by Abraham Flexner, 1910
In 1908 the Carnegie Foundation for the Advancement of Teaching commissioned educator Abraham Flexner to survey the condition of medical education in the United States and Canada. Flexner spent a year visiting all of the institutions that represented themselves as medical schools and decided that almost all of them were "essentially private ventures, moneymaking in spirit and object." His report received front-page coverage and proved highly embarrassing to the medical profession. Many schools were forced to close (in Louisville they dwindled from seven to one, in Chicago, from fifteen to three), educational qualifications were raised and standardized, and the number of students allowed to study was limited. The change was a revolutionary one; and from it modern medical education was born. The following selection is from the third chapter of the report, "The Actual Basis of Medical Education."
Taking a two-year college course, largely constituted of the sciences, as the normal point of departure, let us survey the existing status. The 155 medical schools of the United States and Canada fall readily into three divisions: the first includes those that require two or more years of college work for entrance; the second, those that demand actual graduation from a four-year high school or oscillate about its supposed "equivalent"; the third, those that ask little or nothing more than the rudiments or the recollection of a common school education.
To the first division, sixteen institutions already belong; six more, now demanding one year of college work, will fully enter the division in the fall of 1910 by requiring a second; and, several more, at this date still in the second division, will shortly take the step from the high school to the two-year college requirement. The Johns Hopkins requires for entrance a college degree which, whatever else it represents, must include the three fundamental sciences, French, and German. No exception has ever been made to this degree requirement; but, recently, admission to the second-year class has been granted to students holding an A.B. degree earned by four years' study, the last of them devoted to medical subjects in institutions where those subjects were excellently taught.
At Harvard the degree requirement has been somewhat unsettled by a recent decision to admit students without degree provided they have had two years of college science; they are to be grouped as "special" students and are required to maintain higher standing in order to qualify for the M.D. degree. But as these students enter on a general rule and as a matter of course, and are, under a slight handicap, eligible to the M.D. degree, they are not accurately described as special. A special student is properly one whom no rule fits; one whose admission presents certain individual features requiring consideration on their merits. Such is not the case with the students under discussion; they enter just as regularly as the degree men, and without that limitation as to number which makes of the "special student" device something of a privilege. Harvard can thus admit any student who is eligible to the schools with the two-year college requirement.
The other institutions under discussion telescope the college and medical courses; the preliminary medical sciences constitute the bulk of two college years; the next two years are reckoned twice. They count simultaneously as third and fourth years of the college and as first and second years of the medical course. At their close the student gets the A.B. degree, but his medical education is already half over. Without exception, the schools belonging to this group are high-grade institutions. They differ considerably, however, in the degree of rigor with which their elevated entrance requirements have been enforced from the start.
At the University of Pennsylvania, for example, in a class of 114, admitted this year (1909-1910) on a one-year college basis, 75 (66 percent) are conditioned; at Ann Arbor, of 36 entering on the two-year college basis, only 8 are conditioned at all, and those mainly in organic chemistry; at Yale, which advanced in 1909-1910 from the high school to the two-year college basis, in a class of 23, there was only one partial condition in biology, and, best of all, failed members of last year's class on the old basis were refused readmission.
Experience elsewhere indicates that the percentage of conditions declines rapidly as students learn by forethought to adjust their work to their ultimate purpose and as the colleges facilitate adjustment by providing the requisite opportunities; both of which processes will be accelerated if the medical schools have the courage - and the financial strength - to close their doors to students who labor under anything more than a slight handicap. Here as elsewhere development follows hard upon actual responsibility.
Our second division constitutes the real problem; out of it additional high-grade medical schools to the number actually required must be developed. About fifty institutions, whose entrance standard approximates high school graduation, belong here. Great diversity exists in the quality of the student body of these institutions: the regents' certificates in New York, state board supervision in Michigan, the control of admission to their medical departments by the academic authorities of McGill and Toronto, insure as capable and homogeneous an enrollment as is obtainable at or about the high school level. A few others, not so well protected, are within measurable distance of the same category - the medical department of Tulane University and Jefferson Medical College (Philadelphia), for example. In general, however, the schools of this division are difficult to classify; for they freely admit students on bases that are not only hopelessly unequal to each other but are even incapable of reduction to a common denominator.
On their actual standards the catalog statements throw little light; there the requirements are cast in the form of a descending scale, running from the top, down. Equally acceptable in their sight are a bachelor's degree from a college or a university, a diploma from an "accredited" high school, an examination in a few specified and several of a wide range of optional studies, and a certificate from the principal of a high school, normal school, or academy, from a "reputable instructor," from a state or city superintendent of education, or from a state board of medical examiners, that stamps the applicant as possessing the "equivalent" of a high school education.
Now it is clear that the alternatives at the top are mainly decorative. The real standard is perilously close to the "equivalent" that creeps in modestly at the bottom. There is, of course, no active prejudice anywhere against Ph.D.'s and A.M.'s and A.B.'s and B.Sc.'s; they are apt to be rather conspicuously exploited, when they drift in. But they do not set the pace; they do not determine or even vitally affect the character of the school. In these instances the medical curriculum either contains the premedical subjects in an elementary form, or, what may be worse, tries to go ahead entirely without them.
The real standard is not influenced by the presence of degree men, and the wonder is that any of them sacrifice the advantage of a superior education by resorting to these institutions. The minimum is, then, the real standard; all else is permissive; for to the needs of those admitted at the bottom the quantity and quality of the instruction must in fairness conform.
To get at the real admission standard, then, of these medical schools, one must make straight for the "equivalent." On the methods of ascertaining and enforcing that, the issue hangs. Now the "equivalent" may be defined as a device that concedes the necessity of a standard which it forthwith proceeds to evade. The professed high school basis is variously sacrificed to this so-called equivalent. The medical schools under discussion agree to accept at face value only graduation diplomas from "approved" or "accredited" high schools. These terms have a definite meaning: they indicate schools which, upon proper investigation, have been recognized by the state universities of their respective states or by some other competent educational organization - in New England, by the College Entrance Certificate Board; in the Middle West, by the North Central Association. High schools and academies not acceptable at full value to state universities or to the bodies just named do not belong to the "approved" or "accredited" class; their diplomas and certificates are not, therefore, entitled to be received in satisfaction of the announced standard. They are nevertheless freely accepted. ...
If the standard were enforced, the candidates in question, not offering a graduation diploma from an accredited high school, would be compelled to enter by written examination. But the examination is, as things stand, only another method of evasion. Neither in extent nor in difficulty do the written examinations, in the relatively rare cases in which they are given, even approximate the high school standard. Nor are they meant to do so. Colleges with medical departments of the kind under discussion do not expect academic and medical students to pass the same or the same kind of examination. A special set of questions is prepared for the medical candidates, including perhaps half the subjects, and each of these traversing about half the ground covered by the academic papers. ...
There remains still a third method of cutting below an actual high school standard - the method indeed that provides much the most capacious loophole for the admission of unqualified students under the cloak of nominal compliance with the high school standard. The agent in the transactions about to be described is the medical examiner, appointed in some places by voluntary agreement between the schools, elsewhere delegated by the state board or by the superintendent of public instruction acting in its behalf, for the purpose of dealing with students who present written evidence other than the diploma of an accredited high school. It is intended and expected that this official shall enforce a high school standard. In few states is this standard achieved. The Education Department in New York, the state boards in Minnesota and Michigan, maintain what may be fairly called a scholastically honest high school requirement; for they require a diploma representing an organically complete secondary school education, properly guaranteed, or, in default thereof, a written examination covering about the same ground; there is no other recourse.
Elsewhere the state board is legally powerless, as in Maryland, or unwilling to antagonize the schools, as in Illinois and Kentucky. The outside examiners, agreed on by the schools in the former case, designated by law in the latter, fall far short of enforcing a high school standard. The examiner, even where distinctly well intentioned, as in Kentucky, never gets sufficient control. The schools do not want the rule enforced, and the boards are either not strong enough or not conscientious enough to withstand them.
