MEDICAL EDUCATION IN TRELAND

by

Doctor Alan Gregg.

May, 1925.
TABLE OF CONTENTS.

DyrRoDUGTORY.

History Of the State ccscosscc cvccvesseccsseecscsere
Soctlal Picture eceocosrevecevevesescesevesercccevsvoce
Language COOH AHR EAHA EEEEOEHREROL OCHO OREO EBEEE
Economic Situation eccceccccacnnsccvscsascessescscese
Distribution of Wealth ecveccvcccrvcascvvevescsevverce
Land Distribution ceaccccccrccncvcsccassssssesevecsces
Political Situation eccocccccovecsccrecsesvnccsccccees
Gignificance of the Present Govermment crccssscssccves
Area and Population sesccecccvccerecsecseaccccsssoces
Illiteracy CHOKE HOOF OTHE H ESCH ELEHESEDEMEEETL OC OR EEE
Elementary Education cocccceccccccacsancssseasesesess
Secondary Blucation csccsccccccccvcsvccccesscvsvecece

UN IVa ITIES CGC FCHEHSHRHESHSHSHSEKHEKERHEHHEESEHHEAHRAHEOHEHBREH OH EHR OGE 16

HAstorles ..c-ccccccvcevcvccecccvccccccccvesseseceees 17
Numbers of Students Enrolled cccccccsccsocccsssssssee 05
Organisation ANd CONtTOL cosccscccccccccccccecererees 24
Finances HOC OHHEHEHSSHOSCHCHEOHT HOR OFS OF OH EOFEEF BEE HT OBC ECeO 37

Libraries POeevoreeceeseevoerveooeeeeeaoeseevee ann eseeecaevseeeene 43

INDIVIDUAL MEDICAL SCHOOLS.

Trinity College, Dublin COCCCECR CCHS EE RHA ORO OEOE 47
University College (National University}, Dublin .... 124
Royal College of Surgeons ceocccscccece-covvceevccevee 159
Apothecaries! Hall Ooeeeseeoseorenseeaseseoevnnesaanaaeene 177
4) 0 on e

INDIVIDU, LEDIC ; e
University College (National University), Cork «-esccsee

University College (National University), Galway -.-+ee.
Queen's University or Belfast Peeeeeeseesecscanenaeaeanneeee

ON. SRATIONS OF it BDI CATION iN I o@ seeece

RECGIMENDATIONS.

Irish Free State SPOT SHCHHHOHHHEEHOCEEEOHRHEEEEREOCHEHHO RESON

Belfast SCHSHSHEHC EHH EHSHEHETHOHTHCHEHEHOEETORAREHE HHO OCHO H ESCO SOROEED

APPENDICES

1. Newspaper Clippings regarding Separate Medical Register
for the Free State. COCR HEHCC HEHEHE OEE HEOC HEE OEE

2. Copy of Letter from President Denis J. Coffey of the
University College (National University), Dublin,
regarding the situation as to Separate Medical Register
for the Free State. eeeoseeeeseceasnseeaaseenaeeeaeeese

S- Memorandum on "Facilities for Clinical Investigation and

178
206
226

261

274
277

278

282

Teaching of Obstetrics in Belfast" prepared by Dr. Lowry.288

4- Supplementary information on Budget of Queen's
University, Relfast, referred to on Page 240) sseeeee

293
261

 

Traditions in the Teaching of Medicine.
Throughout all the schools, including Belfast, it is clearly

apparent that a dominating characteristic of medical education
is the tendency to anphasise the authority of the practitioner,
and the importance, in the future of the students, of such training
and experience as will enable a young man, immediately after
graduation, to umiertake a practice, rough and ready if need be,
under the conditions vhich odtain in Ireland and Unclend or
anywhere in the Colonies.

