medical education

Introduction

      course of study directed toward imparting to persons seeking to become physicians the knowledge and skills required for the prevention and treatment of disease. It also develops the methods and objectives appropriate to the study of the still unknown factors that produce disease or favour well-being.

      Among the goals of medical education is the production of physicians sensitive to the health needs of their country, capable of ministering to those needs, and aware of the necessity of continuing their own education. It therefore follows that the plan of education, the medical curriculum, should not be the same in all countries. Although there may be basic elements common to all, the details should vary from place to place and from time to time. Whatever form the curriculum takes, ideally it will be flexible enough to allow modification as circumstances alter, medical knowledge grows, and needs change.

      Attention in this article is focused primarily on general medical education.

History of medical education

      Although it is difficult to identify the origin of medical education, authorities usually consider that it began with the ancient Greeks' method of rational inquiry, which introduced the practice of observation and reasoning regarding disease. Rational interpretation and discussion, it is theorized, led to teaching and thus to the formation of schools such as that at Cos, where the Greek physician Hippocrates is said to have taught in the 5th century BC and originated the oath that became a credo for practitioners through the ages.

      Later, the Christian religion greatly contributed to both the learning and the teaching of medicine in the West because it favoured not only the protection and care of the sick but also the establishment of institutions where collections of sick people encouraged observation, analysis, and discussion among physicians by furnishing opportunities for comparison. Apprenticeship training in monastic infirmaries and hospitals dominated medical education during the early Middle Ages. A medical school in anything like its present form, however, did not evolve until the establishment of the one at Salerno in southern Italy between the 9th and 11th centuries. Even there teaching was by the apprentice system, but an attempt was made at systemization of the knowledge of the time, a series of health precepts was drawn up, and a form of registration to practice was approved by the Holy Roman emperor Frederick II. During the same period, medicine and medical education were flourishing in the Muslim world at such centres as Baghdad, Cairo, and Córdoba.

      With the rise of the universities in Italy and later in Cracow, Prague, Paris, Oxford, and elsewhere in western Europe, the teachers of medicine were in some measure drawn away from the life of the hospitals and were offered the attractions and prestige of university professorships and lectureships. As a result, the study of medicine led more often to a familiarity with theories about disease than with actual sick persons. However, the establishment in 1518 of the Royal College of Physicians of London, which came about largely through the energies of Thomas Linacre (Linacre, Thomas), produced a system that called for examination of medical practitioners. The discovery of the circulation of the blood by William Harvey (Harvey, William) provided a stimulus to the scientific study of the processes of the body, bringing some deemphasis to the tradition of theory and doctrine.

      Gradually, in the 17th and 18th centuries, the value of hospital experience and the training of the students' sight, hearing, and touch in studying disease were reasserted. In Europe, medical education began slowly to assume its modern character in the application of an increasing knowledge of natural science to the actual care of patients. There was also encouragement of the systematic study of anatomy, botany, and chemistry, sciences at that time considered to be the basis of medicine. The return to the bedside aided the hospitals in their long evolution from dwelling places of the poor, the diseased, and the infirm, maintained by charity and staffed usually by religious orders, into relatively well-equipped, well-staffed, efficient establishments that became available to the entire community and were maintained by private or public expense.

      It was not until the mid-19th century, however, that an ordered pattern of science-oriented teaching was established. This pattern, the traditional medical curriculum, was generally adopted by Western medical schools. It was based upon teaching, where the student mostly listens, rather than learning, where the student is more investigative. The clinical component, largely confined to hospitals (charitable institutions staffed by unpaid consultants), was not well organized. The new direction in medical education was aided in Britain by the passage of the Medical Act of 1858, which has been termed the most important event in British medicine. It established the General Medical Council, which thenceforth controlled admission to the medical register and thus had great powers over medical education and examinations. Further interest in medicine grew from these advances, which opened the way for the discoveries of Louis Pasteur, which showed the relation of microorganisms to certain diseases, Joseph Lister's application of Pasteur's concepts to surgery, and the studies of Rudolf Virchow and Robert Koch in cellular pathology and bacteriology.

