MEDICAL EDUCATION
IN THE UNITED STATES AND CANADA//
A REPORT TO
(THE CARNEGIE FOUNDATION FOR THE ADVANCEMENT OF TEACHING. 8cA-W- "*
ABRAHAM FLEXNER
WITH AN INTRODUCTION BY
HENRY S. PRITCHETT
PRESIDENT OF THE FOUNDATION
BULLETIN NUMBER FOUR
576 FIFTH AVENUE NEW YORK CITY
COPYRIGHT 1910
BY
THE CARNEGIE FOUNDATION FOR THE ADVANCEMENT OF TEACHING
D. B. UPDIKE, THE MERRYMOUNT PRESS, BOSTON
Library
TABLE OF CONTENTS
PAGE
Introduction . vii
PART I
CHAPTER
I. Historical and General 8
II. The Proper Basis of Medical Education .20
III. The Actual Basis of Medical Education 28
IV. The Course of Study : The Laboratory Branches. (A) First and Second
Years 52
V. The Course of Study: The Laboratory Branches. (B) First and Second
Years (continued) ......... 71
VI. The Course of Study : The Hospital and the Medical School. (A) Third
and Fourth Years 91
VH. The Course of Study : The Hospital and the Medical School. (B) Third
and Fourth Years (continued) . . . . . . 105
VIII. The Financial Aspects of Medical Education 126
IX. Reconstruction . . . 143
X. Medical Sects . . 156
XL The State Boards •. . 167
XII. The Postgraduate School . . 174
XIII. The Medical Education of Women 178
XIV. The Medical Education of the Negro ' 180
PART II The Medical Schools of
Alabama 185
Arkansas ............ 187
California 188
Colorado 197
Connecticut 199
District of Columbia 201
iv CONTENTS
Georgia 203
Illinois 207
Indiana 220
Iowa ............. 222
Kansas . . . . . .. . . . . . 225
Kentucky 229
Louisiana 231
Maine 233
Maryland . 234
Massachusetts 239
Michigan 243
Minnesota 247
Mississippi 249
Missouri ............ 251
Nebraska 259
New England 261
New Hampshire 263
New York 265
North Carolina 279
North Dakota 282
Ohio 283
Oklahoma 289
Oregon 291
Pennsylvania 293
South Carolina 300
South Dakota 301
Tennessee 302
Texas 309
Utah 313
Vermont 313
Virginia 314
CONTENTS v
West Virginia 317
Wisconsin 317
Canada 320
APPENDIX
Table showing number in Faculty, Enrolment, Fee Income, Budget of Schools
by States 327
INDEX 337
INTRODUCTION
THE present report on medical education forms the first of a series of papers on pro- fessional schools to be issued by the Carnegie Foundation. The preparation of these papers has grown naturally out of the situation with which the trustees of the Founda- tion were confronted when they took up the trust committed to them.
When the work of the Foundation began five years ago the trustees found them- selves intrusted with an endowment to be expended for the benefit of teachers in the colleges and universities of the United States, Canada, and Newfoundland. It required but the briefest examination to show that amongst the thousand institu- tions in English-speaking North America which bore the name college or university there was little unity of purpose or of standards. A large majority of all the insti- tutions in the United States bearing the name college were really concerned with secondary education.
Under these conditions the trustees felt themselves compelled to begin a critical study of the work of the college and of the university in different parts of this wide area, and to commend to colleges and universities the adoption of such standards as would intelligently relate the college to the secondary school and to the university. While the Foundation has carefully refrained from attempting to become a stan- dardizing agency, its influence has been thrown in the direction of a differentiation between the secondary school and the college, and between the college and the uni- versity. It is indeed only one of a number of agencies, including the stronger colleges and universities, seeking to bring about in American education some fair conception of unity and the attainment ultimately of a system of schools intelligently related to each other and to the ambitions and needs of a democracy.
At the beginning, the Foundation naturally turned its study to the college, as that part of our educational system most directly to be benefited by its endowment. Inevitably, however, the scrutiny of the college led to the consideration of the re- lations between the college or university and the professional schools which had gathered about it or were included in it. The confusion found here was quite as great as that which exists between the field of the college and that of the secondary school. Col- 1 leges and universities were discovered to have all sorts of relations to their professional \ schools of law, of medicine, and of theology. In some cases these relations were of the frailest texture, constituting practically only a license from the college by which a proprietary p^ipal gffrnnl 9^ lavy school was enabled to live under its name. In other cases the medical school was incorporated into the college or university, but remained an imperium in imperio, the college assuming no responsibility for its standards or its support. In yet other cases the college or university assumed partial obligation of support, but no responsibility for the standards of the professional school, while in only a relatively small number of cases was the school of law or of medicine an in- tegral part of the university, receiving from it university standards and adequate
viii INTRODUCTION
maintenance. For the past two decades there has been a marked tendency to set up some connection between universities and detached medical schools, but under the very loose construction just referred to.
Meanwhile the requirements of medical education have enormously increased. The fundamental sciences upon which medicine depends have been greatly extended. The laboratory has come to furnish alike to the physician and to the surgeon a new means for diagnosing and combating disease. The education of the medical practi- tioner under these changed conditions makes entirely different demands in respect to both preliminary and professional training.
Under these conditions and in the face of the advancing standards of the best medical schools it was clear that the time had come when the relation of professional education in medicine to the general system of education should be clearly defined. The first step towards such a clear understanding was to ascertain the facts concern- ing medical education and the medical schools themselves at the present time. In ac- cordance, therefore, with the recommendation of the president and the executive com- mittee, the trustees of the Carnegie Foundation at their meeting in November, 1908, authorized a study and report upon the schools of medicine and law in the United States and appropriated the money necessary for this undertaking. The present report upon medical education, prepared, under the direction of the Foundation, by Mr. Abraham Flexner, is the first result of that action.
No effort has been spared to procure accurate and detailed information as to the facilities, resources, and methods of instruction of the medical schools. They have not only been separately visited, but every statement made in regard to each detail has been carefully checked with the data in possession of the American Medical Asso- ciation, likewise obtained by personal inspection, and with the records of the Asso- ciation of American Medical Colleges, so far as its membership extends. The details as stated go forth with the sanction of at least two, and frequently more, independent observers.
In making this study the schools of all medical sects have been included. It is clear that so long as a man is to practise medicine, the public is equally concerned in his right preparation for that profession, whatever he call himself, — allopath, homeo- path, eclectic, osteopath, or whatnot. It is equally clear that he should be grounded in the fundamental sciences upon which medicine rests, whether he practises under one name or under another.
It will be readily understood that the labor involved in visiting 150 such schools is great, and that in the immense number of details dealt with it is altogether im- possible to be sure that every minute fact concerning these institutions has been ascertained and set down. While the Foundation cannot hope to obtain in so great an undertaking absolute completeness in every particular, such care has been exer- cised, and the work has been so thoroughly reviewed by independent authorities, that the statements which are given here may be confidently accepted as setting
INTRODUCTION ix
forth the essential facts respecting medical education and respecting the institutions which deal with it.
In this connection it is perhaps desirable to add one further word. Educational institutions, particularly those which are connected with a college or a university, are peculiarly sensitive to outside criticism, and particularly to any statement of the circumstances of their own conduct or equipment which seems to them unfavor- able in comparison with that of other institutions. As a rule, the only knowledge which the public has concerning an institution of learning is derived from the state- ments given out by the institution itself, information which, even under the best cir- cumstances, is colored by local hopes, ambitions, and points of view. A considerable number of colleges and universities take the unfortunate position that they are private institutions and that the public is entitled to only such knowledge of their operations as they choose to communicate. In the case of many medical schools the aversion to publicity is quite as marked as it is reputed to be in the case of certain large indus- trial trusts. A few institutions questioned the right of any outside agency to collect and publish the facts concerning their medical schools. The Foundation was called upon to answer the question : Shall such an agency as the Foundation, dedicated to the bet- terment of American education, make public the facts concerning the medical schools of the United States and Canada?
The attitude of the Foundation is that all colleges and universities, whether sup- ported by taxation or by private endowment, are in truth public service corporations, and that the public is entitled to know the facts concerning their administration and development, whether those facts pertain to the financial or to the educational side. We believe, therefore, that in seeking to present an accurate and fair statement of the work and the facilities of the medical schools of this country, we are serving the best possible purpose which such an agency as the Foundation can serve; and, further- more, that only by such publicity can the true interests of education and of the uni versities themselves be subserved. In such a reasonable publicity lies the hope for progress in medical education.
I wish to add with pleasure that notwithstanding reluctance in some quarters to furnish information, the medical schools of the colleges and universities, as well as proprietary and independent medical schools, have generally accepted the view just stated and have seconded the work of the Foundation by offering to those who were engaged in this study every facility to learn their opportunities and resources; and I beg to express the thanks of the trustees of the Foundation to each of these institutions for the cooperation which it has given to a study which, in the very nature of the case, was to bear sharply in the way of criticism upon many of those called on for cooperation.
The report which follows is divided into two parts. In the first half the history of medical education in this country and its present status are set forth. The story is there told of the gradual development of the commercial medical school, distinctly
x INTRODUCTION
an American product, of the mo4ern movement for the transfer of medical education to university surroundings, and of the effort to procure stricter scrutiny of those seek- ing to enter the profession. The present status of medical education is then fully described and a forecast of possible progress in the future is attempted. The second part of the report gives in detail a description of the schools in existence in each state of the Union and in each province of Canada.
It is the purpose of the Foundation to proceed at once with a similar study of medi- cal education in Great Britain, Germany, and France, in order that those charged with the reconstruction of medical education in America may profit by the experi- ence of other countries.
The striking and significant facts which are here brought out are of enormous con- sequence not only to the medical practitioner, but to every citizen of the United States and Canada; for it is a singular fact that the organization of medical educa- tion in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate train- ing whatsoever. As a rule, Americans, when they avail themselves of the services of a physician, make only the slightest inquiry as to what his previous training and preparation have been. One of the problems of the future is to educate the public itself to appreciate the fact that very seldom, under existing conditions, does a patient receive the best aid which it is possible to give him in the present state of medicine, and that this is due mainly to the fact that a vast army of men is admitted to the practice of medicine who are untrained in sciences fundamental to the profession and quite without a sufficient experience with disease. A right education of public opinion is one of the problems of future medical education.
The significant facts revealed by this study are these:
(1) For twenty-five years past there has been an enormous over-production of un- educated and ill trained medical practitioners. This has been in absolute disregard of the public welfare and without any serious thought of the interests of the public. Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany.
(2) Over-production of ill trained men is due in the main to the existence of a very large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occu- pations into the study of medicine.
(3) Until recently the conduct of a medical school was a profitable business, for the methods of instruction were mainly didactic. As the need for laboratories has be- come more keenly felt, the expenses of an efficient medical school have been greatly increased. The inadequacy of many of these schools may be judged from the fact that nearly half of all our medical schools have incomes below $10,000, and these incomes determine the quality of instruction that they can and do offer.
INTRODUCTION xi
Colleges and universities have in large measure failed in the past twenty-five years to appreciate the great advance in medical education and the increased cost of teach- ing it along modern lines. Many universities desirous of apparent educational com- pleteness have annexed medical schools without making themselves responsible either for the standards of the professional schools or for their support.
(4) The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but the facts set forth in this report make it evident that this argument is insincere, and that the excuse which has hitherto been put forward in the name of the poor boy is in reality an ar- gument in behalf of the poor medical school.
(5) A hospital under complete educational control is as necessary to a medical school as is a laboratory of chemistry or pathology. High grade teaching within a hospital introduces a most wholesome and beneficial influence into its routine. Trustees of hos- pitals, public and private, should therefore go to the limit of their authority in open- ing hospital wards to teaching, provided only that the universities secure sufficient funds on their side to employ as teachers men who are devoted to clinical science.
In view of these facts, progress for the future would seem to require a very much smaller number of medical schools, better equipped and better conducted than our schools now as a rule are; and the needs of the public would equally require that we have fewer physicians graduated each year, but that these should be better educated and better trained. With this idea accepted, it necessarily follows that the medical school will, if rightly conducted, articulate not only with the university, but with the general system of education. Just what form that articulation must take will vary in the immediate future in different parts of the country. Throughout the east- ern and central states the movement under which the medical school articulates with the second year of the college has already gained such impetus that it can be regarded as practically accepted. In the southern states for the present it would seem that articulation with the four-year high school would be a reasonable starting-point for the future. In time the development of secondary education in the south and the growth of the colleges will make it possible for southern medical schools to accept the two-year college basis of preparation. With reasonable prophecy the time is not far distant when, with fair respect for the interests of the public and the need for physicians, the articulation of the medical school with the university may be the same throughout the entire country. For in the future the college or the university which accepts a medical school must make itself responsible for university standards in the medical school and for adequate support for medical education. The day has gone by when any university can retain the respect of educated men, or when it can fulfil its duty to education, by retaining a low grade professional school for the sake of its own institutional completeness.
xii INTRODUCTION
If these fundamental principles can be made clear to the people of the United States and of Canada, and to those who govern the colleges and the universities, we may confidently expect that the next ten years will see a very much smaller number of medical schools in this country, but a greatly increased efficiency in medical edu- cation, and that during the same period medical education will become rightly articu- lated with, and rightly related to, the general educational system of the whole country.
In the suggestions which are made in this report looking toward the future de- velopment of medicine, it ought to be pointed out that no visionary or impossible achievement is contemplated. It is not expected that a Johns Hopkins Medical School can be erected immediately in cities where public support of education has hitherto been meager. Nevertheless, it is quite true that there is a certain minimum of equip- ment and a minimum of educational requirement without which no attempt ought to be made to teach medicine. Hitherto not only proprietary medical schools, but colleges and universities, have paid scant attention to this fact. They have been ready to assume the responsibility of turning loose upon a helpless community men licensed to the practice of medicine without any serious thought as to whether they had re- ceived a fair training or not. To-day, under the methods pursued in modern medi- cine, we know with certainty that a medical school cannot be conducted without a certain minimum of expense and without a certain minimum of facilities. The insti- tution which attempts to conduct a school below this plane is clearly injuring, not helping, civilization. In the suggestions which are made in this report as to what constitutes a reasonable minimum no visionary ideal has been pursued, but only such things have been insisted upon as in the present light of our American civilization every community has a right to demand of its medical school, if medicine is to be taught at all.
It seems desirable also in connection with both the medical school and the uni- versity or college to add one word further concerning the relation of financial sup- port to efficiency and sincerity. Where any criticism is attempted of inadequate methods or inadequate facilities, no reply is more common than this: "Our insti- tution cannot be judged from its financial support. It depends upon the enthusiasm and the devotion of its teachers and its supporters, and such devotion cannot be measured by financial standards. "
Such an answer contains so fine a sentiment and so pregnant a truth that it often- times serves to turn aside the most just criticism. It is true that every college must ultimately depend upon the spirit and devotion of those who work in it, but behind this noble statement hides most of the insincerity, sham, and pretense not only of the American medical school, but of the American college. The answer quoted is com- monly made by the so-called university that, with an income insufficient to support a decent college, is trying to cover the whole field of university education. It is the same answer that one receives from the medical school which, with wholly inade- quate facilities, is turning out upon an innocent and long-suffering community men
INTRODUCTION xiii
who must get their medical education after they get out of the institution. In many of these ill manned and poorly equipped institutions there is to be found a large measure of devotion, but the fact remains that such devotion is usually ill placed, and the individual who gives it loses sight of the interests of education and of the general public in his desire to keep alive an institution without reason or right to exist.
It will, however, be urged by weak schools that the fact that an institution is ill manned and poorly equipped is inconclusive; that in the time devoted to the ex- amination of a single school it is impossible to do it justice. Objection of this kind is apt to come from schools of two types, — ineffective institutions in large cities, and schools attached to colleges in small towns in which clinical material is scarce. In my opinion the objection is without force. A trained observer of wide experience can go directly to the heart of a problem of this character. The spirit, ideals, and facilities of a professional or technical school can be quickly grasped. In every in- stance in which further inquiry has been made, the conclusions reached by the au- thor of the report have been sustained.
The development which is here suggested for medical education is conditioned largely upon three factors: first, upon the creation of a public opinion which shall discriminate between the ill trained and the rightly trained physician, and which will also insist upon the enactment of such laws as will require all practitioners of medi- cine, whether they belong to one sect or another, to ground themselves in the funda- mentals upon which medical science rests ; secondly, upon the universities and their attitude towards medical standards and medical support; finally, upon the attitude of the members of the medical profession towards the standards of their own practice and upon their sense of honor with respect to their own profession.
These last two factors are moral rather than educational. They call for an educa- tional patriotism on the part of the institutions of learning and a medical patriotism on the part of the physician.
By educational patriotism I mean this : a university has a mission greater than the formation of a large student body or the attainment of institutional completeness, namely, the duty of loyalty to the standards of common honesty, of intellectual sin- cerity, of scientific accuracy. A university with educational patriotism will not take up the work of medical education unless it can discharge its duty by it; or if, in the days of ignorance once winked at, a university became entangled in a medi- cal school alliance, it will frankly and courageously deal with a situation which is no longer tenable. It will either demand of its medical school university ideals and give it university support, or else it will drop the effort to do what it can only do badly.
By professional patriotism amongst medical men I mean that sort of regard for the honor of the profession and that sense of responsibility for its efficiency which will enable a member of that profession to rise above the consideration of personal
xiv INTRODUCTION
or of professional gain. As Bacon truly wrote, "Every man owes a duty to his pro- fession," and in no profession is this obligation more clear than in that of the mod- ern physician. Perhaps in no other of the great professions does one find greater dis- crepancies between the ideals of those who represent it. No members of the social order are more self-sacrificing than the true physicians and surgeons, and of this fine group none deserve so much of society as those who have taken upon their shoulders the burden of medical education. On the other hand, the profession has been diluted by the presence of a great number of men who have come from weak schools with low ideals both of education and of professional honor. If the medical education of our country is in the immediate future to go upon a plane of efficiency and of credit, those who represent the higher ideals of the medical profession must make a stand for that form of medical education which is calculated to advance the true interests of the whole people and to better the ideals of medicine itself.
There is raised in the discussion of this question a far-reaching economic pro- blem to which society has as yet given little attention ; that is to say, What safeguards may society and the law throw about admission to a profession like that of law or of medicine in order that a sufficient number of men may be induced to enter it and yet the unfit and the undesirable may be excluded?
It is evident that in a society constituted as are our modern states, the interests of the social order will be served best when the number of men entering a given pro- fession reaches and does not exceed a certain ratio. For example, in law and medi- cine one sees best in a small village the situation created by the over-production of inadequately trained men. In a town of two thousand people one will find in most of our states from five to eight physicians where two well trained men could do the work efficiently and make a competent livelihood. When, however, six or eight ill trained physicians undertake to gain a living in a town which can support only two, the whole plane of professional conduct is lowered in the struggle which ensues, each man becomes intent upon his own practice, public health and sanitation are neglected, and the ideals and standards of the profession tend to demoralization.
A similar state of affairs comes from the presence of too large a number of ill trained lawyers in a community. When six or eight men seek to gain their living from the practice of the law in a community in which, at the most, two good lawyers could do all the work, the demoralization to society becomes acute. Not only is the process of the law unduly lengthened, but the temptation is great to create busi- ness. No small proportion of the American lack of respect for the law grows out of the presence of this large number of ill trained men seeking to gain a livelihood from the business which ought in the nature of the case to support only a much smaller number. It seems clear that as nations advance in civilization, they will be driven to throw around the admission to these great professions such safeguards as will limit the number of those who enter them to some reasonable estimate of the number who are actually needed. It goes without saying that no system of stan-
INTRODUCTION xv
dards of admission to a profession can exclude all the unfit or furnish a perfect body of practitioners, but a reasonable enforcement of such standards will at least relieve the body politic of a large part of the difficulty which comes from over- production, and will safeguard the right of society to the service of trained men in the great callings which touch so closely our physical and political life.
The object of the Foundation in undertaking studies of this character is to serve a constructive purpose, not a critical one. Unless the information here brought to- gether leads to constructive work, it will fail of its purpose. The very disappearance of many existing schools is part of the reconstructive process. Indeed, in the course of preparing the report a number of results have already come about which are of the highest interest from the constructive point of view. Several colleges, finding themselves unable to carry on a medical school upon right lines, have, frankly facing the situation, discontinued their medical departments, the result being a real gain to medical education. Elsewhere, competing medical schools which were dividing the stu- dents and the hospital facilities have united into a single school. In still other instances large sums of money have been raised to place medical education on a firmer basis.
In the preparation of this report the Foundation has kept steadily in view the interests of two classes, which in the over-multiplication of medical schools have usually been forgotten, — first, the youths who are to study medicine and to become the future practitioners, and, secondly, the general public, which is to live and die under their ministrations.
No one can become familiar with this situation without acquiring a hearty sym- pathy for the American youth who, too often the prey of commercial advertising methods, is steered into the practice of medicine with almost no opportunity to learn the difference between an efficient medical school and a hopelessly inadequate one. A clerk who is receiving $50 a month in the country store gets an alluring brochure which paints the life of the physician as an easy road to wealth. He has no realization of the difference between medicine as a profession and medicine as a business, nor as a rule has he any adviser at hand to show him that the first requi- site for the modern practitioner of medicine is a good general education. Such a boy falls an easy victim to the commercial medical school, whether operating under the name of a university or college, or alone.
