Chapter 27

• Chapter Summary
• Evaluation of Cooper Medical College
• Evaluation of the Faculty
• Financial Affairs
• Summary

Evaluation of Cooper Medical College

1901-1902

Educational Standards. In so far as national standards of medical education existed in 1901-1902, they were those promulgated by the Association of American Medical Colleges. The most controversial issues under consideration by the Association were: (1) requirements for admission to medical school and (2) duration and content of the annual lecture program. The Association met at San Francisco in 1894, and voted to amend their constitution to specify: (1) a high school diploma as the minimum requirement for admission to medical school and (2) four annual graded courses of lectures of not less than six months' duration each as a minimum requirement for graduation. ^[1] 

By 1901-1902 Cooper Medical College had met both these requirements. As we have already reported, in 1884 the Faculty of the College adopted the high school diploma as the minimum standard for admission, and on 1 January 1894 its three-year graded curriculum was replaced by a four-year graded program, each annual lecture series being of six months' duration. ^{[2]  [3]} 

As pointed out previously, the Cooper College Faculty weakened its academic program in 1895 by adopting several provisions for skipping the first year of the curriculum. One of these provisions was private study of first-year subjects followed by the passing of an examination by the Faculty. Another means of by-passing the first year was one year's pupilage with a physician approved by the Faculty. Effective in 1900, the Cooper College Faculty closed these two loopholes by the simple proscription: "Private study will not hereafter admit to advanced standing. ^{[4]  [5]} 

Admission Requirements. On 1 November 1898 the Faculty of Cooper Medical College issued a "Preliminary Announcement of Change of Course " which included the following revised Requirements for Admission to take effect on 15 August 1902: ^[6] 

The above version of admission requirements represents no substantial change from the policy adopted in 1884 to the effect that a high school education was sufficient preparation for admission to Cooper Medical College.

With respect to the critical issue of admission standards, which ultimately determine the quality of the profession, the Faculty was well aware that Presidents Eliot of Harvard, Gilman of Hopkins and Jordan of Stanford all advised that a bachelor's degree or its equivalent should ultimately be required for entrance to medical school. Nevertheless, the Faculty was unprepared to take such a step. Like other free-standing proprietary schools, Cooper College depended upon tuition for its support. High standards for admission would have resulted in a disastrous reduction in the student body and in tuition income. It was growing increasingly clear to the Directors and Faculty of the College that only financial underwriting by a parent body such as a university could provide for the higher admission standard called for by the presidential triumvirate.

The Annual Lecture Program. Throughout the two decades prior to 1901-1902 the lecture program at Cooper College consisted of an optional Short (Intermediate) Course of three months (February 1 to April 30), and a required Long (Regular) Course of six months (June 1 to November 30). The annual total of instruction by lecture was nine months, only six months of which were required.

The "Preliminary Announcement of Change of Course," issued on 1 November 1898 and referred to above, announced the following major changes in the dates and duration of the lecture program.

In order to conform to the almost universal custom of colleges to begin courses in the fall and conclude them the following spring, the Faculty decided to eliminate the optional Short Course of lectures entirely. Instead it would give annually a single required Regular Course of eight months' duration to be held during the winter instead of the summer months.

This new arrangement was initiated in 1899 and phased in over a two-year period so that on 15 August 1900 a regular schedule was established to begin August 15th each year, and continue for eight months (i.e., to mid-April).

Henceforth, Requirements for Graduation at Cooper College included the satisfactory completion of a graded curriculum of four annual Regular Courses, each of eight months' duration. ^[7] 

AAMC Survey of Lecture Courses. In connection with its limited effort to evaluate American medical education, the Association of American Medical Colleges conducted a survey by questionnaire of sixty-six of the 160 medical schools in order to determine the number and length of their annual lecture courses The following results of the survey were reported at the 1904 meeting of the Association: ^[8] 

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Length of Lecture Course

4 years of 6 months each             6 Schools

4 years of 7 months each             19 Schools

4 years of 7 1/2 months each        2 Schools

4 years of 8 months each             23 Schools

4 years of 8 1/2 months each        1 Schools

4 years at 9 months each            15 Schools

---

Total Schools in Survey 66

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The above data showed that four annual courses of eight months each was the pattern most frequently chosen by the sixty-six medical schools surveyed. We have just seen that Cooper Medical College adopted that schedule in 1899, making it possible for us to conclude that the College was then following common practice with respect to the number and duration of its lecture courses. We also learned from the survey that 15 trend-setting medical schools had by 1904 already extended their annual courses to nine months, theoretically enhancing their programs over those of schools with a shorter curriculum.

