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A short history of providing medical history within the British medical undergraduate curriculum N H Metcalfe,1,2 E Stuart3 1
SSC Lead in History of Modern Medicine, Hull York Medical School, University of York, York, UK 2 GP, York 3 Hull York Medical School, University of York, York, UK Correspondence to Dr N H Metcalfe, Hull York Medical School, John Hughlings Jackson Building, University of York, York YO10 5DD, UK; neilmetcalfe@ doctors.org.uk Accepted 11 October 2013 Published Online First 13 November 2013
ABSTRACT This article aims to discuss the history of medical history in the British medical undergraduate curriculum and it reviews the main characters and organisations that have attempted to earn it a place in the curriculum. It also reviews the arguments for and against the study of the subject that have been used over the last 160 years. INTRODUCTION The study of medical history is not new. As far back as the 4th century BC Hippocrates reported: ‘The physician should know what the physician before him has known if he does not want to deprive himself and others’.1 Despite it not being a new subject, it is one that has struggled to be accepted within medical undergraduate curriculums in a variety of countries over the centuries.2 This article first summarises the numerous arguments from generations of scholars for and against medical students studying medical history. It is also the first article to document the chronology of the teaching of the history of medicine within medical schools in Britain, to record notable people and organisations that have attempted to incorporate medical history within the undergraduate curriculum, and look at the steps and progress that has been made. The article specifically focuses on the history of medicine in British medical undergraduate curriculums.
HISTORICAL ARGUMENTS SUPPORTING THE STUDY OF MEDICAL HISTORY BY MEDICAL STUDENTS
To cite: Metcalfe NH, Stuart E. Med Humanit 2014;40:31–37.
There have been a number of arguments given in favour of the study of the history of medicine by medical students, and the range of possible benefits from doing so. Those benefits include furthering the medical knowledge and understanding of the student, improving their written and analytical skills, and subsequently giving overall benefit to all of the medical profession as a whole. Some have thought that medical history offers general life skills. Charles Singer (1876–1960, see figure 1), an important character in medical history research and its teaching as detailed later, felt that studying medical history ‘would improve people’s writing skills’.3 Frederick Cartwright (1909–2001), the former Head of History of Medicine at King’s College Medical School, London shared this view. He was concerned by the ‘inability of the majority of medical writers, especially the younger generation, to express themselves in plain, simple English’.4 Since then, Robert Arnott (1951–), the Founder and then Director at the Centre for the History of
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Medicine at University of Birmingham Medical School, has concurred and gone on to suggest that studying medical history would also aid ‘developing (the medical students’) critical and analytic approaches to medical knowledge and practice’.5 The then Professor of History at the University of Reading, Michael Biddiss (1942–), agreed that physicians require ‘critical scepticism in regard to authenticity and reliability of the available evidence’,6 a skill which is widely needed and used in clinical and research practice. Medical history was also proposed by Singer to be used within a curriculum ‘connecting its various parts’,3 therefore, being of benefit to tutors and students alike. It has also been proposed that studying medical history offers experience to undergraduates. The eminent physician Sir William Osler (1849–1919), a staunch supporter of medical history, revealed the experience the subject gives to medical students: ‘History maketh a young man to be old, without either wrinkles or grey hairs; privileging him with the experience of age, without either the infirmities or inconveniences thereof ’.7 Arnott felt that medical humanities were an important aspect of study and worthy of teaching and research.8 He also explained how the subject allows ‘broadening their educational horizons…(and) approaches to learning that are based on curiosity and the exploration of knowledge’.5 Consequently, he felt the subject permits the students to be exposed to a world beyond the walls of the classroom, laboratory and hospital, and then can inspire them to study other topics.5 Some have suggested that having some knowledge of medical history when studying medicine can help the overall medical degree. One of the first published papers supporting the study of medical history was an article by Alexander Henry (1822–1893), a former subeditor of the BMJ. In an article in the BMJ in 1860, Henry felt that studying the subject encourages ‘scientific pursuit of our profession’,9 and that ‘an extensive knowledge of what has already been done, may keep you from going over ground already trodden’.9 Over a century later, in 1968, Donald Hunter (1898–1978), a physician, wrote in the Middlesex Hospital Journal: ‘The history of medicine, like that of mankind, is made up of advance and regression, of success and reverse. We can learn from both’.1 He went on to reveal: ‘It is necessary to emphasise that the mistakes made by the doctor at the bedside today are the same as the generation before him’.1 Thus he suggested that only by knowing earlier problems and errors within the medical and scientific profession could they be avoided in the future. 31
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Figure 1 Photograph of Charles Singer (1876–1960).
