Popular Science Monthly/Volume 27/September 1885/The Present Aspect of Medical Education
|THE PRESENT ASPECT OF MEDICAL EDUCATION.|
By WILLIAM GILMAN THOMPSON, M. D.
THERE is no branch of education which attracts so little public interest and support as proper medical instruction, yet no one would gainsay the necessity that, if there are to be physicians at all, the community should be guaranteed that they have been most thoroughly trained.
It is not so very long since an air of mystery, which no laymen would attempt to penetrate, enveloped the art of medicine. It required generations to separate medical practice from alchemy, astrology, and the search for the elixir of life. The traditions and influence of Hippocrates and of Sydenham lasted well into the past century, and down to 1750 almost all of the scanty medical literature was in Latin, and the gradually accumulating facts of observation were still too little systemized to be weaned from an admixture of the most unreasonable speculation and pseudo-philosophic discussion. As late as 1784 the condition of medical education in the United States was most rudimentary, and for some time thereafter dissections of the human body could only be made by stealth. The functions of physician, nurse, apothecary, and often, too, of pastor, farmer, dentist, and veterinary surgeon, were frequently combined in one person in the early part of the present century.
What a contrast appears to-day! Popular medicine and hygiene are becoming everywhere the fashion. Public sentiment and action are aroused in regard to all manner of sanitary and curative measures. When men of distinction are ill, the conditions of their pulse, temperature, and respirations are telegraphed all over the civilized world, to be read at the breakfast-table in the morning newspaper. Their medicines and their doses are minutely described; diagrams of the course of a bullet, or startling pictures of microscopic sections of tumors, or views of cholera-germs, appear in our daily papers; and in the most popular family magazines we read articles upon the "anatomy of the brain," or "how to trap a soil-pipe." We have a mother's magazine devoted to improvements in baby-feeding and the scientific development of the infant mind. The book-stores abound in popular works upon every medical topic, from the subject of singers' sore throats to the treatment of sea-sickness, consumption, or the opium-habit. A great deal of all this, especially the newspaper medicine, is fostered by a maudlin craving for every detail of that which is exciting or horrible. It is to cater to the same kind of feeling that newspapers describe how many lumps of sugar a condemned murderer took in his coffee on the morning of his hanging. The germ-theory, too, has given a great impetus to popular medicine.
The germ appeals to the average mind: it is something tangible; it may be hunted down, captured, colored, and looked at through a microscope, and then, in all its varieties, it can be held directly responsible for so much damage. There is scarcely a farmer in the country who has not read of the germ-theory. A cow-boy in Arizona was shot dead in the saddle recently by a comrade for the insult implied by calling him a "d—d microbe"!
Still, a great deal of this popular medical talk and instruction is the outcome of an earnest desire to learn to alleviate the growing evils of heredity and environment, especially in overcrowded cities. The importance of a universal knowledge of, and attention to, the laws of physiology and hygiene is becoming more and more appreciated, and the elements of these subjects are taught in the public and private schools. The mental training to be acquired through the observation of biological and physiological facts is recognized as being of the greatest importance, and laboratory courses of instruction in these studies are already introduced in many of our colleges and universities side by side with the classics. There is a wide-spread popular interest in the thorough training of nurses for the sick, and in such practical and beneficial work as the establishment of diet-kitchens for the sick poor, and sanitary reforms of all kinds. We have "Sanitary Protective Leagues" and "Sanitary Aid Societies," composed principally of laymen, and instruction in "First Aid to the Injured" is given to policemen, firemen, and enthusiastic young ladies! Very many laymen also interest themselves most liberally in the establishment and management of hospitals and dispensaries.
All these activities, directed toward improving the public health and alleviating sickness and suffering, are most gratifying and commendable, and call for increasing thoroughness in methods of educating physicians, for, without the co-operation of the public with scientific men who devote their lives to the study of these subjects, much benevolent energy as well as time and expense are wasted or misapplied. Is it not clearly of vital moment that the public for its own protection should see to it, by legislation or other means, that the medical schools of this country are of the highest order? A dozen well-trained and properly qualified physicians will be of vastly more benefit anywhere than a hundred "M. D.'s" who have slipped through some of our so-called medical "colleges" in the easy manner that is still quite possible. It is disgraceful, and yet it happens constantly, that men are graduated by prominent medical schools or colleges in this country without ever having listened to an abnormal heart sound, seen a case of measles, or been present at a confinement. "But," it is asked, "why should the general public take any interest in medical education? Why not let doctors manage their own 'shops,' as they always have done, unaided by public support?"
