With the compliments of the writer. 
REFORM IN MEDICAL EDUCATION. 
PRESIDENTIAL ADDRESS, 
AMERICAN SOCIETY OF NATURALISTS, 
NEWYORK, DECEMBER 29th, 1898. 
H. P. BOWDITCH, M. D., LL. JX, D. Sc. 
[Reprinted from Science, N. 8., Vol. VIII., No. 209, Pages 921-927, 
December 30, 1898.] [Reprinted from SCIENCE, N. S.. Vol. VIII., No. 209, 
Pages 921-921, December 30, 1898.'] 
REFORM IN MEDICAL EDUCATION* 
The choice of a physiologist as the pre- 
siding officer of the Society of American 
Naturalists might, perhaps, have justified 
me in selecting some of the problems con- 
nected with experimental physiology as the 
subject of my remarks this evening, but, as 
questions of this sort are wont to awaken 
but a languid interest except among those 
who are themselves engaged in physiolog- 
ical research, I have thought it better to 
allow my choice of a subject to be guided 
by the fact that we are nearly all of us 
actively engaged in teaching as well as in 
studying our sciences, and to address you 
this evening upon some topic connected 
with education. 
My own experience of 27 years as a pro- 
fessor of physiology and of 10 years as 
Dean of the Harvard Medical Faculty nat- 
urally inclines me to discourse upon the 
subject of medical education and, since the 
great profession of medicine demands from 
its practitioners a certain familiarity with 
the fundamental truths of all the natural 
sciences, it can surely not be inappropriate 
to ask the representatives of those sciences 
to consider with me how far the progress 
of medicine and of the allied sciences has 
made it desirable to revise our methods of 
imparting medical instruction. 
Let me say at the outset that in speaking 
of the profession of medicine I use the term 
*Address of the President, delivered before the 
American Society of Naturalists at the New York 
meeting, December, 1898. 2 
not in its narrow sense, to designate the art 
of curing disease, but in its broader signifi- 
cation, to include a study of the whole en- 
vironment of man as far as it affects the 
production and maintenance of a healthy 
mind in a healthy body. 
In what I shall have to say on this sub- 
ject I shall confine myself chiefly to the 
medical schools of this country, though it 
will be found, I think, that the conclusions 
to which I shall endeavor to lead you will 
have their application to medical schools 
through the world. 
The most important event in the history 
of medical education in this country oc- 
curred some thirty years ago, when many of 
the principal schools abandoned the plan 
of giving a series of winter lectures, which 
were attended by all the students, irrespec- 
tive of their proficiency, and established a 
graded system of instruction in which the 
studies of one year were preparatory to 
those of the next. Those whose experience 
in medical education is confined to the 
period since this change was made can 
scarcely appreciate the value and impor- 
tance of the reform which raised the med- 
ical schools of the country from a condition 
in which they were aptly compared to joint- 
stock manufacturing companies, concerned 
only in taking in as large an amount as 
possible of raw material in the shape of 
medical students and in turning out a 
maximum of the finished product, i. e., 
doctors of medicine, with a minimum cost 
to the producer. ‘ Cheap doctors and plenty 
of them ’ seems to have been the motto of 
the medical schools of that period. Since 
this reform the medical schools of the coun- 
try have been conducted on sound educa- 3 
tional principles and the best of them com- 
pare favorably with the medical schools of 
Europe. 
During the last quarter of a century the 
improvement in medical education in this 
country has consisted chiefly in increas- 
ing the requirements for admission, in the 
lengthening of the course and in the exten- 
sion of the laboratory method of instruction. 
Important as these improvements have been, 
it may fairly be asked whether they have 
kept pace with the requirements imposed 
upon teachers by the remarkable advance 
in every department of medicine during the 
last thirty years. 
