Medical_Education

Medical Education. Up to 1858 each University, Royal College of Physicians or of Surgeons, and Apothecaries' Hall in Great Britain and Ireland laid down its own regulations for study and examination, and granted its degree or licence without any State supervision. In that year, pursuant to the Medical Act, 21 & 22 Vict. c. 90, the General Medical Council of Medical Education and Registration was established, consisting of twenty-three members, of whom seventeen were appointed by the various licensing bodies and six by the Crown. This number was increased by the amended act of 1886 to twentynine, three of the six additional members being elected by the profession as "direct" representatives. The object of the act was "to enable persons requiring medical aid to distinguish qualified from unqualified practitioners." To this end the "Medical Register" was established, on which no person's name could be inscribed who did not hold a diploma or licence from one or more of the licensing bodies after examination. By the 1886 act a qualifying examination was defined as "an examination in medicine, surgery, and midwifery," conducted by universities or by medical corporations, of which one must be capable of granting a diploma in medicine, and one in surgery. The Council is authorized to require from the licensing bodies information as to courses of study and examinations, and generally as to the requisites for obtaining qualifications; and to visit and inspect examinations either personally or by deputy. If the visitors think the course of study and examination of any licensing body is not sufficient to ensure that candidates obtaining its qualification possess the requisite knowledge and skill for the efficient practice of their profession the Council, on a report being made, may represent the same to the Privy Council. The Privy Council may, if it sees fit, deprive the accused body of its power to grant registrable qualifications. From this statement it will be seen that the powers of the Council are limited; nevertheless, by their cautious application, and by the loyal manner in which the licensing bodies have acted on the recommendations and suggestions which have from time to time been made, the condition of medical education has been improved; and although there is not a uniform standard of examination throughout the United Kingdom, the Council has ensured that the minimum requirements of any licensing body shall be sufficient for the production of trustworthy practitioners.

One of the first subjects to which the Council applied itself was the establishment of a system of examinations in general knowledge. Such examinations have to be passed before beginning medical study. On presentation of a certificate to the registrars of the Council, and on evidence being produced that the candidate is sixteen years of age, his name is inscribed on the "Students' Register." The subjects of examinations are: (a) English language, including grammar and composition (marks not exceeding 5% of the total obtainable in this section may be assigned to candidates who show a competent knowledge of shorthand); (b) Latin, including grammar, translation from specified authors, and translation of easy passages not taken from such authors; (c) mathematics, comprising arithmetic; algebra, as far as simple equations inclusive; geometry, the subject-matter of Euclid, Books I., II. and III., with easy deductions; (d) one of the following optional subjects - Greek, French, German, Italian or any other modern language. Certificates are accepted from all the universities of Great Britain and Ireland, from the leading Indian and colonial universities, from government examination boards, and from certain chartered bodies. The German Abiturienten Examen of the gymnasia and real-gymnasia, the French diplomas of Bachelier es Lettres and Bachelier es Sciences, and corresponding entrance examinations to other continental universities are also accepted.

As regards professional education, the Council divided its resolutions into "requirements" and "recommendations"; the former consisting of demands on the licensing bodies, non-compliance with which renders them liable to be reported to the Privy Council; the latter are regarded merely as suggestions for the general conduct of education and examination. The requirements may be summarized as follows: (a) Registration as a medical student. (b)  Five years of bona-fide study between the date of registration and the date of the final examination for any diploma entitling the holder to be registered under the Medical Acts. (c) In every course of professional study and examination the following subjects must be contained, the Council offering no opinion as to the manner in which they should be distributed or combined for the purposes of teaching or examination, this being left to the discretion of the bodies or of the student - (i.) physics, including the elementary mechanics of solids and fluids, and the rudiments of heat, light and electricity; (ii.) chemistry, including the principles of the science, and the details which bear on the study of medicine; (iii.) elementary biology; (iv.) anatomy; (v.) physiology; (vi.) materia medica and pharmacy; (vii.) pathology; (viii.). therapeutics; (ix.) medicine, including medical anatomy and clinical medicine; (x.) surgery, including surgical anatomy and clinical surgery; (xi.) midwifery, including diseases peculiar to women and to new-born children; (xii.) theory and practice of vaccination; (xiii.) forensic medicine; (xiv.) hygiene; (xv.) mental disease. (d) The first of the four years must be passed at a school or schools of medicine recognized by any of the licensing bodies; provided that the first year may be passed at a university or teaching institution where the subjects of physics, chemistry and biology are taught; and that graduates in arts or science of any university recognized by the Council, who shall have spent a year in the study of these subjects, and have passed in them, shall be held to have completed the first of the five years of medical study. (e)  The study of midwifery practice must consist of three months' attendance on the indoor practice of a lying-in hospital, or the student must have been present at not less than twenty labours, five of which shall have been conducted throughout under the direct supervision of a registered practitioner.

