The Development of American Medical Education from the Turn of the Century to the Era of Managed Care

American Medical Education in the Mid1800s In the middle nineteenth century, it was easy to become a doctor in America. Entrance requirements to medical school were nonexistent other than the ability to pay the fees. The standard course of instruction in the middle nineteenth century consisted of two 4-month terms of lectures during the winter, with the second term identical to the first. The curriculum generally consisted of seven courses: anatomy; physiology and pathology; materia medica, therapeutics, and pharmacy; chemistry and medical jurisprudence; theory and practice of medicine; principles and practice of surgery; and obstetrics and the diseases of women and children. Instruction was wholly didactic: 7 or 8 hours of lectures a day, supplemented by textbook reading. Laboratory work was sparse, and even in the clinical subjects, no opportunity to work with patients was provided. Examinations were brief and superficial; virtually the only requirement for graduation was the ability to pay the fees. Students who desired a rigorous medical education had to supplement what they learned in medical school in other ways, such as through enrollment at nondegree-granting extramural private schools, study in Europe, or work in hospitals as house pupils. Middle nineteenth century medical schools were autonomous institutions. University or hospital affiliations, in the few cases in which they existed, were nominal. The faculties were small, typically consisting of six or eight professors. The professors owned the schools and operated them for profit. A commercial spirit thus pervaded the schools, for the faculty shared the spoils of what was left of student fees after expenses. For this reason the schools commonly were called proprietory schools. The mark of a good medical school, like that of any business, was considered its profitability. Because an amphitheater was virtually the only requirement to operate a medical school, physical facilities were meager. The second floor above the corner drug store would suffice; a school that had a building of its own was considered amply endowed. The Creation of the Modern American Medical School While American medical education was floundering in the middle 1800s, reform of the system already was beginning. At the root of the transformation was a series of underlying events: the revolution in experimental medicine that was proceeding in Europe; the existence of a cadre of American doctors traveling to Europe (particularly Germany) to learn laboratory methods; the emergence of the modern university in America; the development of a system of mass public education to provide qualified students for the university; and the cultivation of a habit of philanthropy among some very rich industrialists. Together, these developments provided the infrastructure for a new system of medical education soon to appear. The creation of America’s current system of medical education occurred in two overlapping stages. In the first stage, which began in the middle of the nineteenth century, a revolution in ideas occurred concerning the purpose and methods of medical education. After the Civil War, medical educators began rejecting traditional notions that medical education should inculcate facts through rote memorization. Rather, the new objective of medical education was to produce problem solvers and critical thinkers who knew how to find and evaluate information for themselves. To do so, medical educators deemphasized the traditional didactic teaching methods of lectures and textbooks and began speaking of the importance of self-education and learning by doing. Through laboratory work and clinical clerkships, students were active participants in their learning, not passive observers as before. A generation before John Dewey, medical educators were espousing the ideas of what later came to be called progressive education. At the same time, a revolution occurred in the institutional mission of medical schools. The view emerged that the modern medical school should not only engage in the highest level of teaching but also should be committed to the discovery of new knowledge through research. This meant that medical schools no longer could remain freestanding institutions. Rather, they had to become integral parts of universities and hire scientifically trained, full-time faculty who, like all university professors, were researchers and teachers. In the early 1870s, the first lasting reforms occurred, as Harvard, Pennsylvania, and Michigan extended their course of study to 3 years, added new scientific subjects to the curriculum, required laboratory work of each student, and began hiring full-time medical scientists to the faculty. In the late 1870s, the plans for the new Johns Hopkins Medical School were announced, although for financial reasons the opening was delayed until 1893. When the school finally did open, it immediately became the model by which all other medical schools were measured, much as the Johns Hopkins University in 1876 had become the model for the modern American research university. A college degree was required for admission, a 4-year curriculum with 9-month terms was adopted, classes were small, students were examined frequently, the laboratory and clinical clerkship were the primary teaching devices, and a brilliant full-time faculty made medical research and medical education part of its mission. In the 1880s and 1890s, schools across the country started to emulate the pioneering schools, and a campaign to reform American medical education began. By the turn of the century, the university medical school had become the acknowledged ideal, and proprietary schools already were closing for lack of students. Nevertheless, ideas alone were insufficient to create the modern medical school. The