THE AIMS AND METHODS OP MEDICAL 
EDUCATION. 
BY >/ 
WILLIAM C. DABNEY, M.D., 
PROFESSOR OF THE PRACTICE OF MEDICINE IN THE UNIVERSITY OF VIRGINIA. 
FROM 
T II K MEDICAL N RWS, 
December 30, 1893. [Reprinted from The Medical News, December 30, 1893.] 
THE AIMS AND METHODS OF MEDICAL 
EDUCA TIO N} 
By WILLIAM C. DABNEY, M.D., 
PROPBSSOR OF THE PRACTICE OF MEDICINE IN THE UNIVERSITY OF 
VIRGINIA. 
The ultimate aim of medical education is to fit 
those who enter upon the study of medicine to 
prevent and cure disease and to relieve suffering. 
For the proper accomplishment of this work, several 
things are necessary : 
1. A sufficient development of the faculty of 
observation and of the reasoning faculty to enable 
the person to judge of cause and effect, and to draw 
proper conclusions from ascertained facts. 
2. An ability and a willingness to work. 
3. A knowledge of the work done by others 
directly or indirectly connected with medical 
matters. 
4. A just appreciation of the extent and character 
of the work that they undertake and of the respon- 
sibility that they assume. 
I propose to consider in this paper the importance 
of these different subjects, and shall endeavor to 
show by what methods the mental training and 
1 Read before the Section on Medical Pedagogics of the Pan- 
American Medical Congress, September 7, 1893. 2 
discipline of a medical student may be best accom- 
plished. 
Let me say in the beginning, however, that, in 
considering the requirements of those entering 
upon the study of medicine, I have in view the 
great numbers who yearly enter our lecture-rooms 
with very moderate intellectual capacity, scant liter- 
ary training, and often the most deplorable ignorance 
of the gravity of the task and the responsibility on 
which they are entering. These are the men and 
women who treat the great masses of our people, and 
who need, therefore, the best medical education and 
training which can be given them. 
I recognize the fact—so encouraging to all who 
are interested in higher medical education—that 
among those entering upon the study of medicine, 
there is from year to year a larger and larger 
number whose minds have been broadened and 
enlightened by preliminary training and who are 
thoroughly alive to their own responsibility and the 
needs of humanity; but the medical teacher should 
always keep in mind the needs and requirements of 
the average medical student, and not of the favored 
few who by reason of natural ability or superior 
preliminary training will overcome all obstacles and 
far outstrip their less favored associates. 
I have stated briefly the chief requisites of those 
entering upon the study and practice of medicine. 
The next question that presents itself is: What are 
the best means of attaining these requisites? I shall 
consider this question under the following headings: 
i. The studies calculated to develop the faculty 
of observation. 3 
2. The studies calculated to develop the reason- 
ing faculties. 
3. The order in which the various branches of 
medicine should be studied. 
4. The time that should be given to laboratory 
work and lectures each day. 
5. The value and importance of didactic lectures 
and of daily recitations. 
6. The objects and methods of clinical instruc- 
tion. 
7. The importance of a high standard of gradu- 
ation in medical colleges, with especial reference to 
the character of the work to be done by the gradu- 
ate in after-life. 
1. The studies calculated to develop the faculty 
of observation. No argument would seem to be 
necessary to show the importance of a habit of 
careful observation of details in the study and prac- 
tice of medicine; yet it is surprising to see how 
many persons, well educated in other respects, are 
wofully deficient in this. It would take me beyond 
the scope of this paper to consider, except in the 
most cursory manner, the means by which the faculty 
of observation is to be developed before the study 
of medicine is entered upon. Yet it is a matter of 
the utmost importance, especially at the present time 
when so many institutions of learning are arranging 
the studies in their academic courses, with reference 
to the subsequent professional studies of the stu- 
dent. 
The academic studies that seem to me of most 
importance for this purpose are geology, zoology, 
and botany, especially the last. All of these branches 4 
of study necessitate the most careful observation 
of details, but botany is of especial value because of 
its intimate connection with bacteriology. 
When the study of medicine itself is entered upon, 
chemistry, anatomy, histology, bacteriology are the 
studies that necessitate careful observation, and are 
therefore of the utmost .importance, not only on 
account of their intrinsic value, but as a means of 
mental training and discipline as well. There are 
of course other subjects that necessitate careful 
observation—indeed, all branches of knowledge do 
—but those named seem to me the most useful for 
developing this faculty in the medical student. 
