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The Sansum Clinic!

SANSUM CLINIC

A LEGACY OF MEDICAL INNOVATION Erin T. Graffy with Erno S. Daniel, M.D., Ph.D.

THE STORY OF TODAY’S SANSUM CLINIC is actually the fascinating history of two clinics—the original Sansum Medical Clinic and the Santa Barbara Clinic—serving a small but forwardlooking community. Their narrative of how they each began, developed, and melded to forge an exceptional healthcare provider is also a way of looking into the vital signs of the community of Santa Barbara and seeing what makes it extraordinary.

Part One: The Sansum Clinic Story

Nineteenth-Century Beginnings: Santa Barbara as Health Haven Santa Barbara’s modern medical history begins during the nineteenth century. After California became a state, and Santa Barbara entered its American period, the city began attracting a following as a health resort. Health-minded individuals were lured to Santa Barbara for a number of different reasons. A local physician, Samuel Brinkerhoff, in practice during the 1860s, proposed that the fumes from the offshore oil seepages in the Santa Barbara Channel had medicinal properties and would be good for those with respiratory ailments. Visitors from the other side of the Rockies certainly felt revitalized and invigorated after staying in Santa Barbara—and were then partly convinced that indeed Brinkerhoff’s lauded oil-scented breezes must have done the trick.1 Travel writer Charles Nordhoff extolled the virtues of Santa Barbara in his 1873 book, California for Health, Pleasure, and Residence. Nordhoff’s glowing descriptions highlighted Santa Barbara’s temperate climate, which attracted a good number of well-to-do travelers from the cold East Coast to visit Santa Barbara as a health resort or winter retreat.2 Many people during the last half of the nineteenth century came to partake of the sulfur hot springs in Montecito for their purported curative effects on rheumatism and 61


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other ailments. Santa Barbara was on the map as a “sanatorium.” As a side observation, it is interesting to note that at this time Santa Barbara already had two women doctors in town, when even one was an uncommon occurrence to find statewide. Cottage Hospital: Setting the Stage for Local Health By 1888, the community of Santa Barbara had some five thousand residents, and about two dozen doctors. Despite the small size of the town, a campaign was initiated that Santa Barbara should have its own hospital. The financial instigator was a woman named Mary A. Ashley, the ABOVE: The opening of Cottage Hospital in 1891 was a watershed event in the history of healthcare in Santa Barbara. (Santa Barbara Historical Museum)

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widow of physician Dr. James Ashley, who passed away in 1876. Mrs. Ashley had not only the foresight but also the determination to rouse the citizens to build their own community hospital. Pleasantly feisty and persistent, Mary Ashley had taken up her cause at the ripe old age of sixty-nine, an age when most of her peers were heading toward the rocking chair rather than rocking the establishment. The modern hospital movement in the United States—which established facilities that were organized, orderly, and clean with a staff of nurses—was in its infancy.3 For a town the size of Santa Barbara, the thought of pursuing the establishment of its own hospital was rather ambitious. Further, the hope was to serve the seriously ill patients of Santa Barbara, San Luis Obispo, and Ventura counties. The hospital Ashley envisioned was a series of bungalows; each of the various medical departments would be housed in


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separate cottages. Although construction costs determined that the design ultimately ended up as a simpler, single three-story building, the name “Cottage Hospital” stayed with the project. Cottage Hospital was completed in 1891, and with it brought a focus to all the medical services in the community. Within three years, the Medical Society of Santa Barbara was created4 to serve the population of now 5800 people. In 1895, Cottage Hospital brought in its first surgeon, Dr. Richard Hall. A few years before his arrival in town, Dr. Hall had made medical history when he performed the first successful appendectomy in the U.S.5 Upon his arrival at Cottage Hospital, Dr. Hall put in place the town’s first operating room.6 A few years later, one of the very first X-ray machines in the country was installed in Santa Barbara by Dr. Hall. Twentieth Century: The First Clinic After the turn of the century, Nathaniel Bowditch Potter emerged as one of the prominent physicians in the country. A Harvard Medical School graduate, he was professor of clinical medicine at Columbia University’s College of Physicians and Surgeons, Chief of the Medical Division of St. Mark’s Hospital, a consulting physician to three other hospitals, and he had been

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63 the only American member of the Societé Médicale des Hospitaux Paris.7 His important research in metabolic diseases attracted the support of the Carnegie Foundation. With its financial assistance, Dr. Potter was able to establish the Memorial Laboratory and Clinic for the Study and Treatment of Nephritis, Gout and Diabetes of Columbia University in New York City Hospital in 1916. (It should be noted that at this time, the concept of a clinic was very different. The term referred to hospital-based outpatient facilities geared toward research, rather than group medical practices housed in one facility.) Dr. Potter himself was failing from diabetes, nephritis, heart disease, and tuberculosis. His own physicians strongly urged him to move away from the frozen East Coast and into a warmer, healthier climate. Though his heath was rapidly failing, Dr. Potter’s main concern was for the future of his fledgling clinic. He approached the Carnegie Foundation with his predicament and a query: could the research clinic possibly be moved to the West Coast? The head of the Carnegie Foundation ABOVE: Santa Barbara moved to the forefront of diabetes research with the arrival of Nathaniel Bowditch Potter in 1917. (From the book, A Victor: Nathaniel Bowditch Potter)


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was the former president of the Massachusetts Institute of Technology, the brilliant Dr. Henry S. Pritchett. He not only gave his approval to the relocation of the clinic, he most likely was the one who encouraged Dr. Potter to look at Santa Barbara. Pritchett was quite familiar with the town, as he was one of the many East Coast men of fortune who began to spend their winter months in Santa Barbara at the Potter Hotel (no relation to Dr. Potter).8 For years, Pritchett had been spending a good portion of his time in Santa Barbara, and in 1915 he bought a house on Junipero Plaza. When Dr. Potter’s celebrated clinic moved west and was established at Cottage Hospital, it was considered to be another feather in the collective cap of the medical community here. Establishing a research department at a hospital was quite forward-looking and was an especially ambitious undertaking for a community as small as Santa Barbara. Dr. Potter quickly got his clinic in Santa Barbara underway, and soon pa-

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tients around the country were referred by their doctors to come under the care of the renowned program. Potter’s right-hand man and chief of clinic here was Dr. Hilmar M. Koefod. Like Dr. Potter, Koefod had also been an ailing physician when he arrived. He had developed diabetes, which at this time was considered a death sentence, and came out to Santa Barbara to live out what time remained to him. Like Dr. Potter, he also was both a Harvard Medical School graduate and a leading medical expert in his field; Koefod was considered to be one of the country’s foremost cardiac specialists.9 The Potter Metabolic Clinic did well in Santa Barbara. In fact it was such a success that within one year the clinic had already started to run out of laboratory space. George Owen Knapp and three other local philanthropists, Frederick ForABOVE: The Potter Metabolic Clinic. With the death of Dr. Potter, the search began to find a replacement to run the clinic. (Sansum Clinic Collection)


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rest Peabody, Clarence Black, and C.K.G. Billings came to the rescue. They had contributed to previous hospital projects, and now they were stepping forward again to help healthcare. In the fall of 1918, the men announced they would build a new state-of-the-art laboratory and clinic for research at the hospital to be named the Potter Metabolic Wing. A half-year later (in an era long before the city required permits, planning, and design review boards), the project broke ground for what was designed to be the finest clinic and medical research building on the coast. In a sad turn of events, Dr. Potter was too ill to attend the ceremonies for the medical clinic being launched in his name. Three months later he died from complications of diabetes. While the city and the medical community mourned the loss of their premier medical specialist, the question on everyone’s mind was—who now would head up the renowned clinic? The chief of staff at Cottage Hospital was Dr. Franklin Nuzum and he thought he knew just the man to fill Potter’s shoes. Nuzum had been originally recruited to Santa Barbara from Chicago by his patient, George Owen Knapp. In short, Nuzum knew he had the philanthropist’s ear. Dr. Nuzum sat down with Knapp and told him that back at his alma mater, Rush Medical College, exceptional work was being done in diabetes by a fellow alumnus. The researcher’s name was Dr. William David Sansum. Dr. William David Sansum: Medical Researcher As chairman of the board of directors for Cottage Hospital, George Owen Knapp took it upon himself to meet and

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65 interview Dr. Sansum. He found an eager man of forty, passionate about his work in metabolic diseases, with a keen interest in one of the most puzzling, diabetes mellitus. At this time diabetes was considered a death sentence: the patient could last just months or perhaps a few years depending on the severity of the condition and the ability to maintain a rigid diet. Diabetes became the subject of Sansum’s doctoral thesis, and the related theme in nearly twenty scholarly papers he wrote in eight years. Sansum’s work was published in the Journal of American Medical Association (JAMA) and he was cited in the Chicago Tribune.10 Knapp quickly determined that Dr. Sansum was the man with the interest, energy, and ability to fill the shoes of Dr. Potter. In November 1920, Sansum took the train from Chicago to Santa Barbara with his wife and young son, Donald. He wasted no time pouring his enthusiasm into the Potter Metabolic Clinic, acquainting himself with staff, meeting patients, and resuming his all-important research on metabolic diseases, in particular, diabetes. Diabetes Research At this time up in Toronto, Canada, there were two researchers who were also working on diabetes research, Dr. Frederick Banting and Charles Best. They were specifically trying to extract a substance which they noted was normally secreted by the pancreas, yet was not found in individuals with diabetes. The researchers surmised that this hormone was needed by the body to break down and process sugar or glucose. In 1921, Banting and Best achieved a breakthrough with their discovery of this


!66 hormone they named insulin. They injected this pancreatic extract into an emaciated diabetic fourteen-year-old boy who was near death. Amazingly, he recovered his strength and survived. Insulin then became a lifesaving extract for diabetics, forever freeing them from the death sentence of type 1 (juvenile onset) diabetes. During this era in medical research, such findings were often shared instead of being locked up under copyright laws and licensing. Therefore, Dr. Sansum was able to communicate regularly with the Toronto researchers. Banting and Best donated their patent and never sought to benefit financially from their research. This act of generosity allowed the life-saving extract to be affordable for the half-million diabetics in the U.S. at that time. Sansum read their report thoroughly and set about producing insulin locally. Sansum brought together a remarkable team of scientists who were to play key roles in the insulin production efforts of his clinic. They included Dr. Norman Blatherwick, a chemist; Loyal C. Maxwell, a former research chemist for the U.S. Bureau of Standards; and later two addi-

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tional chemists, Drs. Marion Bell and Melville Sahyun. Within four months of the Canadian breakthrough, Dr. Sansum was working to obtain his own insulin from beef pancreas through the slaughterhouses that were in Goleta at that time. Across the country other scientists were also attempting to produce insulin. One significant problem common to all these early efforts was the ability to extract active insulin and produce potent batches. Dr. Sansum found that the timing between last feeding, slaughter, and processing of the pancreatic tissue all affected potency. At this point in development, only minuscule amounts of insulin could be produced. When Sansum finally obtained a sufficient supply of potent extract, he was ready to administer the first dose to a patient named Charles Cowan. This was a momentous occasion. On May 31, 1922, after two years of research ABOVE: Dr. William David Sansum was recruited to replace Dr. Potter. Dr. Sansum was already one of the foremost researchers in the treatment of diabetes in the country. (Santa Barbara Historical Museum)


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by Dr. Sansum and his staff, and just twenty weeks after the successful treatment by the Canadians, the first American patient was injected with insulin produced in the U.S. at the Potter Clinic in Santa Barbara. Charles Cowan was a fiftyone-year-old diabetic from Anaheim who was down to ninety pounds and literally at death’s door. Within three days of receiving the injections, Cowan tested sugar-free. He re-gained his weight, recovered his health, and would live to the age of ninety, with regular insulin injections the rest of his life.11 Newspapers across the country heralded the astonishing news of a “lifesaving serum” available in Santa Barbara. On October 8, 1922, a front page article in the New York Times put Santa Barbara medicine on the international map. “Serum proves boon in fighting diabetes. Ravages of disease checked by insulin/Treatment developed with rare success in Santa Barbara clinic/Relief almost certain/Carnegie Corporation aids research.” The press release was picked up by newspapers all over the world. Diabetes sufferers from across the country applied to come to the Potter Metabolic Clinic at Cottage Hospital for treatment. However, the availability of insulin was limited and the insulin treatments were very costly. The price of producing the insulin in Santa Barbara ran $100 per day, an enormous sum of money in 1922, when an average annual salary was around $1200. Continued funding was needed for research at the Potter Clinic. During the summer of 1922, Dr. Sansum received a visit from Henry Pritchett, president of the Carnegie Corporation. Based on Pritchett’s review, the Carnegie Corpora-

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67 tion awarded $15,000 to Dr. Sansum’s group with a promise of further funding. When a local philanthropist Anna Blaksley Bliss underwrote a new children’s wing at Cottage Hospital, it freed up the central floor for Dr. Sansum’s diabetic patients. He was taking only the most serious cases due to his constrained insulin supply. Patients stayed in the Potter Metabolic Clinic at Cottage Hospital for months and sometimes for years. Charles Cowan stayed there from November 1920 until April 1924. Dr. Sansum supervised treatment and also promoted a strict dietary regimen. (It was known that he would discharge patients who violated his diet.) Sansum organized classes for diabetic patients and wrote publications, including a book on the normal diet. Dr. Sansum’s work in the production of insulin took up most of the focus and activities of the Potter Metabolic Clinic in the early 1920s. Much of it was scientific research in the effort to stabilize and purify insulin to make it safe and effective for injection into patients. The Potter Clinic researchers were in competition with scientists elsewhere, including pharmaceutical firms with large teams of chemists, such as Eli Lilly. The supply of pancreas that Dr. Sansum used came from Frederick N. Gehl’s slaughterhouse on what is now South Fairview Avenue in Goleta. After being harvested, the pancreatic tissue was immediately placed in alcohol before further processing. When Pearl Chase and other civic activists closed down the abattoirs in Goleta, Dr. Sansum was forced to use the next available slaughterhouse, the Hauser Packing Company in Los Angeles, some one hundred miles away.


