Transactions of the American Medical Association.
Vol. II. pp. 956.
(Concluded.)
REPORT ON MEDICAL EDUCATION.
This able report is, we presume, from the pen of Dr. F. Campbell
Stewart, of New York, and embraces a discussion of the follow-
ing topics:
Sec. 1.—’An examination into the general condition of Medical
Education in the United States, in comparison with the state of medical
education in other enlightened nations; noticing, as occasion may call
for, the courses of instruction, the practical requirements for graduation,
the modes of examination for conferring degrees, and the number of
pupils and of graduates at the several Medical Institutions in the
United States.
Sect. 2.—The requirements of the United States Army and Navy
Boards of Medical Examiners.
Sect. 3.—The legal requirements, exacted of medical practitioners
in the several States of the Union.
Sect. 4.—Such measures, prospective or established, in reference to
Medical Education and the reputable standing of the profession, as may
be deemed worthy of special consideration.
To these will be added a fifth section, to comprise the considera-
tion of certain matters not contemplated by the constitution, and which
were specially referred to this committee.
It is our purpose to consider each of these several subjects separately,
and we shall do this in the order in which they have been arranged.
Without following the committee through the first three sections,
which may be considered as preliminary to the fourth, or to
that which considers “such measures prospective or established in
relation to medical education, and the reputable standing of the
profession, as are deemed worthy of special consideration,” we
shall devote the few remarks we have to make on this report to
this section.
It is to this branch of the question, that the minds of the pro-
fession are chiefly directed. The necessity of a progressive reform
in our systems of medical education, is, we think, as deeply felt
by the great mass of the intelligent and thinking portion of the
medical men of the United States, as it was at the commencement
of the movement, which resulted in the institution of the National
Medical Association. It is in fact to a wide spread conviction of
growing errors and defects in the management of medical colleges,
that the Association owes its existence ; and the most prominent
topic which occupied the attention of the first convention in New
York, was that of medical education, in connection with the
facility of obtaining diplomas, from corporations existing indepen-
dent of the medical community, and irresponsible to it.
Two methods of correcting these evils suggested themselves to
the friends of reform; one was, to seek the improvement of
existing institutions, by certain recommendatory resolutions, and
thus to elevate the standard of medical education, and render the
diploma more valuable to its possessor; and the other, for the
profession to take into their own hands the power of granting
degrees, independent of medical colleges, and to receive into their
ranks only such as had submitted to an examination by a Board
of Examiners, who received their authority from the suffrages of
their medical brethren, organized into State or County Medical
Societies.
The former plan was deemed most advisable. It was argued,
that recommendations coming from the assembled wisdom and
intelligence of the profession, having for their object the improve-
ment of medical education, would possess a weight and authority,
which the colleges could not fail to respect, and that the profes-
sors in these institutions, some of whom were amongst the most
eminent medical practitioners of the country, would cheerfully
co-operate in any measures which might promote this desirable
object, irrespective of their private interests.
The principal measures, recommended by the Association for
this end, were :—
Firstly. The requirement of a more thorough preliminary educa-
tion, from young men about to engage in the study of medicine,
than has heretofore been requisite.
Secondly. The extension of the lecture term from four to six
months.
Thirdly. A uniform and elevated standard of requirements for
the degree.
Fourthly. The devotion of more time to clinical lectures, and
study at the bed side.
Fifthly. More attention to practical anatomy and practical
pharmacy.
To report how far these recommendations have been complied
with, and thus to present an index of the progress of medical
improvement, constituted the chief motive for the appointment of
a permanent committee on Medical Education.
In regard to preliminary education, the committee believe that,
owing to the rivalry of medical colleges, the facilities granted
for obtaining diplomas, together with a want of a feasible plan
for the accomplishment of the desired end, it has come to be
entirely disregarded. To remedy this glaring defect, the committee
propose the institution of “ Primary Boards of Examiners,” as
recommended by the Medical Society of the State of New York.
These Boards are to be created by state and local medical
societies, and their certificates of the qualifications of students to
enter upon the study of medicine shall be required prior to their
reception into the offices of practitioners or teachers.
In regard to the extension of the lecture term the committee
remark :
“ It affords us pleasure to inform you that the recommendations of the
Philadelphia Convention, in regard to the lengthening of the. lecture
term, have been responded to by several of the most important and
flourishing among the colleges; many of which have not only added to
the length of the regular course, but given in addition a preliminary
and gratuitous series of lectures.