new teaching methods were extremely costly to implement, and hospitals had to be persuaded to join medical schools in the work of medical education. Thus, an institutional and an intellectual revolution were needed. Between 1885 and 1925 this revolution occurred. Large sums of money were raised, new laboratories were constructed, an army of full-time faculty was assembled, and clinical facilities were acquired. Medical schools, which had existed autonomously during the proprietary era, became closely affiliated with universities and teaching hospitals. Catalyzing this process was an influential muckraking report in 1910 by Abraham Flexner of the Carnegie Foundation, which vividly contrasted the ideal conditions of medical education, as exemplified by the Johns Hopkins Medical School, with the deficient conditions that still existed at so many other medical schools. In retrospect, it is remarkable how easily the fundraising task went. Medical schools everywhere in the country enjoyed astonishing successes at raising large amounts of money from the public. However, the task of acquiring suitable clinical facilities proved much more formidable. Most medical schools in the late nineteenth century had affiliations with hospitals, but the schools were severely restricted in how they could use those facilities. Medical schools could not appoint the hospital staffs to assure that hospital physicians had academic and clinical credentials, and medical faculty seldom was permitted to engage in clinical research. Most importantly, with few exceptions, medical students were not permitted to work in the hospital wards as clinical clerks. The clerkship was alive and healthy at Johns Hopkins, where it had been introduced by William Osler in 1893, and it was functioning with moderate success at the University of Pennsylvania, the University of Michigan, Jefferson Medical College, and Western Reserve. Elsewhere it was languishing, so that educationally meaningful contact between students and patients remained uncommon. These problems arose from the reluctance of hospitals of this period to assume a responsible role in medical education. Hospitals at this time tolerated medical student teaching reluctantly, as long as it was regulated carefully and did not interfere with their other functions. Hospital trustees often professed their desire to participate in medical education, but what they had in mind was instruction of a restricted sort: amphitheater lectures, ward walks, outpatient clinics, and section teaching—but not clerkship. Students in the early 1900s could receive good training in physical diagnosis and the use of certain medical instruments, but they rarely were permitted responsible contact with patients. Students endured repeated indignities. Throughout the nineteenth century, if they were permitted to enter hospitals, they frequently were required to use separate entrances. No institution better illustrated the unwillingness of hospitals of this period to participate in medical education than Roosevelt Hospital of New York City. After the Civil War, Roosevelt established a relationship with Columbia University’s College of Physician and Surgeons, and soon the hospital became the medical school’s major clinical resource. Roosevelt’s amphitheaters and clinics were used regularly by the school for teaching, and the hospital was a popular choice among Columbia students for fourth-year electives. Recognizing this fact, the medical school asked Roosevelt three times—in 1905, 1908, and 1910—to become a true teaching hospital, as the Johns Hopkins Hospital had become for the Johns Hopkins Medical School. In exchange, the medical school offered to build Roosevelt a new surgical pavilion and secure it a $1,300,000 endowment. Each time, however, Roosevelt rejected the proposal, mainly because it did not wish to have medical students working in the wards as clinical clerks. In frustration, Columbia turned to Presbyterian Hospital, which in 1910 agreed to become a true teaching hospital based on the Johns Hopkins model. The consequences of these events were different for Presbyterian and Roosevelt Hospital. Presbyterian, by virtue of its relationship with the medical school, became a great international center of medical education and research. Roosevelt, in contrast, went into eclipse. It never again served as the central teaching facility of a medical school, and as a result it became nothing more than another fine community hospital. It literally had the opportunity for international eminence in medicine in its hands, but it threw that opportunity away. From the perspective of medical history, the example of Roosevelt Hospital clearly illustrates that the limiting factor in medical education in the early 1900s came from the hospital side, not the medical side. However, there are other lessons. As officials of Roosevelt Hospital discovered, no hospital, then or now, can lay claim to any more than local significance without a close and harmonious relationship with a medical school. In addition, there was nothing in the external environment dictating that Presbyterian would become a medical mecca while Roosevelt would descend into mediocrity. Both events resulted from decisions the respective hospital boards made of their own initiative. This is an important reminder to us today as we are forced to contend with the powerful external forces of the medical marketplace. Just as the past was not predetermined, neither is the future. It can and will be influenced by the choices we make today and the principles we choose to defend. By the 1920s, the institution-building process in American medical education was complete. The money to support medical education properly had been raised, and the modern teaching hospital had been invented, allowing the special problems of clinical education to be resolved. 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