!68 Sansum drove his big Dodge Brothers sedan down Pacific Coast Highway to the packinghouse at night in order to retrieve the fresh bovine glands immediately after slaughter. They were placed in large tin milk cans filled with alcohol and loaded up in the back of Sansum’s sedan; he would not return home until nearly three in the morning. Unfortunately this was all taking place during Prohibition. On a return trip from the slaughterhouses in Los Angeles, Dr. Sansum was stopped in Malibu for transporting cans containing alcohol preservative in his car. After his brief arrest, he phoned officials in Washington, D.C., outlining the problem. Dr. Sansum and the Potter Clinic then received an alcohol permit through the federal authorities in Los Angeles, and treatments were continued in Santa Barbara with fresh insulin extracts.12 In February 1923, Eli Lilly Pharmaceuticals shipped its first experimental insulin to ten selected doctors in the U.S., Dr. Sansum being one of them. However, local production of insulin was still needed to match the demand of Sansum’s many seriously ill patients. Within a month, the free supply of experimental medicine ended as Lily’s production became commercially available. Dr. Sansum announced that they would begin charging for the insulin, which was previously provided at no cost to the patients other than the $21-a-week fee for their stay in the hospital. His charge to the patients was below cost, since it did not account for equipment and depreciation (It should be noted that Sansum never turned away a patient for lack of ability to pay.) By this time, Dr. Sansum had received a gift of a one hundred-ton hydraulic

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press from a grateful parent of a patient which allowed him to produce much larger quantities of insulin. Sansum’s chemist, Dr. Blatherwick, was able to make local insulin far more potent as well.

By the end of 1923, the cost of locally produced insulin dropped from $100 a day to $20.13 Still, the Potter Metabolic Clinic's expenses were running $60,000 per year, with annual revenues of $40,000. Thankfully, the Clinic received generous outside support, and by the end of 1924, thirtyone donors contributed more than $33,000


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toward the Clinic’s operation.14 Diabetes Puts Santa Barbara on Healthcare Map Dr. Sansum continued his research into the effect of diet on health and metabolism. His book, The Normal Diet, came out in 1925 followed by The Treatment of Diabetes Mellitus with Higher Carbohydrate Diets in 1928. His groundbreaking works, based on his successful dietary regime, was diametrically opposed to standard scientific practice of the time. Before the advent of insulin and even after its arrival, the medical community had long promoted high fat starvation diets, which Dr. Sansum was replacing with a complete reversal: a higher carbohydrate menu. By reintroducing the previously prohibited carbohydrates into the diabetic diet, Sansum greatly contributed to the patients’ feeling of well-being. His breakthrough findings were published in the Journal of the American Medical Association (JAMA) in January 1926.15 His work captured the attention of his peers as well as thousands of diabetics across the nation. Franklin Knight Lane, Secretary of the Interior under President Woodrow Wilson, told a reporter for the San Francisco News, ”Major Max C. Fleischmann [president of General Foods and a steady contributor to Cottage Hospital] and Dr. William D. San-

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69 sum, both of Santa Barbara, should be listed among the real rulers of California. They are outstanding figures of their type and character, representing the principal interests that form the basis of prosperity and happiness in the Golden State.” Arthur Brisbane frequently reported on Dr. Sansum’s latest research. The renowned editor for William Hearst’s newspapers called Sansum, “Santa Barbara’s genius.” The Hon. John Murphy, from Sansum’s home state of Wisconsin, told the United Press that “Dr. Sansum of Santa Barbara is a nationally known medical authority, second in prominence in this country only to the Mayo brothers of Rochester, Minnesota.”16 By 1928, Dr. Sansum was listed in the national register of “Who’s Who in America.” Potter Metabolic Clinic Becomes Sansum Medical Clinic. As commercial insulin became successfully developed and manufactured, LEFT: The successful use of insulin to treat diabetes at the Potter Clinic was trumpeted in the New York Times, October 8, 1922. ABOVE: Henry Pritchett was the president of the Carnegie Corporation. Corporation funding was vital in financing diabetes research at the Potter Clinic. (Santa Barbara Historical Museum)


!70 the initial wave of diabetic patients who came to Santa Barbara ebbed. In 1925, a major earthquake struck Santa Barbara. Cottage Hospital and the Potter Metabolic Clinic therein survived with minimal damage, but the city’s other two hospitals, St. Francis and County General, were hit hard. There was an immediate need to transfer their patients to Cottage, which put a strain on services. For awhile it was a challenge to keep the Clinic going as well as the manufacture of insulin and all the associated tasks. Not surprisingly, at the end of that year, the Potter Metabolic Clinic showed a deficit for the first time. Cottage Hospital held an emergency meeting over the financial matter, and with it came some major changes. Hospital officials decided to officially disband the Potter Metabolic Clinic, and to roll over its operations into the Santa Barbara Cottage Hospital Research Department. This caused Dr. Sansum no small amount of anxiety. Staff and energy would be diverted to cancer and cardiology research and the focus of the clinic would no longer exclusively be on diabetes. His troubles were not yet over. In 1928, Sansum was informed that the 1929 allotment from the Carnegie Foundation would be the last, since its philanthropic focus was shifting from health to education. The Potter Metabolic Clinic had been receiving funding from the Foundation since the Clinic’s founding in 1916. Without that infusion of capital, the Cottage Hospital trustees quickly elected to end Dr. Sansum’s salary of $12,000. Still, because of stipulations made by benefactors of the hospital’s Potter Wing, Dr. Sansum would still be allowed to

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freely use the facilities and retain an office at the hospital. Nonetheless, key staff members of his clinic left to take other positions or to continue their education in pursuit of advanced degrees. In reviewing these developments in the fall of 1928, Dr. Sansum made the decision to start his own clinic. He would continue to use hospital facilities, but he would bring in his own medical specialists. In preparation for the opening of his own clinic, Dr. Sansum began hiring, often from his alma mater, Rush Medical College in Chicago, as well as the Mayo Clinic. The Mayo Clinic was the first integrated group practice in the nation. It was started in the 1880s by Dr. William Worrell Mayo and his sons, Dr. William J. Mayo and Dr. Charles H. Mayo. It was significantly reorganized in 1916 and came to national prominence as a premier healthcare and scientific institution. The Mayo team approach of pooled resources and skills to address health issues and medical problems became a new standard in medical practice. Their reputation for excellence was worldwide. It only made sense for Dr. Sansum to tap the best: Robert A. Hare, M.D. An older man, Hare was a lecturer at Rush Medical College and a physician Sansum greatly respected and was both a professional and business advisor to Sansum. Percival Allen Gray, M.D. A Rush Medical College graduate, he had been one of Sansum’s interns and was already a specialist in diabetes.


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Delbert McNamara, M.D. He was one of the first local physicians with expertise in the new field of electrocardiography; his specialty was cardiology. Doris Erkenbeck McNamara, M.D. Delbert’s wife was from the College of Medical Evangelists (later, Loma Linda University), where Drs. Sansum, Gray, and Koehler were regular lecturers. Hildahl I. Burtness, M.D.M.D. A graduate of Rush Medical College, “Burt” was devoted to the research and treatment of diabetes, and was to become Sansum’s best friend and protegé. Dr. Burtness was named Man of the Year in Santa Barbara in 1979, and Burtness Auditorium at Cottage Hospital was named after him.

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71 Leonard J. Brunie, M.D. and his wife, Yolanda S. Brunie, M.D. This couple came from Battle Creek Sanitarium, the first sanitarium in the nation. 17 His work was in gerontology and her field was pediatrics. Barkley S. Wyckoff, D.M.D. Barkley was an oral surgeon from the Mayo Clinic. John Childrey, M.D. Also from the Mayo Clinic, Childrey was an ear, nose, and throat specialist.

The earthquake of June 1925 caused tremendous damage and led to the disbanding of the Potter Metabolic Clinic. Shown is the damage wrought to the San Marcos Building in downtown Santa Barbara. (Santa Barbara Historical Museum)


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Alfred Koehler, M.D. A young internist from Johns Hopkins who had served as Henry Ford’s personal physician in Detroit, Koehler specialized in endocrine research. Dr. Fritz Bischoff A Ph.D. in biochemistry, he headed up insulin research. Ruth Bowden, B.S. She was a dietician at Potter Metabolic Clinic and Cottage Hospital and returned to work with Dr. Sansum. She was a coauthor with Dr. Sansum and Dr. Ware on numerous scientific papers and books on diet and nutrition. Freeman Spinney was hired as business manager. The Sansum Medical Clinic, while utilizing a number of specialists, had as its focus the diabetic patient. It was also a private clinic, under the ownership and chairmanship of one person. It opened in 1928, just a year before the onset of the Great Depression. In these initial years, Sansum Medical Clinic was very successful. When it became known that Dr. Sansum had organized a private clinic, more patients came from out of town and out of state than Cottage Hospital could accommodate. Local hotels cooperated, even adding diabetic dietitians to their staffs. Newspapers across the country reported celebrities such as Mary Miles Minter and Harold Lloyd,18 or captains of industry such as Warren Bechtel coming to Sansum to receive expert care. It became popular for Hollywood celebrities to check into Cottage Hospital for extended health checkups. Long after Santa Barbara’s Flying A movie studio had

closed, Santa Barbara was still a favorite place for show business people to get away for weekends. The top floor of the Potter Wing at Cottage Hospital was reserved for the use of film stars and their entourages. Dr. Hildahl Burtness was involved in working with them and recalled celebrities such John Barrymore, Zeppo and Groucho Marx, Jimmy Cagney, Lionel Barrymore, and Gloria Swanson checking in anonymously at Cottage Hospital. 19 The Sansum Medical Clinic was doing so well, that philanthropist George Knapp counseled Dr. Sansum to take it one step further. Knapp proposed that Sansum ABOVE: Among the early hires for the new Sansum Clinic was Dr. Hildahl I. Burtness, a specialist in diabetes treatment and who was to become one of Dr. Sansum’s closest friends. (Sansum Clinic Collection)


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build a separate clinic building, on property owned by Knapp on West Pueblo Street. Sansum bought three lots from Knapp and a fourth from the chief of police, George C. Sloan. The properties fronted West Pueblo between Bath and Castillo streets, directly across from Cottage Hospital. Knapp hired Carleton Winslow, a leading architect of the Spanish Colonial Revival style to design the two-story building. The decade of the 1920s saw a number of medical facilities and programs initiated in Santa Barbara. The Santa Barbara Clinic opened its doors in 1921. George Knapp established the Knapp School of Nursing as a memorial to his wife, Louise, after she passed in 1923. Max Fleischmann, whose ABOVE: Also joining the Sansum staff early on was Dr. Doris Erkenbeck McNamara. (Sansum Clinic Collection)

