Medical Education in America

Rethinking the training of American doctors.

By Abraham Flexner

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.

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.’

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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