The advantages arising from this improvement in our system are
evident, and we are most happy to find that the apprehensions of those
who feared that students would not consent to an increased tax upon
their time, have not been fulfilled. The classes recently in attendance
at those colleges which have extended the term, bear the same propor-
tion to those of the colleges that have made no change as they formerly
did, and in some instances they have been larger than ever. While we
record the fact of the partial success of this innovation, and announce
to you our belief that it meets with the approval of a large majority of
the profession throughout the country, we regret to learn that, at one
or two institutions, the enlightened Faculties of which were among
the first to adopt the recommendation, a return to the old period of
four months has been decided upon. This circumstance we regret the
more, because we conceive that the period of one session was scarcely
sufficient to test the matter fully, and because it may occasion hesita-
tion and delay in other bodies that were about to make the change.
The attendance by students upon a term of six months is a reasonable
exaction ; it is only two-thirds of the time required everywhere else than
in this country ; and experience has shown that it is impossible for
professors to impart the instruction that they are required to give, in a
shorter period, without crowding and condensing to an extent which
precludes the possibility of satisfactory and comprehensive illustration.
We feel convinced that it must ultimately prevail, and all that is
wanting to insure its immediate and general adoption, is concert of
action on the part of the colleges. We are satisfied that objections will
not be raised by the student, when he is made fairly to understand that
the change is principally for his advantage and convenience.”
Upon the subject of elevating the standard of qualifications for
a degree the committee are equally explicit.
“The importance of imposing additional restrictions upon students
and practitioners, and of elevating, as far as practicable, the standard
of education, should be admitted by all who are at all familiar with the
subject.
It has been shown that, during the last five years, there have been
graduated, annually, as many as from one thousand to fourteen hundred,
by the colleges whose returns have been given, alone; and it is com-
puted that as many as sixteen hundred diplomas are granted every
year by the medical schools of the country. The number of candidates
rejected is so small as scarcely to bear an appreciable proportion ; and
it is well known that not only many of the unsuccessful applicants for
degrees, but also many of the students who have attended only one
course of lectures, and never applied for an examination, enter at once
upon the active duties of the profession, and engage in practice.
These are recognized and held by the public in the same light as
regular graduates. The consequence is, that their want of general and
professional knowledge, which is often manifested in courts of justice
and elsewhere, reflects directly upon the profession of which they are
supposed to be bona fide members, and tends materially to bring it into
general disrepute. Nor is this want of a proper education confined
exclusively to those who are possessed of no diploma.
We regret that candor and justice compel us to admit, that the most
deplorable ignorance and unfitness for the responsible duties of a phy-
sician are often exhibited by those who hold the diploma, and who are
thus endorsed as being qualified and competent. This fact is so noto-
rious, that it would be a waste of time to cite instances in support of
it. We may, however, assert, upon our personal responsibility, that
we have known more than one graduate of some of our colleges, who
could neither translate the Latin of his diploma, nor yet write and
speak his own language correctly ! The records of the army and navy
show us how small a proportion of candidates for medical officers pass
a satisfactory examination and are approved ; and yet, nearly all of
these are graduates in medicine, for the most part fresh from their
studies, and subjected, not to a rigorous, but a fair and impartial ex-
amination.”
The deficiency of hospital clinical instruction in our schemes of
medical education, and the substitution in some of the medical
colleges of what are termed “ college clinics,” for bed side instruc-
tion in hospitals, are condemned by the committee in most unquali-
fied terms.
We were scarcely prepared for the assertion made by the com-
mittee, that “ there are, comparatively speaking, but very few
institutions in the country, whose rules require attendance upon
bed side practice prior to graduation.”
This deficiency the committee attribute to two causes.
“ The first, is the circumstance of its not being generally insisted
upon, and made obligatory ; and the second, because so many subjects
are taught in a very limited period of time, and so many lectures to be
attended to, and prepared for, that the young men have, in reality, no
time to devote to additional duties.”