The interests of the general public have been so generally lost sight of in this matter that the public has in large measure forgot that it has any interests to pro- tect. And yet in no other way does education more closely touch the individual than in the quality of medical training which the institutions of the country provide. Not only the personal well-being of each citizen, but national, state, and municipal sanitation rests upon the quality of the training which the medical graduate has re- ceived. The interest of the public is to have well trained practitioners in sufficient number for the needs of society. The source whence these practitioners are to come is of far less consequence.
xvi INTRODUCTION
In view of this fact, the argument advanced for the retention of medical schools in places where good clinical instruction is impossible is directly against the public interest. If the argument were valid, it would mean that the sick man is better off in the hands of an incompetent home-grown practitioner than in those of one well trained in an outside school. Such an argument ought no longer to blind the eyes of intelligent men to the actual situation. Any state of the Union or any province of Canada is better off without a medical school than with one conducted in a com- mercial spirit and below a reasonable plane of efficiency. No state and no section of a state capable of supporting a good practitioner will suffer by following this policy. The state of Washington, which has no medical school within its borders, is doubt- less supplied with as capable and well trained a body of medical practitioners as is Missouri with its eleven medical schools or Illinois with its fourteen.
The point of view which keeps in mind the needs and qualifications of the medi- cal student and the interests of the great public is quite a different one from that which the institution which conducts a medical department ordinarily occupies. The questions which look largest to the institutions are : Can we add a medical school to our other departments? and if so, where can we find the students? The questions which the other point of view suggest are : Is a medical school needed ? Cannot those qualified to study medicine find opportunities in existing schools? If not, are the means and the facilities at hand for teaching medicine on a right basis?
While the aim of the Foundation has throughout been constructive, its attitude towards the difficulties and problems of the situation is distinctly sympathetic. The report indeed turns the light upon conditions which, instead of being fruitful and inspiring, are in many instances commonplace, in other places bad, and in still others, scandalous. It is nevertheless true that no one set of men or no one school of medi- cine is responsible for what still remains in the form of commercial medical educa- tion. Our hope is that this report will make plain once for all that the day of the commercial medical school has passed. It will be observed that, except for a brief his- torical introduction, intended to show how present conditions have come about, no account is given of the past of any institution. The situation is described as it exists to- day in the hope that out of it, quite regardless of the past, a new order may be speedily developed. There is no need now of recriminations over what has been, or of apolo- gies by way of defending a regime practically obsolete. Let us address ourselves re- solutely to the task of reconstructing the American medical school on the lines of the highest modern ideals of efficiency and in accordance with the finest conceptions of public service.
It is hoped that both the purpose of the Foundation and its point of view as thus stated may be remembered in any consideration of the report which follows, and that this publication may serve as a starting-point both for the intelligent citizen and for the medical practitioner in a new national effort to strengthen the medical profession and rightly to relate medical education to the general system of schools of our nation.
INTRODUCTION xvii
The Foundation is under the greatest obligation in the preparation of this report to leading representatives of medicine and surgery in this country for their coopera- tion and advice. The officers of the various medical associations and of the Associa- tion of American Medical Colleges have furnished information which was invaluable and have given aid in the most cordial way. We are particularly indebted for con- stant and generous assistance to Dr. William H. Welch of Johns Hopkins Uni- versity, Dr. Simon Flexner of the Rockefeller Institute, and Dr. Arthur D. Bevan, chairman of the Council on Education of the American Medical Association. In ad- dition, our acknowledgments are due to Dr. N. P. Colwell, secretary of the Council on Education of the American Medical Association, and to Dr. F. C. Zapffe, secretary of the Association of American Medical Colleges, for most helpful cooperation. I wish to acknowledge also our indebtedness to a number of eminent men connected with various schools of medicine who have been kind enough to read the proof of this report and to give us the benefit of their comment and criticism.
HENRY S. PRITCHETT. April 16, 1910.
PART I MEDICAL EDUCATION
IN THE UNITED STATES AND CANADA
CHAPTER I
HISTORICAL AND GENERAL
THE American medical school is now well along in the second century of its history.1 It began, and for many years continued to exist, as a supplement to the apprentice- ship system still in vogue during the seventeenth and eighteenth centuries. The likely youth of that period, destined to a medical career, was at an early age inden- tured to some reputable practitioner; to whom his service was successively menial, pharmaceutical, and professional: he ran his master's errands, washed the bottles, mixed the drugs, spread the plasters, and finally, as the stipulated term drew towards its close, actually took part in the daily practice of his preceptor, — bleeding his patients, pulling their teeth, and obeying a hurried summons in the night. The quality of the training varied within large limits with the capacity and conscientious- ness of the master. Ambitious spirits sought, therefore, a more assured and inspiring discipline. Beginning early in the eighteenth century, having served their time at home, they resorted in rapidly increasing numbers to the hospitals and lecture-halls of Leyden, Paris, London, and Edinburgh. The difficulty of the undertaking proved admirably selective ; for the students who crossed the Atlantic gave a good account of themselves. Returning to their native land, they sought opportunities to share with their less fortunate or less adventurous fellows the rich experience gained as they "walked the hospitals" of the old world in the footsteps of Cullen, Munro, and the Hunters. The voices of the great masters of that day thus reechoed in the recent western wilderness. High scientific and professional ideals impelled the youthful enthusiasts, who bore their lighted torches safely back across the waters.
Out of these early essays in medical teaching, the American medical school devel- oped. As far back as 1750 informal classes and demonstrations, mainly in anatomy, are matters of record. Philadelphia was then the chief center of medical interest. There, in 1762, William Shippen the younger, after a sojourn of five years abroad, began in the very year of his return home, a course of lectures on midwifery. In the following autumn he announced a series of anatomical lectures " for the advantage of the young gentlemen now engaged in the study of physic in this and the neighbor- ing provinces, whose circumstances and connections will not admit of their going abroad for improvement to the anatomical schools in Europe; and also for the en- tertainment of any gentlemen who may have the curiosity to understand the anatomy of the Human Frame." From these detached courses the step to an organized medi- cal school was taken at the instigation of Shippen's friend and fellow student abroad,
1 This statement has reference only to the United States and Canada, with which the present account alone deals. As a matter of fact, a chair of medicine was established at the University of Mexico towards the close of the sixteenth century. A complete medical school was there developed. James J. Walsh : "First American Medical School," in New York Medical Journal, Oct. 10, 1908 (based on Historia de la medicina en Mexico des de la epoca de los Iiulios, hasta la present*. Por Francisco Flores. Mexico, 1886).
4 MEDICAL EDUCATION
John Morgan, who in 1765 proposed to the trustees of the College of Philadelphia the creation of a professorship in the theory and practice of medicine. At the ensuing Commencement, Morgan delivered a noble and prophetic discourse, still pertinent, upon the institution of medical schools in America. The trustees were favorable to the suggestion ; the chair was established, and Morgan himself was its first occupant. Soon afterwards Shippen became professor of anatomy and surgery. Thirteen years previously the Pennsylvania Hospital, conceived by Thomas Bond, had been estab- lished through the joint efforts of Bond himself and Benjamin Franklin. Realizing that the student "must Join Examples with Study, before he can be sufficiently qualified to prescribe for the sick, for Language and Books alone can never give him Adequate Ideas of Diseases and the best methods of Treating them," Bond now argued successfully in behalf of bedside training for the medical students. " There the Clinical professor comes in to the Aid of Speculation and demonstrates the Truth of Theory by Facts," he declared in words that a century and a half later still warrant repetition; "he meets his pupils at stated times in the Hospital, and when a case presents adapted to his purpose, he asks all those Questions which lead to a certain knowledge of the Disease and parts Affected; and if the Disease baffles the power of Art and the Patient falls a Sacrifice to it, he then brings his Knowledge to the Test, and fixes Honour or discredit on his Reputation by exposing all the Morbid parts to View, and Demonstrates by what means it produced Death, and if perchance he finds something unexpected, which Betrays an Error in Judgement, he like a great and good man immediately acknowledges the mistake, and, for the benefit of sur- vivors, points out other methods by which it might have been more happily treated.""1 The writer of these sensible words fitly became our first professor of clinical medi- cine,1 with unobstructed access to the one hundred and thirty patients then in the hospital wards. Subsequently the faculty of the new school was increased and greatly strengthened when Adam Kuhn, trained by Linnaeus, was made professor of materia medica, and Benjamin Rush, already at twenty-four on the threshold of his brilliant career, became professor of chemistry.
Our first medical school was thus soundly conceived as organically part of an in- stitution of learning and intimately connected with a large public hospital. The instruction aimed, as already pointed out, not to supplant, but to supplement ap- prenticeship. A year's additional training, carrying the bachelor's degree, was offered to students who, having demonstrated a competent knowledge of Latin, mathema- tics, natural and experimental philosophy, and having served a sufficient apprentice- ship to some reputable practitioner in physic, now completed a prescribed lecture curriculum, with attendance upon the practice of the Pennsylvania Hospital for one
1 An essay on Th» Utility of Clinical Lecturgt, by Thomas Bond, 1766.
2 There is no record of Dr. Bond's appointment, but in the minutes of the Hospital trustees he "is rcouested by the Trustees and Professors to continue his Clinical Lectures at the Hospital as a Branch of Medical Education." Quoted by Packard: Hittory of Medicine in tht United State*, p. 201.
HISTORICAL AND GENERAL 5
year. This course was well calculated to round off the young doctor's preparation, reviewing and systematizing his theoretical acquisitions, while considerably extend- ing his practical experience.
Before the outbreak of the Revolution, the young medical school was prosperously started on its career. The war of course brought interruption and confusion. More unfortunate still, for the time being, was the local rivalry — ominous as the first of its kind — of the newly established medical department of the University of Penn- sylvania; but wise counsels averted disaster, and in 1791 the two institutions joined to form a single faculty, bearing, as it still bears, the name of the university, — the earliest of a long and yet incomplete series of medical school mergers. Before the close of the century three more " medical institutes," similar in style, had been started : one in 1768 in New York, as the medical department of King's College, which, how- ever, temporarily collapsed on the British occupation and was only indirectly restored to vigor by union in 1814 with the College of Physicians and Surgeons, begun by the Regents in 1807; another, the medical department of Harvard College, opened in Cambridge in 1783, and twenty-seven years later removed to Boston so as to gain access to the hospitals there;1 last of the group, the medical department of Dartmouth College, started in 1798 by a Harvard graduate, Dr. Nathan Smith, who was himself for twelve years practically its entire faculty — and a very able faculty at that.
The sound start of these early schools was not long maintained. Their scholarly ideals were soon compromised and then forgotten. True enough, from time to time seats of learning continued to create medical departments, — Yale in 1810, Transyl- vania in 1817, among others. But with the foundation early in the nineteenth cen- tury at Baltimore of a proprietary school, the so-called medical department of the so-called University of Maryland,2 a harmful precedent was established.3 Before that a college of medicine had been a branch growing out of the living university trunk.
1 The removal took place in 1810. But definite arrangements for clinical teaching long remained vague. Dr. R. C. Cabot quotes.the Harvard Catalogue of 1833 as follows : " The lectures for medical students are delivered in Boston. . . . During lectures the students may find in the city various opportunities for practical instruction." A hospital is first mentioned in 1835, " when it is stated that students may attend the medical visits at the Massachusetts General Hospital." R. C. Cabot: "Sketch of the De- velopment of the Department of Clinical Medicine," in Harvard Medical Alumni Quarterly, Jan., 1904, p. 666.
2 In recent years an effort has been made to fill out the non-existent university by an affiliation with St. John's College (Annapolis), whereby it becomes nominally the department of arts of the Univer- sity of Maryland. This is, of course, a makeshift. A university begins with a school of arts and sciences ; it cannot be formed of loosely associated schools of dentistry, pharmacy, and even law, whether with or without still looser connection with a remote college of arts. Analogous in type are the so-called medical departments of the Universities of Buffalo, Toledo, and Memphis, which at this writing still lack academic affiliation. Their titles cannot disguise the fact that they are in essence in- dependent medical schools, nor does a university charter make a university.
3 This was in imitation of London, as against the Edinburgh or the Leyden example, followed by the four earlier schools. But the London schools never conferred the degree or gave the right to practise : for the bestowal of degrees is the function of a university, the qualification for practice is determined by the state. The American departure in both these respects developed evils from which England has never suffered.
6 MEDICAL EDUCATION
This organic connection guaranteed certain standards and ideals, modest enough at that time, but destined to a development which medical education could, as experi- ence proved, ill afford to forego. Even had the university relation been preserved, the precise requirements of the Philadelphia College would not indeed have been permanently tenable. The rapid expansion of the country, with the inevitable decay of the apprentice system in consequence, must necessarily have lowered the terms of entrance upon the study. But for a time only : the requirements of medical educa- tion would then have slowly risen with the general increase in our educational re- sources. Medical education would have been part of the entire movement instead of an exception to it. The number of schools would have been well within the number of actual universities, in whose development as respects endowments, laboratories, and libraries they would have partaken; and the country would have been spared the demoralizing experience in medical education from which it is but now painfully awakening.
Quite aside from the history, achievements, or present merits of any particular in- dependent medical school, the creation of the type was the fertile source of unfore- seen harm to medical education and to medical practice. Since that day medical col- leges have multiplied without restraint, now by fission, now by sheer spontaneous generation. Between 1810 and 1840, twenty-six new medical schools sprang up; be- tween 1840 and 1876, forty-seven more;1 and the number actually surviving in 1876 has been since then much more than doubled. First and last, the United States and Canada have in little more than a century produced four hundred and fifty-seven medical schools, many, of course, short-lived, and perhaps fifty still-born.2 One hundred and fifty-five survive to-day.5 Of these, Illinois, prolific mother of thirty- nine medical colleges, still harbors in the city of Chicago fourteen ; forty-two sprang from the fertile soil of Missouri, twelve of them still "going" concerns; the Empire State produced forty -three, with eleven survivors;4 Indiana, twenty-seven, with two survivors; Pennsylvania, twenty, with eight survivors; Tennessee, eighteen, with nine survivors. The city of Cincinnati brought forth about twenty, the city of Louisville eleven. These enterprises — for the most part they can be called schools or institutions only by courtesy — were frequently set up regardless of opportunity or need: in small towns as readily as in large, and at times almost in the heart of the wilderness. No field, however limited, was ever effectually preempted. Wherever and whenever the roster of untitled practitioners rose above half a dozen, a medical school was likely at any moment to be precipitated. Nothing was really essential but
lContrib. to Hittory ofMed. Educat., N. S. Davis (Washington, 1877, p. 41).
•These were usually frauds, suppressed by police or by post-office departments. Postgraduate and osteopathic schools are not included in these figures.
1 Including osteopathic schools, of which there are eight, but not including postgraduate schools, of which there are thirteen, one of them in Kansas City without students at present. The last-named institution retains its organization in order to obtain staff recognition at the Kansas City Hospital.
* Not including four postgraduate schools.
HISTORICAL AND GENERAL 7
professors. The laboratory movement is comparatively recent; and Thomas Bond's wise words about clinical teaching were long since out of print. Little or no invest- ment was therefore involved. A hall could be cheaply rented and rude benches were inexpensive. Janitor service was unknown and is even now relatively rare. Occasional dissections in time supplied a skeleton — in whole or in part — and a box of odd bones. Other equipment there was practically none. The teaching was, except for a little anatomy, wholly didactic. The schools were essentially private ventures, money- making in spirit and object. A school that began in October would graduate a class the next spring; it mattered not that the course of study was two or three years ; immigra- tion recruited a senior class at the start.1 Income was simply divided among the lec- turers, who reaped a rich harvest, besides, through the consultations which the loyalty of their former students threw into their hands. " Chairs " were therefore valuable pieces of property, their prices varying with what was termed their "reflex" value: only re- cently a professor in a now defunct Louisville school, who had agreed to pay $3000 for the combined chair of physiology and gynecology, objected strenuously to a di- vision of the professorship assigning him physiology, on the ground of "failure of consideration;" for the "reflex" which constituted the inducement to purchase went obviously with the other subject.2 No applicant for instruction who could pay his fees or sign his note was turned down/ State boards were not as yet in existence. The school diploma was itself a license to practise. The examinations, brief, oral, and se- cret, plucked almost none at all; even at Harvard, a student for whom a majority of nine professors "voted" was passed.3 The man who had settled his tuition bill was thus practically assured of his degree, whether he had regularly attended lectures or not. Accordingly, the business throve. Rivalry between different so-called medical centers was ludicrously bitter. Still more acrid were — and occasionally are — the local animosities bound to arise in dividing or endeavoring to monopolize the spoils. Sud- den and violent feuds thus frequently disrupted the faculties. But a split was rarely fatal: it was more likely to result in one more school. Occasionally, a single too masterful individual became the strategic object of a hostile faculty combination. Daniel Drake, indomitable pioneer in medical education up and down the Ohio Val- ley, thus tasted the ingratitude of his colleagues. As presiding officer of the faculty of the Medical College of Ohio, at Cincinnati, cornered by a cabal of men, only a year since indebted to him for their professorial titles and profits, he was compelled to put a motion for his own expulsion and to announce to his enemies a large major-
1 This is recent as well as ancient history, e.g. :
Tufts College Medical School opened 1893 first class graduated 1894
Illinois Medical College 18»4 1885
Birmingham Medical College 1894 1895
College of Physjcians and Surgeons, Little Rock 1906 1907
College of Physicians and Surgeons, Memphis 1900 1907
2 The sale of chairs is not even now wholly unknown. At the North Carolina Medical College (Char- lotte, N. C.) the faculty owns the stock, and the sale of one's stock carries with it one's chair.
3 There were at Harvard at one time only seven professors and an examination was conducted even if only a majority was present.
8 MEDICAL EDUCATION
ity in its favor. It is pleasant to record that the indefatigable man was not daunted. He continued from time to time to found schools and to fill professorships — at Lex- ington, at Philadelphia, at Oxford in Ohio, at Louisville, and finally again in that beloved Cincinnati, where he had been so hardly served. In the course of a busy and fruitful career, he had occupied eleven different chairs in six different schools, several of which he had himself founded ; and he had besides traversed the whole country, as it then was, from Canada and the Great Lakes to the Gulf, and as far westward as Iowa, collecting material for his great work, historically a classic, The Diseases of the Interior Valley of North America.
In the wave of commercial exploitation which swept the entire profession so far as medical education is concerned, the original university departments were practi- cally torn from their moorings. The medical schools of Harvard, Yale, Pennsylvania, became, as they expanded, virtually independent of the institutions with which they were legally united, and have had in our own day to be painfully won back to their former status.1 For years they managed their own affairs, disposing of professor- ships by common agreement, segregating and dividing fees, along proprietary lines. In general, these indiscriminate and irresponsible conditions continued at their worst until well into the eighties. To this day it is as easy to establish a medical school as a business college,1 though the inducement and tendency to do so have greatly weakened. Meanwhile, the entire situation had fundamentally altered. The preceptorial system, soon moribund, had become nominal. The student registered in the office of a physician whom he never saw again. He no longer read his master's books, submitted to his quizzing, or rode with him the countryside in the enjoy- ment of valuable bedside opportunities. All the training that a young doctor got before beginning his practice had now to be procured within the medical school. The school was no longer a supplement; it was everything. Meanwhile, the practice of medicine was itself becoming quite another thing. Progress in chemical, biological, and physical science was increasing the physician's resources, both diagnostic and remedial. Medicine, hitherto empirical, was beginning to develop a scientific basis and method. The medical schools had thus a different function to perform : it took them upwards of half a century to wake up to the fact. The stethoscope had been in use for over thirty years before, as Dr. Cabot notes,3 its first mention in the cata- logue of the Harvard Medical School in 1868-9; the microscope is first mentioned
1The first step towards depriving the medical school of virtual autonomy was taken when the univer- sity undertook to collect the fees and thenceforward to administer the finances of the department by means of an annual budget. This took place at Harvard in 1871, at Yale in 1880, at the University of Pennsylvania in 1896. The scope of the medical faculty has gradually shrunk since. Columbia, which gave up its medical department to the College of Physicians and Surgeons in 1814, contracted a nominal relation with that school in I860; in 1891 the connection became organic.
* In New York, however, the chartering of educational institutions is in the hands of the Regents, who have large powers. Nevertheless, they have recently given a limited charter to the Brooklyn Postgraduate School, a corporation practically without resources and relying on hospital and student fee income (the latter thus far small) to carry it through. •Cabot, loc. cit., p. 673.
