REPORT OF SUB-COMMITTEE ON MEDICAL ORGANIZATION AND MEDI

CAL EDUCATION.*

BY JOSEPH B. HOWLAND, M. D.,

Massachusetts General Hospital, Boston.

The large general hospitals of this country may be divided into three classes, the city hospital, the endowed hospital, and the university hospital. In considering medical organization in the hospitals we may expect to find a difference according to the object for which the hospital is established. The one under city control is for the sick poor of the city and as a rule has a large visiting staff and divided service. Every ambitious practitioner desires a hospital service for two purposes,-to keep his hand in for the performance of unusual operations, if he be a surgeon; the physician to see as often as possible the diseases not commonly met with in private practice. Both desire them for the standing it gives them with the general practitioners, who naturally have more confidence in hospital men as consultants. What more natural than that such hospital services should be divided to give many men these opportunities? Busy practitioners desire to be as independent in their hospital work as possible and this is accomplished if an institution has three or four surgical and as many medical services with different members of equal standing coming on service every few months of the year. The general hospital under private control, especially if long established, usually has a large visiting staff for the reasons just stated. In this country the university hospitals are few in number and of comparatively recent establishment. In these as a rule we naturally find smaller staffs, each department in charge of a chief with several assistants. To have it otherwise would be as

*Read by Dr. F. A. Washburn.

natural as, for example, to have the department of pathology in the medical school divided among several independent heads. We would not expect, if this were true, the largest amount possible of scientific work to be carried on. The object for which the university hospital is established is for the teaching of students the most advanced methods of diagnosis and treatment.

When most of us received our medical school training a greater part of our time was spent in listening to lectures and our hospital work was usually limited to visiting operating theaters, medical clinics in classes, or large sections; and seeing operations through a pair of opera glasses, or being selected occasionally from a large class to examine a patient. This long distance hospital teaching is being rapidly changed and today in the Johns Hopkins Medical School, the Harvard Medical School, McGill University and others, a considerable part of the third year and practically all of the fourth year is given to teaching medical students in small classes at the bedside, allowing them to take histories, make physical examinations and carry out laboratory examinations.

The following is quoted from a recent report of the SubCommittee on the Medical Organization and Medical Education of the Hospital Conference of New York City. This committee "has proceeded on the theory that a larger participation by the hospitals of the city in the work of medical education is desirable in the interests of public health; furthermore, that an increase in activities of hospitals on the lines indicated is bound to react favorably upon the hospitals themselves." The faculties of the medical schools of Columbia University, Cornell University, and the University of New York have approved of additional sectional work in the New York hospitals and suggest that more medical and surgical clerkships be furnished medical students. The university hospitals are neither sufficient in number nor size to supply this needed clinical material. The city and endowed hospitals must supply the lack. Are we trying to do this in the best way?

It has been contended by hospital managements in the past that the best interests of the patients, for which the hospitals were established, were not looked after if the medical students were allowed free use of the wards. This

has not been the experience of the Massachusetts General Hospital? On the contrary, we believe the patients are better cared for and do not know of a single instance where harm has come to the patient by this practice. If then the course of medical lectures is to be replaced by clinical teaching, is it not important that work may be carried on in a systematic way under one head and not be subject to interruptions, and possibly the opposing interests of changing heads of a large staff?

In the report of the Fourth Conference of the Council on Medical Education of the American Medical Association an ideal course of study is outlined which calls for one year of hospital work before a degree in medicine is given. This is not possible for every student in the limited number of interneships we have today. It will be necessary to do much more teaching in the hospitals than is being done at the present time. I believe it is this demand for more systematic and scientific teaching which is responsible for the changes in hospital staffs that have been made within the past year. At the Massachusetts General Hospital where there are five services, three surgical and two medical, all of which have been divided into periods of four months; one medical service has been recently changed to a continuous one. The chief is to spend more time than formerly in teaching and has one assistant who represents him during his absence and who aids in the teaching and in carrying on investigations. During the summer months the chief will probably be absent and the regular assistant take his work.

The Carney Hospital in Boston has recently made the medical service a continuous one, surgical work having been under one head for some years.

Inquiry of twenty-two of the larger teaching hospitals in the country shows twelve having both medical and surgical service divided: five having both continuous, four having continuous surgical and divided medical service and one has divided surgical and continuous medical service. A few unpaid assistants cannot give all the time necessary to carry out laboratory investigations demanded at the present time, and if we are to hold positions in the front rank of scientific hospitals it will probably be necessary to pay assistants for this work a large enough sum to live on. At the present time many men are qualified for this work and anxious to

do it, but are driven into private practice as soon as they have finished their interne service by the necessity of making their living expenses. In the end this outlay will pay the hospital by surrounding it with desirable men who can be drawn on for staff vacancies.

On the surgical side we need assistants to carry out laboratory investigations and teach our internes the details of the newest methods. Modern surgery now permits of such prolonged and complicated operations that the subject of proper administration of an anaesthetic has increased greatly in importance. Until recently it has been thought that a junior interne would do to administer anaesthetics and the physician who made the study of anaesthesia a specialty was unknown. There is not sufficient return to the anaesthetist merely in the name of having a hospital appointment for that work and we must expect to pay for the service of such a man to teach our nurses, students and internes this branch of medicine.

I believe every large hospital should have the entire time. of at least one such person, and I find that the majority of superintendents agree that this department should be in charge of an expert and intend to bring it about as soon as possible if they have not already done so. At the New Haven Hospital and in Dr. Crile's service at the Lakeside Hospital a nurse has been trained for the work. After a year's trial Dr. Crile writes that he has not in a single instance had an unpleasant anaesthetic experience. We all know that much less ether is used by experts than by inexperienced etherizers.

In 1906 a committee of the University of Toronto and the Toronto General Hospital published statistics showing the organization of the different departments of the principal British and American Hospitals. To all interested in this subject this publication will be of great interest.