HISTORICAL ARGUMENTS AGAINST THE STUDY OF MEDICAL HISTORY BY MEDICAL STUDENTS Arguments against the study of medical history within medical undergraduate programmes have been based both on a perceived lack of direct use to students as well as the logistics of incorporating it into teaching. Some have argued that the subject has little relevance to medical practice, especially in conjunction with the structure of medical school examinations. The following quote summarised the views that had been made in the past regarding this: ‘Knowledge of medical history will not help a physician diagnose an obscure ailment, a surgeon to transplant a heart, or a general practitioner to treat chronic bronchitis’.4 Cartwright felt that teachers have three key tasks to accomplish with their students: ‘First help the student pass his qualifying examination, second to interest him in the subject being taught, third to teach him facts or techniques which will be of value after qualification’.4 This, together, with some medical schools having claimed that ‘there are problems funding medical history and its related teaching’10 has meant that other subjects have been prioritised over medical history.4 6 10 In 1956, The Times published a letter, which suggests that medical history research and study should only be done by retired academics.11 It was suggested: No young man with appreciable research success in science, that is, with at least one respectable, really novel theory to his credit and enough practical experience to know the dreariness and delight of experimental testing of his own theory, is going to surrender this work for the sake of writing about other people’s work. No one who lacks this experience is competent to write history that is safe for serious students of science to treat seriously.11
The author felt that the only way around this was for elderly scientists to pass their knowledge onto younger generations once they are no longer able to generate active scientific research. Interestingly, the conclusion regarding the use of such research, whether done by an elderly or young researcher, was that it was dubious because ‘at best (medical history) can have only the value of literature, not history or science’.11
THE FIRST DELIVERY OF MEDICAL HISTORY IN 19TH CENTURY BRITAIN Moving away from the backdrop summary of the main arguments for and against the study of medical history at medical schools, this article now charts the history of the main events, 32
characters, discussions and organisations that have attempted to place medical history into the British medical school curriculum. The first documented attempt to incorporate medical history into general medical debate came in 1860. At the time, Henry observed that ‘the teaching of history of medicine is a novelty in England… few or no attempts have been made to give an idea (of medical history) to the English medical student or practitioner’.9 Consequently, he began to give a series of lectures at the Grosvenor Place School of Medicine in London on the subject.2 However, it seems that proposals to turn these random lectures, talks or presentations to interested parties, whether at medical societies or to the general public, into a formal subject for medical students did not come until 1886. London doctor Alfred Gubb (1857–1936) suggested in his letter to the BMJ that to get a medical degree ‘(the) history of medicine should be part of the curriculum’.12 Three years later, in 1889, David Lloyd-Owen (1843–1925), who was the first ophthalmic surgeon at Birmingham Children’s Hospital and in this year the President of the Birmingham and Midland Counties branch of the British Medical Association, had gone as far as to construct a plan for teaching of medical history, which he presented to the British Medical Association.13 However, despite these sporadic attempts, there were no medical history lectures taking place within British medical schools by the beginning of the 20th century.
MEDICAL HISTORY IN THE FIRST HALF OF THE 20TH CENTURY In 1903, the physician Joseph Frank Payne (1840–1910) delivered two lectures, known as the FitzPatrick lectures, in honour of the late Dr Thomas FitzPatrick (1832–1900), at the Royal College of Physicians. These were published in the BMJ later that same year.14 15 His ambition was ‘to see the evolution of British medicine worthily presented’.15 He felt that ‘the history of medicine in Britain, it is not too much to say, remains to be written’,14 and the aims of his lectures were to act as foundations in the teaching of history of medicine.15 An important year was 1908, as this saw the creation of the first lectureship in the history of medicine, which occurred at Edinburgh University.16 This position was held by physician and medical historian John Comrie (1875–1939, see figure 2), until his death. It was documented that over the first 19 years of this post over 1000 students attended his lectures.17 However, despite some possible successes for the subject, Singer felt in 1919 that these were minor.3 Consequently he reported in that year: ‘England is almost the only country where there is no adequate provision for the teaching of medical history’.3 He proposed ways that could improve the profile of the subject and increase interest, with students and in the medical profession. He suggested the need ‘of two or three chairs to be held by men who would devote their lives to the task of setting forth the history of medicine’.3 Such men, he proposed, would be involved in giving historical lectures at various medical schools. He also felt the need for the ‘establishment, preferably in London, of a special institute’.3 This institute would provide a focal reference source to medical historians and students. In 1927, Comrie’s opinions were voiced that ‘at the present time, no medical school in Great Britain required its students to learn the history of the subject, and there were only a few at which it was possible for the student who desired it to obtain such instruction’.16 Singer himself tried to help the development of the subject with the publication of A Short History of Medicine in 1928, a book considered to have great historical value.18 However, much was still to be done. Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
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Figure 3
Figure 2 Photograph of John Dixon Comrie (1875–1939).
The Wellcome Trust Sir Henry Solomon Wellcome (1853–1936, see figure 3) was an American pharmaceutical businessman, who himself had a personal interest in medical history and medical relics.19 He began building his personal collection of such artefacts while in America and moved to the UK in 1880. He provided the first temporary collection of his historical objects at 54 Wigmore Street, London (see figures 4 and 5) in 1913, under the title the ‘Historical Medical Museum’.19 During the First World War (1914–1918) the museum was used to illustrate military surgery, and following the war it became Wellcome’s primary interest and where he displayed various exhibitions. However, visitor numbers were low due to admission being restricted to medical professionals who had to request entry in writing. In 1930, he bought a site on Euston Road, London (see figure 6), in order to build somewhere for his collections. In 1932, the new Wellcome Research Institute opened, and housed his medical museums, library and two of his research laboratories. He intended the museum ‘to be useful to students and useful to all those engaged in research’.19 By Wellcome’s death in 1936 his collection totalled around 1.5 million books and objects.19 His death triggered the formation of the Wellcome Trust, whose primary duty was to maintain and expand the collections, and also to fund biomedical research. On 2 December 1949, the Wellcome National Medical Library was formally opened and it was reported that its scale was ‘comparable, in its own subjects, to that of the great national museums’.20 Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
Photograph of Sir Henry Wellcome (1853–1936).
