NHLBI). In 1984, Dr. Smith recruited Dr. David Levine to become a primary faculty member in the Division.
The Levine Years, 1986-1996
Shortly thereafter, having grown the Division to the third largest in the Department of Medicine in research and clinical practice income, Dr. Smith stepped down from the Directorship to start a pharmacoepidemiology program in the Division of Clinical Pharmacology. To replace him, Dr. McKusick appointed Dr. William Hazzard, then Vice Chair of the Department of Medicine. Dr. Hazzard maintained stewardship of the Division for a year, at which point he was recruited to become Chairman of the Department of Medicine at Wake Forest University’s Bowman Gray School of Medicine. In 1986, the Department of Medicine’s new Chairman, Dr. John Stobo, appointed Dr. Levine, first as Interim Director of the Division, and then as permanent Director, following a national search.
The Division was still small: the faculty, fellows, and staff were all located in close proximity (on the fourth and fifth floors of the Harvey Building, and the third floor of the Carnegie Building in Johns Hopkins Hospital) and would bump into the Division Director daily. Over the next 15 years, this small cadre of energetic, talented, and committed academicians would evolve into one of the largest and most prominent divisions at Johns Hopkins, renowned nationally for its scholarly work.
During these years, the Division had four main goals: 1) further development of the fellowship in general internal medicine; 2) recruitment of faculty; 3) development of a broad research agenda; and 4) creating a clinician-educator program. Development of the fellowship was given the highest priority. The fellowship was built in collaboration with the Division of General Internal Medicine at the Johns Hopkins Bayview Medical Center, known for its strength in medical education and curriculum development.
Initially, Dr. Levine directed the fellowship himself. In 1988, he asked Dr. Eric Bass to assume the post. Under Dr. Bass’s enlightened leadership, the fellowship matured into a world renowned program, emphasizing state-of-the art multidisciplinary scholarly training, with outstanding mentorship. Dr. Bass not only promoted growth of the fellowship, but instilled innovative curricula, experiences, evaluation mechanisms, and a dedication to professional and career growth that promoted the fellowship into its place of national prestige today. Over 100 fellows have graduated from the program, with 16 current fellows in training. The fellowship has become one of the most competitive in the country, with the vast majority of its graduates becoming leaders in research, medical education, clinical practice, and administration in American medicine and public health. Several of these individuals now hold positions as dean, vice dean, department chair, division director, and endowed professor at various schools of medicine and public health. Many alumni stayed at Hopkins and contributed substantially to its growth and reputation. These include: Drs. Lawrence Appel, Eric Bass, Mary Catherine Beach, Ebony Boulware, Fred Brancati, Geetanjali Chander, Jeanne Clark, Sarah Clever, Joe Cofrancesco Jr., Lisa Cooper, Gail Daumit, Richard Moore, Jodi Segal, Jeremy Sugarman, and J. Hunter Young.
Faculty recruitment was also a high priority for a growing division. The goal was to as to provide breadth and depth of research, teaching, mentoring, and clinical experience. Two key faculty members were already on staff when Dr. Levine assumed the Director post: Drs. Diane Becker and Richard Moore.
Dr. Diane Becker began her research program with the conduct of her doctoral thesis, which focused on cardiovascular risk in siblings of adults with premature coronary artery disease. Over the next 25 years, this thesis grew into a landmark NIH-funded cohort study. Today, the Sibling Study continues to produce new knowledge regarding biological, genetic, behavioral, and socio-cultural risk factors for cardiovascular disease, as well as effective interventions to lower overall cardiovascular risk profiles in these families. Dr. Becker has also been a pioneer in community-based intervention research, particularly with high risk populations.
Dr. Richard Moore began his research during his fellowship at Hopkins, concentrating on clinical trials, epidemiological methodology, and pharmacoepidemiology. When the HIV epidemic hit, he focused his program on HIV-AIDS, including its epidemiology, treatment, risk profile, outcomes, costs, and policy implications. His pioneering efforts created an internationally recognized model for outcomes research. In 2003, he was asked by the Department of Medicine to lead the Moore Clinic—one of the nation’s busiest and best known programs for the care of patients with HIV-AIDS.