Besides, the examiners lack time, machinery, and encouragement for the proper performance of their ostensible office. They are busy men: here, a county official; there, a school principal; elsewhere, a high school professor. A single individual, after his regular day's work is over, without assistance of any kind, is thus expected to perform a task much more complicated than that for which Harvard, Columbia, and the University of Michigan maintain costly establishments.
There is no set time when candidates must appear. They drop in as they please, separately - now, before the medical school opens; again, long after; sometimes with their credentials; sometimes without them. There is no definite procedure. At times, the examiner concludes from the face of the papers; at times, from the face of the candidate. The whole business is transacted in a free and easy way. In Illinois, for example, the law speaks of "preliminary" educational requirements; the state board graciously permits them to become subsequents.
Students enter the medical schools, embark on the study of medicine, and, at their convenience, "square up" with one of the examiners. An evening call is arranged; there is an informal talk, aiming to elicit what "subjects" the candidate "has had." He may, after an interview lasting from thirty minutes to two hours, and rarely including any writing, be "passed" with or without "conditions"; if with conditions, the rule requires him to reappear for a second "examination" before the beginning of the sophomore year; but nothing happens if he postpones his reappearance until a short time before graduation. Besides, a condition in one subject may be removed by "passing" in another! "No technical questions are asked; the presumption is that the applicant won't remember details."
Formerly, written examinations were used in part; but they were given up "because almost everybody failed." And it may at any moment happen that an applicant actually turned down by one examiner will be passed by another. The most flagrantly commercial of the Chicago schools operate "premedical" classes where a hasty cram, usually at night, suffices to meet the academic requirements of the Illinois state board: "The examiner's no prude, he'll give a man a chance," said the dean of one of them. ...
To all the disorder that prevails in schools of this grade in the United States, the Canadian schools at the same level present, with two exceptions, a forcible contrast. There, too, "equivalents" are accepted; but they are equivalents in fact as in name, for they are probed by a series of written examinations, each three hours in length, held at a stated time and place, only and actually in advance of the opening of the medical school, entrance to which is absolutely dependent on their outcome.
The quality of the student body thus accumulated in the schools under discussion bears out the above description. "The facilities are better than the students"; "The boys are imbued with the idea of being doctors; they want to cut and prescribe; all else is theoretical"; students accepted in chemistry or physics "don't know a barometer when they see it"; "It is difficult to get a student to want to repeat an experiment (in physiology). They have neither curiosity nor capacity." "The machinery doesn't stop the unfit." "Men get in, not because the country needs the doctors but because the schools need the money." "What is your honest opinion of your own enrollment?" a professor in a Philadelphia school was asked. "Well, the most I would claim," he answered, "is that nobody who is absolutely worthless gets in!"
We have still to deal with schools of our third division. They are most numerous in the South, but they exist in almost all medical "centers" - San Francisco, Chicago, - there plainly on the sufferance of the state board, for the law, if enforced, would stamp them out - St. Louis and Baltimore. Outside the South they usually make some pretense of requiring the "equivalent" of a high school education; but no examiner of any kind is employed, and the deans are extremely reluctant to be pinned down. Southern schools of this division, after specifying an impressive series of acceptable credentials ranging once more from university degrees downward, announce their satisfaction with a "grammar school followed by two years of a high school," or in default thereof a general assurance of adequate "scholastic attainments" by a state, city, or county superintendent, or some other person connected with education or purporting to be such; but the lack of such credentials is not very serious, for the student is admitted without them, with leave to procure them later.
Many of the schools accept students from the grammar schools. Credentials, if presented, are casually regarded and then usually returned; a few may be found, rolled up in a rubber band in a dusty pigeonhole. There is no protection against fraud or forgery. At the College of Medicine and Surgery, Chicago, a thorough search for credentials or some record of them was made by the secretary and several members of the faculty, through desk drawers, safe, etc., but without avail. The school is nevertheless in "good standing" with the Illinois state board, and is "accredited" by the New York Education Department to the extent of three years' work.
