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Medical Education in the United States of America.
MEDICAL EDUCATION IN THE UNITED STATES OF AMERICA.
242
protected against the repeated inoculations of cancer may develop tumours of their own. It must also not be forgotten that these results obtainable in mice cannot be looked upon as applicable directly to the human subject. They are enormously suggestive, but do not, at any rate in our opinion, point the way as yet to practical therapy. The experiments have fully shown that the problems presented by spontaneous tumours are far more difficult than those of transplanted cancer, for the methods successful in preventing or retarding the growth of transplanted tumours have been utterly without action on the continued growth of spontaneous tumours. From what
The remuneration of the instructors in higher education is nearly everywhere absurdly small, and the value of such an endowment, if properly administered, should be great. A difficulty, however, immediately con. fronted the trustees, for it was recognised that under the name of colleges many institutions existed which were con. cerned mainly with secondary education, and not with truly professional or technical instruction. In fact, we are told that this is true of a large majority of all the institutions in the United States bearing the name of "college." In conditions such as these the trustees of the Carnegie Foundation, before making grants to teachers in pursuance of States.
have said, as well as from Mr. BALFOUR’S the terms of the Trust, felt themselves compelled to institute eloquent exposition of the matter at the annual meeting, an inquiry into the work of the colleges and universities in reported elsewhere, it is clear that progress has been made ; the area with which they had to deal. The trustees have definite ideas are being obtained as to the conditions under accordingly published a report detailing the results ascerwhich malignant tumours grow. The continuation and the tained during a visit to 150 different medical schools, a extension of the work of the Fund are in consequence urgently report which will prove of great value both to the institutions called for, and we trust that the public, obtaining this concerned and to the public. Medical education is a matter assurance from medical men, will facilitate by their purses in which the public have every reason to be deeply interested, the efforts of the Fund. In addition to Dr. E. F. BASHFORD, and the more information on the subject that can be supplied many distinguished men have been working in the to the public the less hold will quackery have upon them. laboratories of the Fund, and many of them have We can believe that some of the institutions have resented come from foreign countries ; while in support of its interthe curiosity of the trustees, but this was inevitable. A national character the Fund continues to distribute tumours similar inquiry into the state of medical education in Great and other material for investigation to many laboratories Britain, France, and Germany is to be made, so that abroad as well as at home. The value of the work done by the experiences and performances in medical education may Fund is shown by the fact that several of the foreign workers undergo international comparisons. in the laboratories have, at the termination of their labours This study of the transatlantic medical schools has shown The that for the last 25 here, received important pathological posts abroad. years past there has been in the United Imperial Cancer Research Fund fully justifies its existence, States an over-production of uneducated medical practiand if it be supported as it should be, we may look forward tioners, in utter disregard oE the public welfare. When it with confidence to the results which it will achieve. And is stated that in the United States there are four or five a demand for patience, which Dr. BASHFORD does not make times as many medical men in proportion to the population but which we may make for him, is legitimate. The as there are, for instance, in Germany, it is clear that the problem is a vast and complex one, and the road to the number of medical men is unnecessarily large. Many of the truth has to be hewed through obstacles of many kinds. men are ill-trained, and this is due to the existence we
mainly
very large number of medical schools started for the purpose of earning a profit for their founders, and supported
of
Medical Education in the United States of America. THE standard of medical education has changed greatly within the last hundred years, and the improvements in teaching have been enormous, but even at the present day
a
which young men are seduced from industrial occupations into the study of medicine. Until a I short time ago it was possible for the managers of a medical
by advertisements, by
school to derive perhaps, do their
no
small amount of
gain
from it, and still,
public, for the duty by pupils teaching quality instruction was mainly given through lectures and the workgiven at different schools of medicine, and perhaps even ing expenses were small. But, as the need for laboratory work greater differences are to be found in the equipments of the has become more keenly felt, the expenses of any medical various schools. The process of levelling up has for years pro- school worthy of being called efficient have greatly increased. notable differences exist
in the
THE LANCET,
July 9th (p. 137)
and the
of the
ceeded in this country, but even with us the standards attained by different schools are not identical, although the General Medical Council prevents gross disparities ; while vast variations undoubtedly exist amongst the medical schools of the United States of America. This has been brought out by the Carnegie Foundation for the Advancement of Teaching in a manner which has proved too frank for some susceptibilities.1 Some five years ago, it may be remembered, the Carnegie Foundation was established and provided with an endowment for the purpose of increasing the salaries of teachers in the colleges and universities of the United 1
their
and 16th
(p. 181), 1910.
