Mep k Vheanre Actwwun fe Mah ug gs
EDVCAM? W Ho Wat Her see

LOOKING TO THE FUTURE

“Wougk nelos News You

OUTLINE OF A TALK JANUARY 17, 1944
New York University

We are discussing reform that may take place in medical education.
There are two valid reasons that might be advanced in support of the study
of reform, one general and one peculiar to the present time. One of the
principal differences between plants and animals is that animale move in
their environment. Now it ise extremely important if an animal ie moving
for him to know a little ahead of time what he is getting into. Three of
the five senses of most animals meet thie need of knowing what ie going
on at a distance - sight, smell, and hearing. The other two senses, touch
and taste, only function with objects no loner at a distance. We ought
to study our environment and look into the future age we would look into the
distance to see what we are getting into if only in self-protection. This
is a general and constant adjustment and reform. The other and more tempo-
rary case for reform, is that if we don't look out the New World will be on
the other side of the Atlantic and North America will become the Old World.
This is even more likely in a victorious America, since victory usually
enshrinee the convictions and the conventions of those who were running
things when the victory was secured. Europe is likely to disregard the
opinione of the elderly generation and the more so since it was cleared
of most of its finest representatives in the last war, for the leaders in
the present war were the younger generation in the last war, and that was
a generation which, in Europe at least, was decimated and is now enfeebled.

I suppose an introductory speaker to a series of lectures such as

these has pase-neeriy the task of describing or defining some of the iasues
involved. I have never read a monograph or eseay on the essence of reform
so that perhaps the three following aspects of it will prove to be a
somewhat sophomoric approach. First, I want to discuas the price tags, the
penalties and the essential prerequisites of reform in medical education,
second, to examine a little the motives and reasone for reform, and third,
to make some suggestions as to the direction and nature of specific changes
that might be desirable.

I. I may as well say thet before we take up the price tags of
reform, I would Like to make it clear that by reform in medical education
I do not mean mere changes in the curriculum. Faculties of medicine seem
to me to have always relieved their consciences of the charge of conserva-
tism by getting thoroughly etirred up from time to time on the subject of
the curriculum. Frank Swinnerton, in a book review, once predicted a suc-
cess in England for the book he was reviewing “wince‘he said,"thie book
caters to that overwhelming interest in bastardy which is the natural pre-
occupation of a thoroughly virtuous people." In the same way the medical
faculties with no intention whatsoever of erring on the elde of radicalism
will discuss new departures in the currioy, wie but wi hort ay change of

oe Vveaeke Stes
heart. Usually one would expegt : ies sare years, #ince

 

the younger member of the faculty is usually in his niddle thirties, and by
the time he has retired some thirty years have elapsed, and the entire
personnel hag changed. If there are no little adjustments in between times,
the changes are likely to be rather violent. One mst remember that every
system that has any qualities or advantages probably has the defects of those
same qualities, and the intelligent thing is to knew the price tag on any

radioal reform.
3.

I am going to assume that in talking of reform of medical education
we are not talking about those changes, appropriate to any particular spe-
clalty alone, but rather to general changes in the whole of medical education
which are in a sense changes in the highest common factor of the whole pro-
cess. It would be a great deal easier thing to discuss reform in medical
education if qualifications and the work of those holding the M.D. degres
were always the same, but refleot upon the following subdivisions of medicine
and you will see that reform in medieal education needs very careful con-
sideration and reconsideration before it can wisely be adopted wholesale:
General Practice, Internship, Pediatrics, Industrial Medicine, Military
Medicine, Obstetrics, Surgery, Orthopedics, Ophthalmology, Ear Nose and Threat,
Vrology, Gynecology, Psychiatry, Neurology, Neurosurgery, Dermetolozy,
Pathology, Roentgenology, Hospital Administration, Public Health Admini-
stration, Bacteriology and Immnology, Parasitology, Research work, and
teaching in all of the above and the medical aciences.

When it comes to the actual price tage of a reform of medioal
education, I would think of the following, firat, efemikk, there is a loss
of at least a passage of a good deal of time before the reform can be put
through. There has to be a good deal of time spent in discussions such aa
we are having today. Then you have to get agreement among the different
medical sohoole and not only that»but you have to get acceptance by the
colleges of what the new requirements of the medioal schoole may be, and
still more important, you muet have the medical profession ready to accept
the qualifications of the newly trained men in lieu of the old style quali~

fications. Thies takes particularly vivid and tangible form in persuading
hospital boards to change their stendards for interns and other appointments.
They will suspect that any change is a retrograde movement, and time is
needed to convert them to a more accurate and sensible impression.