The fifth year of study is intended to be devoted to clinical work and may be passed at any one or more public hospitals or dispensaries, British or foreign, recognized by the licensing authorities; six months of this year may be passed as a pupil to a practitioner possessing such opportunities of imparting practical knowledge as shall be satisfactory to the medical authorities. This latter method is rarely employed.

The "recommendations" of the Council contain suggestions which may or may not be acted on by the bodies. For the most part they are complied with in connexion with the system of practical and clinical teaching.

The Council satisfies itself that its requirements are acted on, and that the examinations are "sufficient," by cycles of inspection about every five years. The examination of each licensing body is visited by an inspector, who forwards his report to the Council, which sends each report to the body for its information and remarks. As yet it has never been the duty of the Council to report to the Privy Council that any examination has not been found sufficient.

Most universities exact attendance at more classes than the colleges and halls; for instance, botany and natural history are taught to their students, who are also examined in them. But with these exceptions the system of professional education is fairly uniform. Since 1875 attendance on "practical" classes has been called for in all subjects. Under this system the larger classes in which the subjects are taught systematically are broken up, and the students are taught the use of apparatus and the employment of methods of investigation and observation. Tutorial instruction is superimposed on teaching by lecture. Much the same plan is adopted in respect of clinical instruction: not only is the student taught at the bedside by the lecturer, but he receives, either from the housesurgeon or house-physician or from a specially appointed clinical tutor, an insight into methods of examination of diseases, and learns practically the use of the stethoscope and other aids to diagnosis, and of surgical and obstetrical instruments. In fact, it may be said that each subject of instruction is duplicated. If this is taken into account, it must be evident that the time of the student is fully occupied, and the belief is rapidly growing that five years is too short a period of study. As a matter of fact, the average time taken to obtain a British licence to practise is upwards of six years. The probability is that the solution of the difficulty. will be found in the inclusion of such subjects as physics, biology and chemistry in a "preliminary scientific" examination, which may have to be undertaken before registration as a medical student, thus leaving the whole five years to be devoted to purely professional study.

The German regulations in regard to professional study are few. They are those for the Staats Examen, for which the university degree is no longer necessary. The regulations for the admission of candidates to the Staats Examen are contained in the royal proclamations of the 22nd of June 1883. They comprise: (a) Certificate of a course of study at a classical gymnasium of the German Empire. In exceptional cases, the same from a classical gymnasium outside the German empire may be considered sufficient. (For details of the course of study and examinations, see Minutes of the General Medical Council, vol. xxvii. appendix 3.) (b) Certificate from a university, certifying a course of medical study of at least nine halfyears at a university of the German empire. (c) Certificate that the candidate has passed, entirely at a German university, the medical Vorprilfung, and thereafter has attended for at least four half-years the medical studies of a university. (d) The special testimony of the clinical directors bearing witness that the candidate has taken part as Praktikant (clerk or dresser) during two half-years at the medical, surgical, and gynaecological clinics; has himself delivered two cases of labour in the presence of his teachers or assistant physicians; and has attended for a half-year as Praktikant the clinic for diseases of the eye.

The medical Vorprufung referred to is necessary alike for the Staats Examen and the degree of Doctor of Medicine. It takes place at the end of the second year (fourth semestre), and includes the subjects of experimental physics, chemistry, botany, zoology, anatomy and physiology. It is conducted by a board appointed yearly by the Minister of Education.

No one can practise medicine in France who does not possess the diploma of Doctor of Medicine of a French university. The. qualification of Officier de sante is no longer granted.

