Pain, suffering, and premature death from disease have ravaged human beings from the beginning of recorded time. This harsh fact was as true for colonial America, where life expectancy as late as 1800 was only twenty-five years, as for every other known society. Yet the aspiration for health and the desire to explain the mysteries of disease have also characterized all known human societies. Thus, inhabitants of colonial America sought medical care from a variety of practitioners of folk, herbal, and Indian medicine. In addition, some members of the clergy, such as the Protestant New England clergyman Cotton Mather (1663–1728), incorporated the healing art in their services to the colonists.
In the eighteenth century, practitioners of "regular, " or "allopathic, " medicine began to become more commonplace. A small number of elite practitioners obtained medical degrees, primarily by studying medicine in Edinburgh, Leiden, or London. This mode of study was not economically feasible for more than a few. Of necessity, the apprenticeship tradition became the dominant system of medical training, with the typical preceptorial period lasting three years. Apprentice physicians would study medicine with a practicing physician, who would allow the apprentice the opportunity to participate in his practice in exchange for a fee and the performance of various menial chores.
In the early nineteenth century, the "proprietary" medical school became the dominant vehicle of medical instruction in America. In 1800, only four medical schools existed: the University of Pennsylvania (founded in 1765), King's College (1767), Harvard (1782), and Dartmouth (1797). Between 1810 and 1840, twenty-six new schools were established, and between 1840 and 1876, forty-seven more. In the late nineteenth century, dozens of additional schools sprouted. Originally, these schools were intended to be a supplement to the apprenticeship system. However, because they could more readily provide systematic teaching, by the middle of the nineteenth century they had superseded the apprenticeship as the principal pathway of medical education.
Though the first schools were created with lofty ambitions, the quality of instruction at the proprietary schools rapidly deteriorated, even based on the standards of the day. Entrance requirements were nonexistent other than the ability to pay the fees. Disciplinary problems arising from outrageous student behavior were commonplace. The standard course of instruction in the mid-nineteenth century consisted of two four-month terms of lectures during the winter, with the second term identical to the first. The curriculum generally consisted of seven courses: anatomy; physiology and pathology; materia medica, therapeutics, and pharmacy; chemistry and medical jurisprudence; theory and practice of medicine; principles and practice of surgery; and obstetrics and the diseases of women and children. Instruction was wholly didactic: seven or eight hours of lectures a day, supplemented by textbook reading. Laboratory work was sparse, and even in the clinical subjects, no opportunity to work with patients was provided. Examinations were brief and superficial; virtually the only requirement for graduation was the ability to pay the fees. Students who wished a rigorous Medical Education had to supplement what they learned in medical school in other ways, such as through enrollment at non-degree-granting extramural private schools, study in Europe, or work in hospitals as "house pupils."
The mid-nineteenth-century proprietary schools, such as Bennett Medical College and Jenner Medical College in Chicago, were independent institutions. University or hospital affiliations, in the few cases in which they existed, were nominal. The faculties were small, typically consisting of six or eight professors. The professors owned the schools and operated them for profit. A commercial spirit thus pervaded the schools, for the faculty shared the spoils of what was left of student fees after expenses. The mark of a good medical school, like that of any business, was considered its profitability. Since an amphitheater was virtually the only requirement to operate a medical school, physical facilities were meager. The second floor above the corner drugstore would suffice; a school that had a building of its own was considered amply endowed.
The Creation of the Modern Medical School
While American medical education was floundering in the mid-1800s, the reform of the system was already beginning. At the root of the transformation was a series of underlying events: the revolution in experimental medicine that was proceeding in Europe; the existence of a cadre of American doctors traveling to Europe (particularly Germany) to learn laboratory methods; the emergence of the modern university in America; the development of a system of mass public education to provide qualified students for the university; and the cultivation of a habit of philanthropy among some very rich industrialists. Together, these developments provided the infrastructure for a new system of medical education soon to appear.
