EXAMINATIONS IN MEDICINE. 
Read at the Second Pan-American Medical Congress, Mexico, 
Nov. 16, 1896. 
BY C. H. ALDEN, A.M., M.D. 
ASST. SURG. GENERAL U.S. ARMY, PRESIDENT ARMY MEDICAL SCHOOL. 
WASHINGTON, D. C. 
REPRINTED FROM THE 
.JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
JANUARY g, 1897. 
CHICAGO: 
American Medical Association Press. 
1897. EXAMINATIONS IN MEDICINE. 
Read at the Second Pan-American Medical Congress, Mexico, 
Nov. 16,1896. 
BY C. H. ALDEN, A.M., M.D. 
ASST. SURG. GENERAL U. S. ARMY, PRESIDENT ARMY MEDICAL SCHOOL. 
WASHINGTON, D. C. 
REPRINTED FROM THE 
JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION, 
JANUARY 2, 1897. 
CHICAGO: 
American Medical Association Press. 
1897. EXAMINATIONS IN MEDICINE. 
AN ENQUIRY INTO THEIR INFLUENCE UPON MEDICAL 
EDUCATION AND THE BEST METHODS OF CON- 
DUCTING THEM. 
My subject, that of examinations for medical men, 
can not fail to have engaged the attention, the very 
earnest attention, of each one of us at some period of 
our career. All of us have undergone the trial. 
Some of the younger physicians present may even 
now have recently passed through some such ordeal 
or are about to do so, and none of us are so old as not 
to have lively recollections of our experiences in this 
regard. 
It has been said that the present is an age of exam- 
inations. They have without doubt become greatly 
multiplied in recent times, and the reason is not diffi- 
cult to find. The rapid expansion of the bounds of 
human knowledge leading to widened and prolonged 
preparation for the professions, especially that of 
medicine; the institution of the Civil Service, aiming 
to fill offices by merit and not by favor; increased 
competition, have all naturally led to more numerous 
and severer tests of proficiency and fitness. 
The attainment of the degree of Doctor of Medicine 
and entrance upon the practice of the profession are 
guarded among all advanced peoples and civilized 
nations by a careful examination into the qualifica- 
tions of the candidate. Nor would we have it other- 
wise. The student and candidate of today becomes 
the practitioner and teacher of tomorrow, and while the 
former feels the pressure of the ordeal he is undergo- 
ing, the latter feels the importance both to the body 
of which he is a member and to the community at 
large of thoroughness and care in the selection of 4 
those who are to be admitted to the responsibilities 
and duties of the practicing physician. 
The subject of examination needs to be looked at 
from two points of view, the point of view of the can- 
didate and that of the examiner, and they are natur- 
ally very different. The examination presents diverse 
aspects as regarded by the two classes most directly 
interested. Much of the strain experienced by those 
undergoing examination for medical positions is una- 
voidable because inseparable from the circumstances 
under which the examinations are held. The candi- 
date can not divest himself of the importance to his 
future career of the result at stake. He is perhaps 
competing for the degree which is to mark his entrance 
into the profession and to which he has devoted years 
of hard work; for one of the much sought hospital 
appointments with its opportunities for professional 
improvement; for some municipal or State position 
with its fixed and certain compensation; for license 
under the State Board, or for entrance into one of the 
National Services, the Army, the Navy, etc., which 
service may have for him special attractions. The 
candidate can not forget the importance of the occa- 
sion, and this necessarily makes it a most anxious 
one. It comes, too, usually at an age when calmness 
and self-control have not yet been acquired and are 
hardly to be expected. 
Nor, it must be remembered, does all the strain 
and labor fall to the share of the candidate. The 
examiner has his full share, if he faithfully execute 
his most delicate and responsible duty. As we shall 
see more particularly hereafter, his part requires 
careful preparation as well as the exercise of patience, 
tact and sound judgment. 