Before he can inscribe as a student of medicine the applicant must have obtained the diplomas of Bachelier es lettres  and Bachelier es sciences. Although the course of professional study may be completed in four years, a longer time is generally taken before the student proceeds to the final examination for the doctor's degree. Each year is divided into four trimestres;  at each trimestre the student must make a new inscription. The trimestres are (r) November and December, 56 days; (2) January, February, March, 86 days; (3) April, May, June, 86 days; (4) July, August, 56 days. Practically there are no regulations determining the division of the various subjects, or the number of lectures in each course, or requiring the student to attend the courses. The medical faculty of each university puts before the student a scheme recommending a certain order of studies (Division des etudes) for each of the four years of the medical course, and, as a matter of fact, this order of study is enforced by the system of intermediate examinations (Examens du fin d'annee). All the lecture courses are free, as also are the clinics and the hospital service, and there is no system of ascertaining the regularity of attendance at lectures, or of certificate of attendance. If, however, the student fails to pass the Examen du fin d'annee he is debarred from making the next trimestral inscription, and thus loses three months. The lectures are, however, closely attended. In contrast to the freedom in regard to attendance on systematic lectures, there are strict direction and control in regard to hospital attendance and practical courses. The student is required to sign a register ad hoc each time he goes in and out. From the beginning of the third year, e.g. from the ninth quarterly inscription, hospital attendance is enforced till the end of the fourth year. No one can renew his trimestral inscription without producing a schedule of his last trimestral stage, showing that during it he had not absented himself more than five times without explanation. Practical work is obligatory during each of the four years.

Besides systematic courses of lectures, Conferences are held by the assistant-professors (agreges) in natural history, physiology, general pathology, internal pathology, external pathology. At the end of the first year the student is examined in osteology, myology and the elements of physiology; at the end of the second year, in anatomy and physiology in all their branches; at the end of the third year, in medicine and surgery; at the end of the fourth year, an examination is held over the whole field of study.

No one is allowed to enter on the study of medicine without passing the Artium examen of a secondary school. This is the equivalent of the German Abiturienten Examen of a classical gymnasium. After study for two semestres  an examination must be passed in psychology, logic and history. The special professional examinations consist of (1) preliminary scientific, in botany, zoology, physics, chemistry; (2) first special or professional, anatomy (orally and by dissections), physiology, and pharmacology; (3) second special or professional, written examinations in medicine, surgery, medical jurisprudence; practical and oral in operative surgery, in clinical medicine, and clinical surgery; and oral in pathological anatomy, medicine, surgery; and midwifery. The completion of the full medical course takes six years, of which the first two are devoted to the study of the natural sciences.

## AuTxoRrTIES

The history of the development of medical education from the earliest times down to 1894 will be found treated of generally in Puschmann's Geschichte des medicinischen Unterrichts  (Leipzig, 1889-1905) translated by E. H. Hare (London, 1891). Those desiring more special information on the subject in regard to the details of British institutions should consult the annals of the various universities and colleges of Great Britain and Ireland. The following works supply much interesting information regarding the gradual rise and development of teaching and examination: Annals of the Barber Surgeons, by Sydney Young (1890); History of the Royal College of Surgeons of Ireland, by Cameron (1886); Early Days of the Royal College of Physicians of Edinburgh, by Peel Ritchie (1899); Historical Sketch of the Royal College of Surgeons of Edinburgh, by Gairdner (1860); Memorials of the Faculty of Physicians and Surgeons of Glasgow, by Duncan (1896); The Story of the University of Edinburgh, by Sir A. Grant (1884); University of Glasgow, by Stewart (1891). (J. B. T.) As late as 1880 medical education in the United States was in a deplorable condition. In the early history of the country, before and shortly after the beginning of the 19th century, the few medical colleges had shown a disposition to require a liberal education on the part of those who entered upon their courses, and some effort was made, through the agency of state boards, to control the licence to practise. But as the country increased in population and wealth preliminary requirements were practically abolished, the length of the courses given each year was shortened to four or five months or less, and in the second and final year there was simply a repetition of the courses given during the first year. This is to be attributed mainly to the fact that there was no general national or state supervision of medical training. Medical colleges could obtain incorporation under state laws without difficulty, and brought considerable advantages in the way of prestige and increased practice to those concerned. That the existence of a college depended solely upon the fees of the students encouraged the tendency to make both entrance and graduation requirements as easy as possible, especially as there was no state supervision, and the mere possession of a diploma entitled the holder to practise. Fortunately, during this period the practical character of the clinical instruction given in the better colleges fitted the graduates in some measure for the actual necessities of practice, while the good traditions of medicine as a learned profession stimulated those who adopted it as a career, so that in the main the body of practitioners deserved and held the confidence and respect of the community. From the middle of the 19th century there has been constant agitation on the part of the physicians themselves for an improvement in medical education. The first notable result was an increase in the time of instruction from two to three years (Chicago Medical College, 1859; Harvard Medical School, 1871), the lengthening of each session to six months or more, and the introduction of graded courses instead of a repetition of the same lectures every year. The improvement thus begun became marked during the decade 1890-1900, amounting almost to a revolution in the rapidity with which the course of instruction was amplified. Many factors co-operated to produce this result: the general development of scientific instruction in the colleges and secondary schools, the influence of the large number of medical graduates who completed their training by study in European schools, the adoption by many states of stringent regulations regarding the licence to practise within their borders, the good examples set by many leading schools in voluntarily raising their requirements for entrance and graduation, and, perhaps above all in its general effect, the agitation continually maintained by several national or state associations which in a measure have exerted the general regulating control that in other countries has been enforced by national legislation. Among the most influential of these associations are the American Medical Association, the American Academy of Medicine, the Association of American Medical Colleges, the Illinois State Board of Health, and the University of the State of New York.

