No. 4644.

AUGUST 31, 1912.

THE LANCET.

LONDON: SATURDAY, AUGUST 31, 1912.

Address to Students.IN this our annual Students’ Number of THE LANCET there

will be found the usual epitome of the curriculum which themedical student must pursue before he can terminate the

I

first phase of his studies by having his name placed on theroll of the General Medical Council; and when this desiredend is reached he will see that he has only accomplishedone lap in a long race, and will all too quickly find out that’’ once a student always a student " is a true description ofthe medical life. Degrees and diplomas signify merely thefoundation, more or less stable, upon which the young

practitioner has to erect the structure of future knowledge,the edifice of his professional experience. We attemptwithin the pages of this issue of THE LANCET to give full in-formation as to the various Universities and Medical Schools,through the medium of whose professors, class-rooms, andlaboratories the student can receive the training necessaryto enable him to satisfy his examiners ; and it is at once

apparent that in this country our medical training, so much

debated, so much criticised, and in a few directions still so

incoherent, is none the less nobly planned both to secure forthe public an adequate band of professional men to under-take the private and public duties which fall to those whohave the health of the country in their charge, and at thesame time to allow of a proper development of scientific

medicine along lines which are rapidly multiplying in,

number.

The vastly increasing range of what are called medical

studies, the incursions of medicine into provinces hithertoconsidered strictly biological, chemical, mathematical, andeven meteorological, must to a great extent embarrass thosewho have the conduct of the education of the student. Theyhave eternally before them a double difficulty : they have todecide what to do and how to do it-what to exclude so that

the curriculum may be kept tolerably wieldy, and what toinclude so that it may form a sufficiently high standard ofentrance to the profession, as well as a nucleus for future

expansion. In dealing with a complicated and shiftingproblem a policy of compromise has to a certain extent

been necessary. To decide summarily and beforehand upon aschedule which should define with rigour exactly whatsubjects should be taught to every medical studentat every step in his career, and which should state also

how much of these subjects every medical student

should know by a certain date in his pupillage-todecide upon a schedule which attempted that sort of

thing would not simplify medical education one whit,nor would it, in spite of its uniformity, endow this

country with a more highly qualified medical profession than

we now have under the existing flexible, if faulty, system.The relative importance of botany and microscopy, pharma»cology and chemistry, is constantly changing. In clinical

work we find the same signs of development and progress.For when we get beyond the inevitable beginnings,which are founded directly upon anatomy, physiology,and chemistry, we see that whole groups of subjects, whichwere deemed of primary importance to the practitioner a.

few years ago, have lost that proud position from various-obvious circumstances; they remain matters with which.the student must be acquainted, but which, owing tonew groupings and correlations of facts, are no longer of the-first significance ; while other subjects which had seemed.mere excrescences on practical knowledge are seen to requireclose familiarity and earnest attention from the student..

In such a position the General Medical Council, which hasoften been pressed to be more speedy and drastic in reform-

ing the curriculum of the medical student, is exercising awise discretion in proceeding deliberately. An acute, and

by no means eulogistic, critic of European medical educa-tion, Dr. ABRAHAM FLEXNER, in a recent report 1 to the-Carnegie Foundation for the Advancement of Learning, has.declared that the medical student in this country is placed,in exceptionally favourable conditions for learning the

principles of medicine as well as for acquiring a veritable-clinical experience in the wards ; and those in charge of our-

system of medical education are rightly loth to run the-risk of minimising their great practical success bypursuing vague ideals. If they seem to hasten slowly, this-

impression is only produced on those who do not appreciate-the meaning of the progress made in recent years. If the-

system under which all medical men who have passed the-

necessary tests would enter the medical profession through-the same State gate has not yet commended itself to them,-it is not because it has received no consideration. And that

public events may lead in this direction sooner rather than.later is becoming probable.

It is commonly said that one of the chief arguments.against the institution of a one-portal system is that.

, it would destroy that flexibility of our educational’

system, which those who have thought most about

the subject consider to be extraordinarily valuable to,

. the student, enabling him later to develop an individualityI

and breadth in his work which would not otherwise be

j possible. This is not so certain a sequence of events as it

) formerly appeared to be, and was. General changes in the., relations of the profession of medicine to the country are’

, all towards a kind of specialisation of function, whereby

different classes of medical men will have different duties;b to perform, when it will be highly inconvenient that

L they should appear to have entered the profession byt different doors, permitting the public to tabulate them

t as belonging to classes of varying importance. If a one-

) portal system produced a standard of professional attain

t ment which would ensure the public being providul) with adequate service from medical men, whether as

fprivate practitioners or as State or municipal officials, it

should be easy to graft upon such a licence to practise a]1J

additional tests and rewards in correspondence with the bent

1 THE LANCET, August 3rd, 1912, p. 320.

570 AN ADDRESS TO STUDENTS.

of different groups of workers. There are many and greatpractical difficulties in the way of any such scheme, and thenecessary interference with vested interests and old-time

associations is not a thing to be lightly disregarded.But too much may be made of these difficulties,while the assumption that the examinations necessaryto enter the profession through the one State gatewould be of a stereotyped and official character is in

contradiction to our knowledge of the ways of those whohave hitherto conducted our medical education.