During this period we have seen the 
germ theory of disease established upon a 
firm basis and extended so as to throw 
light upon a large number of morbid pro- 
cesses with which it was formerly supposed 
to have no connection. Antiseptic methods 
have revolutionized the surgeon’s art. The 
study of the internal secretion of glands has 
led to the development of a system of glan- 
dular therapeutics. The use of the anti- 
toxin treatment has robbed one, at least, 
of the most dreaded diseases of more than 
half of its terror, while the use of instru- 
ments of precision has increased the accu- 
racy of our diagnosis in nearly all the ills 
to which flesh is heir. 
At the beginning of this period it was 
possible to impart to an intelligent medical 
student in a three years’ course of study a 
considerable fraction of the acquired med- 
ical knowledge of the time and to train 
him to safely use the comparatively simple 
methods of diagnosis and treatment then in 
vogue. At the present time, were we to 
seek to give to the same student a similar 4 
proportion of the accumulated knowledge 
now at the disposal of the profession and to 
teach him the use of the refined modern 
methods for the studj7 and cure of disease, 
it may be reasonably estimated that a ten 
or even a fifteen years’ course of study 
would be required. As it is obviously im- 
possible to prolong the course of medical 
study to anything like this extent, the ques- 
tion arises : In what way shall newly ac- 
quired knowledge in the science and practice 
of medicine be incorporated into the exist- 
ing curriculum of the medical student? 
Up to the present time this question does 
not seem to have been seriously considered. 
As new and important subjects have forced 
themselves upon the attention of the med- 
ical profession, our schools have sought to 
meet the new condition simply by adding 
to the existing curriculum a more or less 
lengthy course of instruction on the subject 
in question. Thus the importance of en- 
abling physicians to recognize pathogenic 
microbes has led to the establishment of a 
department of bacteriology in our principal 
medical schools, while the great advance 
made in the treatment of special classes of 
disease has occasioned the appointment of 
numerous professors of specialties, such as 
gynaecology, orthoepedic surgery, paediatrics, 
etc. 
The medical curriculum has thus grown 
by what may be called, in biological lan- 
guage, a process of accretion, and there has 
been little or no attempt to make room for 
new instruction by the omission of less 
valuable courses or parts of courses, though 
in certain directions the advance of knowl- 
edge, by demonstrating the inaccuracy of 
previously accepted views, has led to a 5 
simplification of instruction. When it has 
been found absolutely impossible to add 
any further courses a remedy for the con- 
gestion of instruction has been found in 
the prolongation of the medical curriculum 
from three years to four. 
It is, of course, evident that this process 
cannot be indefinitely continued. In fact, a 
slight study of the subject suffices to show 
that a limit has already been reached. In- 
deed, as long ago as 1870 Huxley was so 
thoroughly impressed with the crowded 
condition of the medical curriculum in 
England that he expressed “a very strong 
conviction that any one who adds to med- 
ical education one iota or one tittle beyond 
what is absolutely necessary is guilty of a 
very grave offence,”* and quite recently 
Professor M. Foster, in speaking of the 
enormously increased requirements in med- 
ical education, has expressed himself as fol- 
lows : a Kow it is obvious that, whatever 
may have been possible once, it is impos- 
sible nowadays to demand that all or each 
of these things should be learnt by the 
student of medicine. Though possibly the 
power of man to learn is increasing; though 
each science as it becomes more and more 
consolidated can be expounded and appre- 
hended with greater ease; though the grasp- 
ing of one science is in itself a help to the 
grasp of other sciences, yet beyond doubt 
that which has to be learnt is enlarging far 
more rapidly than is man’s ability to 
learn. ”f 
To extend the course of instruction in the 
* ‘Medical Education.’ Collected Essays, Yol. 111., 
D. Appleton & Co., 1894. 
f Address to the Students of Mason University 
College, Birmingham, October 3, 1898. 6 
medical schools of this country beyond the 
present four-year limit does not, under the 
prevailing conditions of education in Amer- 
ica, seem desirable, and the curriculum of 
most of our schools is already so crowded 
that no considerable amount of instruction 
can possibly be added. In what way, then, 
can we give to our medical students an 
adequate amount of information on all the 
subjects embraced in the constantly widen- 
ing domain of medical science and art ? In 
other words, how shall instruction keep 
pace with knowledge ? 
