HOSPITAL INTERNESHIPS

During the past three decades, attention of the recent graduate has been increasingly attracted to the great value of spending an additional year or two as an interne in a large hospital, where he has an opportunity to apply his medical knowledge while still under supervision and before he enters on an independent practice. In 1912 there were not enough hospitals using internes to provide places for all graduates. With the improvements in medical schools, and the greatly improved qualifications of modern medical graduates, however, their services became of greater value to the hospitals and the demand for internes was greatly increased. At the same time, the number and size of hospitals were greatly increased, which provided additional places. At present, therefore, the demand for internes would exceed the supply, even if the numbers graduating each year should be doubled. The great value of the hospital interne training is that the graduate has an opportunity to secure experience in the care of sick people while he is still under observation, so that any errors will be corrected without injury to the patients. Before these hospital interneships were available, the graduate had to secure the experience in his own active practice without any safeguards in cases of error. It is gratifying to state, however, that the ill results in the care of patients were extremely few in spite of the lack of the opportunity for interne training. The number of hospitals seeking internes is now sufficiently large to warrant a requirement in all States that medical graduates should not be licensed to practice their profession unless they have completed an interneship in a general hospital.

THE HOSPITAL AN IMPORTANT EDUCATIONAL FACTOR

An interneship in a general hospital has now come to be recognized, not only as a rounding-out process for the training of the general practitioner, but also as the basis for graduate medical work leading to a higher degree of knowledge and skill in the various specialities. In other words, an interneship in a general hospital now occupies an important zone separating undergraduate from graduate medical education. As hospitals are increasing in number, so also are they developing as an important factor in medical and public health education. Besides their value in the education of medical students, nurses, and internes, they are also places where physicians can secure a higher degree of training as a specialist in some clinical field, such as in skin diseases, surgery, internal medicine, children's diseases, or in diseases of the eye, ear, nose, and throat or some other speciality. They are also important in their communities as educational centers, not only for the higher instruction of the physicians in the neighborhood, but also through their patients, nurses, and others, as a means of keeping the people of the community informed in regard

to matters relating to infant welfare, public health, and disease prevention.

II. NEWER PROBLEMS IN MEDICAL EDUCATION

As a direct result of the great changes and improvements in medical education, newer problems have been developed. Among these may be mentioned the higher cost of medical education, an overcrowded medical curriculum, an unusual rush into specialization by recent graduates, the elaborate equipment required for the practice of modern medicine, and the decreased number of physicians in rural communities as compared with the increasing proportion of physicians in the cities.

HIGHER COST OF MEDICAL EDUCATION

Prior to 1900, with only a few exceptions, medical schools were maintained entirely on the fees obtained from students, and some could still pay out dividends after all expenses were paid. As medical schools were developed, however, the costs were enormously increased. The larger buildings, with the correspondingly larger expenses for heat, light, and care; the several essential and better equipped laboratories; the larger numbers of skilled teachers, many of whom necessarily devoted their entire time to teaching; the special and highly technical apparatus; the maintenance of library and museum; the more elaborate curriculum, with the higher costs of administration-the cost of all these required a higher income than could be obtained from students' fees alone. To provide a training in accordance with the present wide knowledge of the causes, recognition, treatment, and prevention of diseases, the medical schools must now have, in addition to students' fees, incomes from either State appropriations or private endowment.

An investigation covering the college year of 1914-15 showed that the average income of each college was $68,277, of which $23,795 was from students' fees, and the average of expenditures was $66,253. The average cost of instruction per student in that year was $419, whereas he paid in tuition fees only $150. In brief, it cost three times as much to teach a medical student as he paid in tuition fees. For the session of 1920-21 an investigation showed that the average cost of instruction for each student increased to $655, whereas the average fee paid by each student had increased to only $185. The average income of each medical school was $130,672, including $35,135 from students' fees. The average expenditure by each college was $123,947, of which $46,162 was for full-time teachers; $21,131 for part-time teachers; $19,068 for wages of clerks, janitors, etc.; and $36,974 for maintenance and supplies.

To offset these greatly increased costs of furnishing medical education, great sums have been donated by the large educational foundations, private donors, and State legislatures; so that, where formerly gifts of more than a few thousand dollars were very rare, in later years the gifts of from many hundred thousands to a few millions became so frequent as to be considered a matter of course.

SCHOLARSHIPS AND LOAN FUNDS

The requirements for admission to medical schools have been increased since 1912, from a high-school education or less, to two or more years of college work. This increased time requirement, as well as the higher tuition fees in medical schools, has added considerably to the time and expense of obtaining a medical education. So far as the student is able to do so, it is reasonable to expect him to pay at least a fair portion of the amount necessary to provide him with that training. There always has been, however, a considerable number of students who do not have sufficient money to pay tuition. fees and are struggling to secure a medical training. As a rule, also, this group of students contains many who have unusual qualifications and ability, and from this group in times past many physicians of high attainments have come. As the educational standards and costs of medical education have advanced, more scholarships and loan funds for the aid of such students have been established. At the present time, 576 scholarships are reported in 46 medical schools. Each of these scholarships is available only once in four years; so that only 144 are available each year. Loan funds are also available in 31 medical schools.

