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obstetrics. This is a survival of the archaic condition of the profession when surgical operations were mostly left to the barbers and obstetrics to the midwives, and of that more modern epoch when the physicians thought themselves, and were considered by the world, the 'superior persons' of the profession. I remember a story was current in my young days of a great court physician who was travelling with a friend, like himself, bound on a visit to a country house. The friend fell down in an apoplectic fit, and the story ran that the physician refused to bleed him because it was contrary to professional etiquette for a physician to perform that operation. Whether the friend died or whether he got better because he was not bled I do not remember, but the moral of the story is the same. On the other hand, when a famous surgeon, irritated by the pretensions of the physicians, was asked whether he meant to bring up his son to his own calling, ‘No,' he said, 'he is such a fool, I mean to make a physician of him.'
Nowadays, it is happily recognised that medicine is one and indivisible, and that no one can properly practice one branch who is not familiar with, at any rate, the principles of all. Thus the two great things that are wanted now are, in the first place, some means of enforcing such a degree of uniformity upon all the examining bodies. that none shall permit a disgracefully low minimum or pass examination; and, in the second place, that some body or other shall have the power of enforcing upon every candidate for the licence to practice the study of the three branches, or what is called the tripartite qualification. All the members of the late Commission were agreed that these were the main points to be attended to in any proposals. for the further improvement of medical training and qualification.
But, such being the ends in view, our views as to the best way of attaining them were singularly divergent, so that it came about that eleven commissioners made seven reports. There was one main majority report, and six minor reports, which differed more or less from it, chiefly as to the best method of attaining these two objects.
The majority report recommended the adoption of what is known as the conjoint scheme. According to this plan, the power of granting a licence to practice is to be taken away from all the existing licensing bodies, whether they have done well or ill, and to be placed in the hands of a body of delegates (divisional boards), one for each of the three kingdoms. The licence to practice is to be conferred by passing the delegate examination. The licensee may afterwards, if he pleases, go before any of the existing licensing bodies and indulge in the luxury of another examination and the payment of another fee, in order to obtain a title, which does not legally place him in any better position than that which he would occupy without it.
Under these circumstances, of course, the only motive for obtaining the degree of a University or the licence of a medical corporation would be the prestige of those bodies. Hence the 'black sheep' VOL. XV.-No. 84.
would certainly be deserted, while those bodies which have acquired a reputation by doing their duty would suffer less.
Hence, as the majority report proposes that the existing bodies shall be compensated for any loss they may suffer, out of the fees of the examination for the State licence, the curious result would be brought about, that the profession of the future would be taxed, for all time, for the purpose of handing over to wholly irresponsible bodies a sum, the amount of which would be large for those who had failed in their duty and small for those who had done it.
The scheme in fact involves a perpetual endowment of the 'black sheep,' calculated on the ratio of their ill-gained profits.1 I confess that I found myself unable to assent to a plan which, in addition to the rewarding the evil doers, proposed to take away the privileges of a number of examining bodies which confessedly were doing their duty well, for the sake of getting rid of a few who had failed. It was too much like the Chinaman's device of burning down his house to obtain a poor dish of roast pig-uncertain whether, in the end, he might not find a mere mass of cinders. What we do know is that the great majority of the existing licensing bodies have marvellously improved in the course of the last twenty years, and are improving. What we do not know is that the cumbrous and complicated scheme of the divisional boards will ever be got to work at all.
My own belief is that every necessary reform may be effected, without any interference with vested interests, without any unjust depreciation of the prestige of institutions which have been, and still are, extremely valuable, without any question of compensation arising, and by an extremely simple operation. It is only necessary, in fact, to add a couple of clauses to the Medical Act to this effect: (1) That from and after such a date no person shall be placed upon the Medical Register unless he possesses the threefold qualification. (2) That from and after the same date no examination shall be accepted as satisfactory from any licensing body except such as has been carried on in part by examiners appointed by the licensing body, and in part by coadjutor-examiners of equal authority, appointed by the Medical Council and acting under their instructions.
In laying down a rule of this kind the State confiscates nothing, and meddles with nobody, but simply acts within its undoubted right of laying down the conditions under which it will confer certain privileges upon medical practitioners. No one can say that the State has not the right to do this; no one can say that the
The fees to be paid by candidates for admission to the examinations of the Divisional Board should be of such an amount as will be sufficient to cover the cost of the examinations and the other expenses of the Divisional Board, and also to provide the sum required to compensate the medical authorities, or such of them as may be entitled to compensation, for any pecuniary losses they may hereafter sustain by reason of the abolition of their privilege of conferring a licence to practice.' Report 50, p. xii.
State unduly interferes with any private enterprise or corporate interest unjustly, in laying down its own conditions for its own service. The plan would have the further advantage that all those corporate bodies which have obtained (as many of them have) a great and deserved renown by the admirable way in which they have done their work, would reap their just reward in the thronging of students, thenceforward as formerly, to obtain their qualifications; while those who have neglected their duties, who have in some one or two cases, I am sorry to say, absolutely disgraced themselves, by a happy and natural euthanasia, would sink into oblivion.
Two of my colleagues, Professor Turner and Mr. Bryce, M.P., whose practical familiarity with examinations gave great weight to their opinions, expressed their substantial approval of this scheme, and I am unable to see the force of the objections taken into it. It is, indeed, urged (Report II. p. vii.) that the difficulty and expense of adequately inspecting so many examinations and of guaranteeing their efficiency would be great, and that the difficulty in the way of a fair adjustment of the representation of existing interests and of the representation of new interests upon the General Medical Council would be almost insuperable.