In seeking an answer to this question it 
may be assumed that a medical school of 
the first rank should be an institution in 
which the most advanced instruction in all 
departments of medicine can be obtained, 
and on this assumption it is, of course, im- 
possible to arrange a course of study that 
every student must follow in all its details, 
for in the time which may properly be de- 
voted to a course of professional study it is 
quite impossible for even the most intelli- 
gent students to assimilate all the varied in- 
formation which such a school may reason- 
ably be expected to impart. 
It seems, therefore, to be evident that in 
arranging a course of medical study a dis- 
tinction must be made between those sub- 
jects which it is essential that every student 
should know, and those subjects which it is 
desirable that certain students should know, 
i. e., between those things of which no man 
who calls himself a physician can afford to 
be ignorant, and those which are important 
for certain physicians but not for all. In 
other words, provision must be made both 
for required and for elective studies. 
The introduction of the elective system 7 
into a professional school is not an alto- 
gether novel proposition. For several 
years a large part of the instruction in the 
fourth year of the Harvard Medical School 
has been given in elective courses in various 
specialties, such as ophthalmology, otology, 
etc. The extension of the elective system 
to the earlier years of the course would be 
attended by no difficulty as far as details oi 
administration are concerned, and has, in- 
deed, been advocated by President Eliot in 
a speech at the dinner of the Harvard Med- 
ical Alumni Association in 1895. But the 
question may, perhaps, be asked whether it 
will be possible under such a system to se- 
cure the proper training of youug men for 
the duties of a profession in which experi- 
ence of life contributes so largely to success, 
and in which, therefore, a student at the 
beginning of his career may be supposed to 
be peculiarly in need of the guidance of his 
teachers. 
It is true that in the academic depart- 
ment of Harvard University the capacity of 
the average student to choose his course 
wisely and well has been demonstrated by 
the experience of many years, but it may be 
properly urged that the success of the system 
in the academic department does not neces- 
sarily justify its extension to a professional 
school. The responsibility of the medical 
faculty in granting the degree of M.D. is 
very different from that of the academic 
faculty in giving the A.B. diploma, since an 
imperfectly qualified practitioner of medi- 
cine may endanger the lives of his patients, 
while an unworthy graduate of the academic 
department can, as a rule, injure no one but 
himself. Hence the medical faculty may 
ustly be required to exercise greater caution 8 
in bestowing tbe degree of M.D. than is nec- 
essary in the case of the A.B diploma. We 
must, therefore, enquire whether it is pos- 
sible to obtain the advantages of a flexible 
curriculum consisting largely of elective 
courses without losing the security against 
superficial and imperfect work which the 
preseht compulsory system is supposed to 
afford. 
Any one who is familiar with the existing 
methods of medical instruction is aware 
that in nearty every department many 
things are taught which are subsequently 
found to be of use to only a fraction of 
those receiving the instruction. Thus the 
surgical anatomy of hernia is taught to men 
who will subsequently devote themselves 
to dermatology; future obstetricians are 
required to master the details of physio- 
logical optics, and the microscopical anat- 
omy of tumors forms a part of the instruc- 
tion of men destined to a career as alienists. 
Now, no one can question the propriety of 
including instruction on all these subjects 
in the curriculum of a medical school, but 
it may be questioned whether every student 
should be forced to take instruction in them 
all. It may, perhaps, be urged that no 
choice of studies can be made without 
determining, to some extent, the direction 
in which the work of the future practitioner 
is to be specialized, and that such specializa- 
tion cannot be properly and safely permitted 
until the student has completed his medical 
studies. To this it may be answered that, 
whatever may be the dangers of too early 
specialization, the dangers of crowding the 
medical course with instruction of which 
many students do not feel the need and of 
thus encouraging perfunctory and super- 9 
ficial work are certainly no less serious. 
