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The American Medical Association Defines National Standards

Harvard, Hopkins and a few other progressive institutions introduced comprehensive medical reform in their own medical schools which then served as models. Unfortunately, adoption of these prototypes by other schools was initially slow and limited. It was clear that general acceptance of higher and more costly standards by a majority of the independent and highly competitive American medical schools would require consensus among them on standards, and an effective means of gaining voluntary compliance.

It was generally agreed that government intervention was not a practical solution to the problem, and that medical associations would be the most effective agents in defining standards and inducing the medical schools to accept them.

We have already noted that the American Medical Association was founded in 1847 under the leadership of Dr. Nathan Davis, and that he influenced the Association to make reform of medical education one of its primary goals. At the National Medical Convention in 1846 that preceded the meeting in 1847 when the A. M. A. was organized, Dr. Davis proposed the following Resolution which was adopted: [22]

That it is desirable that a uniform and elevated standard of requirements for the degree of M. D. should be adopted by all the Medical Schools of the United States.

To implement this resolution, the A. M. A. established a Standing Committee on Medical Education in 1847 with which Dr. Davis was associated. Unfortunately, progress on medical education was interrupted by the Civil War (1861-1864).

When, after the war, the A. M. A. returned to the subject at its annual meeting in Baltimore in 1866, Dr. Davis was appointed to chair a Committee Appointed to Call a Convention of Delegates from the Several Medical Colleges in the United States. The Convention was charged with the task "of thoroughly revising the present system of medical college instruction." Pursuant to this mandate, a Convention of Teachers of the Medical Colleges was convened in Cincinnati on 3 May 1867, just prior to the Annual Meeting of the A. M. A. in the same city on May 7 to 10. Twenty-four delegates from nineteen colleges were in attendance at the Convention. Among those present were several familiar luminaries: Dr. Nathan Davis from Chicago Medical College; Dr. Samuel Gross from Jefferson Medical College; Dr. Joseph McDowell from Missouri Medical College; and Dr. Thomas Logan representing Toland Medical College. The Medical Department of the University of the Pacific was in suspension at the time.

The Cincinnati Convention prepared an historic document known as "Report of the Committee of Medical Teachers" which was submitted by Dr. Davis to the A.M.A. at its Annual Meeting a few days later. The Association unanimously approved the Resolutions contained in the Report and urged their adoption "by all the medical colleges in our country." The object of the Resolutions was to establish national standards for medical education. The following is a summary of the proposed requirements: [23]

Resolved 1st, That every student applying for matriculation in a medical college, shall be required to show, either by satisfactory certificate, or by direct examination by a Committee of the Faculty, that he possesses a thorough knowledge of the common English branches of education.

2d. That every medical student be required to study four full years, including three regular annual courses of medical college instruction, before being admitted to an examination for the degree of Doctor of Medicine.

3rd. That the minimum duration of a regular annual lecture term, or course of medical college instruction, shall be six calendar months.

4th. That every medical college shall embrace in its curriculum the following branches, to be taught by not less than nine Professors, namely: Descriptive Anatomy, including Dissections; Inorganic Chemistry, Materia Medica, Organic Chemistry and Toxicology; General Pathology, Therapeutics, Pathological Anatomy and Public Hygiene; Surgical Anatomy and Operations of Surgery; Medical Jurisprudence and Medical Ethics; Practice of Medicine, Practice of Surgery, Obstetrics, and Diseases of Women and Children; Clinical Medicine and Clinical Surgery. And that these several branches shall be divided into three groups or series, corresponding with the three courses of medical college instruction required, as follows:

The first or Freshman Series shall embrace Anatomy, etc.

The second or Junior Series shall embrace Chemistry, etc.

The third, or Senior Series shall embrace Practical Medicine, etc.

The instruction in the three series is to be given simultaneously and to continue throughout the whole of each annual college term; each student attending the lectures on such branches as belong to his period of progress in study, in the same manner as the Sophomore, Junior, and Senior Classes, each pursue their respective studies simultaneously throughout the college year, in all our literary colleges

At the close of each series the student shall submit to a thorough examination, by the proper members of the Faculty, and receive a certificate indicating the degree of his progress.

5th. That every medical college should immediately adopt some effectual method of ascertaining the actual attendance of students, upon its lectures and other exercises, and at the close of each session, of the attendance of the student a certificate, specifying the time and the course of instruction actually attended, should be given, and such certificate only should be received by other colleges as evidence of such attendance.

