With the compliments of the writer.

REFORM IN MEDICAL EDUCATION.

PRESIDENTIAL ADDRESS,

AMERICAN SOCIETY OF NATURALISTS,

NEWYORK, DECEMBER 29th, 1898.

H. P. BOWDITCH, M. D., LL. JX, D. Sc.

[Reprinted from Science, N. 8., Vol. VIII., No. 209, Pages 921-927,December 30, 1898.]

[Reprinted from SCIENCE, N. S.. Vol. VIII., No. 209,Pages 921-921, December 30, 1898.']

REFORM IN MEDICAL EDUCATION*The choice of a physiologist as the pre-

siding officer of the Society of AmericanNaturalists might, perhaps, have justifiedme in selecting some of the problems con-nected with experimental physiology as thesubject of my remarks this evening, but, asquestions of this sort are wont to awakenbut a languid interest except among thosewho are themselves engaged in physiolog-ical research, I have thought it better toallow my choice of a subject to be guidedby the fact that we are nearly all of usactively engaged in teaching as well as instudying our sciences, and to address youthis evening upon some topic connectedwith education.

My own experience of 27 years as a pro-fessor of physiology and of 10 years asDean of the Harvard Medical Faculty nat-urally inclines me to discourse upon thesubject of medical education and, since thegreat profession of medicine demands fromits practitioners a certain familiarity withthe fundamental truths of all the naturalsciences, it can surely not be inappropriateto ask the representatives of those sciencesto consider with me how far the progressof medicine and of the allied sciences hasmade it desirable to revise our methods ofimparting medical instruction.

Let me say at the outset that in speakingof the profession of medicine I use the term

*Address of the President, delivered before theAmerican Society of Naturalists at the New Yorkmeeting, December, 1898.

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not in its narrow sense, to designate the artof curing disease, but in its broader signifi-cation, to include a study of the whole en-vironment of man as far as it affects theproduction and maintenance of a healthymind in a healthy body.

In what I shall have to say on this sub-ject I shall confine myself chiefly to themedical schools of this country, though itwill be found, I think, that the conclusionsto which I shall endeavor to lead you willhave their application to medical schoolsthrough the world.

The most important event in the historyof medical education in this country oc-curred some thirty years ago, when many ofthe principal schools abandoned the planof giving a series of winter lectures, whichwere attended by all the students, irrespec-tive of their proficiency, and established agraded system of instruction in which thestudies of one year were preparatory tothose of the next. Those whose experiencein medical education is confined to theperiod since this change was made canscarcely appreciate the value and impor-tance of the reform which raised the med-ical schools of the country from a conditionin which they were aptly compared to joint-stock manufacturing companies, concernedonly in taking in as large an amount aspossible of raw material in the shape ofmedical students and in turning out amaximum of the finished product, i. e.,doctors of medicine, with a minimum costto theproducer. ‘ Cheap doctors and plentyof them ’ seems to have been the motto ofthe medical schools of that period. Sincethis reform the medical schools of the coun-try have been conducted on sound educa-

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tional principles and the best of them com-pare favorably with the medical schools ofEurope.

During the last quarter of a century theimprovement in medical education in thiscountry has consisted chiefly in increas-ing the requirements for admission, in thelengthening of the course and in the exten-sionof the laboratory method ofinstruction.Important as these improvements have been,it may fairly be asked whether they havekept pace with the requirements imposedupon teachers by the remarkable advancein every department of medicine during thelast thirty years.

During this period we have seen thegerm theory of disease established upon afirm basis and extended so as to throwlight upon a large number of morbid pro-cesses with which it was formerly supposedto have no connection. Antiseptic methodshave revolutionized the surgeon’s art. Thestudy of the internal secretion of glands hasled to the development of a system of glan-dular therapeutics. The use of the anti-toxin treatment has robbed one, at least,of the most dreaded diseases of more thanhalf of its terror, while the use of instru-ments of precision has increased the accu-racy of our diagnosis in nearly all the illsto which flesh is heir.

At the beginning of this period it waspossible to impart to an intelligent medicalstudent in a three years’ course of study aconsiderable fraction of the acquired med-ical knowledge of the time and to trainhim to safely use the comparatively simplemethods of diagnosis and treatment then invogue. At the present time, were we toseek to give to the same student a similar

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proportion of the accumulated knowledgenow at the disposal of the profession and toteach him the use of the refined modernmethods for the studj 7 and cure of disease,it may be reasonably estimated that a tenor even a fifteen years’ course of studywould be required. As it is obviously im-possible to prolong the course of medicalstudy to anything like this extent, the ques-tion arises : In what way shall newly ac-quiredknowledge in the science and practiceof medicine be incorporated into the exist-ing curriculum of the medical student?