      In the United States, medical education was greatly influenced by the example set in 1893 by the Johns Hopkins (Johns Hopkins University) Medical School in Baltimore. It admitted only college graduates with a year's training in the natural sciences. Its clinical work was superior because the school was supplemented by the Johns Hopkins Hospital, created expressly for teaching and research carried on by members of the medical faculty. The adequacy of medical schools in the United States was improved after the Carnegie Foundation for the Advancement of Teaching published in 1910 a report by the educator Abraham Flexner (Flexner, Abraham). In the report, which had an immediate impact, he pointed out that medical education actually is a form of education rather than a mysterious process of professional initiation or apprenticeship. As such, it needs an academic staff, working full-time in their departments, whose whole responsibility is to their professed subject and to the students studying it. Medical education, the report further stated, needs laboratories, libraries, teaching rooms, and ready access to a large hospital, the administration of which should reflect the presence and influence of the academic staff. Thus the nature of the teaching hospital was also influenced. Aided by the General Education Board, the Rockefeller Foundation, and a large number of private donors, U.S. and Canadian medical education was characterized by substantial improvements from 1913 to 1929 in such matters as were stressed in the Flexner report.

Modern patterns of medical education

      As medical education developed after the Flexner report was published, the distinctive feature was the thoroughness with which theoretical and scientific knowledge were fused with what experience teaches in the practical responsibility of taking care of human beings. Medical education eventually developed into a process that involved four generally recognized stages: premedical, undergraduate, postgraduate, and continuing education.

Premedical education and admission to medical school

      In the United States, Britain, and the Commonwealth countries, generally, medical schools are inclined to limit the number of students admitted so as to increase the opportunities for each student. In western Europe, South America, and most other countries, no exact limitation of numbers of students is in effect, though there is a trend toward such limitation in some of the western European schools. Some medical schools in North America have developed ratios of teaching staff to students as high as 1 to 1 or 1 to 2, in contrast with 1 teacher to 20 or even 100 students in certain universities in other countries. The number of students applying to medical school greatly exceeds the number finally selected in most countries.

      Requirements to enter medical school, of course, vary from country to country, and in some countries, such as the United States, from university to university. Generally speaking, in Western universities, there is a requirement for a specified number of years of undergraduate work and passing of a test, possibly state regulated, and a transcript of grades. In the United States entry into medical school is highly competitive, especially in the more prestigious universities. Stanford University, for instance, accepts only about 5 percent of its applicants. Most U.S. schools require the applicant to take the Medical College Admission Test, which measures aptitude in medically related subjects. Other requirements may include letters of recommendation and a personal interview. Many U.S. institutions require a bachelor's degree or its equivalent from an undergraduate school. A specific minimum grade point average is not required, but most students entering medical school have between an A and a B average.

      The premedical courses required in most countries emphasize physics, chemistry, and biology. These are required in order to make it possible to present subsequently courses in anatomy, physiology, biochemistry, and pharmacology with precision and economy of time to students prepared in scientific method and content. Each of the required courses includes laboratory periods throughout the full academic year. Student familiarity with the use of instruments and laboratory procedures tends to vary widely from country to country, however.

Undergraduate education

      The medical curriculum also varies from country to country. Most U.S. curriculums cover four years; in Britain five years is normal. The early part of the medical school program is sometimes called the preclinical phase. Medical schools usually begin their work with the study of the structure of the body and its formation: anatomy, histology, and embryology. Concurrently, or soon thereafter, come studies related to function—i.e., physiology, biochemistry, pharmacology, and, in many schools, biophysics. After the microscopic study of normal tissues (histology) has begun, the student is usually introduced to pathological anatomy, bacteriology, immunology, parasitology—in short, to the agents of disease and the changes that they cause in the structure and function of the tissues. Courses in medical psychology, biostatistics, public health, alcoholism, biomedical engineering, emergency medicine, ethical problems, and other less traditional courses are becoming more common in the first years of the medical curriculum.

      The two or more clinical (clinic) years of an effective curriculum are characterized by active student participation in small group conferences and discussions, a decrease in the number of formal lectures, and an increase in the amount of contact with patients in teaching hospitals and clinics.

