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The Physician Looks at Dental Education*
DENTAL ECONOMICS THE PHYSICIAN LOOKS A T DENTAL EDUCATION* B y JAM ES S. M cL E S T E R f, M .D ., B irm ingham , A la.
H E regard in which a profession is held, and its usefulness, depend in large degree on the depth of culture and the breadth of learning of its indi vidual members. Recognizing this, the medical profession has been engaged for the past twenty-five years in the eleva tion of educational standards, and to day, I am told, the dental profession is concerning itself w ith the same process. H ow rapidly you are proceeding and how w ell satisfied you are w ith results, I am not informed, b u t as a former mem ber of the Council on M edical Education of the American M edical Association, I may be able to tell you something of the difficulties we have encountered and to draw an analogy between your problems and ours. T hirty-three years ago, ju st after the Boer W ar, a British medical officer told me this: T h e M edical Corps of the British Army in South Africa was or dered to accept w ith ou t scrutiny the grad uates of any European medical school, but not those of American schools. T h e latter must undergo investigation. T his humiliated me greatly, for that order was issued w ith good reason. A t that time, in 1900, while we had many of the best medical schools, we also had many of the poorest. Indeed, it has been stated that we were distinguished by having all
T
*Read at the Second G eneral M eeting of the Seventy-Seventh A n n u a l Session of the A m er ican D ental A ssociation, New O rleans, La., Nov. 5, 1935. fP re sid e n t of the A m erican M edical Asso ciation.
Jour. A.D.A., Vol. 23, March, 1936
of the poorest. Now, all of that is changed. Any physician who has grad uated in the past ten years from a recog nized American school has had excellent training, the equal of the best. T his has come about through the w ork of the Council on Medical Education of the American M edical Association. T his council began about twenty-five years ago to inspect medical schools and to rate them as Class A, B or C. T h e schools were graded upon many things, but, first of all, upon their entrance requirements and the fidelity w ith which these were observed. I can remember the time when a man of the most elementary education, or none at all, if he were ambitious and had saved a little money, could, without further preparation, enter immediately on the study of medicine. Now, every American school, preliminary to accept ance, demands as a minimal educational requirement two years of college work. M ost of them require a bachelor’s de gree. T h e schools were graded also on the number of full-time teachers, the character of the curriculum, the adequacy of hospital facilities, the equipment of the laboratories, the library, the physical plant and many other things. You will wonder how a body of this kind, w ithout legal authority, could en force its rulings. T h e council’s influence first became effective when the several state legislatures recognized its classi fication and decreed that their examining boards would license for the practice of medicine only graduates of Class A schools. Those schools rated as B and
503
504
T he Journal of the American D ental Association
C were then forced to improve their standards and facilities in such a manner as to m erit the A rating or to close their doors. About half of the total number followed the latter course. As a result, with the exception of a few so-called “outlaw ” schools, all American medical schools are now of the highest grade. W ere I to meet th at European officer today, I could truthfuly say th a t in America we have no poor medical schools, that our least efficient is the equal of their best; and that our best are unequaled in the world. Standardization is of course the big problem. I t has always been so w ith us, and will be so w ith you. T ru e, there will always be a few outstanding schools w ith liberal endowment, directed by men of vision, and in dentistry, as in medicine, these schools w ill lead the way. In point of equipment, admission require ment and excellence of teaching person nel, they w ill meet, and in some respects excel, all ordinary standards. But, these are not the schools w ith which we are concerned. I t is the school w ith insuf ficient means, the school th a t leans solely or even too heavily on the tuition th at the student pays, that is our chief concern. Such a school, too often, has a teaching staff composed largely of part-tim e men who are heavily burdened w ith every day practice. I t is an old, old argum ent that a certain number of schools of lower grade, should be recognized in order to afford opportunity to the boy of limited preliminary education, the boy who, be cause of restricted funds, must hurry through his professional training. “Give the poor boy a chance” is w hat we have heard time and again. B ut we have found in medicine, as I know you are finding in dentistry, that this is a fallacious argu ment. T h e answer should be “Give the patient a chance.” T o do anything else is fatal. M u st we lower the standards