the effectiveness of the medical training is judsed more,
apparently, by the ready facility of the newly fledged doctor
to deal with the varied danands of general practice than by the
thoroughness with whith he pursues studies followins his graduation
or the mumber of places available for men wishing to enter research
or teaching. Irish Kedical Schools tale little account of the
necessities of developing teachers, and aver. less of the desirability
of ttaining research men. This shois itself in the almost careless
attitude assumed towards the medical sciences or thoroushnoss of
instruction in these branchese Everywhere, the stanlards seam to
be to teach no more than the 'ordimry genoral practitioner would
woudd need" of the various preliminary and essential discip]ines
such as Physiology, 3acteriolosy anu Pathology. is is natural, the
favourite recourse of teachers holding such a philosophy is the

qualifying examination, and much of the training of the Irish
262

medical students Is nicely calculated to pass the canmlidate
throush these examinations rather than to furnish him

with a sound preparation in the medical sciences and a last-
ing conviction that he rust remain an investicator an3 a2
student to the end of his professional life in order to
cualify as a doctor.

It should de noted, however, that this attitude of
teachers in Ireland has virtues as well as fuults.. It is
within the purse of the student and within the budzet of
the school. It is rare t2 o26 any specialty unduly emphasised
at the expense of sound cormion sense, and, although the slieracter
of much of the instruction in Ireland suj;oests the Trade School
rather than the University, the product - as experience shows -
is at least amply able to maintain itself in competition with the
graduates of other schools ir the British Isles.

Domination by the prostitioner over the character of the
teaching is probably responsivle for, or indeed mary orivinate
from, the wide separation that existe, esvecisll, is Dublin, between
the clinical and the pre-clinical instruction.  Teashirco given
in the hospitals Is almost entirely separate fro- that of the
schools: Men half wav throuch several schools may Ge conrrenated
into a sincle hoepital to receive the clinical instruction thore,
and it is in these hosnitals more than anywhere ulse tbat the
authority of the practitioner in relicine, rather thun the
teacher and Investigator, is most uppsrert.

Another result of tie dominence of the practitioner in
263
medical instruction is expressed in the almost universal expectation
in Ireland that medical education be paid for entirely by the students?
fees to the College or Hospital. This orientation is in striking
contrast to that of sone of the more important schools elsevhere in
the Yorld. It is responsibile for much of the inferiority seer in
the teaching of the pre-medical sciences in Ireland.

Were the influence of the teacher ani investigator in medicine
stronger in the Irish schools, one nicht expect that attention would
long ago have been paid to the markedly inadequate preparation iw the
courses of Physios, Chemistry and Biolosy which should precede
those of the Medical School.

It is further to be noted that new orientations and change in
the methods and objectives of medical education take place more
slowly among practitioners or a Faculty dominated by practitioners
than under conditions where the acad@anic and research influence is
strongere Probably, therefore, same of the backwardness of pre-
medical instruction in Ireland in regard to medicins is due to
the dominance of the practitioner's conceptions regarding medical

education.

The Number _of Schools.

Hard as it is to assign an order of importance revarding the
causes of the excess number of schools in Ireland, certainly religious
and political differences are largely responsible. Hospitals have
been largely fostered by religious groups, and with the Protestant ami
Catholic religions side by side, medical schools have grown up and

flourished with the encouragement of the numerous hospitals.

Prejudices and ambitions, at heart
204

religious, political, ory at least factional, are responsible for
the contimed support of both hospitals and medical schools,
vhich might otherwise find existence too difficlt.

Te economical difficulties of the Irish, the limited amount
of land available, and the low devcloyment of industry and
commerce, tend to make professional careers exceptionally desir-
able for the ambitious youn; men of the country who are denied
adequate opportunities if they stay at home. Thus, Ireland
has exported some 70 to 90 per cent of her medical graduates,
and the production of doctors has assumed certain characteristics
of an industry dependent on export for its existence.

A moderately good education in medicine afforded to a young
man possessing ambition and the traditional Irish senius for
dealing.with people has ensured to this product for export a
better: opportunity from the point of view of the individual than
any career in Ireland Involvins a similar amount of expenditure

or preparation.