It is obvious that many of the medical schools in the United States must be inefficient, for nearly half of them have an
income of less than £ 2000 a year each. It is the opinion of the trustees of the Carnegie Foundation and their advisers, from the consideration of the facts contained in this report, that true progress in medical teaching in the United States will require a smaller number of schools, but they will have to be much better equipped than are the majority of schools at present. So far as the public are concerned, it would be better that fewer physicians should be graduated every year, but they should be better educated and better trained. For one great disadvantage under which medical education
243 c The out-patient departments, or dispensaries,"as entirely unknown here-is classes. 1 are usually called, are often very thinly attended, the unsatisfactory state of the preliminary education of they Medicine is now so complex a ’which is excellent hearing in one way, as it points to the fact the medical student. subject, and it depends so greatly on other sciences, that a1that, at any rate away from the great centres, the question I student who enters it ill-provided with general knowledge isof hospital abuse is not so acute in the United States as it with us. But the position has its educational difficulties. is in his professional studies, though heavily handicapped teachers all over the world are perplexed in attempting to For instance, at one school the visitors were told that there decide where general education should stop and professional was"a dispensary room, and almost every day someone education begin. Even in the short time, however, during cornea." When in spite of these inadequate provisions we which the Carnegie Foundation has been acting some bene- learn that the examination results are often exceedingly ficial results have been attained in the country of its good, it is obvious that the examinations fail in being not origin. Some colleges, finding themselves unable to carry sufficiently practical. As has been said, and as might have been guessed, the on a medical school on the lines required by the present state of medical science, have decided to discontinue their report of the trustees of the Carnegie Foundation has given medical department, and in other cases, where two ill- offence in some quarters, but recognising, as we do, the provided and competing schools have little more than splendid work that is done in the leading medical schools of managed to exist, they have united into a single school, far the United States, we cannot help believing that such better qualified to fulfil efficiently the function of medical drastic criticism will do good. We have referred mainly to
labours in America-and it is not
the schools in the United States in our remarks, but the position is similar in Canada, where the smaller schools offer
education. The difficulties in the future
are
Every one of the
great.
medical education that may undoubtedly prove a serious danger to the public, but where the two great schools, McGill and Toronto, are deserving of the high praise accorded to them.
a
United States possesses the right to make what laws it chooses for the instruction and examination of medical
students, and
to this fact must undoubtedly be attributed number of medical schools existing. For instance, large in the State of Illinois there are 14 distinct medical schools, and Missouri has 11. When the public are more alive to the importance of the proper training of medical men,
the
they
will insist
schools.
THE
facilities for in of the discovered some teaching colleges by the visitors from the Carnegie Foundation. In many we hear that anatomy is taught almost entirely by tutorial classes, or "quiz-classes"" as they are called ; subjects fen which
dissection in
they
were
some cases are
little value.
utterly wanting,
in such small numbers
provided
are
Not
infrequently,
we
are
tion of the annual
report of the Chief Inspector of Factories
Workshops for the year 1909. It will therefore be The convenient to consider both reports simultaneously. report upon the use of lead compounds in pottery is a highly
and
and in others
as
to
into the
equipment imagine the lack of
It is difficult to
report of the Departmental Committee appointed
inquire dangers attendant on the use of lead in the arts and industries, and into the question also of injury to health arising from dust in the manufacture of earthenware and china, was issued within a short period of the publica-
of all medical
the sufficient
on
Industrial Perils.