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73 wife, Sarah, was one of Dr. Sansum’s diabetic patients, made possible a $500,000 surgical wing and maternity ward at Cottage Hospital. The Santa Barbara Children’s Clinic opened in 1924. The new $66,000 Sansum Medical Clinic building was to be opened in January 1930, but construction delays put off the opening until June 1931. The completed building featured sixty spacious rooms including dedicated areas for ear, nose, and throat ailments, oral surgery, xrays, research space for clinical metabolic and cardiac studies, and classroom space for lectures and dietician classes. The underlying concept and focus of the Sansum Medical Clinic was to examine and treat health problems of patients, who did not require hospitalization, with the latest research and medical advances. Patients could receive thorough examinations without the exorbitant price tag (at that time $10 to $12 a day) of a hospital stay. Patients of the Sansum Clinic could rent rooms or apartments available in the neighborhood. Furthermore, Cottage Hospital maintained an out-patient dining room under the supervision of a dietitian, so Sansum patients could utilize Cottage Hospital for their meals. At the same time, if Sansum clients needed in-patient services, they could be readily admitted to Cottage Hospital across the street. More doctors soon joined the original staff of eleven physicians. These included Dr. James H. Saint, a British surgeon, who was a Fellow of the Royal College of Surgeons, and a member of the Royal College of Physicians of England, who came to Santa Barbara from the Mayo Clinic. Dr. Sansum’s brother, John Sansum, came from their hometown of Baraboo, Wisconsin, to become assistant man-


!74 ager, maintenance superintendent, and groundskeeper of the new facility. Sansum Clinic and the Great Depression Timing is everything. By 1932, the country’s economic downturn had reached deep into Santa Barbara County. The medical profession was not spared. Hospital beds at Cottage were now all too often empty. Philanthropists were not funding new projects, underwriting research, or donating monies towards new construction. Local doctors at that time were customarily expected to provide a generous part of their practice as public charity. This was before the era of private insurance and state and federal programs. This practice became more difficult as patient counts dropped and payments fell in arrears. A statement from the Santa Barbara County Medical Society urged “... all individual patients who are unable to meet both the doctor’s bill and hospital bill promptly to settle the hospital bill first and in full.” 20 The number of patients at Sansum Medical Clinic shrank significantly because of the economy and also because insulin was now widely available. Additionally, Sansum was now extended financially due to construction of his new building. The value of property plunged fifty percent within just three years of Sansum’s purchase of the Pueblo Street real estate. In 1933, Dr. Sansum gathered the staff together to discuss the financial situation. He laid out before his team various options, including pay cuts and asking the married couples to choose who would stay on the payroll. Doris McNamara left

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her position so her husband could stay, while both the Brunies resigned to open a practice in Pasadena. Dr. Hare moved back east. The substantial salaries Dr. Sansum had been paying his top physicians ($500 per month) were cut ten percent. By 1934 salaries had been slashed thirty percent.21 Within a few more years, Dr. Gray transferred his practice to the Santa Barbara Clinic. The oral surgeon, Dr. Barkley Wykoff, found his patient load was hampered by his association with the Sansum Medical Clinic, as other doctors were hesitant to refer patients when he was involved with competing specialists. With Dr. Sansum’s blessing and the generous gift of the oral surgery equipment, Dr. Wyckoff left to open his own practice. Yet through it all, research and treatment were maintained at Sansum Medical Clinic. Into his decade in Santa Barbara, Sansum with his colleagues continued to publish important findings. A dozen articles were published in such distinguished journals as the Journal of the American Medical Association (JAMA), California and Western Medicine, Journal of Nutrition, and Annals of Internal Medicine. Sansum published several more books on diet and nutrition, including a manual for diabetic patients. One interesting observation Dr. Sansum made during this period came from his perspective on diet and disease. At a medical convention in Los Angeles, he attributed the reduced incidence of certain illnesses during the Depression years to the fact that “people eat more sensibly during economic adversity when all they can afford are the cheap but nutritious staple foods. Feasting induces disease, famine diminishes its incidence.”22


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He gave well-received lectures twice a week at his clinic, and patients under his treatment were expected to attend the talks. In 1937, Dr. Sansum toured the European continent, Scandinavia, and Russia, and subsequently made presentations about the dire healthcare conditions he found in the Soviet Union. World War II The Sansum staff was further reduced when the U.S. entered World War II and Drs. McNamara and Burtness were called to active duty. First to leave was Dr. Delbert McNamara, who went on to serve as commander of the Medical Supply Office of the Third Marine District. Dr. Burtness served as Navy Commander in New Guinea and at naval hospitals in San Diego and San Francisco. At home, Dr. Doris McNamara returned and worked double time to make up for the absent male physicians. Douglas F. McDowell, a young internist who joined Sansum in 1938 after

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75 completing his residence at Cottage, served as an Air Corps flight surgeon during the war. Meanwhile, as the driving force behind the clinic that bore his name, Dr. Sansum continued his energetic pursuit of diabetes research and treatment. He found time to publish several more papers and revised his entry previously written for the Cyclopedia of Medicine. In summer of 1942, Sansum had a checkup that indicated that a heart attack was perhaps imminent. Heart disease was hereditary in his family, and lifestyle and overwork added to the risk. At the advice of his physician he restricted his activities and spent six months away from stress and management tasks. When recovered, Its new building on West Pueblo Street, which opened in 1931, testified to the success of Sansum Clinic, a success which allowed it to weather the financial strains of the Great Depression. (Santa Barbara Historical Museum)


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Sansum announced he was retiring from active practice, but would continue his research. In 1944, his brother John died from a sudden heart attack. This event prompted Dr. Sansum to take stock of his lifework and to consider how to perpetuate his crusade in diabetes research. He drew up a will, and through it created the Sansum Clinic Foundation as a non-profit corporation “to encourage, foster, promote, further and to engage in scientific and educational research work of every kind and nature.” This entity was later renamed the Sansum Research Foundation, and is now known as the Sansum Diabetes Research Institute. The Sansum Research Foundation was kept separate from Sansum Medical Clinic. ABOVE: The Second World War brought another set of challenges to Sansum Clinic. (Santa Barbara Historical Museum)

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After having established Santa Barbara as the center in the United States for groundbreaking advances in diabetes research and treatment, Dr. William D. Sansum passed away in January 1948 from an aneurysm, at the age of sixty-seven. He left a legacy of hundreds of thousands of diabetics who benefitted from his research and treatments as highlighted in the prolific number of articles and books, demonstrated in his groundbreaking diets, and established in a well-respected clinic specializing in the diagnosis and treatment of diabetes. Now, with his passing, the question arose; would his clinic continue? Could the Sansum Medical Clinic continue? Dr. Sansum had made known his desire for manager Freeman Spinney and dietician Ruth Bowden to be equal partners in the Clinic. In the months following Sansum’s death, the Clinic operated under that arrangement. The state attor-


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ney general then stepped in to explain that under California law all partners must have medical degrees in medical partnerships. Spinney unhappily resigned and moved out of town, while Bowden resignedly accepted the news and stayed. This meant the Clinic would now either be dissolved as a corporation or sold by the Sansum estate. Rather than dismantle the corporation, Sansum’s medical successors determined to keep the Clinic open and his name memorialized. Dr. McNamara led the effort with several other doctors to secure funding and buy the Clinic from the estate. The Sansum heirs were paid $250,000 to convey the Clinic to six physicians on staff: Delbert McNamara, Hildahl Burtness, Alfred Koehler, Douglas F. McDowell, Doris McNamara, and James H. Saint. Dr. Delbert McNamara was elected chairman of the newly formed partnership and served for the next ten years. Allan M. Duncan was hired as business manager. The 1950s Coming into the 1950s, Sansum Clinic saw the re-

Dr. William D. Sansum died in January 1948 at age sixtyseven, leaving behind a lasting legacy in diabetes research and treatment. (Santa Barbara Historical Museum)

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77 turn of physicians from active duty in both World War II and a little later the Korean War and these men came back armed with knowledge of the latest medical breakthroughs. One of the ironies of war is that enormous medical advances are often created out of battlefield necessity. For instance, penicillin was first produced in large quantities to treat wounds during World War II which increased surgical survival rates. The widespread use of antibiotics revolutionized medicine. World War II also served as a vast laboratory for advances in the field of orthopedics and neurology.23 The knowl-


!78 edge and techniques learned by medical personnel in the war were readily adapted to civilian life. An example of this at Sansum was demonstrated by Dr. Wayland Stephenson who served during the war at the naval hospital in Long Beach. At war’s end and after completion of his residency, he began practicing at Sansum as the first neurologist on staff, specializing in epilepsy. Sansum Medical Clinic was growing. In 1951 there were fourteen physicians at the clinic; that figure increased thirty percent in four years. In fall of 1955, a threestory addition was built to provide offices for six more doctors as well as space for related work. At the end of the 1950s, there were more than twenty physicians at Sansum Medical Clinic, all of them receiving the same salary of $9,000 a year. The first clinic physician to answer the call to active military duty was cardiologist Dr. Delbert McNamara. (Sansum Clinic Collection)

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Sansum Becomes Diversified Multi-Specialty Clinic Returning veterans, in-migration and the postwar baby boom all added to a growing patient load into the 1960s. New specialists were recruited to treat a growing variety of medical problems. In response to patient needs, it was decided that Sansum should become a diversified multi-specialty group. General surgeon Dr. Ernest Smith was hired, along with surgical colleague Dr. William Stevenson. Dr. Jerrold Peerman Nesselrod, a nationally known professor of colon and rectal surgery from the East Coast was recruited, and gynecologist Lowell McClellan also joined the group. (However, obstetrics and pediatric services were not offered. These services were provided by the Santa Barbara Clinic. Most Sansum patients who were from out of town were seeking extended physicals, as well as medical evaluation.) Additional specialists included urologist Dr. Fred Heidner and gastroenterologist Dr. George Scott. As medical treatment continued to evolve, it became clear that there was a need for up-to-date cancer treatment at Sansum. Oncologist Dr. Charles Chapman was hired and brought high standards of hematology/oncology practice to the group. Dr. Simon Jameson, an infectious disease specialist was added. Later Dr. Tom Jones became the first neurosurgeon at Sansum. Diagnostic cytology became an important part of screening for women’s cancers and also diagnosing certain pulmonary diseases. A husband-and-wife team, Drs. Francis and Mariana Masin were hired in the 1960s to conduct specialty laboratory testing, and they became significant researchers in the field of cytology.


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The partnership of six doctors formed in the aftermath of William Sansum’s death now oversaw in just over a decade thirtyfive physicians. The Sansum group was still a “small” partnership, an arrangement that would soon be in need of transformation. In the early 1960s, Richard Ellis was hired as business manager. He advised that a professional corporation should be formed as the organizational foundation of the medical practice, while the partnership should continue to own the property. Based on his advice, the Sansum Medical Clinic was transformed from a partnership of physicians into a professional corporation with three managing partners, originally Drs. George Scott, Clayton Klakeg and William Kucera. Encinal Properties became the entity that owned the buildings and grounds.24 Out-of-Town Clientele By the 1960s two-thirds of the patients seeking care at Sansum Medical Clinic were from out of town. 25 This trend had started after the war, as there was a shift in the attitude of Americans who had traveled abroad and across the nation. As the country expanded with new technologies and in-migration, people now readily looked beyond the borders of their own hometowns for the goods and services they needed. For example, before the postwar boom, Las Vegas was still a small town with a population even less than that of Santa Barbara. Las Vegas did not yet have its famous hotels and casinos of the 1950s and 1960s. It was also lacking medical specialists. A businessman who had just opened the first hardware store in Las Vegas came to Santa Barbara for a complete physical. He was so impressed by the expertise at

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79 Sansum Medical Clinic, he spread the word about its services and physicians to other businessmen back home in Nevada. Early on, nearly ten percent of Sansum patients came from Las Vegas alone. For decades, a steady stream of patients came from Las Vegas to the Sansum Clinic to stay for a week while they had their complete medical check-ups and evaluations done. The reputation of Sansum also spread through California’s Central Valley and particularly in Bakersfield where superior healthcare specialists were in short supply. Ranchers and farmers from the Central Valley made up a large percentage—up to thirty-five percent during some decades—of Sansum patients. After Dr. Delbert McNamara cared for the governor of Sinaloa and other prominent businessmen from Guadalajara in the latter part of the 1950s and early 1960s, a number of patients regularly came to Sansum from Mexico as well. During this era, it was not uncommon to find twenty to forty out-of-town patients per week at Sansum for their weeklong checkup. Although some patients might have had a need to check into Cottage Hospital, most would check into Sansum at the beginning of the week and stay in the neighborhood. Beginning in the 1960s, many families took advantage of the nearby Encina Lodge, located across the street from Sansum at 2220 Bath Street. During the 1970s , 1980s and 1990s, patients arrived in large recreational vehicles (RVs) and selfcontained campers, and were allowed to stay at Sansum. An area of the parking lot was set aside for RVs and these clinic guests were provided with water and power hook-ups for campers. The custom of several-day checkups lessened somewhat in the early 1980s