HISTORICAL AND GENERAL 9
the following year. The schools had not noticed at all when the vital features of the apprentice system dropped out. They continued along the old channel, their ancient methods aggravated by rapid growth in the number of students and by the lowering in the general level of their education and intelligence. Didactic lectures were given in huge, badly lighted amphitheaters, and in these discourses the instruc- tion almost wholly consisted. Personal contact between teacher and student, be- tween student and patient, was lost. No consistent effort was made to adapt medical training to changed circumstances. Many of the schools had no clinical facilities whatsoever, and the absence of adequate clinical facilities is to this day not prohibi- tive. The school session had indeed been lengthened to two sessions; but they were of only sixteen to twenty weeks each. Moreover, the course was not graded and the two classes were not separated. The student had two chances to hear one set of lec- tures— and for the privilege paid two sets of fees. To this traffic many of the ablest practitioners in the country were parties, and with little or no realization of its enormity at that! "It is safe to say," said Henry J. Bigelow, professor of surgery at Harvard in 1871, "that no successful school has thought proper to risk large existing classes and large receipts in attempting a more thorough education."1 A minority successfully wrung a measure of good from the vicious system which they were powerless to destroy. They contrived to reach and to inspire the most capable of their hearers. The best products of the system are thus hard to reconcile with the system itself. Competent and humane physicians the country came to have, — at whose and at what cost, one shudders to reflect; for the early patients of the rapidly made doctors must have played an unduly large part in their practical training. An annual and increasing exodus to Europe also did much to repair the deficiencies of students who would not have neglected better opportunities at home. The Edin- burgh and London tradition, maintained by John Bell, Abernethy, and Sir Astley Cooper, persisted well into the century. In the thirties, Paris became the medical student's Mecca, and the statistical and analytical study of disease, which is the dis- criminating mark of modern scientific medicine, was thence introduced into America by the pupils of Louis,2 — the younger Jackson, "dead ere his prime," Gerhard, and their successors. With the generation succeeding the civil war, the tide turned decisively towards Germany, and thither continues to set. These men subsequently became teachers in the colleges at Philadelphia, New York, Boston, Charleston, and else- where; and from them the really capable and energetic students got much. One of the latter, who in recent years has wielded perhaps the greatest single influence in the country towards the reconstruction of medical education, says of his own school, the College of Physicians and Surgeons of New York, in the early seventies: "One can decry the system of those days, the inadequate preliminary requirements, the short courses, the dominance of the didactic lecture, the meager appliances for
1 Medical Education in America, by Henry J. Bigelow, Cambridge, the University Press, 1871, p. 79. a Osier : • ' Influence of Louis on Modern Medicine, " Bulletin Johns Hopkins Hospital, vol. iii. , nos. 77, 78.
10 MEDICAL EDUCATION
demonstrative and practical instruction, but the results were better than the system. Our teachers were men of fine character, devoted to the duties of their chairs; they inspired us with enthusiasm, interest in our studies and hard work, and they imparted to us sound traditions of our profession ; nor did they send us forth so utterly igno- rant and unfitted for professional work as those born of the present greatly improved methods of training and opportunities for practical studies are sometimes wont to suppose. Clinical and demonstrative teaching for undergraduates already existed. Of laboratory training there was none.1" l As much could perhaps be said of a half-dozen other institutions. The century was therefore never without brilliant names in ana- tomy, medicine, and surgery; but they can hardly be cited in extenuation of condi- tions over which unusual gifts and perseverance alone could triumph. Those con- ditions made uniform and thorough teaching impossible; and they utterly forbade the conscientious elimination of the incompetent and the unfit.
From time to time, of course, the voice of protest was heard, but it was for years a voice crying in the wilderness. Delegates from medical schools and societies met at Northampton, Massachusetts, in 1827, and agreed upon certain recommendations lengthening the term of medical study and establishing a knowledge of Latin and natural philosophy as preliminary thereto. The Yale Medical School actually went so far as to procure legislation to this end. But it subsequently beat a retreat when it found itself isolated in its advanced position, its quondam allies having failed to march.2 As far back as 1835, the Medical College of Georgia had vainly suggested concerted action looking to more decent methods; but no step was taken until, eleven years later, an agitation set up by Nathan Smith Davis resulted in the formation of the American Medical Association, committed to two propositions, viz.) that it is desirable "that young men received as students of medicine should have acquired a suitable preliminary education," and "that a uniform elevated standard of require- ments for the degree of M.D. should be adopted by all the medical schools in the United States." This was in 1846; much water has flowed under the bridge since then; and though neither of these propositions has even yet been realized, there is no denying that, especially in the last fifteen years, substantial progress has been made.
In the first place, the course has now at length been generally graded * and ex-
1Wm. H. Welch: "Development of American Medicine," Columbia Unwerrity Quarterly Supple- ment, Dec., 1907.
1 Wm. H. Welch : " The Relation of Yale to Medicine " (reprinted from Yale Medical Journal for Nov., 1901), p. 20, and note 28, pp. 30, 31.
•A certain amount of ungraded teaching is still to be found, especially in the south and west. For example, at Chattanooga, no examinations are held at the close of the first year ; the examinations at the close of the second year are supposed to cover two years' work, the practical outcome of which is obvious. More frequently, clinical lectures are delivered to the juniors and seniors together, — at least, as far as a single amphitheater is capable of containing the combined classes. This is the case at the University of Louisville. At certain other schools, the work is only partially graded, e.g., the Memphis Hospital Medical College, Tennessee Medical College, University of Arkansas, Birmingham Medical College, Ensworth Medical College (St. Joseph. Mo.), Hahnemann, San Francisco, Kansas Medical (Topeka), Woman's Medical (Baltimore), Maryland Medical, Mississippi Medical, American
HISTORICAL AND GENERAL 11
tended to four years, still varying, however, from six l to nine months each in du- ration. Didactic teaching has been much mitigated. Almost without exception the schools furnish some clinical teaching; many of them provide a fair amount, though it is still only rarely used to the best teaching advantage; a few are quite adequately equipped in this respect. Relatively quicker and greater progress has been made on the laboratory side since, in 1878,2 Dr. Francis Delafield established the laboratory of the Alumni Association of the College of Physicians and Surgeons of New York ; 3 in the same autumn Dr. William H. Welch opened the pathological laboratory of the Bellevue Hospital Medical College, from which, six years later, he was called to organize the Johns Hopkins Medical School in Baltimore. It is at length everywhere conceded that the prospective student of medicine should prove his fitness for the undertaking. Not a few schools rest on a substantial admission basis ; the others have not yet abandoned the impossible endeavor at one and the same time to pay their own way and to live up to standards whose reasonableness they cannot deny. Finally, the creation of state boards has compelled a greater degree of conscientiousness in teach- ing, though in many places, unfortunately, far too largely the conscientiousness of the drillmaster.
In consequence of the various changes thus briefly recounted, the number of med- ical schools has latterly declined. Within a twelvemonth a dozen have closed their doors. Many more are obviously gasping for breath. Practically without exception, the independent schools are scanning the horizon in search of an unoccupied univer- sity harbor. It has, in fact, become virtually impossible for a medical school to com- ply even in a perfunctory manner with statutory, not to say scientific, requirements and show a profit. The medical school that distributes a dividend to its professors or pays for buildings out of fees must cut far below the standards which its own catalogue probably alleges. Nothing has perhaps done more to complete the dis- credit of commercialism than the fact that it has ceased to pay. It is but a short step from an annual deficit to the conclusion that the whole thing is wrong anyway.
In the first place, however, the motive power towards better conditions came from genuine professional and scientific conviction. The credit for the actual initiative belongs fairly to the institutions that had the courage and the virtue to make the start. The first of these was the Chicago school, which is now the medical de- Medical (St. Louis), St. Louis College of Physicians and Surgeons, Barnes Medical, Western Eclec- tic (Kansas City), Eclectic Medical (New York), Eclectic Institute (Cincinnati). 1The low-grade southern schools have a nominal seven months' course; but as they allow students to enter without penalty several weeks later and have liberal Christmas holidays besides, the course is actually less than six months.
2 Prior to this date Drs. Francis Delafield, E. G. Janeway, and others had given courses at Bellevue Hospital and elsewhere in histology, pathology, etc. See George C. Freeborn : History of the Associa- tion of the Alumni of the College of Physicians and Surgeons, New York, p. 10, etc. Instruction in pathological anatomy in the Harvard Medical School had begun in 1870 with the appointment of Dr. R. H. Fitz to an instructorship in that subject.
5 This laboratory was at first independent of the faculty of the College of Physicians and Surgeons.
12 MEDICAL EDUCATION
partment of Northwestern University, and which in 1859 initiated a three-year graded course. Early in the seventies the new president of Harvard College startled the bewildered faculty of its medical school into the first of a series of reforms that began with the grading of the existing course and ended in 1901 with the require- ment of an academic degree for admission.1 In the process, the university obtained the same sort of control over its medical department that it exercises elsewhere.2 Towards this consummation President Eliot had aimed from the start; but he was destined to be anticipated by the establishment in 1893 of the Johns Hopkins Med- ical School on the basis of a bachelors degree, from which, with quite unprecedented academic virtue, no single exception has ever been made.8 This was the first medical school in America of genuine university type, with something approaching adequate endowment, well equipped laboratories conducted by modern teachers, devoting them- selves unreservedly to medical investigation and instruction, and with its own hospital, in which the training of physicians and the healing of the sick harmoniously combine to the infinite advantage of both. The influence of this new foundation can hardly be overstated. It has finally cleared up the problem of standards and ideals; and its graduates have gone forth in small bands to found new establishments or to recon- struct old ones. In the sixteen years that have since elapsed, fourteen more institu- tions have actually advanced to the basis of two or more years of college work ; others have undertaken shortly to do so. Besides these, there are perhaps a dozen other more or less efficient schools whose entrance requirements hover hazily about high school graduation. In point of organization, the thirty-odd schools now supplying the distinctly better quality of medical training are not as yet all of university type. Thither they are unquestionably tending; for the moment, however, the very best and some of the very worst* are alike known as university departments. Not a few so-called university medical departments are such in name only. They are practically independent enterprises, to which some university has good-naturedly lent its pres- tige. The College of Physicians and Surgeons of Chicago is the medical department of the University of Illinois, but the relation between them is purely contractual ; the state university contributes nothing to its support The Southwestern University of Texas possesses a medical department at Dallas, but the university is legally protected against all responsibility for its debts.5 These fictitious alignments retard
1Seepage28.
1 A vein of unmistakable uneasiness runs through Bigelow's address on Medical Education in America, previously referred to: "Most American medical colleges are virtually close corporations, . . . ad- ministered by their professors, who receive the students' fees, and upon whose tact and ability the success of these institutions depends. A university possesses over all its departments a legal jurisdic- tion ; but it may be a question of expediency how far this shall be enforced" (p. 59).
•See, however, p. 28.
*«.a.. University of Arkansas, Willamette University, Cotner University (Lincoln, Nebraska), West- ern University (London, Ontario), Epworth University, Fort Worth University, etc.
•Other university departments of this nominal character are: medical department of the University of Arkansas (Little Rock); College of Physicians and Surgeons (Los Angeles), which is nominally the medical department of the University of Southern California; Denver and Gross College of
HISTORICAL AND GENERAL 13
the readjustment of medical education through further reduction in the number of schools, because the institutions involved are enabled to live on hope for perhaps another decade or more. It is important that our universities realize that medical education is a serious and costly venture; and that they should reject or terminate all connection with a medical school unless prepared to foot its bills and to pitch its instruction on a university plane. In Canada conditions have never become so badly demoralized as in the United States. There the best features of English clinical teaching had never been wholly forgotten. Convalescence from a relatively mild over- indulgence in commercial medical schools set in earlier and is more nearly completed.
With the creation of the heterogeneous situation thus bequeathed to us, it is clear that consideration for the public good has had on the whole little to do; nor is it to be expected that this situation will very readily readjust itself in response to public need. A powerful and profitable vested interest tenaciously resists criticism from that point of view; not, of course, openly. It is too obvious that if the sick are to reap the full benefit of recent progress in medicine, a more uniformly arduous and expen- sive medical education is demanded. But it is speciously argued that improvements thus accomplished will do more harm than good: for whatever makes medical edu- cation more difficult and more costly will deplete the profession and thus deprive large numbers of all medical attention whatsoever, in order that a fortunate minority may get the best possible care. It is important to forestall the issue thus raised; otherwise it will crop out at every turn of the following discussion, in the effort to justify the existing situation and to break the force of constructive suggestion. It seems, therefore, necessary to refer briefly at this point to the statistical aspects of medical education in America, so far as they are immediately pertinent to the ques- tion of improvement and reform.
The problem is of course practical and not academic. Pending the homogeneous filling up of the whole country, inequalities must be tolerated. Man has been not in- aptly differentiated as the animal with "the desire to take medicine."1 When sick, he craves the comfort of the doctor, — any doctor rather than none at all, and in this he will not be denied. The question is, then, not merely to define the ideal training of the physician; it is just as much, at this particular juncture, to strike the solution that, economic and social factors being what they are, will distribute as widely as possible the best type of physician so distributable. Doubtless the chaos above char- acterized is in part accounted for by crude conditions that laughed at regular me- thods of procedure. But this stage of our national existence has gone by. What with widely ramifying railroad and trolley service, improving roads, automobiles, and
Medicine, which is nominally the medical department of the University of Denver; School of Medi- cine of the University of Georgia; Albany (New York) Medical College, which is nominally the medical department of Union TJniversity; medical department of Western University (London, Ont.), etc. For none of these alliances is there a valid reason; on the contrary, there is in every instance a good reason why the university concerned should break off the connection.
1 Osier: Aequanimitas, p. 131.
14
MEDICAL EDUCATION
rural telephones, we have measurably attained some of the practical consequences of homogeneity. The experience of older countries is therefore suggestive, even if not altogether conclusive.
Professor Paulsen, describing in his book on the German Universities the increased importance of the medical profession, reports with some astonishment that "the number of physicians has increased with great rapidity so that now there is, in Ger- many, one doctor for every 2000 souls, and in the large cities one for every 1000."1 What would the amazed philosopher have said had he known that in the entire United States there is already on the average one doctor for every 568 persons, that in our large cities there is frequently one doctor for every 400 a or less, that many small towns with less than 200 inhabitants each have two or three physicians apiece!8
Over-production is stamped on the face of these facts ; and if, in its despite, there are localities without a physician, it is clear that even long-continued over-produc- tion of cheaply made doctors cannot force distribution beyond a well marked point. In our towns health is as good and physicians probably as alert as in Prussia; there is, then, no reason to fear an unheeded call or a too tardy response, if urban commu- nities support one doctor for every 2000 inhabitants. On that showing, the towns have now four or more doctors for every one that they actually require, — something worse than waste, for the superfluous doctor is usually a poor doctor. So enormous an overcrowding with low-grade material both relatively and absolutely decreases the number of well trained men who can count on the profession for a livelihood. According to Gresham's law, which, as has been shrewdly remarked, is as valid in edu- cation as in finance, the inferior medium tends to displace the superior. If then, by having in cities one doctor for every 2000 persons, we got four times as good a doc- tor as now when we provide one doctor for every 500 or less, the apothecaries would find time hanging somewhat more heavily on their hands. Clearly, low standards and poor training are not now needed in order to supply physicians to the towns.
1 Thilly's translation, p. 400.
2 New York, 1 : 460 ; Chicago, 1 : 580 ; Washington, 1 : 270 ; San Francisco, 1 : 370. These ratios are calculated on the basis of figures obtained from Folk's Medical Register, the American Medical Direc- tory, and estimates prepared by the U. S. Census Bureau. The force of the figures as to the number of physicians cannot be broken by urging that many physicians no longer practise. Such have been carefully excluded by the compilers of the American Medical Directory. Figures used throughout this report were obtained from these sources.
3 Examples may be cited at random from every section of the country in proof of the fact that over- crowding is general, not merely local or exceptional, e.g. :
Ohio:
Killbrook, population 807. has three doctors
|
Houston |
227 |
• |
|
Texas: Wellington |
87 |
five |
|
Whitt |
378 |
four |
|
Whitney |
7M |
•ix |
|
Massachusetts: Colerain |
80 |
two |
|
Harding |
100 |
U |
|
Nebraska: Eustin |
292 |
* |
|
Crofton |
40 |
u |
|
Oregon: K..-,il |
870 |
U. |
|
Oaston |
182 |
• |
(Prom the American Medical Directory. 1000.)
HISTORICAL AND GENERAL 15
In the country the situation follows one of two types. Assuming that a thousand people in an accessible area will support a competent physician, one of two things will happen if the district contains many less. In a growing country, like Canada or our own middle west, the young graduate will not hesitate to pitch his tent in a sparsely settled neighborhood, if it promises a future. A high-grade and comparatively expensive education will not alter his inclination to do this. The more exacting Canadian laws rouse no objection on this score. The graduates of McGill and Toronto have passed through a scientific and clinical discipline of high quality ; but one finds them every year draining off into the freshly opened Northwest Territory. In truth, it is an old story. McDowell left the Kentucky backwoods to spend two years under Bell in Edinburgh; and when they were over, returned contentedly to the wilderness, where he originated the operation for ovarian tumor in the course of a surgical practice that carried him back and forth through Kentucky, Ohio, and Tennessee. Benjamin Dudley, son of a poor Baptist preacher, dissatisfied with the results first of his apprenticeship, then of his Philadelphia training, hoarded his first fees, and with them subsequently embarked temporarily in trade ; he loaded a flat-boat with sun- dries, which he disposed of to good advantage at New Orleans, there investing in a cargo of flour, which he sold to the hungry soldiers of Wellington in the Spanish peninsula. The profits kept Dudley in the hospitals of Paris for four years, after which he came back to Lexington, and for a generation was the great surgeon and teacher of surgery in the rough country across the Alleghanies. The pioneer is not yet dead within us. The self-supporting students of Ann Arbor and Toronto prove this. For a region which holds out hope, there is no need to make poor doctors, — still less to make too many of them.
In the case of stranded small groups in an unpromising environment the thing works out differently. A century of reckless over-production of cheap doctors has re- sulted in general overcrowding; but it has not forced doctors into these hopeless spots. It has simply huddled them thickly at points on the extreme margin. Certain rural communities of New England may, for example, have no physician in their midst, though they are in most instances not inaccessible to one. But let never so many low-grade doctors be turned out, whether in Boston or in smaller places like Burlington or Brunswick, that are supposed not to spoil the young man for a country practice, these unpromising places, destined perhaps to disappear from the map, will not attract them. They prefer competition in some already over-occupied field. Thus, in Vermont, Burlington, the seat of the medical department of the Uni- versity of Vermont, with a population of less than 21,000, has 60 physicians, one for every 333 inhabitants;1 nor can these figures be explained away on the ground that the largest city in the state is a vortex which absorbs more than its proper share; for the state abounds in small towns in which several doctors compete in the service of less than a thousand persons: Post Mills, with 105 inhabitants, has two doctors ; 1 American Medical Directory; Polk (1908) gives 75 active physicians, a ratio of 1 :280.
16 MEDICAL EDUCATION
Jeffersonville, with 400, has two; Plainfield, with 341, has three. Other New England states are in the same case. It would appear, then, that over-production on a low basis does not effectually overcome the social or economic obstacles to spontaneous dispersion. Perhaps the salvation of these districts might, under existing circum- stances, be better worked out by a different method. A large area would support one good man, where its separate fragments are each unable to support even one poor man. A physician's range, actual and virtual, increases with his competency. A well qualified doctor may perhaps at a central point set up a small hospital, where the seriously ill of the entire district may receive good care. The region is thus better served by one well trained man than it could possibly be even if over-production on a low basis ultimately succeeded in forcing an incompetent into every hamlet of five and twenty souls. This it cannot compel. It cannot keep even the cheap man in a place without a "chance;" it can only demoralize the smaller places which are ca- pable of supporting a better trained man whose energies may also reach out into the more thinly settled surrounding country. As a last resort, it might conceivedly be- come the duty of the several states to salary district physicians in thinly settled or remote regions, — surely a sounder policy than the demoralization of the entire pro- fession for the purpose of enticing ill trained men where they will not go.1 We may safely conclude that our methods of carrying on medical education have resulted in enormous over-production at a low level, and that, whatever the justification in the past, the present situation in town and country alike can be more effectively met by a reduced output of well trained men than by further inflation with an inferior product. The improvement of medical education cannot therefore be resisted on the ground that it will destroy schools and restrict output : that is precisely what is needed. The illustrations already given in support of this position may be reinforced by further examples from every section of the Union, — from Pennsylvania with one doctor for every 636 inhabitants, Maryland with one for every 658, Nebraska with one for every 602, Colorado with one for every 328, Oregon with one for every 646. It is frequently urged that, however applicable to other sections, this argument does not for the pre- sent touch the south, where continued tolerance of commercial methods is required by local conditions. Let us briefly consider the point. The section as a whole contains one doctor for every 760 persons. In the year 1908, twelve states2 showed a gain in population of 358,837. If now we allow in cities one additional physician for every increase of 2000, and outside cities an additional one for every increase of 1000 in population, — an ample allowance in any event, — we may in general figure on one more physician for every gain of 1500 in total population. We are not now arguing that a ratio of 1 : 1500 is correct; we are under no necessity of proving that. Our conten-
1 These officials would combine the duties of county health officer with those now assigned in large towns to the city physician.
'This includes Kentucky, Virginia, Tennessee, North Carolina, South Carolina, Georgia, Florida, Alabama, Mississippi, Louisiana, Texas, Arkansas.
