Curricular Reforms 1879 to 1883
Following the original meeting of the Provisional Association of American Medical Colleges in May 1876, to which we have referred, Dr. Biddle, President of the Association, recommended to all medical colleges that they increase their graduation standards by requiring completion of three identical Annual Lecture Courses instead of the usual two (each Course of five months duration).
President Biddle's recommendation was discussed by the MCP Faculty on 15 March 1877 and "the Dean was instructed to reply to the Association of American Medical Colleges that our College was ready to accept the plan proposed if it be accepted by the other school in this city and by the schools throughout the country; and that we favor an additional regulation, requiring that every student, before being admitted to lectures, be subjected to a rigorous examination." This was a perfectly safe position for the Faculty to take because most of the other medical schools in the country would certainly not follow the Association's recommendation.
As will be further discussed below, in 1879 the MCP finally adopted Dr. Biddle's proposal for three identical Annual Lecture Courses as the first step in a major overhaul of the curriculum.
Meanwhile an exasperated Dr. Gibbons, Sr., in 1877 again entered the lists in defense of contemporary American medical education as he knew and cherished it. His description of student life at the Medical College of the Pacific provides a rare glimpse of their academic schedule. 
American physicians have written so much in complaint of the low standard of education in this country, and the low grade of our medical schools, that it is but reasonable for foreigners to take them at their word and presume on their ignorance and incompetence. I have heard of a man who was so impressed with a sense of his own unworthiness that he begged every person he met to give him a kick. His humility finds a parallel in some of our self condemning physicians, journalists and writers. . .
The truth is that we have in the profession a self constituted aristocracy who assume a superiority not founded on superior merit, and who would willingly provide laws for the brotherhood. But the only aristocracy which the profession will ever acknowledge is that of merit. The late Dr. Condie, who walked the streets of Philadelphia in the practice of medicine for fifty years, used to say that to drive a horse was a sign of weakness in the legs, and to drive a pair was a sign of weakness in the head. I should not like to say amen to this, but I submit that men who live in cities and drive two horses have no more right to dictate to the profession than the average country doctor. I might change my opinion should I come to drive two horses. . .
But let us look at home - for it is here that I wish to particularly direct your attention. In this new country, and with all the disadvantages of remote location and other circumstances, the range of study and practice in the school to which I am attached is so far superior to that of the great Pennsylvania schools thirty or forty years ago as to render the latter almost ridiculous. Then the microscope was unknown to the student. Now it is his daily companion. And so of the stethoscope, the speculum, the laryngoscope, the ophthalmoscope, the clinical thermometer, and other adjuvants to different branches of study.
I am sorry that a disposition exists in certain quarters to decry and frown down our California medical schools. . . In the college to which I am attached, the life of the student is one of constant industry and activity. Three days in the week he goes the round of the County Hospital, with its 400 patients, inspecting them for himself under the guidance of the professors - now in the medical ward, then in the surgical, from that to the ward for women and children, and for diseases of the eye and ear, and so forth. At the college he has a similar opportunity of investigating disease in the dispensary patients, who crowd there on three day of every week in numbers greater than can be properly disposed of. He handles chemicals in the laboratory, investigates morbid anatomy, and works in the dissecting room. All this is done, not merely during the regular lecture term of five months, but the whole year round. Didactic teaching also goes on throughout the year. Advanced students have opportunities of attending cases of labor under the private supervision of the professors. The stethoscope, the forceps, the clinical thermometer, the sphygmograph, the laryngoscope and other instruments old and new, are not forgotten. Examinations are made daily during the lectures, and the final examination for the degree is thorough and searching. When I graduated in the University of Pennsylvania, my examination occupied a short three quarters of an hour. At present two or three hours are required for each professor in our school. Our examinations are partly in writing , giving us a permanent record of the results. . .
And when I take a general survey of the condition and progress of medical science, and the character and qualifications of medical men in our own country, and especially in California, so far from feeling any sense of humility and shame, I proclaim myself proud of my profession, glad to be in it and of it, to be identified with it, to live in it and, when the time shall come, to die in it.
In spite of his apparent satisfaction with the state of the art in California, Professor Gibbons and his MCP colleagues at about this time began seriously to consider major curricular reform. The Faculty's final decision to adopt a more advanced standard of education was announced one year later on 17 April 1878 at the Annual meeting of the California State Medical Society in San Jose. The announcement was included in the Report of the Society's Committee on Medical Education, chaired by Dr. H. S. Orme of Los Angeles. In his Report, Dr. Orme lamented the parlous state of American medical education and asked a rhetorical question: 
Has anything been done to remedy these evils? We think there has; the bright light of a new day dawns upon us from the East. The Medical School of Harvard University, in 1871, as you are aware, inaugurated a system of education in that institution, which has stood the test of experiment for over six years, and has fairly won for that venerable university the imperishable honor of being the pioneer in the greatest of modern medical reforms. . .