      Clinical work begins with general medicine and surgery and goes on to include the major clinical specialties, including obstetrics and gynecology, pediatrics, disorders of the eye, ear, nose, throat, and skin, and psychiatry. The student works in the hospital's outpatient, emergency, and radiology departments, diagnostic laboratories, and surgical theatres. The student also studies sciences closely related to medicine, such as pathology, microbiology, hematology, immunology, and clinical chemistry and becomes familiar with epidemiology and the methods of community medicine. Some knowledge of forensic (legal) medicine is also expected. During the clinical curriculum many students have an opportunity to pursue a particular interest of their own or to enlarge their clinical experience by working in a different environment, perhaps even in a foreign country—the so-called elective period. Most students find clinical work demanding, usually requiring long hours of continuous duty and personal commitment.

      In the United States after satisfactory completion of a course of study in an accredited medical school the degree of doctor of medicine (M.D.) or doctor of osteopathy (D.O.) is conferred. In Britain and some of the other Commonwealth countries the academic degree conferred after undergraduate studies are completed is bachelor of medicine and of surgery (or chirurgery), M.B., B.S. or M.B., CHb. Only after further study is the M.D. degree given. Similar degrees are conferred in other countries, although they are not always of the same status.

Postgraduate education

      On completion of medical school, the physician usually seeks graduate training and experience in a hospital under the supervision of competent clinicians and other teachers. In Britain (United Kingdom) a year of resident hospital work is required after qualification and before admission to the medical register. In North America, the first year of such training has been known as an internship, but it is no longer distinguished in most hospitals from the total postgraduate period, called residency. After the first year physicians usually seek further graduate education and training to qualify themselves as specialists or to fulfill requirements for a higher academic degree. Physicians seeking special postgraduate degrees are sometimes called fellows.

Continuing education

      The process by which physicians keep themselves up-to-date is called continuing education. It consists of courses and training opportunities of from a few days to several months in duration, designed to enable physicians to learn of new developments within their special areas of concern. Physicians also attend medical and scientific meetings, national and international conferences, discussion groups, and clinical meetings, and they read medical journals and other materials, all of which serve to keep them aware of progress in their chosen field. Although continuing education is not a formal process, organizations designed to promote continuing education have become common. In the United States the Accreditation Council for Continuing Medical Education was formed in 1985, and some certifying boards of medical specialties have stringent requirements for continuing education.

      The quality of medical education is supervised in many countries by councils appointed by the profession as a whole. In the United States these include the Council on Medical Education and the Liaison Committee on Medical Education, both affiliates of the American Medical Association, and the American Osteopathic Association. In Britain the statutory body is the General Medical Council, most of whose members are from the profession, although only a minority of the members are appointed by it. In other countries medical education may be regulated by an office or ministry of public instruction with, in some cases, the help of special professional councils.

Medical school faculty

      As applied to clinical teachers the term full-time originally implied an educational ideal: that a clinician's salary from a university should be large enough to relieve him of any reason for seeing private patients for the sake of supplementing his salary by professional fees. Full-time came to be applied, however, to a variety of modifications; it could mean that a clinical professor might supplement his salary as a teacher up to a defined maximum, might see private patients only at his hospital office, or might see such patients only a certain number of hours per week. The intent of full-time has always been to place the teacher's capacities and strength entirely at the service of his students and the patients entrusted to his care as a teacher and investigator.

      Courses in the medical sciences have commonly followed the formula of three hours of lectures and six to nine hours of laboratory work per week for a three-, six-, or nine-month course. Instruction in clinical subjects, though retaining the formal lecture, have tended to diminish the time and emphasis allowed to lectures in favour of experience with and attendance on patients. Nonetheless, the level of lecturing and formal presentation remains high in some countries.

Requirements for practice

      Graduation from medical school and postgraduate work does not always allow the physician to practice. In the United States, licensure to practice medicine is controlled by boards of licensure in each state. The boards set and conduct examinations of applicants to practice within the state, and they examine the credentials of applicants who want licenses earned in other states to be accepted in lieu of examination. The National Board of Medical Examiners holds examinations leading to a degree that is acceptable to most state boards. National laws regulating professional practice cannot be enacted in the United States. In Canada the Medical Council of Canada conducts examinations and enrolls successful candidates on the Canadian medical register, which the provincial governments accept as the main requirement for licensure. In Britain the medical register is kept by the General Medical Council, which supervises the licensing bodies; unregistered practice, however, is not illegal. In some European countries graduation from a state-controlled university or medical school in effect serves as a license to practice; the same is true for Japan.