An enormous majority of English medical men, for instance,take the diplomas of the English Conjoint Board. On all

hands it has been allowed that the examinations of this

Board are thorough, fair, and conducted in such a way as

rightly to deserve their position of being very generally usedas models for other educational centres. There is no

reason to suppose that a one-portal system, if it were

instituted, would not make use of exactly similar machinerywith the same satisfactory results ; there is no reason why aState examination should not be as absolutely fair and

widely inclusive, while leaving the universities and medical

corporations to impose what tests they liked for their degreesand diplomas; and thexe in this way would be recognisedas the academic hall-marks which they should be, and wouldnot be used as licences to practise. The medical student

might have to be asked to pay in the aggregate morefees. But the possibilities of arrangement are unlimited

if the great medical corporations showed approval, whilea most valuable simplification of the examinational systemwould follow, and the invidious use of professional’titles would disappear. It is an open secret that

some 34 ago a one-portal system only failed to

be established in this country by the vote of a repre-

sentative of a single body of the 20 or so which at

that time had the right to grant degrees and diplomas.A change which so recently met with nearly unanimous

support may at any moment become a practical policy,and the question is brought at this mome t to the attention

’of medical students and their teachers because there are

many indications that a mutual agreement between the

medical profession and the public in favour of a one-portalsystem may after all be reached.

The students who are joining the medical profession thisOctober are doing o at an extremely critical period in the

history of our profession ; any alteration that their medical’curriculum may possibly undergo during the six years or

more while they are engaged in meeting the tests of

’examiners, is as nothing to the revolution that is actuallytaking place in professional practice. In these circum-

stances it is to us a little astonishing to learn that

ttbe number of recruits to our ranks does not appearto have decreased to the extent which was antici-

pated. No definite information, justified by figures, canbe as yet forthcoming, as the deans of the various schoolshave not received the notices of entry, save in a few cases.Stil1 there are circumstances on which rough estimates can’be based, and those to whom such circumstances are knownare fairly evenly divided in their views. Some believe that

the recent skrinkage in medical students will be maintained<0}’ exaggerated, while some anticipate a larger entry than

last year. For our part, we should not be surprised if thefalling-off were considerable, the apprehensions as to the

security of medical practice in the future having been so

generally expressed. But we cannot consider all those appre-

hensions justified. Medical men should be perfectly aware of

the strength of their cause, and of the feeling in the mindsof all thinking members of the public in these days, that itis essential to the well-being of a community to have

a properly equipped medical service. This implies that

general sentiment is on the side of those who demand thatthe conditions under which that service is supplied should be

satisfactory to the workers, should secure them adequateremuneration for their labours, and should leave them free tolive a life of professional independence. The troubles that

are now immediately ahead must inevitably find a solutionbefore those who enter our ranks this coming session

are taking part in the practical struggle of earning a profes-sional livelihood, and our new students may feel fairlycertain that before they find a place on the Medical Registermuch or all of the present turmoil will have abated. And theresult may be greatly increased opportunities in the medicallife. A time of transition must have its grave trials, and it is

not prophesied that these trials will be escaped, but ourfaith in the good sense of the country at large, by whom-soever it is governed, is sufficiently strong to make us feelthat no attempt could ever be successful, or would ever

nowadays be intentionally made, to enslave our membersiBut we conceive it to be absolutely necessary that the atten-tion of all students should be directed to the relations which

ought to exist between the profession which they have justjoined and the public which they intend to serve. It is from

the perpetual obscuring of these relations that has arisen the

existing crisis. The abuses of contract practice were

crying aloud before any heed was paid. Now the medical

profession is determined, solidly determined, to mend thoseabuses or do away with the system. Our new recruits will

be joining us during a time of anxious contest, but they can

rely confidently on the ultimate victory of medicine in itsdetermination to secure proper recognition at the hands ofthe State. The old bondage of contract practice will not befor them.

The unfair growth of contract practice has been a

singular phenomenon in our professional history. Started

originally by medical men out of charitable motives, the

public in larger numbers, and (unfortunately) in in-

creasingly substantial positions, soon began to avail

themselves of the contract terms which had been framed

with extreme moderation. The first medical men who

decided to see their poorer patients upon cooperativeterms were most careful to inquire into their needs and

their inability to pay before admitting them to what was

essentially a charitable list. It was then generally admittedthat any excess of charitable work on the part of the

medical man not only became an unfair tax on his

time, but prevented him from ministering to publicneeds in other and possibly more urgent directions.

But soon a different spirit sprang up, and everyoneknows how quickly and how disastrously the principleof cooperative medical practice spread until all the

evils of an unchecked contract system were upon us.

571THE STUDENT’S GUIDE.

