The American Way of Educating Doctors

Kenneth M. Ludmerer. Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care. New York: Oxford University Press, 1999. xxvi + 399 pp. Notes and index. $29.95.

From the beginning America's medical needs were met in makeshift fashion. Unlike the mother country no cadre of university-educated physicians stood at the head of the healing trades to exert influence over the burgeoning ways of treating sick people. Few graduates of English or Continental medical schools made the risky voyage across the Atlantic to take up the primitive life of a colonial practitioner. Not until 1765 did a medical school, modeled on Edinburgh, offer a limited number of opportunities to residents of Philadelphia and beyond. For the average person who was ill, especially away from the few costal cities, help came from practically trained men and women who variously called themselves doctors, druggists, or midwives. Even as late as a century ago the vast majority of American doctors were trained in practical ways with little or no exposure to a university.

For nearly 300 years the American physician trained in an apprenticeship; a private course, sometimes in a hospital or dispensary; or in an independent, short-term medical school, unrelated to any university, and often run for the benefit of the physician--entrepreneurs who owned it. The degrees offered by such schools were readily accepted as a prima facie license to practice, making efforts to control medical teaching far more difficult than in Europe. In the American federal system, furthermore, each state was a law unto itself in chartering medical schools and opening its boundaries to a wide range of practitioners. Small wonder that a French scholar, writing in 1894, could deplore the remarkable freedom to practice medicine in the United States. "God help you," he wrote, "if you fall into the hands of an American physician!"

By the time of the Frenchman's visit, however, all this had begun to change. As Kenneth Ludmerer explained in his earlier study, Learning To Heal (1985), the years after 1870 were a watershed in American medical education. The new type of university being developed at Harvard, Cornell, Johns Hopkins, Yale, Wisconsin, and Chicago, along with a vast expansion of high schools and the rise of medical philanthrophy, created a framework within which fundamental change could take place. The stunning achievements in laboratory science of the late nineteenth century, moreover, led to a new understanding of the physical and chemical make-up of the human body. This understanding, in turn, demanded a more comprehensive standard of medical learning than prevailed in the still backward medical schools of America. The large number of Americans who went to Germany in the 1870s and 1880s to learn the new medicine agitated for a more thorough, science-based curriculum on their return. Understandably, these reformers met stiff resistance in the practical schools where they taught. Indeed, as late as the turn of the century, the number of practice-based schools, cut off from both universities and hospitals, was actually increasing, not decreasing, and "the fate of modern medical education remained highly uncertain." ¹

The modern medical school was created only in the fin-de-siècle years. In place of the freestanding medical school, with its two short terms, didactic lectures, and haphazard clinical teaching, emerged the university school of medicine, equipped with laboratories, staffed by research-minded teachers, and closely affiliated with a teaching hospital. The transformation was surprisingly swift once momentum was gained. In hurrying the transformation, a report written for the Carnegie Foundation for the Advancement of Teaching in 1910 by a Louisville schoolmaster named Abraham Flexner became the classic charter for reform. In tones of biting moral condemnation Flexner castigated schools and educators that put private interest or commercial profit above the welfare of the public. In striking prose he set down in one document the accumulated lessons of four decades of reform. The medical...