Again, at the International Congress of Medicine in London, in August, 1913, an important discussion of these problems was introduced by an account of the Henry Phipps Psychiatric Clinic which has been established in Baltimore for the treatment of mental disorders, and for teaching and research in this subject. In the course of the discussion special emphasis was laid upon “the necessity for teaching the medical profession and the public that many mental disorders are absolutely recoverable, that good hospital and scientific treatment save many, that the mere economy of our monster institutions represents a sham economy paid for by the patients and their families, and that psychiatry must extend beyond the asylums.”[81]
Emphasis was also laid upon the importance of making these hospitals, for the care and cure of those suffering from mental illness, centres for scientific education and research and for the development of prophylactic measures. For, unless medical students are provided with facilities for the study of these early cases the present deplorable condition of affairs will be perpetuated. All honest medical work is essentially research; for every individual patient presents problems which need investigation; and facilities should be provided for making such enquiries under the most favourable conditions. As Dr. Flexner has well said,[82] it is impossible “to develop two types of physician, one to find things out, the other to apply what has been ascertained. For the same kind of intelligence, the same sorts of observation, knowledge and reasoning power are needed for the application as for the discovery of effective therapeutic procedure.”
This last consideration leads us to the examination of another potent factor in the present situation, viz.:—
The Attitude of the Medical Profession. When it is remembered that mental factors play an important rôle in the causation and continuance not only of obviously mental disorder but also of bodily troubles, and that therefore successful diagnosis and treatment must inevitably take these factors into account, it may seem remarkable that the medical profession as a whole should take so little interest in, and know so little of psychology. Even when the psychological aspect of their problems becomes the outstanding element in diagnosis and treatment, the vast majority of medical practitioners show little or no inclination to satisfy their scientific curiosity and to endeavour to understand the condition of their patients.
But this attitude becomes more comprehensible, and in a certain measure more excusable, when we look into the courses of instruction provided for students in our medical schools. What training in psychiatry—to say nothing of psychology and psychopathology—have they received in the schools? How many hours have been spent in lectures or demonstrations upon mental diseases? And how has this modicum of time been spent? How many hours are devoted to actual personal investigation of patients suffering from early mental disorder? All the instruction in such matters that our students get at present in most of the medical schools is given in a few hours during one term, when they visit an asylum where demonstrations are given of advanced cases of mental disease: “melancholia,” “mania,” “dementia,” etc.
Lest we may be accused of wild statements, let us quote again from the Medico-Psychological Association’s report. (The italics are ours.):—
“... the attention given to mental diseases before qualification is much less than that given in many other countries. Owing to the absence of clinics, the medical student has no opportunity of observing borderland or undeveloped cases.” (p. [6].)
“To this absence of teaching facilities is due the lack of knowledge of the general practitioner, who should be competent to recognise, and possibly to deal with, some of the earliest symptoms; to this we owe the lack of real equipment in those who enter the lunacy service.” (p. [21].)
In this connection it is interesting to quote from a comparatively recent report on medical education. Four years ago the Carnegie Foundation for the Advancement of Teaching published a report on “Medical Education in Europe.” This work was remarkable both for its perspicacity and thoroughness and for the frankness and detachment with which its author, Dr. Abraham Flexner, expressed the opinions he had formed after a detailed study of the medical schools of this country and on the Continent. This valuable and important document was barely noticed by the medical press in this country. But this is not the place for a discussion of the psychology of this conspiracy of silence. For it certainly does not imply any reflection upon the impartiality or the thoroughness of Dr. Flexner’s research; on the contrary, it is a silent tribute to the seriousness of the exposure of the weaknesses of our medical schools. But the report is also a most valuable appreciation of the strength of our methods of medical education. It provides a minute analysis and comparison of the methods of teaching clinical medicine in Great Britain and on the Continent. The summary clearly defines the distinctive merits of the British system, and has such an important bearing upon the questions we are considering in this book that we will quote its most essential paragraph.
“The limitations by which medical education in Great Britain is hampered have now been candidly exposed. It is nevertheless true that in respect to the student, nowhere else in the world are conditions so favourable. In our discussion of Germany we pointed out that its clinical instruction was overwhelmingly demonstrative; that the student saw and heard but almost never did. Clinical education in England has completely avoided this wasteful error. It is primarily practical. It makes, indeed, the huge mistake of assuming that a more scientific attitude towards the problems of disease is in some occult way hostile to practicality; for it protests against the adoption of modern methods of investigation, as though practical teaching would be in some inexplicable fashion endangered thereby. However, that may be, the English are indubitably correct in holding that sound medical training requires free contact of the student with the actual manifestations of disease. It is the merit of English and, as we shall also perceive, of French medical education that the student learns the principles of medicine concurrently with the upbuilding of a veritable sense-experience in the wards, and that he acquires the art of medicine by increasingly intimate and responsible participation in the ministrations of physician and surgeon. The great contribution of England and France to medical education is their unanswerable demonstration of the entire feasibility of the method of instruction which the end sought itself imposes.”[83]