HISTORICAL AND GENERAL 17
tion is simply that, starting with our present overcrowded condition, production henceforth at the ratio of one physician to every increase of 1500 in population will prevent a shortage, for the next generation at least. In 1908 the south, then, needed 240 more doctors to take care of its increase in population. In the course of the same year, it is estimated that 500 vacancies in the profession were due to death.1 If every vacancy thus arising must be filled, conditions will never improve. Let us agree to work towards a more normal adjustment by filling two vacancies due to death with one new physician, — once more, a decidedly liberal provision. This will prove sufficiently de- liberate; it would have called for 250 more doctors by the close of the year. In all, 490 new men would have amply cared for the increase in population and the vacancies due to death. As a matter of fact, the southern medical schools turned out in that year 1144 doctors; 78 more southerners were graduated from the schools of Baltimore and Philadelphia. The grand total would probably reach 1300, — 1300 southern doctors to compete in a field in which one- third of the number would find the making of a decent living already difficult. Clearly, the south has no cause to be apprehensive inconsequence of a reduced output of higher quality.2 Its requirements in the matter of a fresh sup- ply are not such as to make it necessary to pitch their training excessively low.
The rest of the country may be rapidly surveyed from the same point of view. The total gain in population, outside the southern states already considered, was 975,008, — requiring on the basis of one more doctor for every 1500 more people, 650 doctors. By death, in the course of the year there were in the same area 1730 vacancies. Replacing two vacancies by one doctor, 865 men would have been re- quired ; in most sections public interest would be better cared for if they all remained unfilled for a decade to come. On the most liberal calculation, 1500 graduates would be called for, and 1000 would be better still. There were actually produced in that year, outside the south, 3497, i.e., between two and three times as many as the country could possibly assimilate; and this goes on, and has been going on, every year.
It appears, then, that the country needs fewer and better doctors; and that the way to get them better is to produce fewer. To support all or most present schools at the higher level would be wasteful, even if it were not impracticable; for they can-
1 Based on figures collected by the American Medical Association.
2 As Kentucky is one of the largest producers of low-grade doctors in the entire Union, it is interest- ing to observe conditions there. The following is the result of a careful study of Henderson County made for me by one thoroughly acquainted with it.
Total population, 35,000 ; number of doctors, 56 ; ratio, 1 : 624.
DISTRIBUTION Place
City of Henderson Anthaston Baskett Cairo Corydon Dixie Geneva Hebardsville
Throughout the county there are doctors within five miles everywhere.
|
Population |
No. Drs. 1 |
tatio |
Place |
Population |
No. Drs. J |
*tatio |
|
17,500 |
27 1 |
1:644 |
Zion |
250 |
S |
:84 |
|
24 |
1 ] |
1:24 |
Robards |
500 |
9 1 |
: 187 |
|
200 |
2 |
:100 |
Niagara |
100 |
9 |
:94 |
|
200 |
1 |
:200 |
McDonald's Landing |
25 |
||
|
1,000 |
4 |
:250 |
Alzey |
25 |
1 |
:25 |
|
900 |
1 |
:300 |
Smith Mills |
200 |
9 |
:«7 |
|
100 |
2 |
:50 |
Spottsville |
700 |
9 |
:294 |
|
400 |
2 |
:200 |
i
18 MEDICAL EDUCATION
not be manned. Some day, doubtless, posterity may reestablish a school in some place where a struggling enterprise ought now to be discontinued. Towards that remote contingency nothing will, however, be gained by prolonging the life of the existent institution.
The statistics just given have never been compiled or studied by the average medical educator. His stout asseveration that "the country needs more doctors" is based on "the letters on file in the dean's office," or on some hazy notion respecting conditions in neighboring states. As to the begging letters: selecting a thinly set- tled region, I obtained from the dean of the medical department of the University of Minnesota a list of the localities whence requests for a physician have recently come. With few exceptions, they represent five states:1 fifty-nine towns in Minne- sota want a doctor ; but investigation shows that these fifty-nine towns have already one hundred and forty-nine doctors between them !2 Forty-one places in North Dakota apply ; they have already one hundred and twenty-one doctors. Twenty-one applica- tions come from South Dakota, from towns having already forty-nine doctors; seven from Wisconsin, from places that had twenty -one physicians before their prayer for more was made; six from Iowa, from towns that had seventeen doctors at the time. It is clear that the files of the deans will not invalidate the conclusion which a study of the figures suggests. They are more apt to sustain it: for the requests in question are less likely to mean "no doctor" than poor doctors,3 — a distemper which con- tinued over-production on the same basis can only aggravate, and which a change to another of the same type will not cure. As to general conditions, no case has been found in which a single medical educator contended that his own vicinity or state is in need of more doctors: it is always the "next neighbor." Thus the District of Columbia, with one doctor for every two hundred and sixty-two souls, maintains two low-grade medical schools. "Do you need more doctors in the District?" was asked of one of the deans. "Oh, no, we are making doctors for Maryland, Virginia, and Pennsylvania," — for Maryland, with seven medical schools of its own and one doctor for every six hundred and fifty-eight inhabitants; for Virginia, with three medical schools of its own and one doctor for every nine hundred and eighteen; for Pennsylvania, with its eight schools and one doctor for every six hundred and thirty- six persons.
With the over-production thus demonstrated, the commercial treatment of medi- cal education is intimately connected. Low standards give the medical schools ac- cess to a large clientele open to successful exploitation by commercial methods. The
1 The general distribution in these states shows that over-production prevails in new states as in old ones : Minnesota 1 : 981 ; South Dakota 1 : 821 ; Iowa 1 : 605; North Dakota 1 : 971 ; Wisconsin 1 : 936.
* Ten of the fifty-nine were without registered physicians ; but of these ten, two are not to be found on the map, two more are not in the Postal Guide; of the other six, four are in easy reach of doctors ; two, with a combined population of one hundred and fifty, are out of reach.
8 Occasionally these applications, which create the impression of a dearth, come from apothecaries who have a rear office to rent, a physician with a practice to sell, etc.
HISTORICAL AND GENERAL 19
crude boy or the jaded clerk who goes into medicine at this level has not been moved by a significant prompting from within; nor has he as a rule shown any forethought in the matter of making himself ready. He is more likely to have been caught drift- ing at a vacant moment by an alluring advertisement or announcement, quite com- monly an exaggeration, not infrequently an outright misrepresentation. Indeed, the advertising methods of the commercially successful schools are amazing.1 Not infre- quently advertising costs more than laboratories. The school catalogues abound in exaggeration, misstatement, and half-truths.3 The deans of these institutions occasion- ally know more about modern advertising than about modern medical teaching. They may be uncertain about the relation of the clinical laboratory to bedside instruction ; but they have calculated to a nicety which "medium" brings the largest "return." Their dispensary records may be in hopeless disorder; but the card system by which they keep track of possible students is admirable. Such exploitation of medical edu- cation, confined to schools that admit students below the level of actual high school graduation, is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by so- ciety for its own highest purposes, not a business to be exploited by individuals ac- cording to their own fancy. There would be no vigorous campaigns led by enlight- ened practitioners against tuberculosis, malaria, and diphtheria, if the commercial point of view were tolerable in practice. And if not in practice, then not in educa- tion. The theory of state regulation covers that point. In the act of granting the right to confer degrees, the state vouches for them ; through protective boards it still further seeks to safeguard the people. The public interest is then paramount, and when public interest, professional ideals, and sound educational procedure concur in the recommendation of the same policy, the time is surely ripe for decisive action.
1 One school offers any graduate who shall have been in attendance three years a European trip.
2 See chapter viii., " Financial Aspects of Medical Education," especially p. 135.
3 A few instances may be cited at random :
Medical Department, University of Buffalo: "The dispensary is conducted in a manner unlike that usually seen. . . . Each one will secure unusually thorough training in taking and recording of his- tories (p. 25). There are no dispensary records worthy the name.
Halifax Medical College: "First-class laboratory accommodation is provided for histology, bacte- riology and practical pathology" (p. 9). One utterly wretched room is provided for all three.
Medical Department, University of Illinois: "The University Hospital ... contains one hundred beds, and its clinical advantages are used exclusively for the students of this college " (p. 56). Over half of these beds are private, and the rest are of but limited use.
Western University (London, Ontario): Clinical instruction. "The Victoria Hospital . . . now con- tains two hundred and fifty beds, and is the official hospital of the City of London," etc. (p. 14). On the average, less than thirty of these beds are available for teaching.
The Medical Department of the University of Chattanooga : "The latest advances" are taught "in the most entertaining and instructive manner;" professors are "chosen for their proficiency ;' "spec- ulative research pertains " to the department of physiology ; the department of pathology is " pro- vided with a costly collection of specimens and generous supply of the best microscopes (one, as a matter of fact); " the hospitals afford numerous cases of labor' !
CHAPTER II
THE PROPER BASIS OF MEDICAL EDUCATION
WE have in the preceding chapter briefly indicated three stages in the develop- ment of medical education in America, — the preceptorship, the didactic school, the scientific discipline. We have seen how an empirical training of varying excellence, secured through attendance on a preceptor, gave way to the didactic method, which simply communicated a set body of doctrines of very uneven value; how in our own day this didactic school has capitulated to a procedure that seeks, as far as may be, to escape empiricism in order to base the practice of medicine on observed facts of the same order and cogency as pass muster in other fields of pure and applied science. The apprentice saw disease; the didactic pupil heard and read about it; now once more the medical student returns to the patient, whom in the main he left when he parted with his preceptor. But he returns, relying no longer altogether on the senses with which nature endowed him, but with those senses made infinitely more acute, more accurate, and more helpful by the processes and the in- struments which the last half-century's progress has placed at his disposal. This is the meaning of the altered aspect of medical training : the old preceptor, be he never so able, could at best feel, see, smell, listen, with his unaided senses. His achieve- ments are not indeed to be lightly dismissed; for his sole reliance upon his senses greatly augmented their power. Succeed as he might, however, his possibilities in the way of reducing, differentiating, and interpreting phenomena, or significant aspects of phenomena, were abruptly limited by his natural powers. These powers are nowa- days easily enough transcended. The self-registering thermometer, the stethoscope, the microscope, the correlation of observed symptoms with the outgivings of chemical analysis and biological experimentation, enormously extend the physician's range. He perceives more speedily and more accurately what he is actually dealing with; he knows with far greater assurance the merits or the limitations of the agents which he is in position to invoke. Though the field of knowledge and certainty is even yet far from coextensive with the field of disease and injury, it is, as far as it goes, open to quick, intelligent, and effective action.
Provided, of course, the physician is himself competent to use the instrumentali- ties that have been developed! There is just now the rub. Society reaps at this mo- ment but a small fraction of the advantage which current knowledge has the power to confer. That sick man is relatively rare for whom actually all is done that is at this day humanly feasible, — as feasible in the small hamlet as in the large city, in the public hospital as in the private sanatorium. We have indeed in America medi- cal practitioners not inferior to the best elsewhere; but there is probably no other country in the world in which there is so great a distance and so fatal a difference between the best, the average, and the worst.
PROPER BASIS OF MEDICAL EDUCATION 21
The attempt will be made in this chapter and the next to account for these dis- crepancies in so far as they are traceable to circumstances that antedate the formal beginning of medical education itself. The mastery of the resources of the profession in the modern sense is conditioned upon certain definite assumptions, touching the medical student's education and intelligence. Under the apprentice system, it was not necessary to establish any such general or uniform basis. The single student was in personal contact with his preceptor. If he were young or immature, the preceptor could wait upon his development, initiating him in simple matters as they arose, postponing more difficult ones to a more propitious season ; meanwhile, there were always the horses to be curried and the saddle-bags to be replenished. In the end, if the boy proved incorrigibly dull, the perceptor might ignore him till a convenient excuse discontinued the relation. During the ascendancy of the didactic school, it was indeed essential to good results that lecturers and quizmasters should be able to gauge the general level of their huge classes ; but this level might well be low, and in the common absence of conscientiousness usually fell far below the allowable minimum. In any event, the student's part was, parrot-like, to absorb. His medical education consisted largely in getting by heart a prearranged system of correspon- dences,— an array of symptoms so set off against a parallel array of doses that, if he noticed the one, he had only to write down the other: a coated tongue — a course of calomel; a shivery back — a round of quinine. What the student did not readily apprehend could be drilled1 into him — towards examination time — by those who had themselves recently passed through the ordeal which he was now approaching; and an efficient apparatus that spared his senses and his intellect as entirely as the drillmaster spared his industry was readily accessible at tempt- ingly low prices in the shape of "essentials" and "quiz-compends." Thus he got, and in places still gets, his materia medica, anatomy, obstetrics, and surgery. The med- ical schools accepted the situation with so little reluctance that these compends were — and occasionally still are — written by the professors2 and sold on the pre-
1"A reiteration of undisputed facts in their simplest expression," is Bigelow's way of putting it. Loe. cit., p. 11.
2 From the last catalogues of certain medical publishers :
" QUIZ-COMPENDS : "
Physiology, by A. P. Brubaker, Professor of Physiology, Jefferson Medical College, Philadelphia.
Oynecology, by Wm. H. Wells, Demonstrator of Clinical Obstetrics, Jefferson Medical College,
Philadelphia.
Surgery, by Orville Horwitz, Prof, of Genito-Urinary Surgery, Jefferson Medical College, Philadelphia.
Diseases of Children, by Marcus P. Hatfield, Professor of Diseases of Children, Chicago Medical College.
Special Pathology, by A. E. Thayer, Professor of Pathology, University of Texas.
"ESSENTIALS:"
Surgery, by Edward Martin, Professor of Clinical Surgery, University of Pennsylvania.
Anatomy, by C. B. Nancrede, Professor of Surgery, University of Michigan.
Obstetrics, by W. E. Ashton, Professor of Gynecology, Medico-Chirurgical College, Philadelphia.
Oynecology, by E. B. Cragin, Professor of Obstetrics, Columbia University.
Histology, by Louis Leroy, Professor of Medicine, College of Physicians and Surgeons, Memphis.
Diseases of the Skin, by H. W. Stelwagon, Prof, of Dermatology, Jefferson Medical College, Phila.
Diseases of the Eye, by Edward Jackson, Professor of Ophthalmology, University of Colorado.
22 MEDICAL EDUCATION
raises.1 Under such a regime anybody could, as President Eliot remarked, "walk into a medical school from the street," and small wonder that of those who did walk in, many "could barely read and write."2 But with the advent of the laboratory, in which every student possesses a locker where his individual microscope, reagents, and other paraphernalia are stored for his personal use; with the advent of the small group bed- side clinic, in which every student is responsible for a patient's history and for a trial diagnosis, suggested, confirmed, or modified by his own microscopical and chemical examination of blood, urine, sputum, and other tissues, the privileges of the medical school can no longer be open to casual strollers from the highway. It is necessary to install a doorkeeper who will, by critical scrutiny, ascertain the fitness of the appli- cant: a necessity suggested in the first place by consideration for the candidate, whose time and talents will serve him better in some other vocation, if he be unfit for this; and in the second, by consideration for a public entitled to protection from those whom the very boldness of modern medical strategy equips with instruments that, tremendously effective for good when rightly used, are all the more terrible for harm if ignorantly or incompetently employed.
A distinct issue is here presented. A medical school may, the law permitting, eschew clinics and laboratories, cling to the didactic type of instruction, and arrange its dates so as not to conflict with seedtime and harvest ; or it may equip laboratories, develop a dispensary, and annex a hospital, pitching its entrance requirements on a basis in keeping with its opportunities and pretensions. But it cannot consistently open the latter type of school to the former type of student. It cannot provide laboratory and bedside instruction on the one hand, and admit crude, untrained boys on the other. The combination is at once illogical and futile. The funds of the school may indeed procure facilities; but the intelligence of the students can alone ensure their proper use. Nor can the dilemma be evaded by alleging that a small amount of laboratory instruction administered to an unprepared medical student makes a "practitioner," while the more thorough training of a competent man makes a "sci- entist."* At the level at which under the most favorable circumstances the medical student gets his education, it is absurd to speak of an inherent conflict between science and practice. We shall have occasion later to touch on the relation of teaching and
1 For example, in the Atlanta College of Physicians and Surgeons ; Medical Department, University of Nashville ; North Carolina Medical College (Charlotte); Medical Department, University of Pitts- burgh; John A. Creighton Medical College (Omaha, Nebraska); Starling-Ohio Medical College (Columbus); George Washington University (D. C.).
2The American Medical Asiociation Bulletin, vol. iii., no. 5, p. 262.
* At a medical convention recently held, a professor in an institution on the basis of a "high school education or its equivalent," made this point in a speech, as against the medical department of a university, which requires for entrance college work: TTie lower-grade institution made "doctors," it was averred; the higher made only " scientists." Now it chances that for the last two years both sets of students have submitted to a practical examination in subjects like urinalysis, which assuredly it behooves the "doctor" as well as the "scientist" to master. At these examinations the "doctors" show an average of 59 percent; the "scientists," 77 per cent. On the combined written and practical examinations this year, the "doctors" in question averaged 65.2 per cent, the "scientists" averaged 83.1 percent.
PROPER BASIS OF MEDICAL EDUCATION 23
research,1 between which it is necessary to establish a modus Vivendi. But that pro- blem has nothing to do with the point now under discussion, — viz., as to how much education or intelligence it requires to establish a reasonable presumption of fitness to undertake the study of medicine under present conditions.
Taking, then, modern medicine as an attempt to fight the battle against disease most advantageously to the patient, what shall we require of those who propose to enlist in the service? To get a somewhat surer perspective in dealing with a ques- tion around which huge clouds of dust have been beaten up, let us for a moment look elsewhere. A college education is not in these days a very severe or serious dis- -4 — cipline. It is compounded in varying proportions of work and play; it scatters I whatever effort it requires, so that at no point need the student stand the strain of prolonged intensive exertion. Further, the relation of college education to specific professional or vocational competency is still under dispute. It is clear, then, that a college education is less difficult, less trying, less responsible, than a professional edu- cation in medicine. It is therefore worth remarking that the lowest terms upon which a college education is now regularly accessible are an actual four-year high school training, scholastically determined, whether by examination of the candidate or by appraisement of the school.
Technical schools of engineering and the mechanic arts afford perhaps an even more illuminating comparison. These institutions began, like the college, at a low level; but they did not long rest there. Their instruction was too heavily handicapped by ignorance and immaturity. To their graduates, tasks involving human life and welfare were committed : the building of bridges, the installation of power plants, the construction of sewage systems. The technical school was thus driven to seek stu- dents of greater maturity, of more thorough preliminary schooling, and strictly to confine its opportunities to them. Now it is noteworthy that, though in point of in- tensive strain the discipline of the modern engineer equals the discipline of the mod- ern physician, in one important respect, at least, it is less complex and exacting. The engineer deals mainly with measurable factors. His factor of uncertainty is within fairly narrow limits. The reasoning of the medical student is much more complicated. He handles at one and the same time elements belonging to vastly different cate- gories : physical, biological, psychological elements are involved in each other. More- over, the recent graduate in engineering is not at once exposed to a decisive respon- sibility ; to that he rises slowly through a lengthy series of subordinate positions that search out and complete his education.2 Between the young graduate in medicine and his ultimate responsibility — human life — nothing interposes. He cannot now- adays begin with easy tasks under the surveillance of a superior; the issues of life
1 See page 55.
2 It is interesting to observe the tendency towards conferring only a bachelor's degree in engineering at graduation instead of the degree of C.E., etc. The bachelor in engineering usually goes to work at laborer's wages ; he is years reaching the degree of responsibility with which the graduate in med- icine usually begins.
24 MEDICAL EDUCATION
and death are all in the day's work for him from the very first. The training of the doctor is therefore more complex and more directly momentous than that of the technician. Be rt noted, then, that the minimum basis upon which a good school of engineering to-day accepts students is, once more, an actual high school education, and that the movement towards elongating the technical course to five years con- fesses the urgent need of something more.
There is another aspect of the problem equally significant. The curriculum of the up-to-date technical school is heavily weighted, to be sure; but except for mathema- tics, the essential subjects with which it starts are separate sciences that presuppose no prior mastery of contributory sciences. Take at random the College of Engi- neering of the University of Wisconsin. In the first year the science work is chem- istry, and though the course is difficult, it demands no preceding acquaintance with chemistry itself or with any other science; second-year physics is in the same case, and the mechanics of the second semester looks back no further than to the physics of the first.
Very different is the plight of the medical school. There the earliest topics of the curriculum proper — anatomy, physiology, physiological chemistry — already hark back to a previous scientific discipline. Every one of them involves already acquired knowledge and manipulative skill. They are laboratory sciences at the second, not the primary, stage. Consider, for example, anatomy, the simplest and most funda- mental of them all. It used to begin and end with the dissection of the adult cada- ver. It can neither begin nor end there to-day ; for it must provide the basis upon which experimental physiology, pathology, and bacteriology may intelligently be built up. Mere dissection does not accomplish this; in addition to gross anatomy, the stu- dent must make out under the microscope the normal cellular structure of organ, muscle, nerve, and blood-vessel; he must grasp the whole process of structural de- velopment. Histology and embryology are thus essential aspects of anatomical study. No treatment of the subject including these is possible within the time-limits of the modern medical curriculum unless previous training in general biology has equipped the student with the necessary fundamental conceptions, knowledge, and technical dexterity. It has just been stated that physiology presupposes anatomy on lines involv- ing antecedent training in biology; it leans just as hard on chemistry and physics. The functional activities of the body propound questions in applied chemistry and applied physics. Nutrition and waste — what are these but chemical problems within the realm of biology? The mechanism of circulation, of seeing, or hearing — what are these but physical problems under the same qualifications? The normal rhythm of physiological function must then remain a riddle to students who cannot think and speak in biological, chemical, and physical language.