Qne further point in maintaining a larce number of schools in
Ireland has been the stron;; sectional feelin:, reinforced by
traditional prejudice, and the close attachment of the people to

each section of their own country. Thus, Southern Irelani is
desirous that Cork shall continue as a,University, since their
sons need not so far from home nor lose caitact with an atmosphere

which they understand and sympathise with.
269

As is true everywhere, a medical faculty ensures
to a community a type of medical service and hospital facilities
which it is loth to lose, and, once established, a medical

faculty is given up only under protest.

Political and Relicious Differences.

The problem of medical education, as already indicated,
is much complicated by the almost inveterate prejudices existing
between the members of two different religious faiths and two
different political symvathies.

The relatively recent days of alnost incredible
violence and bitterness are wnfortunately no novelty in TIrelan,
historically speaking. Such political and religious differences
as there have been in the past have resulted in the conviction
that "oil and water cannot mix", such a conviction standing behind
the incredibility of any fusion of Trinity College and the Nation-
al University. Tolerance, conciliation and co-operation are
aborted by mistrust. This difficulty is, of course, most promounced
in Dublin, but it is precisely in Dublin that the importance of
tolerance and conciliation is greatest. These differences have
ramifications outside of Ireland, for broadly spcaking the Aner ican-
Irish may be said to be entirely Catholic in sympathy, while those
Irish who have had the closest ties with Inzlani are Protestant.

In matters of medical education, the relizious and

political differences are most apparent in the field of hospital
control and in the relatious of the Irish schools to the
General Medical Council of Great Britain. Protestant
schools can hardly expect to enter into satisfactory
relations with hospitals controlled by orders of Catholic
Sisters (indeed, their administra$ion is sallin:; enough to
the medical manbers of their owm religion). The relations
oetween the Free State Government and the General Medical
Council of Great Britain have already become strained, not
because of the policy of the Council within its appropriate
field but because it represents control of Irish educetion,
which is alleged to be imnosed from without.

Medical education in Ireland, then, is no simple ecucational
matter but one involving some of the deepest, most sensitive

and most maltreated emotions and sympathies of the Irish people.

Inadequate Preliminary Trainin-=.

This has been referred to above as possibly one of the results
of a strong domination of Medical Wucation on the part of the
practitioners. Putting this possible cause to one side, the fact
remains, and it is widely tharacteristic of the schools in Ireland,
that their entering students are quite inadequately prepared to
take up the medical sciences. One docs not find, as in Megland, a
small group among: the entorins classes who have bee. extrenely
well prepared by University courses in Chanistry, Physics, or even

Physiology. One meets, on the other hand, a sroup of youths
267

who have come up to the University with almost no training at all

in the Sciences which would bear most significantly upon their
medical training. The attempt to put Chemistry, Physics and

Biology back into the schools has proved a failure, and these
courses are given at present in the Universities as though they
were unfortunate, but necessary, formalities, to be gotten over
with as quickly as possible and with the minimum effort in order

to pass admission requirements, Men failing in the first attempt

to pase their presregistrationy Physics, Chemistry and Biology, are
given subsequent opportunities at short intervals until they do,

and this contributes to give these subjects the minimum of emphasis
and importance in the eyes of the students. There is, indeed, no
school preparing for a medical course in Treland which is adequately
equipped to give these courses in Sciences, and consequently no stand-

ard exists of what might be done in this rarticular.

Development of Teachers.

Granted that the nresent number of schools in Ireland will
continue undisturbed, the problem of securing an adequate group of
welletrained aesistants to become possible future professors in these
schools is, within the Free State at least, a serious one. Belfast,
though severely handicapped by lack of funde to support young men
training themselves for future academic positions, is nevertheless in

a better position to draw such material from Sctoland and tngland,.
268

In the achools of the Free State, facilities for the
encouragement of such a group scarcely exist, and this unfortunate
situation is avgravated by both sectionalism and, in the case of
Trinity College and the Royal Collece of Surgeons, religious and
political difficulties. If Galway and the Royal College of Surgeons,
as seems not unlikely, are to be given up, it would appear that
only Cork, the National University (University College, Dublin)
and Trinity College, Dublin, will remain, and certainly not a very
large group of young men will enter training for academic careers
when the field for such careers is so limited. This does not .
“qualify the atatement that it ia extremely important for the future
of Irieh medicine that such facilities should be afforded to the
proper type of young man, and in all the schools it was declared
| that able men were to be sometimes found and could be encouraged