MEDICAL HISTORY IN THE SECOND HALF OF THE 20TH CENTURY By the middle of the 20th century, medical history was a specialty aided by a minority. Stephen Toulmin (1922–2009), a British philosopher, author and educator, summarised this when he reported in 1956: ‘In spite of the devotion and achievement of Dr Charles Singer and a very few others little ground had been covered in the history of medicine field… the real problem lies here—in the lack, not of potential students, but of opportunities for serious scholarship in the subject’.21 A suggestion to rectify this was made in the same year by the Scottish Physician and Director General of the Emergency Medical Services Sir Francis Fraser (1885–1964), who in his search for ‘practical methods of interesting both undergraduates and postgraduates who are studying medicine in London’, suggested creating a university department covering the fields of history and philosophy of medicine.22
The Worshipful Society of Apothecaries of London The Worshipful Society of Apothecaries helped stimulate medical history development in the mid-20th century. It’s Faculty of the History of Medicine and Philosophy of Medicine and Pharmacy owes its existence to the Society’s Future Activities Committee, which was originally appointed by the Court of Assistants at a meeting on 14 March 1944.23 In the Committee’s meeting of 11 October 1950 there was the suggestion for 1951 of holding ‘Lectures in minor medicine and the common maladies; also the History of Medicine’.23 Between 1955 and 1958 several lectures were given that despite the ‘view of the very disappointing response to the various (medical history) courses’23 led to the Faculty being incorporated in 33
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Figure 4 Photograph of the Historical Medical Museum, 54 Wigmore Street, London.
1959. One of the main aims of this Faculty ‘was to bring the history of medicine to students, especially medical undergraduates’.24 Therefore, they created a panel of speakers to help arrange programmes of future events: ‘Schools, societies, and other bodies who are corporate members are invited to use this panel so that all undergraduate and postgraduate students and others who wish to do so may have an opportunity of learning something of the historical background of their profession’.25 Over 70 corporate bodies, including universities, medical schools and corporations, had enrolled and could use the Faculty’s facilities and also their panel of lecturers who could be asked to deliver medical history lectures.25 In 1961, seven Lecturers from the Society had been given formal appointments at medical schools.26 These medical schools included King’s College Hospital, Leeds, Middlesex Hospital, St Mary’s Hospital, St Thomas’s Hospital, The London, and University College London.26 The Faculty also established the Osler lecture in 1960, which was an annual event aimed at medical students.25 Five hundred invitation cards were printed for each lecture, with 100 large billposters, and were distributed to medical schools, many of whom had ‘a personal link between the lecturer and the students attending’.24 The Faculty went further by trying to encourage direct student involvement with them. They created an annual medical history essay competition for undergraduates and postgraduates.25 They also invited the student bodies at medical schools ‘to appoint official student delegates to the faculty’.27 This was aimed to encourage lecture attendance, and three such medical school representatives were appointed in 1962.
Figure 5 Medical history exhibition at the Historical Medical museum, 54 Wigmore Street, London in 1913. 34
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Figure 6 The Wellcome Research Institute, London. In 1965, the Faculty reviewed the progress they had made since their foundation. They felt they had succeeded in many areas, including enrolling many medical schools and universities, and also individual members. However, efforts to ‘arouse and develop interest in the subject among medical students’24 had mixed success. The panel of volunteer lecturers who were willing to travel, without fee, in order to deliver history of medicine lectures, only received eight lecture requests in 5 years.24 This was despite individual letters being sent every year to the Deans of all medical schools who were corporate members, the majority of whom had ‘seemed to welcome this service and hope to take advantage of it’.24 The level of uptake at the Osler lectures was felt to be poor, at less than 20 students per lecture, as was the fact that once the three student delegates had moved into a junior doctor post that ‘no successors have yet been found’.24 Consequently, the Worshipful Society of Apothecaries of London wrote to the General Medical Council (GMC) and the Royal Commission on Medical Education summarising: We think that the committee will agree that the Faculty’s experience shows that the alternative possibilities of voluntary effort have been exhausted. One or more of the various schemes tried by the Faculty might well be useful, but only as a supplement to regular teaching. We think that it would be highly misleading and encouraging to the complacency which has already contributed to the academic neglect of this subject in Britain to suggest that the History of Medicine is worth studying but that it should be done by voluntary effort. If it is worthy of study then it is worthy of a place in the syllabus and of regular teaching appointments in the medical schools.24
The letter was said to be well received by its recipients but no specific changes or recommendations from them resulted.23
An academic department for medical history Elsewhere, in 1962 the University College London, with financial assistance from the Wellcome Trust, created an academic department for the History of Medicine.28 Also in London, in the 1966–1967 academic year, the history of medicine was incorporated into the students’ curriculum at Middlesex Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
Hospital after a 2-year trial period.28 However, by the end of the 1960s the subject was still struggling to get a foothold into the universities. Cartwright felt in 1969 that the subject would not be able to get guaranteed specific teaching time in the British medical undergraduate curriculum time. Instead its teachers must ‘interweave past history with present practice that the student will find an increased interest in the subject under consideration’,4 in the form of lectures, historical societies and school magazines.4
The 1970s The Worshipful Society of Apothecaries of London set up an official diploma in the history of medicine in 1970,23 which was aimed primarily at those called upon to teach history of medicine. At a meeting of the British National Committee for the History of Science, Medicine and Technology on 22 May 1969 a questionnaire survey was agreed to send to all the heads of departments of science, technology, medicine, philosophy, history, liberal studies and history and philosophy of science that were listed in the contemporaneous issue of Scientific Research in British Universities and Colleges.29 The results of the data collected from early 1970 included that ‘a considerable number of departments in medical schools and other institutions reported that historical points were normally touched on in the course of teaching, and that some idea of historical development was considered of advantage to the medical student’.29 In terms of medical schools, the Report mentioned that University College London maintained a subdepartment in medical history with three full time and five part time associates.29 This was mainly for the study of higher degrees though the staff also lectured at the Royal Postgraduate Medical School, Hammersmith, at the Royal Free Hospital and occasionally at other medical schools.29 It was noted that part time or honorary lecturers had been appointed at Bath, Bradford, Edinburgh, King’s College Hospital, Leeds, Middlesex Hospital, Newcastle, Reading, Sheffield and the Welsh National School of Medicine.29 The Report documented that the principle topics of interest at the 35