All this is, however, only preliminary. The physician's concern with normal pro- cess is not disinterested curiosity; it is the starting-point of his effort to comprehend and to master the abnormal. Pathology and bacteriology are the sciences concerned
PROPER BASIS OF MEDICAL EDUCATION 25
with abnormalities of structure and function and their causation. Now the agents and forces which invade the body to its disadvantage play their game, too, according to law. And to learn that law one goes once more to the same fundamental sciences upon which the anatomist and the physiologist have already freely drawn, — viz., bi- ology, physics, and chemistry.
Nor do these apparently recondite matters concern only the experimenting investi- gator, eager to convert patiently acquired knowledge of bacterial and other foes into a rational system of defense against them. For the practical outcome of such investiga- tion is not communicable by rote; it cannot be reduced to prescriptions for mechan- ical use by the unenlightened practitioner. Modern medicine cannot be formulated in quiz-compends; those who would employ it must trouble to understand it. More- over, medicine is developing with beneficent rapidity along these same biological and chemical lines. Is our fresh young graduate of five and twenty to keep abreast of its progress? If so, he must, once more, understand; not otherwise can he adopt the new agents and new methods issuing at intervals from each of a dozen fertile laboratories; for rote has no future: it stops where it is. "There can be no doubt," said Huxley, "that the future of pathology and of therapeutics, and therefore of practical medicine, depends upon the extent to which those who occupy themselves with these subjects are trained in the methods and impregnated with the funda- mental truths of biology."1 Now the medical sciences proper — anatomy, physiology, pathology, pharmacology — already crowd the two years of the curriculum that can be assigned to them ; and in so doing, take for granted the more fundamental sci- ences— biology, physics, and chemistry — for which there is thus no adequate op- portunity within the medical school proper. Only at the sacrifice of some essential part of the medical curriculum — and for every such sacrifice the future patients pay — can this curriculum be made to include the preliminary subjects upon which it presumes.
From the foregoing discussion, these conclusions emerge: By the very nature of the case, admission to a really modern medical school must at the very least depend on a competent knowledge of chemistry, biology,2 and physics. Every departure from this basis is at the expense of medical training itself. From the exclusive standpoint of the medical school it is immaterial where the student gets the instruction. But it is clear that if it is to become the common minimum basis of medical education, some recognized and organized manner of obtaining it must be devised : it cannot be left to the initiative of the individual without greatly impairing its quality. Regular pro- vision must therefore be made at a definite moment of normal educational progress. Now the requirement above agreed on is too extensive and too difficult to be incor- porated in its entirety within the high school or to be substituted for a considerable
1 Quoted by F. T. Lewis in " The Preparation for the Study of Medicine," Popular Science Monthly, vol. Ixxv., no. 1, p. 66.
2 Including botany.
26 MEDICAL EDUCATION
portion of the usual high school course ; besides, it demands greater maturity than the secondary school student can be credited with except towards the close of his high school career. The possibility of mastering the three sciences outside of school may be dismissed without argument. In the college or technical school alone can the work be regularly, efficiently, and surely arranged for. The requirement is therefore necessarily a college requirement, covering two years, because three laboratory courses cannot be carried through in a briefer period, — a fortunate circumstance, since it favors the student's simultaneous development along other and more general lines. It appears, then, that a policy that at the outset was considered from the narrow standpoint of the medical school alone shortly involves the abandonment of this point of view in favor of something more comprehensive. The preliminary require- ment for entrance upon medical education must therefore be formulated in terms that establish a distinct relation, pedagogical and chronological, between the medi- cal school and other educational agencies. Nothing will do more to steady and to improve the college itself than its assumption of such definite functions in respect to professional and other forms of special training.
So far we have spoken explicitly of the fundamental sciences only. They furnish, indeed, the essential instrumental basis of medical education. But the instrumental minimum can hardly serve as the permanent professional minimum. It is even in- strumentally inadequate. The practitioner deals with facts of two categories. Chem- istry, physics, biology enable him to apprehend one set; he needs a different ap- perceptive and appreciative apparatus to deal with other, more subtle elements. Specific preparation is in this direction much more difficult; one must rely for the requisite insight and sympathy on a varied and enlarging cultural experience. Such enlargement of the physician's horizon is otherwise important, for scientific progress has greatly modified his ethical responsibility. His relation was formerly to his pa- tient— at most to his patient's family; and it was almost altogether remedial. The patient had something the matter with him; the doctor was called in to cure it. Pay- ment of a fee ended the transaction. But the physician's function is fast becoming social and preventive, rather than individual and curative. Upon him society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral well-being. It goes without saying that this type of doctor is first of all an educated man.
How nearly our present resources — educational and economic — permit us to ap- proach the standards above defined is at bottom a question' of fact to be investigated presently. We have concluded that a two-year college training, in which the sciences are "featured," is the minimum basis upon which modern medicine can be success- fully taught. If the requisite number of physicians cannot at one point or another be procured at that level, a temporary readjustment may be required; but such an expedient is to be regarded as a makeshift that asks of the sick a sacrifice that must not be required of them a moment longer than is necessary. Before accepting such
PROPER BASIS OF MEDICAL EDUCATION 27
a measure, however, it is exceedingly important not to confuse the basis on which society can actually get the number of doctors that it needs with the basis on which our present number of medical schools can keep going. Much depends upon which end we start from.
CHAPTER III
THE ACTUAL BASIS OF MEDICAL EDUCATION
TAKING a two-year college course, largely constituted of the sciences, as the normal point of departure, let us now survey the existing status. The one hundred and fifty- five medical schools of the United States and Canada fall readily into three divisions: the first includes those that require two or more years of college work for entrance; the second, those that demand actual graduation from a four-year high school or oscillate about its supposed "equivalent;" the third, those that ask little or nothing more than the rudiments or the recollection of a common school education.
To the first division sixteen institutions already belong;1 six more, now demand- ing one year of college work, will fully enter the division in the fall of 1910 by re- quiring a second;8 and several more, at this date still in the second division, will shortly take the step from the high school to the two-year college requirement.3 The Johns Hopkins requires for entrance a college degree which, whatever else it represents, must include the three fundamental sciences, French, and German. No exception has ever been made to this degree requirement ; but recently admission to the second-year class has been granted to students holding an A.B. degree earned by four years' study, the last of them devoted to medical subjects in institutions where those subjects were excellently taught.4 At Harvard the degree requirement has been somewhat unsettled by a recent decision to admit students without degree, provided they have had two years of college science ; they are to be grouped as " spe-
1 Johns Hopkins, Harvard, Western Reserve, Rush (University of Chicago), Cornell, Stanford, Wake Forest (N. C.), Yale, and the state universities of California, Minnesota, North Dakota, Wisconsin, Michigan (exclusive of the homeopathic department), Kansas, Nebraska, South Dakota.
2 Universities of Indiana, Iowa (exclusive of the homeopathic department), Missouri, Pennsylvania, Utah, Syracuse. Several institutions ask one year of college work, without as yet definite announce- ment as to requirement of the second, e.g., Virginia, Fordham, Northwestern, North Carolina. In general, the one-year college requirement is hard to distinguish from the high school requirement, for if conditions are allowed, — and they always are, — it adds but little to the better type of high school education. Northwestern has had two years experience under the one-year college requirement, but has not yet really enforced it. The University of North Carolina was to require a year of college work, 1909-10, but students were admitted on the strength of their unsupported statements " as having had a college year. . . . Practically, this means that the entrance requirements were not enforced."
'Columbia, Dartmouth, Colorado.
4 Practically, this amounts to a recognition of the A.B. degree won after three years of study, — a movement deserving encouragement rather than criticism, as matters now stand. In fact, the Johns Hopkins degree was originally conferred at the close of three years of study, but the academic ma- triculation requirement was considerably higher than in institutions granting the A.B. degree after four years of study. Recently the academic matriculation has been lowered and the A.B. course lengthened to four years. In consequence, the action of the medical department above described in- volves unwittingly a curious discrimination against the Johns Hopkins A.B. degree, for this degree now requires four years and may not include medical subjects. To get the Johns Hopkins M.D., a student has two roads open to him : he may work four years for the Johns Hopkins A.B. and four more for its M.D., — eight in all; or, starting at exactly the same point, he may get his A.B. in four years at an institution that includes in its A.B. the first year in medicine, then enter the Johns Hop- kins medical school and get its M.D. in three years, — that is, seven years in all. A B.S. degree earned in three years, followed by the M.D. earned in four, gives the same result, — a preference, once more, that operates against the Johns Hopkins A.B.
ACTUAL BASIS OF MEDICAL EDUCATION 29
cial" students, and are required to maintain higher standing in order to qualify for the M.D. degree. But as these students enter on a general rule and as a matter of course, and are, under a slight handicap, eligible to the M.D. degree, they are not accurately described as special. A special student is properly one whom no rule fits, one whose admission presents certain individual features requiring consideration on their merits. Such is not the case with the students under discussion : they enter just as regularly as the degree men, and without that limitation as to number which makes of the "special student" device something of a privilege. Harvard can thus admit any student who is eligible to the schools with the two-year college require- ment.1 The other institutions under discussion telescope the college and medical courses: the preliminary medical sciences constitute the bulk of two college years;1 the next two years are reckoned twice. They count simultaneously as third and fourth 1 years of the college and as first and second years of the medical course. At their I close the student gets the A.B. degree, but his medical education is already half over. Without exception, the schools belonging to this group are high-grade institu- tions. They differ considerably, however, in the degree of rigor with which their elevated entrance requirements have been enforced from the start. At the University of Pennsylvania, for example, in a class of 114, admitted this year (1909-10) on a one- year college basis, 75 (66 per cent) are conditioned; at Ann Arbor, of 36 entering on the two-year college basis, only 8 are conditioned at all, and those mainly in organic chemistry; at Yale, which advanced in 1909-10 from the high school to the two-year college basis, in a class of 23, there was only one partial condition in biology, and, best of all, failed members of last year's class on the old basis were refused re-admis- sion. Experience elsewhere indicates that the percentage of conditions declines rapidly as students learn by forethought to adjust their work to their ultimate pur- pose, and as the colleges facilitate adjustment by providing the requisite opportuni- ties: both of which processes will be accelerated, if the medical schools have the courage — and the financial strength — to close their doors to students who labor under anything more than a slight handicap. Here as elsewhere development follows hard upon actual responsibility.
Our second division constitutes the real problem; out of it additional high-grade medical schools to the number actually required must be developed. About fifty insti- tutions, whose entrance standard approximates high school graduation, belong here. Great diversity exists in the quality of the student body of these institutions : the regents' certificates in New York, state board supervision in Michigan, the control of admission to their medical departments by the academic authorities of McGill
1 The rule just described went into effect 1909-10 ; two students took advantage of it in a class of 62. In 1908 there were 254 students with degrees, 23 without.
2 Cornell, Western Reserve, and Stanford combine academic and college courses to the extent of one year only. The pedagogical aspect of the combined course is discussed pp. 73, 74.
SO MEDICAL EDUCATION
and Toronto, insure as capable and homogeneous an enrolment as is obtainable at or about the high school level. A few others, not so well protected, are within mea- surable distance of the same category, — the medical department of Tulane Univer- sity and Jefferson Medical College (Philadelphia), for example. In general, however, the schools of this division are difficult to classify;1 for they freely admit students on bases that are not only hopelessly unequal to each other, but are even incapable of reduction to a common denominator. On their actual standards the catalogue statements throw little light: there the requirements are cast in the form of a de- scending scale, running from the top, down. Equally acceptable in their sight are a bachelor's degree from a college or a university, a diploma from an "accredited" high school, an examination in a few specified and several of a wide range of op- tional studies, and a certificate from the principal of a high school, normal school, or academy, from a "reputable instructor," from a state or city superintendent of education, or from a state board of medical examiners, that stamps the applicant as possessing the "equivalent" of a high school education. Now it is clear that the alternatives at the top are mainly decorative. The real standard is perilously close to the "equivalent" that creeps in modestly at the bottom. There is, of course, no active prejudice anywhere against Ph.D.'s and A.M.'s and A.B.'s and B.Sc.'s; they are apt to be rather conspicuously exploited, when they drift in. But they do not set the pace; they do not determine or even vitally affect the character of the school. In these instances the medical curriculum either contains the pre-medical subjects in an elementary form, or, what may be worse, tries to go ahead entirely without them. The real standard is not influenced by the presence of degree men, and the wonder is that any of them sacrifice the advantage of a superior education by resorting to these institutions. The minimum is, then, the real standard; all else is permissive; for to the needs of those admitted at the bottom the quantity and quality of the instruction must in fairness conform.
To get at the real admission standard, then, of these medical schools, one must make straight for the "equivalent." On the methods of ascertaining and enforcing that, the issue hangs. Now the "equivalent" may be defined as a device that con- cedes the necessity of a standard which it forthwith proceeds to evade. The pro- fessed high school basis is variously sacrificed to this so-called "equivalent." The medical schools under discussion agree to accept at face value only graduation di- plomas2 from "approved" or "accredited" high schools. These terms have a definite meaning: they indicate schools which, upon proper investigation, have been recog- nized by the state universities of their respective states, or by some other competent educational organization, — in New England, by the College Entrance Certificate Board; in the middle west, by the North Central Association. High schools and acad- emies not acceptable at full value to state universities or to the bodies just named
*In Part II each school is separately characterized.
2 As a matter of fact, nongraduates are also admitted on certificates — a violation of standard, of course.
ACTUAL BASIS OF MEDICAL EDUCATION 31
do not belong to the "approved" or "accredited" class: their diplomas and certifi- cates are not, therefore, entitled to be received in satisfaction of the announced standard. They are nevertheless freely accepted. At Tufts, for example, the first year class (1909-10) numbers 151, of whom only little more than half submit creden- tials that actually comply with the standard; of the others, 30 are accepted from non-accredited schools on the strength of diplomas and certificates entitled to no weight on the professed standard of the Tufts Medical School.1 This is a common occurrence. It is defended on the ground that " we know the schools." That is, how- ever, quite impossible. The wisdom of Solomon would not suffice to determine the actual value of credentials so heterogeneous in origin and content. Universities deal- ing with far less various material organize registration and inspection bureaus for their protection and enlightenment. But not infrequently the medical departments of these very institutions, pretending to stand on the same basis as the academic de- partment, refrain from seeking the aid of the university registration office. The me- dical department of Bowdoin is on the college campus, yet its authorities accept cer- tificates that the college would refuse; the medical departments of Vanderbilt, Tufts, George Washington University, Creighton (Omaha), Northwestern, the Universities of Vermont and Pennsylvania,2 are in easy reach of intelligent advice which they do not systematically utilize. In striking contrast, the medical department of the University of Texas at Galveston refers all credentials to the registration office of the university at Austin, the action of which is final.
If the standard were enforced, the candidates in question, not offering a gradua- tion diploma from an accredited high school, would be compelled to enter by written examination. But the examination is, as things stand, only another method of eva- sion. Neither in extent nor in difficulty do the written examinations, in the rela- tively rare cases in which they are given, even approximate the high school stan- dard. Nor are they meant to do so. Colleges with medical departments of the kind under discussion do not expect academic and medical students to pass the same or the same kind of examination: a special set of questions is prepared for the medical candidates, including perhaps half the subjects, and each of these traversing about half the ground covered by the academic papers. At Tufts, the medical matriculate attempts six papers, representing, all told, less than two years of high school work ; and he is accepted on condition if he passes three.3 Papers of similar quality are put forward at Boston University ; those at Bowdoin are more extensive and more difficult, though still below the supposedly equal academic standard. The written examinations held under the authority of the state boards in Kentucky, Pennsylvania, Missouri,* are of
1 Those still remaining are commented on below.
2 The academic authorities here pass on the college year.
s Of the class above mentioned 38 were admitted by examination.
4 A St. Louis cramming establishment, conducted by the wife of a teacher in a local medical school, offers to prepare in a single year, according to the Missouri standard, a boy who has never had any
82 MEDICAL EDUCATION
the same insufficient character. In Michigan they fairly well approximate high school value, — in consequence of which they are decidedly unpopular.1 In Illinois the writ- ten examination has been transformed into an informal after-dinner conversation between candidate and examiner, as we shall presently discover.
There remains still a third method of cutting below an actual high school stan- dard,— the method indeed that provides much the most capacious loophole for the admission of unqualified students under the cloak of nominal compliance with the high school standard. The agent in the transactions about to be described is the medical examiner, appointed in some places by voluntary agreement between the schools, elsewhere delegated by the state board,2 or by the superintendent of public instruction acting in its behalf, for the purpose of dealing with students who present written evidence other than the diploma of an accredited high school. It is intended and expected that this official shall enforce a high school standard. In few states is this standard achieved. The education department in New York, the state boards in Minnesota and Michigan, maintain what may be fairly called a scho- lastically honest high school requirement; for they require a diploma represent- ing an organically complete secondary school education, properly guaranteed, or, in default thereof, a written examination covering about the same ground : there is no other recourse.
Elsewhere the state board is legally powerless, as in Maryland, or unwilling to an- tagonize the schools, as in Illinois and Kentucky. The outside examiners, agreed on by the schools in the former case, designated by law in the latter, fall far short of enforcing a high school standard. The examiner, even where distinctly well inten- tioned, as in Kentucky, never gets sufficient control. The schools do not want the rule enforced, and the boards are either not strong enough or not conscientious enough to withstand them. Besides, the examiners lack time, machinery, and encouragement for the proper performance of their ostensible office. They are busy men : here, a county official; there, a school principal; elsewhere, a high school professor.3 A single individual, after his regular day's work is over, without assistance of any kind, is thus expected to perform a task much more complicated than that for which Harvard, Columbia, and the University of Michigan maintain costly establishments. There is
high school training at all. It is pointed out that by matriculating at once the student may escape any subsequent advance in entrance requirements.
1 In Ohio the examinations are fairly representative of high school values, as far as they go. But up to this time they have not covered a complete high school course and they have little influence on enrol- ment, as tutor-certificates are freely accepted in their stead.
*In these cases, the requirement is really a practice, not an educational regulation. But the effect is the same.
•Occasionally the school has an "arrangement" by which defective candidates are referred to a "coach," who is simultaneously "examiner ;" he thus approves his own work. This is the practice of the George Washington University medical department. Again, the school refers defective candi- dates to the preparatory department of its own university, and shortly after admits them on an as- surance of the "equivalent from that source. This is the Creighton school (Omaha) plan ; out of 56 members of its first-year class (1908-9), 23 were admitted on certificates (not diplomas) of this kind.
ACTUAL BASIS OF MEDICAL EDUCATION 33
no set time when candidates must appear. They drop in as they please, separately: now, before the medical school opens, again, long after ; sometimes with their creden- tials, sometimes without them. There is no definite procedure. At times, the examiner concludes from the face of the papers; at times from the face of the candidate. The whole business is transacted in a free and easy way. In Illinois, for example, the law speaks of "preliminary" educational requirements; the state board graciously permits them to become subsequents. Students enter the medical schools, embark on the study of medicine, and at their convenience "square up"1 with one of the examiners. An evening call is arranged ; there is an informal talk, aiming to elicit what "subjects" the candidate "has had." He may, after an interview lasting from thirty minutes to two hours, and rarely including any writing, be "passed" with or without "condi- tions;" if with conditions, the rule requires him to reappear for a second "exam- ination" before the beginning of the sophomore year; but nothing happens if he postpones his reappearance until a short time before graduation.2 Besides, a condi- tion in one subject may be removed by "passing" in another! "No technical ques- tions are asked; the presumption is that the applicant won't remember details." Formerly, written examinations were used in part ; but they were given up " because almost everybody failed." And it may at any moment happen that an applicant actu- ally turned down by one examiner will be passed by another. The most flagrantly commercial of the Chicago schools3 operate "pre-medical" classes, where a hasty cram, usually at night, suffices to meet the academic requirements of the Illinois state board: "the examiner's no prude, he'll give a man a chance," said the dean of one of them.
In Pennsylvania there was until quite lately no high school requirement by law; but recent legislation fixes the high school or its equivalent, on which the better schools had previously agreed, as the legal minimum. Its value has hitherto varied. In the first place, the examiners have accepted three-year high school graduates: "They come every day and are not turned down." In the second place, the alterna- tives in the matter of studies are so many that he must indeed have had narrow op-
1 Quotation marks indicate throughout words taken down on the spot in the course of interviews with officials.
2 New York, while dealing strictly with applicants for practice who have been educated in New York state, deals somewhat more leniently with the outsider. The New York law provides that to be "re- gistered as maintaining a proper medical standard, "a school must, among other things, "require that before beginning the course for the degree, all matriculates afford evidence of a general preliminary education equivalent to at least a four-year high school course," etc. (Handbook 9, April, 1908, p. 45.) As a matter of fact, a student who received his degree from a school on the accredited or registered list (ibid., pp. 48-70) may, on applying for registration in New York, find his preliminary education to have been below the New York standard. In certain circumstances, he may be allowed to make good his defects, provided they are of limited scope. He is thus bringing his "preliminary " education up to standard, after he has received his M.D. degree. This is a concession that the New York Edu- cation Department makes to the loose educational administration of other states. It is to be hoped that after due notice given it may be discontinued. The offending schools may very properly be ex- cluded from the list.
3 Bennett Medical College, Illinois Medical College, Jenner Medical College, Chicago Night Univer- sity, Reliance Medical College.