Let us look into the methods of medical examina- 
tion now in use. Let us inquire how they can be best 
adapted to fulfill the end in view, to accomplish the 
purpose for which they were instituted, the selection 
of competent men, and how, while fulfilling ade- 
quately this purpose, unnecessary strain and labor 
upon the examiner and examined may be avoided. 5 
Our investigation may, it is hoped, clear up some 
misunderstanding on the part of those presenting 
themselves for examination as to its scope and their 
true relation to the persons who are conducting it. If 
this can be done and the two parties concerned be put 
more en rapport, a highly desirable result will be 
effected. 
The examinations of the undergraduates in medi- 
cine and those held at the end of his course for his 
degree, first claim consideration. Of late, both in this 
country and abroad, the view has been advanced that 
these medical examinations as now conducted have 
an injurious influence upon the preparation of the 
candidate for his future work, that they lead to 
the habit of cramming and memorizing facts as 
laid down in books. It is said that the impor- 
tance of examination has become so much exag- 
gerated that the student thinks the thing to be 
attained is passing the examination rather than the 
acquirement of sound knowledge and practical train- 
ing; that even if facilities for practical work are 
given the student, his mind is ever on the neces- 
sity of preparation for the examination ahead, rather 
than on the careful observation of the clinical cases 
and of the prosecution of the practical work at hand. 
It is feared that the present system loses sight to some 
extent of the true function of medical instruction, 
which is not so much to fill the student with knowl- 
edge as to train his mind, his hand and all his senses, 
and to bring him into actual contact, under guidance, 
with the diseases, injuries and emergencies that he 
may hereafter be called upon to treat. 
Jonathan Hutchinson, late President of the Royal 
College of Surgeons, has pointedly drawn attention to 
this in his address before the Liverpool Medical Col- 
lege in October, 1895, on examinations as an aid to 
education. He says: 
" The scope of the examination in prospect has 
been all-powerful in determining that of the previous 
course of study. 'This I shall want'; 'that I shall not 
be asked,' have been the ever-present motives in the 6 
selection of subjects for reading and thought. What- 
ever was deemed not likely to be questioned about 
has been ruthlessly put aside, whatever its intrinsic 
interest. The demands of the examiner set the pace 
of study, and the breadth of the examination deter- 
mines the narrowness, or otherwise, of the student's 
education." 
Mr. Hutchinson advocates, in order to reduce the 
evils of which he complains, the substitution of 
written for oral questions, and the institution of objec- 
tive or practical examinations as far as possible. He 
makes the rather novel suggestion that the written 
questions should not be prepared by the examiners 
nor at the time of examination, but carefully framed 
in advance and published in volumes, the number of 
questions to cover the ground very extensively and to 
be largely in excess of the needs of any one examina- 
tion; that from these volumes the desired questions 
be selected. He thinks this system would lead to 
more patient and careful testing of qualifications; 
since examiners are usually very busy men and can 
not give sufficient time to this important task. He 
further advocates the so-called divided examinations; 
the examinations being held along through the 
student's course and not crowded into one short 
period at the close. 
Mr. T. Pridgon Teale, F.R.C.S., Member of the 
General Medical Council of Great Britain, introduced 
a resolution at a meeting of that body in June last 
advocating a change in its methods of examination. 
He supported it by some forcible remarks upon the 
need of reform. He stated that the number of rejec- 
tions had been doubled in the last twenty years, and 
the stringency of examinations greatly increased, and 
that these rejections brought no corresponding advan- 
tage to the profession, while they added unnecessarily 
to the time and expense required to pass the ordeal. 
He believes that examinations are too exacting and 
that unsuitable questions are asked, that the examina- 
tions are too hurried and hence an element of chance 
has been introduced, that "good men fail to pass and 7 
unfit men, from a talent for cramming, manage to 
answer questions a little too well to justify rejection." 
He dwells on the interference wfith clinical work and 
practical training which results from the necessity for 
preparing for these numerous examinations. "Stu- 
dents." he says, "are overworked and badly worked." 
Mr. Tobin of Dublin, in an address delivered at St. 
Vincent's Hospital, 1895, speaks in a similar vein. 
Sir William Stokes describes the examination ever 
impending and kept in constant mind by the student 
as "the sword of Damocles." 
