- Email: [email protected]
History of Medicine in US Medical School Curricula
Journal of Anesthesia History xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Journal of Anesthesia History journal homepage: http://www.elsevier.com/locate/janh
History of Medicine in US Medical School Curricula☆,☆☆ Justin Caramiciu, MD a, David Arcella, MD b, Manisha S. Desai, MD c,⁎ a b c
Resident in Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Resident in Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts Clinical Associate Professor, Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
a r t i c l e
i n f o
Article history: Received 15 November 2014 Received in revised form 31 January 2015 Accepted 10 February 2015 Available online xxxx
a b s t r a c t Study Objective: To determine the extent to which the history of medicine (HOM) and its related topics are included within the curriculum of accredited medical schools in the United States. Design: Survey instrument. Setting: US allopathic medical schools. Measurements: An online survey was sent to officials from every medical school in the US. Respondents were asked to provide institutional identifiers, the presence of an HOM elective offered to medical students, the years during which the elective is offered, the existence of an HOM department, and the contact information for that particular department. Nonresponders were contacted by phone to elicit the same information. History of medicine electives included didactic sessions and seminars with varying degrees of credit offered in different years of medical school. Main Results: Based on responses from 119 of 121 contacted medical schools (98%), 45 (37%) included formal lectures or weekly seminars in the medical school curriculum. Five (11%) curricula had or have required HOM, whereas 89% offered elective HOM instruction. Course duration and credit awarded varied. Eighteen (15%) medical schools included departments dedicated to HOM. Providing education in HOM was limited by faculty interest, clinical training hours, and low interest. Conclusions: Data collected by our study suggest that substantial barriers exist within the academic medical community towards a wider acceptance of the importance of HOM. Causes for such lack of interest include absence of questions on written or oral tests related to HOM, difficulty in publishing articles related to HOM in peer reviewed journals, near absence of research grants in HOM, difficulty in getting academic promotions or recognition for activities related to HOM, and a lack of support from academic chairpersons for activities related to HOM. © 2015 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.
Introduction Limited information exists on the extent of history of medicine (HOM) teaching in medical schools in the United States. It may be argued that interest in the study of HOM began in the 19th century as scientific medicine made significant strides. Medical historians have argued about the utility of teaching medical history, what should be included in such teaching, and who should teach such courses.1–4 The discipline of HOM has its roots in Germany, where Karl Sudhoff (1853-1938) established an Institute of the History of Medicine in
☆ This work was supported by intramural funds. ☆☆ This work was presented at the Spring Meeting of the Anesthesia History Association, Dearborn, Michigan, on May 2, 2014, and also at The Annual Meeting of the American Society of Anesthesiologists, New Orleans, Louisiana, on October 13, 2014. ⁎ Corresponding author at: Department of Anesthesiology, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. E-mail address: [email protected] (M.S. Desai).
Leipzig in 1905.5 Abraham Flexner (1866-1959) published a detailed study of medical school education in the United States and Canada in 1910 and suggested that Johns Hopkins Medical School ought to be considered a model for education. 6 William Osler (1849-1919), William Welch (1850-1934), and Howard Kelly (1858-1943) at that institution were firm supporters of history, and it is not surprising that the first Department of History of Medicine was established at Johns Hopkins University in 1929.7 Henry Sigerist (1891-1957), a student of Sudhoff, was appointed the first Welch Professor in History of Medicine in 1932.8 Earlier, in 1927, Edward Krumbhaar (1882-1966) from the University of Pennsylvania established the American Association for the History of Medicine (AAHM), an association that had begun publishing its own journal, the Bulletin of the History of Medicine, in 1939.9 The second department of medical history was established at the University of Wisconsin at Madison in 1947, with Erwin Ackerknecht (1906-1988) as Chairman.10 Sigerist was born in Paris to Swiss parents and earned a medical degree from the University of Zurich. He served as a medical officer
http://dx.doi.org/10.1016/j.janh.2015.02.010 2352-4529/© 2015 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
2
J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx
in the Swiss Army but devoted the rest of his career to HOM. He moved to the United States in 1932 and was appointed director of Johns Hopkins University’s Institute of the History of Medicine. He was a prolific writer and very influential in shaping the direction in which medical history would evolve. 8 He was a visible and public spokesman not only for HOM but also for matters relating medicine to society. He appeared on the cover of Time Magazine on January 30, 1939, and was a popular speaker for nonmedical audiences. Being a strong proponent of the government’s role and obligation in providing health care to all citizens, he wrote about socialized medicine in the Soviet Union 11, and his ideas were used in the creation of socialized medicine in Canada.12 As a result of his views on socialized medicine, he was opposed by the American Medical Association and other proponents of the status quo. He left the United States in 1947 and retired to Switzerland, where he died in 1957. A case for inclusion of medical history in the curriculum has been made since the beginning of the 20th century. 4,13–16 These pleas have been ignored largely, and there has been a gradual decline in the percentage of medical schools offering or requiring courses in medical history. There has also been a gradual shift in the training and background of medical historians, from MD historians to PhD historians.17 This is evident in membership, presentations, and publications of the AAHM, including the Bulletin of the History of Medicine. Most medical history courses are taught by PhD historians, and topics being researched place emphasis on society and policy rather than physicians, patients, and disease. The aim of our study was to define the current state of coursework offered in HOM in US medical schools. We wished to determine whether medical history had been “crowded out” of the curriculum. We proceed to explain changes in the nature of work undertaken by MD historians and PhD historians, and the arenas in which these historians operate. We conclude by proposing a mechanism by which these divergent groups may work together rather than at odds with each other.