to be of very
told,’’ the school interesting document, in which the question of lead poisoning is dealt with at very considerable length, and the statistics which the committee had before them showed a very marked
skeleton" is defective, and the students possess no "bones""’of their own. In physiology the teaching is in a majority of the colleges confined to lectures, and work is unknown. Sometimes some new physiopractical logical apparatus is shown, but it has been bought
decrease in the number of cases for the year 1909. In 1896 there were 432 cases reported in the United Kingdom. In 1908 the number was 117, and in 1909 it had fallen to 58. The committee came to the conclusion that lead poisoning was largely to be accounted for by defective conditions of labour, especially when not associated with adequate exhaust draughts. Undue pressure of work was also held to
requirements laid down by the law and is unused. Chemistry appears to be equally hear of absence of running water at the we unprovided for ; desks and of a single set of reagents being provided for a whole class. In the teaching of pathology very little use is be an important factor in producing an outbreak of the made of necropsies. We are told that at one college the disease, while the report also mentions that the committee
merely
to
satisfy
students witness
a
the
‘6 few"
year; at another four is also much neglected. to be
has
great
or
necropsies
in the
five " are to be
In clinical
seen.
course
Bacteriology
teaching there
appears In many instances the student to do with the cases; he merely
need for reform.
nothing personally
listens to what is said about them. In many of the colleges clinical facilities are almost wanting, in others only a few beds
arrived at the belief that the
of the
available.
In one I I medical
to contract lead
enhanced
by any On this
system.
I
susceptibility of any class of poisoning was, without doubt, insufficient nourishment of the physical
workers
medical
account Dr.
A. A.
HILL,
witnesses, in his evidence referred to
attacks
to
one
of the
poverty
as
of
predisposing plumbism. Sir THOMAS OLIVER and other witnesses, carefully selected for expert knowledge, strongly advocated the provision of milk to workers in lead processes before they commenced
university" we learn top building hospital," and their morning shift. The necessity of this had, it was was inspected it contained only two patients. Sometimes the clinical opportunities depend on a certain stated, been recognised by certain manufacturers, who had lecturer, and if he resigns from the school the beds under his voluntarily made this provision for years. The committee authority can no longer be used for the instruction of the made many recommendations dealing with the medical are
that the when it
floor of the
is the
242
protected against the repeated inoculations of cancer may develop tumours of their own. It must also not be forgotten that these results obtainable in mice cannot be looked upon as applicable directly to the human subject. They are enormously suggestive, but do not, at any rate in our opinion, point the way as yet to practical therapy. The experiments have fully shown that the problems presented by spontaneous tumours are far more difficult than those of transplanted cancer, for the methods successful in preventing or retarding the growth of transplanted tumours have been utterly without action on the continued growth of spontaneous tumours. From what
The remuneration of the instructors in higher education is nearly everywhere absurdly small, and the value of such an endowment, if properly administered, should be great. A difficulty, however, immediately con. fronted the trustees, for it was recognised that under the name of colleges many institutions existed which were con. cerned mainly with secondary education, and not with truly professional or technical instruction. In fact, we are told that this is true of a large majority of all the institutions in the United States bearing the name of "college." In conditions such as these the trustees of the Carnegie Foundation, before making grants to teachers in pursuance of States.