Articles have appeared in some American journals 
drawing attention to this subject. A writer in the 
New York Medical Journal, June 20, 1896, says: 
"Examinations are directed too much to finding out 
what a man's stock of memorized facts amounts to and 
too little to finding out how far he has learned the 
art of studying by himself and how well qualified he 
is by natural gifts." 
It may be that the evils complained of do not exist 
to the same extent in the United States as in Europe, 
yet the remarks of the eminent physicians and teach- 
ers quoted give valuable warning of dangers to be 
avoided, and suggest possible improvements of our 
methods. 
Let us consider the most important points as to 
methods used. Although my remarks on this subject 
are naturally based on experience gained on boards of 
examination of young medical men applying for 
admission to the medical staff of the army, they will 
for the most part, it is believed, be applicable to med- 
ical examinations in general. I desire to say briefly 
here that the method pursued in the army examina- 
tions have been evolved from long experience of the 
department, examinations having been held from a 
very early period of its history. Although they are 
not perfect nor all that could be desired, still they 
combine, it is believed, the most important elements, 
are practical as well as theoretical and accomplish the 
ends in view quite as satisfactorily as can perhaps be 
expected under existing circumstances. 8 
In the first place it is important that the scope of a 
medical examination shall be so arranged as to deter- 
mine the fitness of the candidate for the particular 
position or duties in question and not for any other. 
The examination for the degrees is designed simply 
to test the candidate's thorough acquaintance with 
the branches taught in the college curriculum and to 
ascertain if he has availed himself faithfully of the 
practical advantages afforded him. Examination in 
outside or preliminary branches should come at the 
beginning of his medical career, though it too often 
is not required at all. Neither in this nor in the 
examination for hospital appointments is it desirable 
to go into the literary or physical qualifications of the 
candidate. 
The conditions are different as regards the medical 
staff, and these conditions are sometimes not under- 
stood by medical gentlemen applying for admission. 
The service may require exposure to extremes of heat 
and cold and to great fatigue, and the young medical 
officer must be thoroughly able to do duty under all 
circumstances. The government in appointing a 
medical officer takes him for life, if he desires to 
stay and is worthy of being retained, and it is essen- 
tial that he shall be not only sound in health at 
the time, but free from any defect or incipient disease 
that is likely to disable him and render him useless 
and a burden upon the nation. A very considerable 
number of candidates find themselves thrown out by 
the physical examination who might be spared the 
expense and trouble of presenting themselves had 
they appreciated the necessity of a thoroughly good 
physique. Persons have been known to present 
themselves for examination with gross defects such 
as hernia, anchylosed joints, mutilated hands and 
serious defects of vision and hearing. 
The preliminary examination of candidates for the 
medical staff in subjects of general education, such as 
arithmetic, geography, history and literature, has 
sometimes excited surprise. It seems to some not 
only unnecessary, but almost an indignity to subject 9 
a medical man to such an ordeal. It is to be remem- 
bered. however, that the army examination is practi- 
cally open to all graduates and that the possession 
of a degree in medicine does not, under the present 
system of medical education in the United States, 
guarantee the amount of liberal cultivation or even of 
general information, which all will agree is essential 
for a scientific man. The army medical man becomes 
the associate of educated men, of officers who have 
been trained at West Point, and it is clearly impor- 
tant he should be a man of equal culture. 