The next price tag on reform is the financial cost of it. "Whenever
the shangesa call for such things as new facilities, more space, or a dif-
ferently trained teaching force, or a larger teaching force, I need only
say that the General Education Board put in something like $86,000,000 in
support of reforms in medical education, and thie sum wae probably matched
by gifts from other sources for the same purpose. Apart from the financial
cost, reform usually meets with opposition, The newly recommended changes
are unfamiliar and are in contrast to procedures well known. They lack
prestige, whereas the present procedure is considered sound and well established.
The new ig likely to be poorly equipped at the outset and thus make a shabby
comparison with the well equipped old style, and the reforms are likely to
call for the services of new men and thet fact may be a sinister threat to
the older men.

The final price tag I shall mention for reform ie that reform
usually does leave out something that was really quite good in the old way
of doing things. It is very difficult to stage a reform without some actual
losses, and one is therefore faced with the question of what is the relative
value of the things that are sacrificed.

I1.Certainly we must know the motives and reasons for reform if it
is to be intelligently planned and carried through. Reform i# needed in
medical education, first, because there are so many new subjects and leads

for study: Biophysics, Chemotherapy, Psychological Medicine, Biostatistios,
Medical Economios, Forensic Medicine, Geriatrics, are fields oalling for
more time and more attention, and within already establiehed medical depart-
ments certainly the increased knowledge of internal secretions, nutrition,
and heredity prese also for a bit more of the students' time.

The second reason for reform of medical education is that both the
relative and the absolute numbers of diseases have changed with or without
our new therapeutic agents. Acute infections and epidemics are decreasing
in their numbere and seriousness. Chronic diseases are increasing. Chronic
malnutrition is being recognized in steadily larger’ quantities, and this
will probably continue for a decade or two before we can say that chronic
malnutrition has followed the path of acute Infections and ie diminishing.
Nervous and mental phenomena, both of the mild and everyday type and of the
extreme forms, appear to be on the increase. There is an increasing amount
of work done in preventive medicine and public health, and it would appear
likely that the present already increased number of physicians on governmental
salaries of one kind or another will not diminish but rather grow larger.

In other words, medicine itself has not the same composition or complexion
that it had, nor is the dieposition of human forces to combat disease along
the same fronts that were oharacteristic of say 1910.

To develop a bit further the idea that the methods of practice are
changing, one hae to note the steady growth of the health insurance principle,
the increase of group practice, the large development of diagnostic labora-
tories and their inoreasing utilization by doctors, the steady increase in
hospital facilities, and the increasing conviction throughout the population

that the doctor in many instances at least oan “deliver the goods". The
horror and aversion connected with going to a hospital is certainly deoreas-
ing, and a doctor's services are coming to be considered by many a community
far more in the light of a public necessity than an unattainable luxury for
the privileged few. Furthermore, there is clear evidence that medicine is
being practiced in a different way, since there is a ateady drift into
specialization and the young doctors are no longer settling in the sountry
or in the small towns in preference to the big cities. The problem of medical
care ig coming to be more and more a problem in distribution rather than the
quality of medical care.

Should our methods of teaching not reflect the substantial changes
noted above? If it is true that we have a lot more to teach than used to
be the case, is the right answer merely to tack on one or two years more to
the medical curriculum? Would it not be better if we could find some method
of teaching more economical of time than the one we use now? If observation,
reasoning, and a comparison of one's experience with the experience of others
are the three principal activities of the student and his teacher, why not
lay more specific emphasia on these procedures and leave the transfer of
specific bits of information to the student as his responsibility? Let the
medical student realize that if he knows how to find out what he wants to
know, then he will not have to oarry it all around in his head with him. It

seems to me that not only is the method of teaching challenged by present

needg,. but in one or two other ways we should reform the schools. Prevention
and a good orientation in human biology ought to come into the course earlier
and stay longer. I think that we should county, also on some sort of a con-

nection with the work of a hospital on the part of a new graduate. The moat
7.

inexcusable waste in a doctor's life occurs just after he has completed his
hospital internship or residenoy. He then is at the maximim of his strength,
ambition, and training, and yet he ia obliged to remain relatively inactive
in the work that he le capable of doing and wait and wait and wait. He
ought to have immediate institutional connectiona that would utilize his
ability and extend his experience.