34 MEDICAL EDUCATION
portunities who cannot piece together scraps enough to gain conditional admission. "The more subjects, the more points," one dean is quoted as saying. Partial certifi- cates— a year's work taken here, a subject or part of a subject taken there — may be added up until the sum equals arithmetically the "units" of a high school course. Moreover, the same subject can be counted twice: English grammar and rhetoric are two subjects, not one; so are English literature and English classics; so biology and zoology. Now, aside from these duplications, it is absurd to sum up fragmentary or isolated "credits" of this kind as "equivalent" to a high school course, even if the details were each adequately tested, as they are not. For a school curriculum is an organic thing in whose continuity and interrelations its educational virtue resides. One subject bears upon another; one year reinforces another. A curriculum has, as such, unity, purpose, method. It is not merely a question of time, still less of de- tached specified amounts without reference to time.1
Things are not essentially different in Baltimore, where the entire matter is regu- lated by voluntary action on the part of the three schools belonging to the division under consideration. The "examination" is of the usual kind: "on a strict account- ing they would all fail." In Louisville, students are admitted into the local school, the medical department of the University of Louisville, by either examination or certificate. The examination covers less than a four-year high school course; certifi- cates are accepted from two-year high schools as full satisfaction of the requirements. Worse still, the school also admits students without either, in flat disregard of its professed standard and of the state board. St. Louis, Denver, Nashville, Pittsburgh, furnish further illustration. In none of these does the examiner exact, whether through examination or in evaluation of certificates, the preliminary standard which he is ostensibly appointed to enforce. In most cases the very word "preliminary" is a misnomer, just as we have found it to be in Illinois. For example, the Ohio re- quirement is not really preliminary to medical education. The schools on the so-called high school or equivalent basis admit students who have not completely satisfied the examiner. Strictly speaking, these students should not be allowed to proceed to the sophomore class; for their medical school credits beyond the first year cannot count until after the admission requirements have been satisfied. Meanwhile they may have reached the senior class. And the moment they satisfy the examiner in re- spect to "preliminaries," now "subsequents" to the extent of two or three years, that moment their previous work in the medical school automatically becomes "good." At Vanderbilt the first-year class had been studying two months, — yet not a single "preliminary" credential had been even submitted to the examiner; at Louisville
1 It is useless to review all the states separately, for the differences are not very significant. Ohio, however, may be instanced as a state in transit towards the Michigan standard. At present, the ex- aminer accepts as equivalent to graduation from an approved high school several alternatives, none of which is really equivalent: (1) whole years taken in different institutions, provided they sum up four; (2) certificates from "known instructors," testifying that candidates have "made up" condi- tions,— no fixed periods of study being required in such cases; (3) examinations, covering hitherto less than the high school course.
ACTUAL BASIS OF MEDICAL EDUCATION 35
work begins November 15, but students have until January 8 before even calling on that functionary. Even Michigan wavers here: for March 1, 1910, had come around before all the first-year students of the Detroit School of Medicine had satisfied the state board. In such cases the requirement may be preliminary to graduation, or to practice, or to what-not; it is absurd to regard it as preliminary to medical education. For the whole purpose of a preliminary is to guarantee a certain degree of training, maturity, and knowledge before the student crosses the threshold of the medical school, on the ground that he is not fit to cross the threshold without it; and this purpose is abandoned if he is allowed to enter without it and subsequently, by hook or crook, in hastily snatched moments, to go through the form of a perfunc- tory compliance that becomes complete some time before he comes up for his M.D. degree. There is no retroactive virtue in such a feat. Educational futility can go no farther. A high school "preliminary requirement,11 scrappily accumulated as a side issue incidental to attendance in the medical school, is worse than nothing to the extent that it has interfered with undivided attention to medical study.1
To all the disorder that prevails in schools of this grade in the United States, the Canadian schools at the same level present, with two exceptions,2 a forcible contrast. There, too, "equivalents" are accepted; but they are equivalents in fact as in name, for they are probed by a series of written examinations, each three hours in length, held at a stated time and place, only and actually in advance of the opening of the medical school, entrance to which is absolutely dependent on their outcome.
The quality of the student body thus accumulated in the schools under discussion bears out the above description. "The facilities are better than the students;" "the boys are imbued with the idea of being doctors ; they want to cut and prescribe ; all else is theoretical;" students accepted in chemistry or physics "don't know a baro- meter when they see it ;" "it is difficult to get a student to want to repeat an experi- ment (in physiology). They have neither curiosity nor capacity." "The machinery does n't stop the unfit." " Men get in, not because the country needs the doctors, but because the schools need the money.1" " What is your honest opinion of your own enrolment?" a professor in a Philadelphia school was asked. "Well, the most I would claim," he answered, "is that nobody who is absolutely worthless gets in"!
1 Some state boards are already in possession of the legal right to enforce a preliminary requirement. The Illinois law, for example, says : "The State Board of Health shall be empowered to establish a standard of preliminary education deemed requisite to admission to a medical college in good stand- ing" (par. 6 b, ch. 91, Kurd's Revised Statutes, 1908). The board is apparently free to refuse ex- amination to any applicant whose completed entrance certificate does not bear date four years prior to his M.D. diploma. The present policy of the Illinois board thus squarely contravenes the obvious intention or the statute. Contrast with this lax procedure the Scotch requirement: "The student must within fifteen days of the commencement of study, obtain registration." (Regulations for the Triple Qualification, ch. i. § 2.)
8 Laval University, Montreal, which admits students below grade ; but they must come to the United States to practise, for they have no standing in Canada ; and Western University, London, Ont., which leaves the entire question to the discretion of the student, who, it is supposed, will conform to the local requirement of the place in which he expects to settle.
86 MEDICAL EDUCATION
We have still to deal with schools of our third division. They are most numerous in the south, but they exist in almost all medical "centers," — San Francisco, Chicago, — there plainly on the sufferance of the state board, for the law, if enforced, would stamp them out, — St. Louis and Baltimore. Outside the south they usually make some pretense of requiring the "equivalent" of a high school education; but no ex- aminer of any kind is employed, and the deans are extremely reluctant to be pinned down. Southern schools of this division, after specifying an impressive series of ac- ceptable credentials ranging once more from university degrees downward, announce their satisfaction with a "grammar school followed by two years of a high school," or in default thereof a general assurance of adequate "scholastic attainments" by a state, city, or county superintendent, or some other person connected with education or purporting to be such ; but the lack of such credentials is not very serious, for the student is admitted without them, with leave to procure them later. Many of the schools accept students from the grammar schools. Credentials, if presented, are casually regarded and then usually returned ; a few may be found, rolled up in a rubber band, in a dusty pigeonhole. There is no protection against fraud or forgery. At the College of Medicine and Surgery, Chicago, a thorough search for credentials or some record of them was made by the secretary and several members of the fac- ulty, through desk drawers, safe, etc., but without avail. The school is nevertheless in "good standing " with the Illinois state board, and is "accredited" by the New York Education Department to the extent of three years' work. At the medical department of the University of Georgia I was told : " We go a long way on faith." In visits to med- ical colleges certificates were found from non-existent schools as well as from non-exis- tent places.1 Of course a few fairly competent students may be found sprinkled in these institutions. But for the most part, the student body gets in on the "equivalent." At the Atlanta School of Medicine, 73 per cent of last year's first-year class entered thus; at the Mississippi Medical College (Meridian, Mississippi), 80 per cent; at Bir- mingham Medical College, 62 per cent. In point of quality, the classes are not com- petent to use such opportunities as are provided. In Atlanta the Grady Hospital is open for bedside clinics to groups of six students; on the average, two come. In Chattanooga it is "rare to get a medical student who knows even a little algebra; it is impossible to use with medical students the text-books in science used in freshman academic classes." At Charlotte I was told that "it is idle to talk of real laboratory work for
1 Accepted certificates are in this form :
To Dean :
Sir : I have examined Mr , of , and find his scholastic attainments equal
to those requisite for a first-grade teacher's certificate in our public schools, with the equivalent of two years of high school study.
Yours very truly.
(Siffn here) Superintendent of Public Inttruction.
These are furnished to the student by the medical college ; he needs only to have them signed. The college does not investigate the signature ; no official mark or seal is asked. Even the medical de- partment of Vanderbilt accepts preliminary certificates in this form.
ACTUAL BASIS OF MEDICAL EDUCATION 37
students so ignorant and clumsy. Many of them, gotten through advertising, would make better farmers. There's no use in having apparatus for experimental physio- logy— the men couldn't use it; they're all thumbs."
Statistical proof of inadequacy of preparation is furnished by what one may fairly call the abnormal mortality within schools operating on the basis of "equivalents." The standards of promotion in these schools watch narrowly the action of the state boards, which are usually lenient. The schools are too weak financially to do otherwise; doubtful points are resolved in the boy's favor.1 Hence the school exam- inations play less havoc than would follow tests strictly constructed in the public interest. Yet the mortality from one cause or another by the close of the first year runs from 20 to 50 per cent. At the Medico-Chirurgical College of Philadelphia an initial first-year enrolment of 152 in October fell to 1002 by the following January first; of these, 60 passed without conditions, much less than one-half the original class enrolment; at Tufts the entering class 1908—9 shows in the catalogue an enrol- ment of 141 ; 75 were promoted, with or without conditions, into the sophomore class;3 at Cornell, on its former high school basis, the failures at the close of the first year in a period often years averaged 28 per cent; at Buffalo, the failed and condi- tioned of three successive first-year classes amounted to 40 per cent of the total en- rolment; at Vanderbilt, out of a class of 70, the dropped, conditioned, and failed amounted to 44 per cent; at the College of Physicians and Surgeons, Atlanta, 70 per cent, out of a class of 99. In schools on the higher basis, i.e., two years of college work or better, the instruction is more elaborate, the work more difficult, and the examinations harder; for scientific ideals rather than chances with the state board dominate. Yet the mortality drops decisively. At the Johns Hopkins, the mortality during three successive years averages less than 5 per cent, only half of which is due to failure; at Ann Arbor, on the one-year college basis, the mortality is below 10 per cent. The exhibit made by institutions that have tried both standards is especially instructive. At the University of Missouri, during the last three years of the high school or equivalent basis, there was a mortality due to actual failure of 35 per cent; during the following three years, when one year of college work was required, the mortality fell to 12£ percent. At the medical department of the University of Minne- sota, during the last three years of the high school requirement, the mortality was
1The dean of one school admitted that he carried "men easily from class to class, but plucked them in the last year," — an excellent thing for the school : it collects three years' fees and still avoids a low record in the state board examinations.
2 Some dropped out because unable to qualify, a few for lack of funds, others because of inability to do the work ; but the enormous number that drop or fail throws a strong light on the miscellaneous character of the enrolment obtained on the "equivalent" basis.
3 It is relatively immaterial to our argument what became of the other 66 ; they represent fatalities for most of which low standards are to blame. As a matter of fact they are thus accounted for : 14 were dropped students (not catalogued with their class on account of conditions); 20 failed of pro- motion ; 17 took all or a portion of first-year examinations 1908-9, but did not return 1909-10 ; 15 left before the final examinations.
88 MEDICAL EDUCATION
18 per cent;1 in the three years following, on the basis of one year of college work, the mortality was about 10 per cent. At the University of Virginia, in the last two years on the old basis, 38 per cent of the students failed in one or more subjects; an increase in entrance requirements by one college year reduces the fatalities to 14 per cent, despite the augmented difficulty of the work. The medical department of the University of Texas has gradually advanced from a two-year high school basis to a four-year high school basis; on the lower standard there were 34 per cent of hopeless failures in 1903, as against 13 per cent of hopeless failures in 1908, on the higher. The requirement of a college year assists doubly, — first, in eliminating the sham equivalents; next, in strengthening the equipment of those who actually persist. Canada accomplishes the former by means of the examinations already noticed, with the result that the mortality there is distinctly less than ours, at something like the same ostensible level.2
The breaches made by the fatalities above described are repaired by immigration, which on investigation proves to be in most instances only another way of evading standards, — entrance and other. To some extent, good students who find themselves in a poor school endeavor to retrieve their error by transferring themselves to a better ; again, there is a certain amount of enforced emigration annually from schools that, like the University of Wisconsin, offer medical instruction in the first two years only. In the main, however, the " lame ducks" move, and, strangely enough, into schools that are at the moment engaged in rejecting a number equally lame. The interchange is veiled by pretended examinations; but the character of the examination can be guessed from the quality of the students that pass it. Two standards are thus often broken at once : An ill equipped student registers in a low- grade Chicago school. At the close of a year or two, he transfers to the College of Physicians and Surgeons, which might have declined him originally. He has thus cir- cumvented its admission requirements. If, now, he has previously failed in the medical coursessofarpursued,and succeeds "on examination" in passing, he has simultaneously circumvented the professional requirements as well. Instances of both kinds abound in schools at and below the high school basis. In 1908-9 the Medico-Chirurgical College of Philadelphia accepted failures from the Jefferson Medical College and
1 This relatively low mortality is to be ascribed to the fact that the student body, though on the high school basis, contained no "equivalents."
1 A tabular statement will perhaps help to bring these facts home. Three institutions on the high basis (Johns Hopkins, Harvard, University of Minnesota) show :
Total enrolment Dropped before examinations Failed and conditioned Patted without condition! 757 2 per cent 17 per cent 81 per cent
Seven of the strongest schools in the United States on the high school or equivalent basis (Jefferson Medical, New York University, University of Maryland, Medieo-Chirurgical, Tufts, Yale, and Uni- versity of Pennsylvania (the last two before elevating their standard) show :
2390 11 per cent 38 per cent £1 per cent
McGill and Toronto show :
945 5 per cent 28 per cent 67 per'cent
ACTUAL BASIS OF MEDICAL EDUCATION 39
the University of Pennsylvania and advanced them to the classes to which they had been denied promotion by the teachers who knew them best; at the same time the Jefferson Medical College1 itself accepted and in the same way advanced failures from New York University and the University of Pennsylvania; Tufts admits as "specials" students failed at Dartmouth, Queen's (Kingston, Ontario), and the Medico-Chirurgical of Philadelphia; the medical department of the University of Illinois (College of Physicians and Surgeons, Chicago) fairly abounds in rejected students from other schools, and in emigrated students from the low-grade insti- tutions of Chicago and elsewhere; of the same character is a large part of the en- rolment of the medical department of Valparaiso University. Failures from Ann Arbor are regarded as worthy of advancement by Northwestern (Chicago). The Physi- cians and Surgeons of Baltimore gives time and subject credit — after "examination," of course — to failures turned out of the University of Buffalo, New York University, the University of Pennsylvania, the Jefferson Medical College, and Yale; the Uni- versity of Maryland is equally indiscriminate, advancing to the classes which they had failed to reach students from most of the same institutions and some from the local College of Physicians and Surgeons and the Baltimore Medical College, besides. Other Jefferson Medical failures, not to be found in the two Baltimore schools just named, should be looked for in the Baltimore Medical College, together with failures from Tufts, Long Island Hospital Medical College, etc. The upper classes of two Baltimore schools — the Maryland Medical College and the Atlantic Medical Col- lege— are largely recruited by emigration from other schools;2 the latter of these had (1908-9) a senior class of 31, a freshman class of 1, — and every member of the senior class had been admitted to advanced standing from some other school.3
Is this the best that can be done? Will the actual enforcement of a real and ade- quate standard starve any section of the country in the matter of physicians?
The question can be answered without guesswork or speculation. The south re- quires something like 400 doctors annually.4 How high a standard can it enforce, and still get them? In the year 1908—9 there were 15,791 male students in four-year high schools in six southern states,6 — Alabama, Georgia, Louisiana, South Carolina, Vir-
1 This institution, like others, admits to advanced standing a considerable number of students from schools whose entrance requirements are much below its own ; e.g., in the session above referred to, there were several students from the medical department of Fort Worth University, whose entrance requirement is nominal ; from the University or Oregon, College of Physicians and Surgeons, San Francisco, Keokuk, Denver and Gross. At the same time, it deals severely with its own student body, for it refuses promotion annually to a large number, who emigrate chiefly to Baltimore.
2 Mississippi Medical College, Meridian, was similarly recruited.
3 Among other schools guilty of advancing students to whom promotion had been refused by their own schools may be mentioned : College of Physicians and Surgeons, Atlanta, Georgetown Univer- sity (Washington, D. CA Denver and Gross, University of Colorado, George Washington Univer- sity, Milwaukee Medical College.
4 The former secretary of the Southern Medical College Association calculated that 300 would suffice.
5 For these figures we are indebted to a painstaking census conducted by the secondary school in- spectors maintained in these states by the General Education Board.
40 MEDICAL EDUCATION
ginia and Texas; there were in the previous year 5877 male students in the academic departments of the southern state universities, and 1653 more in endowed institu- tions of similar grade;1 a population of over 23,0002 bordering on high school gradua- tion and widely distributed over the entire area. Our question is thus already an- swered. The best material for the making of a few hundred southern doctors annually does not have to be torn from the plough.
But these figures convey by no means the whole truth. The south is in the midst of a genuine educational renaissance. Within the last few years every southern state under the leadership of the state university, the state department of education, and certain endowed institutions like Vanderbilt University, has set enthusiastically to work to develop its common and secondary school systems after the admirable model furnished by the robust communities of the middle west. The professors of secondary education in the state universities are the evangelists of this auspicious movement. Young, intelligent, well trained, these sturdy leaders ceaselessly traverse the length and breadth of their respective states, stimulating, suggesting, guiding, organizing. It is an inspiring spectacle. Three years ago the high school had no legal standing in Virginia; to-day the state is dotted with two-year, three-year, and four-year high schools, created by local taxation, with a considerable subvention from the state treasury. There are already 2511 boys in fairly well equipped four-year high schools, and as many more in private institutions of equal value; and the two-year and three- year schools are growing rapidly into fuller high school stature. It needs no argument to prove that Virginia can at once procure its doctors from among the bvna-jide gra- duates of such high schools and better. What is true of Virginia is tine of every other southern state. In Alabama, for example, three years ago there was scarcely a pub- lic high school in the state ; to-day there are 61 public four-year high schools,3 1 1 pri- vate four-year high schools, and 15 town and city three-year high schools. Of the 345 teachers employed in these schools, 184 are college graduates and 55 more have had at least two years of college work. Of course the situation is uneven; it lacks homogeneity. Standards are more or less confused; distinctions are not everywhere clear. The schools have frequently shot up like ungainly boys, who first get their height and fill up afterwards; their four years are not yet the four years of Boston or Indianapolis. But this is a phenomenon of hopeful omen ; it provides the frame- work for a vigorous and imminent maturity. The universitiesand the professional schools have in this emergency a clear duty : to call things by their right names, to abandon the apologetic attitude, to cease from compromises which tempt the student from the high school and then set up the successful temptation as a sufficient excuse for their
1 Compiled from the Report of the United States Commissioner of Education, 1908.
* Not including four-year high schools of Mississippi, Florida, North Carolina, Tennessee, Arkansas, and Kentucky, which would considerably increase these figures. They are omitted because equally reliable data are not at hand.
* Under legislative enactment approved August 7, 1907, the state contributes $2000 a year to aid any county that establishes its own nigh school
ACTUAL BASIS OF MEDICAL EDUCATION 41
own folly in so doing. Let them reinforce the high school by the opposite policy; they will soon perceive the needlessness of the exceptions which they still suggest, and often even require. How much longer will the southern people, generously spend- ing themselves in the effort to create high school systems, continue to handicap their development by allowing medical education legally to rest on an ante-bellum ba^s?
The duty of the southern universities at this juncture is clear. They are equally bound to assist the development of the secondary school and to furnish the southern people an improved type of physician. They do both if, while actually enforcing the standard above advocated, they provide the best medical training obtainable at that level. As a matter of fact, a highly useful doctor can be trained on the high school basis if his defects, frankly admitted, are made the occasion for more, instead of less, efficient instruction. The weak southern schools apologize for their wretchedness by alleging the shortcomings of the student body. But the shortcomings of the students are a call for better, rather than an excuse for worse, teaching. On the whole, a south- ern university will for a time probably do best to put its strength unreservedly into the improved instruction of a larger body of students at the high school level, rather than to train a smaller body on a somewhat higher basis. What with the other influences working to discredit the proprietary medical school, if Tulane, Vanderbilt, and Texas furnish actual high school graduates with an education as good as that of Toronto or of McGill, they will soon get control of the field, they will educate the southern public to look to them for their physicians, and they will induce the state legislatures to support a position undeniably reasonable, so that when they at last make the upward move, there will be no low-grade medical schools to profit by the step and to make it a pretext for the continuance of commercialism in medical education.1 »
The state of Texas has taken a sound and yet conservative position. Beginning with 1909, it has decreed a gradual annual rise of standard that will shortly re- sult in making its four-year high school the legal basis of medical education. Cau- tious elevation thus avoids all danger of breaking with the state school system. The statute is not free from defects, for it provides for the acceptance, at their face value, of the medical student certificates of reciprocating states; but the Texas state board, having dealt vigorously with the worst of the Texas schools, will in all probability make effective use of the power in its hands. Other southern states must inevitably follow. It is of course important that they should not move faster than their edu- cational facilities; but it is equally important that they should not move any more slowly. Thus far, Texas alone has made an effort to keep pace.
The situation is even clearer, in so far as it touches the rest of the country. We estimate2 that outside the south 1500 doctors annually graduated will provide for
1 For more detailed consideration on this point, the reader is referred to the discussions in Part II of the various southern states.