The preliminary examination referred to is in tended 
to ascertain this and does not require special prepara- 
tion. It is not too much to ask, for instance, that the 
candidate shall be able to add and subtract fractions 
and understand the rule of three, that he shall have 
at least some knowledge of his own country and of 
the more important geographic features beyond these 
limits; that, for instance he does not locate Plymouth 
Rock on the coast of Virginia, nor the city of Vera 
Cruz on the coast of Peru; has a generally correct 
idea of the origin and course of the Mississippi River 
and can locate the Mediterranean Sea, etc. He ought 
not to complain if required to give at least a general 
idea of the most important events in the history of 
his country and of the world, such as the Declaration 
of Independence, the war of 1812, the reign of Queen 
Elizabeth of England or the battle of Waterloo. To 
say, as a candidate has been known to do, that at the 
great engagement referred to, George Washington was 
in command of one of the opposing armies, is cer- 
tainly hardly allowable. Of literature, too, the candi- 
date is expected to have such a knowledge as a 
gentleman acquires in ordinary reading. He should 
at least know the names and chief works of prominent 
authors. Certainly a physician can lay no claim to 
be an educated man if he knows nothing of Shakes- 
peare, of Milton, of Cervantes, of Moliere, of Schiller, 
of Prescott, of Longfellow, etc., and yet such igno- 
rance is occasionally found among candidates for the 
medical staff. 10 
If the medical colleges of the country held a 
preliminary examination before matriculation and 
required a certain standard of general education to be 
attained, as some colleges now do, and as it is hoped all 
eventually will, this inquiry into the preliminary edu- 
cation might be waived in the case of applicants for 
the army medical service. The day will probably come 
when a degree in the arts may be required of all can- 
didates as is now done for entrance to the Johns 
Hopkins Medical College, but at present it is not 
possible. 
It is much to be desired that the time of the exam- 
iners and of the candidates should not be taken up by 
such non-medical branches, but devoted to medicine 
and surgery alone. As a step in this direction the 
applicant for the army medical staff is now allowed, 
if he desires it, to take his physical and preliminary 
examination at some military station near his home 
under the supervision of the post medical officer. A 
considerable number of applicants are thereby saved 
unnecessary expense and disappointment. 
The plan of dividing the examination for the med- 
ical degree, already practiced, it is understood, in 
some countries of Europe and in Mexico and Cuba, 
and now coming into use in the United States, so 
that examinations are held during the course instead 
of being crowded together at the end, is believed to 
be a good one. Medical education now extends over 
so large a field and so long a period that such division 
of the examination seems almost necessary. It has 
the advantage of giving more time and therefore more 
thoroughness to each examination and lessens the 
strain upon the candidates. In army examinations it 
is impracticable to any great extent, but the prelim- 
inary examination referred to, held near the candi- 
date's home, partially carries out the idea. 
The question of the relative value of written and 
oral examinations is one that has received much atten- 
tion and excited much discussion. In former times 
the oral was the usual method, but in late years as 
competition has increased and the necessity for closer 11 
scrutiny has arisen the written examination has come 
more and more into favor. There can be no doubt that 
the written examination has many advantages. It is in 
many respects a fairer test, as thereby the candidate 
is placed more at his ease and is better able to show 
what he knows than under the excitement and hurry 
of oral questioning. It largely eliminates the ele- 
ment of nervousness and puts the diffident man and 
the confident one more nearly on an equality. It 
affords the best means of determining the comparative 
merits of several candidates who may be examined 
together, since all are given the same questions. 
Granting these advantages to the written method, the 
oral examination can not, for army examinations at least, 
be wholly abandoned. By it the examiner is brought 
into close personal contact with the candidate, can 
insist on direct answers to his questions, can ascer- 
tain if the applicant is certain of his answers and his 
reasons therefore, can better estimate how much he 
simply remembers and how much he carries with him 
for use, can test his presence of mind and thus better 
judge the young man's capacity for the work he may 
be called on to do. A combination of the written and 
oral methods is for the reasons stated the best, and is 
now practiced in the examinations for the army. 
The way in which either mode of examination is 
carried out is perhaps of more importance than the 
choice between them. It is highly important that the 
questions, either written or oral, should be planned 
with great care. It will not do to leave their prepa- 
ration until the time of the examination, as they are 
then apt to be hastily and carelessly framed and to 
repeat too frequently questions already asked. It 
may well take almost as much pains and time for the 
examiner to prepare his written questions as for the 
candidate to answer them. The art of question mak- 
ing is by no means a natural gift or one that can be 
taken up by any one without study. It costs time 
and labor to select questions so that they shall well 
cover the various divisions of the subject, and to 
frame them so that they shall be clear and promptly 12 
understood by the candidate, call for exactly what the 
examiner desires to know and not invite too discur- 
sive writing whereby the candidate may try to hide 
his ignorance of the main point. A good plan is to 
prepare, for weeks in advance and at one's leisure, 
numerous written questions extended over a wide 
field so that all the important branches of the subject 
may be represented and then at the time of examina- 
tion to select and arrange a set containing the desired 
number. 
