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CHAPTER VII.

MEDICAL EDUCATION.1

RAISING THE STANDARD.

Medical education in this country is now making one of the longest strides forwarıl that has occurred in its history. This step is the lengthening of the course to three and four years of eight or nine months, instead of the old course of two years of four or five months. We say this step is now being taken, for while many schools have already lengthened their courses during the last eight years, there are others which have arranged to do so soon, and still others which are certain to foilow along afterwards. So the work of ligler metlical education is still in a progressive state, in that many medical schools have not as yet entered upon their full course of instruction, but it is probable that nearly all of the colleges will have completed this extension during the next four or five years. When they have done so, and one can take a retrospective glance and see that every medical school has added one or two years to its course, and has lengthened the annual session to eight or nino months, the question will naturally arise, What was the moving cause of this extension? Why was it that the medical colleges, which for decades had been contented with a course of two years of four or fivo months each, began to adopt courses of three or four years of eight or nine months each ?

In fact, this question has already been answered by several writers, but the explanations must have come from different standpoints, as they arrive at difierent conclusions. It is said by some that the Illinois State board of health, of which Dr. John H. Rauch was secretary, was the prime cause, when it announced that no school having a course of less than three years would be considered in good standing and that its graduates could not practice in Illinois without first undergoing an examination. Others say that the medical practice acts adopted in several States during the last five or six years began the work; others attribute it to the resolutions of the American Medical College Association in favor of higher education; others claim that "it was inaugurated by the American Institute of Homeopathy in 1888, when it was ordered that ‘After the coilege sessions of 1890-91 each anıl all of the homeopathic schools of America will require of their candidates for graduation at least three years of medical study, including three full courses of didactic and clinical instruction of at least six months each.''

It is probable that many of the leading medical institutions had for some time been in favor of extending the course, but wero deterred from fear that their students would leave for competing colleges where less time was required. But when some

1 By A. Erskine Miller. 2 The Association of American Medical Colleges, at its meeting in San Francisco, June 7, 1894, "Resolred, That students graduating in 1899 or subsequent classes be requireıl to pursue the study of medicine four years and to have attended four annual courses of lectures of not less than six months' duration each."

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of the institutions which constituted departments in leavily endowed universities became less dependent upon tuition fees, they were able to adopt longer courses without considering its effect upon attendance. Besides, about this time the number of medical students was becoming unusually large, so that some schools did not really desiro an attendance larger than they could well accommodate. By adopting a longer course they would still have as many students as desired, and they would send out graduates better prepared to gain credit for themselves and for the institution.

Many of the State boards of health now announce that they will not recognize any institution unless it exacts a full threo years' course of study and complies with all other standard requirements of education.' One of the results likely to follow from this elevation of the course is that there will be fewer new colleges coming into existence, for unless an institution has a good standing with the State boards of health or examining boilies, it can not reasonably expect to meet with much success. But as the present number of medical colleges will be ample for many years to come, 110 complaint will be made ljecause others can not come into existence. In fact, medical education would be advanced if somo institutions already existing were consolidated with others in the same locality.

"The chief difficulty in making a high standard unirersal lies in the number of the medical colleges. It is, indeeil, a sorry admission that the medical schools in this country aro the greatest enemy to medical progress, not in themselves but in their number.

The remely lies in their amalgamation. Let the absurdity cease of small towns having three, four, or six of these struggling institutions, no one of which can liavo a vigorous liso.

“Thero is now all over the country a growing disposition for the universities to take chargo of medical teaching and to develop their medical departments with all thie zeal they give to the others. Wo see it in Michigan; we see it in California and Colorado; we seo it in Louisiana and Texas as strikingly as in our Eastern States. There is nothing but good in this. The power, the means, the spirit of the wiversity go out to its branclı; the university in turi gains by the reputation of its medical faculty, and by the recognition that medicine is an essential part of the new learning which leads on to the higliest attainable civilization.”?

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EFFECT ON ATTENDANCE OF LENGTIIENING THE COURSE.

The question may be asked, How has the attendance of síudents been affected by the requirement of another year of study? Adiling one year to the course means not only increasing the amount of time required, but also an increase in the financial outlay. It would therefore naturally be expected that many young men would be led to seek other lines of employment. In order to determine this question somewhat definitely the statistics for tho last five years have been collected of medical, dental, pharmaceutical, and law students, as all of these have had lengthened courses. Instead of any decrease, however, wo find the number of students to havo grown steadily larger. In 1888–89 the number of medical students was 15,029; since that time the number has gone steadily forward to 19,752 in 1892-93. As yet even the number of graduates las suffered no special loss, except in the dental schools, irlere tho munber of graduates in 1891-92 was 1,282 and fell to 507 in 1892-93, when the graduating class first encountered the three-year regulation.

Athough the actual number of students in attendance during the last five years has regularly increased, it is still very probable that many have been kept out by

Since the above was written the regulations have been maile still inoro stringent. In Oregon, Montana, and linnesota after 1898 an attendance upon four courses of lectures will be required.

"The Regents of the Stato University (of New York] have voted to conser the university degree M. D. only after one year's postgraduate study subsequent to receiving the degree of bachelor or doctor of medicine from some registered medical school, and only on candidates who have spent not less than four years total study in accredited medical schools."-N. Y. Med. Record, July 20, 1895.

