Medical Education in America

Rethinking the training of American doctors.

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 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 investment was therefore involved. A hail 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. Income was simply divided among the lecturers, 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 recently a professor in a now defunct Louisville school, who had agreed to pay three thousand dollars for the combined chair of physiology and gynecology, objected strenuously to a division 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. 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 practice. The examinations brief, oral, and secret—plucked almost none at all; even at Harvard, a student for whom a majority of nine professors ‘voted’ was passed. 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 centres was ludicrously bitter. Still more acrid were, and occasionally are, the local animosities bound to arise in dividing or endeavoring to monopolize the spoils. Sudden and violent feuds thus frequently disrupted the faculties. A split, however, 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 Valley, 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 majority 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 Lexington, 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 had traversed the whole country, as it then was, from Canada and the Great Lakes to the Gulf, and as far west 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 practically 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. For years they managed their own affairs, disposing of professorships 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, 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 enjoyment 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 its first mention in the catalogue of the Harvard Medical School in 1868-69; the microscope is first mentioned the following year.

The schools simply 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 amphitheatres, and in these discourses the instruction almost wholly consisted. Personal contact between teacher and student, between 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 prohibitive. 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. A student had two chances to hear one set of lectures—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.’

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