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Original article above were the history of anaesthesia, pharmacy and psychology.29 It concluded: ‘Compared to 10 years ago the establishment of teaching in the subject has increased most markedly. It should be observed, however, that the increase is largely concentrated in the history of science…the history of medicine is still a fringe subject, albeit a highly respected one, in medical education… those institutions fortunate in having enthusiasts for the subject, even a few amateur ones, could consider themselves as being appropriate points of development in the next wave of expansion of the subject’.29
THE INFLUENCE OF THE GENERAL MEDICAL COUNCIL In 1993, the GMC initiated course restructuring of undergraduate medical degrees in the UK. This was done in an attempt to ‘abandon the old and rigidly defined and distinct preclinical and clinical components of medical education’, and to broaden the areas of study of undergraduates. The GMC documents Tomorrow’s Doctors30–32 suggested a broader and more humane approach to medical training should be offered in medical schools. Tomorrow’s Doctors also suggested a significant proportion of time be set apart for courses, now known as student selected components (SSCs). For these, students could choose parts of their medical education from different options. Subjects within the medical humanities were ideally placed to lead to a more ‘humane’ product. Similarly, the modules were seen to be an ideal time for ‘opportunities for historical engagement’.6
MEDICAL HISTORY IN THE 21ST CENTURY A recent study led by Neil Metcalfe (1979–), then Clinical Research Fellow in Medical Education and current SSC Lead in the History of Modern Medicine at Hull York Medical School, has helped quantify the position of medical history within these SSCs at British medical schools as of 2010.33 It revealed that 15 of the 32 medical schools in the UK offer a SSC in medical history.33 Teaching focus and methods within these SSCs varied quite widely, but most frequently looked at 20th century and 21st century time periods.33 The teaching was usually delivered by medical professionals, either from primary or secondary care, who usually had a personal interest in the subject.33 The study also found that most of the medical history SSCs were aimed at first and second year medical students.33 Medical schools had a range of reasons for offering the SSC including increasing the student breath of study, development of student writing skills but interestingly due also to direct requests for the topic from students.33 However, in some cases there were limiting factors to the availability of such teaching, such as insufficient time, lack of staff and inadequate teaching facilities or financing.33 These difficulties are not obviously the sole problem of current medical history providers. The recent study led by Metcalfe33 shows that since the last comparable study 40 years previously, that medical history is being taught more widely in British medical schools. This is even taking into consideration that it was specifically looking at SSCs and not including the Intercalated Bachelor degrees that are also now offered at various establishments, nor general exposure in other parts of the curriculum. Clearly medical history is a much more widely taught and studied subject than it was 40 years ago. However, it shows that more progress is still needed if the subject is to be fully incorporated at British medical schools.
CONCLUSION Medical history has had its supporters and critics. This article has shown that the subject has been aided by a small group of 36
its supporters throughout the decades who have been working, researching and advertising the specialty against many opponents and curriculum pressures. These have particularly been Comrie, Singer, the Wellcome Library, the Worshipful Society of Apothecaries, and more recently aided by the GMC. There have obviously been many other supporters in that time frame as well, for which an article such as this cannot possibly detail. The creation of SSCs has helped increase the acceptance and inclusion of the subject since the early 21st century. However, even with such an useful medium, it is still only provided in a minority of medical schools. The history of the subject shows it has become more widely used within the medical undergraduate courses in Britain but it will need ongoing support and energies of others to help direct and expand it in the future. Acknowledgements We are grateful for the help of Dee Cook, Archivist at The Worshipful Society of Apothecaries of London, as well as to Kate Richardson, Deputy Archivist at the Royal London Hospital Archives and Museum for their help in directing and sourcing NHM’s research at their respective establishments. Finally, we are grateful to the Wellcome Library for their permission to reproduce the images within this article. Contributors The concept of the article was created by NHM who then conducted the research including the visits to the archives. ES wrote the first draft of the study. NHM and ES helped with rewriting of drafts before submission. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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Hunter D. History as a dimension of medicine. Middlesex Hosp J 1968;68:20–6. Cassedy J. History of medicine and related sciences in Europe—notes on teaching and study. Bull Hist Med 1969;43:270–83. Singer: C. The teaching of medical history. BMJ 1919;2:141–42. Cartwright FF. The place of medical history in undergraduate education. J R Soc Med 1969;62:1053–60. Arnott R. The University of Birmingham Medical School and the History of Medicine. Med Humanit 2002;28:33–4. Biddiss M. Tomorrow’s doctors and the study of the past. Lancet 1997;349:874–76. Osler W. A note on the teaching of the history of medicine. BMJ 1902;2:93. Arnott R. Medical humanities. J Med Ethics 2001;27:104–05. Henry A. Lectures on the history of medicine: delivered at the Grosvenor Place School of Medicine. BMJ 1860;1:219–23. Meakin R. Medical humanities in udergraduate medical education—moving on. Med Humanit 2002;28:32. Aucken I. History of Science. The Times. August 17 1956. Gubb A. History of medicine as a branch of professional education. BMJ 1886;2:393. Lloyd-Owen DC. The study of the history of medicine. BMJ 1901;2:1637–38. Payne JF. FitzPatrick lectures on the history of medicine. BMJ 1903;1:1477–80. Anon. Obituary Joseph Frank Payne. BMJ 1910;2:1749. Comrie JD. A vindication of the section. BMJ 1927;2:205. Comrie JD. History of medicine. BMJ 1926;2:93–4. Abbot ME. A short history of medicine—a review of Dr Singer’s Book. CMAJ 1929;21:451–53. Poynter FNL. The Wellcome Historical Medical Museum and Library and its services to Research in the History of Medicine. (Sonderdruck aus: Verhandlungen des XX. Interntaionalen Kongresses für Geschichte der Medizin Berlin, 22–27. August 1966). Hildesheim: Georg Olms Verlagsbuchhandlung, 1968. Anon. Wellcome historical medical library. BMJ 1949;2:1350–51. Toumlin S. History of Science: Opening up a New Field of Study. The Times August 15 1956. Fraser FR. History of Science: Value in Higher Education. The Times August 18 1956. The Worshipful Society of Apothecaries of London (Faculty of the History of Medicine and Pharmacy). Fifteenth Annual Report and List of members 1973–74. Copeman WSC, Poynter FNK. Memorandum on the Place of the History of Medicine in Medical Education submitted by the Faculty of the History of Medicine and Pharmacy of the Worshipful Society of Apothecaries of London to the Committee on Medical Education of the General Medical Council, written to the Registrar of the Sub-Committee on Medical Education of the General Medical Street on 16th February 1965. Manuscript E/4/6/1/2/ Box 21, Worshipful Society of Apothecaries of London. The Worshipful Society of Apothecaries of London (Faculty of the History of Medicine and Pharmacy). First annual report and list of members 1959–60. London: Harrison and Sons Ltd, 1960.
