During most of this century, the quality of American medical education has been and remains excellent. In the middle of the 19th Century, medical education in the United States was largely a shambles. The ignorance of most physicians during the Civil War contributed to an appalling death rate among the wounded and to the overall loss of about 375,000 soldiers' lives from disease alone during the four years when about 160,000 died in battle. Long after French doctors abandoned such harmful "remedies," calomel was commonly prescribed by our military physicians, adding to natural illness, diarrhea and mercury poisoning. Calomel and tarter emetic (another poison) were banned by a brave Union surgeon general, William Alexander Hammond, who thus drew a court-martial from the Army and condemnation from the American Medical Assn.
As late as 1871, Charles Eliot, president of Harvard University, proposed that written examinations be required for graduation from Harvard Medical School. Harvard professor of surgery, Henry Jacob Bigelow, objected on the grounds that more than half of his students could barely write.
How did American medical education evolve from so shabby a state to the world's best in less than a century? The answer to that question is by no means simple, nor is it widely understood, but it is provided with accuracy, clarity and the descriptive skill of a first-rate storyteller by Kenneth M. Ludmerer in "Learning to Heal."
Dr. Ludmerer teaches history at the Washington University and internal medicine at the Washington University School of Medicine. As a scholarly historian who is also a respected practicing physician, Ludmerer brings understanding and insight to his analysis of the development of American medical education. He identifies the 19th-Century origins of medical educational reform in the influence of Americans who studied in Europe, where both sagacious bedside medicine and revolutionary scientific discovery were relatively advanced.
One of those Americans, William Henry Welch, became the founding professor of pathology at Johns Hopkins, the first truly great medical school in the United States, in the late years of the 19th Century. Welch alone in our history was simultaneously president of the AMA and a member of the National Academy of Sciences. Welch discovered the bacillus that causes gas gangrene, and was an inspiring teacher. Simon Flexner, who discovered one of the causes of bacillary dysentery, was Welch's student and younger colleague at Johns Hopkins and subsequently director of the Rockefeller Institute, which was also to have a profound effect upon medical education.
Simon Flexner's brother, Abraham, a Johns Hopkins graduate but neither a physician nor a biologist, authored the famous "Flexner report," financed by the Carnegie Foundation. The Flexner report was in part an astute analysis of the principles of excellent-to-good medical education existing in a handful of places in 1910 and also a dramatic expose of the mediocre-to-disgraceful medical education that was far more prevalent in the United States at that time.
The Flexner report helped to advance educational reform, but has quite mistakenly been widely perceived to have created the blueprint for the modern medical school. This misconception periodically rouses cries for "a new Flexner report" to solve complex difficulties continually arising in medical education as a consequence of scientific discovery, technological advances and dilemmas and demographic, social and economic change. Solutions to such complicated, multifaceted problems in medical education are more likely to be found by critical thinkers working in the field than to be formulated by a new "commission" or another Flexner--to spring, as it were, full grown like Athena from the head of Zeus.
Physicians, university educators, philanthropists, scientists, engineers, economists, political scientists, sociologists, philosophers, lawyers, hospital administrators, political scientists and countless others share concerns about medical education if for no other reason than that sooner or later all of us need a doctor. For all directly or indirectly interested in medical education--whether as participants, planners, critics or chroniclers, or simply as a result of intellectual curiosity--Kenneth Ludmerer's history book should be a good place to begin. His explorations illuminate the disparate influences upon American medical education--from worst to best. Implicit in this story, fascinating in itself, are many lessons to be learned if the future of American medical education is to be marked by progress rather than a repetition of old errors or the passive acceptance of decay.