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

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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.

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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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all provide better than adequate care for the sick. It must carry out far-reaching research plans in medicine to en- rich our cultural base and eventually make even better medi- call care possible. And it must teach-must train its students to carry on -both the other parts of its program with com- petence and assurance. Let us now examine how that is 'being done at the present time at the Cornell-New York Hospital Medical Center. When the medical school first moved uptown to its present quarters and assumed its impressive hybrid title, a most important change was made in the nature of the faculty that requires some discussion. At that time the men responsi'b'le for the shaping of the new unit felt that the job of running its various subdlivisions required the undivided attention of the men in charge. Accordingly, the professorships of the major clinical departments were made for the first time full time positions. It was required that the men who filled these positions should hold no others and should have no private practice outside the hospital. Many of the men who already had large and lucrative practices naturally felt unwilling to give them up so that the personnel shifted sharply with the move. This was the logical culmination. of the trend to hospital medicine-to the picture of the physician as a specialist. The new men were themselves products of the new training and their efforts were oriented to it. With the rapid ad- vances in laboratory techniques and the overwhelmingly massive addition of source information to each facet of medicine the institution of full time clinical professors foredestined the Cornell student to be slanted for spe- cialization. Surprisingly the curriculum and the methods of teaching have had to be changed very little to point the way to the new medicine. The student spends the first two years of his course in the classrooms and laboratories of the five buildings fronting on York Avenue. He takes anatomy and biochemistry, physiology and bacteriology, pathology and pharmacology. He is then briefly introduced to physical di- agnosis. The third year he spends on the wards of the various clinical specialties. The fourth year he spends mainly in the out-patient departments. The variable factor is not, obviously, the subjects taught, but the orientation of the men who do the teaching. The increasing segmentation of labor at all levels is the phenomenon of our age. The expanding complexities of Kipx Bay-Yorkville Health Center. Stadentf get first Ivana' experience u in pnblir health work. civilization have brought us to a point where no one can hope to follow it all-few can hope to fo-llow more than one or two threads. This is especially true in medicine where the geometrically multiplying data are inexorably eradicating the general practitioner. In his place is spring- ing up a veritable horde of specialists. The specialties are formed and then sub-divided. As the divisions overlap one with the other, they split again. The orderly procession of it all must delight the Aristotelian lover of the syllogism, but it cannot help but confound us who hope to find somewhere in the maze a niche of our own. Faced with this situation the school can do nothing else but try to fit us for the specialist future, and this it is doing. In so doing it is forced to choose carefully the weightqof each course, each fragment of course, in the curriculum. For that reason it must weed out not just that which is completely valueless but also that which is of relatively little use in train- ing us for the future that has been chosen for us. The preclinical courses are taught, with minor excep- tions, with an eye to the clinical problems and procedures that arise from them. Especially in the dynamic sciences of physiology and biochemistry we are early madeto see the . . . laboratory advice and arrirtancef' D80 --,tt Q-L 'al W Q. clinia learn the 1 is thi beconi based into often, most Rathe basic Mu widely the pf ology there bemoa search of thi eries 2 llle W4 made trainin ITIOIE 1 Thei Certain Q and rn Which trainini flecessa all, me is a lil of lengths bfi add, ratio al This HFC of infc his foul Out th, Orin the if dang