In one other direction I should like to see medical education undergo
something of a reform. We could well make a more careful seleotion of medical
etudents, and this especially in reference to character and social conscience.
There are plenty of M.D.'s in the United States, but there aro tony too few
good doctors. As long as the selection of medical students rests so strongly
on purely intellectual records, we shall have an embittered clientele, be-
cause doator’s characterg and desire for being helpful are quite as important
as sharpnese of mind or nimbleness of wit. The present foreshortening of
the premedical and medical curriculum is, I think, likely to be an almost
unqualified tragedy. No education can be thoroughly examined without reference
to the maturity of the recipient. It would be perhaps a neat device to be
able to eat all one needed for the week on Monday morning, but it can't be
done, and crowding the medical scurriculum into the minimum period throws
grave doubt in my mind on the nature of the agsimilation thereof. The main
thing to do is to watch with very great care the present obligatory experience
so that our inferences from it will be sound.

III, Though subsequent speakers will cover in considerable detail the
specific directiona in which reform might move, I will run over briefly some

of the changes that seem to me to be desirable, and I would divide these
8.

remarks into changes in the premedical course, changee in the medical school,
and changes on the subject of postgraduate education.

I would like to see a better course in general science, especially
biology, in the secondary schools. Generally, in the United States the
teaching in science in secondary echools is of poor quality, one or two of
the private boys schools, such as Andover and Exeter,’ being notable exceptions.

I think the college requirement for premedicai work should not ox-
tend beyond & year in physics, a year in biology, and two years in chemistry.
I would like to see more emphasis on the things not now considered as pre-
medical subjects, English, sociology, economics, anthropology, mathematics,
psychology, philosophy, and esology, but more important, I should like to
see premedical students allowed a maximum of electives and be judged upon
the marke secured in subjects of their own choice. I believe that in that
way medicine could begin to attract a definitely better group of young men
and women. I would like to see liberal exceptions made in the cases of
candidates for entrance in lively acknowledgment of the great variety of
talents needed inside medicine.

In the medical school I would Like to see less emphasis on depart-
mente and more acknowledgment of the importance of teaching the faoulties of
observation and reasoning and comparison (i.e. using the libraries intelli-
gently). I would like to have more examples set by the professors in the
clinical subjects on the way to handle human beings so that the students will
get in this manner more experience than is the case now. In the selection
of teachers in the medical school I would like to see more attention paid to

width of choice and care in final appointment. In the selection of medical
atudents I would like to see a larger number eliminated before entering and,
if necessary, during the course when their oonduct ie open to undoubted
criticism for moral or ethical reasons. I see no reason why a atudent should
be allowed to stay on in a sohool becauge he has been there two years if he
is known to be so lazy or so unprinei pled as to be dangerous to defenceless
patients a year or two later. I should like to see the degree for American
doctors changed to M.B., which would cover four years of medical school and
one year of internship, and the M.D. degree supplant the certificate of the
specialty bearde, this to take place after the year 1950 and the M.D. to be
accompanied always by the year in which it was conferred. If this were the
case, then M.D. with no date would mean that it was old style, and within
50 years it would quietly but firmly disappear. In terms of the courses
in the schools I wuld like to see the time devoted to anatomy reduced in
favor of study of human biology, especially genetics and heredity, growth
and aging, and the effect of environment on the organism. Physiology I

Neu oagyorsis KS,
should like to see euthaetked more tes human physiology, and also some at-
tention given to the physiology of the organiam as a whole, 6B, tropisme,
instinctual drives, eto. This would provide a mich better basie for medical
psychology. The teaching of psyohiatry I would like to see through each one
of the four years. The first year should be largely through physiology as
just noted, the second year, medical psychology, the third year, clinical
lectures and seminars, and the fourth year, clinical work. Similarly, hygiene
I should like to see spread over four years, the firet year carrying bio-
etatistios and the physiology of measurement of performance,: the second year»

epidemiology and environmental oontrol, the third year, socialized medicine
Lo.

and public health administration, and the fourth year, preventive medicine
with practical work.

In the postgraduate field I should like to see the state boards
of licensure carrying on thelr work in some state hospital reserved for this
purpose, where a candidate for licensure would spend a week and thus be
obliged to reveal his ways of thinking and his skill in handling patients
as well as his matery of pen and paper. In increasing measure specialty
training hae got to be postgraduate. If the M.D. were connected with post-
graduate training in the specialty, I should like to have it accompanied by
a thesis, and I think the selection of something worth writing a theeis about
ig an important guide to forming an opinion of the intelligence of the
candidate.

If we have got to have refresher courses in medicine, there ought
to be entrance examinations for such courses, and these ought to be exclusively
ona tutoring or coaching basis. This would provide both income and experience
for young teacherge and would be a great deal better for the recipients than

the present procedures.

M