Clinical Methods in the United States
The spread and refinement of the history and physical examination in the United States followed the development of medical education. This development has been the subject of a recent book by Ludmerer. The outline below follows his excellent account.
The Civil War pointed up with brutal clarity the deficiencies of American physicians. One estimate is that 110,000 Union soldiers died from wounds and 225,000 from disease; 50,000 Confederate soldiers died from wounds and 150,000 from disease! Percussion was performed by only a small portion of physicians. Very few used the thermometer. Stethoscopes were rarely used. Large doses of laxatives and emetics were given for therapy. The U.S. government finally required that each physician entering the army or navy pass a compulsory examination: barely 25% passed.
The U.S. physician of this time was a product of the medical education system of several dozen proprietary and a few university schools. Admission requirements consisted of one question: Can the applicant pay the fees? Instruction was almost totally didactic; anatomy was taught without benefit of dissection. The faculty of a typical proprietary school was composed of six to eight professors. The pervasive spirit was commercialism, with the teachers sharing the spoils of what was left of student tuition after expenses were paid. There were some bright spots. Alternatives and supplements available included apprenticeship, being a house pupil in a hospital, additional work during the summer by extramural non-degree-granting schools, and by going to Europe—especially France—as has been described above.
There was a profound skepticism toward medical science and experimentation among American physicians from 1800 until the last half of the century. This reflected the influence of the French School. The laboratory sciences were distrusted. In 1832 American physicians who had studied in France founded the Society for Medical Observation. By way of contrast, American physicians influenced by study in Germany founded in 1908 the American Society for Clinical Investigation. This attitude against research profoundly influenced medical education until beyond the Civil War. It is illustrated by the fact that at no medical school in the 1860s did research constitute a part of a faculty member’s responsibilities (Ludmerer, 1985). The faculty lectured and administrated on the school’s time, and saw private patients on their own time.
An extraordinary change occurred between 1850 and 1890: American physicians journeyed to Germany for their postgraduate education. As noted earlier, 15,000 went between 1870 and 1914. The physicians who went to Germany had to have significant means: a spartan living cost $900 a year. Consequently they were young, male, from the East Coast, and the upper strata of society (Ludmerer, 1985). They took one of two paths. They gained practical experience in the newly developing specialties of ophthalmology, dermatology, laryngology, obstetrics, and surgery, and then came home to go into private practice. This group—estimated to be some 10,000 of the number cited above—mostly went to Vienna, where the New Vienna School provided exceptional clinical opportunities. A smaller group went to study the fundamental medical sciences. These people came back to America and became the leaders in American medicine until well in the 1940s: William Welch, Franklin Mall, Henry Bowditch, etc. When these individuals returned, they were frustrated beyond measure because America simply had nothing comparable to the German university.
Professional schools, including medicine, moved into the universities
A development that fortunately paralleled the return from Germany of these individuals was the emergence of the American university between 1865 and 1890. “After the Civil War, the old-fashioned college evolved into the modern university. At the root of this transformation was the astounding growth of information that occurred in all scholarly fields”. Professional schools, including medicine, moved into the universities. The presidents of these universities, for a variety of reasons, vigorously promoted the welfare of their medical schools. “To university leaders, research and teaching in medicine carried a special imperative, for such work offered the hope of better diagnosis and treatment of disease”.
Between 1871 and 1893 these two forces, the German-trained physicians and ascendance of the university, acted to produce a profound change in American medical education at four universities: Harvard, Pennsylvania, Michigan, and Johns Hopkins.
At Harvard, Charles Eliot became president in 1870. He was a chemist who had worked in the laboratory and spent time abroad in Germany. He felt deeply the need to teach science with laboratories. He had a poor view of medical education: “The ignorance and general incompetency of the average graduate of American Medical Schools, at the time he receives the degree which turns him loose upon the community, is something horrible to contemplate.” His strong views on the need to reform medical education met with resistance and hostility on the part of the older faculty.
In November 1869, Eliot took the unprecedented step of assuming the chair at a meeting of the medical faculty, a seat he did not relinquish for the next forty years. No other event more dramatically symbolized the desire of the modern university to take charge of medical education. With the support of his faculty allies, Eliot tried to push through his ideas of reforming the medical school. For a year, as the two factions locked horns, the faculty was torn with strife. This was no conflict between elite and ordinary physicians but a civil war within the ranks of the elite. A deep chasm divided those with French from those with German views of medical science, providing a microcosm of the conflict besetting the elite medical community throughout America.
Eliot pushed through his ideas successfully, and in 1871 appointed Henry Bowditch, just back from Ludwig’s laboratory in Germany, as the faculty member in physiology. Bowditch was the first medical professor in America to be full-time in teaching and research. The laboratory became the seat for teaching a greatly expanded basic science curriculum. This focus upon the laboratory fostered a new educational philosophy: “the primary goal of medical education, in the eyes of the Harvard faculty, was not to provide students an encyclopedic knowledge of facts but to foster the student’s ability to think critically, to solve problems, to acquire new information, to keep up with the changing times. This could best be done in the laboratory rather than in the lecture hall”.
The University of Pennsylvania medical school underwent similar reforms in 1877, followed closely by the University of Michigan. The reforms in these three schools set the stage for the most extraordinary development of all: the opening of the Johns Hopkins Medical School in 1893. This new medical school embodied astonishing innovations from its inception: strict admission requirements for students; two years of rigorous basic science training with plentiful laboratory experience; two years of clinical experience at the hospital bedside; a faculty chosen solely for their teaching and research ability; a view that research was one of its high priorities.
Johns Hopkins Medical School
The acquisition of William Osler as professor and head of medicine at the Johns Hopkins Medical School was of the highest importance in the development of medical education and the foundation of clinical work as a science in the United States. In this one man there was a confluence of all the forces described earlier in this chapter: an appreciation of the importance of the laboratory and research; a reverence for the clinical greats who had laid the foundations of physical diagnosis—Auenbrugger, Laennec, Louis; a solid foundation in pathology. “His training and historical interest had given him the knowledge and perspective to incorporate in one medical educational setting all that the heritage of medicine had slowly and painfully evolved up to that time” (Harvey, 1973).
The medical clinic instructional model that Osler put into effect revolutionized medical teaching in the art and science of diagnosis and patient care. There were three aspects to the clinic. There was a live-in resident staff with graded experience: from the new graduate to more senior residents of several years’ experience. Instruction in methods of history taking and physical diagnosis was emphasized to a degree not seen since Louis. Medical students became actual members of the patient care team, taking histories, doing physicals, doing the laboratory work, and making rounds with the residents and faculty. Thus evolved the medical clerkship, which was extended to surgery, obstetrics and gynecology. This clerkship did for the clinical students what laboratory work did for the scientists.
“From the proprietary schools of the Civil War to the Johns Hopkins Medical School of 1893, the teaching of medicine had changed dramatically”. Three basic changes had occurred: the curriculum was more rigorous; many new subjects were added; the student became an active participant rather than a passive observer.
Source: Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition.