Medical Education in America

Rethinking the training of American doctors.

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 Edinburgh 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 discriminating mark of modern scientific medicine, was thence introduced into America by the pupils of Louis,—the younger Jackson, ‘dead ere his prime,’ Gerhard, and their successors. With the generation succeeding the war, the tide turned decisively toward Germany, and thither continues to set. These men subsequently became teachers in the colleges at Philadelphia, New York, Boston, Charleston, and elsewhere; and from them the really capable and energetic students got much. One of the latter, who has in recent years wielded perhaps the greatest single influence in the country toward 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 meagre appliances for 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 to 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 ignorant 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.’

As much could perhaps be said of a half-dozen other institutions. The century was therefore never without brilliant names in anatomy, medicine, and surgery; but they can hardly be cited in extenuation of conditions over which unusual gifts and perseverance alone could triumph. Those conditions 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. 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, namely, 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 requirements for the degree or 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 extended to four years, still varying, however, from six to nine months each in duration. 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, Dr. Francis Delafield took charge of the newly established laboratory of the Alumni Association of the College of Physicians and Surgeons of New York; 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 teaching, though in many far too largely the conscientiousness of the drillmaster.

In consequence of the various changes thus briefly recounted, the number of medical schools has latterly declined. Within a twelve-month period 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 university harbor. It has, in fact, become virtually impossible for a medical school to comply 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 discredit 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 thus 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 department 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 requirement of an academic degree for admission. In the process, the university obtained the same sort of control over its medical department that it exercises elsewhere. Toward this consummation President Eliot had aimed from the start; but he was destined to be anticipated by the establishment in 1898 of the Johns Hopkins Medical School on the basis of a bachelor’s degree, from which with quite unprecedented academic virtue no single exception has ever been made. 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 themselves 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 immense 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 reconstruct old ones. In the sixteen years that have since elapsed, fourteen more institutions 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 prestige. 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. These fictitious alignments retard 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 this country. 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 expensive medical education is demanded. But it is speciously argued that improvements thus accomplished will do more harm than good; for whatever makes medical education 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. Anyone, however, who has taken the trouble to examine the statistical aspects of medical education in America knows very well that the enormous over-production of doctors in this country precludes any present possibility of such a danger.

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