Moreover, it will, doubtless, be found per- 
fectly possible to establish such a relation 
between the required and the elective 
courses that the requirements in each 
department will be in no way lowered, 
while a certain freedom of choice is per- 
mitted with regard to the direction in 
which the work is pursued. To illustrate 
this point, allow me to describe a possible 
arrangement of a course of study in the 
department of physiology with which I 
am, of course, more familiar than with 
any other. 
In the Harvard Medical School instruc- 
tion in physiology is now given in a course 
of about 100 lectures, besides recitations, 
conferences and practical laboratory work. 
Were the work to be rearranged in accord- 
ance with the above plan it would probably 
be found possible to condense into a course 
of about 50 or 60 lectures all the most im- 
portant facts of physiology with which 
every educated physician must necessarily 
be familiar. Attendance upon these lec- 
tures, combined with a suitable course 
of text-book instruction, would suffice to 
guard against gross ignorance of physio- 
logical principles. In addition to this re- 
quired work, short courses of eight or ten 
lectures should be provided,giving advanced 
instruction in such subjects as the physi- 
ology of the special senses, cerebral locali- 
zation, nerve-muscle physiology, the in- 
ternal secretion of glands, the physiology 
of the heart, circulation and respiration, 
the digestive secretions, the reproductive 
organs, etc. These courses should be elec- 
tive in the sense that no student should be 
required to take them all. Each student 10 
might, however, very properly be required 
to choose a certain number of courses, which, 
when once chosen, become, for him required 
courses leading to examinations. The num- 
ber of special courses which each student 
should be thus required to elect should be 
sufficiently great to render the total amount 
of physiological instruction in no way in- 
ferior to that which is given under the pres- 
ent system. 
It would, doubtless, be found desirable 
in practice not to confine the possibility of 
taking elective courses to the year in which 
the required instruction is given, for a stu- 
dent may frequently, in the latter part of 
his course, become interested in a subject 
like mental diseases, for instance, and will 
then be glad of an opportunity to take spe- 
cial instruction on the physiology of cerebral 
localization. The elective courses should, 
therefore, be so arranged that they may be 
taken in any part of the medical curriculum. 
There is, in my opinion, no doubt that an 
arrangement of instruction similar to that 
here suggested for physiology could be ad- 
vantageously adopted in the departments of 
anatomy, histology, bacteriology, medical 
chemistry, pathology, surgery, and in the 
courses of instruction in the various spe- 
cial diseases, such as dermatology, opthal- 
mology, etc. Whether the instruction in 
clinical medicine and clinical surgery can 
be thus modified is a question about which 
more doubt may be entertained and which 
I prefer to leave to persons of greater ex- 
perience than myself in methods of clinical 
instruction. 
Under the existing conditions of medical 
education the introduction of the elective 
system in some form or other seems to be an 11 
essential condition to any further important 
advance. If it be said that under this sys- 
tem the medical degree will cease to have 
the definite meaning now attached to it, and 
that it will be impossible to tell from his 
diploma in what way a physician has been 
educated, it may be replied that, though 
the degrees of A.8., A.M., Ph.D. and S.D. 
are affected with exactly this same uncer- 
tainty of signification, their value seems in 
no way diminished thereby. As long as the 
M.D. degree stands for a definite amount of 
serious work on medical subjects directed 
on the lines above indicated we may be rea- 
sonably sure that those who hold it will be 
safe custodians of the health of the commu- 
nity in which they practice. 
If it be urged that the elective system in 
medical education will lead to the produc- 
tion of a class of physicians who, owing to 
the early specialization of their work, will 
be inclined to overrate the importance of 
their specialty and to see in every disease 
an opportunity for the display of their 
special skill, it may be pointed out that 
this result is apt to be due not so much to 
early as to imperfect instruction in the 
work of a specialist, and that, since the 
elective system tends to encourage thor- 
oughness in special instruction, the evil 
may be expected to diminish rather than 
to increase. 