In the late 1980s, The Division also recruited several new key faculty members from outside Hopkins. One new recruit was Dr. Daniel Ford. After completing the Osler Training Program, Dr. Ford undertook a post-doctoral fellowship in clinical epidemiology at the NIMH. At Hopkins, he developed a broad research program on primary care, with a special emphasis on mental health. From 1994 to 2006, he also directed the University Health Service, then a core clinical activity of the Division. In 1998, he obtained a post-doctoral training grant from HRSA to support research in primary care—a grant that continues to be a core source of funding for the GIM Fellowship. Dr. Ford now serves as Vice Dean for Clinical Research in the School of Medicine and was named the David M. Levine Professor of Medicine in 2005.
Another key recruit from the 1980’s was Dr. Neil Powe. Dr. Powe had completed training as a Robert Wood Johnson Clinical Scholar at the University of Pennsylvania, earning an MBA the Wharton School of the University of Pennsylvania. At Hopkins, he joined the Program in Health Technology Assessment and Finance led by Dr. Earl Steinberg, a pre-eminent health services researcher. In his early years on faculty, Dr. Powe focused on evaluation of a range emerging technologies. In the early 1990s, Dr. Powe’s attention turned more specifically towards the epidemiology and treatment of end-stage renal disease. He joined the Welch Center for Prevention, Epidemiology, and Clinical Research. Founded by Dr. Paul Whelton, a nephrologist-epidemiologist with a joint appointment in GIM, the Welch Center had already gained national recognition for its work on the clinical epidemiology of cardiovascular and renal disease. When Dr. Whelton departed to take the post of Vice Chancellor for Health Sciences at Tulane, Dr. Powe assumed the role of Welch Center Director and Director of the Clinical Epidemiology Concentration in the Department of Epidemiology. The Center is now home to 28 full-time research faculty, most with primary or secondary appointments in GIM, who constitute a unique bridge between the Schools of Medicine and Public Health.
In the 1990s, the Division made a number of important internal recruitments from the GIM Fellowship. Dr. Lawrence Appel built a research program around prevention of cardiovascular and renal disease. Today, he is Professor of Medicine, Epidemiology, and International Health, and the Director of Johns Hopkins ProHealth—an NIH-funded center of excellence for community-based trials of cardiovascular prevention. He is an internationally recognized expert in nutritional aspects of hypertension and on non-pharmacologic approaches to primary prevention. Dr. Fred Brancati built a research program around the epidemiology and prevention of type 2 diabetes and related conditions. Today, he is Professor of Medicine and Epidemiology and Director of the Division of General Internal Medicine. Dr. Lisa Cooper built a research program around physician-patient communication, with particular emphasis on understanding and eradicating racial and ethnic disparities in health care. She has become an internationally recognized expert in this field and has earned a sterling reputation as a mentor for students, residents, fellows, and junior faculty.
It was also early in the 1990s that Dr. Stobo, in response to an urgent need for educators and internal medicine consultants committed to build a group of general internists who would have focused careers as clinician-educators. With funding from the Johns Hopkins Hospital, the Department formed a financially independent unit based on the 7th floor of the Johns Hopkins Outpatient Center. In 1991, he recruited Dr. William Aronstein, who had completed his Osler residency and practiced two years in the Indian Health Service in Zuni, New Mexico. 1n 1992, Dr. Aronstein was joined by Dr. Shawn Stinson who had just completed a year as Assistant Chief of Service, and by Dr. John Flynn, who had completed both his tenure as Assistant Chief of Service as well as a rheumatology fellowship. This Group was soon joined by Drs. Lisa Simonson (1994), Patricia Thomas (1995), Stephen Sisson (1995), and Don Martin (1996). In 1995, Dr. Aronstein left Hopkins to lead a collaborative clinical and research effort with Samsung Medical Institutions in Seoul, South Korea. At that point, Dr. Flynn assumed Clinical Directorship of the Division. As a result of Dr. Aronstein’s efforts, Samsung Medical Institutions awarded the University funds for the Samsung Chair which is presently held by Dr. Levine. Dr. D. William Schlott joined the group and was named Tumulty Associate Professor with the funding provided in honor of Dr. Philip Tumulty in 1994. He established clinical operations at Green Spring Station in conjunction with Dr. Amy Gordon and Dr. Paul G. Auwaerter.
