m V/ 7/ the "complements 
" OF THE WRITER 
REFORM IN MEDICAL EDUCATION 
PRESIDENTS ADDRESS 
Delivered at the Annual Meeting of the American Society of 
Naturalists, New York, December ■?<?, i8g8 
BY 
H. P. BOWDITCH, M.D., LL.D., D.Sc. 
[Reprinted from me Boston Medical and Sun/ical Journal 
of December 29, 1898.] REFORM IN MEDICAL EDUCATION.1 
PRESIDENT’S ADDRESS BEFORE THE AMERICAN 
SOCIETY OF NATURALISTS. 
H. P. BOWDITCH, M.D., LL.D., D.SC. 
The choice of a physiologist as the presiding officer 
of the American Society of Naturalists might per- 
haps have justified me in selecting some of the prob- 
lems connected 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 
physiological research, I have thought it better to al- 
low my choice of a subject to be guided by the fact 
that we are nearly all of us actively engaged in teach- 
ing as well as in studying our sciences, and to address 
you this evening upon some topic connected with 
education. 
My own experience of twenty-seven years as a 
professor of physiology and of ten years as Dean of 
the Harvard Medical Faculty naturally 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 funda- 
mental 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 prog- 
ress of medicine and of the allied sciences has made 
it desirable to revise our methods of imparting medical 
instruction. 
1 Delivered at Hie Animal Meeting of the American Society of 
Naturalists, New York, December 29, 1898. 2 
Let me say at the outset, that in speaking of the 
profession of medicine I use the term not in its nar- 
row sense, to designate the art of curing disease, but in 
its broader signification, to include a study of the 
whole environment of man as far as it affects the pro- 
duction and maintenance of a healthy mind in a 
healthy body. 
In what I shall have to say on this subject I shall 
confine myself chiefly to the medical schools of this 
country, though it will be found, I think, that the con- 
clusions to which I shall endeavor to lead you will 
have their application to medical schools throughout 
the world. 
The most important event in the history of medical 
education in this country occurred 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, irrespective of their 
proficiency, and established a graded system of instruc- 
tion 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 importance of the reform which raised the medi- 
cal schools of the country from a condition in which 
they were aptly compared to joint-stock manufactur- 
ing 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, that is, doctors of medicine, with a 
minimum of 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 re- 
form the medical schools of the country have been 
conducted on sound educational principles, and the 
best of them compare favorably with the medical 
schools of Europe. 3 
During the last quarter of a century the improve- 
ment in medical education in this country has consisted 
chiefly in increasing the requirements for admission, in 
the lengthening of the course and in the extension 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 
processes with which it was formerly supposed to have 
no connection. Antiseptic methods have revolution- 
ized the surgeon’s art. The study of the internal 
secretion of glands has led to the development of a 
system of glandular therapeutics. The use of the 
antitoxin treatment has robbed one at least of the 
most dreaded diseases of more than half of its terror, 
while the use of instruments of precision has increased 
the accuracy 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 medical knowledge of the time and to train 
him to safely use the comparatively simple methods of 
diagnosis and treatment then in vogue. At the pres- 
ent time were we to seek to give to the same student 
a similar 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 study 
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 impossible to 
prolong the course of medical study to anything like 4 
this extent the question arises: In what way shall 
newly acquired knowledge in the science and practice 
of medicine be incorporated into the existing curricu- 
lum of the medical student? 
Up to the present time this question does not seem 
to have been seriously considered. As new and im- 
portant subjects have forced themselves upon the 
attention of the medical 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 enabling physicians to recognize patho- 
genic microbes has led to the establishment of a de- 
partment of bacteriology in our principal medical 
schools, while the great advance made in the treatment 
of special classes of disease has occasioned the ap- 
pointment of numerous professors of specialties, such 
as gynecology, orthopedic surgery, pediatrics, etc. 
The medical curriculum has thus grown by what 
may be called, in biological language, 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 knowledge, by 
demonstrating the inaccuracy of previously accepted 
views, has led to a simplification of instruction. 
When it has been found absolutely impossible to add 
any further courses a remedy for the congestion 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. Indeed, 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 5 
medical education one iota or one tittle beyond what 
is absolutely necessary is guilty of a very grave 
offence,” 2 and quite recently Prof. M. Foster in speak- 
ing of the enormously increased requirements in medi- 
cal education has expressed himself as follows : “ Now 
it is obvious that, whatever may have been possible 
once, it is impossible nowadays to demand that all of 
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 
apprehended with greater ease, though the grasping 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.”3 
To extend the course of instruction in the medical 
schools of this country beyond the present four-year 
limit does not, under the prevailing conditions of edu- 
cation in America, 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 
subjects embraced in the constantly widening 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 as- 
sumed 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, impossible to arrange 
a course of study that every student must follow in all 
its details, for in the time which may properly be de- 
* Medical Education ; Collected Essays, vol, iii. D. Appleton & Co. 
1894. 
3 An Address to the Students of Mason University College, Bir- 
mingham, October 3, 1898. 6 
voted to a course of professional study it is quite im- 
possible for even the most intelligent students to as- 
similate all the varied information which such a school 
may reasonably be expected, to impart. 
It seems, therefore, to be evident that in arranging 
a course of medical study a distinction must be made 
between those subjects which it is essential that every 
student should know and those subjects which it is de- 
sirable that certain students should know, that is, be- 
tween 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 re- 
quired and for elective studies. 