6th. That a Committee of Five be appointed by the President (of the Convention), whose duty it shall be to present the several propositions adopted by the Convention, to the Trustees and Faculties of all the Medical Colleges in this country, and solicit their definite action thereon, with a view to the early and simultaneous practical adoption of the same throughout the whole country. And that the same Committee be authorized to call another Convention whenever deemed advisable.

In submitting the above recommendations to the A. M. A., Dr. Davis extolled the benefits that would accrue to American medical education if the above reforms were adopted. He pointed out that "the plan proposed requires no legislative aid, and no exterior influences, but simply the cooperative action of all the principal medical colleges in the country. It is simply their voluntary co-operative action that gives to the present system all its binding force, and their voluntary action in the adoption of the revised plan would make it equally the practical law of the profession throughout the whole country." [24]

What were the prospects for "cooperative action of all the principal medical colleges of the country?" For an early answer to the question we turn to the Minutes of the next meeting of the A. M. A. held in Washington in May 1868. Dr. A. B. Palmer of Michigan, Chairman of the Committee on Medical Education, submitted a discouraging report: [25]

The Committee on Medical Education regret to report that the various questions respecting this subject, which for so long a period have demanded the attention of the American profession, have not yet received a practical solution. . . The plan of reform (approved at the A. M. A. meeting in 1867), though containing many excellent features, must be conceived as a rather hastily conceived ideal decidedly in advance of realization. . . Some of the changes the plan proposes, and generally regarded as desirable, are believed to be too great to be soon accomplished; and besides other defects, no provision is made in the plan for a repetition of the lectures to the same students. . .

Dr. Davis, who was not a member of the Palmer committee, requested the floor to counter the negative report. He stated that several schools had endorsed the reform plan adopted at the meeting in 1867 and that evident progress was being made. The following resolution was then proposed and adopted: [26]

Resolved, That the American Medical Association refers the whole subject of medical education to the faculties of the regular medical colleges of the nation, pledging itself to adopt and enforce any system or plan that may be agreed upon by two-thirds of all recognized medical colleges.

Resolved, That the resolution be referred to the Committee already acting in this matter (A. M. A. Committee on Medical Education), and they are requested to report within two years from this session.

When the next Annual Meeting of the A.M.A. convened in May 1869 at New Orleans, medical education was again a major issue. Dr. Baldwin, President of the Association, devoted his lengthy Presidential Address to the subject. He stated that he concurred fully with the sentiments on medical education expressed in the following excerpt from a letter he had recently received from "a gentleman who is one of the most distinguished surgeons of the age" (undoubtedly Samuel Gross): [27]

The future holds no promise of amendment. We shall go on from bad to worse until the people can stand it no longer, and then we may hope to be able to effect some reform by our efforts as a great national association. The medical schools are getting worse every year, belowering the standard of education, and opening their doors more widely by the reduction of their fees. The time is near at hand when honorable men will cease to take any interest in medical teaching"

Dr. Baldwin then continued his Address by expressing his equally despairing view of the standards enacted at the Annual Meeting in 1967: [28]

The plan of action you have adopted, that of endeavoring to induce forty or fifty medical colleges, with conflicting interests, to agree voluntarily upon a "uniform and elevated standard of requirements for the degree of M. D.," and adopt it in good faith, has become almost a Utopian idea, a forlorn hope. Though urged with all the force that truth could impart, and enforced with all the appealing earnestness that the gravity of the subject could inspire, yet (the) views and wishes (of the A. M. A.) have not impressed themselves on the schools to such an extent as to change their course of action. It seems to me that all hope of reform through this means must be abandoned.

President Baldwin concluded his Address by saying that he could see no mode by which reform of medical education could be accomplished, except through enforcement by "Federal Legislation" and the founding of "one or more National Medical Schools" that would serve as national standards.

At the same meeting, the Annual Report of the Committee on Medical Education also deplored the condition into which the profession had fallen and the lack of progress toward reform. Furthermore, the decision at the previous A. M. A. meeting "to refer the whole subject of medical education to the faculties of the regular medical colleges of the nation," was sharply criticized. The Committee stated: [29]

In this connection, we cannot refrain from most respectfully but most earnestly enquiring what the medical colleges of the nation have done in the past to entitle them to the confidence of the profession in this matter for the future. . . For twenty years it has been in their hands or entirely at their command. . . Any five years of that time would have sufficed for every change to have been made, had the schools, as a body, so willed it. . . There cannot be found then, in the opinion of your Committee, anything in the past action of the schools which warranted this Association in again committing the subject to their keeping. . .