!80 when insurance no longer covered such extensive examinations. However, patients so valued the Sansum service and treatment, that many patients still requested the customary thorough evaluation even if they had to pay for most of it out-ofpocket. An interesting note was that one of the physicians doing the intake on patients was Dr. James McNamara. He was the son of Drs. Delbert and Doris McNamara, founding physicians of the Sansum Clinic. James followed in his family’s medical tradition, graduating from his mother’s alma mater, Loma Linda University. Sansum Expansions By the 1970s, Sansum had fifty doctors who now could not be accommodated within the space of the original clinic building, originally designed to hold one fourth that number. The clinic bought several houses on Encinal Avenue (an alley between Pueblo, Los Olivos, Bath, and Castillo streets no longer in existence) and turned them into offices for the various specialty services. The problem with using these small wooden houses as medical facilities became clear when an electrical fire broke out in one of them. The structure, built in the 1920s, burned easily, and many papers and archives relating to the Sansum’s history were lost. To provide additional space, Drs. Gilbert White and James McNamara even had their offices in a trailer for awhile. There was clearly a need for refurbished and expanded facilities. The original 1931 clinic building was edging toward a half-century in age. Properties were consolidated and the small homes on Encinal Avenue were razed. In 1976 the

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old clinic was replaced with a $3 million 65,000-square-foot structure for fifty-five physicians and support services.26 Additionally a small building on the corner of Pueblo and Bath streets, originally the office of Dr. Franklin Nuzum of Cottage Hospital, was acquired by the clinic. The Sansum Research Connection Continues Medical research had been the foundation of the Sansum Medical Clinic since its inauguration, and while the focus turned to clinical specialization, assessment, and treatment, research remained an important component and underlying theme for Sansum throughout the century. For this reason, many doctors at the clinic wishing to keep a connection with research, served on the board of the Sansum Medical Research Foundation. Additionally, over the course of the clinic’s history, there were always Sansum physicians who retained a spirit of medical inquiry and investigation and wanted to remain involved with research, and took advantage of the facilities at the Sansum Medical Research Foundation. Dr. Alfred Koehler, one of the founding physicians of the clinic, continued Dr. Sansum’s work in diet and nutrition, focusing on the role that fat and cholesterol play in degenerative diseases. His studies were years ahead of their time in showing a relationship between cholesterol and arteriosclerosis. A pioneering bone marrow transplantation was performed by Dr. Casimir Domz, who was both directing research at the Foundation as well as maintaining a clinical practice. His was the first successful bone marrow transplant in a patient with an immune deficiency.


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Hematologist Dr. Abraham Potolsky took note of the miserable side effects his cancer patients suffered when undergoing chemotherapy. Dr. Potolsky worked to develop criteria by which doctors could adjust chemotherapy to achieve maximum benefits while avoiding side effects. Endocrinologist Dr. Lowell Sparks carried on a tradition started by Dr. Sansum, by spending a portion of each day in the research laboratory. Among his many projects, he evaluated the drug glyburide and found it to be the most potent diabetic oral medication available at the time. It was subsequently approved by the Federal Drug Administration for the treatment of diabetes. Sansum was one of a special select medical groups in the nation chosen by the F.D.A. to study new drugs for arthritis. Dr. Bernard Drury and Dr. Edwin McGinn evaluated sulindac (later released under

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81 the brand name Clinoril). Some of the patients in the study were on the drug for three years, the longest clinical experience on record at that time. New studies investigating the mechanisms of strokes were initiated by Dr. George Austin, a neurosurgeon. In particular his team studied the effects of surgical treatments on blood flow, and thus oxygen supply, to the brain. Sansum Medical Clinic neurologist Richard Lowenthal, M.D. developed a facility for histochemical study on muscle tissue as a vital component of a neuromuscular research program being launched at the Clinic. He found that the most powerful technique to diagnose and The well-appointed waiting room of Sansum Clinic. By the end of the 1950s over twenty physicians were in residence there. (John C. Woodward Collection)


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The staff of Sansum Medical Clinic, c. 1957. Back Row, left to right: Casimiz Domz, Kenneth McNiece, Wayland Stephenson, Bernard Drury, Earnest Smith, Robert I. Cord. Middle Row: Clayton Klakeg, Kevin Fay, John Knight, William Stephenson, Hildahl Burtness, Delbert McNamara, John Merritt, Douglas McDowell, Alan Duncan. Front Row: Virgil Hepp, Frank Leikie, Jerome Griffith, William Kucera, Dale Creek, Doris McNamara, Paul Brickly, Byron Gifferd. (Sansum Clinic Collection) study neuromuscular disease was through direct examination of muscle tissue obtained through needle biopsy. Since the demanding requirements of this approach made histochemistry unavailable in most routine pathology labs, Sansum was the only facility between Los Angeles and San Francisco studying muscle histochemistry. The internationally acclaimed husband-and-wife team of cytologists Drs. Francis and Marianna Masin were pioneers in the field of cytology—studying cells in relation to various cancers. Their research studies were published worldwide. The Masins identified malignant cells from body secretions such as urine or sputum. This allowed the scien-

tists to discover cancer in the throat, lungs, or bladder before the tumor would grow large enough to be seen on an x-ray.27 Sansum physicians also stayed at the forefront of medical innovation. Fiber optic endoscopy was introduced at the Sansum Medical Clinic’s gastroenterology laboratory and was utilized by four physicians: Sansum physicians Drs. George E. Scott and Albert Svoboda, Dr. John Hobson of Santa Barbara Clinic and independent physician Dr. William A. Davidson. When Charles Chapman joined the Cancer Center of Santa Barbara in 1970, he was the first medical oncologist in Santa Barbara. He remained there until his re-


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Dr. Benjamin Bakewell was one of the founders of the Quisisana Sanitarium in 1906. By the time of this 1922 photograph, the facility had become St. Francis Hospital. (Santa Barbara Historical Museum)

tirement in 1990, which lasted for a mere seven days when he returned to Sansum Medical Clinic until 2002.28 By the mid-1980s there were sixty physicians at Sansum Medical Clinic, representing virtually every medical specialty, with the exception of pediatrics and obstetrics.

Part Two: The Santa Barbara Clinic Story The one great outstanding problem before the medical profession is that involved in the delivery of adequate scientific medical service to all the people, rich and poor, at a cost which

can be reasonably met by them in their respective stations in life. Rexwald Brown, M.D., 193129 At virtually the same time that Dr. Sansum arrived in town to serve the Potter Metabolic Clinic, the Santa Barbara Clinic was being launched. The word “clinic� implied a slightly different concept than we know it today. In the early 1900s, clinics were hospitalbased research-oriented facilities, treating a specified population. The Potter Metabolic Clinic of 1917 was a good example of this; the clinic treated patients with metabolic conditions, i.e., diabetes, nephritis, and gout. The Sansum Medical Clinic was


!84 started in 1928 at Cottage Hospital in the same vein to continue the work of the Potter Metabolic Clinic after it closed. Then the clinic became completely independent of the hospital and with its own facility and offices in 1931. It should be noted that the Sansum Medical Clinic began under the direction of one man with a focus on research and treatment of diabetes, serving a nationwide patient base. It then developed from there and broadened its focus and purpose to handle patients other than just diabetics. The Santa Barbara Clinic had, first and foremost as the name implied, its community in mind. It was founded by men of vision with a new and innovative almost revolutionary approach to healthcare: a clinic which was to be a group approach to healthcare delivery to patients from all walks of life. Their story and vision and commitment to the community underlie the century-long success of the Santa Barbara Clinic. The Founding Fathers The narrative of the Santa Barbara Clinic begins with three men. Dr. Benjamin Bakewell (1877 - 1953) Benjamin Bakewell was born in New Jersey in 1877. When he was five, his family moved to Santa Barbara, where his father became rector of the Trinity Episcopal Church (1883- 1888) and oversaw its construction. Around 1890, the family moved to Oakland where his father was to serve another church. Bakewell graduated from the University of California medical school in San Francisco in 1902 and interned at St. Luke’s Hospital there for two years, before returning to Santa Barbara for health reasons.

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Dr. Benjamin Bakewell In 1906, he joined Dr. Harold Sidebotham and Dr. Philip Chancellor and bought an unused portion of the Catholic cemetery at the intersection of California and East Arrellaga streets. There they built a two-story private sanatorium which they named Quisisana Sanitarium. Quisisana meant “here you get well� and the sanitarium was a kind of medically supervised health spa. It was typically a small hospital setting (thirtyfive beds in this case) designed for rest, recuperation, and recovery. After getting the sanitarium off the ground, the partners determined to have an order of nuns take over the facility and in 1908 it was sold to the St. Francis Sisters of the Sacred Heart who eventually enlarged the complex and changed the name to St. Francis Hospital. Dr. Bakewell continued on in practice by himself, restricting it to gynecology and obstetrics.


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85

Dr. Rexwald Brown

Dr. Hilmar Koefod

Dr. Rexwald Brown (1878-1940) Rexwald Brown was born in 1878 and raised in Joliet, Illinois. During the Spanish-American War, he served as assistant surgeon to the medical reserve corps of the U.S. Navy and upon his return took his medical degree from Northwestern University in Chicago. He became chief surgeon for the Armour Meat Company. It was the Armour family’s connections in Santa Barbara that prompted Brown’s move here. He became house physician for the Potter Hotel, where the Armours had frequently wintered. He next served as house surgeon for the Southern Pacific Railroad. With his skill and repute as a surgeon established, he was called upon by the local hospitals, and served at Quisisana under Dr. Bakewell. During World War I, he served this time as captain in the Army Medical Corps with the American Expeditionary Force in France. It was here that he ob-

served the triage process and the military medical approach to treating soldiers. A prolific writer, Dr. Brown also devoted much time to clinical investigation and published many papers and reports and ruminated on matters of health and society. He was particularly passionate about making healthcare affordable and accessible for all patients. Dr. Hilmar Koefod (1888-1974) Dr. Hilmar Koefod hailed from Minnesota, and received his medical degree summa cum laude from Harvard University. He was awarded a Moseley traveling fellowship by his alma mater and went to London for post-graduate work, studying Photos of the three founders of the Santa Barbara Clinic courtesy of Sansum Clinic Collection (Bakewell and Koefod) and Santa Barbara Historical Museum (Brown).


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with Sir William Osler (the “Father of Modern Medicine”) and famed cardiologists Sir John Parkinson, and Sir James MacKenzie, specializing in military cardiac cases. Koefod published “The Immediate Effect of Cigarette Smoking on Healthy Men and on Cases of Soldiers' Hearts," in the respected medical journal The Lancet, August 18, 1917. It This was a sensation throughout the medical world as this was the first time this theory had been substantiated with medical documentation. Dr. Koefod entered the service in 1918, but was soon discharged because he had developed diabetes. One of his mentors, Dr. Henry Christian, the dean of the Harvard Medical School, advised Koefod to go to the Potter Clinic in Santa Barbara.30 By this time Koefod was a renowned heart specialist, and when he came to Santa Barbara in 1918, he was tapped by Dr. Potter to work at his Metabolic Clinic. About the time of Potter’s death, Dr. Koefod left Potter Clinic for the opportunity to work with Dr. Herbert Moffitt, the brilliant head of University of California School of Medicine in San Francisco who had just reorganized it and oversaw the completion of a new hospital. The Need for Improved Healthcare Between 1900 and 1920, the population of Santa Barbara essentially tripled. Healthcare services necessarily grew to accommodate the increase:

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1906 Quisisana Sanitarium 1908 St. Francis Hospital 1908 Visiting Nurse Association ! (VNA) 1911 VNA General Dispensary

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1914 VNA School Nursing Program and Infant Welfare Station 1917 Potter Clinic This period of change and expansion was also mirrored throughout American society, as the population shifted from rural to urban and to industrialization. The Progressive movement of the time sought to improve all aspects of modern life: education, labor conditions, business practices, and welfare. Healthcare was another field that was undergoing major revision. The touchstone for medical reform was the Flexner Report on medical education published in 1910. Named for its author, Abraham Flexner, who produced it for the Carnegie Foundation, the report exposed how early twentieth-century U.S. medical education in most cases was substandard and offered remedies. The report suggested the need for higher standards and standardization in medical schools, dispensing with diploma mills and proprietary medical institutions.31 This report also brought into perspective the issue of “organized medicine.” The implication was that higher standards were needed not just for medical institutions but were needed for healthcare to evolve from the answer-to-no-one individualism of the solo practitioner. Doctors often practiced medicine (or taught others through an apprenticeship system) using any standard they wished. In short, the medical establishment status quo required a second look and an overhaul. The Clinic Concept During World War I, Dr. Brown was greatly influenced by watching the collaborative process of physicians. He saw


