1935

SOME CONSIDERATIONS OF MEDICALEDUCATION.

VIII. 1

Neithe’l’ Teacher nor Ta1f,qht at Fault.-Tlle " Bloc7t " System.--The science Student at the Pzcblie School.

IN the previous chapter it was pointed out that it wa:

allowed on all hands that the medical curriculum was ove:

full, or, to put it in other words, that the statutory timof five years did not seem to be sufficient to allov

a fair proportion of students to obtain their qualifications. Something over 80 per cent. of the students occupymore than the statutory five years in their attempt;to obtain a place on the Medical Register, and it il

impossible to believe that any large proportion of these merowe a check to their professional career to inherent faults o:their own, to idleness, slackness, or stupidity ; and it i:

equally impossible to attribute this deplorable waste oj

effort to remissness on the part of teachers or frailty on thEpart of examiners. There are idle students, supine teachersand incompetent examiners, but no one with any experiencEof the enormous pains now taken with regard to thE

machinery of medical education, or in the least appreciative of the earnest, absorbing, and generally ill-paid labour:of the lecturers, will think for one moment that the radicatrouble is any default on the part of teacher or taught.With regard to the one-portal system, the suggestion that

it would by its simplicity remedy the condition of affairiis interesting, but impractical because the advocates of this

system have not, at any rate at present, sufficiently strongarguments to produce any effect either on the General MedicalCouncil or on the legislature. The suggestion that thE

statutory time of the curriculum should be extended has alscbeen dealt with, and most of us will be in agreement withwhat is apparently the opinion of the General MedicalCouncil, that the time has not arrived for this. In the presentposition of affairs the curriculum is indefinitely extended, sothat the failure of the students to meet the demands made

upon them forms a practical equivalent to a statutoryprolongation of the time of studentship, only this

prolongation occurs in a disappointing and vexatiousmanner. There remains, lastly, to consider the advisa-bility that the student should reach his medical schoolin a better state of preparation, so that he shallhave much less trouble with his preliminary scientificsubjects, and consequently more time to devote to his finalsubjects, and the importance of this point is enhanced bythe fact that the General Medical Council has now adoptedthe view that for these official subjects a distinct period ofnot less than 24 months shall be kept sacred.

This means the formal introduction into the medicalcurriculum of the block" system, which has many advocatesand also many opponents. A large number of medicalstudents having difficulty with their preliminary subjects,whether these are the ancillary subjects of chemistry,physics, and biology, or the directly professional subjectsof anatomy and physiology, occupy more than three

years of the statutory five years in study pursued in class-rooms before they are free to attack without interruption thefinal subjects of medicine, surgery, and midwifery. It iscertain that to a great many of these students timeis of vast importance, so that they are unwilling(or their parents are unwilling for them) to postponetheir introduction to clinical work until they shall havesatisfied their examiners upon all the introductory subjects.To work at anatomy and physiology in the detailed wayrequired by an approaching test examination leaves thestudent with but little leisure and aptitude for other studies,yet many students by industry and determination recover toa great extent the place which they have lost in the earlypart of the race, being able with success to conduct whatare called overlapping studies. Remembering this, and

1 Nos. I., II., III., IV., V., VI., and VII. were published inTHE LANCET of Oct. 23rd (p. 1232) and 30th (p. 1301), Nov. 13th(p. 1459). 20th (p. 1531), and 27th (p. 1616), and Dec. 4th (p. 1694) and11th (p. 1766), 1909, respectively.

remembering also that a certain number of students areable to coach their fellows in the introductory subjectswhile working for the final subjects, it becomes a seriousmatter to compel all students to keep for any specified periodthe whole of their time free for clinical and pathologicalwork. On the other hand, two years must appear tobe the very minimum of time in which it is possiblenowadays to acquire such a genuine knowledge of actualmedical and surgical practice as would warrant any uni-

versity or licensing body in granting a degree or a diplomato an applicant. Further, the pressure on the GeneralMedical Council to make the examination in the professionalsubjects even more wide-ranging than it is at present-toinclude, for example, such subjects as anaesthetics andelectro-therapeutics-has to be taken into account. Thosewho see no harm in a certain amount of overlapping possessa strong argument in the fact that, scientific medicine beingbuilt upon a foundation of anatomy and physiology, littlebut good can come of a certain amount of fusion ofstudies. But the more the final subjects of the curriculumtend to become multiplied or specialised the more remotebecomes the connexion between them and the details ofanatomy and physiology taken as a whole. All these con-siderations no doubt weighed with the General MedicalCouncil in deciding that at least the last two years of thestudent’s time should be spent in clinical and pathologicalwork, but upon this decision follows the difficulty that nowthe first three years of the student’s time may not provesufficient for his preliminary scientific studies, including hisanatomy and physiology.