The creation of America's current system of medical education occurred in two overlapping stages. In the first stage, which began in the middle of the nineteenth century, a revolution in ideas occurred concerning the purpose and methods of medical education. After the Civil War, medical educators began rejecting traditional notions that medical education should inculcate facts through rote memorization. Rather, the new objective of medical education was to produce problem-solvers and critical thinkers who knew how to find out and evaluate information for themselves. To do so, medical educators deemphasized the traditional didactic teaching methods of lectures and textbooks and began speaking of the importance of self-education and learning by doing. Through laboratory work and clinical clerkships, students were to be active participants in their learning, not passive observers as before. A generation before John Dewey, medical educators were espousing the ideas of what later came to be called "progressive education."
At the same time, a revolution occurred in the institutional mission of medical schools. The view emerged that the modern medical school should not only engage in the highest level of teaching but also should be committed to the discovery of new knowledge through research. This meant that medical schools could no longer remain freestanding institutions. Rather, they had to become integral parts of universities and hire scientifically trained, full-time faculty who, like all university professors, were researchers as well as teachers.
In the early 1870s, the first lasting reforms occurred, as Harvard, Pennsylvania, and Michigan extended their course of study to three years, added new scientific subjects to the curriculum, required laboratory work of each student, and began hiring full-time medical scientists to the faculty. In the late 1870s, the plans for the new Johns Hopkins Medical School were announced, though for financial reasons the opening was delayed until 1893. When the school finally did open, it immediately became the model by which all other medical schools were measured, much as the Johns Hopkins University in 1876 had become the model for the modern American research university. A college degree was required for admission, a four-year curriculum with nine-month terms was adopted, classes were small, students were frequently examined, the laboratory and clinical clerkship were the primary teaching devices, and a brilliant full-time faculty made Medical Research as well as medical education part of its mission. In the 1880s and 1890s, schools across the country started to emulate the pioneering schools, and a campaign to reform American medical education began. By the turn of the century, the university medical school had become the acknowledged ideal, and proprietary schools were already closing for lack of students.
Nevertheless, ideas alone were insufficient to create the modern medical school. The new teaching methods were extremely costly to implement, and hospitals had to be persuaded to join medical schools in the work of medical education. Thus, an institutional as well as an intellectual revolution was needed. Between 1885 and 1925 this revolution occurred. Large sums of money were raised, new laboratories were constructed, an army of full-time faculty was assembled, and clinical facilities were acquired. Medical schools, which had existed autonomously during the proprietary era, became closely affiliated with universities and teaching hospitals.
No individual contributed more dramatically to the institution-building process than Abraham Flexner (1886– 1959), an educator from Louisville who had joined the staff of the Carnegie Foundation for the Advancement of Teaching. In 1910, Flexner published a muckraking report, Medical Education in the United States and Canada. In this book, he described the ideal conditions of medical education, as exemplified by the Johns Hopkins Medical School, and the deficient conditions that still existed at most medical schools. Flexner made no intellectual contribution to the discussion of how physicians should be taught, for he adopted the ideas that had developed within the medical faculties during the 1870s and 1880s. However, this report made the reform of medical education a cause célèbre, transforming what previously had been a private matter within the profession into a broad social movement similar to other reform movements in Progressive Era America. The public responded by opening its pocketbook, state and municipal taxes were used to fund medical education, private philanthropists, George Eastman and Robert Brookings among them, and philanthropic organizations all contributed significant sums to support medical education. In the two decades that followed the public provided the money and clinical facilities that had long eluded medical schools. In addition, an outraged public, scandalized by Flexner's acerbic depiction of the proprietary schools still in existence, brought a sudden end to the proprietary era through the enactment of state licensing laws, which mandated that medical schools operated for profit would not be accredited.
Graduate Medical Education
Through World War I, medical education focused almost exclusively on "undergraduate" medical education—the years of study at medical school leading to the M.D. degree. At a time when the great majority of medical school graduates entered general practice, the four years of medical school were considered an adequate preparation for the practice of medicine. Abraham Flexner's 1910 report did not even mention internship or other hospital training for medical graduates.
