MEDICAL EDUCATION IN THE UNITED STATES.
A great deal of discussion has recently taken place on the subject of medical education in the United States. To a foreigner, or to one not acquainted with the influences that have led to and have kept up this discussion, it might seem to be the result of a spontaneous outburst of popular feeling, earnestly demanding much-needed progress. Really, however, the very reverse is the case; and the revolutionists are those whose kind and sympathetic interest in the welfare of the community is prompted solely by selfish considerations. The changes urged by these self-condemning philanthropists are not demanded by the medical profession nor by the public; neither have they been, nor will they be, sustained by both or by either. This assertion is clearly proved by the experience of the University of Pennsylvania, In 1846 the American Medical Association recommended to all medical colleges certain changes and improvements in their courses of instruction. In consequence of this recommendation the University of Pennsylvania extended its session to six months: not a single medical college in the country followed its progressive lead, and after continuing the experiment for six years at great pecuniary loss, it was reluctantly obliged to retrace its steps, and to return to the old standard as to length of session. During the period of this advance the classes of the University fell off greatly, and the classes of other medical schools correspondingly increased. Even medical men sent their sons to other medical schools, to save the time and money necessary for the longer course. Indeed, medical men, as a rule, have sought to evade the restrictions as to length of time of study, etc. more than any other class; and the statement, that the "student usually dates his medical studies from the time he buys his first Chemistry" applies more frequently to the sons of physicians than to any others. Hence, I declare that these proposed changes are not demanded by the medical profession nor by the public.
The writer of a recent article in Lippincott's Magazine (Dr. H.C. Wood) on "Medical Education in the United States" seems to have been so lost in admiration at the methods of instruction followed in European medical colleges as to be utterly blind to the good in the system of medical education as it exists in this country—a system the necessary result of our political, social, financial and territorial conditions; a system which, though in the abstract may not be the best, is certainly, judging from its results, the best possible under our peculiar circumstances. This much abused system of medical education (only greatly improved in its extent and thoroughness—improvements developed by the constant advances in knowledge) is the same system which has produced the great medical men of the United States during the past seventy-five years—medical practitioners whose success has been surpassed by none in Europe; surgeons whose skill has been, and is, world-wide in reputation; authors whose works are standard authorities everywhere. It is the same system of medical instruction—I quote verbatim (italics mine) from this article that holds it up to scorn—which "accomplished such splendid results during the late rebellion." The writer says: "The great resources of the medical profession were proved during the civil war, when there was created in a few months a service which for magnitude and efficiency has rarely if ever been equaled. Indeed, military medicine was raised by it to a point never reached before that time in Europe and the results achieved have, in many points, worked a revolution in science." After this frank declaration of the inestimable value and glorious results of American medical education, the writer draws the logical(?) sequence that it (American medical education) is responsible for a case of most heartrending malpractice, which he relates, compared to which the Japanese hari-kari were merciful mildness, and approaching more nearly the tortures by crucifixion as administered by this same kind-hearted people. With about as much reason and justice might he conclude that the American system of Sunday-school education is lamentably inferior to that of Great Britain, because(!) Jesse Pomeroy was a possibility in that most respectable town of Boston.
Dr. Wood alludes to the ignorance of the American medical student, and makes a statement "not founded on the authority of official publication," in which he endeavors to show that from "six to ten per cent." of American medical students have an ignorance of vulgar fractions and rudimentary astronomy that would exclude them from an ordinary infant-school. Every one familiar with the students attending our first-class American medical colleges knows perfectly well that in origin and in culture they compare favorably with the young men engaged in the study of law and divinity, or with those entering upon mercantile or manufacturing pursuits. True, there are some imperfectly educated, but certainly not "six or ten per cent." destitute of that knowledge taught even in American infant-schools, and without knowing, and without the statement "being founded on the authority of any official publication," I infer that in Europe, owing to their "better methods," similar knowledge is communicated to the average European child many months before its birth.