It seems probable that here, as far as England is concerned,the public schools will come to the rescue. Inasmuchas every medical student is compelled to pass an entranceexamination of a general character before commencinghis medical studies-which means that he must goto school somewhere-if more of his time at school were

spent in definite preparation for a medical career his curri-culum would be lengthened without more money being spentthan would otherwise have been spent on his education.That is to say, that the very legitimate objection on the part ofthe medical student, or usually of his parents and guardians,to spend an increased sum upon training for a professionwhich, already by no means a cheap one to enter, offers inreturn no great pecuniary prizes, would be to some extent met.With the continuous expansion of our knowledge in everybranch of science it is at least possible, and to many itappears inevitable, that the general education of boys andgirls destined for one or another of the scientific callingsmust give way at an earlier period than has hitherto beennecessary to the special training which is to be the stock-in-trade of their various careers. This means, as has been

pointed out in these columns, that we may have toask the schoolmaster to hold the balance squarelybetween the claims of science and the claims of thehumanities upon the school hours of those of the cominggeneration who are to practise the profession of medicine.The influence which a capable teacher of the elements ofscience can exert over a lad during the last two years ofschool life is very great, for by the time the pupil has reachedthat period of his education he should have learnt how tolearn, and his mind should be in its most receptive state-somuch plastic material ready to be moulded into methods ofaccurate observation, and indued with a right appreciation ofthe experimental method and all that it entails. If thestudent brings such a training with him to a medical schoolhe has gained a solid and practical advantage from his

school-days beyond the expansion of his mind and its equip-ment with a store of knowledge. It is to be desired in mostcases that the school-boy, who has elected to follow medicine,should receive a grounding in the principles of chemistry andphysics at least before he passes the arts examination," which is the portal to his professional studies. Of course,if time is of no object to the student he can acquire thisgrounding after spending a full school life in general educa-tion, but if he desires to become a medical man at the

average age (and this is now about 26 years) he will makehis path easier by beginning his scientific work soon afterthe age of 16. Many of the English public schools arenow perfectly able to instruct their boys in physics andchemistry, and some of them claim to be able to givebetter instruction than will be obtained at certain of themedical schools, but there is still difficulty at most

1936

public schools as regards biological teaching. This forone reason has made the General Medical Council lookwith no great favour on the instruction of schoolboysin the preliminary scientific subjects, while recognition ofschoolboy instruction as part of the statutory course mustalways seem unfair to Scottish, and particularly to Irish,students, where no system exists of big public schools whichpossess laboratories and an equipment of teachers andmaterial for a scientific education.But the General Medical Council has no reason whatever

to be concerned whether the schoolboy takes up scientificsubjects or no before he begins his statutory career: all thatthe Council requires is that he should begin this career

by passing some examination in Arts. What has to be

thought of, then, is this. The intending medical studentmust go to school, and his schooling must be paid for. Whenhe is a student he will take six or seven years to obtain his

qualifications, mainly owing to his difficulties with the pre-liminary subjects. But if he works at those subjects atschool he will probably only take the statutory five years toget qualified after joining a medical school, while his

schooling will cost no more than if he had de-voted himself to the humanities. Will his schooling beworth less ? Probably not. Since the old days whenapprentices were bound to a trade with many years of

indenture, sometimes commencing at 12 years of age, nocalling in England has seemed to require this kind of segre-gation except the calling of the naval officer. The tacticsof the navy with regard to its officers have always beento "catch them young," but no other trade or professionat the present time considers this proceeding necessary.However partial the attempt in this direction may be,the strictly professional part of a schoolboy’s educa-tion would have to be undertaken at the risk of makinghim as a professional man narrow. By inducting him into apurely professional educational course before he has com-

pleted his general instruction we must undoubtedly run a riskof depriving him of something that is valuable. None theless, such is the difficulty caused by the present overcrowdedstate of the medical curriculum, and such is the obviouswaste of effort implied in the long delay which the studentsundergo in obtaining their qualifications, that it is quitepossible that reform will come in this direction. If