Materials and Methods American medical schools accredited by the AAMC were included in a survey on HOM in their respective curricula. The extramural elective compendium, a searchable database available from the AAMC, was used to contact elective coordinators at each school electronically. The survey instrument was hosted by a commercial Web site (SurveyMonkey, Palo Alto, California). Each coordinator was asked to respond to nine brief questions, available in the Appendix 1. We contacted medical school registrars (by phone) at institutions where survey responses were not initially obtained from elective coordinators. Information was further collected through examination of available online elective catalogs for schools that could not provide information on HOM. We sought to obtain information pertaining to prevalence of HOM at medical schools in the United States. This information included whether an HOM elective or seminar series was offered at each institution. If HOM instruction was identified, we inquired about requirement status, credits awarded, and hours included. We also sought to understand to whom the course was being offered. We finally inquired about the presence of a department of HOM and dedicated faculty. The study was approved by the Institutional Review Board at University of Massachusetts School of Medicine. Our questionnaire was directed at medical school officials who would not be expected to know details about how history of anesthesia was taught at their medical school or department of anesthesiology. Therefore, our questionnaire did not include questions about the teaching of anesthesia history.
Results Elective coordinators from 18 of 121 (15% response rate) medical institutions responded to the survey online. The remaining medical schools were contacted via phone through registrar office (76 of 121, 63%) institutions. Questions were posed verbally and recorded. Data were confirmed and missing information was obtained through elective catalogs available on institutional Web sites (Table 1). Schools were identified as having an HOM elective if they offered a didactic session or seminar series including HOM. Based on responses and information gathered from 119 of 121 medical schools (98%, we were unable to collect information from 2 institutions), 45 (37%) included formal lectures or a seminar series in their medical school curricula. Of these, 5 (11%) curricula required instruction in HOM, whereas the rest (89%) offered HOM instruction on an elective basis. The year during which courses are offered is shown in Table 2. History of medicine education was offered to medical students during all four years of training. Course duration and credit awarded varied greatly. Eighteen (15%) medical schools included departments dedicated to HOM, which included an average of five to six full-time faculty members. Discussion History struggles for inclusion in the curricula within institutions of higher learning in the sciences, and the curricular emphasis of history has diminished over the decades. This trend is not unique to history, and many disciplines once considered important in the making of wholesome civil society continue to fight an uphill battle as both pragmatic and economic factors dominate increasingly many aspects of academia. One can argue that, among all the species that inhabit our planet, man alone is aware of the past. Everything that is known with certainty can be considered to be within the realm of history. This is true because the future is largely unknown, and the present is fleeting. When history is viewed from this perspective, one is surprised that more attention is not paid to this important aspect of every discipline. The study of history is an examination of change and provides the means through which we understand how today’s world has been shaped. The many challenges faced by medicine are understood better with the perspective offered by historical knowledge. The comprehension of scale, timing, causation, and continuity of change are necessary to understand the evolution of past events and how they apply to the present. 18 History is an essential part of our educational system for this reason, providing students with necessary tools to move forward with a better understanding of their own environment. 19 History also offers information on human behavior in societal context. History collectively provides data on human behavior and is the best way to understand why we exhibit certain behaviors in a variety of settings. 18
Table 1 HOM summary data in four-year allopathic programs.
Institutional responses
HOM course offered
Required vs elective
HOM department
Yes
No
Total (%)
119
2
98
Yes
No
Total (%)
45
74
38
Required
Elective
% Req.