of the profession, must we lessen the average o f efficiency and must we destroy the esteem in which physicians and den tists as a whole are held in order to give the poor boy a chance? However much we may sympathize w ith the ambitious boy who has neither the time nor the means to meet the higher standards of education, we must, in the interest of the public w elfare and of the profession as a whole, answer no. In dentistry as in medicine, the profession must strive con tinually to elevate its educational stand ards. H ow high should these standards be? I t is obvious that the law of diminishing returns applies here as elsewhere and that we could, in our enthusiasm, conceivably raise standards to an impossible point. Theoretically, they should be elevated to the point a t which the maximum benefit occurs to the greatest number. W hether we have reached this point in medicine and w hether you are approaching it in dentistry, it is difficult to say. O f far reaching importance was the action of the Council on M edical Education and H ospitals of the American Medical As sociation when it recently appointed a “blue p rin t” committee whose function it will be during the next two years to study this question, and to determine, as accurately as possible, the type of medical training th at w ill be required of their physicians by the American people of the future. G uided by these studies, this com mittee w ill draft plans for the curriculum of tom orrow, and according to their abil ity to meet these new standards, medical schools w ill again be classified. I t is tru e in both medicine and den tistry th a t in prescribing a minimum standard, we can go no faster than the public and the profession as a whole is prepared to go, but I am sure you have been pleasantly surprised in your profes sion, as w e have been in ours, by the high
D ental Economies degree of sympathy exhibited by the American people tow ard your efforts. T h e public is prepared, it has seemed to me, to approve heartily the high est standards that the profession feels justified in establishing. Therefore, as an observer who, for twenty-five years, has watched w ith intense interest the development of medical standards to constantly higher levels, I can, I think, say to you that, in the standardiza tion of dental education, you can, with full assurance of public support, afford to proceed rapidly and travel far. T h e question of preliminary education is probably your most difficult problem, as it has been w ith us. W h y should a liberal education in the arts and sciences be required of a man whose practice is to be confined to one limited sphere ? T h e answer is simple : T h e education of a pro fessional man is designed not merely to provide utilizable information of a tech nical nature, but rather to give the per son in addition to his technical training, a broad view of life and to develop his mental processes. Is it important that the dentist be able to observe accurately, to correlate w hat he sees, and to reason soundly? If it is, and I think we can all so agree, he m ust have a well-trained mind and a broad cultural background such as is associated only with a good preliminary education. I hope this Asso ciation w ill always prescribe as a mini mal requirement for admission to the study of dentistry a relatively high de gree of preliminary education, the equiv alent, say, of at least two years of college work and that suitable means will be found for enforcing the observance of this standard. T here are other equally important things. W e m ust freely admit that standards of admission do not constitute everything, and that neither do curricu
505
lum and equipment. W e can have all of this and yet fail because the influence of the teacher on the pupil is lacking. T h e most im portant thing in any educational program is that subtle indefinable influ ence which the teacher, consciously or unconsciously, exerts in molding the character and developing the methods of thought and the scientific ambitions of the pupil. I t is recognized th at the physician or dentist who is engaged not only in teaching, but also in the practice of his profession, brings to the pupil a human interest th at is thoroughly essen tial and w ithout which he would develop in a one-sided manner, but the full-time teacher who is engaged solely in teaching and in research exerts an influence of equal importance. T h e full-time teacher stimulates the pupil’s interest in the pure sciences and helps to give him the inquir ing, the skeptical turn of mind th at is so important to the advancement of any pro fession. In the fixing of standards, there fore, much thought should be given al ways to the number of full-time teachers of professorial rank required of the school. T rue, full-time teachers of the right type are not easy to find and the necessary funds are not always available ; but such men are essential. T h e necessity for adequate endowment is obvious. W e have found in medicine, as I believe you are finding in dentistry, that teaching is such an expensive thing that, to merit approval, the school can not subsist solely on the fees provided by students. T h e day is long past when the expenses of a school of medicine or den tistry can be adequately met by the pu pils’ tuition. T h e fact had best be faced squarely that to meet educational stand ards the dental school must have in lib eral amount other sources of income than that supplied by the student. I should like to say just a word re garding the personnel of your standard
506
T h e Journal of the American D ental Association
izing board. I think we can agree that such a board is essential. Fortunately, I do not know how your board is formed and therefore, w ithout embarrassment, can tell you of ours. T h e Council on M edical Education and Hospitals of the A .M .A . is composed of seven members, who are nominated by the president of the American M edical Association. Each serves seven years. T h is council is re sponsible only to the house of delegates. I t frequently includes in its conferences the representatives of the Association of American M edical Colleges and other agencies, but such outside agencies have
no voice in its deliberations or its final decisions. These last are made by the council alone. T h is makes for a single ness of purpose and an independence of action th a t otherwise could not be ob tained. If the dental profession is to m erit the confidence and the high regard of the American people to which you and I be lieve that it is entitled, educational stand ards must be raised to constantly higher levels. T his, I believe, can be accom plished only through the regulating influ ence of a small completely independent standardizing board.