National Standards Imposed. At a meeting of the AAMC in Chicago on 10 April 1905 a new constitution was adopted that reaffirmed the minimum entrance requirement as "a diploma from an accredited high school." It was decided to increase the curriculum to "a four years' course of study in four calendar years, each annual course to have been not less than thirty teaching weeks (seven months)." This undemanding standard for the annual lecture course was less than that already adopted by forty-one (over half) of the sixty-six medical schools surveyed by the AAMC and reported in the above table. Nevertheless, the AAMC was reluctant to press for higher standards simply because it was assumed, no doubt correctly, that many schools would object and would refuse to participate in the Association

In 1905 the halting efforts of the AAMC to set standards received welcome support from an important source. The National Confederation of Examining and Licensing Boards announced that it was adopting as its standard the AAMC's admission and curriculum requirements. Pursuant to this action by the National Confederation, the State of California decreed that the admission standards for medical schools in the State should in no particular be less than those established by the AAMC for that year. This California statute did not affect Cooper Medical College for it had already met (and exceeded ) the AAMC requirements. However, the policy of the National Confederation had a beneficial effect nationwide in that it denied registration to graduates of the many schools not meeting AAMC standards, thereby putting irresistible pressure on them to make some modest reforms.

The decision of the National Confederation to enforce the matriculation and curriculum guidelines of the Association of American Medical Colleges as a national standard can be seen as recognition of the Association's long struggle to induce medical colleges to adopt higher standards voluntarily. This action also called attention to the powerful leverage of the National Confederation of Licensing Boards on the medical schools. In spite of this helpful development, the AAMC was actually making little progress in reforming medical education and a more effective agency under the aegis of the AMA was needed to achieve better results. ^{[9]  [10]  [11]} 

AMA Council on Medical Education. In spite of its limited past success in the arena of medical education, the American Medical Association had continued its efforts, in parallel with those of the AAMC, to reform American medical schools. For example, at its annual meeting in 1900 the AMA revised its constitution to prescribe that no state society or other organization would be allowed representation at future AMA conventions if it admitted to membership anyone who received the MD degree in less than four years of graded instruction. ^[12] 

This move to put pressure on the many inferior medical schools in the country was followed in 1902 by the appointment of a new AMA Committee on Medical Education to survey the problem of medical education in the country and make recommendations concerning the role which the AMA should play in its improvement. On the advice of this committee the AMA voted at its annual meeting in 1904 to establish a permanent agency, the Council on Medical Education, for the purpose of inspecting, classifying and improving American medical schools. ^{[13]  [14]} 

On 20 April 1905 the Council on Medical Education hosted its first annual conference in Chicago. The objective was to enlist the cooperation of the state medical societies, the AAMC, the Southern Medical College Association and the federated licensing boards in a coordinated assault on the low standards in many of the nation's 160 medical schools. Through data collection and analysis, and leadership in promoting reform, the Council was destined to play a major role in the improvement of American medical education in the twentieth century. The original purpose of the American Medical Association when founded in 1847 was to elevate the standards of medical education in the country. In the Council on Medical Education the AMA had at last created an effective instrument for the task. ^{[15]  [16]  [17]} 

Early Council Method of Grading Medical Schools We have seen that Cooper Medical College readily fulfilled the admission and curriculum requirements of the AAMC However, none of the AAMC efforts served to gauge the quality of the education provided by Cooper College relative to that of other schools.

In searching for some practical means of measuring quality, the Council on Medical Education recognized that the performance of medical school graduates on state licensure examinations was an elementary, yet reasonably objective, criterion of a medical school's capacity to educate. From the results of these licensure examinations, as published periodically in the JAMA, the Council divided medical schools into the following three classes based on the percentage of failure of their students on the licensure examination: ^[18] 

Class 1, schools with less than 10 per cent of failures.
Class 2, schools with 10 to 20 per cent failures.
Class 3, schools with more than 20 per cent failures.

The following performance data on State Board Examinations are derived from a JAMA Table that included all physicians who graduated from American medical schools during the period from 1900 to 1904 inclusive, and who took the State Board Examination in 1904. ^[19] 

The above table shows that graduates of Cooper Medical College during the period from 1900 to 1904 had a failure rate on the State Board Examination of 8.5% (i.e., less than 10 per cent). The failure rates of graduates of seven other well-known medical schools are listed for comparison. On the basis of this very gross indicator of institutional performance, Cooper Medical College rated as a Class 1 school, as did the other schools listed in the table.