By World War I, however, medical knowledge, techniques, and practices had grown enormously. There was too much to teach, even in a four-year course. Accordingly, a period of hospital education following graduation—the "internship"—became standard for every physician. By the mid-1920s the internship had become required of all U.S. medical graduates.
The modern internship had its origins in the informal system of hospital appointments that dated to the early nineteenth century. Until the end of the century, such positions were scarce, available only to a tiny handful of graduates. Though such positions allowed the opportunity to live and work in a hospital for a year or two, they were saddled with considerable education deficiencies. Interns had limited clinical responsibilities, and the positions involved a considerable amount of nonmedical chores like maintaining the hospital laboratories. During the first two decades of the twentieth century, the internship was transformed into a true educational experience. Internship now provided a full schedule of conferences, seminars, rounds, and lectures as well as the opportunity to participate actively in patient management.
Internships came in three forms. The most popular was the so-called "rotating" internship, in which interns rotated among all the clinical areas. Some hospitals, particularly those associated with medical schools, offered "straight" internships in medicine or surgery, in which interns spent the entire time in that field. The third type was the "mixed" internship, a cross between the rotating and straight internship. Mixed internships provided more time in medicine and surgery and less in the various specialties than rotating internships. Typically, internships lasted one year, though some were as long as three years. All forms of internship provided a rounding-out clinical experience that proved invaluable as a preparation for general medical practice.
Medical education in the early twentieth century faced another challenge: meeting the needs of individuals who desired to practice a clinical specialty (such as ophthalmology, pediatrics, or surgery) or to pursue a career in medical research. To this end the "residency"—a several-year hospital experience following internship—became the accepted vehicle.
The modern residency was introduced to America at the opening of the Johns Hopkins Hospital in 1889. Based upon the system of "house assistants" in the medical clinics of German universities, the Hopkins residency was designed to be an academic experience for mature scholars. During World War I, the Hopkins residency system began to spread to other institutions, much as the Hopkins system of undergraduate medical education had spread to other medical schools the generation before. By the 1930s, the residency had become the sole route to specialty training. In doing so, it displaced a variety of informal, educationally unsound paths to specialty practice that had preceded it, such as taking a short course in a medical specialty at a for-profit graduate medical school or apprenticing oneself to a senior physician already recognized as a specialist.
Residency training before World War II had three essential characteristics. First, unlike internship, which was required of all medical school graduates before they could receive a license to practice medicine, residency positions were reserved for the elite. Only one-third of graduates were permitted to enter residency programs following the completion of an internship, and only about one-quarter of first-year residents ultimately completed the entire program. Second, the defining educational feature of residency was the assumption of responsibility by residents for patient management. Residents evaluated patients themselves, made their own decisions about diagnosis and therapy, and performed their own procedures and treatments. They were supervised by—and accountable to—attending physicians, but they were allowed considerable clinical independence. This was felt to be the best way for learners to be transformed into mature physicians. Lastly, the residency experience at this time emphasized scholarship and inquiry as much as clinical training. The residency system assumed many characteristics of a graduate school within the hospital, and residents were carefully trained in clinical research. Residency came to be recognized as the breeding ground for the next generation of clinical investigators and medical scholars.
Evolution and Growth
Scientific knowledge is continually growing. In addition, the diseases facing a population are constantly changing, as are medical practices, cultural mores, and the health care delivery system. Thus, of necessity, medical education is always evolving to reflect changing scientific and social circumstances.
After World War II, medical educators continued to emphasize the importance of "active learning" and the cultivation of problem-solving skills. However, the postwar period witnessed several important curricular innovations: the development of an organ-based curriculum by Western Reserve (1950s); the invention of "problem-based" learning by McMaster (1970s); the introduction of a primary care curriculum by New Mexico (1980s); and the establishment of the "New Pathway" program at Harvard Medical School (1980s). In addition, all medical schools reduced the amount of required course work, increased the opportunity for electives, and began to provide early clinical experiences during the first and second years of medical school.