At the Medical Department of the University of Georgia I was told: "We go a long way on faith." In visits to medical colleges certificates were found from nonexistent schools as well as from nonexistent places. Of course a few fairly competent students may be found sprinkled in these institutions. But for the most part, the student body gets in on the "equivalent." ...
Statistical proof of inadequacy of preparation is furnished by what one may fairly call the abnormal mortality within schools operating on the basis of "equivalents." The standards of promotion in these schools watch narrowly the action of the state boards, which are usually lenient. The schools are too weak financially to do otherwise; doubtful points are resolved in the boy's favor. Hence the school examinations play less havoc than would follow tests strictly constructed in the public interest. Yet the mortality from one cause or another by the close of the first year runs from 20 to 50 percent.
At the Medico-Chirurgical College of Philadelphia, an initial first-year enrollment of 152 in October fell to 100 by the following January 1; of these, 60 passed without conditions, much less than one-half the original class enrollment; at Tufts, the entering class, 1908-1909, shows in the catalog an enrollment of 141 - 75 were promoted, with or without conditions, into the sophomore class; at Cornell, on its former high school basis, the failures at the close of the first year in a period of ten years averaged 28 percent; at Buffalo, the failed and conditioned of three successive first-year classes amounted to 40 percent of the total enrollment; at Vanderbilt, out of a class of 70, the dropped, conditioned, and failed amounted to 44 percent; at the College of Physicians and Surgeons, Atlanta, 70 percent, out of a class of 99.
In schools on the higher basis, i.e., two years of college work or better, the instruction is more elaborate, the work more difficult, and the examinations harder; for scientific ideals rather than chances with the state board dominate. Yet the mortality drops decisively. At the Johns Hopkins, the mortality during three successive years averages less than 5 percent, only half of which is due to failure; at Ann Arbor, on the one-year college basis, the mortality is below 10 percent.
The exhibit made by institutions that have tried both standards is especially instructive. At the University of Missouri, during the last three years of the high school or equivalent basis, there was a mortality due to actual failure of 35 percent; during the following three years, when one year of college work was required, the mortality fell to 12 1/2 percent. At the Medical Department of the University of Minnesota, during the last three years of the high school requirement, the mortality was 18 percent; in the three years following, on the basis of one year of college work, the mortality was about 10 percent. At the University of Virginia, in the last two years on the old basis, 38 percent of the students failed in one or more subjects; an increase in entrance requirements by one college year reduces the fatalities to 14 percent, despite the augmented difficulty of the work.
The Medical Department of the University of Texas has gradually advanced from a two-year high school basis to a four-year high school basis; on the lower standard there were 34 percent of hopeless failures in 1903 as against 13 percent of hopeless failures in 1908 on the higher. The requirement of a college year assists doubly - first, in eliminating the sham equivalents; next, in strengthening the equipment of those who actually persist. Canada accomplishes the former by means of the examinations already noticed, with the result that the mortality there is distinctly less than ours, at something like the same ostensible level.
The breaches made by the fatalities above described are repaired by immigration, which on investigation proves to be in most instances only another way of evading standards - entrance and other. To some extent, good students who find themselves in a poor school endeavor to retrieve their error by transferring themselves to a better; again, there is a certain amount of enforced emigration annually from schools that, like the University of Wisconsin, offer medical instruction in the first two years only. In the main, however, the "lame ducks" move, and, strangely enough, into schools that are at the moment engaged in rejecting a number equally lame. The interchange is veiled by pretended examinations; but the character of the examination can be guessed from the quality of the students that pass it.