Up to the present time this question doesnot seem to have been seriously considered.As new and important subjects have forcedthemselves upon the attention of the med-ical profession, our schools have sought tomeet the new condition simply by addingto the existing curriculum a more or lesslengthy course of instruction on the subjectin question. Thus the importance of en-abling physicians to recognize pathogenicmicrobes has led to the establishment of adepartment of bacteriology in our principalmedical schools, while the great advancemade in the treatment of special classes ofdisease has occasioned the appointment ofnumerous professors of specialties, such asgynaecology,orthoepedic surgery, paediatrics,etc.

The medical curriculum has thus grownby what may be called, in biological lan-guage, a process of accretion, and there hasbeen little or no attempt to make room fornew instruction by the omission of lessvaluable courses or parts of courses, thoughin certain directions the advance of knowl-edge, by demonstrating the inaccuracy ofpreviously accepted views, has led to a

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simplification of instruction. When it hasbeen found absolutely impossible to addany further courses a remedy for the con-gestion of instruction has been found inthe prolongation of the medical curriculumfrom three years to four.

It is, of course, evident that this processcannot be indefinitely continued. In fact, aslight study of the subject suffices to showthat a limit has already been reached. In-deed, as long ago as 1870 Huxley was sothoroughly impressed with the crowdedcondition of the medical curriculum inEngland that he expressed “a very strongconviction that any one who adds to med-ical education one iota or one tittle beyondwhat is absolutely necessary is guilty of avery grave offence,”* and quite recentlyProfessor M. Foster, in speaking of theenormously increased requirements in med-ical education, has expressed himself as fol-lows :

a Kow it is obvious that, whatevermay have been possible once, it is impos-sible nowadays to demand that all or eachof these things should be learnt by thestudent of medicine. Though possibly thepower of man to learn is increasing; thougheach science as it becomes more and moreconsolidated can be expounded and appre-hended with greater ease; though the grasp-ing of one science is in itself a help to thegrasp of other sciences, yet beyond doubtthat which has to be learnt is enlarging farmore rapidly than is man’s ability tolearn.”f

To extend the course of instruction in the* ‘Medical Education.’ Collected Essays, Yol. 111.,

D. Appleton & Co., 1894.f Address to the Students of Mason University

College, Birmingham, October 3, 1898.

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medical schools of this country beyond thepresent four-year limit does not, under theprevailing conditions of education in Amer-ica, seem desirable, and the curriculum ofmost of our schools is already so crowdedthat no considerable amount of instructioncan possibly be added. In what way, then,can we give to our medical students anadequate amount of information on all thesubjects embraced in the constantly widen-ing domain of medical science and art ? Inother words, how shall instruction keeppace with knowledge ?

In seeking an answer to this question itmay be assumed that a medical school ofthe first rank should be an institution inwhich the most advanced instruction in alldepartments of medicine can be obtained,and on this assumption it is, of course, im-possible to arrange a course of study thatevery student must follow in all its details,for in the time which may properly be de-voted to a course of professional study it isquite impossible for even the most intelli-gent students to assimilate all the varied in-formation which such a school may reason-ably be expected to impart.

It seems, therefore, to be evident that inarranging a course of medical study a dis-tinction must be made between those sub-jects which it is essential that every studentshould know, and those subjects which it isdesirable that certain students should know,i. e., between those things of which no manwho calls himself a physician can afford tobe ignorant, and those which are importantfor certain physicians but not for all. Inother words, provision must be made bothfor required and for elective studies.

The introduction of the elective system

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into a professional school is not an alto-gether novel proposition. For severalyears a large part of the instruction in thefourth year of the Harvard Medical Schoolhas been given in elective courses in variousspecialties, such as ophthalmology, otology,etc. The extension of the elective systemto the earlier years of the course would beattended by no difficulty as far as details oiadministration are concerned, and has, in-deed, been advocated by President Eliot ina speech at the dinner of the Harvard Med-ical Alumni Association in 1895. But thequestion may, perhaps, be asked whether itwill be possible under such a system to se-cure the proper training of youug men forthe duties of a profession in which experi-ence of life contributes so largely to success,and in which, therefore, a student at thebeginning of his career may be supposed tobe peculiarly in need of the guidance of histeachers.