The answer is that, so long as a medical college is dependent entirely upon the fees of its students for support, the highest educational good can not be attained. The question concerns endowment. A review of a few facts and statistics will demonstrate this need.
The medical profession in the United States, like many branches of industry, is at present suffering severely from over-repletion. There are more doctors, in proportion to the population, than in any other country in the world. The laws of supply and demand tend to lead many men toward those schools where they can soonest secure their diplomas with least expenditure of time and money (and too often of energy). The schools become overcrowded, and new ones spring up with alarming rapidity. A century ago, with a population of 3,000,000, there were two medical schools. To-day, with a population of 50,000,000, we have eighty-seven medical schools, distributed through twenty-eight States and the District of Columbia. Of these schools, thirty-nine have been opened within fifteen years, and twenty-one (or about twenty-six per cent) within five years past. With them are associated over 1,300 instructors (many of whom offer their services gratuitously) and over 10,000 students, while about 3,600 new doctors are annually "turned loose upon the community," as the daily press courteously expresses it. Forty-six per cent of the schools offer only a two-years course of instruction, three of them offer a four-years course, and the remainder offer, although only few require, a three-years course. The inaugurators of the reform of prolonging the course of study were the Chicago Medical College and the schools at Harvard and the University of Pennsylvania. At but few schools is the instruction graded for different years, and students are usually compelled to pay for hearing twice over the same course of lectures in two years. This, with a little dissection, a thesis, and examinations upon the lectures, is frequently all that is required of them before receiving a diploma. Almost all practical work is optional, and, instead of each student being obliged to secure a hospital experience, he is lucky if he obtains an appointment as interne after an additional competitive examination for which he has crammed himself full during months of toil over textbooks and lecture-notes.
The better class of students feel the inefficiency of this system and so far as possible supplement it by attending small "quiz classes" for recitations and practical work, which are, however, entirely independent of the colleges, and are in no sense obligatory. The success of these small voluntary classes (often conducted by men who are without any official connection with the colleges) in drawing students, who thus incur considerable additional expense, is in itself a severe commentary upon the poverty of the colleges which restricts them from making their own advantages all that they should be.
Such is the system in vogue to-day at a large number of our medical colleges. There are, fortunately, a few where a much higher standard is not only encouraged but required. No wonder that our students, immediately after graduating, go by the hundred to Paris, Berlin, Vienna, etc., where the Government encourages professional schools, laboratories, and scientific bureaus by substantial support and thorough system. They go abroad, partly because it is the fashion, and gives them a sort of advertisement as having done the proper thing, and partly to learn a new and useful language, and study foreign methods of life. But the fundamental reason of their going is that, instead of sitting in a huge lecture-hall with two or three hundred other men, to take notes verbatim of a lecture which often might be read in a textbook at home, they can join small classes in which they practically demonstrate every fact for themselves, under the guidance of an instructor.
Lectures have their value, certainly, but it is a relative value which is greatly enhanced by practical teaching. A gigantic picture of a sore throat, hung on the wall of a lecture-hall, is after all far less instructive for a student than looking into the real throat, telling what he sees there, and then looking again, while what he at first omitted is pointed out to him.
There are many demonstrations which can be better made, and many theories which can be more conveniently discussed, in a lecture; still, it is well to bring a student face to face with at least one patient before intrusting him with a diploma and license to practice at large.
But practical work, at its commencement at least, means increased expense. There must be separate and well-appointed laboratories for chemical, physiological, anatomical, and pathological research, rooms for photography, germ-culture, delicate electrical apparatus, for hygienic and therapeutic demonstrations, for libraries, and for the reception and treatment of many classes of patients at clinics. Moreover, assistant instructors and demonstrators are needed, in order that each student may receive a fair share of personal attention. (At present the classes are so large that candidates for graduation are often unknown by sight even to a majority of their instructors.)
Suppose for a moment that the professors of a medical college put their hands in their own pockets and provide these improvements, as they have already done in some instances to a limited extent. Many students will leave for cheaper and easier colleges, and the fees are likely to fall off so much that professorships having no endowments to rely upon must be abandoned. Thus the lack of endowment is a virtual check upon all growth. Division of labor with a new assistant instructor means division of personal income with him. The expense of maintaining a new laboratory means a further reduction of the professor's income. As Dr. O. W. Holmes wittily says, "A school which depends for its existence on the number of its students, can not be expected to commit suicide in order to satisfy an ideal demand for perfection." General Eaton (to whose admirable report on medical education the writer is indebted for many of the statistics of this article) strongly advises that every medical school or college be required by law to procure forthwith an endowment of not less than $300,000.