Upon the subject of college clinics the committee hold the
following language :
“An attempt has been made within the few last years to afford a
substitute for hospital attendance, by introducing what are called
“College Clinics,” and thus enabling professors to exhibit and explain
to their students such cases of disease as may be presented for out-door
treatment. That this system is better than no clinical instruction at
all, we freely admit; but that it should ever be permitted to take the
place of hospital attendance, when the latter can be procured, we con-
tend to be wholly wrong. It is impossible for students to derive that
advantage which is expected to result from witnessing the consecutive
treatment of cases, by seeing persons affected with disease once or
twice only, without being able to watch the effects of the medicinal
agents employed, and the final result. There is another objection,
likewise, to this imperfect system of clinical teaching which is worthy
of consideration, as it affects the whole profession, and particularly
those members of it whose practice is confined principally to the mid-
dle and lower classes of society, and whose business lies chiefly with
that class of the community which is unable to pay a full compensa-
tion for medical services, and yet can easily afford some remune-
ration to their medical attendants. It is known to your committee that
numerous individuals so situated, and well to do in the world, are in
the habit of resorting to the cliniques of the schools to obtain, gratui-
tously, advice for which they are fully able to pay. Thus a direct
and positive injury is inflicted upon a large and deserving class of our
brethren, whose means of livelihood and pecuniary receipts are pro-
portionally curtailed.
We concur unanimously in the opinion that they present no ade-
quate equivalent to the student, when resorted to as a substitute for
actual hospital attendance, while, at the same time, they are a direct
source of injury to many deserving members of the profession.”
In regard to the study of practical anatomy, we are informed by
the committee that a most glaring deficiency exists in some of our
medical colleges, which even announce in their published circulars,
“ that attention to it will not be made obligatory upon those who
enrol themselves as their pupils.”
Attention to practical pharmacy is equally disregarded, though
this is often taught in the offices of country practitioners, where
the preceptor requires the aid of his pupils in preparing and
putting up medicines.
The committee justly regard atttention to this department of
medicine, of the greatest importance, and recommend the course
adopted in Edinburgh as worthy of imitation; viz., “ that prior to
receiving his diploma, every candidate should be required to pro-
duce evidence of his having been engaged, during a period of at
least three months, in compounding medicines, either in his pre-
ceptor’s office, or in the shops of recognized apothecaries, members
of a college of pharmarcy.”
In the admirable scheme of private instruction devised by the
late Dr. Parrish, under whose guidance some of the most distin-
guished medical men of the country commenced their studies, six
months in the shop of a scientific apothecary was regarded as an
essential preliminary to a thorough medical education.
The last subject discussed by the committee, is “ the propriety of
establishing independent Boards of Examiners, for conferring
licenses to engage in the active practice of medicine and surgery.”
In this matter the committee concur in the opinion, that the pro-
fession require protection, and they regard legal measures as the
only effectual means of securing it.
The following extract from the report exhibits some of the
grounds upon which this conclusion is based:
“ It appears to us that there are but two courses to be pursued to
insure the public and the profession that protection which both are
entitled to claim and expect: the one is through the profession itself,
and the schools ; and the other through the law.
So long as charters for medical colleges can be obtained with the
facility which is now afforded, and so long as professorships continue
to be sought after, not only for the direct profits which they yield, but
also for the indirect and valuable advantage which they offer by
enabling those who hold them to become extensively and favourably
known, thus leading to the attainment of business and distinction, every
inducement will be held out to young men to engage in the study of
the profession—and rivalry and competition among the institutions
themselves, to obtain popularity and large classes, must lead inevitably
to the cheapening of the degree, and a lessening of the requirements
for obtaining it. We all know that the reputation and success of an
institution are proportionate with the size of its classes, and the num-
ber of its graduates. Hence, every means is resorted to for obtaining
the foremost numerical position. The degrees from all the colleges
confer the same rights, and yield similar honours : the public look only
at the parchment, and make no distinction as to the source whence it
was obtained. This being the case, no inducement is held out to the
teachers to impose adequate restrictions upon their pupils, and none is
offered to the pupils themselves for incurring more trouble and expense
than may be absolutely necessary for obtaining the doctorate.