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A short history of providing medical history within the British medical undergraduate curriculum N H Metcalfe and E Stuart Med Humanities 2014 40: 31-37 originally published online November 13, 2013
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Original article
A short history of providing medical history within the British medical undergraduate curriculum N H Metcalfe,1,2 E Stuart3 1
SSC Lead in History of Modern Medicine, Hull York Medical School, University of York, York, UK 2 GP, York 3 Hull York Medical School, University of York, York, UK Correspondence to Dr N H Metcalfe, Hull York Medical School, John Hughlings Jackson Building, University of York, York YO10 5DD, UK; neilmetcalfe@ doctors.org.uk Accepted 11 October 2013 Published Online First 13 November 2013
ABSTRACT This article aims to discuss the history of medical history in the British medical undergraduate curriculum and it reviews the main characters and organisations that have attempted to earn it a place in the curriculum. It also reviews the arguments for and against the study of the subject that have been used over the last 160 years. INTRODUCTION The study of medical history is not new. As far back as the 4th century BC Hippocrates reported: ‘The physician should know what the physician before him has known if he does not want to deprive himself and others’.1 Despite it not being a new subject, it is one that has struggled to be accepted within medical undergraduate curriculums in a variety of countries over the centuries.2 This article first summarises the numerous arguments from generations of scholars for and against medical students studying medical history. It is also the first article to document the chronology of the teaching of the history of medicine within medical schools in Britain, to record notable people and organisations that have attempted to incorporate medical history within the undergraduate curriculum, and look at the steps and progress that has been made. The article specifically focuses on the history of medicine in British medical undergraduate curriculums.
HISTORICAL ARGUMENTS SUPPORTING THE STUDY OF MEDICAL HISTORY BY MEDICAL STUDENTS
To cite: Metcalfe NH, Stuart E. Med Humanit 2014;40:31–37.
There have been a number of arguments given in favour of the study of the history of medicine by medical students, and the range of possible benefits from doing so. Those benefits include furthering the medical knowledge and understanding of the student, improving their written and analytical skills, and subsequently giving overall benefit to all of the medical profession as a whole. Some have thought that medical history offers general life skills. Charles Singer (1876–1960, see figure 1), an important character in medical history research and its teaching as detailed later, felt that studying medical history ‘would improve people’s writing skills’.3 Frederick Cartwright (1909–2001), the former Head of History of Medicine at King’s College Medical School, London shared this view. He was concerned by the ‘inability of the majority of medical writers, especially the younger generation, to express themselves in plain, simple English’.4 Since then, Robert Arnott (1951–), the Founder and then Director at the Centre for the History of
Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
Medicine at University of Birmingham Medical School, has concurred and gone on to suggest that studying medical history would also aid ‘developing (the medical students’) critical and analytic approaches to medical knowledge and practice’.5 The then Professor of History at the University of Reading, Michael Biddiss (1942–), agreed that physicians require ‘critical scepticism in regard to authenticity and reliability of the available evidence’,6 a skill which is widely needed and used in clinical and research practice. Medical history was also proposed by Singer to be used within a curriculum ‘connecting its various parts’,3 therefore, being of benefit to tutors and students alike. It has also been proposed that studying medical history offers experience to undergraduates. The eminent physician Sir William Osler (1849–1919), a staunch supporter of medical history, revealed the experience the subject gives to medical students: ‘History maketh a young man to be old, without either wrinkles or grey hairs; privileging him with the experience of age, without either the infirmities or inconveniences thereof ’.7 Arnott felt that medical humanities were an important aspect of study and worthy of teaching and research.8 He also explained how the subject allows ‘broadening their educational horizons…(and) approaches to learning that are based on curiosity and the exploration of knowledge’.5 Consequently, he felt the subject permits the students to be exposed to a world beyond the walls of the classroom, laboratory and hospital, and then can inspire them to study other topics.5 Some have suggested that having some knowledge of medical history when studying medicine can help the overall medical degree. One of the first published papers supporting the study of medical history was an article by Alexander Henry (1822–1893), a former subeditor of the BMJ. In an article in the BMJ in 1860, Henry felt that studying the subject encourages ‘scientific pursuit of our profession’,9 and that ‘an extensive knowledge of what has already been done, may keep you from going over ground already trodden’.9 Over a century later, in 1968, Donald Hunter (1898–1978), a physician, wrote in the Middlesex Hospital Journal: ‘The history of medicine, like that of mankind, is made up of advance and regression, of success and reverse. We can learn from both’.1 He went on to reveal: ‘It is necessary to emphasise that the mistakes made by the doctor at the bedside today are the same as the generation before him’.1 Thus he suggested that only by knowing earlier problems and errors within the medical and scientific profession could they be avoided in the future. 31
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Figure 1 Photograph of Charles Singer (1876–1960).