2. The studies calculated to develop the reasoning 
faculties. The academic studies that are valuable 
for developing the reasoning faculties and that are 
of especial value to those who propose to enter 
upon the study of medicine are physics and logic. 
I do not mean to exclude mathematics from this 
list, but I have not named it specifically because, to 
some extent at least, it is a subject studied by all, 
and its value for purposes of mental discipline is 
universally recognized. Nor would I underrate the 
value of the languages—ancient and modern—not 
only on account of the wide field that they open up 
for instruction and entertainment, but because of the 
broadening influence that they exert upon the mental 
faculties. I am old-fashioned enough to believe 
even in the study of Greek, not only for its own 
sake but for its influence upon the intellectual 
faculties as well. Still it seems to me that no other 
academic studies are as useful to develop the reason- 
ing faculties of the student who proposes to enter 5 
upon the study of medicine, as those first named— 
physics and logic. 
The medical studies proper that are most useful 
for this purpose are physiology and pathology 
viewed in its broader aspect. I shall speak of this 
more in detail when I come to consider the value of 
didactic lectures. 
3. The order in which the various branches of 
medicine should be studied. There is but little differ- 
ence of opinion at the present day on this point, 
and it is almost universally conceded that some knowl- 
edge at least of chemistry, anatomy, normal histology 
and phyisology is absolutely necessary before the 
student can profitably engage in the study of the so- 
called practical branches. 
A few colleges, I believe, still expect the student 
to begin his medical studies with the daily attend- 
ance upon lectures on anatomy, chemistry, physiol- 
ogy, materia medica, obstetrics, practice, surgery, 
and perhaps a number of special subjects, but the 
number of these schools is growing rapidly less, and 
it is almost certain that in a short time all medical 
schools that are worthy of the name will adopt a 
graded course and give the student some time for 
study outside of the lecture-room. 
4. The time that should be given to lectures and 
laboratory work each day. Not many years ago the 
students in many, if not most, medical schools were 
expected to attend lectures from 8 or 9 a.m. till 5 
or 6 p.m., with an intermission for dinner of one 
hour. The dissections were to be made at night. 
It is hard to conceive how the intellectual faculties 
of a student could be developed by this process. 6 
Mental confusion and physical fatigue would com- 
bine to retard rather than aid the development of 
these faculties. Three hours a day, at most, is all 
the time, it seems to me, that should be required of 
the student so far as listening to didactic lectures is 
concerned ; and scarcely any more time should be 
given to laboratory instruction, if both didactic 
lectures and laboratory instruction are given on the 
same day. 
From four to six hours more, the time depending 
on the physical health and mental training of the 
student, might be profitably spent in carefully read- 
ing in some good text-books the subjects of the 
lectures of the day and comparing what has been 
seen in the laboratory with the teachings of those 
who are specially skilled in laboratory work. 
I do not speak here of clinical instruction; I shall 
allude to that briefly a little later on. I need only 
say just now that it seems to me far better that the 
undergraduate should see a few cases daily and 
study them thoroughly, than that he should have his 
mind crowded with different subjects, none of which 
can be properly digested. 
5. The value and importance of didactic lectures 
and of daily recitations. There is at present a mani- 
fest tendency to do away in great part with the old- 
fashioned didactic lectures, and to substitute for 
them laboratory and clinical work on the one hand 
and the reading of judicious text-books on the other. 
Nor can it be denied that the change has been of 
immense value to medical education; but I am 
firmly convinced that on many branches of medicine 
didactic lectures, if properly given, are of great 7 
value as a means of education—that is, as a means 
of making men think and reason for themselves. 
For example, in the study of the practice of med- 
icine, with all the excellent books on the subject, 
none can or does explain the connection between 
morbid anatomy, causes, symptoms, etc., as is done 
in the didactic lecture, nor can an author emphasize 
in a text-book the points that may be of especial 
moment without making the book of inordinate 
length. I would offer an earnest plea, then, for the 
retention of didactic lectures as a means of educa- 
tion—of teaching men to think—not to the exclusion 
of other methods, but as a valuable adjuvant thereto. 