5
45
11
Yes
No
Total (%)
18
119
15
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx Table 2 HOM course offering over four-year allopathic programs. MS year offered HOM
Institutions offering HOM
Percent of total (%)
1 2 3 4 1, 2 3, 4 1, 2, 3, 4
1 1 1 13 4 5 20
2.2 2.2 2.2 29 8.9 11 44
The importance of studying HOM was heralded as early as 1904 when Cordell 13 described the absence of the HOM in the curriculum as an “inexcusable apathy” and “shocking regret.” In 1922, Ray Lyman Wilbur suggested that 10% to 15% of the third and fourth year of medical curricula should include HOM electives. 15 In 1927, the Council on Medical Education suggested that subjects such as medical history should be grouped along with medical ethics, economics, and jurisprudence under “social relations of the physician.” 15 Sigerist 14 reported in 1937 that of 77 medical schools in the United States, 30% had no instruction in medical history, 10% had occasional lectures, and 60% offered regular courses. There was in fact only one department of medical history, and that was located at Johns Hopkins University. In 1955, a systematic survey of the teaching of medical history conducted by the American Medical Association revealed that 88% of medical schools in the United States were offering either required or elective courses in medical history.15,20 It appeared that medical history had become an integral part of curricula at this time. Soon thereafter, focus shifted towards social and behavioral science because of the rising importance of public health and preventive medicine. 15,20 Since then, we have observed a steady decline in the prevalence of HOM in medical curricula. The trend has been attributed to the rise of graduate-level education on medical history and its development as an independent profession.15 However, we believe that the real reason for this displacement is the explosion in medical knowledge in recent decades, as well as the development of new specialties and disciplines within medicine. Furthermore, despite many attempts to find examples whereby the study of history affects current medical practice of medicine, such efforts are largely unsuccessful. Little by little, history has been “crowded out” by other topics that are perceived as more directly affecting clinical care. These include biomedical ethics, biostatistics, epidemiology, health economics, patient-doctor relationship, gender issues, society and medicine, and international health. We found that only 18 (15%) medical schools had HOM departments and that the average faculty size was 5 to 6 in number. The modest staffing of HOM faculty rosters reflects many factors, including the lack of funding for history-related research, the insufficient support from peers and medical school administrators, and perhaps the apathy of medical students who may question the relevance of HOM to professional provision of clinical care. History of medicine departments struggle for recognition and funding, and new graduates with doctoral degrees in HOM struggle to find suitable employment, a situation similar to that faced by nonmedical historians seeking an academic career. At the University of Massachusetts, an elective HOM course has been taught since 2006. Seminars are open to any who wish to attend, including physician trainees. Each year, a new book is presented to the class, and throughout the series, each student presents a topic of his or her choosing related to HOM. The course, from a medical and social perspective, aims to give students a greater understanding of the longstanding tradition of which they have become a part. Amidst newly overwhelming responsibility, an understanding of medical history and societal impact can help students recognize their role outside of the classroom. As we continue to educate future
3
physicians, it is important to maintain if not increase educational focus on building socially conscious and well-informed physicians. Although such efforts may have virtually no direct effect on clinical practice, the study of HOM may serve as a prudent educational supplement for physicians emerging at a time of great social change in medicine in the United States. History of anesthesia is an integral part of the residency curriculum at the Department of Anesthesiology at University of Massachusetts Medical School. CA-1 (“first-year”) residents are encouraged to read a popular historical narrative book related to history of anesthesia (Ether Day by Julie M. Fenster) 21 and to view a Hollywood film (The Great Moment). 22 Because many geographical sites related to the history of anesthesia are located in New England, a series of three annual tours is offered to all members of the department. 23 Sites toured include those related to Horace Wells in Hartford, Connecticut; homes and artifacts related to William Thomas Green Morton in Charlton and Wellesley, both in Massachusetts; Mount Auburn Cemetery in Cambridge, Massachusetts; and the Francis A. Countway Library of Medicine, the Ether Dome, and the Ether Monument, all in Boston, Massachusetts. In addition, we include Grand Rounds and lectures on topics related to history of anesthesiology. These activities have encouraged residents and faculty members to conduct research, make presentations at scientific conferences, and publish original articles related to history of anesthesia.24–26 History of medicine as a discipline has undergone considerable transformation over the past half century, especially the past two to three decades. Early domination by clinician historians, exemplified by Sir William Osler,27,28 was followed in the 1960s and 1970s by a significant migration of professionally trained historians away from a variety of related fields and into the HOM. Their efforts greatly added to the increasing body of knowledge that emerged in the following decades. This shift has been termed cultural turn and contributed greatly to the evolution of the discipline of medical history. This group saw itself as medical historians trained in the ways of Henry Sigerist, Karl Sudhoff, Erwin Ackerknecht, and their successors. 29 The field saw a dichotomy between clinician historians and medical historians. Clinician historians mostly study topics that are classified as biographical and descriptive; in contrast, medical historians study the interactions of society and medicine in the widest possible context.29 Although there is some overlap, the American Osler Society is primarily composed of clinician historians who celebrate the life and career of William Osler, whereas a majority of the members of the AAHM are nonclinicians. Physicians’ membership in the AAHM declined from 75% in 1956 to 44% in 2002. 