Two standards are thus often broken at once: An ill-equipped student registers in a low-grade Chicago school. At the close of a year or two, he transfers to the College of Physicians and Surgeons, which might have declined him originally. He has thus circumvented its admission requirements. If, now, he has previously failed in the medical courses so far pursued, and succeeds "on examination" in passing, he has simultaneously circumvented the professional requirements as well. Instances of both kinds abound in schools at and below the high school basis. ...
Is this the best that can be done? Will the actual enforcement of a real and adequate standard starve any section of the country in the matter of physicians? The question can be answered without guesswork or speculation.
The South requires something like 400 doctors annually. How high a standard can it enforce and still get them? In the year 1908-1909 there were 15,791 male students in four-year high schools in six Southern states - Alabama, Georgia, Louisiana, South Carolina, Virginia, and Texas; there were in the previous year 5,877 male students in the academic departments of the Southern state universities and 1,653 more in endowed institutions of similar grade: a population of over 23,000 bordering on high school graduation and widely distributed over the entire area. Our question is thus already answered. The best material for the making of a few hundred Southern doctors annually does not have to be torn from the plow.
But these figures convey by no means the whole truth. The South is in the midst of a genuine educational renaissance. Within the last few years every Southern state under the leadership of the state university, the state Department of Education, and certain endowed institutions like Vanderbilt University has set enthusiastically to work to develop its common and secondary school systems after the admirable model furnished by the robust communities of the Middle West.
The professors of secondary education in the state universities are the evangelists of this auspicious movement. Young, intelligent, well-trained, these sturdy leaders ceaselessly traverse the length and breadth of their respective states, stimulating, suggesting, guiding, organizing. It is an inspiring spectacle. Three years ago the high school had no legal standing in Virginia; today the state is dotted with two-year, three-year, and four-year high schools, created by local taxation, with a considerable subvention from the state treasury. There are already 2,511 boys in fairly well-equipped four-year high schools, and as many more in private institutions of equal value; and the two-year and three-year schools are growing rapidly into fuller high school stature. It needs no argument to prove that Virginia can at once procure its doctors from among the bona fide graduates of such high schools and better. ...
The situation is even clearer, insofar as it touches the rest of the country. We estimate that outside the South 1,500 doctors annually graduated will provide for all the real and many imaginary needs. There are at this date something like 8,000 public and over 1,000 private high schools, so widely dispersed over the area under consideration that on the average few boys need go over five miles to school. In the public high schools alone there are enrolled 300,000 boys. What excuse exists for cutting under the high school? We can indeed do better than to accept as the basis of a medical education the high school "flat." In the colleges, universities, and technical schools of the North and West, exclusive of preparatory and professional departments, there were, in 1908, 120,000 male students. The number swells with unprecedented rapidity; long before the country has digested the number of doctors now struggling for a livelihood, it will have doubled.
Already, in 1907, 903 of the doctors graduated in that year held academic degrees; that is to say, fully one-half of the number the country actually needed could conform to the standard that has been urged, or better. There is at this moment absolutely nothing in the educational situation outside the South that countenances the least departure from the scientific basis necessary to the successful pursuit of modern medicine.
For whose sake is it permitted? Not really for the remote mountain districts of the South, for example, whence the "yarb doctor," unschooled and unlicensed, can in no event be dislodged; nor yet for that twilight zone, on the hither edge of which so many low-grade doctors huddle that there is no decent living for those already there and no tempting prospect for anybody better: ostensibly, "for the poor boy." For his sake, the terms of entrance upon a medical career must be kept low and easy. We have no right, it is urged, to set up standards which will close the profession to "poor boys."
What are the merits of this contention? The medical profession is a social organ, created not for the purpose of gratifying the inclinations or preferences of certain individuals but as a means of promoting health, physical vigor, happiness - and the economic independence and efficiency immediately connected with these factors. Whether most men support themselves or become charges on the community depends on their keeping well, or if ill, promptly getting well. Now, can anyone seriously contend that in the midst of abundant educational resources, a congenial or profitable career in medicine is to be made for an individual regardless of his capacity to satisfy the purpose for which the profession exists?