Then there is another means of instruction which 
I believe to be of inestimable value, but that unfor- 
tunately cannot be thoroughly applied in large 
medical schools—I mean daily recitations on the 
subject of the previous lecture. These recitations 
are a means of instruction to both teacher and 
pupil; the teacher learns from them what points he 
has failed to make clear, and the student is taught 
not only what he had failed to catch before, but 
something far more important than that—the neces- 
sity for careful and thorough study and preparation. 
Much as I value the didactic lecture as a means of 
instruction, or rather of education, if I were compelled 
in my own teaching to abandon it or the daily reci- 
tations, I would unhesitatingly discard the didactic 
lecture, for in the course of the recitations nearly 
all the explanations needed could be given. 
6. The objects and methods of clinical instruction. 
There are two objects to be attained by clinical in- 
struction : the first, which is of great importance to 8 
the student, is the method of conducting the examina- 
tion of a patient; and the second is to teach the 
symptoms and signs of diseased conditions. 
For the attainment of these objects it is essential 
that the student should not only see examinations 
made by others, but that he should see and hear and 
feel for himself. It is equally important, too, that the 
student should understand the significance of what 
he does see and hear, and for this reason it seems to 
me far better that the undergraduate at least should 
see but a few cases a day, and should be required to 
study them thoroughly, both at the bedside and in 
the text-books. 
Another point seems to me of the greatest impor- 
tance in connection with clinical instruction, namely, 
that the student should have been thoroughly drilled 
in the principles of medicine before he begins to 
study cases, so that he can understand the signifi- 
cance of the various symptoms and signs, and their 
connection with the morbid changes in the body. 
For example, how can a student understand the 
passive hyperemia and dropsy of advanced cardiac 
disease, who knows nothing of the anatomy and 
physiology of the heart and vessels, and how can he 
apply the proper treatment unless he has studied the 
pathology of the process and the action of drugs? 
7. The importance of a high standard of gradua- 
tion in medical schools, with especial reference to the 
character of the work to he done by the graduate in 
after-life. If I may judge from my own observations 
and conversations I have had with a number of 
physicians who are interested in medical education, 
the importance of a high standard of graduation on the subsequent work of the student is not appreci- 
ated as it should be. It goes without saying that a 
man with very scant knowledge of medicine is not 
a suitable person to intrust with the health and 
lives of his fellow-creatures, but it seems to be a 
common impression that the defects and deficiencies 
of early training will be corrected by the experience 
of subsequent practice. Doubtless this in a measure 
is true; but there is another side to the subject 
which I believe to be equally true and of vast im- 
portance in medical education, namely, that the 
graduates of a school having a high standard of 
graduation will have a higher aim and do better 
work all through life than the graduates of a school 
having as good or better facilities for instruction, 
but whose requirements for graduation are relatively 
low. My attention was first called to this matter 
in 1885, when the graduates of a number of differ- 
ent schools appeared before me, as a member of the 
Board of Medical Examiners of Virginia, to undergo 
their “State examination.” It was a matter of 
profound astonishment to me and to my colleagues 
on the Board to see the superficial character of the 
answers given to many of the questions by men of 
good sense, fair general education, and graduates 
of schools having admirable facilities for instruction, 
and whose faculties would compare favorably with 
any in the world. 
I well remember the surprise depicted on the faces 
of some of these young men who were rejected, and 
the statement made by some of them that they had 
“ never been taught that all these details were neces- 
sary in medicine” ! The superficial character of the 
9 10 
answers sometimes received and accepted may be 
judged also by the questions asked. I know of an 
instance, for example, in which in a written ex- 
amination on anatomy, lasting two or three hours, 
one of the six questions was, “Describe the alimen- 
tary canal and its appendages.” Now, how can a 
young man of average capacity be expected to learn 
thoroughness when the questions given him on ex- 
amination are of such a character that only the 
most superficial answers can be given ? How can 
earnest, painstaking, careful, and thorough work 
be expected of him in after-life when his training 
has been such as to encourage the reverse, and that 
training has been received from men of acknowledged 
ability and experience? 
In conclusion, then, I would plead most earnestly 
for a higher standard of graduation, not only be- 
cause it necessitates more knowledge of medical 
matters when the student graduates, but because it 
gives him a keener sense of the gravity of the duties 
that he has assumed and of the responsibilities that 
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