We think that no material and lasting good can arise from an eleva-
tion of the standard of requirements by one or two colleges alone. The
only manner in which the desired, end could be obtained would be, by
the cooperation of all the colleges, in the establishment of a uniform
curriculum ;—and is this practicable ? Can it be expected that rival
institutions, possessing a great diversity of interests, and unequal faci-
lities for teaching, will unite in a general scheme, which would have
the effect of concentrating students at such colleges as are in reality
best prepared to impart instruction'? We unhesitatingly answer in the
negative—it is useless even to ask it. But let each State of our Union
authorise the establishment of a board of disinterested examiners, who
shall have no direct interest in view, and the obtaining of whose certi-
ficate shall be always obligatory, prior to permitting an individual to
engage in practice, and a direct check is at once imposed, which will
make it to the interest of the schools to raise their standard to the
level of that established by the licensing boards, and a fair and just
rivalry will then commence between the colleges, as to which shall
impart the requisite amount of information in the shortest space of time,
and at the least expense to the student.”
How far the conclusions of the committee will be sustained by
the future action of the Association, is yet to be proven. It must
be confessed, that the measures, so auspiciously commenced for
imparting to the schools a higher tone of instruction, and a. deeper
sense of their responsibility in granting the degree, have not, thus
far, been as successful as the profession had reason to expect.
To this fact the report before us, bears ample evidence. But
few of the medical colleges have made any important changes
in their curriculum of studies, while others have adopted regula-
tions altogether at variance with the expressed sentiments of the
Association. It is to be feared indeed that some of these institu-
tions are disposed to act independently of the profession, and to
pursue such course, both in the education of their students, and in
the granting of the degree, as their own judgment or their sup-
posed pecuniary interests may dictate. That such corporations
have a right, under the laws of the land, to adopt this course,
cannot be questioned, while the duty of the great body of the pro-
fession to protect themselves and the public against what they
conceive to be an injurious and degrading policy, is equally clear
and imperative.
The plan proposed by the committee, emanating as it does from
gentlemen of high character, specially selected to examine into
this important and difficult question, is at least entitled to the
most respectful consideration from the body who intrusted to
them this duty.
The committee have not failed to perceive the difficulties atten-
dant upon the organization of independent boards of examiners, in
the several States, invested by law with the power of granting
the degree. They foresee impediments which may arise on the
part of medical colleges which in many of the States now exclu-
sively exercise this prerogative. But inasmuch as legal restric-
tions to the practice of medicine are rarely imposed, and as irregu-
lar practitioners without diplomas may and do practice with the
same facility as those who hold them, it is suggested that the right
to practice conferred by these charters is in fact of little practical
value; and that the educated and high minded men who occupy the
chairs in many of our medical colleges, would readily yield to the
general voice, and abandon a valueless prerogative, especially if
they could see that by so doing they would be advancing the
general welfare.
Embarrassments might also arise in carrying out the details
of the plan proposed by the committee, even admitting that
the principle upon which it is based, is recognized by the state
legislatures ; but these are not insurmountable if the question
is seriously entertained, and if the united influence of the profes-
sion is brought to bear upon its accomplishment.
In the State of New Jersey, Examining Boards appointed by
the State Medical Society have long been in successful action,
and no physician can be admitted into medical fellowship in that
state, or can be invested with a legal right to practice there, unless
he holds a license from such a Board. The consequence is, that
in no state in the Union, is the medical profession more respec-
table and better informed, and in none does quackery find less
encouragement.
Appended to the report are two papers, one from the medical
faculty of Harvard University in opposition to extension of the lecture
term beyond four months, and the other in favor of this measure
from a special committee appointed by the Association to sustain
the course of action which it has uniformly recommended, as an
important means of improving our systems of medical education.
The length to which our remarks have extended, will preclude
an examination into the merits of these able papers; while we can-
not withhold our regret that the medical faculty of one of the
most renowned institutions of learning in the country, should be
found arrayed against a measure which the general voice of the
profession had so formally sanctioned : we fear that this course
will encourage inferior schools in continuing their imperfect
courses, and even in further curtailment, if they deem it important
to their interests.
With these observations w’e must take leave of the volume of
Transactions, without even a passing notice of the other and
varied contents which enrich its pages. The vexatious delay which
has so far prolonged its appearance, (for which the committee of
publication are not responsible,) will we trust be avoided in future.
In consequence of it, little time has been afforded for the perusal
and study of the many valuable papers which the volume contains,
by the great mass of those who are intimately interested in these
proceedings. We trust, however, that the work will meet with
the reception which it so justly merits, and that it will find a place
on the shelves of all the thinking and active practitioners through-
out the Union.