The Klag Years, 1996 to 2004
After a dynamic decade, Dr. Levine stepped down as Division Director in 1996. The Department of Medicine’s then Chairman, Dr. Edward Benz, named Dr. Michael Klag to replace him. Dr. Klag had already built an international reputation in the epidemiology of cardiovascular and renal disease. Under Dr. Klag’s leadership, the Division continued to flourish with enhanced research and clinical programs, along with faculty, fellow, and staff development. The Division underwent important planned growth in faculty, areas of research, training, and interrelationships with other divisions in the Department of Medicine, other departments in the School of Medicine, and the Schools of Public Health and Nursing. During Dr. Klag’s tenure, the Division doubled in size and spread itself across four different sites—a challenging obstacle to unity. Dr. Klag gave high priority to divisional unity and brought all elements—research, clinical, teaching—“back to the table together.” This was critical for the health and future of the Division. Equally important, Dr. Klag championed equity in visibility, promotability, and reward structures for all faculty and staff.
The growth and development of the Clinician Educator Group under the leadership of Dr. Flynn, and with the support of Dr. Benz, was a major accomplishment during these years. In 1997, the Group size doubled with the additions of Drs. Carol Ann Huff, Redonda Miller, and Kimberly Peairs (who had each just completed a year as Assistant Chief of Service) as well as Drs. Gregory Prokopowicz, Mark Hughes, Jeffrey Magaziner and Joseph Cofrancesco, Jr. who had just completed his GIM fellowship. Dr. Bimal Ashar (1998), who is now the Medical Director of the Executive Health Program, and Dr. Spyridon Marinopoulos (2001), who is now the Director of University Health Services, joined soon thereafter. Subsequent recruitments to this Group have included Dr. Gail Berkenblit (from the Osler Housestaff) in 2002, Dr. Sarah Clever (from the GIM Fellowship) in 2003, and Dr. Rosalyn Stewart (from University of Maryland) in 2004. On October 16, 2001, the D. William Schlott Professorship in Clinical Medicine was established in honor of clinical and educational excellence provided by Dr. Schlott. Dr. Flynn was the inaugural recipient of this professorship.
By 2005, the Clinician Educator Group had achieved a major influence over the training programs of Johns Hopkins, with one-third of the faculty leading the Clinical Skills course in School of Medicine (three Firm Faculty leaders, and two Associate Program Directors). That year, both Drs. Flynn and Sisson won national awards from the Society of General Internal Medicine—one for program building, the other for creating a novel internet learning system.
Growth of the GIM research enterprise also continued under Dr. Klag who recruited seven alumni of the GIM Fellowship Program to faculty. Dr. Jeremy Sugarman, an internationally regarded expert in bioethics, was recruited to the Harvey M. Meyerhoff Chair of Bioethics and Medicine after a successful career at Duke. Dr. Jeanne Clark was recruited to build a program in the clinical epidemiology of fatty liver disease, obesity, and related conditions. Dr. J. Hunter Young, a former Hopkins Assistant Chief of Service mentored by Dr. Klag, joined the faculty with a focus on the genetic and molecular epidemiology of hypertension and related conditions. Dr. Gail Daumit, who originally came to Hopkins as a Robert Wood Johnson Clinical Scholar, was recruited to pursue research in the epidemiology and treatment of medical conditions in adults with severe mental illness. Dr. Ebony Boulware was recruited to build a health services research program in transplantation, with particular emphasis on meta-analysis, cost-effectiveness analysis, and systematic literature synthesis. Following a Greenwall Foundation Fellowship in Ethics, Dr. Mary Catherine Beach continued her work in the area of physician-patient communication and relationships. And Dr. Geetanjali Chander was recruited to build a research program in the area of substance abuse, HIV, and hepatitis.