17 In 1980, about half of the presenters at the annual meeting of AAHM were physicians, but the percentage has dropped to 30% in 2000. 17 Members of these groups differ in the format of their research writings and in the nature of their investigations. The work of clinician historians often revolves around celebrating the lives and careers of prominent physicians, and events around significant advances in medicine. Descriptive or biographical in nature, sometimes multiauthored, and less than 5000 words in length, their work is usually published in journals devoted to clinical medicine. Medical historians explore various facets of the interactions of society and medicine. Often lacking direct clinical significance, their work is authored typically by one individual, is penned to 8000 to 15,000 words in length, and is published in journals specifically dedicated to medical history. Medical historians often gain prominence not on the basis of publication of articles in journals but by the books they author. Editors of medical history journals often consider descriptive and biographical work to be passé, simplistic, or repetitive, whereas those of medical journals consider articles by medical historians too narrowly focused, remote, or without clinical significance. It has been mentioned that there are no history in the work of clinician historians
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
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J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx
and no medicine in the work of medical historians. Yet, despite these differences, an increasing number of physicians who have received formal training in history continue to build bridges between the groups, and many physicians attend and play an important role in the governance and meetings of AAHM. Medical historians, including physicians with formal training in history, face many obstacles in their careers. They find academic opportunities to be scarce, funding of research activities difficult, and their work largely undervalued by medical academia. The difference in backgrounds of clinician historians and medical historians is not unique because a similar dichotomy existed between clinician investigators and biomedical research conducted by PhD scientists. Teamwork, cross-training, and dual training programs have allowed these groups to work together, and we see no reason why such a process cannot work for clinician and medical historians. Medical students, residents, fellows, and junior faculty should learn about great medical achievements as well as the evolution of medicine. Those wishing to conduct independent investigation can pursue formal training into history or collaborate with a medical historian to delve into a specific aspect of medical history. There are more similarities than differences in the manner in which scientific and historic investigations are conducted. The two groups can and must work together and create a strong curriculum so that medical students automatically think of historical aspects of every new topic they encounter. After all, that is the purpose of historical study—not only to document and acknowledge great achievements of the past but, equally important, to understand the complex interplay between society and medicine. Conclusion The didactic curriculum in US medical school offers only a limited amount of exposure to HOM. The prevalence of HOM course work has seen little change over the past 50 years, whereas the number of departments dedicated to HOM has risen. This is most likely due to the growth of history in graduate-level education as an independent study. We feel that HOM is a qualitatively important topic that should be included in the professional education of medical students, even as they face quantitatively heavier course loads. A major obstacle in convincing medical school officials to include HOM in the curriculum is the perception that HOM does not directly affect clinical practice. Other hurdles faced by both clinician and medical historians are the scarcity of academic job offerings, a lack of recognition by colleagues, and difficulty in obtaining financial support for research activities. Appendix 1. The following survey was disseminated to elective coordinators at allopathic medical schools throughout the United States using the AAMC elective compendium Web site as source for contact information 1. Name of your medical school. Comment box 2. Does your medical school offer any courses related to the History of Medicine (HOM)? Yes/No/Comment box 3. Is the HOM course required or elective? Required/Elective 4. What is the duration of the course? (hours/credits) Comment box 5. Does your school have a department dedicated to HOM? Yes/No 6. If so, how many full-time/part-time faculty are in the department? Comment box
7. Contact information for your department of HOM: Comment box 8. To which medical students is the HOM course available? 1/2/3/4/Other (comment box) 9. Comments about HOM course at your medical school: Comment box
References 1. Blake JB. Education in the History of Medicine: Macy Foundation—National Library of Medicine Conference. New York: Hafner Publishing Company;1968. 2. Galdston I, ed. On the Utility of Medical History: Monograph I, Institute on Social and Historical Medicine—The New York Academy of Medicine. New York: International University Press, Inc.; 1957. 3. Rosen G. The place of history in medical education. Bull Hist Med. 1948;22(3): 594-629. 4. Shortt SED. History in the medical curriculum: a clinical perspective. JAMA. 1982;248(1):79-81, http://dx.doi.org/10.1001/jama.1982.03330010053031. 5. Stein C. Divining and knowing: Karl Sudhoff's historical method. Bull Hist Med. 2013;87:198-224, http://dx.doi.org/10.1353/bhm.2013.0019. 6. Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching; Bulletin No. 4. New York: The Carnegie Foundation for the Advancement of Teaching; 1910. 7. Grauer NA. Leading the Way: A History of Johns Hopkins Medicine. Baltimore: Johns Hopkins Medicine in association with The Johns Hopkins University Press; 2012. 8. Fee E, Brown TM, eds. Making Medical History: The Life and Times of Henry E. Sigerist. Baltimore: The Johns Hopkins University Press; 1997. 9. Long ER. Memoir of Edward Bell Krumbhaar, 1882-1966. Philadelphia: College of Physicians of Philadelphia; 1967. 10. Rosenberg CE, Erwin H. Ackerknecht, social medicine, and the history of medicine. Bull Hist Med. 2007;81(3):511-532. 