The introduction of the elective system into a pro- 
fessional school is not an altogether 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 of admin- 
istration are concerned and has indeed been advocated 
by President Eliot in a speech at the dinner of the 
Harvard Medical Alumni Association in 1895. But 
the question may perhaps be asked, whether it will be 
possible under such a system to secure the proper 
training of young men for the duties of a profession 
in which experience of life contributes so largely to 
success, and in which, therefore, a student at the be- 
ginning of his career may bei supposed to be peculiarly 
in need of the guidance of his teachers. 
It is true that in the academic department of Har- 
vard University the capacity of the average student to 
choose his courses wisely and well has been demon- 
strated by the experience of many years, but it may be 
properly urged that the success of the system in the 7 
academic department does not necessarily 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 medicine 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 justly be required to 
exercise greater caution in bestowing the degree of 
M.D. than is necessary in the case of the A.B. diploma. 
We must, therefore, inquire whether it is possible to 
obtain the advantages of a flexible curriculum 
ing largely of elective courses without losing the se- 
curity against superficial and imperfect work which 
the present compulsory system is supposed to afford. 
Any one who is familiar with the existing methods 
of medical instruction is aware that in nearly every 
department many things are taught which are subse- 
quently 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 de- 
vote themselves to dermatology, future obstetricians 
are required to master the details of physiological op- 
tics and the microscopical anatomy of tumors forms a 
part of the instruction of men destined to a career as 
alienists. Now no one can question the propriety of 
including instruction on all these subjects in the cur- 
riculum of a medical school, but it may be fairly ques- 
tioned 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 a 
future practitioner is to be specialized, and that such 
specialization 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 8 
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 en- 
couraging perfunctory and superficial work, are cer- 
tainly no less serious. Moreover, it will doubtless be 
found perfectly 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 permitted 
with regard to the direction in which the work is pur- 
sued. To illustrate this point allow me to describe a 
possible arrangement of a course of study in the depart- 
ment of physiology, with which I am of course more 
familiar than with any other. 
In the Harvard Medical School instruction in physi- 
ology is now given in a course of about one hundred 
lectures, besides recitations, conferences and practical 
laboratory work. Were the work to be rearranged in 
accordance with the above plan it would probably be 
found possible to condense into a course of about fifty 
or sixty lectures all the most important facts of physi- 
ology with which every educated physician must ueces 
sarily be familiar. Attendance upon these lectures 
combined with a suitable course of text-book instruc- 
tion would suffice to guard against gross ignorance of 
physiological principles. In addition to this required 
work, short courses of eight or ten lectures should be 
provided, giving advanced instruction in such subjects 
as the physiology of the special senses, cerebral locali- 
zation, nerve-muscle physiology, the internal secretion 
of glands, the physiology of tbe heart, circulation and 
respiration, the digestive secretions, the reproductive 
organs, etc. These courses should be elective in the 
sense that no student should be required to take them 
all. Each student might, however, very properly be 
required to choose a certain number of courses, which, 
when once chosen, become, for the student choosing 9 
them, required courses leading to examinations. The 
number 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 inferior to that which is given under the present 
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 student 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 special 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 arrange- 
ment of instruction similar to that here suggested for 
physiology could be advantageously adopted in the 
departments of anatomy, histology, bacteriology, 
medical chemistry, pathology, surgery and in the 
courses of instruction in the various special diseases, 
such as dermatology, opthalmology, 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 experience 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 essential condition to any 
further important advance. If it be said that under 
this system 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. 10 
are affected with exactly this same uncertainty of sig- 
nification, 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 reason- 
ably sure that those who hold it will be safe custo- 
dians of the health of the community in which they 
practise. 
If it be urged that the elective system in medical 
education will lead to the production 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 oppor- 
tunity 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 thoroughness in special instruction, the 
evil may be expected to diminish rather than to 
increase. 
I have spoken of the extension of laboratory in- 
struction as an important forward step in the improve- 
ment of educational methods in medicine during the 
last quarter of a century and I desire to bring my 
remarks to a close with a few words on the relation 
between laboratory and didactic methods in medicine 
and on the employment of both methods in a system 
of instruction including both required and elective 
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 altogether 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 11 
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 lectures which can be better taught by labo- 
ratory methods tends to obscure the equally important 
fact that there are many other subjects in the presen- 
tation 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 evi- 
dence. In this connection it is interesting to recall 
the wise words of Huxley, 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 who shall 
gather all that together, and extract from it that 
which is capable of being assimilated by the mind.” * 
To what extent the laboratory can replace the 
lecture-room will of course depend 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 didactic instruction to a greater 
extent than is possible in subjects like physiology and 
pathology, where inferences from observations and 
conflicting views must frequently be presented. In no 
department of medicine, however, will it probably be 
found possible to dispense entirely with a systematic 
course of lectures in which a trained instructor may 
give to his class the benefit of his accumulated expe- 
rience. 
4 Medical Education: Collected Essays, vol. iii. D. Appleton & 
Co. 1894. 12 
A consideration of the nature of the subject taught 
will also furnish a guide for the employment of labo- 
ratory and didactic methods in the required and elec- 
tive courses above suggested. In general the required 
courses, being comparatively elementary and concerned 
chiefly with the presentation of well-ascertained facts, 
may be made demonstrative 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 will be more nearly reached. It will 
therefore be necessary to present and weigh the evi- 
dence 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 of instruction seems 
to be a short course of carefully prepared didactic lect- 
ures 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 
instruction is generally recognized and it is in the hope 
of helping to secure this recognition that I have ad- 
dressed these remarks to you this evening. In what- 
ever way the remedy is to come it should not be long 
delayed, for the difficulty of giving adequate instruc- 
tion to constantly increasing classes seeking informa- 
tion over a constantly widening field of knowledge is 
felt each year with greater and greater keenness.