How, practically, can this be carried into effect? Let us take the third year students first. A class of 100 students may be divided into ten sections, each of which may be called a clinical unit, which should be in charge of one instructor. Let us follow the course of such a unit through the day. On Mondays, Wednesdays, and Fridays at 9 a.m. elementary instruction in physical diagnosis. From 10 to 12 a.m. practical instruction in the out-patient department. This may consist in part in seeing the cases in a routine way, in receiving instruction how to take histories, and in becoming familiar with the ordinary aspect of disease as seen in a medical outclinic. At 12 o’clock a senior teacher could meet four, or even five, of the units, dealing more systematically with special cases. The entire morning, or, where it is customary to have the hospital practice in the afternoon, a large part of the afternoon, two or three hours at least, should be spent in the out-patient department. No short six weeks’ course, but each clinical unit throughout the session should as a routine see out-patient practice under skilled direction. Very soon these students are able to take histories, have learned how to examine the cases, and the out-patient records gradually become of some value. Of course all of this means abundance of clinical material, proper space in the out-patient department for teaching, sufficient apparatus and young men who are able and willing to undertake the work.
On the alternate days, Tuesdays, Thursdays and Saturdays, the clinical unit (which we are following) is in the surgical out-patient department, seeing minor surgery, learning how to bandage, to give ether, and helping in all the interesting work of a surgical dispensary. Groups of three or four units should be in charge of a demonstrator of morbid anatomy, who would take them to postmortems, the individual men doing the work, and one day in the week all the units could attend the morbid anatomy demonstration of the professor of pathology. I take it for granted that the student has got so far that he has finished his pathological histology in his second year, which is the case in the more advanced schools.
Other hours of the day for the third year could be devoted to the teaching of obstetrics, materia medica, therapeutics, hygiene and clinical microscopy. At the end of the session in a well-conducted school the third-year student is really a very well-informed fellow. He knows the difference between Pott’s disease and Pott’s fracture; he can readily feel an enlarged spleen, and he knows the difference between Charcot’s crystals and Charcot’s joint.
In the fourth year I would still maintain the clinical unit of ten men, whose work would be transferred from the out-patient department to the wards. Each man should be allowed to serve in the medical, and, for as long a period as possible, in the surgical wards. He should be assigned four or five beds. He has had experience enough in his third year to enable him to take the history of the new cases, which would need, of course, supervision or correction by the senior house officer or attending physician. Under the supervision of the house physician he does all of the work connected with his own patients; analysis of the urine, etc., and takes the daily record as dictated by the attending physician. One or two of the clinical units are taken round the wards three or four times in the week by one of the teachers for a couple of hours, the cases commented upon, the students asked questions and the groups made familiar with the progress of the cases. In this way the student gets a familiarity with disease, a practical knowledge of clinical methods and a practical knowledge of how to treat disease. With equal advantage the same plan can be followed in the surgical wards and in the obstetrical and gynaecological departments.
An old method, it is the only method by which medicine and surgery can be taught properly, as it is the identical manner in which the physician is himself taught when he gets into practice. The radical reform needed is in the introduction into this country of the system of clinical clerks and surgical dressers, who should be just as much a part of the machinery of the wards as the nurses or the house physicians.
There is no scarcity of material; on the contrary, there is abundance. Think of the plethora of patients in this city, the large majority of whom are never seen, not to say touched, by a medical student! Think of the hundreds of typhoid fever patients, the daily course of whose disease is never watched or studied by our pupils! Think how few of the hundreds of cases of pneumonia which will enter the hospitals during the next three months, will be seen daily, hourly, in the wards by the fourth year men! And yet it is for this they are in the medical school, just as much as, more indeed, than they are in it to learn the physiology of the liver or the anatomy of the hip-joint.
But as you may ask, how does such a plan work in practice? From a long experience I can answer, admirably! It has been adopted in the Johns Hopkins Medical School, of which the hospital, by the terms of the founder’s will, is an essential part. There is nothing special in our material, our wards are not any better than those in other first-class hospitals, but a distinctive feature is that greater provision is made for teaching students and perhaps for the study of disease. Let me tell you in a few words just how the work is conducted. The third year students are taught medicine:
First, in a systematic course of physical diagnosis conducted by Drs. Thayer and Futcher, the Associate Professors of Medicine, in the rooms adjacent to the out-patient department. In the second half of the year, after receiving instruction in history-taking, the students take notes and examine out-patients.