I have spoken of the extension of labora- 
tory instruction as an important forward 
step in the improvement of educational 
methods in medicine during the last quarter 
of a century, and I desire to bring my re- 
marks to a close with a few words on the 
relation between laboratory and didactic 
methods in medicine and on the employ- 12 
ment of both methods in a system of in- 
struction including both required and elec- 
tive courses. 
There is perhaps no field of human 
activity in which the pendulum of reform 
makes wider excursions than in that of 
education. Whenever any given method 
is found to give unsatisfactory results there 
is a strong tendency to abandon it alto- 
gether in favor of some entirely different 
method. Thus the obvious defects of the 
oral system of examination employed in the 
Harvard Medical School thirty years ago 
led to its complete abandonment and to the 
adoption of the written examination book, 
though there is little doubt that a system 
combining the advantages of both the oral 
and the written methods could easily have 
been devised. In the same way the fact 
that many subjects have been, and indeed 
still are, taught in systematic didactic lec- 
tures which can be better taught by labora- 
tory methods tends to obscure the equally 
important fact that there are many other 
subjects in the presentation of which the 
living personality of the lecturer is a very 
important factor and which, indeed, can be 
properly presented to students only by those 
who have had much experience in weighing 
scientific evidence. In this connection it is 
interesting to recall the wise words of Hux- 
ley, who expressed himself on this subject 
as follows : “ What the student wants in a 
professor is a man who shall stand between 
him and the infinite diversity and variety 
of human knowledge, and wTho shall gather 
all that together and extract from it that 
which is capable of being assimilated by 
the mind.” * 13 
To what extent the laboratory can re- 
place the lecture room will, of course, de- 
pend upon the nature of the subject taught. 
In such a branch as Anatomy, where facts 
learned by observation form the greater 
part of the knowledge to be imparted, 
laboratory work can be substituted for di- 
dactic instruction to a greater extent than 
is possible in subjects like Physiology and 
Pathology, where inferences from observa- 
tions and conflicting views must frequently 
be presented. In no department of medi- 
cine, however, will it probably be found 
possible to dispense entirely with a system- 
atic course of lectures in which a trained 
instructor may give to his class the benefit 
of his accumulated experience. 
A consideration of the nature of the sub- 
ject taught will also furnish a guide for the 
employment of laboratory and didactic 
methods in the required and elective courses 
above suggested. In general the required 
courses, being comparatively elementary 
and concerned chiefly with the presentation 
of well ascertained facts, may be made de- 
monstrative in their character and may be 
conducted in accordance with laboratory 
methods, though a short course of didactic 
lectures, parallel with laboratory work, will 
in most cases be found to be essential. In 
the elective courses which provide advanced 
instruction in many directions the limits of 
our knowledge wrill be more nearly reached. 
It will, therefore, be necessary to present 
and weigh the evidence for and against the 
various conflicting views which are almost 
certain to be held with regard to subjects 
lying within what Foster has called the 
‘ penumbra ’ of solid scientific acquisition. 
For this purpose the most suitable method 14 
of instruction seems to be a short course of 
carefully prepared didactic lectures which 
should, however, be varied by demonstra- 
tions whenever the nature of the subject 
will allow. 
It is, however, unnecessary to discuss 
these and other details at the present time. 
They will speedily arrange themselves as 
soon as the necessity for a comprehensive 
reform in our methods of medical instruc- 
tion is generally recognized, and it is in the 
hope of helping to secure this recognition 
that I have addressed these remarks to you 
this evening. In whatever way the remedy 
is to come it should not be long delayed, for 
the difficulty of giving adequate instruction 
to constantly increasing classes seeking in- 
formation over a constantly widening field 
of knowledge is felt each year with greater 
and greater keenness. 
H. W. Bowditch. 
Haevakd Medical School.