have said, as well as from Mr. BALFOUR’S the terms of the Trust, felt themselves compelled to institute eloquent exposition of the matter at the annual meeting, an inquiry into the work of the colleges and universities in reported elsewhere, it is clear that progress has been made ; the area with which they had to deal. The trustees have definite ideas are being obtained as to the conditions under accordingly published a report detailing the results ascerwhich malignant tumours grow. The continuation and the tained during a visit to 150 different medical schools, a extension of the work of the Fund are in consequence urgently report which will prove of great value both to the institutions called for, and we trust that the public, obtaining this concerned and to the public. Medical education is a matter assurance from medical men, will facilitate by their purses in which the public have every reason to be deeply interested, the efforts of the Fund. In addition to Dr. E. F. BASHFORD, and the more information on the subject that can be supplied many distinguished men have been working in the to the public the less hold will quackery have upon them. laboratories of the Fund, and many of them have We can believe that some of the institutions have resented come from foreign countries ; while in support of its interthe curiosity of the trustees, but this was inevitable. A national character the Fund continues to distribute tumours similar inquiry into the state of medical education in Great and other material for investigation to many laboratories Britain, France, and Germany is to be made, so that abroad as well as at home. The value of the work done by the experiences and performances in medical education may Fund is shown by the fact that several of the foreign workers undergo international comparisons. in the laboratories have, at the termination of their labours This study of the transatlantic medical schools has shown The that for the last 25 here, received important pathological posts abroad. years past there has been in the United Imperial Cancer Research Fund fully justifies its existence, States an over-production of uneducated medical practiand if it be supported as it should be, we may look forward tioners, in utter disregard oE the public welfare. When it with confidence to the results which it will achieve. And is stated that in the United States there are four or five a demand for patience, which Dr. BASHFORD does not make times as many medical men in proportion to the population but which we may make for him, is legitimate. The as there are, for instance, in Germany, it is clear that the problem is a vast and complex one, and the road to the number of medical men is unnecessarily large. Many of the truth has to be hewed through obstacles of many kinds. men are ill-trained, and this is due to the existence we
mainly
very large number of medical schools started for the purpose of earning a profit for their founders, and supported
of
Medical Education in the United States of America. THE standard of medical education has changed greatly within the last hundred years, and the improvements in teaching have been enormous, but even at the present day
a
which young men are seduced from industrial occupations into the study of medicine. Until a I short time ago it was possible for the managers of a medical
by advertisements, by
school to derive perhaps, do their
no
small amount of
gain
from it, and still,
public, for the duty by pupils teaching quality instruction was mainly given through lectures and the workgiven at different schools of medicine, and perhaps even ing expenses were small. But, as the need for laboratory work greater differences are to be found in the equipments of the has become more keenly felt, the expenses of any medical various schools. The process of levelling up has for years pro- school worthy of being called efficient have greatly increased. notable differences exist
in the
THE LANCET,
July 9th (p. 137)
and the
of the
ceeded in this country, but even with us the standards attained by different schools are not identical, although the General Medical Council prevents gross disparities ; while vast variations undoubtedly exist amongst the medical schools of the United States of America. This has been brought out by the Carnegie Foundation for the Advancement of Teaching in a manner which has proved too frank for some susceptibilities.1 Some five years ago, it may be remembered, the Carnegie Foundation was established and provided with an endowment for the purpose of increasing the salaries of teachers in the colleges and universities of the United 1
their
and 16th
(p. 181), 1910.
It is obvious that many of the medical schools in the United States must be inefficient, for nearly half of them have an
income of less than £ 2000 a year each. It is the opinion of the trustees of the Carnegie Foundation and their advisers, from the consideration of the facts contained in this report, that true progress in medical teaching in the United States will require a smaller number of schools, but they will have to be much better equipped than are the majority of schools at present. So far as the public are concerned, it would be better that fewer physicians should be graduated every year, but they should be better educated and better trained. For one great disadvantage under which medical education
243 c The out-patient departments, or dispensaries,"as entirely unknown here-is classes. 1 are usually called, are often very thinly attended, the unsatisfactory state of the preliminary education of they Medicine is now so complex a ’which is excellent hearing in one way, as it points to the fact the medical student. subject, and it depends so greatly on other sciences, that a1that, at any rate away from the great centres, the question I student who enters it ill-provided with general knowledge isof hospital abuse is not so acute in the United States as it with us. But the position has its educational difficulties. is in his professional studies, though heavily handicapped teachers all over the world are perplexed in attempting to For instance, at one school the visitors were told that there decide where general education should stop and professional was"a dispensary room, and almost every day someone education begin. Even in the short time, however, during cornea." When in spite of these inadequate provisions we which the Carnegie Foundation has been acting some bene- learn that the examination results are often exceedingly ficial results have been attained in the country of its good, it is obvious that the examinations fail in being not origin. Some colleges, finding themselves unable to carry sufficiently practical. As has been said, and as might have been guessed, the on a medical school on the lines required by the present state of medical science, have decided to discontinue their report of the trustees of the Carnegie Foundation has given medical department, and in other cases, where two ill- offence in some quarters, but recognising, as we do, the provided and competing schools have little more than splendid work that is done in the leading medical schools of managed to exist, they have united into a single school, far the United States, we cannot help believing that such better qualified to fulfil efficiently the function of medical drastic criticism will do good. We have referred mainly to
labours in America-and it is not
the schools in the United States in our remarks, but the position is similar in Canada, where the smaller schools offer
education. The difficulties in the future
are
Every one of the
great.
