Cornell University Medical College - Samaritan Yearbook (New York, NY)

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i . . . the .fludentr virited the wards, exam- ined the patientr and followed their c0zzr.re. ' before it affiliated with the university. Their belief in the new teaching method was assuredly one of the factors in their decision to withdraw from the unhappy arrangement with New York University. They demanded autonomy in the arrangement o-f their medical curriculum and the free- dom to appoint the men they wanted to teach the way they wanted. At the same time that the revolution in the teaching of clinical medicine occurred another radical change was being effected in the opposite direction-that was the establish- ment of laboratories in the clinical subjects with work in them required of the students. Until shortly before the turn of the century the anatomy dissecting lab was the only one fou-nd consistently at all medical schools and the only one at any of them in which the students were required to -participate. However, in Europe, especially in Germany, the physiology, bacteriology and chemistry laboratories were legion in number and had been turning out important re- searches for many years. Americans interested in those sub- jects to any degree had to go to Europe to learn the tech- niques and even the subject matter. Although the two trends seem to be in opposite direc- tions they really stem from the same source-the wide- spread i-ntroduction into clinical medicine of the scientific method and its basic procedures. The theory of infection was relatively newly proven, human physiology and nutri- tion were i-n their infancyg biochemistry was a newly coined word. Above alll, case studies were being carried out in a more systematic fashion and with more understanding of the underlying mechanisms of pathology and pathophysi- ology. The spheres overlapped in the use of laboratory procedures in the workup of the patient-the cultures, the blood studies in ever-increasing number. To the art of medicine was fused the added dimension of laboratory sci- ence. To cope with it the student now had to learn and understand the tests and their bases. No longer could medicine be apprehended from the following of the prac- titioner on his private rounds and the listening to a series of didactic lectures. The new medicine was essentially hospital medicine. The procedures became more complicated than the routine phy- sician could perform in the home or office. The complete study of the patient required close surveillance for a period of time. It was becoming increasingly advantageous for any medical school to be associated closely with a large '6 hospital whose wards would be filled with a variety of cases for study. The new Corne'll's needs were largely hlled by its intimate , connection with Bellevue and then with the New York Hospital and other scattered units in which the various medical specialties were emphasized. The students began to spend more and more time in the hospi- tal itself. Simultaneous with the need for more hospital space was the -need for more laboratory space. With only anatomy as a lab course previously little or no room was needed to house a medical school. A dissecting room, a few offices and classrooms-that was all. Now, suddenly, many labo- ratories were needed with divers types of equipment and physical arrangement. Many amphitheaters-some with provisions for demonstrating patients-were called for. Many classrooms with facilities 'for demonstrations had to be provided. All of these were included in the new, won- derful building donated by Colonel Payne and designed by the medical faculty. It was a model building and one of the most elabora-te belonging to any medical college. The superior facilities attracted superior students and superior men to the faculty and accounted in no small measure for the rapid growth in prestige of the new institution. The increasing -complexity in subject matter and physical plant brought about a compensatory increase in the size of the staff. The natural outcome of this was the appo-intment of .full time departments in the pre-clinical subjects and the gradually increasing use of full -time men in the clinical subjects as well. New departments were created and en- larged as .the need for them became apparent. It was felt that to cope with the broadening field of the medical school curriculum students really needed more than a high school background. They actually needed a firm grounding in the basic sciences which had only recently begun to become organized in their own right. Accordingly, the final step in the organization of the new school was actually taken several years later when a college degree was made a requirement for admission. This was considered a daring step for a fledgling school to take, and the conse- quences were promptly noted in the reduced size of -the student body which inevitably followed. Within a few years, how- ever, a new, large body of well qualified candidates pre- sented itself for admission and the school has always since that time had many more applicants than it could admit. ha Stl ph di' de of pr: gm ins --l the pro me W bi' tial lon, and inir the day 'I ting old addr cine of t port sooq exce. sity pern dcisi tural Tl possi educz more ratioi it pc 3 C0 other subje that 1