11. Sigerist HE. Socialized Medicine in the Soviet Union. New York: W.W. Norton;1937. 12. Duffin J. The guru and the godfather: Henry Sigerist, Hugh MacLean, and the politics of health care reform in 1940s Canada. Can Bull Med Hist. 1992;9(2): 191-218. 13. Cordell EF. The importance of the study of the history of medicine. Med Libr Hist J. 1906;2(4):268-282. 14. Sigerist HE. Medical history in the medical schools of the United States. Bull Hist Med. 1939;7(2):627-662. 15. Burns CR. History in medical education: the development of current trends in the United States. Bull N Y Acad Med. 1975;51(7):851-869. 16. Temkin O. An essay on the usefulness of medical history for medicine. Bull Hist Med. 1946;19(1):9-47. 17. Joy RJT. The history of the development of the history of medicine and its teaching in the United States. In: Morris LE, Schroeder ME, Warner ME, eds. A Celebration of 75 Years Honoring Ralph Milton Waters, M.D., Mentor to a Profession. Park Ridge, Illinois: Wood Library-Museum of Anesthesiology; 2004: 1-7. 18. Stearns PN. Thinking History. Washington, D.C.: American Historical Association; 2004. 19. Patel PM, Desai SP. A clinician's rationale for the study of history of medicine. J Educ Perioper Med. 2014;16(4):1-12. 20. American Medical Association. Medical education in the United States and Canada: fifty-fourth annual report on medical education in the United States and Canada by the Council on Medical Education and Hospitals of the American Medical Association. JAMA. 1955;159(6):578-579, http://dx.doi.org/10.1001/jama.1955.02960230027010. 21. Fenster JM. Ether Day: The Strange Tale of America's Greatest Medical Discovery and the Haunted Men Who Made It. New York: HarperCollins; 2001. 22. The Great Moment (in Black and White) Preston Sturges (Director), Rene Fullop-Miller (Screen Writer), Joel McCrae (cast), Betty Field (cast); Universal Studios; 1944. 83 minutes. 23. Desai MS, Desai SP. Alternate methods to teach history of anesthesia. Anesth Analg. 2014;118:438-447, http://dx.doi.org/10.1213/ANE.0000000000000052. 24. Cooper B, Desai SP. Mount Auburn Cemetery and its importance to the history of anesthesia. Bull Anesth Hist. 2012;30(2):25-29. 25. Aponte-Feliciano A, Desai SP, Desai MS. William James Morton (1845-1920): like father, like son (?). Bull Anesth Hist. 2013;31(1):18-20. 26. Desai MS, Chennaiahgari SR, Desai SP. History of anesthesia teaching in US residency programs: results of a nationwide survey. J Clin Anesth. 2012;24(2): 101-103, http://dx.doi.org/10.1016/j.jclinane.2011.06.013. 27. Osler W. A note on the teaching of the history of medicine. Br Med J. 1902;2(2167):93. 28. Bliss M. William Osler: A Life in Medicine. Oxford: Oxford University Press; 1999. 29. Huisman F, Warner JH. Locating Medical History: The Stories and Their Meanings. Baltimore: The Johns Hopkins University Press; 2004.
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
Contents lists available at ScienceDirect
Journal of Anesthesia History journal homepage: http://www.elsevier.com/locate/janh
History of Medicine in US Medical School Curricula☆,☆☆ Justin Caramiciu, MD a, David Arcella, MD b, Manisha S. Desai, MD c,⁎ a b c
Resident in Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire Resident in Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts Clinical Associate Professor, Department of Anesthesiology, University of Massachusetts School of Medicine, Worcester, Massachusetts
a r t i c l e
i n f o
Article history: Received 15 November 2014 Received in revised form 31 January 2015 Accepted 10 February 2015 Available online xxxx
a b s t r a c t Study Objective: To determine the extent to which the history of medicine (HOM) and its related topics are included within the curriculum of accredited medical schools in the United States. Design: Survey instrument. Setting: US allopathic medical schools. Measurements: An online survey was sent to officials from every medical school in the US. Respondents were asked to provide institutional identifiers, the presence of an HOM elective offered to medical students, the years during which the elective is offered, the existence of an HOM department, and the contact information for that particular department. Nonresponders were contacted by phone to elicit the same information. History of medicine electives included didactic sessions and seminars with varying degrees of credit offered in different years of medical school. Main Results: Based on responses from 119 of 121 contacted medical schools (98%), 45 (37%) included formal lectures or weekly seminars in the medical school curriculum. Five (11%) curricula had or have required HOM, whereas 89% offered elective HOM instruction. Course duration and credit awarded varied. Eighteen (15%) medical schools included departments dedicated to HOM. Providing education in HOM was limited by faculty interest, clinical training hours, and low interest. Conclusions: Data collected by our study suggest that substantial barriers exist within the academic medical community towards a wider acceptance of the importance of HOM. Causes for such lack of interest include absence of questions on written or oral tests related to HOM, difficulty in publishing articles related to HOM in peer reviewed journals, near absence of research grants in HOM, difficulty in getting academic promotions or recognition for activities related to HOM, and a lack of support from academic chairpersons for activities related to HOM. © 2015 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.
Introduction Limited information exists on the extent of history of medicine (HOM) teaching in medical schools in the United States. It may be argued that interest in the study of HOM began in the 19th century as scientific medicine made significant strides. Medical historians have argued about the utility of teaching medical history, what should be included in such teaching, and who should teach such courses.1–4 The discipline of HOM has its roots in Germany, where Karl Sudhoff (1853-1938) established an Institute of the History of Medicine in
☆ This work was supported by intramural funds. ☆☆ This work was presented at the Spring Meeting of the Anesthesia History Association, Dearborn, Michigan, on May 2, 2014, and also at The Annual Meeting of the American Society of Anesthesiologists, New Orleans, Louisiana, on October 13, 2014. ⁎ Corresponding author at: Department of Anesthesiology, University of Massachusetts Medical School, 55 Lake Ave North, Worcester, MA 01655. E-mail address: [email protected] (M.S. Desai).