In a short time many general practitioners found

themselves confronted with the situation that part of

their income was being paid to them in return for an

enormous amount of work under contract that could never be

remunerative-more, that could only just be made to paywhen the duties were performed in a perfunctory mannerand at the least possible cost. Then arose the extremelydangerous position, for medicine and for the public alike,under which thousands of persons were seen in crowded

surgeries in a mechanical way, and in an incredibly shortspace of time, for capitation fees rarely attaining to 5s. a

year and even dropping to 2d. a week. At last the medical

profession revolted against the tyranny of some of the

medical aid associations, and refused to undertake contract

practice on such unfair terms. A series of articles, the

result o local investigations, was published in these columns,revealing the sad situation, and then commenced at oncethe contest known as the Battle of the Clubs. The medical

aid associations, which had captured the principal share ofmedical clubs, fought hard to maintain an evil predominance.Representations made to them, pointing out the hardshipsunder which their medical officers suffered, were respondedto in many cases by the introduction into the practitioners’districts of salaried medical officers to do the work of the

medical aid associations, and at once the practitioners saw

that, not only were their professional profits seriouslydiminished by the fact that persons well able to pay reason-able fees took advantage of terms of contract practice whichhad never been intended for them, but that also a grave

uncertainty of tenure was being introduced into pro-fessional business. Victory, however, gradually inclined tothe medical profession, who were supported in a bitter

struggle by the organisation of the British Medical

Association and by articles in the British Medical Journal ’

and THE LANCET, which produced their proper impressionon the public mind. The evils of contract practice remain,but some of its more glaring defects were being remediedwhen the measure for national insurance against sicknessand invalidity was introduced last summer. Throughthis measure it was at once seen that there was a greatopportunity for medical men to escape from the terrors ofunfair and oppressive contract practice, and mainly withthat in view the medical profession took a strong stand

against the provisions for the administration of medical

benefits as proposed. To get free from the medical aid asso-

ciations was the desire of most of those who were engaged in

general practice. They did not necessarily wish to haveno club clients, but they hoped to recover the professionalindependence which had been gradually lost as contract

practice evolved from a charity into a business. This

is the basis of the present stand being made by a

vast majority of the medical profession against the

working of the National Insurance Act. They consider

rightly that the composition of the Local Insurance

Committees affords them no guarantee that the abuses

of contract practice will not be perpetuated under the

Act, with all the prestige of law behind them ; and,having so far failed to secure from the Government con-

cessions which would certainly remove the danger, theypropose to substitute for the machinery erected under

the Act for the distribution of medical benefits a Public,

Medical Service, designed at the same time to really insurethe public against invalidity and secure themselves againstimposition.

In this critical position of the medical profession it speaks.volumes for the great promise of the medical life that ithas proved sufficiently attractive to new collaborators..

Their adherence displays the faith that must be in all of usthat the progress of medical science is irresistible, and that

any check which it may receive will be only temporary iu,character. Here we must recall the fact, often though it hasbeen mentioned, that more than any other unit of societythe members of the medical profession have inside the fence.of their calling a choice of vastly varying careers. This it is.

that has ensured a constant recruiting of our ranks in spite’of the grave professional troubles of recent years, and the-circumstance continues to have its appeal. The con-

sultant and specialist, the general practitioner, the State

official, the officer, the pure pathologist-all are within ourfold and have a common professional aim and code, although,they lead lives that vary in every detail. Hence, the medical I

profession gives so wide an invitation that, despite the dark:days through which it is passing, fresh candidates for itstrials and triumphs will not be wanting. Those who- respond Ito the invitation will do so this year when the coherence.

of all the different branches of medicine is fiercely in.evidence. We congratulate our latest brethren upon

deciding to pursue a calling that promises to all ;a,

life of the highest utility, and to some the purest possibledelights through knowledge acquired and, difficulties.

surmounted.

THE STUDENT’S GUIDE.SESSION 1912-1913.

A PREFATORY STATEMENT.

THE following is a brief explanation of the scheme upon"which this guide to a medical career in this country isconstructed.

The General Council of Medical Education and Registra-tion, conveniently known as the General Medical Council, isthe controlling authority, under the Privy Council, of themedical education of the land. Under the provisions of theMedical Acts various universities and corporations are recog-nised as being examining bodies whose degrees or diplomasentitle to medical registration, and it is among the duties 01’the General Medical Council to keep the official register andto ensure by periodical visitations that the tests of toovarious examining bodies are maintained at a due standard.We begin by describing the powers of the General MedicalCouncil, and go on to give in detail the regulations of thevarious examining bodies.But the student must be taught as well as examined, and

the systems under which he can obtain instruction do not.conform to one pattern. The curriculum of the medicabstudent falls into two parts, the preliminary subjects and theprofessional subjects, and the two cannot be sharply divided..The extent to which they are allowed to overlap under different.,schemes of education varies a good deal, while the extent to.which they ought to overlap is a perennial subject of debate.The important preliminary subjects are chemistry, phar-macology, physics, biology, anatomy, and physiology, and

they are taught in the school proper ; the professional