Economic aspects

      The income of a medical school is derived from four principal sources: (1) tuition and fees, (2) endowment income or appropriation from the government (taxation), (3) gifts from private sources, and (4) donation of teachers' services. Tuition or student fees are large in most English-speaking countries (except in U.S. state universities) and relatively small throughout the rest of the world. Tuition in most American schools, however, rarely makes up more than a small part of total operating expenses. The total cost of maintaining a medical school, if prorated among the students, would produce a figure many times greater than the tuition or other charges paid by each student. The costs of operating medical schools in the United States increased by about 30 times between the late 1950s and the mid-1980s.

      The expenses of medical education fall into two groups: those of the instruction given in the medical sciences and those connected with hospital teaching. In the medical sciences the costs of building maintenance, laboratory equipment and supplies, research expenses, salaries of teachers, and wages of employees are heavy but comparable to those in other departments of a university. In the clinical subjects all expenses in connection with the care of patients usually are considered as hospital expenses and are not carried on the medical school budget, which is normally reserved for the expenses of teaching and research. Here the heavy expenses are salaries of clinical teachers and the cost of studying cases of illness with a thoroughness appropriate to their use as teaching material.

      To a considerable degree in free-market countries, the cost of securing an adequate medical education has tended to exclude the student whose family cannot contribute a large share of tuition and living expenses for four to 10 years. This difficulty is offset in some medical schools by loan funds and scholarships, but these aids are commonly offered only in the second or subsequent years. In Britain scholarships and maintenance grants are available through state and local educational authority funds, so that an individual can secure a medical education even though the parents may not be able to afford its cost.

Scientific and international aspects

      Medical education has the double task of passing on to students what is known and of attacking what is still unknown. The cost of medical research is borne by only a few; the benefits are shared by many. There are countries whose citizens are too poor to support physicians or to use them, countries that can support a few physicians but are too poor to maintain a good medical school, countries that can maintain medical schools where what is known can be taught but where no research can be carried out, and a few countries in which teaching and research in medicine can be carried on to the great advantage of the world at large.

      A medical school having close geographical as well as administrative relationships with the rest of the university of which it forms a part usually profits by this intimate and easy contact. Medicine cannot wisely be separated from the biological sciences, and it continues to gain immensely from chemistry, physics, mathematics, and psychology, as well as from modern technology. The social sciences contribute by making physicians aware of the need for better distribution of medical care. Contact with teachers and the advancing knowledge in other faculties also may have a corollary effect in advancing medicine.

      With the development of the World Health Organization (WHO) and the World Medical Association after World War II, there has been increasing international interest in medical education. WHO conducts a regular program for aiding countries in the development and expansion of their educational facilities. World War II showed the advantages and economy derived from satisfactory systems of medical education: defects and diseases were more widely and accurately detected among recruits than ever before, health and morale were effectively maintained among combatants, and disease and battle injuries were effectively treated.

Alan Gregg Edward Lewis Turner Harold Scarborough

Additional Reading

Among the many books devoted to the subject of medical education are the following historical discussions: Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (1910, reprinted 1973); and Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (1985). For special information, see the following official publications: Association of American Medical Colleges, AAMC Directory of American Medical Education, 1986–87, 33rd ed. (1986), Medical School Admission Requirements, 1988–89, 38th ed. (1987), and Physicians for the Twenty-first Century: Report to the Project Panel on the General Professional Education of the Physician and College Preparation for Medicine (1984). Studies include Mohan L. Garg and Warren M. Kleinberg, Clinical Training and Health Care Costs: A Basic Curriculum for Medical Education (1985); and Marjorie Price Wilson and Curtis P. McLaughlin, Leadership and Management in Academic Medicine (1984).For new developments in medical education, see the periodicals The Journal of Medical Education (monthly), Medical Education (bimonthly), and WHO Chronicle (bimonthly). Opportunities for continuing medical education appear semiannually in JAMA: The Journal of the American Medical Association (weekly).

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