In spite of failure to date, the Committee on Medical Education had not lost faith in the ultimate success of continuing pressure on the medical schools by the A. M. A. They recommended the following prescription:

The agencies by which reforms will be effected and advances made, we believe, will be chiefly these:

- a more general formation of active medical societies that act harmoniously with the A. M. A.

- the influence of high-toned and independent medical journals

- but above and beyond all other influences we would place the action of the A. M. A. If it will act in this matter firmly, consistently, steadily progressive, it will in due time effect every desirable change, and the profession will rapidly rise in the respect and confidence of the public.

These disparate views reflected the confusion and frustration within the A. M. A. in 1869 . Obviously it had failed to induce a significant change in the inferior programs of the majority of the fifty-odd "regular" medical schools then existing (as distinguished from homeopathic, eclectic and other formula schools). As the premier medical organization in the nation, the A. M. A. faced a crucial dilemma over the course it should follow in overcoming the intransigence of the medical schools, the very institutions that were undermining public confidence in the profession.

The debate on reform of medical education during the 1869 meeting of the A. M. A. finally concluded with the Report of the Ad Hoc Committee on Various Propositions and Communications from Medical Societies, etc. chaired by the tenacious Dr. Davis. The following observations and recommendations by the Committee were approved: [30]

Whereas, The results of all the efforts made during the last twenty-five years to elevate the standard of medical education, through concert of action among the numerous medical colleges of this country, have proved with equal clearness that such concert of action in an efficient manner is unattainable; therefore,

Resolved, That whatever is done to establish and maintain a just and fair standard of medical education throughout our whole country must be done by the profession itself, through its own voluntary organizations, in the same manner that it now establishes and enforces its Code of Ethics. . .

Resolved, That this Association earnestly requests each State medical society to appoint annually one or more boards of examiners, composed of five thoroughly qualified members, whose duty it shall be to meet at suitable times and places for the examination of all persons, whether graduates of colleges or not, who propose to enter upon the practice of medicine in their respective States, except as have been previously examined and licensed by a similar board in some other State. . .

Resolved, That each State medical society be requested to require its examining board to exact of every applicant for examination. . . proof of having had a proper general education and of having completed a full course of medical studies in a regularly organized and recognized medical school.)

The objectives of the above resolutions as set forth by Dr. Davis were met in California when the State Legislature enacted a law in 1876 to regulate the practice of medicine. As a result of this statute, which we shall later discuss, State Boards of Medical Examiners under the aegis of State Medical Societies were established in California. Other states also passed medical licensing laws whose chief objective was to disbar unlicensed practitioners. We shall see how the Boards ultimately contributed to the reform of medical education.

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Assessment of A. M. A. Efforts to Reform Medical Education

In spite of continuing efforts by the A. M. A. and dedicated physicians such as Nathan Davis to achieve an acceptable standard of medical education in every regular medical school in the country, reform was essentially stalled in 1869. Relatively few schools followed the lead of Harvard et al in revising their entrance and graduation requirements. In fact, the overall status of medical education grew worse during the final decades of the century. This was due to the proliferation of inferior schools that were unable or unwilling to incorporate into their programs the information stemming from the scientific revolution in medical and basic sciences then in progress. The number of medical schools increased from fifty in 1870 to 162 in 1906 [31] [32]

Year Medical Colleges
1870 50
1880 100
1890 133
1900 160
1906 162

The increase of 112 new medical schools, mostly of inferior grade, over a period of thirty-six years was not related to the health needs of the people but to professional vanity and the amplitude of student fees. As a result there was still a crisis in American medical education at the turn of the century.

We should not leave the subject of the A. M. A. without recalling that from its very inception the Association was committed to the improvement of medical education. Furthermore, one cannot follow the transactions of the organization without being impressed by the time and earnest consideration devoted to the subject, and without recognizing the impediments to success imposed by the self-serving and reactionary outlook of physicians at the time.