HISTORICAL ARGUMENTS AGAINST THE STUDY OF MEDICAL HISTORY BY MEDICAL STUDENTS Arguments against the study of medical history within medical undergraduate programmes have been based both on a perceived lack of direct use to students as well as the logistics of incorporating it into teaching. Some have argued that the subject has little relevance to medical practice, especially in conjunction with the structure of medical school examinations. The following quote summarised the views that had been made in the past regarding this: ‘Knowledge of medical history will not help a physician diagnose an obscure ailment, a surgeon to transplant a heart, or a general practitioner to treat chronic bronchitis’.4 Cartwright felt that teachers have three key tasks to accomplish with their students: ‘First help the student pass his qualifying examination, second to interest him in the subject being taught, third to teach him facts or techniques which will be of value after qualification’.4 This, together, with some medical schools having claimed that ‘there are problems funding medical history and its related teaching’10 has meant that other subjects have been prioritised over medical history.4 6 10 In 1956, The Times published a letter, which suggests that medical history research and study should only be done by retired academics.11 It was suggested: No young man with appreciable research success in science, that is, with at least one respectable, really novel theory to his credit and enough practical experience to know the dreariness and delight of experimental testing of his own theory, is going to surrender this work for the sake of writing about other people’s work. No one who lacks this experience is competent to write history that is safe for serious students of science to treat seriously.11
The author felt that the only way around this was for elderly scientists to pass their knowledge onto younger generations once they are no longer able to generate active scientific research. Interestingly, the conclusion regarding the use of such research, whether done by an elderly or young researcher, was that it was dubious because ‘at best (medical history) can have only the value of literature, not history or science’.11
THE FIRST DELIVERY OF MEDICAL HISTORY IN 19TH CENTURY BRITAIN Moving away from the backdrop summary of the main arguments for and against the study of medical history at medical schools, this article now charts the history of the main events, 32
characters, discussions and organisations that have attempted to place medical history into the British medical school curriculum. The first documented attempt to incorporate medical history into general medical debate came in 1860. At the time, Henry observed that ‘the teaching of history of medicine is a novelty in England… few or no attempts have been made to give an idea (of medical history) to the English medical student or practitioner’.9 Consequently, he began to give a series of lectures at the Grosvenor Place School of Medicine in London on the subject.2 However, it seems that proposals to turn these random lectures, talks or presentations to interested parties, whether at medical societies or to the general public, into a formal subject for medical students did not come until 1886. London doctor Alfred Gubb (1857–1936) suggested in his letter to the BMJ that to get a medical degree ‘(the) history of medicine should be part of the curriculum’.12 Three years later, in 1889, David Lloyd-Owen (1843–1925), who was the first ophthalmic surgeon at Birmingham Children’s Hospital and in this year the President of the Birmingham and Midland Counties branch of the British Medical Association, had gone as far as to construct a plan for teaching of medical history, which he presented to the British Medical Association.13 However, despite these sporadic attempts, there were no medical history lectures taking place within British medical schools by the beginning of the 20th century.
MEDICAL HISTORY IN THE FIRST HALF OF THE 20TH CENTURY In 1903, the physician Joseph Frank Payne (1840–1910) delivered two lectures, known as the FitzPatrick lectures, in honour of the late Dr Thomas FitzPatrick (1832–1900), at the Royal College of Physicians. These were published in the BMJ later that same year.14 15 His ambition was ‘to see the evolution of British medicine worthily presented’.15 He felt that ‘the history of medicine in Britain, it is not too much to say, remains to be written’,14 and the aims of his lectures were to act as foundations in the teaching of history of medicine.15 An important year was 1908, as this saw the creation of the first lectureship in the history of medicine, which occurred at Edinburgh University.16 This position was held by physician and medical historian John Comrie (1875–1939, see figure 2), until his death. It was documented that over the first 19 years of this post over 1000 students attended his lectures.17 However, despite some possible successes for the subject, Singer felt in 1919 that these were minor.3 Consequently he reported in that year: ‘England is almost the only country where there is no adequate provision for the teaching of medical history’.3 He proposed ways that could improve the profile of the subject and increase interest, with students and in the medical profession. He suggested the need ‘of two or three chairs to be held by men who would devote their lives to the task of setting forth the history of medicine’.3 Such men, he proposed, would be involved in giving historical lectures at various medical schools. He also felt the need for the ‘establishment, preferably in London, of a special institute’.3 This institute would provide a focal reference source to medical historians and students. In 1927, Comrie’s opinions were voiced that ‘at the present time, no medical school in Great Britain required its students to learn the history of the subject, and there were only a few at which it was possible for the student who desired it to obtain such instruction’.16 Singer himself tried to help the development of the subject with the publication of A Short History of Medicine in 1928, a book considered to have great historical value.18 However, much was still to be done. Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
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Figure 3
Figure 2 Photograph of John Dixon Comrie (1875–1939).
The Wellcome Trust Sir Henry Solomon Wellcome (1853–1936, see figure 3) was an American pharmaceutical businessman, who himself had a personal interest in medical history and medical relics.19 He began building his personal collection of such artefacts while in America and moved to the UK in 1880. He provided the first temporary collection of his historical objects at 54 Wigmore Street, London (see figures 4 and 5) in 1913, under the title the ‘Historical Medical Museum’.19 During the First World War (1914–1918) the museum was used to illustrate military surgery, and following the war it became Wellcome’s primary interest and where he displayed various exhibitions. However, visitor numbers were low due to admission being restricted to medical professionals who had to request entry in writing. In 1930, he bought a site on Euston Road, London (see figure 6), in order to build somewhere for his collections. In 1932, the new Wellcome Research Institute opened, and housed his medical museums, library and two of his research laboratories. He intended the museum ‘to be useful to students and useful to all those engaged in research’.19 By Wellcome’s death in 1936 his collection totalled around 1.5 million books and objects.19 His death triggered the formation of the Wellcome Trust, whose primary duty was to maintain and expand the collections, and also to fund biomedical research. On 2 December 1949, the Wellcome National Medical Library was formally opened and it was reported that its scale was ‘comparable, in its own subjects, to that of the great national museums’.20 Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
Photograph of Sir Henry Wellcome (1853–1936).
MEDICAL HISTORY IN THE SECOND HALF OF THE 20TH CENTURY By the middle of the 20th century, medical history was a specialty aided by a minority. Stephen Toulmin (1922–2009), a British philosopher, author and educator, summarised this when he reported in 1956: ‘In spite of the devotion and achievement of Dr Charles Singer and a very few others little ground had been covered in the history of medicine field… the real problem lies here—in the lack, not of potential students, but of opportunities for serious scholarship in the subject’.21 A suggestion to rectify this was made in the same year by the Scottish Physician and Director General of the Emergency Medical Services Sir Francis Fraser (1885–1964), who in his search for ‘practical methods of interesting both undergraduates and postgraduates who are studying medicine in London’, suggested creating a university department covering the fields of history and philosophy of medicine.22
The Worshipful Society of Apothecaries of London The Worshipful Society of Apothecaries helped stimulate medical history development in the mid-20th century. It’s Faculty of the History of Medicine and Philosophy of Medicine and Pharmacy owes its existence to the Society’s Future Activities Committee, which was originally appointed by the Court of Assistants at a meeting on 14 March 1944.23 In the Committee’s meeting of 11 October 1950 there was the suggestion for 1951 of holding ‘Lectures in minor medicine and the common maladies; also the History of Medicine’.23 Between 1955 and 1958 several lectures were given that despite the ‘view of the very disappointing response to the various (medical history) courses’23 led to the Faculty being incorporated in 33
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Figure 4 Photograph of the Historical Medical Museum, 54 Wigmore Street, London.
1959. One of the main aims of this Faculty ‘was to bring the history of medicine to students, especially medical undergraduates’.24 Therefore, they created a panel of speakers to help arrange programmes of future events: ‘Schools, societies, and other bodies who are corporate members are invited to use this panel so that all undergraduate and postgraduate students and others who wish to do so may have an opportunity of learning something of the historical background of their profession’.25 Over 70 corporate bodies, including universities, medical schools and corporations, had enrolled and could use the Faculty’s facilities and also their panel of lecturers who could be asked to deliver medical history lectures.25 In 1961, seven Lecturers from the Society had been given formal appointments at medical schools.26 These medical schools included King’s College Hospital, Leeds, Middlesex Hospital, St Mary’s Hospital, St Thomas’s Hospital, The London, and University College London.26 The Faculty also established the Osler lecture in 1960, which was an annual event aimed at medical students.25 Five hundred invitation cards were printed for each lecture, with 100 large billposters, and were distributed to medical schools, many of whom had ‘a personal link between the lecturer and the students attending’.24 The Faculty went further by trying to encourage direct student involvement with them. They created an annual medical history essay competition for undergraduates and postgraduates.25 They also invited the student bodies at medical schools ‘to appoint official student delegates to the faculty’.27 This was aimed to encourage lecture attendance, and three such medical school representatives were appointed in 1962.
Figure 5 Medical history exhibition at the Historical Medical museum, 54 Wigmore Street, London in 1913. 34
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Figure 6 The Wellcome Research Institute, London. In 1965, the Faculty reviewed the progress they had made since their foundation. They felt they had succeeded in many areas, including enrolling many medical schools and universities, and also individual members. However, efforts to ‘arouse and develop interest in the subject among medical students’24 had mixed success. The panel of volunteer lecturers who were willing to travel, without fee, in order to deliver history of medicine lectures, only received eight lecture requests in 5 years.24 This was despite individual letters being sent every year to the Deans of all medical schools who were corporate members, the majority of whom had ‘seemed to welcome this service and hope to take advantage of it’.24 The level of uptake at the Osler lectures was felt to be poor, at less than 20 students per lecture, as was the fact that once the three student delegates had moved into a junior doctor post that ‘no successors have yet been found’.24 Consequently, the Worshipful Society of Apothecaries of London wrote to the General Medical Council (GMC) and the Royal Commission on Medical Education summarising: We think that the committee will agree that the Faculty’s experience shows that the alternative possibilities of voluntary effort have been exhausted. One or more of the various schemes tried by the Faculty might well be useful, but only as a supplement to regular teaching. We think that it would be highly misleading and encouraging to the complacency which has already contributed to the academic neglect of this subject in Britain to suggest that the History of Medicine is worth studying but that it should be done by voluntary effort. If it is worthy of study then it is worthy of a place in the syllabus and of regular teaching appointments in the medical schools.24
The letter was said to be well received by its recipients but no specific changes or recommendations from them resulted.23
An academic department for medical history Elsewhere, in 1962 the University College London, with financial assistance from the Wellcome Trust, created an academic department for the History of Medicine.28 Also in London, in the 1966–1967 academic year, the history of medicine was incorporated into the students’ curriculum at Middlesex Metcalfe NH, et al. Med Humanit 2014;40:31–37. doi:10.1136/medhum-2013-010418
