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Chicago in 1921.3 The committees were unanimous in their decision that an interneship in a general hospital was not only essential to round out the education of the general practitioner, but also should be the foundation on which further training in the various specialties should be based.
Following a third inspection made in 1923, a schedule of principles regarding graduate medical education was prepared which provided for admission requirements, records, supervision, curriculum, graded instruction, qualified teachers, properly equipped laboratories, library and museum facilities, essential hospital and outpatient material, annual announcements, and regulations in regard to the granting of degrees and diploma-like certificates. On the basis of these principles, out of 35 institutions investigated, a list of only 15 approved graduate medical schools was prepared. Since 1923, however, 19 other institutions have been added, making a total at the present time of 34. To this list has been added 16 hospitals in which, through a higher interneship or residency, a physician can perfect himself in the practice of some specialty.
Where in 1916 only 20 postgraduate schools were offering courses of unknown quality and quantity, there are now 50 institutions giving courses that have been investigated and found worthy of approval. A list of medical subjects has also been prepared, after each of which is given the names of graduate medical schools or hospitals in which opportunity for higher training in that subject or specialty can be obtained. The physician, therefore, is now provided with a carefully prepared list of graduate schools from which he can make an intelligent selection. As time goes on, an even greater use will be made of the abundance of hospital and dispensary patients in providing opportunities for physicians to perfect themselves in the practice of their profession and thereby render a better care to the people coming to them for treatment.
LIMITATION OF ENROLLMENTS
During the improvement of medical education, medical schools found it necessary to limit the enrollment in their classes so that better supervision could be given to the student's individual work, and the results have shown the wisdom of such action. This limitation, however, coupled with the unprecedented rush of students into medical schools, increased the difficulty of well-qualified students in securing enrollment in medical schools. After having applied to one medical school after another and securing the reply that their classes were full, a student would send a letter simultaneously to a score or more of the remaining institutions. As a result he would be enrolled by two or more medical schools, although when the session began he could attend only one. This practice resulted in vacancies which otherwise might have been filled. Following the opening of the session of 1924-25, an investigation showed that after all registrations were completed, 1,355 vacancies still remained. Some of these students had registered and actually paid matriculation fees at two or more medical schools. Thus the capacity of medical schools is still adequate although some qualified students were temporarily debarred. The Class A medical schools report that, without much difficulty or expense, they can provide capacity for an additional 5,000 students. Our well-equipped colleges should soon provide more space, or other high-grade medical colleges should be established. Properly qualified students show a laudable desire to enter well-established medical schools, since it is this type of medical school, rather than the lower type, in which the enrollments are first filled.
3 The several fields of clinical specialization that were studied are shown in the following list The minimum, years designated after each subject represent what were considered by the committee as essential to insure efficiency in the specialty:
(a) Surgery, general 3
•(b) Surgery, orthopedic 3
(c) Surgery, genito-urina,ry 3
(d) Gynecology and obstetrics 3
(e) Ophthalmology 2
(f) Otolaryngology 2
(g) Internal medicine 3
(h) Pediatrics 3
(1) Neuropsychiatry 3
(]) Dermatology 2
(k) Public health and hygiene 2
—Amcr. Med. Assoc. Bull., vol. IS, Xo. 1, Jan., 292i,
SPECIALIZATION IN MEDICINE
In the past 50 years the exact knowledge of the recognition, treatment, and prevention of diseases has increased more than in all previous ages. This increase is but a parallel to the marvelous developments in other fields of knowledge and experience, all of which have occurred during the same time. With this expansion of medical knowledge and the multiplication of the methods and agencies for the diagnosis and treatment of diseases, it is but natural that physicians in increasing numbers should desire to limit their practice Mithin the narrow bounds of some specialty in medicine. Such, indeed, is necessary if a physician expects to develop the highest degree of knowledge and skill in any specialty. That many physieians are specializing is but a parallel to what is done in other professions. Among engineers, for example, there are now those who specialize in civil, electrical, aeronautical, mechanical, or chemical engineering; and in law there are those specializing in, or limiting their practice to, patents, wills, corporations, bankruptcies, or to civil, criminal, or divorce cases.
With such specialization in medicine comes the importance of developing as specialists those who are highly skilled as diagnosticians and who are especially qualified to decide what particular form of treatment will best meet the patient's needs. At present, this field is occupied largely by those referred to as specialists in "internal medicine" or "internists," many of whom have demonstrated unusual skill in diagnosis. 27301°—27 7
CHANGES IN GENERAL PRACTICE
Several factors are leading to changes in the routine of medical practice. As the knowledge of medicine has been enormously increased, many valuable laboratory aids have been devised for the diagnosis and treatment of diseases. The advantage of being where all these aids are available has led to a rapid increase in the number of patients seeking treatment in hospitals. The tendencies of the public also to seek specialists makes the hospital additionally advantageous, since its staff includes physicians representing the several specialities, and in unusually complicated cases the judgment of the group can be readily obtained. Hence, access to a hospital has come to be looked on, both by recent graduates and by the public, as very helpful if not essential for an up-to-date physician.