English students should benefit by a general move

among those intending to practise medicine towards join-ing the modern side of a good public school, we can onlyconceive that the example would be followed elsewhere. Andthe fact is undoubted that students who are capable of pro-ceeding to pass the examination in the preliminary scientificsubjects on arriving at a medical school have an enormousadvantage over their compeers. It is impossible not tosympathise with the desire of the science masters in publicschools to be in proper accord with the General MedicalCouncil and have their instruction recognised as counting aspart of the statutory time of the student’s career, but theirinstruction is none the less valuable because it is givenpreliminary to and not as part of the medical curriculum. At

present the science masters can, as a matter of fact, dispensewith the recognition of the Council if they can obtain that ofany statutory body granting medical qualifications, but we seeno reason why the student intending to be a medical man shouldnot do at any rate the first year of his scientific studies before

joining the medical school and concurrently with his generalstudies, but he must be prepared to do this as a voluntaryact. It must be a matter of arrangement between him andhis parents to secure for him an early start, and we cannotexpect the General Medical Council to take cognisance ofthese schoolboy studies while only certain divisions of theUnited Kingdom can supply the necessary machinery.The argument behind most of the proposals which have been

discussed for the reform of the educational curriculumof the medical student was that subjects for the final exami-nations were neglected because the students had to spend toomuch time over the earlier subjects. The number and varietyof the suggestions to meet the abuse prove how general was thefeeling calling for these different expressions. The EducationCommittee of the General Medical Council showed in its inter-esting reports the enormous value of the work which ithas done, and the Council has supported these efforts andbrought order for the time being into the curriculum.

By deciding definitely that 24 months must be spent by the

student in uninterrupted clinical and pathological work,’theCouncil has taken a step which should certainly ensure muchless waste of effort and of time, and much less disappoint-ment and expense at the final end of the curriculum; butthere necessarily remain for consideration the difficultiesattached to the teaching and learning of the earlier subjects.Attention henceforth will be centred more upon the problemsconnected with these subjects, and it is probable that theposition of the science masters in the public schools whodesire to begin the education of the medical student whenhe is in his sixteenth year will receive greater attention thanheretofore.

ASYLUM REPORTS.

The Twentieth Annual Report of the Asylums Committee- asto the London County Asylums for the Year ending March 31st,1909.1-This voluminous report contains a vast mass ofstatistics relating to the ten institutions under the control ofthe London County Council. The figures relating to directadmissions show that the number of patients admitted

directly from the parishes have remained fairly constant forthe past seven years, ranging from 3439 in 1902 and 3686 in1903 to 3588 in 1907 and 3613 in 1908. The value of these

figures as a guide to the incidence of insanity is somewhatdiscounted owing to their dependence on the amount ofaccommodation available, and for this reason a comparisonwith earlier years is useless. Now, however, that the bulk ofLondon certified lunatics are housed in the county asylums thenumbers of direct admissions should from 1908 onwards forman approximately correct index to the fluctuations in occurring

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insanity in the county. A table showing the duration of the,

present attack prior to admission indicates that while 1473, out of 3450 direct admissions (excluding congenital cases) were admitted within one month of the onset of the illness,:

no less than 508 had been mentally disordered for more than12 months before admission, and 106 of these for more thanfive years. The number of patients discharged "recovered"

; shows a continued tendency to decline, the figure for; 1908 being lower than in any year since 1902. Of

the 1179 patients discharged recovered 8-06 per cent.were over 60 years of age, and 5’51 per cent. under 20. In8-39 per cent. the attack was of less than three months’’

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duration, and in 26’46 per cent. the attack has lasted fromthree to six months. Of the 1179 recoveries 621 had been

1 suffering from recent mania and recent melancholia. Out-

of the large mass of registered lunacy the medical super- intendents of the asylums consider that only 3 04 per cent.s of the patients have a favourable prospect of recovery,

6’01 per cent. being doubtful and 90 95 per cent. unfavour-able. The deaths continue to show a decreasing pro-portion when calculated on the average population

s of the asylums. This may partly be accounted forr

by the accumulation of chronic cases of insanity, which,1 having passed the period of possible recovery, remaint inmates until their deaths, often at advanced ages, thus

e swelling the bulk on which the proportion is calculated. Inthe 1540 deaths recorded, as many as 36’ 04 per cent. were*e over 60 years of age, and of these 17 - 14 were over 70. The

report contains the conclusions of the Asylums Committeeupon the report of the Royal Commission upon the Care ofthe Feeble-minded. Most of the recommendations of the

’y Royal Commission embody principles which are commended:d to the committee by its experience in dealing with the insane,and, indeed, many follow the lines of suggestions which thecommittee has itself put forward at various times. The

e committee is of opinion that the amount of laboriouswork laid upon it, should the recommendations be realised’in legislation, would be incalculable, but it recognises that

n it is only by measures which deal comprehensively andn thoroughly with feeble-mindedness that the tide of insanity

can be stemmed. We regret that we can derive little hope-)o from the report that the Mental Hospital devised by Dr.y Henry Maudsley and for the purposes of which he has givenie

a magnificent donation is likely to be shortly established.n The necessity for an easily accessible situation in connexion

with the clinic and out-patients’ department, which it is

it intended shall be attached to the hospital, has rendered thetask of selection of a site very difficult.

London : P. S. King and Son. Pp. 312. Price 2s.