? Dr. J. M. Da Costa, of Philadelphia.

the lengthened course. It should be borne in mind that the same students are now kept in attendance a longer time, and therefore help to swell the enrollment for another year.

Enrollment during fire years.

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Total medical
Per cent graduating.
Dental
Pharmaceutical
Law...

3. 799
25. 3
696

689
1, 268

4,469
20.8
913

759
1,424

4, 931

27. 1. 1,012

733 1, 727

4,521

25. 3 1. 282

722 1,976

4, 911

21.9 b 307

827 2, 400

a Decrease due in part to failure of one important school to report.

Docrease due to its being the first graduating class afiected by the change to a three years' course.

LEGAL CONTROL OF THE PRACTICE OF MEDICINE.

Unless it be the American Medical College Association, probably nothing has contributed so much to the advancement of medical education in the United States as the establishment of State licensing boards, frequently calleıl boards of health on account of a union of their functions. Here we see how far-reaching and important a little clause sometimes becomes, in a law which directs the licensing boards to register all graduates “of colleges in good standing." Probably no one of the legislators who first voted for the bill containing these words, now found in the law of several tates, had any idea of what a powerful leverage they would become in the hands of State licensing boards for stimulating medical colleges to lengthen their course of study and raise tho requirements for entrance and graduation. But wlieu the Illinois State board anuounced that no medical school would be regarded in good standing which did not require three courses of lectures, the institutions immeiliately began to fall into line in lengthening their courses, for in truth many schools had favored such an extension before, but were deterreil from taking the step because their competitors did not adopt it. Now, however, they recognized the fact that all schools would soon be compelled to advance their standards. This valuable work of State licensing boards was soon recognized in other States, and now we find such boards in thirty-five States and Territories, all of them contributing to a large extent in placing modical education upon a plane where it will reflect honor upon its followers.

It was not many years ago wheu, in almost any State in the Union, anyone could hang out his sign as a medical practitioner and charge as bigh fees as the best qualified physician iu the town. Why, then, should one spend several years in preparing for luis work and deplete his purse with the hope of being able to refill it again? It might be said that the meritorious physician would be able eventually to show beyond doubt his qualifications, while the half-educated doctor would be unable to hide his mistakes. That is true to some extent, but the latter generally i

recognize this fact himself, and when the truth begins to reveal itself to the people, he quietly moves off, possibly to another section of the same city, and begins to plod his old course in a country new. The meritorions doctor then sees that what he expected has taken place, but as a vacancy has occurred, another one soon moves in who has possibly bought out the good will of the departing brother, and then perhaps begins again the identical course of events. , Besides, medical knowledge and skill do not alone determine a physician's success; there are other things that help to decide it. An air of self confidence, a good personal appearance, a cheerful and sociable disposition, and a happy faculty for making acquaintances go far toward securing a reputation as an able physician, and if united with a good degree of dependence on vis medicatrix naturæ he may enjoy many happy days of visiting patients, drawing a reil over ill-timed prescriptions, collecting good fees, and receiving high encomiums from warm-hearted friends.

It nay bo said that the well qualified physician should also endeavor to possess these external requisites, that they are really as essential in restoring health to the invalid as a well selected prescription; but that is no reason why they should constitute the stock in trade; no reason why the confiding patient should be left to chance or to nature when by the administration of the proper medicine, convalescence would at once begin. But, above all, that is no reason why, so far as can be avoided and when perhaps a life is in danger, dependence should be had upon some one supposed to possess both knowledge and skill, when in fact he has neither. This only illustrates the etse with which deception can be practiced in the healing art, and why the governments of Europe and so many States of this country have adopted regulations to secure at least presumptive evidence that medical practitioners are qualified for their responsible duties. The people have not sufficient time, as individuals, to examine into the qualifications of physicians, to say nothing of the opportunities and knowledge necessary to properly determino such a question. Frequently it is not until soine member of the family has been suddenly taken sick that the question arises what physician shall be called, and the query is quite often determined by lurrying to the first drug store and inquiring of the clerk for the nearest physician.

There are eighteen States in which the diploma of no medical college confers the right to practice, but all candidates for this privilege must undergo an examination. These States are Alabama, Arkansas, Florida, Georgia, Maryland, Minnesota, Mississippi, New Jersey, New York, North Carolina, North Dakota, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Virginia, Washington. In seventeen other States the diploma conters this right only when the board of health or other determining body shall have declared the college to be “in good standing,” and this has been interpreted to mean that they are satistied with the entrance requirements, the length of the term, the number of courses required before graduation, the character of the instruction given, and all other items which aid in fully qualifying the graduate to practice. In some instances State boards have announced in advance that they would recognize no college which did not require so many courses of lectures, or which did not have an annual session of so many months. Medical institutions would then see that they must comply with these requirements or else their graduates from such States would be on uueqnal footing with those from other behools, and consequently the number of their students would be diminished. In self-defense, therefore, they must comply with all reasonable stipulations.

"I conspicuous effect of these laws has been seen in the improvement of the standard of medical education. To them, more than to any one cause, is due the difference which exists between the condition now and in 1870. In Alabama, Colorado, Connecticut, Illinois, Nebraska, Oregon, South Dakota, and Washington, at least three full courses of five to six months each, no two in the same year, are demanded. The State of Oregon, after 1898, will require four courses of six months each from physicians who wish to practice in that State. There is not only a prolongation of the period of study as the effect of these laws, but there is also an

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