The latter objection is unintelligible to me. I am not aware that any proposal for such adjustment has been fairly discussed, or even made, and until that has been done, it may be well not to talk about insuperable difficulties. As to the notion that there is any difficulty in getting the coadjutor-examiners, or that the expense will be overwhelming, we have the experience of Scotland, in which every University does, at the present time, appoint its coadjutor-examiners, who do their work just in the way proposed.
Whether in the way I have suggested, or by the Conjoint Scheme, however, this is perfectly certain: the two things I refer to have to be done: the threefold qualification must be required; the limit of the minimum qualification must be fixed; and any scheme for the improvement of the relations of the State to medicine which does not fulfil these two requirements thoroughly has no chance of finality.
But when these reforms are effected, when there is a medical council armed with a more real authority than it at present possesses; when a licence to practice cannot be obtained without the threefold qualification; and when an even minimum of qualification is exacted for every licence, is there anything else that remains that any one seriously interested in the welfare of the medical profession, as I may most conscientiously declare myself to be, would like to see done? I think there are three things.
In the first place, even now, when a four years' curriculum is required, the time allotted for medical education is too brief. A young man coming at eighteen to study medicine is probably abso
lutely ignorant of the existence of such a thing as anatomy, or physiology, or indeed of any branch of physical science. He comes into an entirely new world; he addresses himself to a kind of work of which he has not the smallest experience. Up to that time his work has been with books: he rushes suddenly into work with things, which is as different from work with books as anything can well be. I am quite sure that a very considerable number of young men spend a very large portion of their first session in simply learning how to learn subjects which are entirely new to them. And yet it is to be remembered that, in this period of four years, they have to acquire a knowledge of all the branches of a great and responsible practical calling; of medicine, surgery, obstetrics, general pathology, medical jurisprudence, and so forth. Anybody who knows what these things are, and who knows what is the kind of work which is necessary to give a man the confidence which will enable him to stand at the bedside and say to the satisfaction of his own conscience what shall be done, and what shall not be done, must be aware that if a man has only four years to do all this in he will not have much time to spare. But that is not all. As I have said, the young man comes up, probably ignorant of the existence of science; he has never heard a word of chemistry he has never heard a word of physics, he has not the smallest conception of the outlines of biological science; and all these things have to be learned as well and crammed into the time which, in itself, is barely sufficient for the acquirement of a fair amount of that knowledge which is requisite for the satisfactory discharge of his professional duties.
Therefore it is quite clear to me that, somehow or other, the curriculum must be lightened. It is not that any of the subjects which I have mentioned need not to be studied, and may be eliminated. The only alternative therefore is to lengthen the time given to study Everybody will admit that the practical necessities of life in this country are such that, for the average medical practitioner at any rate, it is hopeless to think of extending the period of professional study beyond the age of twenty-two. So that as the period of study cannot be extended forwards, the only thing to be done is to extend it backwards.
The question is how this can be done. My own belief is that if the Medical Council, instead of insisting upon that examination in general education which I am sorry to say I believe to be entirely futile, were to insist upon a knowledge of elementary physics, chemistry, and biology, they would be taking one of the greatest steps which at present can be made for the improvement of medical education. The great majority of the young men who are going into the profession have practically completed their general education—or they might very well have done If the interval between this so-by the age of sixteen or seventeen. age and that at which they commence their purely medical studies were employed in obtaining a practical acquaintance with elementary physics, chemistry, and biology, in my judgment it would be as good as
two years added to the course of medical study. And for two reasons: in the first place, because the subject-matter of that which they would learn is germane to their future studies, and is so much gained; in the second place, because a great deal might be cleared out of the course of their professional studies which at present occupies time and attention; and last, but not least-probably most-they would then come to their medical studies prepared for that learning from Nature which is what they have to do in the course of becoming skilful medical men, and for which, at present, they are not in the slightest degree prepared by their previous education.
The second wish I have to express concerns London especially, and I may speak of it briefly as a more economical employment of the teaching power in the medical schools. At this present time, every great hospital in London—and there are ten or eleven of them-has its complete medical school, in which not only are the branches of practical medicine taught, but also those studies in general science, such as chemistry, elementary physics, general anatomy, and a variety of other topics which are what used to be called (and the term was an extremely useful one) the institutes of medicine. That was all very well half a century ago; it is all very ill now, simply because those general branches of science, such as anatomy, physiology, chemistry, physiological chemistry, physiological physics, and so forth, have now become so large, and the mode of teaching them is so completely altered, that it is absolutely impossible for any man to be a thoroughly competent teacher of them, or for any student to be effectually taught, without the devotion of the whole time of the persons who are engaged in teaching. I undertake to say that it is hopelessly impossible for any man at the present time to keep abreast with the progress of physiology unless he gives his whole mind to it; and the bigger the mind is, the more scope he will find for its employment. Again, teaching has become, and must become still more, practical, and that also involves a large expenditure of time. But if a man is to give his whole time to any business he must live by it, and the resources of the schools do not permit them to maintain ten or eleven sets of physiological and other specialists.
If the students, in their first one or two years, were taught the institutes of medicine, in two or three central institutions it would be easy to have those subjects taught thoroughly and effectually by persons who gave their whole mind and attention to the subject; while, at the same time, the medical schools of the hospitals would remain what they ought to be-great institutions in which the largest possible opportunities are afforded for acquiring practical acquaintance with the phenomena of disease. So that the preliminary or earlier half of medical education would take place in the central nstitutions, and the final half would be devoted altogether to practical studies in the hospitals.
I happen to know that this conception has been entertained, not