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Medical Colleges Organize to Reform

Officers of the A. M. A. had little confidence in the ability of the medical colleges to reform themselves. Nevertheless, it could be anticipated that they would at some point, in view of the stalemate in the A. M. A., make renewed efforts to do so. This is an opportune juncture to summarize these efforts which were not initiated until 1876.

With the laudable goal of reform in mind, Dr. J. B. Biddle of Jefferson Medical College and five other professors, all of whom were from the Middle West or South, sent an invitation to all medical schools to send representatives to a convention in Philadelphia on 2 June 1876. The purpose of the convention was "to consider all matters relating to reform in medical college work." Representatives of twenty-two medical schools attended the convention which proceeded to form a "Provisional Association of American Medical Colleges" and pass a few resolutions one of which "recommended that all medical colleges offer three courses of lectures (presumably of at least five months each)." Dr. Biddle was elected President of the Association. [33]

A second meeting of the new Association was convened at Chicago in June 1877 in response to the call of President Biddle. Twenty-six colleges were represented. A constitution, bylaws and Articles of Confederation were adopted including the name of "American Medical College Association" and the statement that "The objects of the Association shall be the advancement of medical education in the United States and the establishment of a common policy among medical colleges in the more important matters of college management." The medical curriculum proposed at this meeting was hardly revolutionary. It consisted of the traditional three-year apprenticeship during which the student must attend two regular courses of identical lectures. This was a long step backward from the national standards adopted by the A. M. A. in Cincinnati in 1867. Dr. Biddle was elected President of the American Medical College Association and Dr. Nathan Davis was chosen Vice-President.

Meetings of the Association were held in Buffalo in 1878 (15 colleges represented); in Atlanta in 1879; in New York in 1880 (25 colleges represented); in Richmond in 1881 (18 colleges represented); in Cincinnati in 1882 (11 colleges represented). Little was accomplished by the Association. After it decided in 1880 to recommend three courses of lectures instead of two, twelve medical colleges withdrew from the Association. They feared loss of revenues if they adopted the lengthened curriculum. Their withdrawal was a fatal blow to the Association. Among the defectors were such well-known institutions as the New York College of Physicians and Surgeons, Jefferson Medical College, Rush Medical College, and Dartmouth Medical College.

The Association died. It had tried to raise standards too rapidly. No annual meeting was held during the years 1883 through 1889. There could be no better demonstration of the tenacity with which the majority of American medical schools clung to the traditional two courses of identical lectures as the major feature of the curriculum, and to lecture fees paid by students to the professors as the main source of support.

In March 1890 the five medical colleges in Baltimore and the staff of the Johns Hopkins University invited representatives from each of the 133 then-existing medical schools in the United States to convene at Nashville in May 1890 "for the consideration of reforms urgently needed in the system of medical education hitherto in operation in this country." The invitation made clear that the agenda would include discussion of

  1. Three years Course of Six-Months Sessions

  2. Graded Curriculum

  3. Written and Oral examinations

  4. Preliminary examination in English

  5. Laboratory Instruction in Chemistry, Histology and Pathology

By this time resistance to reform had decreased and some seventy medical colleges, a majority of the 133 existing schools, sent representatives to the Nashville meeting. The original American Medical College Association was reorganized under the new name of "Association of American Medical Colleges" - a title that it retains to the present day. Dr. Nathan Davis served as President of the A. A. M. C. from 1891 through 1894 while the organization shepherded American medical colleges toward acceptance of the national standards he had called for in 1846 and defined in 1867.

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State Licensing Boards Spur Reform

In 1891 the National Confederation of State Licensing Boards voted to require a minimum of three years of medical training. This decision to deny licensure to laggard schools was critical. It initiated at last an appreciable nationwide movement toward reform. By 1893, 96 percent of schools required at least three years of study, and when the A. A. M. C. met in San Francisco in 1894, twenty-one of the seventy-one members voted to require a four-year course to be effective for the graduating class of 1899. Cooper Medical College had already implemented such a requirement. In the Annual Announcement for 1893, the Faculty announced "the adoption of a four years' curriculum to take effect January 1st, 1894, for all students matriculating after that date." [34]

But much further progress was still needed, particularly in the content and methods of medical education nationally. In his Report on Medical Education in the United States and Canada to the Carnegie Foundation in 1910, Abraham Flexner mercilessly exposed the gross deficiencies still existing in the programs of the generality of American medical schools, a subject to which have already briefly referred and will later return. [35]

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