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doctors—each with a different specialty—working together to diagnose and treat the wounded soldiers efficiently. There was feedback and an opportunity to confer with one another to render the most expedient treatment. He contemplated upon this approach and envisioned the same process in a civilian setting. He was further enthused by the example of the newly reorganized Mayo Clinic. Brown could also foresee the benefit of physicians sharing a single facility. Instead of each doctor maintaining his own separate office as was the custom at the time, a group of physicians would work interactively under one roof. What truly lit Dr. Brown’s passion was the realization that overhead costs (rent, utilities, staffing) could be apportioned and thus medical care could be made more affordable for people of moderate circumstances. He began to write articles in medical journals about the possibility of a group practice of specialists as a new framework, feeling that too often the “Medical profession was bounded down by traditions and precepts.” 32 His initial articles were largely ignored and received little response. Brown then shared his vision with a number of his colleagues, looking for mutual enthusiasm and kindred spirits, but could get no traction. As he later remembered it: In the latter part of 1919, and in the early months of 1920, enthused by my experiences in the World War where I learned the advantages of grouping of doctors in the treatment of disease and injury, I advocated the idea of collaboration among many doctors in Santa Barbara. At my

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87 home and in my office, many meetings were held between invited doctors to discuss the likelihood of establishing a medical group in this city. I talked this matter over with my lay friends, but my enthusiasm, and the seeds of my ardor fell on stony ground, except for the souls of Dr. Benjamin Bakewell and George Owen Knapp.33 It must be remembered at this time, most doctors were not specialized; this new concept was what Dr. Brown saw borne in battlefield triage. Virtually all doctors were sole proprietors, and were mostly general practitioners. Brown realized that a solo general practitioner could not realistically keep up on every advance made in all the areas of medicine and could not effectively be all things to all patients. Full-time specialists at this time comprised less than seventeen percent of all U.S. physicians, and most of these were in large cities or university settings and not in small communities. Brown also thought specialists could be in danger of having a restriction of vision and become too absorbed in their own field. Yet a specialist could remain current in his own field, and working collaboratively with other specialists could provide optimum resources and knowledge to help a patient. This was why he held the group practice clinic model in such high regard. Very few multi-specialty group practices existed in the country; the Mayo Clinic being the first and most prominent of these. After World War I, other physicians with similar experiences during their military service were enthused about the


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concept of a group practice. For the first several years after the war, a handful of group practices were launched across the country, averaging perhaps two or three such practices per state. The Santa Barbara Clinic became the first group practice in California. The American Medical Association, however, did not take kindly to the idea. Some of its criticism raised the possibility that cliques of doctors might shut out competition, or that group practices could lead to contract medicine and prepaid health plans which in turn could be an economic threat to independent physicians. There was also a strong suspicion that group practice in a clinic setting could lead to socialized medicine. Nonetheless, Dr. Brown was not deterred.

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assistance to fund a building, but perhaps just as important, his expertise in business. His first suggestion to the physicians was to bring back Dr. Hilmar Koefod from San Francisco as partner in the clinic. Knapp remembered the young Koefod from his time at the Potter Clinic and was very impressed that Koefod was personable, pragmatic, and perceptive—traits which would complement’s Brown’s visionary nature. As a founder of the Quisisana Sanitarium, Bakewell had brought

Dr. Bakewell and I agreed that there were real constructive possibilities of joining forces for the organization of a medical group. After a time, Mr. Knapp, then at the height of his organizing abilities said, “Go ahead, get your associates, I’m willing to finance the experiment.”34 The philanthropist was unhampered by medical tradition and protocol. As a businessman he could understand operational efficiencies and how to tap into talent. Brown’s concept struck a chord with Knapp who knew how to get medical projects off the ground, having funded the Potter Clinic and major improvements to Cottage Hospital, the Knapp School of Nursing, and later helped launch Sansum Medical Clinic. Knapp proffered not only his financial

One of the major figures in the development of health care in Santa Barbara was George Owen Knapp, who was involved at various times in the funding of Cottage Hospital, the Potter Clinic, Sansum Clinic, the Santa Barbara Clinic, and the Knapp School of Nursing. (Santa Barbara Historical Museum)


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his business acumen to the sanatorium partnership; now his practical and detailed management skills would be assets to the new clinic. Brown and Koefod opened a practice in the San Marcos Building at State and Anapamu streets in April 1920, while they also worked on creating the clinic. Dr. Brown now limited his practice to surgery and Koefod focused on internal medicine. Dr. Bakewell still had his individual practice in his own building in obstetrics and gynecology. The three principals recruited four more physicians to join their clinic. Harry Henderson was a pulmonary specialist who also had his office in the San Marcos Building. Henderson had formerly been with the Potter Clinic and he invited another colleague from the Potter Clinic, Dr. Hugh Freidell, who chose to specialize in stomach and intestinal disorders. Dr. Brown recruited two young men out of Rush Medical College: Dr. Henry Profant, ear, nose, and throat specialist; and Dr. George Farman, a specialist in urology. Meanwhile, Knapp purchased property at 1421 State Street and began the construction of a medical office building from which the trio would launch their new clinic concept. The building was completed in six months. On January 21, 1921, the Santa Barbara Clinic officially opened its doors. The building at 1421 State was designed by noted architect Carleton Winslow. It was a one-story building of approximately 60,000 square feet and included twenty-four rooms for offices and patient examinations, a librarybusiness office, and a room for laboratory and staff.

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89 The opening was announced in the local Morning Press on January 23, 1921: Santa Barbara Clinic is Opened The Santa Barbara Clinic is now an established fact. The seven physicians and surgeons who are to practice medicine as a group, after the plan employed at Rochester, Minn. by the Mayo brothers, and at Baltimore at the Johns Hopkins University, yesterday moved their effects into the new clinic building above Sola Street on State Street and before nightfall were ready for the reception of patients. The group activities are to be directed by Dr. Rexwald Brown, the organizer, and Drs. Benjamin Bakewell and Hilmar Koefod. Associated with the three are Drs. H.E. Henderson, H. J. Profant, George K. Farman and Hugh Freidell. The 22 rooms in the attractive mission-style building which has only just been completed, are equipped with the latest apparatus developed in medical science. The building is to serve only as the offices and consulting rooms of the group members. Operations, when necessary, will be performed in local hospitals. Two trained nurses will be in attendance at the clinic as well as a number of office assistants of the physicians and surgeons. Medical benefactor George Owen Knapp then rented the building to the group for $1.00 per year and loaned them $35,000 to furnish and equip the new clinic.35


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Healthcare Delivery Dr. Rexwald Brown believed this group practice/clinic approach of shared costs and therefore reduced fees an important step in making healthcare affordable. He also envisioned health insurance as a viable means for the delivery of healthcare. He wrote a great deal about the many issues in the revision of healthcare delivery. His perspective was well established and no doubt placed him on President Franklin Delano Roosevelt’s radar. When President Roosevelt established the Committee on Economic Security (C.E.S.) in 1934, one of its subcommittees was the Medical Advisory Committee. Dr. Brown was one of only eleven physicians in the country called to serve on this committee, a tribute to his perspective and continuing active interest in the problems and issues of accessible healthcare. While the C.E.S. launched the first comprehen-

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sive federal social insurance program in the nation's history—Social Security—health insurance was contemplated but deferred for later study. On the other hand, Dr. Brown was dubious about the role of socialized medicine. His primary concern revolved around the role of lay people or bureaucrats making decisions in an area where they had no education or expertise. He supported the idea of health insurance, but was wary of physicians being subordinated to the role of technicians for the pecuniary interests of corporations. He wrote numerous editorials on the health of healthcare, such as “The Menace to Medicine” for California and Western Medicine in 1929: Another shadow of the menace is the insistence by groups of private citizens and politicians that medicine be socialized.

The Santa Barbara Clinic opened in January 1921. The building was designed by famed architect Carleton Winslow. (John C. Woodward Collection)


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Socialization means the subjection, by legislative control and political manipulation, of the medical profession in a system of state medicine which includes health insurance and compulsory professional attendance. Carried to a logical end, the states and the nations would compel physicians to practice on terms dictated by lay people.36 Community Orientation Dr. Brown felt it was important that physicians be involved in their community and contribute to their profession. He certainly set the example, as he was president of the Santa Barbara Chamber of Commerce at the time of the 1925 earthquake, served as vice chairman of the Santa Barbara County Board of Health, was chairman of the City Planning Commission, and chairman of the County Probation Department. He also was a charter member of the University Club and the Montecito Country Club and held memberships in the Santa Barbara Club, the Santa Barbara Country Club, and the Valley Club. Respected by his peers, Dr. Brown was elected to serve as president of the Southern California Medical Society, vice president of California State Medical Society, vice president of the California Medical Society, president of the Santa Barbara County Medical Society, the Cottage Hospital surgery staff and the Cottage executive committee. He held memberships in the Western Surgical Association, Los Angeles Clinical and Psychological Association, San Francisco Academy of Medicine, and the American Medical Association. He was charter member of the American College of Surgeons, and a member of Phi Rho Sigma

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91 Medical Society Fraternity. Nationally recognized for his acumen and skill as a surgeon, in 1928 Dr. Brown was named to Who’s Who in America. Dr. Koefod was a founder of the local Channel City Club, the Moore Dental Foundation, and charter president of the Riviera Improvement Association, as well as president of the Santa Barbara Museum of Natural History and president of the Santa Barbara Historical Society. He was advisor to Cate School and on the advisory board of Bank of America. Through his work with his patients he was responsible for the gift and creation of the Ina Campbell Hall at the University of California, Santa Barbara and the creation of the new local Y.M.C.A. building. In 1967 Dr. Koefod was named Santa Barbara Man of the Year for his outstanding civic contributions and also received citations from the California Historical Foundation and Harvard Medical School for his contributions there. Dr. Bakewell was founder of the Quisisana Sanitarium, secretary of Santa Barbara General Hospital, president of the Santa Barbara County Medical Society in 1911, the year before Dr. Brown, and served as Santa Barbara County health officer from 1908 to 1910. He wrote a number of scientific articles and was published in JAMA, California and Western Medicine, and the Western Journal of Obstetrics and Gynecology. He served his community as president of the chamber of commerce in 1915 and 1916, a director of County National Bank in 1920, and in 1927 was named to Who’s Who in California. The Clinic Controversy It is interesting to note that the group


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practice /clinic concept which is so commonplace today was quite the controversy in the early 1920s. Those doctors perturbed the most were general practitioners, who viewed a clinic of specialists as competition. Also, some presumed that these clinics had fee-sharing backroom deals to cut others from competition. Dr. Koefod’s biographer, Yale Griffith, summed it up:

was a leader in planning discussion meetings and bringing in distinguished experts to discuss the latest developments in medicine. Fortunately the criticism and opposition cooled off and independent doctors have learned that the entire medical profession is strengthened by the presence of these two well-equipped and well-staffed clinics.38

The clinic was opposed and criticized by many independent local doctors. There were letters to the editor, complaints with the state and local medical associations, and many difficulties. Many doctors were jealous and concerned about ethics, and the claim that publicity about the clinic was advertising.37 [An article in the Daily News had extolled the virtues of the clinic, comparing it the Mayo Clinic, and encouraged readers as to its affordability through its sliding scale fees.]

The Clinic gradually gained acceptance and continued to grow; physicians were added virtually every year as the need for different specialists was recognized.

