CHANGES IN MEDICAL TEACHING OVER THE PAST CENTURY SAMUEL W. LAMBERT, JR., M.D. New York, N.Y.
ABOUT 6o years ago a gentleman living in Groton, Mass., who spent all his summers at Kennebago Lake in Maine wrote a book titled Trout Fishing in America, in which he described fully his experiences in the Kennebago area. The remainder of his opus was culled from the best authors. A medical wit of that day said that the volume should have been titled Trout Fishing in America, With the Report of One Case. I fear that this treatise may have the same deficiencies, since the greater part of the material in it relates to one school, viz., the Columbia University College of Physicians and Surgeons (P&S). But the progress in medical teaching over the past century has been much the same in all schools-with, of course, minor variations. Many schools have closed their doors permanently and some new ones have come into existence during this period. All the survivors have become affiliated with or have caused to be developed large hospitals used for teaching purposes, whereas previously a medical school was a lone institution without any access to the value of patient care. After passing his final examinations and being licensed by the state, the graduate became a full-fledged practicing physician, possibly without ever having the opportunity of using his five senses-I omit taste and add intelligencetoward the betterment of the art of his chosen profession. There were a few internships available and some young graduates were given the chance to increase their clinical experience by being employed as assistants to establised, practising physicians-a kind of apprenticeship system. However, the majority went into the world and took care of the unsuspecting and cooperative public just as they were. What did medical instruction amount to ioo years ago? The entire course consumed seven months during each of three years; in 1894 this was increased to four years. During this time the student was required to listen to didactic lectures and to view demonstrations. Up to the i88os no previous formal instruction in the liberal arts or sciences or Bull. N. Y. Acad. Med.
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college degree was required for admission. About this time examinations began to be introduced as a requirement for admission. The faculty consisted of a professor of surgery, a professor of the practice of medicine, and similar professors of various branches of medicine. It is obvious that the individual departments were not as well organized as they are today. The student had no contact with patients whatsoever. It is no wonder that the so-called quizzes were organized in a manner in which, upon payment of an extra fee, students were given greater clinical opportunities by outside physicians. The most noteworthy of these extra-curricular forms of instruction was conducted by Dr. Ellsworth Eliot with the purpose of enabling students to qualify better in obtaining internships. These "quizzes" were abolished in 1913. Probably these deplorable conditions of teaching at P&S were described best in the address which Dr. Lewis A. Connor delivered at the inauguration of the new Lying-In Hospital, when it became affiliated in toto with the Cornell medical complex. Dr. Connor's remarks in part were as follows (Harrar, J. A., pp. 75-76): I had come down from New Haven in the fall of i887 to enter P.&S. just at the time that the College was moving from its 23rd Street buildings to the new buildings in West 59th Street. It seemed to have occurred to a number of other youths to do the same thing at the same time, for the entering class there contained well over 3oo men. I suppose there may have been worse medical schools in the country at that time than P&S, but it is really very hard to believe it. All that was done for us as students was to give us the privilege, after paying our fees, of attending didactic lectures all day long for three years and then getting our diploma [sic]. During the last two years we had a few clinical lectures in the Vanderbilt Clinic, but we never came within a mile of touching a patient, and really all the genuine instruction we got was from these extra-mural quizzes, for which we paid our fees and in which we were taught systematically during these three years. I happened to join the quiz that Dr. Sam Lambert, Dr. Jim Markoe, Dr. Painter, and Dr. Gallaudet, the surgeon, started just about that time. It was in my second year, I think, that we began to hear echoes of the obstetrical situation. Most of these men, our quizmasters, had been abroad and had had training in Vol. 52, No. 3, March-April 1976
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obstetrics. They had come back hoping to do obstetrics and found when they got here that the opportunities for them to work, or for them to teach, were practically nil. The College at that time and the Sloane Maternity Hospital, were in the iron grasp of Dr. James McLane, the Dean, who was disrespectfully referred to usually as Jimmie McLane; and Jimmie McLane was a hard-fisted man who knew what he wanted and wasn't in the least interested apparently to provide obstetrical facilities for Dr. Lambert and Dr. Markoe and Dr. Painter and others who thought they were deserving of such facilities. So they were perforce driven to look about to see what they could do for themselves.... The medical teaching in New York could not have been the worst in the country, as Dr. Connor suggested. When Johns Hopkins University School of Medicine recruited its justly heralded "big four" for its full-time faculty, it chose Halsted and Welch, both of whom were New York-trained. When Dr. William Osler was called to Oxford in 1914, Dr. Theodore Janeway, also trained in New York, was persuaded to replace him. He remained at Johns Hopkins University for three years and then resigned with the intention of returning to New York, where he had been head of the medical service at the Presbyterian Hospital. His resignation was due in part to his becoming dissatisfied with full-time teaching at Johns Hopkins and in part to financial causes. Unfortunately, he died of pneumonia before he could again take up his affairs in New York. If anyone ever did, he embodied to perfection the three attributes of the ideal professor of medicine-an investigative bent, teaching ability, and wide clinical experience. But let us return to the iron grasp of Dean Jimmie McLane. This could not and did not last forever. He resigned as dean in I905 and was replaced by his bete noir, Dr. Samuel Lambert, Sr. Then things began to change, since the new dean had learned the value of clinical teaching during his two-year study abroad. The teaching facilities of Vanderbilt Clinic and Sloane Maternity Hospital, which were the only clinical entities at P&S, were completely inadequate to instruct a student body that had grown to about 500. Close affiliation with a large general hospital, allowing the active participation of students on the wards, was a primary necessity; Roosevelt Hospital, just across West 59th Street, was the obvious choice. But Dr. McLane had said no, in Bull. N. Y. Acad. Med.