medical education that may undoubtedly prove a serious danger to the public, but where the two great schools, McGill and Toronto, are deserving of the high praise accorded to them.
a
United States possesses the right to make what laws it chooses for the instruction and examination of medical
students, and
to this fact must undoubtedly be attributed number of medical schools existing. For instance, large in the State of Illinois there are 14 distinct medical schools, and Missouri has 11. When the public are more alive to the importance of the proper training of medical men,
the
they
will insist
schools.
THE
facilities for in of the discovered some teaching colleges by the visitors from the Carnegie Foundation. In many we hear that anatomy is taught almost entirely by tutorial classes, or "quiz-classes"" as they are called ; subjects fen which
dissection in
they
were
some cases are
little value.
utterly wanting,
in such small numbers
provided
are
Not
infrequently,
we
are
tion of the annual
report of the Chief Inspector of Factories
Workshops for the year 1909. It will therefore be The convenient to consider both reports simultaneously. report upon the use of lead compounds in pottery is a highly
and
and in others
as
to
into the
equipment imagine the lack of
It is difficult to
report of the Departmental Committee appointed
inquire dangers attendant on the use of lead in the arts and industries, and into the question also of injury to health arising from dust in the manufacture of earthenware and china, was issued within a short period of the publica-
of all medical
the sufficient
on
Industrial Perils.
to be of very
told,’’ the school interesting document, in which the question of lead poisoning is dealt with at very considerable length, and the statistics which the committee had before them showed a very marked
skeleton" is defective, and the students possess no "bones""’of their own. In physiology the teaching is in a majority of the colleges confined to lectures, and work is unknown. Sometimes some new physiopractical logical apparatus is shown, but it has been bought
decrease in the number of cases for the year 1909. In 1896 there were 432 cases reported in the United Kingdom. In 1908 the number was 117, and in 1909 it had fallen to 58. The committee came to the conclusion that lead poisoning was largely to be accounted for by defective conditions of labour, especially when not associated with adequate exhaust draughts. Undue pressure of work was also held to
requirements laid down by the law and is unused. Chemistry appears to be equally hear of absence of running water at the we unprovided for ; desks and of a single set of reagents being provided for a whole class. In the teaching of pathology very little use is be an important factor in producing an outbreak of the made of necropsies. We are told that at one college the disease, while the report also mentions that the committee
merely
to
satisfy
students witness
a
the
‘6 few"
year; at another four is also much neglected. to be
has
great
or
necropsies
in the
five " are to be
In clinical
seen.
course
Bacteriology
teaching there
appears In many instances the student to do with the cases; he merely
need for reform.
nothing personally
listens to what is said about them. In many of the colleges clinical facilities are almost wanting, in others only a few beds
arrived at the belief that the
of the
available.
In one I I medical
to contract lead
enhanced
by any On this
system.
I
susceptibility of any class of poisoning was, without doubt, insufficient nourishment of the physical
workers
medical
account Dr.
A. A.
HILL,
witnesses, in his evidence referred to
attacks
to
one
of the
poverty
as
of
predisposing plumbism. Sir THOMAS OLIVER and other witnesses, carefully selected for expert knowledge, strongly advocated the provision of milk to workers in lead processes before they commenced
university" we learn top building hospital," and their morning shift. The necessity of this had, it was was inspected it contained only two patients. Sometimes the clinical opportunities depend on a certain stated, been recognised by certain manufacturers, who had lecturer, and if he resigns from the school the beds under his voluntarily made this provision for years. The committee authority can no longer be used for the instruction of the made many recommendations dealing with the medical are
that the when it
floor of the
is the