The integration of specialization and group practice gained acceptance when Dr. Koefod could educate and demonstrate to the medical community the benefits. As his biographer explained, They [local doctors] and other people were afraid that the establishment and growth of the Santa Barbara Clinic and the Sansum Clinic would be the end of good family doctors and independent specialists. Hilmar Koefod was a tactful leader in quieting such opposition. He helped to build a relationship of cooperation and friendship with independent doctors. He

1922-24 Gilbert V. Hamilton 1923 Irving Nat Wills, general surgery, urology 1924-1926! Horace Gray, endocrinology 1926-1927 ! Walter Scott Franklin, opthalmologist 1926 William Mofatt, endocrinologist 1926 Rodney Astatt, established the orthopedic department 1927 Francis J. Hombach, opthalmologist 1928 William R. Hunt, a second ear, nose, and throat specialist By 1927, it was clear that more room was needed and a clinic expansion provided a new 3200-square-foot wing, creating a “T� formation to the facility. The ex-


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tension was designated as the Surgical Division and included the orthopedic and urology departments. In 1928, the Clinic bought property on Chapala Street and annexed a building for an additional space of 1,538 square feet. It only took a year to outgrow this expansion as more specialists joined the clinic, including: Neville Ussher, established Department of Preventative Medicine Howard Eder, established pediatrics Lawrence Eder (brother of Howard), joined as a second specialist in obstetrics/gynecology, one of first board-certified obstetrician/gynecologists in the U.S. Once again more space was needed. At the end of 1929, architect Carleton Winslow drew up plans in the Italian Ve-

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93 netian style and by June of 1930 (again, in only six months), the newly remodeled clinic was completed. This time 4200 square feet were added; the building was widened and a second story added which extended over the original front of the building in a series of arches. (In 1977, this beautiful building was declared a “Structure of Merit” by the City of Santa Barbara, the first so designated. The top of the façade of the expanded building carried the emblem with initials SB encircled by the letter C (signifying the Santa Barbara Clinic). Four plaques were inscribed Ars Medica, Chirurgia, Ars Obstetrica and Radiologia,—highlighting in Latin four branches of medical practice: general medicine, surgery, obstetrics and radiology. These are on the building today at 1421 State Street. The Clinic now had sixteen doctors including: Alfred Wilcox, proctology surgeon

The reception area of the Santa Barbara Clinic. The clinic concept was a subject of some controversy among the medical profession in the 1920s. (John C. Woodward Collection.


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wrote, “When in 1929 the Depression suddenly struck, the question arose as to whether a group like this could survive. The surprising result was that although times were hard, the esprit-de-corps was excellent. The members worked harder and in better harmony than ever. The larger earners gladly shared with those who suffered the greatest drop. It was a heartwarming experience.” 39

Dr. Rodney Atstatt joined the Santa Barbara Clinic staff in 1926 and founded the orthopedic department. (Sansum Clinic Collection) John E. McAdams, who initiated the Dental Department. He left in 1936, and the department was discontinued thereafter. The Santa Barbara Clinic and the Depression When the stock market crashed, the physicians were just finishing the plans for the major building renovation. Unlike Dr. Sansum, who was bearing the cost on his own, the Santa Barbara Clinic financials were shared by the partnership of physicians. While Dr. Sansum’s focus was on the science of medicine, the Santa Barbara Clinic’s design was to be an evolving healthcare institution. The Santa Barbara Clinic was able through shared expenses and governance to weather the economic storm far more easily than Sansum. As Dr. Koefod later

Governance of the Clinic The financial agreement was revised at least eight times during the first decade to deal with the issues of ownership in the clinic and the equitable distribution of earnings. In the beginning was the formation of the partnership—Brown, Koefod, and Bakewell—which served as the executive committee and made all the decisions. The other four young physicians were on salary. The concept of the founders was to bring in young doctors out of medical school to keep the clinic current and vibrant. To attract and keep this talent, the founders offered new doctors limited partnership in the company after a threeyear apprenticeship. These limited partnerships offered a small share of the profits, which would be increased every year; the original partners retained seventy-five percent of the holdings. In 1927, the Santa Barbara Clinic Holding Company was created. The physical properties (owned by the original three partners) were now transferred to all partners, in proportion to their share in the earnings. Two years later, the original three partners transferred another twenty-one percent of their holdings into the Clinic share. They now retained fifty-four percent and they created


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a reserve fund which Koefod had been advocating for some time. The partners agreed to a salary and profit-sharing according to their assigned proportion. In 1930, the trio of original partners proposed a governing board for the Clinic in the case of the death of an original partner. They reduced their share to fiftyone percent, as they wanted to retain control, yet they were extremely pleased with the direction, cooperation, and dedication of the limited partners. They also set retirement at sixty years voluntary and sixty-five for mandatory retirement.40 It was this vision, principled planning and practical policies, and above all a cooperative practice that allowed the Santa Barbara Clinic to weather the Great Depression. A few years into the Depression, Drs. Koefod, Bakewell, and Brown drew up a Declaration of Principles which underscored their original intent and articulated their legacy. (See Pages 96–97) 1940s—The War Years Coming into its third decade, the Clinic found itself working even harder to pull together than during the Depression years but for very different reasons. Dr. Brown retired in 1937 and died in 1940. Dr. Profant died in his sleep at the age of fifty-one in 1944, and Dr. Lawrence Eder died at the age of forty-two in 1942. These departures left three physicians to replace and a gap in the original leadership team. World War II impacted the Santa Barbara Clinic in numerous and distinct ways. The first of course, was the loss of staff due to military service. Six of the fourteen physicians left to serve in the armed forces at some point during the war years: Drs. Atstatt , Graham, Gray,

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Santa Barbara Clinic also lost a number of physicians to military service in World War II, among them Dr. Percival Gray, an internist who worked with Dr. Sansum in the study and treatment of diabetes. (Sansum Clinic Collection) Ussher, Bissell, and Arthur Olsen, as well as consulting radiologist, Dr. Russell Gates. Additionally, key personnel such as clinic manager Charles Karl and head nurse LaVerne Hales were tapped for service. In the meantime, the armed services had come to Santa Barbara. There was a Marine air base at the airport, and the Army built Hoff General Hospital on fiftyeight acres at Las Positas Road and State Street. The complex included 102 buildings including a hospital staffed by four hundred personnel which served 27,000 patients from both the European and Pacific theaters during the war.


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DECLARATION OF PRINCIPLES Inasmuch as the Santa Barbara Clinic has this year passed the sixteenth anniversary of its founding, we feel that its permanence in the life of the community is now reasonably assured. As its horizon has widened, new men have been added to its personnel, both to carry on its activities and to provide for the time when the older members will retire. With these facts in mind, and realizing that these new associates will carry on the work conceived by us, we the original partners and founders wish to make a permanent record of our ideals in what we may term a Declaration of Principles: Whereas The practice of medicine and surgery is ever growing more intricate and complicated, and Whereas It is beyond the powers of a single individual to become thoroughly familiar with its various phases and keep abreast of the constant new developments in its various branches, and Whereas It is evident that our patrons, the public, have a right to receive care and treatment consonant with the newer knowledge at a price within their economic ability to pay Be it therefore resolved That the Santa Barbara Clinic be and is organized as a group of physicians and surgeons trained in special fields each dependent upon the other for the correlation of diagnosis and treatment so that in effect the whole body of the group will constitute a single unit, a magnified family doctor, with the mind and activity of many, but the purpose and effect of one.


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Be it further resolved That the words inscribed in our library: INTEGRITAS : CONCORDIA : INDUSTRIA, be adhered to in thought and action as a guide to the realization of our ideas. We desire that our organization shall constitute a self-perpetuating entity, constantly adding new members as its fields of activity increase and as the older members withdraw. It is the purpose of the group to make of ourselves the instruments of efficiency and service to our patients, realizing that as the strength and reputation of the whole develops, it inevitably will carry forward with it the personal welfare of its individual members. Each member must endeavor to bear his full share of burden and responsibility in the interest of the whole. Each must give his wholehearted aid to the other with no thought of exploitation. Each must be willing to accept constructive criticism when it expresses the general opinion. Each must develop for himself his own particular niche whether it be in the field of organization and direction, the practice of the healing art, in the field of research. We believe we have already satisfactorily demonstrated that group practice by the close association of its members stimulates the ambition to excel and encourages generally the keeping abreast of the times by reading, writing and taking active part in meetings and discussions. Let us liken our ideals to a brightly burning lamp which each will tend diligently, taking care not to dim its luster by selfishness, inefficiency, envy and the desire for self-aggrandizement so that it may ever shine brighter in lighting the way to the realization of our vision: a more complete and successful Santa Barbara Clinic justifying its existence by its usefulness in the cause of the modern practice of medicine.41 A few years into the Depression, Drs. Koefod, Bakewell, and Brown drew up this Declaration of Principles, which underscored their original intent and articulated their legacy.

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A number of physicians from the U.S. Army’s Hoff Hospital off Las Positas Road worked with Santa Barbara Clinic staff to ease patient load during the war. (Santa Barbara Historical Museum) Many military doctors from Hoff Hospital came to the Clinic to help out physicians with the patient load, and enjoyed the opportunity to work in a civilian environment. Additionally some of the Marines from Goleta would come to the Clinic for treatment. Marine pilots came to Dr. Arthur Olsen for ear infections or colds, because at Hoff Hospital their condition could have been reported to their flight surgeon which would ground them from flying.42 At this time, the Clinic usually had a custodian or security personnel stay overnight to handle emergency calls. The Clinic hired college students to sleep overnight in the basement rooms and operate the switchboard to answer phone calls for doc-

tors during the night and contact the physicians and nurses as needed. The upshot was that although many local residents had left town to serve, large numbers of military personnel had arrived and needed medical services. Long hours and shared duties were the order of the day in order to meet the needs of the community. The doctors and nurses of the Santa Barbara Clinic rose to the challenge and buckled down to take care of the patients, working into the evening. Although Dr. Bakewell had been preparing for a peaceful retirement, when the war broke out and the Clinic was in need, he put his plans on hold and went back to work.


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1950s—Specialization and Group Practice Just as in the First World War, substantial new medical knowledge was gained and new technology developed because of World War II. One of the major developments coming out of the war was the expanded use of antibiotics, primarily penicillin and sulfa drugs. The science of blood transfusion was perfected. Orthopedic surgery, nerve injury classification, drugs for malaria and tetanus, and rehabilitation techniques were all developed. After the war, all of these advances led directly to a rapidly increasing specialization in medicine, which was now becoming the norm for physicians rather than the exception. In 1954, it was found that seventy-four percent of the medical school graduating classes of 1945 were full-time specialists.43 Twenty-five years

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99 earlier, that figure had been less than twenty percent. As more doctors became full-time specialists, this in turn this led to a renewed interest in group practices, in which doctors could pool their knowledge and their resources to acquire expensive advanced equipment, all in an effort to provide better healthcare for their patients. 1960s—Community Growth The increase in specialization integrated neatly with the trends in society in which the population was becoming urbanized and was growing due to the baby boom. In Santa Barbara there was an expansion of population due to the relocation of UCSB to a new larger campus in Goleta and the development of the “think tanks,” research firms such as

Architect Carleton Winslow designed the additions for an enlarged Santa Barbara Clinic in 1930. (Sansum Clinic Collection)


!100 Raytheon, Delco, Applied Magnetics, and General Research which attracted new residents from all over the country. The population of the city of Santa Barbara increased fifty-five percent between 1950 and 1970. The Santa Barbara Clinic added more physicians to serve the community and this meant a new generation of doctors with new specialties, among them gastroenterology, nephrology, hematology, and lymphology. Many programs were started by the Clinic in response to the needs of the community. Some of the highlights of this era:44 A group of Family Practice physicians was invited to join the Clinic, and with them the Clinic added a branch location in Goleta. A Montecito office was opened with Drs. Walter Lewis and Melville Haskell. Clinic offices were opened in Carpinteria, Lompoc, and Santa Maria. The Business Medicine Department consulted for employers such as Delco and outof-town companies such as the Johns Manville diatomaceous earth mining operations in Lompoc as well as the toxic waste disposal facility at Casmalia. As commercial and industrial diving in Santa Barbara was putting the city at the forefront of that field nationally, Dr. Hugh Greer began developing a department to address Diving Medicine. Also added was a Doctors’ Weight Management Program.