Leipzig in 1905.5 Abraham Flexner (1866-1959) published a detailed study of medical school education in the United States and Canada in 1910 and suggested that Johns Hopkins Medical School ought to be considered a model for education. 6 William Osler (1849-1919), William Welch (1850-1934), and Howard Kelly (1858-1943) at that institution were firm supporters of history, and it is not surprising that the first Department of History of Medicine was established at Johns Hopkins University in 1929.7 Henry Sigerist (1891-1957), a student of Sudhoff, was appointed the first Welch Professor in History of Medicine in 1932.8 Earlier, in 1927, Edward Krumbhaar (1882-1966) from the University of Pennsylvania established the American Association for the History of Medicine (AAHM), an association that had begun publishing its own journal, the Bulletin of the History of Medicine, in 1939.9 The second department of medical history was established at the University of Wisconsin at Madison in 1947, with Erwin Ackerknecht (1906-1988) as Chairman.10 Sigerist was born in Paris to Swiss parents and earned a medical degree from the University of Zurich. He served as a medical officer
http://dx.doi.org/10.1016/j.janh.2015.02.010 2352-4529/© 2015 Anesthesia History Association. Published by Elsevier Inc. All rights reserved.
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
2
J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx
in the Swiss Army but devoted the rest of his career to HOM. He moved to the United States in 1932 and was appointed director of Johns Hopkins University’s Institute of the History of Medicine. He was a prolific writer and very influential in shaping the direction in which medical history would evolve. 8 He was a visible and public spokesman not only for HOM but also for matters relating medicine to society. He appeared on the cover of Time Magazine on January 30, 1939, and was a popular speaker for nonmedical audiences. Being a strong proponent of the government’s role and obligation in providing health care to all citizens, he wrote about socialized medicine in the Soviet Union 11, and his ideas were used in the creation of socialized medicine in Canada.12 As a result of his views on socialized medicine, he was opposed by the American Medical Association and other proponents of the status quo. He left the United States in 1947 and retired to Switzerland, where he died in 1957. A case for inclusion of medical history in the curriculum has been made since the beginning of the 20th century. 4,13–16 These pleas have been ignored largely, and there has been a gradual decline in the percentage of medical schools offering or requiring courses in medical history. There has also been a gradual shift in the training and background of medical historians, from MD historians to PhD historians.17 This is evident in membership, presentations, and publications of the AAHM, including the Bulletin of the History of Medicine. Most medical history courses are taught by PhD historians, and topics being researched place emphasis on society and policy rather than physicians, patients, and disease. The aim of our study was to define the current state of coursework offered in HOM in US medical schools. We wished to determine whether medical history had been “crowded out” of the curriculum. We proceed to explain changes in the nature of work undertaken by MD historians and PhD historians, and the arenas in which these historians operate. We conclude by proposing a mechanism by which these divergent groups may work together rather than at odds with each other.
Materials and Methods American medical schools accredited by the AAMC were included in a survey on HOM in their respective curricula. The extramural elective compendium, a searchable database available from the AAMC, was used to contact elective coordinators at each school electronically. The survey instrument was hosted by a commercial Web site (SurveyMonkey, Palo Alto, California). Each coordinator was asked to respond to nine brief questions, available in the Appendix 1. We contacted medical school registrars (by phone) at institutions where survey responses were not initially obtained from elective coordinators. Information was further collected through examination of available online elective catalogs for schools that could not provide information on HOM. We sought to obtain information pertaining to prevalence of HOM at medical schools in the United States. This information included whether an HOM elective or seminar series was offered at each institution. If HOM instruction was identified, we inquired about requirement status, credits awarded, and hours included. We also sought to understand to whom the course was being offered. We finally inquired about the presence of a department of HOM and dedicated faculty. The study was approved by the Institutional Review Board at University of Massachusetts School of Medicine. Our questionnaire was directed at medical school officials who would not be expected to know details about how history of anesthesia was taught at their medical school or department of anesthesiology. Therefore, our questionnaire did not include questions about the teaching of anesthesia history.
Results Elective coordinators from 18 of 121 (15% response rate) medical institutions responded to the survey online. The remaining medical schools were contacted via phone through registrar office (76 of 121, 63%) institutions. Questions were posed verbally and recorded. Data were confirmed and missing information was obtained through elective catalogs available on institutional Web sites (Table 1). Schools were identified as having an HOM elective if they offered a didactic session or seminar series including HOM. Based on responses and information gathered from 119 of 121 medical schools (98%, we were unable to collect information from 2 institutions), 45 (37%) included formal lectures or a seminar series in their medical school curricula. Of these, 5 (11%) curricula required instruction in HOM, whereas the rest (89%) offered HOM instruction on an elective basis. The year during which courses are offered is shown in Table 2. History of medicine education was offered to medical students during all four years of training. Course duration and credit awarded varied greatly. Eighteen (15%) medical schools included departments dedicated to HOM, which included an average of five to six full-time faculty members. Discussion History struggles for inclusion in the curricula within institutions of higher learning in the sciences, and the curricular emphasis of history has diminished over the decades. This trend is not unique to history, and many disciplines once considered important in the making of wholesome civil society continue to fight an uphill battle as both pragmatic and economic factors dominate increasingly many aspects of academia. One can argue that, among all the species that inhabit our planet, man alone is aware of the past. Everything that is known with certainty can be considered to be within the realm of history. This is true because the future is largely unknown, and the present is fleeting. When history is viewed from this perspective, one is surprised that more attention is not paid to this important aspect of every discipline. The study of history is an examination of change and provides the means through which we understand how today’s world has been shaped. The many challenges faced by medicine are understood better with the perspective offered by historical knowledge. The comprehension of scale, timing, causation, and continuity of change are necessary to understand the evolution of past events and how they apply to the present. 18 History is an essential part of our educational system for this reason, providing students with necessary tools to move forward with a better understanding of their own environment. 19 History also offers information on human behavior in societal context. History collectively provides data on human behavior and is the best way to understand why we exhibit certain behaviors in a variety of settings. 18
Table 1 HOM summary data in four-year allopathic programs.