It is right to sympathize with those who lack only opportunity; still better to assist them in surmounting obstacles; but not at the price of certain injury to the common weal. Commiseration for the hand-spinner was not suffered for one moment to defeat the general economic advantage procurable through machine-made cloth. Yet the hand-spinner had a sort of vested right: society had tacitly induced him to enter the trade; he had grown up in it on that assurance; and he was now good for nothing else. Your "poor boy" has no right, natural, indefeasible, or acquired, to enter upon the practice of medicine unless it is best for society that he should. ...
So much from the standpoint of the individual. The proper method of calculating cost is, however, social. Society defrays the expense of training and maintaining the medical corps. In the long run which imposes the greater burden on the community - the training of a needlessly vast body of inferior men, a large proportion of whom break down, or that of a smaller body of competent men who actually achieve their purpose? When to the direct waste here in question there is added the indirect loss due to incompetency, it is clear that the more expensive type is decidedly cheaper. Aside from interest on investment, from loss by withdrawal of the student body from productive occupations, the cost of our present system of medical education is annually about $3 million as paid in tuition fees alone. The number of high-grade physicians really required could be educated for much less; the others would be profitably employed elsewhere; and society would be still further enriched by efficient medical service.
The argument is apt to shift at this point. If we refuse to be moved by the "poor boy," pity the small towns; for it is speciously argued that the well-trained, college-bred student will scorn them. Not sympathy for the poor boy requires us now to sacrifice the small town to him, but sympathy for the small town requires us to sacrifice the poor boy to it. Two vital considerations are overlooked in this plea. In the first place, the small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best-trained physician that can be induced to go there.
But, we are told, the well-trained man will not go; he will not pay for a highgrade medical education and then content himself with a modest return on his investment. Now the six-year medical education (that based on two college years) and the four-year medical education (that based on the high school or equivalent) may, as we saw above, be made to cost the same sum. As far as cost is concerned, then, the better sort of four-year medical education must have precisely the same effect on distribution of doctors as the six-year training furnished by the state universities. ...
The truth is that existing conditions are defended only by way of keeping unnecessary medical schools alive. The change to a higher standard could be fatal to many of them without in the least threatening social needs. Momentarily there would be a sharp shrinkage. But forethought would be thus effectively stimulated; trained men would be attracted into the field; readjustment would be complete long before any community felt the pinch. Despite prevailing confusion - legal, popular, and educational - as to what good training in medicine demands, the enrollment in the five schools which have during the last four years required two or more years of college work is already 1,186 students, and is increasing rapidly. ...
It does not follow, however, that if schools generally rose to the college requirement, their losses would be only one-half and the recovery therefrom ultimately assured. For the schools that came off thus lightly were previously attended by a large proportion of high-grade men. A much greater loss would undoubtedly take place in the lower-grade schools; many of them would be practically annihilated. For the tendency of elevated standards and ideals is to reduce the number of students to something like parity with the demand, and to concentrate this reduced student body in fewer institutions, adequately supported. ...
The reconstruction of our medical education on the basis of two years of required college work is not, however, going to end matters once and for all. It leaves untouched certain outlying problems that will all the more surely come into focus when the professional training of the physician is once securely established on a scientific basis. At that moment the social role of the physician will generally expand, and to support such expansion he will crave a more liberal and disinterested educational experience.
The question of age - not thus far important because hitherto our demands have been well within the limits of adolescence - will then require to be reckoned with. The college freshman averages nineteen years of age; two years of college work permit him to begin the study of medicine at twenty-one, to be graduated at twenty-five, to get a hospital year and begin practice at twenty-six or twenty-seven. No one familiar with the American college can lightly ask that this age be raised two years for everybody for the sake of the additional results to be secured from nonprofessional college work. There is, however, little question that compression in the elementary school, closer articulation between and more effective instruction within secondary school and college, can effect economies that will give the youth of twenty-one the advantage of a complete college education. The basis of medical education will thus have been broadened without deferring the actual start.