I am happy to announce to you. . . (that) the Medical Department of the University of California and the Medical College of the Pacific have each conformed to this new system, and have formally established a three years' graded course of medical instruction in their respective schools. This is also gratifying to our sense of local pride, as every true Californian must feel a deep interest in the development and culture of all those who enter upon the study of our profession, and especially in the youth of this coast. These schools are attaining high rank, and we have reason to hope will soon be second to none in America.
Increase from Two to Three Identical Annual Lecture Courses
Dr. Orme was premature in announcing in 1878 that MCP had "formally established a three year's graded curriculum." Actually the MCP did not phase in the graded curriculum until the Session for 1881. Meanwhile only intermediate steps were taken. In 1879 Requirements for Graduation for the first time included attendance at three identical annual lecture courses (each of five months' duration), instead of two identical courses as formerly mandated. The rationale for this change, which had been recommended in 1876 by Dr. Biddle and the Association of American Medical Colleges, was outlined in the Annual Announcement of MCP for 1879, as follows: 
This requirement for three (identical) courses of lectures instead of two is simply putting into execution a long contemplated plan, as it has been the constant desire of the Faculty to raise the standard of medical education, and to graduate capable, rather than many, students. No increase of expense will result, nor will the plan necessarily extend the period of study, but rather provide for a more systematic and profitable use of time, and better fit the student for the arduous and responsible duties of his profession.
Another significant change in graduation requirements in 1879 was to abolish the requirement that: "The candidate must have studied medicine for three years (the terms of attending Lectures included) under the direction of a respectable practitioner." This timely alteration in graduation requirements eliminated the apprenticeship from the medical school curriculum.
The Three Year Graded Curriculum
(Three Course Plan of Medical Education)
The next important step in curricular reform was the adoption in 1881 of the graduation requirement that the student must have completed a graded sequence of three Annual Lecture Courses (also known as the "Three Course Plan of Medical Education"), instead of the three identical Annual Courses previously required. The details of the Three Course Plan were spelled out in the Announcement for 1881: 
The Faculty has now fully completed and established the Three Course plan of education, which has been adopted by a number of the leading Colleges of the United States. While a direct pecuniary disadvantage, it is, nevertheless, a great satisfaction to have accomplished this result, as it has been the constant desire of the Faculty to raise the standard of Medical Education and to graduate capable, rather than many, students. No increase of expense will result, nor will the plan necessarily extend the period of study, but rather provide for a more systematic and profitable use of time, and better fit the student for the arduous and responsible duties of his profession.
In carrying out this plan of a three-years' course, it has been determined to require a matriculating examination, or other evidence of the possession of at least a fair English education, with the expectation of making such examination more complete as the future may determine.
During the First Year the student will be expected to direct his attention mainly to descriptive anatomy with dissections, physiology, chemistry, microscopy and histology, and surgery, upon which subjects an examination will be held at the close of the course. He will, however, be required to attend lectures upon the other subjects whenever a thorough attention to the above branches will permit
In the Second Year, to the studies above enumerated, will be added materia medica and therapeutics, theory and practice of medicine, obstetrics, gynecology, ophthalmology, otology, and pathology, with clinics on the various practical branches. At the close of this year, examinations will be given in descriptive anatomy, physiology and chemistry.
In the Third Year the studies include surgical anatomy, surgery, materia medica and therapeutics, theory and practice of medicine, obstetrics, gynecology, ophthalmology, otology, microscopy and histology, and pathology, with clinics on the various branches. The graduating examination will be oral and written, upon all the subjects considered in the third course. This plan will receive such modification as experience may render advisable.
As previously, graduation requirements still included the submission of a Medical Thesis.
The last academic reform to be introduced was the establishment of a formal requirement for matriculation (that is, for admission to the school.) It is interesting to note that no educational or other requirement for Matriculation in the Medical Department of University of the Pacific or its successor schools was specified in the Annual Announcements from 1859 through 1883, nor was the applicant requested to submit any information regarding prior education or training. 
The first specification of an admission requirement appears in the Annual Announcement of Cooper Medical College for 1884 as follows: 
No student will be admitted to the curriculum who has not attained the age of eighteen years.
All applicants for admission, except such as posses the qualifications hereinafter described, must pass a matriculating examination.