to devote themselves to teaching if they could only be helped over
the most difficult period of their training. With the exception of
Trinity College and Belfast, the main objection and difficulty in
a plan of affording young men such opportunities is the fact that
neither laboratories nor adequate apparatus exist for: more advanced
studies. In some cases, indeed, it is doubtful whether the teachers
are qualified to develop sufficiently their young assistants. Tra~
velling Fellowships would, theréfore, be an eseential feature of

any such programme.
269

Mig Mave.

 

Mo fatuse of Rulfust is assured, low. du point of svyvort
and in rerard to rirtuer of stulents. Tolfaest will not urea:

“ith the General Melital Goumell and, sionit such a trea? oosus
in the Fyee State, “elfast will have aso uwer larger wry of
students than oreviousl;, sivee craduation there will cnavie
aman to practice in Bo land or in the Slonies, wit! my Sorter
aifficulty.

In the cause of Pelfast, one is
close contast ani syorathy with tie otner nedin:
Great Britain, with a serisiuseinted and harieworvin croup of
men who are relatively frec fro. the

religious orisin and sninated by a calficiuntl)

as regards standard of orice

Trinity Collerc, Dublin.

Trinity Collese possesses superior lm oratorics av? auerior

to any other school in Ivrelard. Tt has the spoipaty ana support

of g crow in Dullin and dn Ireland ds oevural welch tac Pine

bu

traditions and sconsilcravle inte lestunl presticve.  Urinity

GColle;e is, furthermore, vell snout, erlowed ta continue ova.
at & Cisadvantacs to turn out Letter traivud and In®husntisl vounger

graduates. A further enrd in Peinityts favour is th: natural
240

and rather intimate relation which it bears to the Universities
of Excland and Seotland and all the advantages which accrue

from such communion.

The Netional University.
University College, Dublin.

Tie Dublin College of the National University, under the
protection of the Prce State Goverment end placed In what is
without dowdt the only clinical eccntre of Ireland, is lixely
to be in the future the most important school in the development
of a strictly National procsractme of med ical instruction. It is
weak, ineffective and ill supported at the present, and its weakness
in the future will be due to the very relationship which ay also
prove its strength, namely its closer relation with the Free State
Goverment. It seems reasonable to suppose that it will be a
matter of several years before the Free State Goverment fully
comprehends its respvonsibilities in the maintenance of ar adequate
med4cal school as part of the Dublin College of the National
University. If any developments should extincsulsh Galway (as
seans probable) or Cork (as seens possible), the National University

College, Dublin, will of course fain in importance...

The Royal Collere of Surgeons, Dublin.
The medical school of the Royal Collese of Surgeons, Dublin,
at present adinitt edly receiving a lower grade of students than
Trinity Collese, is dog@med,unless it secures a very substantial

financial support, to close its doors. It cannot continue to
e714

provide a pre-clinical training equal to that of institutions
which secure State support or shich have their own endowment.
It has only survived up to the present because its object has been
for its students to pass the qualifying examination and vecause it

was not obliged to bear the expense of clinical instruction.

The National University.

University College, Cork.

This College owes its strength to the political importance of
Southern Irelend rather than to any intrinsic excellence, past or
present, of the medical school there. In the intelligent develop-
ment of medical education in Ireland, Cork seems to be likely to
play always a subordinate vart, and certainly any innovations or
adfances to be accomplished in Irelami could not wisely be expected to

develop in, and spread fron, the Medical Faculty at Cork.