No advantage is seen in the plan adopted in some 
medical examinations of placing before the candidate 
a number of questions from which he is allowed to 
select and required to answer a certain percentage. 
The privilege of such selection favors the candidates 
least well prepared and in a competitive examination 
prevents any exact judgment of the relative merits of 
the written answers. 
The examination by oral questions requires equal 
care exercised in a somewhat different way. The 
examiner should prepare himself beforehand and have 
by him a memorandum of the topics upon which he 
intends to question. If he does not do this he is sure 
to repeat himself. The examiner's favorite questions 
soon become known to intending candidates and are 
specially prepared for. The greatest tact is necessary 
in the conduct of an oral examination, a tact born of 
right feeling but attaining its highest development 
only by cultivation. The questioner's manner should 
be calm, quiet and courteous, have no appearance of 
hurry, and it need hardly be added he should avoid 
anything like trying to show his own superior knowl- 
edge or the candidate's ignorance. His object is to 
find out what the person under examination knows 
and to do this must put him under the circumstances 
most favorable for finding out. A great deal depends 
upon the way the oral examination is opened, upon 
the first question. A first question misunderstood 
may so confuse and puzzle the young man that it may 
be impossible to get anything intelligible out of him. 
The questions should be clear and definite, and gen- 13 
erally, at first at least, call for brief and definite 
answers. To begin, as an excellent surgeon but tact- 
less examiner has been known to do, by asking the 
candidate, "What do you know about the brain?" is 
simply to render the candidate almost incapable of 
reply. A wise plan is to spend a few minutes in gen- 
eral inquiries on matters not directly connected with 
the subject of examination and, if possible, to get the 
candidate fairly entered upon it, without his being 
conscious of beginning. 
Of still greater importance is the subject of the 
practical or objective examination as it has been called 
as distinguished from the examination by written and 
oral questions. The development of the practical 
side of medical education, and the greatly increased 
attention paid to laboratory and clinical work in the 
curriculum of our medical colleges is a source of just 
pride and congratulation. We recognize now that it 
is not enough for the medical student to listen to lec- 
tures, he must not only be told what to do and how to 
do it, but trained in doing it under the instructor's 
guidance. Yet it is probable that our tests of his 
practical ability have hardly kept pace with the facil- 
ities afforded him for obtaining it and that profes- 
sional examinations still bring out rather what a 
candidate remembers than what he can do. It is 
manifestly impossible, from the want of time and 
other circumstances surrounding an examination, to 
make actual practical tests of the young physician's 
ability to deal with all the conditions and emergencies 
which he may encounter hereafter. The examination 
by questions must necessarily still be largely depended 
on, yet it would seem possible to test his practical 
acquaintance with laboratory work, and to ascertain 
how he can diagnose and treat disease and injuries at 
the bedside, and perform operations on the cadaver, 
to a greater extent than is now practiced. 
No one is now allowed to present himself for exam- 
ination by the Army Medical Board unless he has at 
least one year's hospital experience or its equivalent 
in private practice. Practical tests are therefore an 14 
essential part of the work of the Board, the candidate 
being required to examine patients at the bedside, 
and his method of diagnosis and treatment carefully 
scrutinized. The performance of operations on the 
cadaver is also required. It has not infrequently 
happened that an applicant for the medical corps has 
passed successfully the written and oral examinations 
but has shown at the bedside or in the operating room 
such unreadiness for practical work as to cause his 
rejection. 
This paper can hardly close without some sugges- 
tions for the special benefit of the person who is 
under examination. 