It is true that in the academic depart-ment of Harvard University the capacity ofthe average student to choose his coursewisely and well has been demonstrated bythe experience of many years, but it may beproperly urged that the success ofthe systemin the academic department does not neces-sarily justify its extension to a professionalschool. The responsibility of the medicalfaculty in granting the degree of M.D. isvery different from that of the academicfaculty in giving the A.B. diploma, since animperfectly qualified practitioner of medi-cine may endanger the lives of his patients,while an unworthy graduate ofthe academicdepartment can, as a rule, injure no one buthimself. Hence the medical faculty mayustly be required to exercise greater caution

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in bestowing tbe degree of M.D. than is nec-essary in the case of the A.B diploma. Wemust, therefore, enquire whether it is pos-sible to obtain the advantages of a flexiblecurriculum consisting largely of electivecourses without losing the security againstsuperficial and imperfect work which thepreseht compulsory system is supposed toafford.

Any one who is familiar with the existingmethods of medical instruction is awarethat in nearty every department manythings are taught which are subsequentlyfound to be of use to only a fraction ofthose receiving the instruction. Thus thesurgical anatomy of hernia is taught to menwho will subsequently devote themselvesto dermatology; future obstetricians arerequired to master the details of physio-logical optics, and the microscopical anat-omy of tumors forms a part of the instruc-tion of men destined to a career as alienists.Now, no one can question the propriety ofincluding instruction on all these subjectsin the curriculum of a medical school, butit may be questioned whether every studentshould be forced to take instruction in themall. It may, perhaps, be urged that nochoice of studies can be made withoutdetermining, to some extent, the directionin which the work of the future practitioneris to be specialized, and that such specializa-tion cannot be properly and safely permitteduntil the student has completed his medicalstudies. To this it may be answered that,whatever may be the dangers of too earlyspecialization, the dangers of crowding themedical course with instruction of whichmany students do not feel the need and ofthus encouraging perfunctory and super-

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ficial work are certainly no less serious.Moreover, it will, doubtless, be found per-fectly possible to establish such a relationbetween the required and the electivecourses that the requirements in eachdepartment will be in no way lowered,while a certain freedom of choice is per-mitted with regard to the direction inwhich the work is pursued. To illustratethis point, allow me to describe a possiblearrangement of a course of study in thedepartment of physiology with which Iam, of course, more familiar than withany other.

In the Harvard Medical School instruc-tion in physiology is now given in a courseof about 100 lectures, besides recitations,conferences and practical laboratory work.Were the work to be rearranged in accord-ance with the above plan it would probablybe found possible to condense into a courseof about 50 or 60 lectures all the most im-portant facts of physiology with whichevery educated physician must necessarilybe familiar. Attendance upon these lec-tures, combined with a suitable courseof text-book instruction, would suffice toguard against gross ignorance of physio-logical principles. In addition to this re-quired work, short courses of eight or tenlectures should be provided,giving advancedinstruction in such subjects as the physi-ology of the special senses, cerebral locali-zation, nerve-muscle physiology, the in-ternal secretion of glands, the physiologyof the heart, circulation and respiration,the digestive secretions, the reproductiveorgans, etc. These courses should be elec-tive in the sense that no student should berequired to take them all. Each student

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might, however, very properly be requiredto choose a certain number of courses, which,when once chosen, become, for him requiredcourses leading to examinations. Thenum-ber of special courses which each studentshould be thus required to elect should besufficiently great to render the total amountof physiological instruction in no way in-ferior to that which is given under the pres-ent system.

It would, doubtless, be found desirablein practice not to confine the possibility oftaking elective courses to the year in whichthe required instruction is given, for a stu-dent may frequently, in the latter part ofhis course, become interested in a subjectlike mental diseases, for instance, and willthen be glad of an opportunity to take spe-cial instruction on thephysiology ofcerebrallocalization. The elective courses should,therefore, be so arranged that they may betaken in any part of the medical curriculum.

There is, in my opinion, no doubt that anarrangement of instruction similar to thathere suggested for physiology could be ad-vantageously adopted in the departments ofanatomy, histology, bacteriology, medicalchemistry, pathology, surgery, and in thecourses of instruction in the various spe-cial diseases, such as dermatology, opthal-mology, etc. Whether the instruction inclinical medicine and clinical surgery canbe thus modified is a question about whichmore doubt may be entertained and whichI prefer to leave to persons of greater ex-perience than myself in methods of clinicalinstruction.