Secondly, three days in the week at the conclusion of the out-patient hours, the entire class meets the teacher in an adjacent room, and the students are taught how to examine and study patients. It is remarkable how many interesting cases can be shown in the course of a year in this way. Each student who takes a case is expected to report upon and “keep track” of it, and is questioned with reference to its progress. The opportunity is taken to teach the student how to look up questions in the literature by setting subjects upon which to report in connexion with the cases they have seen. A class of fifty can be dealt with very conveniently in this manner.
Thirdly, the clinical microscopy class. The clinical laboratory is part of the hospital equipment. It is in charge of a senior assistant, who is one of the resident officers of the hospital. There is room in it for about one hundred students on two floors, each man having his own work-table and locker and a place in which he can have his own specimens and work at odd hours. The course is a systematic one, given throughout the session, from two hours to two hours and a half twice a week, and consists of routine instruction in the methods of examining the blood and secretions, the gastric contents, urine, etc. This can be made a most invaluable course, enabling the student to continue the microscopic work which he has had in his first and second years, and he familiarizes himself with the use of a valuable instrument, which becomes in this way a clinical tool and not a mere toy. The clinical laboratory in the medical school, should be connected with the hospital, of which it is an essential part. Nowadays the microscopical, bacteriological and chemical work of the wards demands skilled labour, and the house physicians as well as the students need the help and super-vision of experts in clinical chemistry and bacteriology, who should form part of the resident staff of the institution.
Fourthly, the general medical clinic. One day in the week, in the amphitheatre, a clinic is held for the third and fourth year students and the more interesting cases in the wards are brought before them. As far as possible we present the diseases of the seasons, and in the autumn special attention is given to malarial and typhoid fever, and later in the winter to pneumonia. Committees are appointed to report on every case of pneumonia and the complications of typhoid fever. There are no systematic lectures, but in the physical diagnosis classes there are set recitations, and in what I call the observation class in the dispensary held three times a week, general statements are often made concerning the diseases under consideration.
Fourth Year Ward Work.The class is divided into three groups (one in medicine, one in surgery, and one in obstetrics and gynecology) which serve as clinical clerks and surgical dressers. In medicine each student has five or six beds. He takes notes of the new cases as they come in, does the urine and blood work and helps the house physician in the general care of the patients. From nine to eleven the visit is made with the clinical clerks, and systematic instruction is given. The interesting cases are seen and new cases are studied, and the students questioned with reference to the symptoms and nature of the disease and the course of treatment. What I wish to emphasize is that this method of teaching is not a ward-class in which a group of students is taken into the ward and a case or two demonstrated; it is ward-work, the students themselves taking their share in the work of the hospital, just as much as the attending physician, the interne, or the nurse. Moreover, it is not an occasional thing. His work in medicine for the three months is his major subject and the clinical clerks have from nine to twelve for their ward-work, and an hour in the afternoon in which some special questions are dealt with by the senior assistant or by the house physicians.
The Recitation Class.As there are no regular lectures, to be certain that all of the subjects in medicine are brought before the students in a systematic manner, a recitation class is held once a week upon subjects set beforehand.
The Weekly Clinic in the amphitheatre, in which the clinical clerks take leading parts, as they report upon their cases and read the notes of their cases brought before the class for consideration. Certain important aspects of medicine are constantly kept before this class. Week after week the condition of the typhoid fever cases is discussed, the more interesting cases shown, the complications systematically placed upon the board. A pneumonia committee deals with all the clinical features of this common disease, and a list of the cases is kept on the blackboard, and during a session the students have reports upon fifty or sixty cases, a large majority of which are seen in the clinic by all of them, while the clinical clerks have in the wards an opportunity of studying them daily.
The general impression among the students and the junior teachers is that the system has worked well. There are faults, perhaps more than we see, but I am sure they are not in the system. Many of the students are doubtless not well informed theoretically on some subjects, as personally I have always been opposed to that base and most pernicious system of educating them with a view to examinations, but even the dullest learn how to examine patients, and get familiar with the changing aspects of the important acute diseases. The pupil handles a sufficient number of cases to get a certain measure of technical skill, and there is ever kept before him the idea that he is not in the hospital to learn everything that is known but to learn how to study disease and how to treat it, or rather, how to treat patients.