Hospital after a 2-year trial period.28 However, by the end of the 1960s the subject was still struggling to get a foothold into the universities. Cartwright felt in 1969 that the subject would not be able to get guaranteed specific teaching time in the British medical undergraduate curriculum time. Instead its teachers must ‘interweave past history with present practice that the student will find an increased interest in the subject under consideration’,4 in the form of lectures, historical societies and school magazines.4
The 1970s The Worshipful Society of Apothecaries of London set up an official diploma in the history of medicine in 1970,23 which was aimed primarily at those called upon to teach history of medicine. At a meeting of the British National Committee for the History of Science, Medicine and Technology on 22 May 1969 a questionnaire survey was agreed to send to all the heads of departments of science, technology, medicine, philosophy, history, liberal studies and history and philosophy of science that were listed in the contemporaneous issue of Scientific Research in British Universities and Colleges.29 The results of the data collected from early 1970 included that ‘a considerable number of departments in medical schools and other institutions reported that historical points were normally touched on in the course of teaching, and that some idea of historical development was considered of advantage to the medical student’.29 In terms of medical schools, the Report mentioned that University College London maintained a subdepartment in medical history with three full time and five part time associates.29 This was mainly for the study of higher degrees though the staff also lectured at the Royal Postgraduate Medical School, Hammersmith, at the Royal Free Hospital and occasionally at other medical schools.29 It was noted that part time or honorary lecturers had been appointed at Bath, Bradford, Edinburgh, King’s College Hospital, Leeds, Middlesex Hospital, Newcastle, Reading, Sheffield and the Welsh National School of Medicine.29 The Report documented that the principle topics of interest at the 35
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Original article above were the history of anaesthesia, pharmacy and psychology.29 It concluded: ‘Compared to 10 years ago the establishment of teaching in the subject has increased most markedly. It should be observed, however, that the increase is largely concentrated in the history of science…the history of medicine is still a fringe subject, albeit a highly respected one, in medical education… those institutions fortunate in having enthusiasts for the subject, even a few amateur ones, could consider themselves as being appropriate points of development in the next wave of expansion of the subject’.29
THE INFLUENCE OF THE GENERAL MEDICAL COUNCIL In 1993, the GMC initiated course restructuring of undergraduate medical degrees in the UK. This was done in an attempt to ‘abandon the old and rigidly defined and distinct preclinical and clinical components of medical education’, and to broaden the areas of study of undergraduates. The GMC documents Tomorrow’s Doctors30–32 suggested a broader and more humane approach to medical training should be offered in medical schools. Tomorrow’s Doctors also suggested a significant proportion of time be set apart for courses, now known as student selected components (SSCs). For these, students could choose parts of their medical education from different options. Subjects within the medical humanities were ideally placed to lead to a more ‘humane’ product. Similarly, the modules were seen to be an ideal time for ‘opportunities for historical engagement’.6
MEDICAL HISTORY IN THE 21ST CENTURY A recent study led by Neil Metcalfe (1979–), then Clinical Research Fellow in Medical Education and current SSC Lead in the History of Modern Medicine at Hull York Medical School, has helped quantify the position of medical history within these SSCs at British medical schools as of 2010.33 It revealed that 15 of the 32 medical schools in the UK offer a SSC in medical history.33 Teaching focus and methods within these SSCs varied quite widely, but most frequently looked at 20th century and 21st century time periods.33 The teaching was usually delivered by medical professionals, either from primary or secondary care, who usually had a personal interest in the subject.33 The study also found that most of the medical history SSCs were aimed at first and second year medical students.33 Medical schools had a range of reasons for offering the SSC including increasing the student breath of study, development of student writing skills but interestingly due also to direct requests for the topic from students.33 However, in some cases there were limiting factors to the availability of such teaching, such as insufficient time, lack of staff and inadequate teaching facilities or financing.33 These difficulties are not obviously the sole problem of current medical history providers. The recent study led by Metcalfe33 shows that since the last comparable study 40 years previously, that medical history is being taught more widely in British medical schools. This is even taking into consideration that it was specifically looking at SSCs and not including the Intercalated Bachelor degrees that are also now offered at various establishments, nor general exposure in other parts of the curriculum. Clearly medical history is a much more widely taught and studied subject than it was 40 years ago. However, it shows that more progress is still needed if the subject is to be fully incorporated at British medical schools.
CONCLUSION Medical history has had its supporters and critics. This article has shown that the subject has been aided by a small group of 36
its supporters throughout the decades who have been working, researching and advertising the specialty against many opponents and curriculum pressures. These have particularly been Comrie, Singer, the Wellcome Library, the Worshipful Society of Apothecaries, and more recently aided by the GMC. There have obviously been many other supporters in that time frame as well, for which an article such as this cannot possibly detail. The creation of SSCs has helped increase the acceptance and inclusion of the subject since the early 21st century. However, even with such an useful medium, it is still only provided in a minority of medical schools. The history of the subject shows it has become more widely used within the medical undergraduate courses in Britain but it will need ongoing support and energies of others to help direct and expand it in the future. Acknowledgements We are grateful for the help of Dee Cook, Archivist at The Worshipful Society of Apothecaries of London, as well as to Kate Richardson, Deputy Archivist at the Royal London Hospital Archives and Museum for their help in directing and sourcing NHM’s research at their respective establishments. Finally, we are grateful to the Wellcome Library for their permission to reproduce the images within this article. Contributors The concept of the article was created by NHM who then conducted the research including the visits to the archives. ES wrote the first draft of the study. NHM and ES helped with rewriting of drafts before submission. Competing interests None. Provenance and peer review Not commissioned; externally peer reviewed.
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A short history of providing medical history within the British medical undergraduate curriculum N H Metcalfe and E Stuart Med Humanities 2014 40: 31-37 originally published online November 13, 2013
doi: 10.1136/medhum-2013-010418 Updated information and services can be found at: http://mh.bmj.com/content/40/1/31
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