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spite of the generous offer by Edward S. Harkness of a large sum for a new hospital. On receipt of this rebuff, Harkness resigned from the governing board of Roosevelt Hospital and became a member of the board at Presbyterian Hospital. To this institution he now made the same offer, and it was accepted. At this time Dean Lambert was an attending physician at the New York Hospital on I 5th and I 6th Streets, but he received a poor reception for his students at that institution. He therefore resigned and became affiliated with St. Luke's Hospital, where he had greater success. An amalgamation agreement was at last formulated with Presbyterian Hospital in 19Io and the negotiations dragged on until I916, when the plan finally fell through because of obstructions and delays created by Columbia University's president, Nicholas Murray Butler. The final agreement was worked out satisfactorily between i919 and I92 I. In the meantime, teaching facilities for students had been instituted at Presbyterian and Bellevue Hospitals. At the latter hospital agreements also were implemented for teaching the students of Cornell University and New York University. Finally, the New York Hospital saw the light, became affiliated with the Cornell Medical School, and in the early 193OS erected the large complex on York Avenue and 68th Street. This achievement was due in part to the philanthropy of Payne Whitney. At a later time New York University took over the entire teaching facilities of Bellevue Hospital and, in addition, erected its own University Hospital. Other small hospitals have formed various connections with teaching institutions. Finally, even Roosevelt Hospital worked out an agreement with P&S and allowed student instruction on its wards. The latest addition to this galaxy of medical teaching and hospital affiliation is The Mount Sinai Hospital, with its recently established medical school. But with all these wonderful facilities made available for teaching, how have things worked out? All great things move slowly. The innovations made by the new dean of P&S in 1905 were not all introduced overnight. The teaching of anatomy was the major arbeit for the student, who spent a great many hours of his first two years in the dissecting room. Lectures were never really given up, but they have become less frequent and more interesting; clinics in which the patient is present and clinical pathological conferences have taken their place to a great degree. Recitations were introduced also. I recall one instance Vol. 52, No. 3, March-April 1976
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in which the professor asked the student to describe the sphenoid bone. The student had learned Gray's Anatomy by heart and when the professor woke up the student was on the maxilla. Dr. George Huntington, the renowned comparative anatomist and professor of anatomy, used to give the most learned lectures on embryological topics; wax models of the anlagen of various organs were wheeled into the amphitheatre by his prosectors. These lectures were far over the heads of most students. One day when I was a student the ex-dean asked me what we were learning from George Huntington's lectures. I replied that we hardly knew what he was talking about. The ex-dean said, "I'll tell him." The professor's retort was, "If they don't know what I'm talking about, they damned well better educate themselves so they do." Over the years, as medicine changed so did the teaching. More time was devoted to work on the wards and in the clinics; even some elective courses were permitted. In i9io the Flexner report was published. It criticized medical schools and their instruction so severely that many schools went out of business-and it really was a business for many of them, as some were merely diploma mills or so-called eclectic schools. At about this time in the majority of schools full-time medicine gradually was being introduced. I doubt if many physicians today remember what medical schools were like without full-time professors. Teachers of all grades had to supplement their meager salaries-if any-by private practice. This gave the physician a much broader view of the care of the sick. If a sick person in a hospital (and are not most of them in hospitals nowadays?) needs financial help, today's physician says, "Get the social service." If the patient needs a special diet, "Get the dietitian," etc. In those days the physician and the family worked the problems out together. There is no doubt that care in the hospital of today is superior to that which can now be furnished in the home, but something is lost from the intimate relation between doctor, patient, and
family. With the evolution of the teaching-medical complex, three facets have developed: research, care of the patient, and teaching. Only great physicians can combine all three. Many doctors of medicine-and doctors of philosophy as well-engage in what is known as basic research without ever seeing a sick person. On the whole, the results have been outstanding. Although we probably learn only of the- successes, the Bull. N. Y. Acad. Med.