Univers ity Cohlere. Galwaye

Galway, due to its ranote location, its probably constant
inadequacy of clinical material and to the rivalry of Cork and Dublin
for the favours of the Free State Goverrment, will probably cease to
function as a Medical Faculty. In any event, Galway would follow |
at considerable distance behind Dublin in its intrinsic importance in

Ireland or in its claims for assistance.
272

Ghief Needs.

The Chief Needs of the Free State Schools are:~

(1) Better Clinioal Facilities

Tis is understood to means~

(a) Modern buildings adequately equipped, essecially
in the point of clinical laboratories for
Patholosy, Chemistry etc-,

(b) Some fonn of amalgamation or re-orranisation of
numerous small hospitals, so that the Medical

_ Faculty would have a better control and more
adequate clinical matorial at its disposal.

The hia¥tus between the pre-clinical instruction
and that obtained in the hospitals should te closed
throuzh placine the hospital under academic,
instead of religious, auspices and direction.

(2) The opportunity to allow a few able youn men interested in
Medical Science 60 continue their training by means of
Resident or Travelling Fellowships grants which would enacle
them later to follow academic careers.

(3) Biucation of those responsible for medical instruction in
Ireland in regard to more important corceptions of medical
education and the canvlete abandorment of the idea that
students' fecs should be considered as properly the main
source of support of a Medical Faculty. Such an orientation
+o those in charce of the medical schools is particularly
important in the case of the colleges of the National University.

(4) Buildings, especially in the case of the National University
College in Dublin, to house better departments of the Medical
Sciences.

(5) It would seam afvisable for the number of medical schools in
Ireland to be reduced outrisht and to improve the remainder
through increased support, whether from fees, gitts or
Goverment subsidies or a combination of all three.
(5)

(1)

(2)

2713

Continued

Ideally, Ireland could be adequately served, and could
even produce a reasonable number of graduates for service
outside of England, if Belfast, Trinity College, the
Dublin College of the National University were to be the

Only Faculties of Nedicine.

Belfast.

The chief needs at Belfast at present are:-

Better Clinical Facilities for the Department of Gynecology
and Obstetrics,

The opportwity to allow a few able young men interested
4m Medical Science to continue their training by means of
Resident or Travelling Fellowships grants which would enable

‘then later to follow academic careers.
ote

Irish Free State.

Tre following suggestions are nals recardirg a
development toward a satisfactory solution of the probvlens
confronting Medical Biucation in Irelund. In several of the
instances given below, steps must be initiated by the Irish;
in some, however, it is possible that the Division of Medical
Bincation could make an initial offer of co-operation.

(1) The Irish Goverrmant will probably isaintain en
_ attitude regarding registration which will

simplify the present situation by placing Ireland
on the Dominion basis, reducing the total number
of stwlents in medicine considerably and resulting
in the abandomment of medical instruetion in
Galway, the Royal College of Surgeons in Dublin
and the nearly extinct and practically negligible
Apothecaries' Hall in Dublin. Cork and Trinity
College, Dublin, will suffer considerably in the
munber of students, and therefore financially»
“heir ultimate fate is diffialt to predict at
present. By the besiming of the Acadenic Year
of 1926-1927, the situation will probably begin to
be stabilised, and & clearer forecast can be made of
the position ani drawing power of the surviving
schools in Irelami.

(2) The Irish Goverment is determined to change the
_ General Medical Council's eontrol of Free State
Schools; this change will be radical in ita
effects, and it is opposed as being likely to
entail the loss of prestige for Irish Scheols
ami their graduatese It would be advisable, in
view of this determination on the part of the Irish
Government, for it to appoint a commission of five
men representing both clinical and pre-clinical
branches and also each of the surviving faculties.
The object of tiis commission should
be to study medical education in Germany and the
United States (and possibly France) with a view to
‘rYecomending to the Govermmant a concerted scheme
of procedure to place Irish medicul elucation oa
sound and comprehensive and national basis.

I would recanmmeni, in case suck a sonmmission
were favoured by the Irish Goverment, that the
Division of Medical Hiucation assist financially
in sharing: the expenses of such study.