Later Council Method of Grading Medical Schools. It was clear to members of the Council on Medical Education that a more comprehensive procedure for classifying medical schools was essential, and that such a procedure must include on-site inspection of and extensive collection of data on each school. The Council then used the information collected on each school to assign it a grade.

Listed below are the ten categories of information selected by the Council as the basis for its grading system. Each category received a grade of 10 for full compliance with accepted standards. Full compliance in all ten categories would result in a grade of 100. We take this opportunity to evaluate Cooper Medical College by entering our own grade for the College in each of the categories with the following result: ^{[20]  [21]} 

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Overall Grade of Cooper Medical College 85

The above grades for Cooper Medical College are based on information to be found in the Annual Announcements of Cooper Medical College and in this and previous chapters. For example, with respect to Category 1, we have shown that over 90 % of Cooper graduates passed the State Board Examination. We therefore assign Category 1 a grade of 9.

Because Cooper College fulfilled the admission and curriculum requirements adopted by the AAMC in 1894, and these represented national standards at the time, we have assigned a grade of 10 to each of Categories 2 and 3.

Category 4 concerns medical school plant. There can be no doubt that the College and Lane Hospital buildings, planned and donated by Dr. Lane, warrant a grade of 10 based on standards of the day.

The chief deficiencies of the school are to be found in laboratory facilities and instruction (Category 5) and in full-time basic science faculty (Category 8), which received grades of 5 and 2, respectively. Category 9 concerns profit motive for conducting the school. Since all tuition income was allocated to support of the school, and the Faculty, with rare exception, receive no payment for teaching, a grade of 10 for Category 9 seems well justified.

In summary, the outcome of this hypothetical inspection process is an overall grade of 85 for Cooper Medical College, a very respectable showing, which we shall later have an opportunity to compare with that in the Flexner Report of 1910. ^[22] 

The Council for Medical Education began its inspection of the nations 160 medical schools in 1906. Each school was visited by some member of the Council or by the secretary, Dr. Colwell; in most instances by both. Each school was graded on its performance in each of the ten categories listed above. On the basis of their overall grades, the schools were then classified into three groups as follows:

Class A, those graded above 70, the acceptable class (82 schools)
Class B, those graded from 50 to 70, the doubtful class (46 schools)
Class C, those graded below 50, the nonacceptable (32 schools)

These results were reported to the Council in 1907. Although the Council was very lenient in its grading, the above summary shows that only half of American medical schools (82 out of 160) were classified as "acceptable." Half (78 out of 160) of American schools were classified as doubtful or nonacceptable. ^{[23]  [24]} 

The above classification of the schools was not published, but each college was privately notified of the rating given to it. As a result of this first inspection by the Council, the first major wave of improvement swept over the medical schools of the country. Fifty schools improved their curricula. Consolidations occurred in many cities having several medical schools. A number of schools went out of business entirely because state boards refused to examine their graduates. It became evident that the 160 schools would in a short period be reduced to less than a hundred. ^[25] 

Even though the delinquent schools were not identified openly, the Council's report caused considerable resentment among the medical colleges. It occurred to the Council that resistance to an on-going evaluation of the schools could be most effectively minimized by its joining with a respected private organization in the further pursuit of reform.

By a fortunate coincidence the trustees of the Carnegie Foundation for the Advancement of Teaching at their meeting in November 1908 authorized a study and report on the schools of medicine in the United States and appropriated money for the project. At the New York meeting of the Council in December 1908, members of the Council expressed keen interest in cooperating with the Foundation in this study. As a result, an informal conference was held with Henry S. Pritchett, President of the Foundation, and Mr. Abraham Flexner who had been chosen by the Foundation to conduct the study. President Pritchett expressed himself as agreeably surprised not only at the efforts being made by the AMA to improve medical education but also at the enormous amount of information that had been collected by the Council.

In the course of further discussion, Mr. Pritchett agreed with the opinion previously expressed by the members of the Council that while the Foundation would be guided very largely by the Council's investigation, to avoid the usual claims of partiality no more mention would be made of the Council's report than of any other source of information. The Foundation report would therefore be, and have the weight of, an independent report of a disinterested body. It would then be published far and wide, and do much to develop public opinion.^{[26]  [27]} 

As a result of understandings such as the above, the Council on Medical Education cooperated fully with Dr. Flexner during his studies of medical education which culminated in the provocative Flexner Report published in 1910. By that date, Cooper Medical College was well on its way to full integration with Stanford University..

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