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failures in their way are just as important if properly evaluated. There have been such achievements as the growing of viruses, the work on diabetes by Banting and Best, and the development of antibiotics-not to forget the earlier arsenicals or even "the bark." Salvarsan and its derivatives cured a great many infestations other than syphilis. Hormonal therapy also has been developed beneficially as well as that of the vitamins. Other researchers have gone into the field of what might be called "machinery." The first of these was oxygen therapy, followed by improved delivery of anesthesia, the development of respirators, renal dialysis, and many more. Finally, open-heart surgery and organ transplantation have been made possible by the use of many of the new mechanical devices. Medical students, interns, and residents are made aware of all these thrilling advances, but are they taught when to use them-or, more properly, when not to? The enthusiasm of the young should be tempered by the wisdom and experience of the seasoned physician. I am reminded of two instances. A long time ago on a cold, snowy night a consultant was called by a nearby physician with the request that the consultant see the physician's wife, whom the doctor had just delivered in his home; because of bad weather he had been unable to get transportation to the hospital. The consultant arrived and found the wife in perfect condition. Then he asked, "Where's the baby?" "The baby was born hopelessly deformed and is on the windowsill." "What are you going to tell your wife?" "That the baby was born dead." The second story is that of an obstetrician. In a certain hospital he had delivered a woman of another hopelessly deformed infant, who would not live more than a week or so at best. About three nights after the delivery the resident informed the obstetrician that the baby had had a severe sinking spell and that several resuscitative measures and machinery had been employed. The obstetrician shouted, "What the hell did you do that for?" The baby died in a short time, as expected. Which doctor was right-the more experienced physician who faced the facts, even in the case of his own child, or the enthusiastic, inexperienced young resident who used all the modern means of survival available with the same end result? A great moral question is involved in the use of these life-saving methods. If there are not enough kidney-dialysis machines to care for Vol. 52, No. 3, March-April 1976
all who need them, who is to decide which patient is to have the use of them? Pneumonia used to be called "the old man's friend," and it was-for a patient who was hopelessly incapacitated by a severe cerebrovascular accident, for one with a prolonged myocardial failure which would no longer respond to any medication, or for a terminal cancer patient. Nowadays many of these pathetic, chronic sufferers-many of whom would welcome death-can be cured of acute infection, only to continue an intolerable existence until they finally are afflicted with some additional condition which is unresponsive to medicine, machinery, and other marvels. In addition, with the increasing availability of organ transplants, a new form of death has arisen, the so-called brain death, produced by irreversible cerebral damage due to trauma in young and previously healthy persons. Here is the supply house for viable normal organs useful for transplantation. Unfortunately, the medicolegal aspect is sometimes difficult to settle either in or out of court. One of the deficiencies in teaching in a large general hospital is that such patients as those mentioned above often are not admitted or not allowed to remain. Therefore, the students and house staff never have the opportunity to learn about terminal care and about when not to use the armamentaria of resources that are now available. Of course, such things should always be employed in the acute cases that crowd the hospitals. The nursing homes and the newly developing hospices should be used somehow for teaching. The majority of those who teach today were taught by physicians whose main medical experience also was confined to large general hospitals; when full-time teaching was instituted, the first professors and instructors who were recruited had been trained outside the ivory tower. Also, the student sees many of his instructors go home at 5 P.M. and thus imagines that the working day is from 8 A.M. to 5 P.M., not realizing that the staff of a hospital does much work that is unseen and unappreciated by the student. "The staff does not make house calls. Why should we? The staff does not see patients at night. Why should we?" No wonder house staffs strike for more pay and less work like members of any other trade union. Who in the medical schools is going to instruct the students and the house staff in the art of medicine? Who will teach them when to hold the science of medicine in abeyance? Bull. N. Y. Acad. Med.
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GE]VERAL REFERENCES [New York], Soc. of the Lying-In HosDalton, J. C.: History of the College of pital, 1938. Physicians and Surgeons in the City of New York. New York, Medical Depart- Lamb, A. R.: The Presbyterian Hospital and the Columbia-Presbyterian Medical ment of Columbia College, 1888. Center, 1868-1943: A History of Great Harrar, James A.: The Story of the LyingIn Hospital of the City of New York. Medical Adventure. New York, Columbia University Press, 1955.
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