MEDICINE AND SOCIAL CHANGES* B y R . G . L E L A N D .f M .D ., C h ica g o , 111.
M
E D IC A L economics is as old as medicine. H istory records that the early emperors required phy sicians of th at time to treat the poor w ith out charge, and to limit their fees for others according to the amounts pre scribed by the rulers’ orders. A careful analysis of the economic principles underlying professional serv ices has hitherto been lacking. An under standing of the problems that confront the medical and dental professions re quires recognition and application of gen eral principles pertaining to the produc tion, distribution, exchange and consump tion of professional services, as contrasted with commercial commodities or mate rial goods. These principles of medical economics are necessarily closely related to medical ethics. T h e first principle of medical *Read at the Second G eneral M eeting of the Seventy-Seventh A nnual Session of the Am erican D ental Association, New Orleans, La., Nov. 5, 1935. fD irec to r of the B ureau of M edical Eco nomics of the A m erican M edical Association.
Jour. A.D.A., Vol. 23, March, 1936
ethics declares, “A profession has for its prim ary object, the service it can render to hum anity; reward or financial gain should be a subordinate consideration. T h e practice of medicine is a profession. In choosing this profession, an individual assumes an obligation to conduct himself in accord w ith its ideals.” T his and the other principles of medi cal ethics were established voluntarily by an independent profession, and not be cause of any legislative or bureaucratic compulsion. T h e origin can be traced to some time in the fourth or fifth century before Christ, and the basic principles then established have survived through out these more than twenty centuries of social, political and other forms of strife and evolution. M oreover, w ithout any compulsion on the p art of forces outside the professions, medicine has sought constantly to advance the standards of medical education, medi cal licensure and hospital practice, and now seeks the certification of specialists. All this and more has been done by medi
H E regard in which a profession is held, and its usefulness, depend in large degree on the depth of culture and the breadth of learning of its indi vidual members. Recognizing this, the medical profession has been engaged for the past twenty-five years in the eleva tion of educational standards, and to day, I am told, the dental profession is concerning itself w ith the same process. H ow rapidly you are proceeding and how w ell satisfied you are w ith results, I am not informed, b u t as a former mem ber of the Council on M edical Education of the American M edical Association, I may be able to tell you something of the difficulties we have encountered and to draw an analogy between your problems and ours. T hirty-three years ago, ju st after the Boer W ar, a British medical officer told me this: T h e M edical Corps of the British Army in South Africa was or dered to accept w ith ou t scrutiny the grad uates of any European medical school, but not those of American schools. T h e latter must undergo investigation. T his humiliated me greatly, for that order was issued w ith good reason. A t that time, in 1900, while we had many of the best medical schools, we also had many of the poorest. Indeed, it has been stated that we were distinguished by having all
T
*Read at the Second G eneral M eeting of the Seventy-Seventh A n n u a l Session of the A m er ican D ental A ssociation, New O rleans, La., Nov. 5, 1935. fP re sid e n t of the A m erican M edical Asso ciation.