Next follows a comment on the poverty of the American medical student. Dr. Wood says: "Even worse than this, however, is the fact that the summer between the winter courses is often not spent in study, but in idleness, or, not rarely, in acquiring in the school-room or harvest-field the pecuniary means of spending the subsequent winter in the city." Alas! this is too true. Providence seems to have ordained that our young American doctors are not always reared in the lap of luxury and wealth as the fittest preparation for the trials, hardships and self-denials of their future lives. It is also true that some other young American professional men have been compelled "in the school-room or harvest-field" to acquire the means to prosecute their professional studies. Daniel Webster, the son of a New England farmer, taught school at Fryeburg, Maine, "upon a salary of about one dollar per diem." "His salary was all saved ... as a fund for his own professional education and to help his brother through college." "During his residence at Fryeburg, Mr. Webster borrowed (he was too poor to buy) Blackstone's Commentaries." Mr. Webster's great rival, Henry Clay, also was compelled to resort to the "school-room and harvest-field to obtain the pecuniary means," etc. etc. etc. The son of the poor widow with seven children "applied himself to the labor of the field with alacrity and diligence;" "and there yet live those who remember to have seen him oftentimes riding his sorry horse, with a rope bridle, no saddle, and a bag of grain." "By the familiar name of the Mill-boy of the Slashes do these men ... perpetuate the remembrance of his lowly yet dutiful and unrepining employments." American biography is so filled with similar instances, showing how the great characters of her great men acquired their development and strength in the stern gymnasium of poverty, even in "the school-room and harvest-field," that I could fill volumes with the glowing records. The youngest American school-boy recognizes Abraham Lincoln and Henry Wilson in this American galaxy. Whose heart has not been stirred by the life-story of the great Hugh Miller, the stonecutter's pick earning for him humble means, thereby enabling him to acquire that learning which made his name a household word even in America. Truth, then, as I have remarked, obliges me to admit that we have in our medical colleges some young men who labor "in harvest-fields and school-rooms" in order that they may honorably pay their way, rather than eat the bread or accept the gratuities of pauperism.
Last March there graduated at the medical department of the University of Pennsylvania one of these self-supporting young men. He was the son of a missionary clergyman: the father was poor in pocket, but the son was not poor in spirit. During the interval between his winter courses of lectures, rather than be a burden to his father, rather than accept gratuitous instruction from the school, he went into the coal regions of Pennsylvania and worked in a coal-mine, as a common miner, to procure funds to enable him to complete his professional studies; and, strange as it may seem, this young miner passed an excellent examination, and received the unanimous vote of the medical faculty for his degree. I mention this case, but every year there are several similar; and we always find that the school-teachers and miners are by no means at the foot of the graduating class.
Concerning clinical teaching, we have the following statement: "The clinical teaching in an American hospital is comprised in the following routine: Once or twice a week, from one to five hundred men being congregated in an amphitheatre, the professor lectures upon a case brought into the arena, perhaps operates, and when the hour has expired the class is dismissed. Evidently, under such circumstances there cannot be the training of the senses, the acquiring of a knowledge of the hourly play of symptoms of disease and of familiarity with the proper handling of the sick and wounded, which is of such vital importance, and which can be the outcome only of daily contact with patients." What can the writer of this sentence mean? Certainly, no one knows better than he does that such is not the practice in the hospital of the University of Pennsylvania, in Bellevue and in many other large hospitals, where clinics and dispensary services are held for several hours daily throughout the year, and where the student has furnished him abundant opportunities four "acquiring a knowledge of the ... symptoms of disease, ... of handling the sick and wounded," etc. etc. That the American medical student profits by these opportunities, and learns his clinic lessons well, is proved by the unexpected and evidently unintended testimony which occurs toward the close of the article, where Dr. Wood says, "The great resources of the medical profession in America were proved during the civil war, when there was created in a few months a service which for magnitude and efficiency has rarefy if ever been equaled. Indeed, military medicine was raised by it to a point never reached before that time in Europe, and the results achieved have in many points worked a revolution in science." The italics in this quotation are mine, as they also are in those which follow.