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The New Pesetas Lane Clinic Approaching the 1970s, the population of Santa Barbara was nearly 70,000 and unincorporated lands from Goleta to Gaviota had an additional 70,000 residents. The Santa Barbara Clinic at 1421 State was stretched to capacity. Closets and the coffee room were now reconfigured to accommodate office staff and treatment rooms. Some of the staff were compelled to use a barn-like structure at the back of the lot. A new building was clearly just what the doctor ordered. A building committee located nearly four acres of land at the juncture of Highway 101, Calle Real and Highway 154 at

The arrival of research firms such as Raytheon, shown here, helped fuel the tremendous population growth on the South Coast in the 1950s and 1960s. The Santa Barbara Clinic met the demand of this burgeoning population growth with an increase in the number of physicians and specialties. (Santa Barbara Historical Museum)


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the foot of San Marcos Pass, available for $45,000 per acre. There was plenty of room for a new facility and enough land for parking for patients, doctors, and staff. Dr. Wilton Doane, chair of the executive committee and Dr. William Gebhart, chairman of the building committee, selected the site for the new main Clinic building at 215 Pesetas Lane. Construction of the new building began in May of 1966. The architectural firm of Ellerbe and Company was considered among the best in the country for the design of medical clinics. Its clients included the Mayo Clinic in Minnesota, the Ochsner Clinic in New Orleans, and the Lahey Clinic in Boston. The sparkling new contemporary building for the Santa Barbara Medical Clinic was finished in just over a year and opened on July 17, 1967. At a cost of $1,450,000 to build, the new Clinic was 52,000 square feet, twoand-a-half times the size of the old clinic, with plenty of room for future expansion. In the spirit of Santa Barbara’s inbred need for controversy over any new construction, however, the new clinic did not escape uncomplimentary public comment. The first concern was that it was “all the way out” at the end of town in a “remote” area that patients might not be able to easily find, although it was barely one-half mile from the new La Cumbre Plaza. Secondly, the new building did not suit the artistic sensibilities of some locals who felt the massive modern-style building simply did not fit in with Santa Barbara’s Spanish charm and traditional red tile roofs. Furthermore, the façade of the building was embellished by the Santa Barbara Clinic’s new logo, sculpted from stainless steel by local artist Julio Agostini. (His welded sculptures also graced the Delco

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101 building in Goleta and the local Unitarian church.) This work featured Aesculapius, ancient Greek god of medicine and healing, with the physician staff and entwining serpent (the symbol of the medical profession) and it was placed above the building’s entrance. There was no small amount of commentary over this display of public art, which had been generously commissioned by a number of physicians’ wives. One of the building committee members, Dr. Gebhart, had a patient who asked, “What happened? Did a Volkswagen hit the building?”45 Also old-timers and long-time staff missed the familiarity and classic design of the old building. It had seemed like one big family before, albeit in tight quarters. Now the crisp contemporary clinic seemed cold and impersonal, however spacious and efficient. Eventually, however, everyone recovered. 1970s—The Clinic becomes a Foundation For a half-century, through Depression, wars, and changes in technology, the Santa Barbara Clinic was able to preserve its original goals: to remain a continuously operating community and regional resource, with excellence in medical treatment and healthcare. By the early 1970s, the Clinic had grown into a large organization and it became clear that former methods of operation and decisions involving everything from healthcare delivery to retirement arrangements needed revision. In addition, the cost of the new Clinic facilities had initially fallen on a professional staff of approximately twentyeight physicians. Management consid-


!102 ered the idea of enlarging the medical staff as one way to help defray the expenses. Along with the financial considerations, however, there was a deliberate and methodical plan to continue to create a true multi-specialty clinic and provide competence in more specialties—from pediatrics to geriatrics. The group of physicians who comprised the Clinic began to reconsider its organizational structure and to recognize the benefits of forming a professional corporation. A series of seminars was held regarding private and public corporations, as well as the concept of a nonprofit foun-

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dation. After many discussions involving administration and legal counsel, the plan was brought forth to transform the Clinic into a nonprofit foundation. This ensured that local citizens and physicians would oversee the translation of healthcare dollars paid by patients and employers into the most effective care. The nonprofit structure also allowed members of the community and other patrons to give financial support to the Clinic. In April of 1973, a board of trustees was selected, and the physicians divested themselves of all ownership of the Clinic, its buildings and grounds. The new Santa Barbara Medical Foundation Clinic (SBMFC) was introduced to the community. The SBMFC was comprised of a foundation under the supervision of the Board of Trustees, and governed by the Board of Governors. Clinic surgeon, Dr. Wilton Doane, then president of the American Group Practice Association, was elected to

Drs. William Gebhart, Wilton Doane, and Vernon Freidell with an early dialysis machine. Gebhart and Freidell co-founded the Santa Barbara Community Dialysis Center; Doane was the founding president when the Santa Barbara Clinic became the Santa Barbara Medical Foundation Clinic in 1973. (Sansum Clinic Collection)


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be the founding president. To provide healthcare, the foundation contracted with the physician group, the Santa Barbara Medical Clinic, Inc., which was governed by its own Board of Directors. This model was ideal for expansion and adaptation to the newly evolving trends in healthcare. It became easier to hire new physicians because there was no financial requirement to “buy in” to the medical group. Income distribution was placed into the hands of a compensation committee. 1970s—Specialization and Accomplishments A number of new specialists were hired during the 1970s, completing departments of internal medicine, surgery, pediatrics, obstetrics/ gynecology, dermatology, neurology, psychiatry, orthopedics, urology, renal diseases, infectious disease, rheumatology, h e m a t o l o g y / o n c o l o g y, gastroenterology, cardiology, radiology, ophthalmology, pulmonary medicine, and family practice. Additional accomplishments which benefitted the community included:46 • The Santa Barbara Community Dialysis Center established by Drs. Gebhart and Freidell. • A renal transplanta-

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103 tion program which performed the first kidney transplant in the area was briefly in operation headed by Dr. Ronald Latimer. • The Clinic brought cardiac surgery to Santa Barbara with the hiring of Drs. Jack Love and Edward Jahnke. • The Business Medicine Department was established and was one of the first in California to use computerized screening of patients. One of the new specialties at the Santa Barbara Clinic was Diving Medicine, developed by Dr. Hugh Greer. (Steve Barsky photograph)


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• Clinic doctors brought new specialization to the area. Internist Dr. Erno Daniel had pursued an interest in the developing medical specialty of geriatric medicine and was among the first physicians in the United States to be certified in the specialty in 1988. He performed clinical studies involving the pre-release testing of tacrine (Cognex), one of the first drugs used to treat mild dementia in Alzheimer patients. •Dr. William Robertson along with Sansum colleagues established a colon and rectal surgery fellowship at Cottage Hospital. Dr. James McKittrick was one of the first vascular surgeons in the region and set up a vascular surgery lab. • Internist Dr. Paul Linaweaver came in with a specialization in undersea medicine and was named Director, West Coast Center for the National Diving Accident Network. Dr. Linaweaver and Dr.

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Hugh Greer operated a hyperbaric decompression chamber at the Santa Barbara Airport through their Diving Medicine Department and sponsored a symposium on diving medicine and nitrogen narcosis . In the late 1970s, Dr. Arthur Greditzer became medical director and then chief executive officer, a position he held for nearly twenty years. Under Dr. Greditzer’s guidance and with his administrators (among them James Cobb, Robert Erra and Lars Bruun-Andersen) the Clinic expanded into Carpinteria, Lompoc, and Santa Maria. Efforts were made to serve working families by offering extended and weekend hours. To serve Spanishspeaking patients and increasing numbers of women, additional physicians joined the staff.

ABOVE: The new Santa Barbara Clinic on Pesetas Lane opened in the summer of 1967. (Sansum Clinic Collection)


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105 of the 1980s. More room was needed. Increasing the size of the building at Pesetas was considered, but could not be done due to planning and zoning considerations, which included a Goleta water moratorium, potential traffic impacts, and the building permitting process. Instead, a multi-campus model was adopted and separate locations for department specialities and neighborhood offices developed. Clinic offices were opened in Carpinteria, Lompoc and Santa Maria, driven partly by the mandate to offer certain insurance plans countywide. The Gynecology Department was moved near Cottage Hospital, Pediatrics and Urgent Care opened on Hitchcock Way, and the Ophthalmology Department relocated to Anapamu Street.

Local artist Julio Agostini designed a new logo for the Santa Barbara Clinic’s new building. (Sansum Clinic Collection)

1980s—Multi-Campus Service and Specialization As a not-for-profit institution, the Clinic continued to solicit donations with the help of a series of fundraisers and development activities. In 1983, a grateful patient of Dr. Melville Haskell’s, Edward Rykenboer, made a $1.6 million-dollar bequest to the Clinic. This money was used to construct the Rykenboer Pavilion, an addition to the main Clinic building on Pesetas Lane. Also, the Carpinteria branch clinic was in large part funded with donations from physicians and the public. The number of physicians increased to forty-five by the late 1970s, then doubled again to more than ninety by the end

Part Three: Medicine, Mergers, and the Rest of the Story Financing Healthcare In the first half of the twentieth century, the business of medicine was conducted a little differently. Medical insurance did not exist, and fees for service was the route for reimbursement. There were no federal or state programs for the poor. Physicians recognized that a portion of their patients were not able to pay, would treat them anyway, and personally absorb the cost. Two issues came to the fore during the 1980s which had an enormous impact on the pricing and affordability of healthcare. The first was Medicare which was


!106 introduced in 1965 as a federal health insurance program designed to cover healthcare costs for people over sixty-five years of age. Soon health programs were overwhelmed with new patients. This ultimately brought about a shift in how medical care was reimbursed and led to managed care programs. The second issue involved lawsuits and liability insurance. Medical malpractice cases were causing an unexpected and exponential increase in insurance premiums. In 1975–76 alone, Santa Barbara Medical Foundation Clinic saw its professional liability insurance jump from $72,000 to $652,000 and this was without the impact of any lawsuits.47 Naturally this crisis and the accompanying risk management decisions dramatically affected healthcare costs. By the 1980s, the Santa Barbara Medical Foundation Clinic was providing care for those covered by Medicare, and those who were under the newly developed prepaid healthcare insurance programs. These HMOs were offered by local employers, including UCSB, Santa Barbara County, and corporations such as Santa Barbara Research and Delco. The first prepaid plan offered exclusively by the Clinic, in collaboration with Blue Cross, was the Ultracare plan for seniors, which in turn led to the development of geriatric services at the Clinic.48 The advent of pre-paid care offered by the Clinic temporarily produced a flurry of criticism from other local physicians, but this gradually waned when it became apparent that this was an inevitable change in the financing of medical care, and that large numbers of local residents were covered by such plans.

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Sansum Clinic did not accept HMO plans, but maintained a traditional approach with the direct physician-patient relationship paramount. Sansum did, however, make a commitment to the health of those who could not otherwise afford medical services. Sansum collaborated with Santa Barbara Neighborhood Clinics (SBNC), to provide more than $250,000 annually in diagnostic services, such as CT scans and heart studies. The SBNC would determine patients in need and refer them to Sansum Clinic. This collaboration put in place the Breast Cancer Prevention Program to provide lowincome women access to free mammograms at Sansum, as well as additional future programs. 1990s—Merging Two Clinics Into the 1990s, the two clinics grappled with the question of how to deliver exceptional healthcare which was affordable and accessible, while dealing with the evolving business of managed modern healthcare with its “third party payers” (i.e. insurance). Eventually the conversation turned to the possibility of combining the two clinics to serve the community better through economies of scale and administrative efficiencies. The idea of merging the Santa Barbara Medical Foundation Clinic with Sansum Medical Clinic had certainly been contemplated over the years. As early as the 1970s, there were informal conversations between Drs. Wilton Doane of SBMFC and James McNamara of Sansum, and discussion continued during the 1980s with SBMFC administrator Robert Erra, who was convinced of the merits of a merger. A merger was revived


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as a serious consideration in the mid1990s under the leadership of Drs. Chris Donner and Robert Wright as opportunities for collaboration between the two groups increased.49 Sansum Medical Clinic had forty-five doctors and the Santa Barbara Clinic had eighty-two doctors on board. Although the two clinics had different histories and philosophies, the concept of joining the strengths of each at the close of the century seemed timely and complementary. On October 1, 1998, after three years of thoughtful deliberation and careful negotiations, the Santa Barbara Medical Foundation Clinic and the Sansum Medical Clinic merged into a single outpatient healthcare institution, the Sansum-Santa Barbara Medical Foundation Clinic. The medical group remained a private, multispecialty entity with offices and facilities countywide, operating as a non-profit medical foundation. The newly merged clinic accepted private pay, traditional insurance, Medicare, managed care, HMO, PPO and other plans and remained an outpatient medical treatment provider, with no plans of becoming a hospital, an HMO, or a teaching institution. Before too long it was determined—to no one’s disagreement—that the name Sansum-Santa Barbara Medical Foundation Clinic was too cumbersome. In 2006, the de-

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107 cision was made to simplify the name, yet provide name recognition with colleagues and patients. In keeping with the names of similar institutions around the country, such as the Mayo Clinic, Cleveland Clinic and Lahey Clinic, the newly combined community medical institution became known simply as Sansum Clinic. Edward Rykenboer, a grateful patient, gave $1.6 million to the Santa Barbara Medical Foundation Clinic in 1983. (Sansum Clinic Collection)


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The result of the Rykenboer bequest was the construction of the Rykenboer Pavilion next to the Clinic building on Pesetas Lane. (Sansum Clinic Collection) Sansum Innovation Continues Many noteworthy activities continued at Sansum Clinic after the merger.50 DIGMAs Sansum Clinic became the first organization in Santa Barbara to introduce DIGMAs to its patients. Doctor’s Interactive Group Medical Appointments (DIGMAs), sometimes called Drop-In Group Medical Appointments, are shared medical visits which integrate behavioral health and primary care. For example, Sansum Clinic’s asthma DIGMA patients could interact with an allergist, a behaviorist, and an asthma educator in a group setting. Integrating healthcare services in this way provided efficient use of resources, by treating multiple complaints simultaneously. Breast Care Innovations In 2000, Sansum Clinic was the first facility in the county to offer digital mammography, performing up to eighty mammogram procedures per day. Images could be transmitted to other health pro-

viders electronically, making it possible to view the results simultaneously by more than one physician. Surveys showed that fewer patients were recalled for additional imaging after digital mammography than after conventional mammography. In addition to decreasing the anxiety associated with a recall procedure, fewer recall exams also meant less radiation exposure. By 2000, the Sansum Clinic was treating more than half of the patients diagnosed with breast cancer each year in Santa Barbara, using state-of-the-art diagnostic technology including digital Breast Biopsy, MRI, and ultrasonography. Sansum Clinic's Breast Care Alliance was created to provide a multidisciplinary approach to caring for women with breast cancer. In 2010, the Breast Care Alliance received the prestigious honor of full accreditation by the National Accreditation Program for Breast Centers administered by the American College of Surgeons.