Graduates of literary, scientific, medical, or pharmaceutical colleges or universities, in good standing, graduates of High schools, and applicants who have passed the examination for admission to any recognized literary or university, or who hold first grade certificates from any Public School Board, as properly qualified teachers shall, on producing proper evidence of the same, be admitted to matriculation without examination
The examination will be practical rather than technical, its object being to determine the candidate's general knowledge and natural capacity, and whether his previous acquirements have been sufficient to enable him to pursue the study of medicine to advantage.
The candidate will be examined in the following branches: English Composition, Physics, Arithmetic and Latin. etc.
The crux of the matter here is that, beginning in 1884 , a High School education was sufficient preparation for admission but, prior to that date, there were no formal admission requirements and standards were undoubtedly even lower.
Assessment of Reforms
With adoption of the Three Course Plan (Three Year Graded Curriculum) in 1881, the Medical College of the Pacific joined Harvard, Pennsylvania and other progressive schools in the vanguard of curricular reform in American medical education.
The length of time required to obtain the M. D. degree was not increased. It remained at three years, but the content of the curriculum was immensely improved.
The combination of Intermediate Lecture and Regular Lecture Programs resulted in a school year of eight or nine months.
The apprenticeship, an outmoded experience that varied widely in quality depending upon the preceptor, was eliminated.
Minimum educational requirements for matriculation were finally established in 1884. These allowed admission on the basis of a High School diploma. Higher admission standards remained one of the major needs in medical education generally, but continued to be widely resisted nationally because higher standards meant fewer students eligible for admission and decreased income for the Professors.
Fees for the Three Course Plan
From 1859 through 1862 Lecture Fees were paid by students directly to individual Professors. From 1863 through 1878 a set charge of $ 130 was paid directly to the School for each Annual Lecture Course. When the three-year program was introduced in 1879, the Faculty decided to provide the lengthened program at no additional expense to the student. The cost of the two-year program was simply prorated over three years as follows: 
The net result of the new arrangement was to establish an overall tuition of $315 for three years of medical education.
Incidentally, the Medical Department of the University of California adopted essentially the same rate of tuition. 
School Finances and Faculty Compensation
The cost of operating the Medical College of the Pacific is indicated by the following excerpts from financial records of the College: 
|1870||$ 1781||$ 1270||$ 511|
|1872 (to July 16)||1788||926||862|
|Balance on Hand on 16 July 1972||$ 2031|
|Allocation to Professors on 24 July 1872||1150*|
|Remaining in reserve||$ 881|
*On 24 July 1872 It was decided to allocate $ 100 to each of the following seven Professors (Bowie, Morse, Gibbons, Sr., Gibbons. Jr., Lane, Cushing and Ellinwood; and to allocate $ 250 to Professor Bentley (Microscopic Anatomy and Pathology) and $ 200 to Professor Price (Chemistry and Toxicology). Total allocation: $ 1150.
The year of 1876 was more prosperous than the earlier ones, as is apparent from the following financial report: 
|1876||$ 8456||$ 6509*||$ 1947|
*On 30 October 1876, another dividend for the Professors was declared. The Dean was directed to disburse $ 200 for each of the past two years to each of the active Professors, making a total of $ 3400. This sum was included among the Expenditures.
The above data show that the Faculty of MCP received only nominal compensation. Further evidence of the fine spirit of the Faculty and their dedication to the school is seen in the following editorial comment in the PMSJ in the fall of 1882: 
It deserves mention that the Faculty of the College have, for several years, performed the duties of their respective Chairs without a dollar of compensation, leaving the entire income of the school to the purchase of the required equipment and the establishment of a fund for future use. The fund is now sufficient to furnish every department lavishly with apparatus, instruments, etc., and to lay the foundation for a museum and a library. This course is proposed to be continued so long as there shall be occasion for it. It might be difficult to find another medical school whose Faculty has done so much work and entirely relinquished the profits of their labor for college purposes.
We now have some idea of the annual income and expenditures of the Medical College of the Pacific. We also know that the only source of College income was student tuition of $ 315, paid at the rate of about $ 150 per year per student from 1870 to 1878 (when the curriculum was of two years' duration) and at an annual rate of about $ 100 from 1879 to 1882 (when the curriculum was extended to three years). Utilizing these figures, we can make a rough estimate of the annual tuition income to the College by tabulating annual MCP matriculants from 1870 to 1882: Please note that the number of graduates was only seven in 1880, less than half the number in the previous two years. Dr. Gibbons pointed out that this was due to increasing the length of the course of instruction from two to three years in 1879.   
|Year||MCP Matriculants||MCP Annual Income||MCP Grads||UCMD Grads|
* Annual graduates from the Medical Department of the University of California are listed for comparison. 
** M. D. degree granted by Cooper Medical College.