This view of the public in regard to the hospital, coupled with the development of the automobile and cement roads, has induced many country people to go to city doctors and to the hospital for treatment. This in turn, has forced some of the country physicians likewise to move to the city. The future practice of medicine, therefore, calls for some arrangement whereby medical care will still be available even in the smaller and more remote rural districts. Just how these facilities can be provided still remains to be seen. The building of hospitals in all communities where there are people enough to maintain them will help. A suggestion has been made that physicians in the larger towns have office hours for a certain day or days of the week in smaller but near-by rural towns. Another suggestion is that health centers or clinics be provided in rural districts where first aid can bo given in emergencies and, when necessary, ambulances can be secured promptly to transport a patient to the nearest hospital.
In 20 years medical education in the United States has undergone a marvelous improvement, so that the medical schools of this country are at least on a par with those of other leading nations. The problems which remain are chiefly those due to the other improvements made. The greatest of all problems is how the benefits of the present-day knowledge of the cause, recognition, treatment, and prevention of diseases can be brought within the reach of the entire population, both /rom the standpoint of accessibility and cost. This problem is one of many other economic and sociological problems which have developed during the past few decades due to the rapidly changing conditions under which we are living. Readjustments will be made under these conditions which will doubtless bring about the desired results.
By Fbedebick C. Waite
Conthnts.—Introduction—(I) Agencies in the progress of dental education: (1) American Dental Association; (2) National Association of Dental Examiners; (3) National Association of Dental Faculties; (4) American Institute of Dental Teachers; (5) Dental Faculties Association of American Universities; (6) Dental Educational Council of America; (7) American Association of Dental Schools; (8) Carnegie Foundation for the Advancement of Teaching—(II) Analysis of progress of dental education: (A) Periods of progress; (11) Thases of progress: (1) Progress in preliminary education, (2) length of the annual school session, (3) number of years in the course, (4) graded curriculum, (!">) breadth of the curriculum, (0) equipment of dental teaching, (7) quality of instruction, (8) standards of scholarship, (9) university control—Conclusion.
Dentistry has evolved from medicine and more especially from the surgical aspect of what we now call medicine. Until the sixteenth century, physic and surgery were separate professions, and what we now call dentistry was a part of surgery rather than of physic. For centuries physic was a calling of greater dignity than surgery. Since the major influence in modern medicine has been physic rather than surgery, this legendary relation to some extent accounts for the fact that dentistry, since its establishment as a separate profession, has not been acknowledged to be on a professional parity with medicine.
Dental education, in both Europe and America, was a part of medical education until 1840, but the dental features in medical education were only incidental, going little beyond some instruction on extraction. No sustained course of lectures on dental subjects was given in any medical school until 1837 and then in only one school. The better dentists were men who, following a medical education, had served an apprenticeship under a preceptor who was a dental practitioner, before they specialized in dentistry.
With the establishment of the Baltimore College of Dental Surgery in 1840 separation of dentistry from medicine began, and the era of distinct institutional education in dentistry inaugurated a type of training in which the mechanical aspect of dental training gradually supplanted the basic medical phase. However, training through apprenticeship, either instead of the dental school course or supplementary to it, remained an important avenue of entrance to dentistry for several decades.
In no instances was there any university control of, or interest in, dental education in its first 25 years. Inasmuch as for 50 years most of the dental schools were independent and proprietary, divorced from medical influence and lacking the broad principles that result from university control, dental education came to be mainly a training in a technical art lacking the basis of general education and also devoid of adequate knowledge of the fundamental medical subjects. In this the profession and the dental schools took pride, and American dentistry came to excel in the mechanical phases.
After the Civil War there appeared in an increasing number of States statutory regulation of both medical and dental practice. This took the form of examinations before licensing boards, but these examinations were waived if an individual were a graduate of either type of professional school. In this policy of waiver arose the stimulus for organization of new dental schools, some of which were of little worth. During the 30 years from 1840 to 1809, inclusive, 13 dental schools had been organized. Of these, 10 were in operation in 1870. During the 15 years from 1870 to 1884, inclusive, 17 new schools were founded and 4 were discontinued, leaving 23 schools in operation in 1884. In the 15 years from 1885 to 1899, inclusive, 57 new dental schools were organized and 29 were discontinued, leaving 51 dental schools in operation at the beginning of 1900. There had been organized in 60 years 87 dental schools, some of which were scarcely more than diploma mills; many of them were happily short-lived. By 1885 the desirability of some regulatory control and standardization of dental schools was apparent.
I. AGENCIES IN THE PROGRESS OF DENTAL EDUCATION
The progress of dental education can not be properly comprehended unless there is some understanding of the leading organized agencies that were factors in this progress, and therefore we shall briefly examine these in the chronological order of their appearance.
1. AMERICAN DENTAL ASSOCIATION
The practitioners of dentistry organized in 1859 the American Dental Association. Through committees it gave some attention to the problem of dental education, but this was a minor feature of the program which most interested its members. To them problems of practice were more compelling than problems of preparation of their successors for practice.
This association, in response to the need for some regulation of dental education, in 1883 appointed a committee to arrange a conference of the executive officers of dental schools, and out of this conference arose the National Association of Dental Faculties in 1884.