But (says the article under review) "the largest proportion of our prominent physicians have educated themselves after graduation." As if this were an extraordinary or unusual circumstance! Certainly, they have; and so have all prominent men in all professions and all pursuits of life, in every age and every country, not even excepting the much-lauded men of Great Britain and the continent of Europe. What young lawyer is entrusted with an important cause immediately after admission to the Bar? And as the young doctor (according to the aforesaid showing) "gains his first practical knowledge while serving as a hospital resident, under the supervision of experienced men," so the young lawyer, even in Great Britain, must gain his first practical knowledge by constant attention at the courts, and by diligently following the proceedings of his preceptor's and other offices. Even the young clergyman, whose business it is to save souls, has to do very much as the young doctor does, and, like him, is often "thrown at once on his own resources, gaining his experience without supervision, and at the expense of the poorer classes, who naturally fall to his charge, and whose ignorance precludes them from an even approximately correct estimate of" his fitness. "It is one of the saddest features of our system that the famed skill of our best" (clergymen) "should so often be acquired at such a cost."
What can be more unphilosophical and illogical than to compare the young doctor, or any other young professional man, to a new piece of machinery, fresh from the manufactory, complete and perfect in all its parts? And yet something like this is attempted in the article before us. Even as Minerva sprang from the brain of Jove the complete and perfect goddess of learning, so would our Utopian writer have the young doctors to come from the brains of their medical professors complete and perfect; only, if his idea be correct, their medical professors have so little brains that the annual graduating medical classes of the United States would be immediately reduced from the frightful army of three thousand "legalized murderers" to the comparatively small and easily counted number of one graduate (of course, springing from one head). No; the young doctor, at graduation, cannot be compared to a new, complete and perfect machine fresh from the manufactory; rather, let him be compared to the young marsupial creature at birth, extremely rudimentary, whose natural, and hence fittest, place is the parental pouch, but which in due time becomes the vigorous and well-developed specimen. I suppose, if I compare the young doctor to the young marsupial, I should also say that his protecting parental pouch, in which he acquires growth and vigor, is the hospital where he goes after graduation, or the practice which he sees under his preceptor's supervision.
The article continues: "The remarks which follow do not apply to the medical department of Harvard College or to one or two other schools" (the italics are mine); and farther on it continues: "In other words, Harvard has copied the European plan of medical teaching in some of its essential features, and as a consequence its medical diploma is the only one issued by any prominent medical American college which is a guarantee that its possessor has been well educated in the science and practice of medicine." Where can we find meekness and modesty like this?—modesty as becoming as it is unexpected and surprising, seeing that the writer fills two professorships in the University of Pennsylvania, Does he hang his head so low in his—I was about to say singular—self-abasement (but, considering, the two professorships, I suppose I should say doubled self-abasement) that he cannot see? or are his eyes so blinded by the effulgence of "Harvard" and "European" plans that he fails to recognize and appreciate the immense advantages offered by his own home institutions? I do not propose to make any invidious remarks concerning Harvard, but I maintain that an honest and just comparison of the schools, of their requirements, of the character of their teachings and the facilities they furnish their students, must show that modesty alone prevented Professor "H.C. Wood, Jr., M.D.," also excepting from his sweeping denunciations the two great schools of Philadelphia, though I only speak for and defend the medical department of the University of Pennsylvania from an attack unjust, uncalled-for and untrue.
R.A.F. PENROSE.
The party opposed to any reforms in medical education has, of course, a right to be heard, and Dr. Penrose is well entitled to represent it both by his position and by the evident heartiness with which he is prepared to defend the existing system at every point. In impugning the motives of those who have attacked it he lays himself open to an obvious retort; but it is sufficient to remark that the contest is not of a nature to call for or justify the use of personalities, which could serve only to divert attention from the real issues.
The arguments put forward by Dr. Penrose may be summarized as follows: 1st, that the proposed changes are not demanded either by the public or by the profession; 2d, that the present system is the best possible in a nation constituted like ours; 3d, that the preparatory education of our medical students is equal to that of law or divinity students, or of young men entering upon mercantile or manufacturing pursuits; 4th, that in certain cases obstacles in the way of a regular and thorough training have been overcome and success achieved in spite of them; and 5th, that it is unavoidable and proper that medical men, as well as members of other professions, should educate themselves after graduation.