(3) Because of the present strength of the practitioners?
. point of view, and because amalgamation or re~orvanisation

of hospital facilities would raise questions of exceptional
difficulty, it would be wisest to expect the first steps
towards a satisfactory syéten of medical education to be
concerned with laboratory mildings, equimet, and teachers
in the medical sciences. If the Covernnent of the Irigh
Free State can be influenced by those most concerned
in improving medical education there to show an intelligent
and substantial interest in medical education in the
Xational University, and after the subject has been adequately
studied, the Irish Covernmment micht make large emough
contributions, together with funds from Irish sources*,
and possible assistance fram the Rockefeller Foumlation,
$0 establish pre-clinicel branches in Dublin on a sound and
thorough basis. In these circumstances, co-operation of the
Division of Medical Biucation would be advisable.

(4) Constant touch with the hospital sitaation in Dublin should
be kept by the officers of the Division of Medical Hiucation
so that, if consulted, they covld have the opportunity to
discourage any extension or continuance of the independence
of clinical from pre-clinical instruction. It is possible
that a time might come in 5 to 10 years then larser Academic
control of existing clinics or an amalgamation on a basis of
toleration and co-operation could be effected. No outside
agency could wisely help to brine this about unless and until
the local athorities are thoroushly convinced of the essential
importance of placing hospital appointments end teaching under
acadenic control.

(5) As the above changes can only come avout as a result of

conviction of the part of the authorities of the Goverrment,
hospitals and schools, the more inmediate problem in Irish
medical elucation is one of encouraging, directly or indirectly,
these authorities to become familiar with the conceptions
and practices of medical education in countries outside their
immediate range of experience. This can be effected in two
Ways s~

* For example, one hundred ani fifty thousand pounds of the "Shite Gross"
funds might be available.
276

(5) Contizmed

(a) The first referred to under (2), a direct invest-
igation and study by a croup appointed for that
purpose

(b) The second through the slower, indirect, but very valuable
. medium of travelling fellowships for men who are later

to occupy important posts in the teachins corps.
Doctor H. F. Moore's position in Dublin, and the exist-
ence of the only bio-chenical lebtoratory in a Free
State hospital, is a result of his study at the
Rockefeller Institute. Though the number of such
fellowships, under the comin: contraction in trish
medical education, will be small, they ere recommended,
especially in the medical sciences, as being eventually
highly useful - if not indispensable - to the complete
maturity of the plans outlined above. I would limit
applications to Trinity College and to the National
University of Dublin, and wait at least until January,
1926, before taking up nesotiations in this revard.

eevee ae eeneeones

Except for the last named, these recormendations are conting mt
upom possible, but by no neans certain, develomments of a situation
whose future is difficult to foresee. The above plan and the conditions
under which it might be accepted to enlist the suvport of the Division
of Medical Biucation of the Rockefellor Fountation. are civen for the
sake of a clearer definition of what would bea satisfactory pro:-ramme

of medical education in the Free State.
274

Be f & bt.

Aside fro: over~crowling, due to stamse in the status of the
Free State Schools. conditions in Belfast are lixely to renain
stable. I would recormend initiatins nesotietions after January
1926, leading to. thé offering of depar thental aid, (with a fow :
subsequent travelling fellowships),in Physiology, Pathology and
Hygiene, over.a three year period on the plan adopted for France
and Italy. This would not only demonstrate generally to the Belfast
authorities the isportance of adequate subordinate persomel in the
pyoper functioning of this medical faculty, but it would provide,
Close at hand, training under competent teachers for a snall
‘maumber of the younger gmeration of Irishmen. Nos ilar opportunity
exists, or for the next few years, éan exist in the Free State umier
the plan recomended for that country. 10,000 a year for three
years would give an adequate opportunity to apply such a programme,
and would furnish an opportunity for acadanic careers in the medical
soiences Wiose influence is most needed both in the Free State and
in. Northern Ireland.

No recommendation ts made regarding Obstetrics and Gynecology,
as this matter is at the present time purely a hospital proposal
and not adequately linked with the Iedical Faculty