2 In chapter a.
42 MEDICAL EDUCATION
all the real and many imaginary needs. There are at this date something like 8000 public and over 1000 private high schools, so widely dispersed over the area under consideration that on the average few boys need go over five miles to school.1 In the public high schools alone there are enrolled 300,000 boys.8 What excuse exists for cutting under the high school? We can indeed do better than to accept as the basis of a medical education the high school "flat." In the colleges, universities, and technical schools of the north and west, exclusive of preparatory and professional departments, there were in 1908, 120,000s male students. The number swells with unprecedented rapidity ; long before the country has digested the number of doctors now struggling for a livelihood, it will have doubled. Already in 1907, 903 of the doctors graduated in that year held academic degrees; that is to say, fully one-half of the number the country actually needed could conform to the standard that has been urged, or better. There is at this moment absolutely nothing in the educational situation outside the south that countenances the least departure from the scientific basis necessary to the successful pursuit of modern medicine.
For whose sake is it permitted? Not really for the remote mountain districts of the south, for example, whence the "yarb doctor,"" unschooled and unlicensed, can in no event be dislodged; nor yet for that twilight zone, on the hither edge of which so many low-grade doctors huddle that there is no decent living for those already there and no tempting prospect for anybody better: ostensibly, "for the poor boy." For his sake, the terms of entrance upon a medical career must be kept low and easy. We have no right, it is urged, to set up standards which will close the profession to "poor boys."
What are the merits of this contention ? The medical profession is a social organ, created not for the purpose of gratifying the inclinations or preferences of certain individuals, but as a means of promoting health, physical vigor, happiness — and the economic independence and efficiency immediately connected with these factors. Whether most men support themselves or become charges on the community depends on their keeping well, or if ill, promptly getting welL Now, can anyone seriously contend that in the midst of abundant educational resources, a congenial or profit- able career in medicine is to be made for an individual regardless of his capacity to satisfy the purpose for which the profession exists? It is right to sympathize with those who lack only opportunity; still better to assist them in surmounting obsta- cles; but not at the price of certain injury to the common weal. Commiseration for the hand-spinner was not suffered for one moment to defeat the general economic advantage procurable through machine-made cloth. Yet the hand-spinner had a sort of vested right: society had tacitly induced him to enter the trade; he had grown up in it on that assurance; and he was now good for nothing else. Your "poor boy"
1 Wilgus, Legal Education in the United States, p. 29.
1 There are 33,000 more in the preparatory departments of colleges and universities.
•We are indebted for these statistics to the United States Commissioner of Education.
ACTUAL BASIS OF MEDICAL EDUCATION 43
has no right, natural, indefeasible, or acquired, to enter upon the practice of medi- cine unless it is best for society that he should.
As a matter of fact, the attainments required by our entire argument are not, as a rule, beyond the reach of the earnest poor boy. He need only take thought in good season, lay his plans, be prudent, and stick to his purpose. Without these qualities, medicine is no calling for him ; with them, poverty will rarely block his way. Besides, if poverty is to be a factor in determining entrance standards, just where does pov- erty cease to excuse ignorance? Apparently the inexcusable degree of ignorance be- gins just where the ability to pay fees leaves off. For the schools that maintain "equivalents'1 for the sake of the "poor boy" are not cheap, and the student who can pay his expenses in them can also pay for something better, and pay his fees the student must; for it is precisely the proprietary and independent schools, avowedly solicitous for the "poor boy," that do the least for him by way of scholarship or other exemption.1 They exact a complete settlement in cash or notes. Thus a four-year medical education in Baltimore, Philadelphia, or Chicago schools, on the "equiva- lent" basis, costs a boy in tuition fees and board about $1420. The same student can go to Ann Arbor, get there two years of college work in the pre-medical sciences and modern languages, and four years in medicine, besides, for an expenditure of SI 466, covering the same items. Thus six years at Ann Arbor are not appreciably more ex- pensive than four years in Baltimore, Philadelphia, or Chicago. Or, if a large city be preferred, he can get his two years in the admirable pre-medical laboratories of the University of Minnesota, at Minneapolis, followed by his four-year medical work there, for very little more. Low entrance requirements flourish, then, for the benefit of the poor school, not of the poor boy. Meanwhile, opportunities exist, in a measure during the school year, still more during vacation, to earn part, perhaps all, of the required sum.2 Doubtless in the near future, the problem will be still further simpli- fied in the interest of the better training by increased scholarship and other endow- ments, as in Germany. Meanwhile, it is dubious educational philanthropy to interrupt a poor boy's struggle upwards by inviting him into a medical school where there are excessively large chances of failure, escaping which he is at once exposed to a disad- vantageous competition with men better trained by far.
So much from the standpoint of the individual. The proper method of calculating cost is, however, social. Society defrays the expense of training and maintaining the medical corps. In the long run which imposes the greater burden on the community, —
1 Three scholarships, amounting to tuition fees for one year, are, however, annually awarded at the University of Maryland.
2 It is stated that at the University of Chicago "the opportunities for taking work are more numer- ous than the number of students desiring to take advantage of them. . . . There is ample opportunity for the energetic student to earn his way, either in whole or in part, and opportunities usually out- number those seeking them. " School Review, January, 1910 (Notes and News). It must, of course, be remembered that only the vigorous and talented can afford to undertake the study of medicine under such conditions. The others are barred just as effectively from the low-grade as from the high-grade school. Students are found "working their way through" at the medical departments of Harvard, Michigan, Toronto, McGill, etc.
44 MEDICAL EDUCATION
the training of a needlessly vast body of inferior men, a large proportion of whom break down, or that of a smaller body of competent men who actually achieve their purpose? When to the direct waste here in question there is added the indirect loss due to in- competency, it is clear that the more expensive type is decidedly the cheaper. Aside from interest on investment, from loss by withdrawal of the student body from produc- tive occupations, the cost of our present system of medical education is annually about 83,000,000, as paid in tuition fees alone. The number of high-grade physicians really required could be educated for much less; the others would be profitably employed elsewhere; and society would be still further enriched by efficient medical service.
The argument is apt to shift at this point. If we refuse to be moved by the "poor boy," pity the small towns; for it is speciously argued that the well trained, college- bred student will scorn them. Not sympathy for the poor boy requires us now to sacrifice the small town to him, but sympathy for the small town requires us to sac- rifice the poor boy to it. Two vital considerations are overlooked in this plea. In the first place, the small town needs the best and not the worst doctor procurable. For * the country doctor has only himself to rely on : he cannot in every pinch hail spe- cialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there. But, we are told, the well trained man will not go; he will not pay for a high-grade medical education and then con- tent himself with a modest return on his investment. Now the six-year medical edu- cation (that based on two college years) and the four-year medical education (that based on the high school or equivalent) may, as we saw above, be made to cost the same sum. As far as cost is concerned, then, the better sort of four-year medical edu- cation mifct have precisely the same effect on distribution of doctors as the six-year training furnished by the state universities. If a Jefferson graduate is not deterred by the cost of his education from seeking a livelihood in the country, the Ann Arbor or Minnesota man will not be deterred, either. But a deeper question may be raised. What is the financial inducement that persuades men scientifically inclined to do what they really like ? — for a man who does not like medicine has no business in it. How far does the investment point of view actually control? Complete and reliable data are at hand. The college professor has procured for himself an even more elaborate and expensive training than has here been advocated for the prospective physician. Did he require the assurance of large dividends on his investment? "The full professor in the one hundred institutions in the United States and Canada which are financially strongest receives on the average an annual compensation of approximately $2500." * But the scholar does not usually advance beyond the assistant professorship : what fig- ure has financial reward cut with him ? "At the age of twenty-six or twenty-seven, after seven years of collegiate and graduate study, involving not only considerable outlay,
1 " The Financial Status of the Professor in America and in Germany." Carntgit Foundation for th« Adtanrement of Teaching, Bulletin II., p. vi.
ACTUAL BASIS OF MEDICAL EDUCATION 45
but also the important item of the foregoing of earning during this period, he is the proud possessor of his Ph. D. and is ready to enter his profession. The next five years he spends as instructor. In his thirty-second year he reaches assistant professorship. He is now in his thirty-seventh year, having been an assistant professor for five years. His average salary for the ten years has been $1325. ... At thirty-seven he is mar- ried, has one child, and a salary of $1800." * In Germany "the road to a professor- ship involves a period of training and of self-denial far longer and more exacting than that to which the American professor submits;"3 in France "there are no pe- cuniary prizes whatever in their calling for even those who attain its highest posts."3 What is even more to the point, — the posts of instructor and assistant in small col- leges situated in out-of-the-way places can be readily filled at slender salaries with expensively trained men. Of course there are compensations. But the point is that a large financial inducement is not indispensable, provided a man is doing what he likes. In most sections the country doctor has better worldly prospects. The fact stands out that it is not income but taste that primarily attracts men into scholarly or professional life. That granted, the prospect of a modest income does not effectually deter ; and not infrequently the charm of living away from large cities may even attract.
Our limited experience with physicians trained at a high level sustains this view. We have thus far produced relatively few college-bred physicians; large cities have bid high for them, without, however, bagging all. Johns Hopkins graduates in med- icine, to take the highest quality the country has produced, are already scattered through thirty-two states and territories. As if to prove that money is not the sole deciding consideration^ dozen have gone as missionaries to the Orient and several into the army and navy. In this country there is a Johns Hopkins man practising at Clay- ton, Alabama, with 1000 inhabitants; at Fort Egbert, Alaska, with 458; at Gorham, Colorado, with 364; at Chattahoochee, Florida, with 460; at Fort Bayard, New Mex- ico, with 724; at Sonyea, New York, with 300; at Blue Ridge Summit, Pennsylvania, with 50; at Wells River, Vermont, with 660; at Fairfax, Virginia, with 200; at Fort Casey, Washington, with 300; at Kimball, West Virginia, with 2000; at Mazomanie, Wisconsin, with 900. They have scattered to the four winds, and inevitably.4 No single influence controls : home, money, taste, opportunity, all figure. When we have produced as large a number of well trained doctors as Germany, they will be found in our villages, just as one finds them over there. Minnesota, closed after 1912 to all low-grade graduates, Kansas and North and South Dakota, agricultural states, Con-
1 Statistics from twenty leading universities, discussed by Guido H. Marx in address. The Problem of the Assistant Professor, before Association of American Universities, January, 1910.
2 Carnegie Foundation, Bulletin II., p. vii.
3 Bodley : France, voL i. p. 54.
4 Western Reserve men (three years of college required for entrance) are to be found in Cochranton, Pennsylvania (population, 724); Solon Springs, Wisconsin (population, 400); Kinsman, Ohio (popula- tion, 824) ; Rawson, Ohio (population, 552).
46 MEDICAL EDUCATION
necticut, Indiana, Colorado, look forward confidently to the high standard basis. Is there any reason founded in consideration for public welfare which holds back Illinois, New York, Pennsylvania, from similar action?
There is, however, still another standpoint from which the question under discus- sion ought to be viewed. We have been endeavoring to combat the argument in favor of admittedly inferior schools dependent on fees on the ground that in the east, north, and west, these schools have already outlived their usefulness; that, even in the south, the need, greatly exaggerated, will gradually disappear. Let us, how- ever, for the moment concede that the south, and perhaps other parts of the country, still require some medical schools operating on the high school basis, or a little less. Does it follow that the proprietary or independent unendowed medical school has thereby established its place? By no means. It is precisely the inferior medical stu- dent who requires the superior medical school. His responsibilities are going to be as heavy as those of his better trained fellow practitioner : to be equally trustworthy, his instruction must be better, not worse. The less he brings to the school, the more the school must do for him. The necessity of recruiting the medical school with high school boys is therefore the final argument in favor of fewer schools, with better equipment, conducted by skilful professional teachers.
The truth is that existing conditions are defended only by way of keeping un- necessary medical schools alive. The change to a higher standard could be fatal to many of them without in the least threatening social needs. Momentarily there would be a sharp shrinkage. But forethought would be thus effectively stimulated; trained men would be attracted into the field; readjustment would be complete long before any community felt the pinch.1 Despite prevailing confusion — legal, popular, and educational — as to what good training in medicine demands, the enrolment in the five schools which have during the last four years required two or more years of college work is already 1186 students, and is increasing rapidly.2 When the Johns Hopkins plans were under discussion in the middle seventies, Dr. John S. Billings, the adviser of the trustees in things medical, suggested that the graduating class be limited to twenty-five. " I think it will be many years before the number of twenty-five for the graduating class can be reached," he said.8 The school opened in 1893; the first class, graduated in 1897, numbered 15; the third, graduated in 1899, numbered 32: so promptly did the country respond. Institutions that have switched from the high
1 It has been calculated that in the supply of doctors the country is now "about thirty-five years in advance of the requirements"! Benedict : Journal of American Medical Auociation, vol. lii., no. 5, pp. 378, 379.
1 In the sixteen schools on the two-year college basis there were (1908-9) 1850 students who had en- tered at that level. The total enrolment in these sixteen institutions was much greater, because the upper classes in several had entered on a lower basis. These figures are far from the total number of college men in medical schools. The pity is that they are scattered through institutions in which they lose the advantage which their education should give them.
* Medical Education: Extract! from Lecture* before the Johnt Hopkins Univertity, 1877-8, p. 22 (Balti- more, 1878).
ACTUAL BASIS OF MEDICAL EDUCATION 47
school to the college standard after due notice given1 have thus far lost only one- half or less of their former enrolment. The only thing that falls in proportion is the income from fees ; the percentage of graduates is reduced much less. At the Univer- sity of Minnesota, there used to be an average first-year attendance of 80 on the high school basis; on the two-year college basis it is now 40; at Harvard on the former basis, 160 new matriculants; now, on a college basis, 79. Western Reserve, with 34 on the high school basis, advanced suddenly in 1901 to a three-year college requirement; the enrolment fell to 12, but by 1908 the loss was practically recovered. Most significant is the demonstration that the greatest loss is due to the transition from the high school or equivalent to the one-year college basis ; the rise from one to two years of college has relatively little effect on enrolment. It would appear that the college requirement compels deliberation. Once decided, the student is not seri- ously hampered by the effort or the expense of an additional year.
It does not follow, however, that if schools generally rose to the college require- ment, their losses would be only one-half and the recovery therefrom ultimately as- sured. For the schools that came off thus lightly were previously attended by a large proportion of high-grade men.2 A much greater loss would undoubtedly take place in the lower-grade schools; many of them would be practically annihilated. For the tendency of elevated standards and ideals is to reduce the number of students to something like parity with the demand, and to concentrate this reduced student body in fewer institutions, adequately supported.
The basis which we have urged for medical education gives an undoubted advan- tage to the university medical departments. We shall see in subsequent chapters that other equally important factors are at work tending to restore medical educa- tion to the university status ; but for the moment the difficulty of procuring anywhere else the necessary educational foundation is perhaps most cogent. A countermove, by way of avoiding this tendency, has recently emanated from certain Philadelphia schools,8 in the form of a suggested five-year course, the first year to be devoted to the pre-medical sciences.
Several serious objections to this proposition may be urged: (1) a single year is insufficient for three laboratory sciences, and makes no provision for modern lan- guages; the very best medical schools could with difficulty give one year's pre-medi-
1 Cornell changed from the high school to the three-year college requirement with less than a year's notice. There was, of course, no chance to readjust matters; the next first-year class (1908) num- bered 15 ; in 1909, this increased to 23.
2 In these schools standards were elevated in advance of the operation of the formal declaration to that effect. For example, Columbia (College of Physicians ana Surgeons, New York) goes to the two-year college basis 1910-11 ; but the entering class 1909-10 contained among its 86 matriculates 48 students with degrees, and 1 1 more who had had two years of college work.
3 These schools have no endowments ; and the pre-medical sciences cannot be properly taught out of fees, as will become evident in chapter viii., "The Financial Aspects of Medical Education. "Hence the work must be mainly make-believe. It would have to be given by already overburdened science teachers or, still worse, by practitioners. The Medico-Chirurgical College of Philadelphia offers these courses "in conjunction with classes in the sister department of pharmacy. "This is absurd.
48
cal work, — they cannot possibly give two; as for anything more liberal, there is no chance at all. Hence the step would shortly prove an obstruction to further progress. (2) Unquestionably, the day is coming when the medical school proper will want a fifth or hospital year, — a culmination that will be indefinitely postponed if the year in question is prefixed to the course and assigned to preliminary training. (3) Finally, the arrangement protracts our present educational disorganization. It proposes that the medical school should do the work of the college, just as it is either doing — or doing without — the work of the high school. Now the strength of an educational system is wholly a question of the competent performance of differentiated function by each of its organic parts. Our tardily awakened educational conscience and in- telligence find themselves confronted with several independent and detached educa- tional agencies, — high schools, colleges, professional schools. Obviously, they are not indifferent to each other; they belong in a definite order and relation. We now know perfectly well what that order, what that relation, is. And the solidity of our educational and scientific progress depends on our success in making it prevail. To no inconsiderable extent, inefficiency has been due to irresponsibility resulting from just this lack of organized relationships; and the cure for evils due to lack of responsibility is not less responsibility, but more; not less differentiation, but more. The reconstruction of our medical education on the basis of two years of required college work is not, however, going to end matters once and for all. It leaves un- touched certain outlying problems that will all the more surely come into focus when the professional training of the physician is once securely established on a scientific basis. At that moment the social role of the physician will generally expand, and to support such expansion, he will crave a more liberal and disinterested educational experience. The question of age — not thus far important because hitherto our demands have been well within the limits of adolescence — will then require to be reckoned with. The college freshman averages nineteen years of age ; two years of college work permit him to begin the study of medicine at twenty-one, to be graduated at twenty- five, to get a hospital year and begin practice at twenty-six or twenty-seven. No one familiar with the American college can lightly ask that this age be raised two years for everybody, for the sake of the additional results to be secured from non-profes- sional college work. There is, however, little question that compression in the ele- mentary school, closer articulation between and more effective instruction within secondary school and college, can effect economies that will give the youth of twenty- one the advantage of a complete college education. The basis of medical education will thus have been broadened without deferring the actual start. Meanwhile we are so far from endeavoring to force a single iron-clad standard on the entire country that our proposition explicitly recognizes at least three concurrent levels for the time being: (1) the state university entrance standard in the south, (2) the two-year college basis as legal minimum in the rest of the country, (3) the degree standard in a small number of institutions.
ACTUAL BASIS OF MEDICAL EDUCATION 49
The practical problem remains. How is the existing situation to be handled? The higher standard is alike necessary and feasible. How long is it to be postponed be- cause it threatens the existence of this school or of that? In general, our medical schools, like our colleges, are local institutions; their students come mainly from their own vicinity. The ratio of physicians to population in a given state is there- fore a fair indication of the number of medical schools needed. Where physicians are superabundant, and high schools and colleges at least not lacking, the medical schools cannot effectively plead for mercy on the ground that elevated standards will be their death. New York has two schools on the two-year college basis or bet- ter; nine others rest on a lower basis. They would improve if they could "afford it."1 But with one doctor for every 600 people in the state, with accessible high schools, with cheap — and in New York City, at least, free — colleges, it is absolutely immate- rial to the public whether they can afford it or not. The public interest demands the change. We may therefore at once assume (what everybody grants) that the problem is insoluble on the basis of the survival of all or most of our present medical schools. To live, they must get students ; they must get them far in excess of the number they will graduate; they must graduate them far in excess of the number of doctors needed. They will therefore require their clientele of ill prepared, discon- tented, drifting boys, accessible to successful solicitation on commercial lines. In- evitably, then, the way to better medical education lies through fewer medical \ schools ; but legal enactments on the subject of medical education and practice will be required before the medical schools will either give up or relate themselves soundly to the educational resources of their respective states. No general legislation is at the moment feasible. The south, for instance, may well rest for a time, if every state will at once restrict examinations for license to candidates actually possessing the M.D. degree, and require after, say, January 1, 1911, that every such degree shall ema- nate from a medical school whose entrance standards are at least those of the state university. Such legislation would suppress the schools that now demoralize the situ- ation; it would concentrate the better students in a few solvent institutions to which the next moves may safely be left. Elsewhere, every available agency should be em- ployed to bring examining boards to reinterpret the word "equivalent" and to adopt efficient machinery for the enforcement of the intended standard. Equivalent means "equal in force, quality, and effect." The only authorities competent to pass on such values are trained experts. The entire matter would be in their hands if the state boards should in every state delegate the function of evaluating entrance credentials to a competently organized institution of learning. In many states, the state university
1The dean of a superfluous southern medical school writes : "Our faculty gets only what's left after all expenses are paid, and that averages $400 per session of seven months. This we will cheerfully forego, and teach gratis, if only a class, or endowment, will pay cost of running the college. We will advance to the highest requirements just as soon as the conditions will admit, and are ready now to open next session under highest requirements if the wherewith to pay expenses is in sight" Ob- serve that there is small consideration here for the "poor boy" or the "back country;" it is simply a question of college survival.
