Medical Education in America

Rethinking the training of American doctors.

The American medical school is now well along in the second century of its history. It began, and for many years continued to exist, as a supplement to the apprenticeship 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 indentured 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 toward 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 conscientiousness 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. 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 developed. As far back as 1750 informal classes and demonstrations, mainly in anatomy, are matters of record. Philadelphia was then the chief centre 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 neighboring provinces, whose circumstances and connections will not admit of their going abroad for improvement to the anatomical schools in Europe; and also for the entertainment 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 medical school was taken at the instigation of Shippen’s friend and fellow student abroad, 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 established 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 find something unexpected, which Betrays an Error in Judgement, he like a great and good man immediately acknowledges the mistake, and, for the benefit of survivors, points out other methods by which it might have been more happily treated.’

The writer of these sensible words fitly became our first professor of clinical medicine, 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 institution of learning and intimately connected with a large public hospital. The instruction aimed, as already pointed out, not to supplant but to supplement apprenticeship. A year’s additional training, carrying the bachelor’s degree, was offered to students who, having demonstrated a competent knowledge of Latin, mathematics, natural and experimental philosophy, and having served a sufficient apprenticeship to some reputable practitioner in physic, now completed a prescribed lecture curriculum, with attendance upon the practice of the Pennsylvania Hospital for one year. This course was well calculated to round off the young doctor’s preparation, reviewing and systematizing his theoretical acquisitions, while considerably extending 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 Pennsylvania; 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 1708 in New York, as the medical department of King’s College, which, however, 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, to gain access to the hospitals there; 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, Transylvania in 1817, among others. But with the foundation early in the nineteenth century, at Baltimore, of a proprietary school, the so-called medical department of the so-called University of Maryland, a harmful precedent was established. Before that, a college of medicine had been a branch growing out of the living university trunk. This organic connection guaranteed certain standards and ideals, modest enough at that time, but destined to a development which medical education could, as experience 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 education would then have slowly risen with the general increase in our educational resources. 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 from which it is but now painfully awakening.

Quite aside from the history, achievements, or present merits, of any particular independent medical school, the creation of the type was the fertile source of unforeseen harm to medical education and to medical practice. Since that day medical colleges have multiplied without restraint, now by fission, now by sheer spontaneous generation. Between 1810 and 1840, twenty‑six new medical schools sprang up; between 1840 and 1876, forty‑seven more; 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 forty‑seven medical schools, many, of course, short‑lived, and perhaps fifty still‑born. One hundred and fifty-six survive to‑day. 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, ten of them still ‘going’ concerns; the Empire State produced forty‑three, with eleven survivors; Indiana, twenty‑seven, with two survivors; Pennsylvania, twenty, with eight survivors; Tennessee, eighteen, with eleven survivors. The city of Cincinnati brought forth about twenty, the city of Louisville eleven.

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