Institutional responses
HOM course offered
Required vs elective
HOM department
Yes
No
Total (%)
119
2
98
Yes
No
Total (%)
45
74
38
Required
Elective
% Req.
5
45
11
Yes
No
Total (%)
18
119
15
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx Table 2 HOM course offering over four-year allopathic programs. MS year offered HOM
Institutions offering HOM
Percent of total (%)
1 2 3 4 1, 2 3, 4 1, 2, 3, 4
1 1 1 13 4 5 20
2.2 2.2 2.2 29 8.9 11 44
The importance of studying HOM was heralded as early as 1904 when Cordell 13 described the absence of the HOM in the curriculum as an “inexcusable apathy” and “shocking regret.” In 1922, Ray Lyman Wilbur suggested that 10% to 15% of the third and fourth year of medical curricula should include HOM electives. 15 In 1927, the Council on Medical Education suggested that subjects such as medical history should be grouped along with medical ethics, economics, and jurisprudence under “social relations of the physician.” 15 Sigerist 14 reported in 1937 that of 77 medical schools in the United States, 30% had no instruction in medical history, 10% had occasional lectures, and 60% offered regular courses. There was in fact only one department of medical history, and that was located at Johns Hopkins University. In 1955, a systematic survey of the teaching of medical history conducted by the American Medical Association revealed that 88% of medical schools in the United States were offering either required or elective courses in medical history.15,20 It appeared that medical history had become an integral part of curricula at this time. Soon thereafter, focus shifted towards social and behavioral science because of the rising importance of public health and preventive medicine. 15,20 Since then, we have observed a steady decline in the prevalence of HOM in medical curricula. The trend has been attributed to the rise of graduate-level education on medical history and its development as an independent profession.15 However, we believe that the real reason for this displacement is the explosion in medical knowledge in recent decades, as well as the development of new specialties and disciplines within medicine. Furthermore, despite many attempts to find examples whereby the study of history affects current medical practice of medicine, such efforts are largely unsuccessful. Little by little, history has been “crowded out” by other topics that are perceived as more directly affecting clinical care. These include biomedical ethics, biostatistics, epidemiology, health economics, patient-doctor relationship, gender issues, society and medicine, and international health. We found that only 18 (15%) medical schools had HOM departments and that the average faculty size was 5 to 6 in number. The modest staffing of HOM faculty rosters reflects many factors, including the lack of funding for history-related research, the insufficient support from peers and medical school administrators, and perhaps the apathy of medical students who may question the relevance of HOM to professional provision of clinical care. History of medicine departments struggle for recognition and funding, and new graduates with doctoral degrees in HOM struggle to find suitable employment, a situation similar to that faced by nonmedical historians seeking an academic career. At the University of Massachusetts, an elective HOM course has been taught since 2006. Seminars are open to any who wish to attend, including physician trainees. Each year, a new book is presented to the class, and throughout the series, each student presents a topic of his or her choosing related to HOM. The course, from a medical and social perspective, aims to give students a greater understanding of the longstanding tradition of which they have become a part. Amidst newly overwhelming responsibility, an understanding of medical history and societal impact can help students recognize their role outside of the classroom. As we continue to educate future
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physicians, it is important to maintain if not increase educational focus on building socially conscious and well-informed physicians. Although such efforts may have virtually no direct effect on clinical practice, the study of HOM may serve as a prudent educational supplement for physicians emerging at a time of great social change in medicine in the United States. History of anesthesia is an integral part of the residency curriculum at the Department of Anesthesiology at University of Massachusetts Medical School. CA-1 (“first-year”) residents are encouraged to read a popular historical narrative book related to history of anesthesia (Ether Day by Julie M. Fenster) 21 and to view a Hollywood film (The Great Moment). 22 Because many geographical sites related to the history of anesthesia are located in New England, a series of three annual tours is offered to all members of the department. 23 Sites toured include those related to Horace Wells in Hartford, Connecticut; homes and artifacts related to William Thomas Green Morton in Charlton and Wellesley, both in Massachusetts; Mount Auburn Cemetery in Cambridge, Massachusetts; and the Francis A. Countway Library of Medicine, the Ether Dome, and the Ether Monument, all in Boston, Massachusetts. In addition, we include Grand Rounds and lectures on topics related to history of anesthesiology. These activities have encouraged residents and faculty members to conduct research, make presentations at scientific conferences, and publish original articles related to history of anesthesia.24–26 History of medicine as a discipline has undergone considerable transformation over the past half century, especially the past two to three decades. Early domination by clinician historians, exemplified by Sir William Osler,27,28 was followed in the 1960s and 1970s by a significant migration of professionally trained historians away from a variety of related fields and into the HOM. Their efforts greatly added to the increasing body of knowledge that emerged in the following decades. This shift has been termed cultural turn and contributed greatly to the evolution of the discipline of medical history. This group saw itself as medical historians trained in the ways of Henry Sigerist, Karl Sudhoff, Erwin Ackerknecht, and their successors. 