The Public Interest

Med Schools: Doing Better, Feeling Worse

Ezekiel J. Emanuel

Spring 1986

MEDICAL EDUCATION, to borrow an epithet originally intended for medicine itself, is “doing better and feeling worse.” Kenneth Ludmerer conveys just how well American medical schools are doing by reminding us of how poorly they were doing. Just one hundred years ago American medical schools were not academic centers, but businesses operated by physicians for profit. The entrance requirements were almost nonexistent, very few medical students possessed bachelor degrees, and some even lacked high school diplomas.  The M.D. degree was obtained after two sixteen-week terms devoid of any laboratory or patient care experience, leading Harvard’s President Eliot to note that “an American physician or surgeon may be, and often is, a coarse and uncultivated person.., quite unable to either speak or write his mother tongue with accuracy.” In his well-written but excessively repetitious book Ludmerer details the revolutionary transformation between 1870 and 1920 that firmly established the current American medical education system.  In the 1870s and 1880s universities began integrating and reforming previously loosely associated and autonomous medical schools. Harvard, Michigan, and Pennsylvania led the reform movement by introducing longer educational programs (three years with an optional fourth) and by arranging courses in a “graded sequence.” Simultaneously came a shift in pedagogic techniques from lectures to more active student engagement through laboratory work in the basic sciences. In 1893 the Johns Hopkins Medical School opened, introducing clinical clerkships in its affiliated hospital where students became integral participants in patient care.

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