Medicine – The Hospital As a College Part 1

THE last quarter of the last century saw many remarkable changes and reformations, among which in far-reaching general importance not one is to be compared with the reform, or rather revolution, in the teaching of the science and art of medicine. Whether the conscience of the professors at last awoke, and felt the pricking of remorse, or whether the change, as is more likely, was only part of that larger movement toward larger events in the midst of which we are today, need not be here discussed. The improvement has been in three directions: in demanding of the student a better general education; in lengthening the period of professional study; and in substituting laboratories for lecture rooms—that is to say, in the replacement of theoretical by practical teaching. The problem before us as teachers may be very briefly stated: to give to our students an education of such a character that they can become sensible practitioners—the destiny of seven-eighths of them. Toward this end are all our endowments, our multiplying laboratories, our complicated curricula, our palatial buildings. In the four years’ course a division is very properly made between the preparatory or scientific branches and the practical; the former are taught in the school or college, the latter in the hospital. Not that there is any essential difference; there may be as much science taught in a course of surgery as in a course of embryology. The special growth of the medical school in the past 25 years has been in the direction of the practical teaching of science. Everywhere the lectures have been supplemented or replaced by prolonged practical courses, and instead of a single laboratory devoted to anatomy, there are now laboratories of physiology, or physiological chemistry, of pathology, of pharmacology, and of hygiene. Apart from the more attractive mode of presentation and the more useful character of the knowledge obtained in this way, the student learns to use the instruments of precision, gets a mental training of incalculable value, and perhaps catches some measure of the scientific spirit. The main point is that he has no longer merely theoretical knowledge acquired in a lecture room, but a first-hand practical acquaintance with the things themselves. He not only has dissected the sympathetic system, but he has set up a kymograph and can take a blood pressure observation, he has personally studied the action of digitalis, of chloroform and of ether, he has made his own culture media and he has “plated” organisms. The young fellow who is sent on to us in his third year is nowadays a fairly well trained man and in a position to begin his life’s work in those larger laboratories, private and public, which nature fills with her mistakes and experiments.

How can we make the work of the student in the third and fourth year as practical as it is in his first and second? I take it for granted we all feel that it should be. The answer is, take him from the lecture-room, take him from the amphitheatre—put him in the out-patient department —put him in the wards. It is not the systematic lecture, not the amphitheatre clinic, not even the ward class—all of which have their value—in which the reformation is needed but in the whole relationship of the senior student to the hospital. During the first two years, he is thoroughly at home in the laboratories, domiciled, we may say, with his place in each one, to which he can go and work quietly under a tutor’s direction and guidance. To parallel this condition in the third and fourth years certain reforms are necessary. First, in the conception of how the art of medicine and surgery can be taught. My firm conviction is that we should start the third year student at once on his road of life. Ask any physician of twenty years’ standing how he has become proficient in his art, and he will reply, by constant contact with disease; and he will add that the medicine he learned in the schools was totally different from the medicine he learned at the bedside. The graduate of a quarter of a century ago went out with little practical knowledge, which increased only as his practice increased. In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient, using books and lectures as tools, as means to an end. The student starts, in fact, as a practitioner, as an observer of disordered machines, with the structure and orderly functions of which he is perfectly familiar. Teach him how to observe, give him plenty of facts to observe, and the lessons will come out of the facts themselves. For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself. The whole art of medicine is in observation, as the old motto goes, but to educate the eye to see, the ear to hear and the finger to feel takes time, and to make a beginning, to start a man on the right path, is all that we can do. We expect too much of the student and we try to teach him too much. Give him good methods and a proper point of view, and all other things will be added, as his experience grows.

The second, and what is the most important reform, is in the hospital itself. In the interests of the medical student, of the profession, and of the public at large we must ask from the hospital authorities much greater facilities than are at present enjoyed, at least by the students of a majority of the medical schools of this country. The work of the third and fourth year should be taken out of the medical school entirely and transferred to the hospital, which, as Abernethy remarks, is the proper college for the medical student, in his last years at least. An extra-ordinary difficulty here presents itself. While there are institutions in which the students have all the privileges to be desired, there are others in which they are admitted by side entrances to the amphitheatre of the hospital, while from too many the students are barred as hurtful to the best interests of the patients. The work of an institution in which there is no teaching is rarely first class. There is not that keen interest, nor the thorough study of the cases, nor amid the exigencies of the busy life is the hospital physician able to escape clinical slovenliness unless he teaches and in turn is taught by assistants and students. It is, I think, safe to say that in a hospital with students in the wards the patients are more carefully looked after, their diseases are more fully studied and fewer mistakes made. The larger question, of the extended usefulness of the hospital in promoting the diffusion of medical and surgical knowledge, I cannot here consider.

I envy for our medical students the advantages enjoyed by the nurses, who live in daily contact with the sick, and who have, in this country at least, supplanted the former in the affections of the hospital trustees.

The objection often raised that patients do not like to have students in the wards is entirely fanciful. In my experience it is just the reverse. On this point I can claim to speak with some authority, having served as a hospital physician for more than 25 years, and having taught chiefly in the wards. With the exercise of ordinary discretion, and if one is actuated by kindly feelings towards the patients, there is rarely any difficulty. In the present state of medicine it is very difficult to carry on the work of a first-class hospital without the help of students. We ask far too much of the resident physicians, whose number has not increased in proportion to the enormous increase in the amount of work thrust upon them, and much of the routine work can be perfectly well done by senior students.