29 The field saw a dichotomy between clinician historians and medical historians. Clinician historians mostly study topics that are classified as biographical and descriptive; in contrast, medical historians study the interactions of society and medicine in the widest possible context.29 Although there is some overlap, the American Osler Society is primarily composed of clinician historians who celebrate the life and career of William Osler, whereas a majority of the members of the AAHM are nonclinicians. Physicians’ membership in the AAHM declined from 75% in 1956 to 44% in 2002. 17 In 1980, about half of the presenters at the annual meeting of AAHM were physicians, but the percentage has dropped to 30% in 2000. 17 Members of these groups differ in the format of their research writings and in the nature of their investigations. The work of clinician historians often revolves around celebrating the lives and careers of prominent physicians, and events around significant advances in medicine. Descriptive or biographical in nature, sometimes multiauthored, and less than 5000 words in length, their work is usually published in journals devoted to clinical medicine. Medical historians explore various facets of the interactions of society and medicine. Often lacking direct clinical significance, their work is authored typically by one individual, is penned to 8000 to 15,000 words in length, and is published in journals specifically dedicated to medical history. Medical historians often gain prominence not on the basis of publication of articles in journals but by the books they author. Editors of medical history journals often consider descriptive and biographical work to be passé, simplistic, or repetitive, whereas those of medical journals consider articles by medical historians too narrowly focused, remote, or without clinical significance. It has been mentioned that there are no history in the work of clinician historians
Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010
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J. Caramiciu et al. / Journal of Anesthesia History xxx (2015) xxx–xxx
and no medicine in the work of medical historians. Yet, despite these differences, an increasing number of physicians who have received formal training in history continue to build bridges between the groups, and many physicians attend and play an important role in the governance and meetings of AAHM. Medical historians, including physicians with formal training in history, face many obstacles in their careers. They find academic opportunities to be scarce, funding of research activities difficult, and their work largely undervalued by medical academia. The difference in backgrounds of clinician historians and medical historians is not unique because a similar dichotomy existed between clinician investigators and biomedical research conducted by PhD scientists. Teamwork, cross-training, and dual training programs have allowed these groups to work together, and we see no reason why such a process cannot work for clinician and medical historians. Medical students, residents, fellows, and junior faculty should learn about great medical achievements as well as the evolution of medicine. Those wishing to conduct independent investigation can pursue formal training into history or collaborate with a medical historian to delve into a specific aspect of medical history. There are more similarities than differences in the manner in which scientific and historic investigations are conducted. The two groups can and must work together and create a strong curriculum so that medical students automatically think of historical aspects of every new topic they encounter. After all, that is the purpose of historical study—not only to document and acknowledge great achievements of the past but, equally important, to understand the complex interplay between society and medicine. Conclusion The didactic curriculum in US medical school offers only a limited amount of exposure to HOM. The prevalence of HOM course work has seen little change over the past 50 years, whereas the number of departments dedicated to HOM has risen. This is most likely due to the growth of history in graduate-level education as an independent study. We feel that HOM is a qualitatively important topic that should be included in the professional education of medical students, even as they face quantitatively heavier course loads. A major obstacle in convincing medical school officials to include HOM in the curriculum is the perception that HOM does not directly affect clinical practice. Other hurdles faced by both clinician and medical historians are the scarcity of academic job offerings, a lack of recognition by colleagues, and difficulty in obtaining financial support for research activities. Appendix 1. The following survey was disseminated to elective coordinators at allopathic medical schools throughout the United States using the AAMC elective compendium Web site as source for contact information 1. Name of your medical school. Comment box 2. Does your medical school offer any courses related to the History of Medicine (HOM)? Yes/No/Comment box 3. Is the HOM course required or elective? Required/Elective 4. What is the duration of the course? (hours/credits) Comment box 5. Does your school have a department dedicated to HOM? Yes/No 6. If so, how many full-time/part-time faculty are in the department? Comment box
7. Contact information for your department of HOM: Comment box 8. To which medical students is the HOM course available? 1/2/3/4/Other (comment box) 9. Comments about HOM course at your medical school: Comment box
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Please cite this article as: Caramiciu J, et al. History of Medicine in US Medical School Curricula. J Anesth Hist (2015), http://dx.doi.org/ 10.1016/j.janh.2015.02.010