The present-day medical curriculum is much more severe than it was 20 years ago, which makes it much more difficult for a student to earn money at the same time he is studying medicine. Nevertheless, many students are still reported to be earning a major portion of their expenses during their medical school time. It is a question, however, whether the money so earned is not at the expense of much valuable experience which they otherwise might have and should have obtained. It is during the student's medical course, while he is under able instructors, that he has the best opportunity of his lifetime to study and observe diseases of patients in both dispensary and hospital. In order to make the best use of this opportunity, therefore,

it would be far better for the student to borrow money with which to meet his expenses or to have the advantage of a free scholarship. A more worthy object for those who have money to give could not be found than in the endowment of more of these scholarships, or the establishing of additional loan funds. In granting these, however, proper safeguards should be established so that they will be used only for students who not only have high scholarly ability, but also are actually in need of financial aid.

THE MEDICAL CURRICULUM

Prior to 1900 little concern was felt regarding the course of instruction, because few of the medical schools had developed their curricula in accordance with the unprecedented expansion of medical knowledge since the time of Pasteur. With the improvements in medical schools since 1900, however, new subjects were rapidly added to the medical curriculum, until it soon became seriously overcrowded. So important became this problem that, in 1908, a special committee of 100 prominent medical educators was appointed by the Council on Medical Education to make a special study and to present a report2 recommending a model medical curriculum. This committee was made up of subcommittees covering the 10 departments of medical teaching, including both the laboratory and clinical subjects. The original plan was to prepare a curriculum consisting of 900 hours each year, or 3,600 hours for the four years, but when the subcommittees' reports were presented in 1909, they called for a total of 4,400 hours. These reports were accompanied by a recommendation, however, that the total be cut down by the colleges to 4,000 hours.

This report doubtless brought some improvements, but the curriculum continued to be overcrowded, and groups representing certain subjects continued to clamor for larger numbers of teaching hours. It became evident, also, that in the teaching of the clinical subjects very rare or highly complicated conditions were being unduly emphasized at the expense of the basic principles of diagnosis and treatment, which were of greater importance to the student. The emphasis laid on special operations also induced graduates, without further special study, to begin immediately the practice of some specialty.

GRADUATE MEDICAL EDUCATION

It is now well recognized that the chief function of the undergraduate curriculum is to furnish a basic training for general practitioners. Then should follow the hospital interneship, which would round out and complete the physician's training as a general practitioner and not further lure him into some specialty before he has

2 Proc. 5th An. Conf., Council on Med. Educ., Chicago, Apr. 5, 1909. Amer. Med. Assoc. Bul., vol. 5, No. 1, Sept., 1909.

secured the essential additional training. The exceptional types of diseases, and the highly technical and complicated forms of treatment, should come after the completion of the general hospital interneship, in special hospitals or in the graduate medical school. The development of graduate medical schools during the past 10 years is helping to solve the curriculum problem, in that a place has been found for certain courses which are better omitted from the undergraduate curriculum. The students of some graduate medical schools aid in the teaching of undergraduate students, who are thereby made familiar with the routine of securing a higher training before they can be qualified for practice in any special field. They learn also where and how the higher training can be obtained, and by observing the work of the graduate students can note the character of that work.

The graduate medical school, therefore, has helped in the solution of three problems in modern medical education: (a) It has aided in an improvement of the medical curriculum in the clearer understanding established as to what subjects belong in the undergraduate department; (b) it has helped to stop an inadvised rush of recent graduates into specialization by transferring the subjects which have stimulated this tendency from the undergraduate to the graduate school curriculum; and (c) better facilities have been provided in the graduate medical schools where graduates can develop the higher knowledge and skill essential for the practice of the specialty selected.

Meanwhile, gradual improvements are being made in graduate medical education in this country. Inspections of the various graduate and postgraduate medical schools which were made by a committee of the American Medical Association in 1916 and 1919 showed that conditions were decidedly unsatisfactory. While a few of these schools were well conducted, in the others the work was unorganized and poorly graded; little or no attention was paid to the character or qualifications of the physician-student, and practically no record was kept aside from his payment of fees. Nevertheless, some of the schools granted pretentious diploma-like certificates for some courses of instruction extending over no more than one or two weeks. By 1923, however, through the suggestions given out during the previous inspections, conditions were considerably improved, and most of the postgraduate medical schools had ceased to grant certificates except for courses of six months or more.

In 1920, in order to secure a basis for the approval of graduate medical schools, 15 special committees were appointed to recommend what preparation was deemed essential to establish proficiecy in each of the 15 specialties to which they were assigned. Their report was presented at the annual conference on medical education in