Meanwhile we are so far from endeavoring to force a single iron-clad standard on the entire country that our proposition explicitly recognizes at least three concurrent levels for the time being: (1) the state university entrance standard in the South; (2) the two-year college basis as legal minimum in the rest of the country; (3) the degree standard in a small number of institutions. ...
No general legislation is at the moment feasible. The South, for instance, may well rest for a time if every state will at once restrict examinations for license to candidates actually possessing the M.D. degree, and require after, say, January 1, 1911, that every such degree shall emanate from a medical school whose entrance standards are at least those of the state university. Such legislation would suppress the schools that now demoralize the situation; it would concentrate the better students in a few solvent institutions to which the next moves may safely be left. Elsewhere, every available agency should be employed to bring examining boards to reinterpret the work "equivalent" and to adopt efficient machinery for the enforcement of the intended standard.
Equivalent means "equal in force, quality, and effect." The only authorities competent to pass on such values are trained experts. The entire matter would be in their hands if the state boards should in every state delegate the function of evaluating entrance credentials to a competently organized institution of learning. In many states, the state university could very properly perform this duty; elsewhere, an equally satisfactory arrangement could be made with an endowed institution. Whatever the standard fixed, it would thus be intelligently enforced.
The school catalogs would then announce that no student can be matriculated whose credentials are not filed within ten days of the opening of the session, and that no M.D. degree can be conferred until at least four years subsequent to complete satisfaction of the preliminary requirement. These credentials, sent at once to the secretary of the state board, would be by him turned over to the registrar of the state or other university, whose verdict would be final. A state that desired to enforce a four-year high school requirement could specify as satisfying its requirements:
Certificate of admission to a state university requiring a four-year high school education.
Certificate of admission to any institution that is a member of the Association of American Universities.
Medical student certificate of the regents of the University of the State of New York.
Certificates issued by the College Entrance Examination Board for fourteen units.
In exchange for such credentials, or for high school diplomas acceptable to the academic authorities acting for the state board, a medical student certificate would be issued; in default thereof, the student must by examination earn one of the aforesaid credentials, in its turn to be made the basis of his medical student certificate. In the Southern states, the legal minimum would be necessarily below the four-year high school; in Minnesota, above it. But the same sort of machinery would work. The schools would have nothing to do with it except to keep systematically registered the name of the student and the number of his certificate; the state board or the university acting for it would keep everything else, open to inspection.
This is substantially what takes place in New York, where the State Education Department superintends the process. What is wanted in other states is an agency similarly qualified. For the present nothing can so well perform the office within a given state as its state university, or, in default thereof, the best of its endowed institutions. This suggestion is perfectly fair to all medical schools, for the credentials would pass through the hands of the state board to the reviewing authority without information as to the purpose of the applicant. The directions required would take up less space in the medical school catalogs than the complicated details they now contain.
It should be further provided that the original credentials of every student be kept on file in the office of the state board or the reviewing university, and that they shall be open to inspection, without notice, by properly accredited representatives of medical and educational organizations. These simple measures would introduce intelligence and sincerity where subterfuge and disorder now prevail. The beneficial results to the high school and the medical school would be incalculable. Nor would the poor boy be subjected to the least hardship; for by exercising forethought, he could accumulate genuine scholastic credits by examination or otherwise, pari passu, during the time he is accumulating the money for his medical education.
So much actually accomplished, the rest will be easier. The reduced number of schools will not resist the forces making for a higher legal minimum. The state universities of the West will doubtless lead this movement; for once established on the two-year college basis, they will induce the states to protect their own sons and the public health against the lower-grade doctors made elsewhere. The University of Minnesota, having by statesmanlike action got rid of all other medical schools in the state, is thus backed up by the legislature and the state board. North Dakota and Indiana have taken the same stand. Michigan and Iowa will probably soon follow. "The adjustment is perhaps difficult, but not too difficult for American strength."
SourceMedical Education in the United States and Canada, Bulletin No. 4, New York, 1910, pp. 28-51.