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The position of a Breast Care Navigator was instituted to work with the Breast Care Alliance to design a comprehensive individual care plan for each patient based on personal needs and medical history. The Navigator was designated to help manage and coordinate office visits, diagnostic tests, and communication between treatment physicians and the primary care physician. Colonoscopy Screening The colonoscopy screening program for those who could not afford it was established by the Sansum Clinic and made financially possible by philanthropist Dr. Virgil Elings. The program, offered through the Neighborhood Clinic, is one of the largest free colon cancer screening programs in the nation. Sansum Clinic and Diabetes Care Following Dr. Sansum’s legacy of diabetes treatment, Sansum Clinic continues as the largest diabetes treatment center between Los Angeles and the San Francisco Bay Area and the most comprehensive treatment center for people with other complex endocrine problems. In 2009 alone, the specialists in the Clinic’s Endocrinology Department treated more than two thousand of the most complicated diabetes patients (totaling 7,630 visits), and five Certified Diabetes Educators offered support programs to more than eight hundred people. Echocardiography Laboratory In April 2011, Sansum Clinic announced the accreditation of its Echocardiography Laboratory, making it the first accredited imaging laboratory of its type in Santa Barbara County.

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109 Doctors’ Weight Management Program 2011 marked Sansum Clinic’s twentyfifth anniversary of the Doctors’ Weight Management program, helping many patients with high blood pressure or diabetes to reduce or eliminate medications, and dramatically reduce their risk of heart disease and other weight-related conditions. Comprehensive Electronic Health Record System In 2011, Sansum Clinic transitioned from paper charts to electronic health records, which was a significant change in the way patients’ healthcare information was managed. The electronic health record system, designed by Epic, was an enormous commitment which required technical changes across all of Sansum’s facilities. Exam rooms were outfitted with computer terminals and physicians could enter medical chart information directly into the system. Patients in turn could access important parts of their chart information from their home computers. The system will create a single and continuously updated electronic chart for each patient, which means records will be complete and accessible by healthcare providers from anywhere at any time. The new technology put Sansum in a class with the best clinics in the nation. Visiting Professorship of Surgery Sansum continued to retain its founding interest in research and investigation. As part of the Clinic’s ninetieth anniversary, Sansum endowed a Visiting Professorship of Surgery through the initiative of surgeon Dr. Ronald Latimer, Emeritus. The program’s purpose was to bring a world-class visiting surgery professor to


!110 Santa Barbara annually so community surgeons could learn from the latest surgical developments. Dr. John Cameron, surgeon and professor of surgery at Johns Hopkins University School of Medicine, came from Baltimore to Santa Barbara as Sansum Clinic’s first Visiting Professor of Surgery to lead Surgical Academic Week. Dr. Cameron had operated on more patients with pancreatic cancer and performed more Whipple operations than any surgeon in the world. This life-saving surgical procedure for pancreatic cancer was improved upon by Dr. Cameron to reduce the death rate during surgery from twenty-five percent to about one percent.51 In 2011 Sansum began the process to create a new Ambulatory Surgery Center located at Foothill and Cieneguitas roads. In 2012, the Cancer Center of Santa Barbara formed a partnership with Sansum Clinic. The alliance merged clinical operations such as radiology, hematology, and nuclear medicine, provided more resources for the Cancer Center in terms of research and clinical trials, and assisted Sansum patients with more centralized care. A Legacy of Medical Innovation Sansum Clinic’s goal continues to be to sustain and build upon the goals of the two original clinics since their founding: to offer to patients a comprehensive, continuously operated community and regional resource, with excellence in medical treatment and healthcare. Sansum Clinic has long been a grateful beneficiary of support from its community as well as patients and friends across the country. From George Owen Knapp, the

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benefactor who made significant contributions to the founding of both clinics and other local medical institutions, to Edward A. Rykenboer, the grateful patient whose bequest provided the pavilion wing of the Pesetas Lane facility, generous donors have supported and sponsored the Clinic with construction funding, equipment, patient education services, free healthcare services, and refurbishing of facilities. Today, Sansum Clinic is the largest private independent non-profit outpatient healthcare organization between Los Angeles and the San Francisco Bay Area, with 180 physicians and more than 30 specialties. It serves more than 150,000 patients, with 600,000 patient visits yearly at 21 patient care facilities from Carpinteria to Santa Maria, and is administered by a Board of Trustees for the benefit of the community. It is among the top dozen employers in Santa Barbara County. Dr. Rexwald Brown, one of the founders of the Santa Barbara Clinic, stated in 1926, “The highest ideal of medicine is the promotion of individual, community, and national health.” Through his vision to create an organization to provide outstanding healthcare for all in his community and the vision of Dr. William Sansum to investigate and treat mankind’s most troubling medical ailments, the community and region now benefit by having at their disposal the largest and most comprehensive outpatient medical center between Los Angeles and the San Francisco Bay Area. Sansum Clinic has met the community's healthcare needs for over ninety years, and expects to do so for another century.


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“Collaboration between the people and the medical profession is essential to the real accomplishment of scientific medicine’s greatest aim: health promotion.” Rexwald Brown, M.D, 192152 1921 Santa Barbara Clinic Founding Physicians Founders Rexwald Brown, M.D. ! Benjamin Bakewell, M.D.! Hilmar Koefod, M.D. ! Associates Harry Henderson, M.D.! Hugh Friedell, M.D. ! Henry Profant, M.D. ! George Farman, M.D. !

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Surgery Gynecology/Obstetrics Internal Medicine

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Pulmonary Gastrointestinal Ear, Nose, and Throat Urology

1928 Sansum Medical Clinic Founding Physicians Founder William David Sansum, M.D. ! Associates Robert A. Hare, M.D. ! ! Percival Allen Gray, M.D. ! ! Delbert McNamara, M.D.! ! Doris E. McNamara, M.D. ! ! Hildahl I. Burtness, M.D. ! ! Leonard J. Brunie, M.D. ! ! Yolanda S. Brunie, M.D. ! ! Barkley S. Wyckoff DM.D. ! ! John Childrey, M.D. ! ! Alfred Koehler, M.D. , Ph.D. ! Fritz Bischoff Ph.D. !! !

Endocrinologist Internal Medicine Internal Medicine Internal Medicine – Electrocardiography Internal Medicine, Women’s Internal Medicine Internal Medicine – Geriatrics Internal Medicine Oral surgery Ear, Nose, and Throat Internal Medicine, Biochemistry Biochemist

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Notes Walker A. Tompkins, The Yankee Barbarenos (Ventura: Movini Press, 2004), 273. 2 Charles Nordhoff, California for Health, Pleasure, and Residence; A Book for Travelers and Settlers (New York: Harper and Brothers, 1872), 114. 3 Rosemary Stevens, The Milbank Memorial Fund Quarterly. Health and Society, ! 60 (Autumn 1982), 551-584. 4 William T. Barry, M.D. “Development of the County Medical Society: President’s Address,” California State Journal of Medicine, Vol. VI, No. 5, (1908), 176. 5 John A. Wyeth, “The Technic of Appendectomy,” JAMA - Journal of the American Medical Association 49 (13 July 1907). 6 Tompkins, Yankee Barbarenos, 294. 7 Walker A. Tompkins, Continuing Quest: Dr. William David Sansum’s Crusade Against Diabetes (Santa Barbara: Sansum Medical Research Foundation, 1977), 13 . 8 Los Angeles Times, 23 June 1912. 9 Walker A. Tompkins, Santa Barbara History Makers (Santa Barbara: McNally & Loftin, 1983), 131-134. 10 Dr. W. A. Evans, “How to Keep Well,” Chicago Tribune, 21 December 1919. 11 Tompkins, Continuing Quest, 71-73. 12 Ibid. 84, 85. 13 Ibid. 91. 14 Ibid. 100. 15 Ibid. 219. 16 Ibid. 105. 17 Battle Creek was the first to use the word sanatarium and its orientation was as a health spa for rest and recovery. Prior to this a “sanatorium” refer1

enced a hospital-like setting, particularly for veterans. 18 “Harold Lloyd Treated by Sansum,” Oakland Tribune, 18 March 1931. 19 Tompkins, Continuing Quest, 175. 20 Medical Society of Santa Barbara County records researched by Erno Daniel, M.D. and quoted, but not cited in his 2011 manuscript on clinic history. 21 Tompkins, Continuing Quest, 136. 22 Ibid. 167. 23 Dwight M. Palmer, M.D., “Recent Advances in Neurology and Psychiatry,” The Ohio Journal of Science 46 (July 1946), 183-185. 24 Erno Daniel, M.D., Ph.D., 90-Year Legacy of Health Care: The Origins and History of Sansum Clinic 1921-2011, 2011, manuscript in Sansum records. 25 Ibid. 26 Los Angeles Times, 14 March 1976, H7. 27 Sansum Medical Research Foundation 40th Anniversary Annual Report, 1983. 28 Daniel, 90-Year Legacy. 29 Erno Daniel, M.D., Ph.D., and Mary Daniel, Perspectives on Healthcare. The Philosophic Foundations of the Santa Barbara Clinic. Writings of Rexwald Brown, M.D. (Manuscript), Santa Barbara Clinic Press, 1998. 30 Yale B. Griffith, “Dr. Hilmar Koefod,” Noticias 27 (Winter 1981), 61-62. 31 Carol Warden, A Tradition of Medical Progress (Santa Barbara: Santa Barbara Medical Foundation Clinic, 1985), 13. 32 Ibid. 10. 33 Ibid. 8. 34 Griffith, “Koefod,” 62. 35 Ibid.


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Notes Rexwald Brown, M.D. “The Menace to Medicine,” California and Western Medicine, 30 (February 1929), 1. 37Griffith, “Koefod,” 63. 38 Ibid. 39 Warden, Tradition, 30. She cites her quotation from Hilmar O. Koefod, M.D. “Clinic Profile: Santa Barbara Medical Clinic, Santa Barbara, California,” 1959. SBMFC Records. 40 Tradition, 31. 41 Daniel, 90-Year Legacy. 42 Warden, Tradition, 46 . 43 Rosemary Stevens, American Medicine and the Public Interest (New Haven: Yale University Press, 1971), 234. 44 Daniel, 90-Year Legacy. As Clinic historian, Dr. Daniel has been compiling the changes and achievements of the 36

Santa Barbara Medical Foundation Clinic since the 1960s. 45 Marilyn McMahon, “Thriving at 90: Sansum Clinic Celebrates Milestone Anniversary,” Santa Barbara NewsPress, 23 January 2011. 46 Daniel, 90-Year Legacy. 47 Warden, Tradition, 96. 48 Daniel, 90-Year Legacy. 49 Ibid. 50 Ibid. 51 Baltimore Sun, “Whipple Surgery,” 30 March 2012. 52 Daniel and Daniel, Perspectives.


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Santa Barbara Historical Museum 2013-2014 Board of Trustees

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William S. Burtness!

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President

Robin Schutte!

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Vice President

Warren P. Miller ! !

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Treasurer

Randall Fox ! !

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Secretary

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George L. Burtness Lawrence T. Hammett David R. Martin Eleanor Van Cott P.A. (Andy) Weber, III John C. Woodward


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The Santa Barbara Historical Museum Wishes to Acknowledge the Generous Financial Support of the Following Towards the Publication of this Issue of Noticias:

SANSUM CLINIC William S. Burtness Liselotte Kuttler Trust Robin Schutte


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Noticias - Sansum Clinic, A Legacy of Medical Innovation