50 MEDICAL EDUCATION
could very properly perform this duty ; elsewhere, an equally satisfactory arrangement could be made with an endowed institution. Whatever the standard fixed, it would thus be intelligently enforced. The school catalogues would then announce that no student can be matriculated whose credentials are not filed within ten days of the opening of the session, and that no M. D. degree can be conferred until at least four years subsequent to complete satisfaction of the preliminary requirement. These cre- dentials, sent at once to the secretary of the state board, would be by him turned over to the registrar of the state or other university, whose verdict would be final. A state that desired to enforce a four-year high school requirement could specify as satisfying its requirements:
(1) Certificate of admission to a state university requiring a four-year high school education ;
(2) Certificate of admission to any institution that is a member of the Association of American Universities;
(3) Medical Student Certificate of the Regents of the University of the State of New York;
(4) Certificates issued by the College Entrance Examination Board for 14- units. In exchange for such credentials, or for high school diplomas acceptable to the
academic authorities acting for the state board, a medical student certificate would be issued; in default thereof, the student must by examination earn one of the afore- said credentials, in its turn to be made the basis of his medical student certificate. In the southern states, the legal minimum would be necessarily below the four-year high school; in Minnesota, above it. But the same sort of machinery would work. The schools would have nothing to do with it except to keep systematically regis- tered the name of the student and the number of his certificate; the state board or the university acting for it would keep everything else, open to inspection.
This is substantially what takes place in New York, where the State Education De- partment superintends the process. What is wanted in other states is an agency similarly qualified. For the present nothing can so well perform the office within a given state as its state university, or, in default thereof, the best of its endowed in- stitutions. This suggestion is perfectly fair to all medical schools, for the credentials would pass through the hands of the state board to the reviewing authority without information as to the purpose of the applicant. The directions required would take up less space in the medical school catalogues than the complicated details they now contain. It should be further provided that the original credentials of every student be kept on file in the office of the state board or the reviewing university, and that they shall be open to inspection, without notice, by properly accredited representa- tives of medical and educational organizations. These simple measures would intro- duce intelligence and sincerity where subterfuge and disorder now prevail. The bene- ficial results to the high school and the medical school would be incalculable. Nor would the poor boy be subjected to the least hardship; for by exercising forethought,
ACTUAL BASIS OF MEDICAL EDUCATION 51
he could accumulate genuine scholastic credits by examination or otherwise, pari passu, during the time he is accumulating the money for his medical education. So much actually accomplished, the rest will be easier. The reduced number of schools will not resist the forces making for a higher legal minimum. The state universities of the west will doubtless lead this movement; for once established on the two-year college basis, they will induce the states to protect their own sons and the public health against the lower-grade doctors made elsewhere. The University of Minnesota, j having by statesmanlike action got rid of all other medical schools in the state, is thus 1 backed up by the legislature and the state board. North Dakota and Indiana have taken the same stand. Michigan and Iowa will probably soon follow. "The adjust- ment is perhaps difficult, but not too difficult for American strength."1
1 Adapted from Billroth: Ueber das Lehren und L«rn«n d*r medicinischen Wiuenachaft, quoted by Lewis, loc. cit.
CHAPTER IV
THE COURSE OF STUDY: THE LABORATORY BRANCHES
(A) FIRST AND SECOND YEARS
THREE characteristic stages are to be discerned in the evolution of medical teaching.1 The first and longest was the era of dogma. Its landmarks are Hippocrates (B.C. 460- 377) and Galen (A. D. 130-200), whose writings were for centuries transmitted as an authoritative canon. Observation and experience had indeed figured considerably in their composition,8 but increasingly remote disciples in accepting the tradition lost all interest in its source. The Galenic system took its place in the medieval univer- sity with Euclid and Aristotle, — a thing to be pondered, expounded and learned; facts had no chance if pitted against the word of the master. So completely was medicine dominated by scholasticism that surgery, employing such base tools as sight and touch, was held to be something less than a trade and accordingly excluded from intellectual company.
The second era is that of the empiric. It began with the introduction of anatomy in the sixteenth century, but did not reach its zenith until some two hundred years later. At its best it leaned upon experience, but its means of analyzing, classifying^ and interpreting phenomena were painfully limited. Medical art was still under the sway of preconceived and preternatural principles of explanation ; and rigorous ther- apeutic measures were not uncommonly deduced from purely metaphysical assump- tions. The debility of yellow fever, for example, Rush explained by "the oppressed state of the system;" and on the basis of a gratuitous abstraction, resorted freely to purging and bleeding. His first four patients recovered; there is no telling how many lives were subsequently sacrificed to this conclusive demonstration. The fact is that the empiric lacked a technique with which to distinguish between apparently similar phenomena, to organize facts, and to check up observation; the art of differentiation through controlled experimentation was as yet in its infancy. Under vague labels like rheumatism, biliousness, malaria, or congestion, a hodgepodge of dissimilar and unrelated conditions were uncritically classed; the names meant nothing, but they answered as explanation, and even sanctioned severe and nauseous medication. Igno- rant of causes, the shrewdest empiric thus continued to confound totally unlike conditions on the basis of superficial symptomatic resemblance; and with amazing assurance undertook to employ in all a therapeutic procedure of doubtful value in any. He combined the vehemence of the partisan with something of the credulity of
1 Nothing would do more to orient the student intelligently than a knowledge of the history of medical science and teaching. It is a great pity that some effort is not made in the better medical schools to interest the student in the subject. A proper historical perspective would render impos- sible such opposition to improved medical teaching as is now based on conscientious but mistaken devotion to outgrown conditions.
*"The correct inductive method was borne in on the triumph of Hippocrates." Compere's Greek Thinluri (translated by Magnus, vol. i. p. 308).
THE LABORATORY BRANCHES 53
a child, persuading too often by ardent insistence rather than by logical proof. His students were thus passive learners, even where the teaching was demonstrative. They studied anatomy by watching a teacher dissect; they studied therapeutics by taking the word of the lecturer or of the text-book for the efficacy of particular remedies in certain affections.
The third era is dominated by the knowledge that medicine is part and parcel of modern science. The human body belongs to the animal world. It is put together of tissues and organs, in their structure, origin, and development not essentially un- like what the biologist is otherwise familiar with ; it grows, reproduces itself, decays, according to general laws. It is liable to attack by hostile physical and biological agencies ; now struck with a weapon, again ravaged by parasites. The normal course of bodily activity is a matter of observation and experience; the best methods of combating interference must be learned in much the same way. Gratuitous specu- lation is at every stage foreign to the scientific attitude of mind.
We may then fairly describe modern medicine as characterized by a severely criti- cal handling of experience. It is at once more skeptical and more assured than mere empiricism. For though it takes nothing on faith, the fact which it accepts does not fear the hottest fire. Scientific medicine is, however, as yet by no means all of one piece; uniform exactitude is still indefinitely remote; fortunately, scientific integrity does not depend on the perfect homogeneity of all its data and conclusions. Modern medicine deals, then, like empiricism, not only with certainties, but also with pro- babilities, surmises, theories. It differs from empiricism, however, in actually know- ing at the moment the logical quality of the material which it handles. It knows, as empiricism never knows, where certainties stop and risks begin. Now it acts confi- dently, because it has facts; again cautiously, because it merely surmises; then tenta- tively, because it hardly more than hopes. The empiric and the scientist both theo- rize, but logically to very different ends. The theories of the empiric set up some unverifiable existence back of and independent of facts, — a vital essence, for example; the scientific theory is in the facts, — summing them up economically and suggesting practical measures by whose outcome it stands or falls. Scientific medicine, therefore, has its eyes open; it takes its risks consciously; it does not cure defects of knowledge by partisan heat; it is free of dogmatism and open-armed to demonstration from whatever quarter.
On the pedagogic side, modern medicine, like all scientific teaching, is character- ized by activity. The student no longer merely watches, listens, memorizes; he does. His own activities in the laboratory and in the clinic are the main factors in his in- struction and discipline. An education in medicine nowadays involves both learning and learning how; the student cannot effectively know, unless he knows how.
Two circumstances have mediated the transformation from empirical to scientific medicine: the development of physics, chemistry, and biology; the elaboration out of them of a method just as applicable to practice as to research. The essential de-
54 MEDICAL EDUCATION
pendence of modern medicine on the physical and biological sciences, already ad- verted to,1 will hereafter become increasingly obvious in the wealth of the curricula based upon them, and no less in the poverty of those constructed without them. But the practical importance of scientific method as such to the general practitioner is by no means so generally conceded. Its function in investigation is granted : there it is justified by its own fruits. But what has this to do with the education or the daily routine of the family doctor?
The question raised is fundamental; the answer decides the sort of medical edu- cation that we shall seek generally to provide. If, in a word, scientific method and interest are of slight or no importance to the ordinary practitioner of medicine,8 we shall permanently establish two types of school, — the scientific type, in which en- lightened and progressive men may be trained; the routine type, in which "family doctors'" may be ground out wholesale. If, on the other hand, scientific method is just as valuable to the practitioner as to the investigator, it may indeed be expe- dient partly, or even in some instances altogether, to set aside gifted individuals as teachers or investigators and to guard the undergraduate student against original work prematurely undertaken. But this will not be construed to involve the abrupt and total segregation of medical education from medical research. Much of the edu- cator's duty may consist in traversing a well known path; but if otherwise he is pro- gressively busy, the well known path will never look exactly the same twice. The medical school will in that case be more than the undergraduate curriculum. Ac- tivities will be in progress that at every point run beyond the undergraduate^ capacity and interest at the moment. But the undergraduate curriculum will not differ in spirit, method, or aspiration from the interests that transcend it.
The conservative in medical education makes much of what he conceives to be a fundamental opposition between medical practice and medical science; occasionally a despairing progressive accepts it. The family doctor represents the former type. One can ask of him — so the conservative thinks — only that he be more or less well grounded in things as they are when he gets his degree. The momentum with which he is propelled from the medical school must carry him to the end of his days, — on a gradually declining curve; but that cannot be helped. The other type — the scien- tific doctor — either himself "investigates," or has a turn for picking up increases due to others. How profound is the opposition here depicted ? Opposition of course there is between all things in respect to time and energy. The doctor who puts on his hat and goes out to see a sick baby cannot just then be making an autopsy on a guinea-pig dead of experimental dysentery. But does the opposition go any deeper? Is there any logical incompatibility between the science and the practice of medi- cine?
1 Chapter ii. p. 24.
1 This is the common contention of the routine schools that run on low admission requirements and employ practitioner teachers.
THE LABORATORY BRANCHES 55
The main intellectual tool of the investigator is the working hypothesis, or theory, as it is more commonly called. The scientist is confronted by a definite situation; he observes it for the purpose of taking in all the facts. These suggest to him a line of action. He constructs a hypothesis, as we say. Upon this he acts, and the practical outcome of his procedure refutes, confirms, or modifies his theory. Between theory and fact his mind flies like a shuttle; and theory is helpful and important just to the degree in which it enables him to understand, relate, and control phenomena.
This is essentially the technique of research: wherein is it irrelevant to bedside practice? The physician, too, is confronted by a definite situation. He must needs seize its details, and only powers of observation trained in actual experimentation will enable him to do so. The patient's history, conditions, symptoms, form his data. Thereupon he, too, frames his working hypothesis, now called a diagnosis. It sug- gests a line of action. Is he right or wrong? Has he actually amassed all the signifi- cant facts? Does his working hypothesis properly put them together? The sick man's progress is nature's comment and criticism. The professional competency of the physician is in proportion to his ability to heed the response which nature thus makes to his ministrations. The progress of science and the scientific or intelligent practice of medicine employ, therefore, exactly the same technique. To use it, whether in investigation or in practice, the student must be trained to the positive exercise of his faculties; and if so trained, the medical school begins rather than completes his medical education. It cannot in any event transmit to him more than a fraction of the actual treasures of the science; but it can at least put him in the way of steadily increasing his holdings. A professional habit definitely formed upon scientific method will convert every detail of his practising experience into an additional factor in his effective education.
From the standpoint of the young student, the school is, of course, concerned chiefly with his acquisition of the proper knowledge, attitude, and technique. Once more, it matters not at that stage whether his destination is to be investigation or practice. In either case, as beginner, he learns chiefly what is old, known, understood. But the old, known, and understood are all alike new to him ; and the teacher in pre- senting it to his apprehension seeks to evoke the attitude, and to carry him through the processes, of the thinker and not of the parrot.
The fact that disease is only in part accurately known does not invalidate the scientific method in practice. In the twilight region probabilities are substituted for certainties. There the physician may indeed only surmise, but, most important of all, he knows that he surmises. His procedure is tentative, observant, heedful, re- sponsive. Meanwhile the logic of the process has not changed. The scientific physician still keeps his advantage over the empiric. He studies the actual situation with keener attention; he is freer of prejudiced prepossession; he is more conscious of liability to error. Whatever the patient may have to endure from a baffling disease, he is not further handicapped by reckless medication. In the end the scientist alone
56 MEDICAL EDUCATION
draws the line accurately between the known, the partly known, and the unknown. The empiricist fares forth with an indiscriminate confidence which sharp lines do not disturb.
Investigation and practice are thus one in spirit, method, and object. What is apt to be regarded as a logical, is really but a practical, difficulty, due to the neces- sity for a division of labor. "The golden nuggets at or near the surface of things have been for the greater part discovered, it seems safe to say. We must dig deeper to find new ones of equal value, and we must often dig circuitously, with mere hints for guides."1 If, then, we differentiate investigator and practitioner, it is because in the former case action is leisurely and indirect, in the latter case, immediate and anxious. The investigator swings around by a larger loop. But the mental qualities involved are the same. They employ the same method, the same sort of intelli- gence. And as they get their method and develop their intelligence in the first place at school, it follows that the modern medical school will be a productive as well as a transmitting agency. An exacting discipline cannot be imparted except in a keen atmosphere by men who are themselves "in training." Of course the busi- ness of the medical school is the making of doctors; nine-tenths of its graduates will, as Dr. Osier holds, never be anything else. But practitioners of modern medicine must be alert, systematic, thorough, critically open-minded; they will get no such training from perfunctory teachers. Educationally, then, research is required of the medical faculty because only research will keep the teachers in condition. A non-pro- ductive school, conceivably up to date to-day, would be out of date to-morrow ; its dead atmosphere would soon breed a careless and unenlightened dogmatism.
Teachers of modern medicine, clinical as well as scientific, must, then, be men of active, progressive temper, with definite ideals, exacting habits in thought and work, and with still some margin for growth. No inconsiderable part of their energy and time is indeed absorbed in what is after all routine instruction; for their situa- tion differs vastly from that of workers in non-teaching institutions devoted wholly to investigation. Their practical success depends, therefore, on their ability to carry into routine the rigor and the vigor of their research moments. A happy adjust- ment is in this matter by no means easy ; nor has it been as yet invariably reached. Investigators, impressed with the practical importance of scientific method to the practising physician, tend perhaps to believe that it is to be acquired only in origi- nal research. A certain impatience therefore develops, and ill equipped student barks venture prematurely into uncharted seas. But the truth is that an instructor, devot- ing part of his day under adequate protection to investigation, can teach even the elements of his subject on rigorously scientific lines. On the other hand, it will never happen that every professor in either the medical school or the university faculty is a genuinely productive scientist. There is room for men of another type, — the
1 C. A. Herter : " Imagination and Idealism in the Medical Sciences," Columbia Univ. Quart., vol. xii., DO. 11, p. 16.
THE LABORATORY BRANCHES 57
non-productive, assimilative teacher of wide learning, continuous receptivity, critical sense, and responsive interest. Not infrequently these men, catholic in their sympa- thies, scholarly in spirit and method, prove the purveyors and distributors through whom new ideas are harmonized and made current. They preserve balance and make connections. The one person for whom there is no place in the medical school, the university, or the college, is precisely he who has hitherto generally usurped the medical field, — the scientifically dead practitioner, whose knowledge has long since come to a standstill and whose lectures, composed when he first took his chair, like pebbles rolling in a brook get smoother and smoother as the stream of time washes over them.
The student is throughout to be kept on his mettle. He does not have to be a passive learner, just because it is too early for him to be an original explorer. He can actively master and securely fix scientific technique and method in the process of acquiring the already known. From time to time a novel turn may indeed give zest to routine; but the undergraduate student of medicine will for the most part ac- quire the methods, standards, and habits of science by working over territory which has been traversed before, in an atmosphere freshened by the search for truth.
For purposes of convenience, the medical curriculum may be divided into two parts, according as the work is carried on mainly in laboratories or mainly in the hospital; but the distinction is only superficial, for the hospital is itself in the full- est sense a laboratory. In general, the four-year curriculum falls into two fairly equal sections: the first two years are devoted mainly1 to laboratory sciences, — anatomy, physiology, pharmacology, pathology; the last two to clinical work in medicine, surgery, and obstetrics. The former are concerned with the study of normal and abnormal phenomena as such ; the latter are busy with their practical treatment as manifested in disease. How far the earlier years should be at all conscious of the latter is a mooted question. Anatomy and physiology are ultimately biological sci- ences. Do the professional purposes of the medical school modify the strict biologi- cal point of view ? Should the teaching of anatomy and physiology be affected by the fact that these subjects are parts of a medical curriculum ? Or ought they be presented exactly as they would be presented to students of biology not intending to be physicians? A layman hesitates to offer an opinion where the doctors disagree, but the purely pedagogical standpoint may assist a determination of the issue. Per- haps a certain misconception of what is actually at stake is in a measure responsible for the issue. Scientific rigor and thoroughness are not in question. Whatever the point of view — whether purely biological or medical — scientific method is equally feasible and essential ; a verdict favorable to recognition of the explicitly medical standpoint would not derogate from scientific rigor. There is no doubt that the sciences in question can be properly cultivated only in the university in their entirety
*An introductory course in physical diagnosis is given in the second year; occasionally clinical work is begun in its latter half.
58 MEDICAL EDUCATION
and in close association with contiguous, contributory, or overlapping sciences. No one of them is sharply demarcated ; at any moment a lucky stroke may transfer a problem from pathology to chemistry or biology. There are indeed no problems in pathology which are not simultaneously problems of chemistry and biology as well. So far the rigorously and disinterestedly scientific viewpoint is valid. These con- siderations, however, still omit one highly important fact: medical education is a technical or professional discipline; it calls for the possession of certain portions of many sciences arranged and organized with a distinct practical purpose in view. That is what makes it a "profession." Its point of view is not that of any one of the sciences as such. It is difficult to see how separate acquisitions in several fields can be organi- cally combined, can be brought to play upon each other, in the realization of a con- trolling purpose, unless this purpose is consciously present in the selection and mani- pulation of the material. Pathology, for example, is a study of abnormal structure and function ; the pathologist as such works intensively within a circumscribed field. For the time being, it pays him to ignore bearings and complications outside his im- mediate territory. Undoubtedly, the progressive pathologist will always be at work upon certain problems, thus temporarily, but only temporarily, isolated. But in the undergraduate class-room he is from time to time under necessity of escaping these limitations : there he is engaged in presenting things in their relations. The autopsy, the clinical history, will be utilized in presenting to the student, even if incidentally, the total picture of disease. Similarly, the anatomist can score many a point for the physiologist without actually forestalling him. He views the body not as a mosaic to be broken up, but as a machine to be taken to pieces, the more perfectly to com- prehend how it works. The pharmacologist is in a similar relation to the clinician. The principles of bacteriology lose nothing in scientific exactitude because, taught as a part of the medical curriculum, they are enforced with illustrations from the bac- terial diseases of man rather than from those of animals and plants; and histology is not the less histology because tissues from the human body are preferably employed.1 In
JThe following quotations from "An Outline of the Course in Normal Histology," by L. F. Barker and C. R. Bardeen (John* Hopkins Hospital Bulletin, vol. vii., nos. 62, 63, p. 100, etc.), forcibly illus- trate the above contention.
" In deciding as to the plan to Ke adopted we have been much influenced, too, by the fact that our students are students of medicine. Thus it will be noticed that in the selection of tissues, those from the human body make up a large part of the material used ; and when animal tissues are employed, special care has been taken to point out how they differ from the human. Moreover, in deciding what to exclude from the course thought was given to the bearing of the specimens on the practical work in medicine which was to follow, and stress was laid upon those portions of human histology which previous experience has taught us are of the most importance in the appreciation and interpretation of the pathological alterations in disease. In the present status of pathological histology a knowledge of certain details is of much greater value than that of others ; and for the student entering medicine, a judicious selection of what shall be given and what shall be left out should be made by some one who has had a more or less wide training in pathological histology.
" Further bearing in mind the life-work for which the student is preparing himself, we have not always chosen the method which would show the finest structural details of the tissues. While the most delicate methods have been introduced in places, we have endeavored to familiarize the stu- dents with a large number of different modes of preparation. The student who has been brought up entirely on 'gilt-edged' histological methods will find himself sadly at a loss in battling with the •rough and ready ' world in which the pathologist has to live." (Somewhat abridged.)
THE LABORATORY BRANCHES 59
short, research, untrammeled by near reference to practical ends, will go on in every properly organized medical school; its critical method will dominate all teaching whatsoever ; but undergraduate instruction will be throughout explicitly conscious of its professional end and aim. In no other way can all the sciences belonging to the medical curriculum be thoroughly kneaded. An active apperceptive relation must be established and maintained between laboratory and clinical experience. Such a re- lation cannot be one-sided; it will not spontaneously set itself up in the last two years if it is deliberately suppressed in the first two. There is no cement like interest, no stimulus like the hint of a coming practical application.1
Medical reference, in the sense that the laboratory sciences should, while freely presented, be kept conscious of their membership in the medical curriculum, has