Reflecting changes in the broader society, medical schools also became more representative of the diverse population they served. Religious quotas against Jewish and Catholic students, established at many medical schools in the early 1920s, disappeared in the 1950s following the revelation of Nazi atrocities and changes in civil rights laws. The admission of African American students, though still short of target levels, roughly tripled from 2.7 percent of enrolled medical students in the 1960s to around 8 percent in the 1990s. Greater success was achieved in the enrollment of women, whose numbers increased from roughly 7 percent of students in the 1960s to about 50 percent in the 1990s.
Graduate medical education also changed significantly following World War II. In the late 1940s and 1950s, residency training became "democratized"—that is, it became available to all medical graduates, not merely the academic elite as before. Between 1940 and 1970, the number of residency positions at U.S. hospitals increased from 5,796 to 46,258. Thus, the number of residents seeking specialty training soared. At the same time, the academic component of residency training diminished. Residency became an exclusively clinical training ground rather than a preparation point for clinical research as before. Most physicians desiring research training now had to acquire that through Ph.D. programs or postgraduate research fellowships.
In addition, the stresses of residency training also increased substantially after Word War II. In the 1960s, intensive care units were introduced, as were new, life-sustaining technologies like ventilators and dialysis machines. Hospitalized patients tended to be much sicker than before, resulting in much more work. In the 1980s, following the death of nineteen-year-old Libby Zion at the New York Hospital, the public began to demand shorter hours and greater supervision of house officers. Ironically, after extensive investigation, Libby Zion's death appeared not to be the result of poor care provided by fatigued or unsupervised house officers. Nevertheless, the movement to regulate house staff hours gained strength.
As medical education was changing, it also grew longer. In the 1960s and 1970s, in response to the public's demand for more doctors, existing medical schools expanded their class size, and forty new medical schools were established. Between 1960 and 1980, the number of students entering U.S. medical schools increased from 8,298 to 17,320. Following World War II, the research mission of medical schools expanded enormously, mainly because of the infusion of huge amounts of research funding from the National Institutes of Health. The number of full-time faculty at U.S. medical schools grew from 3,500 in 1945 to 17,000 in 1965. After 1965, medical schools grew larger still, primarily because of the passage of Medicare and Medicaid legislation that year and the resultant explosion in demands on the schools to provide clinical care. By 1990, the number of clinical faculty at U.S. medical schools had grown to around 85,000, with most of the increase occurring in the clinical departments. By that time one-half of a typical medical school's income came from the practice of medicine by the full-time faculty. By the 1990s, the "academic health center"—the amalgam of a medical school with its teaching hospitals—had become an extremely large and complex organization with many responsibilities besides education and research. By the late 1990s, a typical academic health center could easily have a budget of $1.5 billion or more and be the largest employer in its community.
The Challenge of Managed Care
Though medical schools prospered and served the public well during the twentieth century, a cautionary note appeared at the end of the century. Academic health centers had grown strong and wealthy, but they had become dependent for their income on the policies of the third-party payers (insurance companies and government agencies) that paid the bills. During the managed care era of the 1990s, the parsimonious payments of many third-party payers began causing academic health centers considerable financial distress. For instance, in 2000 the University of Pennsylvania Health System suffered a $200 million operating loss. (All hospitals were threatened financially by managed care, but teaching centers, because of their higher costs, were particularly vulnerable.) In addition, the emphasis of managed care organizations on increasing the "throughput" of patients—seeing as many patients as possible, as quickly as possible—eroded the quality of educational programs. Students and residents no longer had as much time to learn by doing or to study their patients in depth. Hopefully, the desire of the profession and public to maintain quality in education and patient care will allow these difficulties to be surmounted in the years ahead.
Bibliography
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Fleming, Donald. William H. Welch and the Rise of Modern Medicine. Boston: Little, Brown, 1954.
Ludmerer, Kenneth M. Learning to Heal: The Development of American Medical Education. New York: Basic Books, 1985.
———. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 1999.
Norwood, William F. Medical Education in the United States before the Civil War. New York: Arno, 1971.