Strangely enough, in some instances the professors themselves object to the endowment of their chairs, because they fear a sacrifice of their independent methods, or because it seems impossible to secure endowments which would yield as fair incomes as they at present derive from the students' fees. But there is no reason why the students should not continue to pay as they do now, and a certain amount of endowment, required by law, would prevent half a dozen men from forming a new medical college without proper laboratories, apparatus, or facilities of any kind. The experience of the past ten years proves this danger to be a real and increasing one.
The professorships and laboratories once endowed, the professors can be trusted to elevate the standard of medical education very rapidly throughout the country. But there should also be separate State or National Boards of Examiners who alone should have the power of granting licenses to practice medicine, based upon proofs of practical laboratory and hospital work, and upon the diplomas of only first-class colleges, which latter should be raised to a uniform high standard of merit. Applicants for licenses should be examined, not as to what theories they hold, to what "pathy" they conform, or what text-books and lectures they have crammed, but as to what evidence they can give of personal examination of the human body and personal observation of its ailments and witness of the influence of remedies. Laymen can render great assistance in these matters (and the gain is ultimately their own) by furthering appropriate legislation, frowning upon quackery and cheap diplomas, as well as by co-operating with the medical colleges in offering freely the use for clinical instruction of all the hospitals and dispensaries which the public support and control. Most valuable opportunities for clinical observation are at present needlessly wasted through lack of this system. To-day the value of income-bearing funds of the eighty-seven medical colleges does not exceed $350,000, which yield an annual income of only about $20,000. It is instructive to contrast with this statement the fact that the one hundred and forty-five theological schools and colleges of the United States have a productive property of $9,500,000, and an annual income therefrom of nearly $600,000!
Of our eighty-seven medical schools, forty-two are associated with general colleges or "universities," but the connection is usually merely nominal, and no means of support are derived from the parent college. The precarious footing upon which many of these institutions stand is to be inferred from the fact that no fewer than fifty-one other medical colleges founded in the United States within a century have collapsed and vanished.
It is a grave misfortune to have so many medical colleges as now exist, for it is a farce to attempt to educate medical students away from the hospitals and dispensaries which only the largest cities furnish in abundance. The tendency to-day in all branches of education—from the Fröbel Kindergarten system to the study of engineering—is more and more toward placing practical work and personal observation before tradition and theoretical instruction. Surely medical education must not be left behind in facilities.
There are many encouraging signs of speedy improvement in this matter. There is a growing dissatisfaction with the old system. The percentage of medical students who are graduates in letters or science is constantly increasing. At present they number nine per cent, and they have frequently had the advantage of a year or two of biological, physiological, and chemical practice before entering the professional school. The number of such students at the Medical College of the University of Pennsylvania has doubled in the past six years. The number of medical schools which require some sort of preliminary examination for admission is also increasing. A great deal is expected of the Johns Hopkins Hospital and Medical College (which are handsomely endowed) when they shall be in operation. Several chairs have been endowed in the Medical College of the University of Pennsylvania. Mr. Vanderbilt's recent magnificent gift was for a lot and building and not for endowment, but the donor set the excellent example of aiding an already tried institution instead of launching a new one among the many which are at present struggling to float. The work accomplished in the past ten years by physicians themselves through their various societies and organizations in exposing quackery, injurious patent medicines, malpractice, and bargaining in diplomas for which no study has ever been expended, has revealed and corrected an enormous amount of abuse and crime, notwithstanding the very tardy legal and popular support which has attended these efforts. Our great need is a little more system and concentration of energy, or a diversion of some of the wide-spread public interest in general medical topics toward securing and demanding the most thorough medical education for every one who seeks to become a physician. This will be of incalculable service to the entire country; and endowments, whether by State legislation or private bequests and subscriptions, combined with State or national supervision of licenses to practice, will so far advance the thoroughness of work at home by making it independent of large or small classes of students, that we may hope before long to invite foreign students to learn from us how to take the lead in medical education.
- See McMaster's "History of the People of the United States," vol. i, pp. 27-31.
- "Life of Dr. John Warren," p. 314.
- See Spencer on "Education," chap, i, p. 76, "What Knowledge is most worth."
- The writer would be understood as referring only to "regular" schools in this article there are very many others.
- "Boston Medical and Surgical Journal," January 19, 1882.
- "Report of the Commissioner of Education," 1882-'83, clxiii-clxxxiv, 660-672.
- The State Board of Health of Illinois is a praiseworthy pioneer in this field.
- "Conspectus of the Medical Colleges of America," 1884, 1885. Illinois State Board of Health.