It will be observed that none of these arguments except the last, which is based on a mere verbal ambiguity, touches the two subjects discussed in Dr. Wood's article—namely, the need of reform and the methods by which, if practicable, it is to be effected. Dr. Penrose does not venture to assert that the existing system is perfect, or to deny that the suggested changes are in the nature of improvements. What he wishes us to believe is that the system, whatever its defects, is as good a one as Americans have a right to demand, and that it is so closely interwoven with our political and social institutions as to admit of no separate handling. Similar arguments are frequently urged against the desire to raise the standard and widen the avenues of the "higher education." We are thus taught to regard ourselves as a poor and struggling nation with no claim to the possession of intellectual luxuries, or as having bound ourselves to forego any aspirations to an equality with other nations in respect of culture when we secured the advantages of popular government and its social concomitants. It would seem, however, to be a sounder, as it is certainly a more gratifying belief, that precisely because we have attained these advantages it will be easier for us to appropriate all the benefits which civilization has to offer—possible for us to make more rapid strides than have been made by other nations, impeded by a diversity of interests and conflicts between the government and the people. No doubt the comparative youthfulness of the nation will account for our backward condition in certain respects; but surely it is time to abandon this and every similar plea as an argument against any attempt at progress.
We have not space, and for the reasons indicated we see no necessity, to discuss Dr. Penrose's positions in detail. It will be sufficient to notice generally what seems to us their inherent weakness. His assertion that no changes are now demanded by the public or the profession is, he thinks, "clearly proved" by the fact that thirty years ago some that were introduced in the University of Pennsylvania at the suggestion of the American Medical Association ended in failure. But what this experience really proves is, that the defects of the system were even then admitted, while the remedies are still to be applied. At Harvard this has been done; and the question for other medical schools is whether they are to follow the example or to be deterred by a bugbear—whether, for example, the University of Pennsylvania, after raising her scientific and art departments to a higher level, shall be content to let her medical school remain stationary. It is the opinion of intelligent physicians who are not parties to this controversy that the experiment which failed in 1846 would succeed now. The new plan adopted at Harvard, which exacts three years of study, and embraces lectures, recitations, clinical conferences and written examinations of the most stringent character, has, we are informed, attracted a class of very superior men. Compared with the effort made here in 1846, this change may be described as a revolution, and it has proved a success.
We are at a loss to understand what Dr. Penrose wishes to prove by his citation of cases in which eminence has been reached—chiefly, it is to be noticed, in politics or the law—by persons who have had insufficient opportunities for study. If the disadvantage was imaginary, where was the merit of overcoming it? If it was real, as most people would admit, what is the objection to insisting on it as such? In the great majority of cases it is not overcome, and the result is, that the country is overstocked with men engaged in the practice of professions for which they are inadequately qualified. As to the skill that is gained by practice, the ripe knowledge that may result from experience, this cannot without a confusion of terms be described as "education." It will in general be most surely and rapidly acquired by those who have received the best training, and the great object of our higher educational institutions should be to provide such training—not, by maintaining a low standard, to facilitate the efforts of those who, from whatever cause, would find it difficult to meet the demands of a higher one. Such persons may have a claim to encouragement and assistance in their endeavors to reach the mark; but they have no right to expect that the distance shall be regulated to suit their convenience.
Dr. Wood's admissions in regard to the excellence of the army medical service during the war are seized upon with natural exultation by his opponent, who draws from them a legitimate inference in favor of the general status of medical skill and knowledge throughout the country. If Dr. Wood really intended to say—what his language, we confess, would seem to imply—that the service attained its high state of efficiency in a few months, we do not well see how he is to resist the conclusion thus pressed upon him. But we conceive the truth to be that either his phraseology or his recollection of the facts was at fault. It is well known that at the beginning of the war it was impossible to find competent surgeons in anything like the number that was needed, and that the examining boards were consequently forced to be ridiculously lenient. We know of an able surgeon who after a battle found that he had not a single assistant in his corps who could be trusted to perform an operation. This state of matters was the direct result of the imperfect education given in the schools. Not one man in ten who leaves them has ever been practically exercised in operations on the cadaver, and the proportion was still smaller before the war. It is easy therefore to understand, while it would be painful to recall, the circumstances under which the great bulk of our army surgeons acquired the requisite proficiency. The ultimate success of our medical service, like the final triumph of our armies, was preceded by many woeful blunders and mishaps, and, like that, was due in great measure to a lavish outlay which would scarcely have been possible in any European war, and to the general devotion and united efforts which drew out all the resources of the country, of whatever kind, and directed them to the furtherance of a single aim.