First as to the candidate's preparation. It may be 
said that a thoroughly qualified physician needs no 
preparation; still the candidate, if he has time, will 
prudently look into the requirements as far as he may 
be able to discover them. It is generally easy to do 
so, as these requirements are often fully made known 
in advance and sample questions published. He 
should then endeavor carefully to meet these require- 
ments, to supply his defects and honestly to qualify 
himself not only to pass the required examination but 
for the career he hopes to enter upon. This is a very 
different thing from cramming to answer the ques- 
tions that may be propounded. Special instructions 
and special courses so far as they add to the candi- 
date's knowledge and his practical skill are good and 
valuable. If their purpose is simply to enable the 
candidate to pass an examination, to stuff him full of 
the answers to questions that are known to have been 
asked by previous boards and may therefore be asked 
again, without reference to his general training, they 
are bad and useless. The tendency of most persons 
who make a business of preparing candidates for exam- 
inations is to train too fine, so to speak, to magnify 
the importance of their help by crowding the student 
with a mass of minutiae and valueless detail, neglect- 
ing the general principles and wider knowledge which 
is not only of the first importance but more likely to 
be of use at the examination. 15 
In presenting himself for examination the candi- 
date should stand squarely on his own merits; an 
introduction to a member of the board is well enough 
but voluminous and extravagant recommendations do 
harm rather than good. It is well known that they 
are to be had for the asking and have therefore but 
little weight. Reliance upon such outside influence 
is apt to make the examiner think it is needed. Pol- 
itics and social influence have no weight in determin- 
ing the candidate's success or failure. Let him enter 
the examination with a determination to do the best 
he can and to appear exactly as he is without pre- 
tence or exaggeration. Let him remember the old 
proverb. "One can take out of a cask only what has 
been put into it," or as the Spanish forcibly put it, 
" La cuba siempre huele del vino que contuvo." It 
is true there are constitutionally timid men, but 
knowledge and practice give a confidence which 
nothing else will. 
Further, let him not delude himself with the idea 
that success depends on luck and not on merit, for in 
proportion as he cherishes that opinion will sound 
preparation be neglected. He may have full reliance 
upon the fairness of the board, and should disabuse 
himself of the thought that examiners are unfriendly 
or are trying to puzzle him. It is quite the contrary. 
The board can have no possible object in rejecting a 
worthy candidate. The very object of their appoint- 
ment is to obtain, not to exclude men. 
The questions given out, especially those requiring 
written answers, are usually framed with care and 
demand definite answers. Their purport should be 
studied carefully and exact answers given without 
guessing or hedging. A diffuse reply upon some side 
topic to cover up ignorance upon the main one, is a 
waste of time and deceives no one. The candidate 
will as an honorable man accept no aid from comrades 
or memoranda, even if he is not prevented from 
doing so. 
A serious mistake often made by gentlemen under 
examination is that of studying hard just before and 16 
during the intervals of the examination. The man 
who during examination week sits up all night to sup- 
ply his supposed defects not only does not add to his 
stock of permanent and useful knowledge but usually 
brings on such a state of nervous confusion and strain 
that he can not call up the knowledge he actually has. 
It is of the first consequence for success under an 
examination, especially a prolonged examination, that 
the candidate should have a clear head. Overwork 
at the time of examination, largely self-imposed as I 
have indicated, is by no means a small factor in the 
failure of well-trained and promising candidates. 
The points to which I would in conclusion draw 
especial attention are as follows: 
That medical examinations as now conducted often 
have an injurious effect upon the student's prepara- 
tion, leading to cramming and interfering with prac- 
tical work. 
That for life positions, such as the army medical 
staff, an examination into physical condition is neces- 
sary, and under the existing requirements of medical 
colleges, in general education also; that examinations 
should be held at the close of instruction in each sub- 
ject and not altogether just before the degree is 
given. 
That in the examinations by questions, both the 
written and oral methods should be practiced, each 
having distinct advantages, and that the preparation 
of questions requires great care. 
That practical tests of the candidate's readiness for 
his future work are of the highest importance, being 
probably still too much neglected. 
That the preparation of the candidate should be for 
the position rather than for the examination, that he 
should rely on his own merits and not on influence, 
trust to the fairness of his examiners and avoid all 
extra work at time of the ordeal.