Jour. A.D.A., Vol. 23, March, 1936
of the poorest. Now, all of that is changed. Any physician who has grad uated in the past ten years from a recog nized American school has had excellent training, the equal of the best. T his has come about through the w ork of the Council on Medical Education of the American M edical Association. T his council began about twenty-five years ago to inspect medical schools and to rate them as Class A, B or C. T h e schools were graded upon many things, but, first of all, upon their entrance requirements and the fidelity w ith which these were observed. I can remember the time when a man of the most elementary education, or none at all, if he were ambitious and had saved a little money, could, without further preparation, enter immediately on the study of medicine. Now, every American school, preliminary to accept ance, demands as a minimal educational requirement two years of college work. M ost of them require a bachelor’s de gree. T h e schools were graded also on the number of full-time teachers, the character of the curriculum, the adequacy of hospital facilities, the equipment of the laboratories, the library, the physical plant and many other things. You will wonder how a body of this kind, w ithout legal authority, could en force its rulings. T h e council’s influence first became effective when the several state legislatures recognized its classi fication and decreed that their examining boards would license for the practice of medicine only graduates of Class A schools. Those schools rated as B and
503
504
T he Journal of the American D ental Association
C were then forced to improve their standards and facilities in such a manner as to m erit the A rating or to close their doors. About half of the total number followed the latter course. As a result, with the exception of a few so-called “outlaw ” schools, all American medical schools are now of the highest grade. W ere I to meet th at European officer today, I could truthfuly say th a t in America we have no poor medical schools, that our least efficient is the equal of their best; and that our best are unequaled in the world. Standardization is of course the big problem. I t has always been so w ith us, and will be so w ith you. T ru e, there will always be a few outstanding schools w ith liberal endowment, directed by men of vision, and in dentistry, as in medicine, these schools w ill lead the way. In point of equipment, admission require ment and excellence of teaching person nel, they w ill meet, and in some respects excel, all ordinary standards. But, these are not the schools w ith which we are concerned. I t is the school w ith insuf ficient means, the school th a t leans solely or even too heavily on the tuition th at the student pays, that is our chief concern. Such a school, too often, has a teaching staff composed largely of part-tim e men who are heavily burdened w ith every day practice. I t is an old, old argum ent that a certain number of schools of lower grade, should be recognized in order to afford opportunity to the boy of limited preliminary education, the boy who, be cause of restricted funds, must hurry through his professional training. “Give the poor boy a chance” is w hat we have heard time and again. B ut we have found in medicine, as I know you are finding in dentistry, that this is a fallacious argu ment. T h e answer should be “Give the patient a chance.” T o do anything else is fatal. M u st we lower the standards
of the profession, must we lessen the average o f efficiency and must we destroy the esteem in which physicians and den tists as a whole are held in order to give the poor boy a chance? However much we may sympathize w ith the ambitious boy who has neither the time nor the means to meet the higher standards of education, we must, in the interest of the public w elfare and of the profession as a whole, answer no. In dentistry as in medicine, the profession must strive con tinually to elevate its educational stand ards. H ow high should these standards be? I t is obvious that the law of diminishing returns applies here as elsewhere and that we could, in our enthusiasm, conceivably raise standards to an impossible point. Theoretically, they should be elevated to the point a t which the maximum benefit occurs to the greatest number. W hether we have reached this point in medicine and w hether you are approaching it in dentistry, it is difficult to say. O f far reaching importance was the action of the Council on M edical Education and H ospitals of the American Medical As sociation when it recently appointed a “blue p rin t” committee whose function it will be during the next two years to study this question, and to determine, as accurately as possible, the type of medical training th at w ill be required of their physicians by the American people of the future. G uided by these studies, this com mittee w ill draft plans for the curriculum of tom orrow, and according to their abil ity to meet these new standards, medical schools w ill again be classified. I t is tru e in both medicine and den tistry th a t in prescribing a minimum standard, we can go no faster than the public and the profession as a whole is prepared to go, but I am sure you have been pleasantly surprised in your profes sion, as w e have been in ours, by the high
D ental Economies degree of sympathy exhibited by the American people tow ard your efforts. T h e public is prepared, it has seemed to me, to approve heartily the high est standards that the profession feels justified in establishing. Therefore, as an observer who, for twenty-five years, has watched w ith intense interest the development of medical standards to constantly higher levels, I can, I think, say to you that, in the standardiza tion of dental education, you can, with full assurance of public support, afford to proceed rapidly and travel far. T h e question of preliminary education is probably your most difficult problem, as it has been w ith us. W h y should a liberal education in the arts and sciences be required of a man whose practice is to be confined to one limited sphere ? T h e answer is simple : T h e education of a pro fessional man is designed not merely to provide utilizable information of a tech nical nature, but rather to give the per son in addition to his technical training, a broad view of life and to develop his mental processes. Is it important that the dentist be able to observe accurately, to correlate w hat he sees, and to reason soundly? If it is, and I think we can all so agree, he m ust have a well-trained mind and a broad cultural background such as is associated only with a good preliminary education. I hope this Asso ciation w ill always prescribe as a mini mal requirement for admission to the study of dentistry a relatively high de gree of preliminary education, the equiv alent, say, of at least two years of college work and that suitable means will be found for enforcing the observance of this standard. T here are other equally important things. W e m ust freely admit that standards of admission do not constitute everything, and that neither do curricu
505
lum and equipment. W e can have all of this and yet fail because the influence of the teacher on the pupil is lacking. T h e most im portant thing in any educational program is that subtle indefinable influ ence which the teacher, consciously or unconsciously, exerts in molding the character and developing the methods of thought and the scientific ambitions of the pupil. I t is recognized th at the physician or dentist who is engaged not only in teaching, but also in the practice of his profession, brings to the pupil a human interest th at is thoroughly essen tial and w ithout which he would develop in a one-sided manner, but the full-time teacher who is engaged solely in teaching and in research exerts an influence of equal importance. T h e full-time teacher stimulates the pupil’s interest in the pure sciences and helps to give him the inquir ing, the skeptical turn of mind th at is so important to the advancement of any pro fession. In the fixing of standards, there fore, much thought should be given al ways to the number of full-time teachers of professorial rank required of the school. T rue, full-time teachers of the right type are not easy to find and the necessary funds are not always available ; but such men are essential. T h e necessity for adequate endowment is obvious. W e have found in medicine, as I believe you are finding in dentistry, that teaching is such an expensive thing that, to merit approval, the school can not subsist solely on the fees provided by students. T h e day is long past when the expenses of a school of medicine or den tistry can be adequately met by the pu pils’ tuition. T h e fact had best be faced squarely that to meet educational stand ards the dental school must have in lib eral amount other sources of income than that supplied by the student. I should like to say just a word re garding the personnel of your standard
506
T h e Journal of the American D ental Association
izing board. I think we can agree that such a board is essential. Fortunately, I do not know how your board is formed and therefore, w ithout embarrassment, can tell you of ours. T h e Council on M edical Education and Hospitals of the A .M .A . is composed of seven members, who are nominated by the president of the American M edical Association. Each serves seven years. T h is council is re sponsible only to the house of delegates. I t frequently includes in its conferences the representatives of the Association of American M edical Colleges and other agencies, but such outside agencies have
no voice in its deliberations or its final decisions. These last are made by the council alone. T h is makes for a single ness of purpose and an independence of action th a t otherwise could not be ob tained. If the dental profession is to m erit the confidence and the high regard of the American people to which you and I be lieve that it is entitled, educational stand ards must be raised to constantly higher levels. T his, I believe, can be accom plished only through the regulating influ ence of a small completely independent standardizing board.
MEDICINE AND SOCIAL CHANGES* B y R . G . L E L A N D .f M .D ., C h ica g o , 111.
M
E D IC A L economics is as old as medicine. H istory records that the early emperors required phy sicians of th at time to treat the poor w ith out charge, and to limit their fees for others according to the amounts pre scribed by the rulers’ orders. A careful analysis of the economic principles underlying professional serv ices has hitherto been lacking. An under standing of the problems that confront the medical and dental professions re quires recognition and application of gen eral principles pertaining to the produc tion, distribution, exchange and consump tion of professional services, as contrasted with commercial commodities or mate rial goods. These principles of medical economics are necessarily closely related to medical ethics. T h e first principle of medical *Read at the Second G eneral M eeting of the Seventy-Seventh A nnual Session of the Am erican D ental Association, New Orleans, La., Nov. 5, 1935. fD irec to r of the B ureau of M edical Eco nomics of the A m erican M edical Association.
Jour. A.D.A., Vol. 23, March, 1936
ethics declares, “A profession has for its prim ary object, the service it can render to hum anity; reward or financial gain should be a subordinate consideration. T h e practice of medicine is a profession. In choosing this profession, an individual assumes an obligation to conduct himself in accord w ith its ideals.” T his and the other principles of medi cal ethics were established voluntarily by an independent profession, and not be cause of any legislative or bureaucratic compulsion. T h e origin can be traced to some time in the fourth or fifth century before Christ, and the basic principles then established have survived through out these more than twenty centuries of social, political and other forms of strife and evolution. M oreover, w ithout any compulsion on the p art of forces outside the professions, medicine has sought constantly to advance the standards of medical education, medi cal licensure and hospital practice, and now seeks the certification of specialists. All this and more has been done by medi