In 2000, Dr. Klag assumed the additional responsibility of serving as Acting Chair of the Department of Medicine, a position he held until Dr. Myron Weisfeldt was named Chair in 2001. Subsequently, Dr. Edward Miller, Dean of the School of Medicine, named Dr. Klag to become the Vice Dean for Clinical Research—a challenging post under any circumstance, but especially so in the aftermath of the sanctions against the School of Medicine levied by the Office of Human Research Protections. While holding down the Division, Dr. Klag also managed to resuscitate the clinical research enterprise of the School and establish an entirely new system for institutional review.
By 2004, the dual role had become too demanding. Dr. Klag stepped down to focus on his role as Vice Dean, only to be named a few months later as Dean of the Bloomberg School of Public Health. From 2004 to 2005, Dr. Levine stepped back in to serve as Acting Division Director.
The State of the Division in Recent Years and Today
In 2005, Dr. Fred Brancati was named Director of the Division by Dr. Weisfeldt. Top priorities for Dr. Brancati included: 1) unifying the Division financially; 2) upgrading and re-organizing the core administrative infrastructure; 3) enhancing the visibility of the Division at Hopkins and around the United States; 4) preparing for a major downturn in NIH funding; 5) solidifying the new Hospitalist Program at JHH; and 6) moving the Division into three important research areas—cancer, including clinical epidemiology and health services research, women’s health, and medical informatics, with a special emphasis on emerging technologies for management of chronic disease.
The Hospitalist Program was established in 2001, with close involvement of Dr. Flynn. In July 2004, Dr. Flynn recruited a new leader for the Program, Dr. Daniel Brotman. Formerly an Osler House Officer, Dr. Brotman had risen to prominence at Cleveland Clinic as an educator and researcher in the Clinic’s well-established hospitalist program. At Hopkins, Dr. Brotman quickly raised morale, put the Program on firm financial footing, oversaw cooperative arrangements with the Osler Training Program, and established a strong culture of scholarship and research.
In September 2005, the Division launched its first website, now widely thought to be the best of its kind nationally. On November 15, 2006, the Division named the inaugural three winners of its national Housestaff GIM Research competition as means to promote GIM and to expose young talent to the Hopkins environment early in their careers.
In July 2006, after nearly 20 years of outstanding service and achievement, Dr. Bass stepped down as Fellowship Director to devote time to developing and leading new curricula and to launch a new journal focusing on community-based participatory research. Dr. Brancati named a new Director—Dr. Jeanne Clark—and, for the first time, a co-Director, Dr. Geetanjali Chander. Dr. Clark, herself a nationally recognized expert in the clinical epidemiology of obesity and fatty liver disease, launched several reforms, including reinvigorated weekly meetings, quarterly progress reviews, and new Fellowship areas of research emphasis.
In 2005, the Division recruited two PhD researchers with interests in cancer: Dr. Claire Snyder, a new graduate interested in cancer care and quality of life; and Dr. Gail Geller, a senior faculty member with expertise in ethical aspects of genetic counseling.
The most recent changes have been at Greenspring Station where Dr. Howard Levy assumed leadership (after Dr. Auwaerter shifted his primary appointment to the Infectious Disease Division to become its Clinical Director) and recruited three new Clinician-Educators: Drs. Anastasia Roland-Seymour, April Fitzgerald, and Paula Kue.
Today, Hopkins GIM has grown to over 65 primary full-time faculty, 16 fellows, and over 130 staff. Together, they maintain busy practices downtown and in Baltimore County, cover Johns Hopkins Hospital around the clock, play leading roles in the education of medical students and housestaff, and each year bring in over $15 million in external grants and produce over 120 peer-reviewed research articles. General Internal Medicine at Hopkins is alive and well, and we look forward to the innovations in practice, teaching, and research the next 30 years will bring.
Hopkins GIM is grateful to Drs. Diane Becker, John Flynn, Michael Klag, Lawrence Klein, David Levine, Victor McKusick, Richard Moore, Brent Petty, and Craig Smith, for their contributions to this document.