The different states make their own general regulations as to the practice of medicine within their borders. Certain states recognize the medical diplomas granted by other states having equivalent standards of examination. Such certificates are generally required to be (a) of graduation from a "reputable medical school," (b) certificates of moral character, (c) the applicant must be at least twenty-one years of age. These enable the candidate to present himself before the state board for the state examination. In many states the applicant must satisfy the board not only as to his professional, but as to his general education. The standing of the various medical schools is usually left to the state boards, each one determining the matter for its own state, consequently a school may confer a degree recognized as reputable in several states but not in others. Only three or four states regulate the chartering of institutions. In other states any body of men may secure articles of incorporation of a college or school by paying the necessary state fee, without question as to the ability of the incorporator to furnish an education. So strong, however, has been the growth of American public opinion that a four-years' course of medical training has become the standard in medical schools, and in the majority this is in addition to one or two years' training in the natural sciences. There are some sixtyfive state boards, and many have adopted strong medical practice acts.

The standard of preliminary requirements for entrance to the medical schools is being gradually raised, and a large number of the states demand a certificate of a high school education, while the colleges comprising the Association of Medical Colleges, which numbers more than half the American medical schools, accept as an entrance standard a certificate of at least one year's study at a high school. In the report for 1908 of the United States bureau of education of 71 schools, which report the number of their students having an arts degree, it is stated that a degree was held by only 15% of the candidates in medicine. These students were mostly distributed between the Johns Hopkins Medical School (which from the date of its foundation in 1893 has only admitted college graduates, and has in addition stipulated that candidates shall have a knowledge of French and German and have already completed a year's training in the natural sciences), Harvard Medical School and Columbia University, and the medical departments of the universities of California, Michigan and Chicago (Rush Medical College) require on entrance the equivalent of a two-years' college course, which must include French and German, together with physics, chemistry and biology. This tendency is in accordance with the recommended standard of medical education suggested by the Council of Medical Education and adopted by the House of Delegates of the American Medical Association, of which the following is a summary: (a) The preliminary of a four-years' high school education or an examination such as would admit to a recognized university.

(b) In addition a year of not less than nine months devoted to chemistry, physics and biology and one language (preferably French or German) to be taken at a college of the liberal arts.

2\. Previous to entering a medical college every student should receive from the state board a "medical student's entrance certificate" to be given on the production of credentials of training as above.

3\. Four years of study in a medical college having a minimum of a 30-weeks' course each year, with not less than 30 hours' work per week.

4\. Graduation from college to entitle a candidate to present himself for examination before a state board.

5\. A satisfactory examination to be passed before the state board.

Practically all medical schools admit women, but there are three separate schools of medicine for women: The Women's Medical College of Philadelphia, Pennsylvania; Women's Medical College, Baltimore, Maryland; New York Medical College and Hospital for Women - the last being one of the eighteen homoeopathic colleges of the United States.

## Authorities

J. M. Tower, Contributions to the Annals of Medical Progress and Medical Education in the United States, before and during the War of Independence (Washington Government Printing Office, 1874); N. S. Davis, History of Medical Education and Institutions in the United States (Chicago, 1851); Contributions to the History of Medical Education and Medical Institutions in the United States  (Washington, Government Printing Office, 1877); J. B. Beck, An Historical Sketch of the State of Medicine in the American Colonies  (Albany, 1850); Bulletins of the American Academy of Medicine  (The Chemical Publishing Company, Easton, Pa.); H. L. Taylor, "Professional Education in the United States," College Department, University of the State of New York, Bulletin 5, 1899, and Bulletin 8, 1900; " Courses of Study in Medical Schools," Report of the Commissioners of Education (Washington, 1908); F. R. Packard, M.D., The History of Medicine in the United States (1901); Journal of American Medical Association (Aug. 14, 1909); A. Flexner, Medical Education in the U.S. and Canada (1910). (W. H. H.; H. L. H.)