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if YEARS NY FIFTIETH ANNIVERSARY is an occasion for celebration. In the case of a medical school it must also be a time for a recapitulation and re-evaluation of the di- rection taken by the school in its half-century of existence. It is perhaps presumptuous for us, as senior students still involved in the processes we are discussing, to attempt to present our analysis of these trends. But we feel that the fact that we are still engaged in the business of learning to be physicians certainly entitles us to our opinions. We hope that these, carefully weighed and deliberately delivered, may prove to be of some use to those who would study the problem in all its aspects. I ,The present essay is intended as a comparison of the trends in medical education between 1898 and 1948. The political and financial struggles surrounding the founding of Cornell are recounted elsewhere in this book. We are here primarily concerned with the philo-sophical climate of the times. In 1898 there were few university-affiliated medical schools in the country. There were, rather many proprietary schools owned by their faculties, supported solely by tuitions and fees, casually located, and inadequately staffed and supplied. Some of them-in large cities, near large hospitals, with famous physicians on their staffs-obviously offered superior medical education to others which were in smaller towns with only a few teaching physicians. The entire method of education was primitive. Students followed a physician on rounds of his patients for a given period of time-a year or two-and then were admitted to a series off lectures to which they purchased admission. They sat through the jojo same series of lectures for two successive years and then were given a short oral examination after which they were allowed to practice. The calibre of lectures and examinations varied greatly with the location and dignity of the individual school-so, obviously, did the calibre of the men attracted to their staffs and student bodies. The smaller schools, dependent for survival on the fees paid by the students had to keep admitting a sufficient number or fail to survive. They could not afford to be fussy about the kind of men they took in and later graduated as doctors. The larger, endowed schools were much more careful but still required no more than a high school education or its equivalent for admission. The highest level was that of the few un-iversity schools-Harvard, Columbia, johns Hopkins and Pennsyl- vania among the most widely known. . more richly In the 1890's Osler at Hopkins initiated a revolutionary method of medical education. The course was lengthened and bedside instruction of medical students on the wards of the hospital was introduced. The students followed a gradated course beginning with the more fundamental, pre- clinical subjects and progressing through these to the actual study and practice of bedside medicine. Not only were patients brought into the amphitheaters, but the students vis-i-ted the wards, examined the patients and followed their course. The men who founded Cornell were imbued with the spirit of this innovation. They foresaw its tremendous in- fluence on all medical education and had endeavored to in- stitute at least some of its principles in the school they ran

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But all this is but the setting of medical education. It had a two-fo'ld effect on the students. It produced, first of all, the first generation of physicians trained for institutional practice rather than in- dividual private practice. It produced secondly a grou a , P dedicated to the furtherance of medicine through the pursuit type of training given the of the basic sciences and their implications in clinical practice. In.itially these trends were complementary-both groups of men needed to cluster around the large teachin ' 8 institutions of medicine where facilities for intensive study -clinical and laboratory-were available. In many cases the groups overlapped, with men working along both ap- proaches. The need for medical centers lavish with equip- ment and material arose g the need was inevitably fulfilled. With the knowledge churned up in increasing quantity by workers along both avenues of investigation their essen- tial dichotomy has become more and more marked. No longer is it possible for one worker to straddle the clinical and purely laboratory fields. And the necessity of determ- ining the amount of stress to be laid on each approach in the medical curriculum is responsible for the split in present day education wh.ich will be discussed later. The original faculty of the medical school was a dis- tinguished one and as new departments were organized, or old ones re-organized many more outstanding men were added to lit. Because of the important contributions to medi- cine made by these men, as well as the progressive policies of the school, Cornell rapidly became one of the most im- portant medical schools in the country. Its rapid growth soon made clear the inevitable insufficiency even of the excellent building opposite Bellevue. This, plus the neces- sity of tying up with some voluntary hospitall, led to the permanent afiiliation with New York Hospital and the dcision to consolidate the two institutions in one architec- tural unit. This had more than a symbolic importance. It made it possible for the first time for the two phases of education, the pre-clinical and the clinical, to be integrated more completely. It recognized the need for such integ- ration on the higher level of faculty co-operation. It made it possible for both groups of workers to be associated in a common organization and to mee-t informally in each others work areas and formally in joint conferences whose subject matter was of interest to -both. The assurance that the students will carry over into their clinical work medical the essentials of the basic courses of the first two years is predicated on the mutual respect of the teachers in both groups. In the years that the school was located on First Avenue there was a more complete physical severance between the ' an there is in the new two sections of the curriculum th consolidated unit. This split was minimized by the very competent and brilliant instruction of the faculty members and their participation in 'both clinical and pre-clinical work. These men were mainly responsible for the shape of Cor- nellfs development in those years and also laid the attern P for the type of instruction that has continued to be given at the institution. If the pre-clinical teachers do not indicate the tieups the student must make between the courses of his first two years and those of his later career, and if the clinical pro- fessors do not strongly outline the fundamental basis of the clinical entities they are describing, the student will never be a successful practitioner of modern medicine. The con- nection is not often an easy one to trace and the task of making the student see the natural evolution of disease from the processes of physiology and chemistry -he has previously learned is one that takes inhnite pain in its carrying out. Much that has been written in recent years on the subject of medical education .has been aimed at pointing out this fact and suggesting new schemes for accomplishing the rapprochement more effectively. These will be discussed more fully further on. Another important result of the establishment of the medical center was the gathering together in one functional unit of leading workers in all the various medical special- ties. This made it possible for the most thorough and up- to-date methods of attack to be leveled at medical problems from all angles at once. The internist working on diabetes, for example, now had the advantage of expert ophthalmo- logic, endocrinologic, surgical, laboratory advice and assist- ance. He had also close at hand facilities for cllinical and fundamental research on the problem. He had frequent conferences with other men on the staff in which he could glean the most recent advances in their work and their recent clinical experiences. But with this he also acquired the obligation to synthe- size this wealth of experience and transmit it to the student in its clearest and most available fo-rm. The function of a medical center such as ours is threefold. It must first of . . . wzzrdr filled wills az wzriezy of carer for .ftzzdy.