Under the existing conditions of medicaleducation the introduction of the electivesystem in some form or other seems to be an

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essential condition to any further importantadvance. If it be said that under this sys-tem the medical degree will cease to havethe definite meaning now attached to it, andthat it will be impossible to tell from hisdiploma in what way a physician has beeneducated, it may be replied that, thoughthe degrees of A.8., A.M., Ph.D. and S.D.are affected with exactly this same uncer-tainty of signification, their value seems inno way diminished thereby. As long as theM.D. degree stands for a definiteamount ofserious work on medical subjects directedon the lines above indicated we may be rea-sonably sure that those who hold it will besafe custodians of the health of the commu-nity in which they practice.

If it be urged that the elective system inmedical education will lead to the produc-tion of a class of physicians who, owing tothe early specialization of their work, willbe inclined to overrate the importance oftheir specialty and to see in every diseasean opportunity for the display of theirspecial skill, it may be pointed out thatthis result is apt to be due not so much toearly as to imperfect instruction in thework of a specialist, and that, since theelective system tends to encourage thor-oughness in special instruction, the evilmay be expected to diminish rather thanto increase.

I have spoken of the extension of labora-tory instruction as an important forwardstep in the improvement of educationalmethods in medicine during the last quarterof a century, and I desire to bring my re-marks to a close with a few words on therelation between laboratory and didacticmethods in medicine and on the employ-

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ment of both methods in a system of in-struction including both required and elec-tive courses.

There is perhaps no field of humanactivity in which the pendulum of reformmakes wider excursions than in that ofeducation. Whenever any given methodis found to give unsatisfactoryresults thereis a strong tendency to abandon it alto-gether in favor of some entirely differentmethod. Thus the obvious defects of theoral system of examination employed in theHarvard Medical School thirty years agoled to its complete abandonmentand to theadoption of the written examination book,though there is little doubt that a systemcombining the advantages of both the oraland the written methods could easily havebeen devised. In the same way the factthat many subjects have been, and indeedstill are, taught in systematic didactic lec-tures which can be better taught by labora-tory methods tends to obscure the equallyimportant fact that there are many othersubjects in the presentation of which theliving personality of the lecturer is a veryimportant factor and which, indeed, can beproperly presented to students only by thosewho have had much experience in weighingscientific evidence. In this connection it isinteresting to recall the wise words of Hux-ley, who expressed himself on this subjectas follows :

“What the student wants in aprofessor is a man who shall stand betweenhim and the infinite diversity and varietyof human knowledge, and wT ho shall gatherall that together and extract from it thatwhich is capable of being assimilated bythe mind.” *

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To what extent the laboratory can re-place the lecture room will, of course, de-pend upon the nature of the subject taught.In such a branch as Anatomy, where factslearned by observation form the greaterpart of the knowledge to be imparted,laboratory work can be substituted for di-dactic instruction to a greater extent thanis possible in subjects like Physiology andPathology, where inferences from observa-tions and conflicting views must frequentlybe presented. In no department of medi-cine, however, will it probably be foundpossible to dispense entirely with a system-atic course of lectures in which a trainedinstructor may give to his class the benefitof his accumulated experience.

A consideration of the nature of the sub-ject taught will also furnish a guide for theemployment of laboratory and didacticmethods in the required and elective coursesabove suggested. In general the requiredcourses, being comparatively elementaryand concerned chiefly with the presentationof well ascertained facts, may be made de-monstrative in their character and may beconducted in accordance with laboratorymethods, though a short course of didacticlectures, parallel with laboratory work, willin most cases be found to be essential. Inthe elective courses which provide advancedinstruction in many directions the limits ofour knowledge wr ill be more nearly reached.It will, therefore, be necessary to presentand weigh the evidence for and against thevarious conflicting views which are almostcertain to be held with regard to subjectslying within what Foster has called the‘ penumbra ’ of solid scientific acquisition.For this purpose the most suitable method

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of instruction seems to be a short course ofcarefully prepared didactic lectures whichshould, however, be varied by demonstra-tions whenever the nature of the subjectwill allow.

It is, however, unnecessary to discussthese and other details at the present time.They will speedily arrange themselves assoon as the necessity for a comprehensivereform in our methods of medical instruc-tion is generally recognized, and it is in thehope of helping to secure this recognitionthat I have addressed these remarks to youthis evening. In whatever way the remedyis to come it should not be long delayed, forthe difficulty of giving adequate instructionto constantly increasing classes seeking in-formation over a constantly widening fieldof knowledge is felt each year with greaterand greater keenness.

H. W. Bowditch.Haevakd Medical School.