History of Medical Education

1. History of Medical Education Vineet Arora, MD History of Medicine April 10, 2003 University of Chicago

2. Ancient Times- The Vedas- 600 years B.C. • diseases viewed as punishments from angry deities • priests made offerings or conjectures • first select group of distinct healers • Aryuveda and is based on the teaching two books, Charaka Samhita and Sushruta Samhita

3. Early Importance of Clinical Training • “The man who has had nothing but theoretical training and is unskilled in the details of treatment knows not what to do when he comes to a patient and behaves himself as pitiably as a coward on a battle-field.” • After training, pupil petitions king to practice independently • “Keep thy hair and nails short, keep thy body clean, wear white linen, put on shoes, carry a stick or umbrella in thy hand. Let thy bearing be humble and thy heart pure and free from guile.”

4. Egypt- Rise of the temple school • Lay Men • sick laid out so passers by could offer opinion • “in the land where the fruitful soil bore abundance of herbs potent for good or evil, nearly everyone was, so to speak, a doctor.” • Homer, the Odyssey • Professional practitioners • pupils trained and lived at temple schools • First to author medical text • Practiced surgery • mummification Ramses II

5. Greeks before Hippocrates: All in the Family • family legacies • medical knowledge confined to relations of Cheiron and Asklepios (son of Apollo- sun god) • entire professional class traced to Asklepios • Asklepiadae bound into a guild united into societies

6. sufferers slept in temple and waited for dreams if no dreams after 3 days, consultation with oracle for proxy led to profitable and cunning business historical example of medical fraud Role of inhalants? Dream Cures Abaton- where dream cures took place The Oracle at Delphi

7. Hippocrates 460 to 377 B.C. • Descendent of Asklepios • Father of medicine • sought after for his successful cures • writings • provide us with historical perspective on medical education • ethical training and scientific training • Iatreion attached to the doctor’s residence-- patients operated on and treated there • oath • 4 humors

8. Alexandria- Museum and Serapeum • 2 institutions where learned men received accommodation • devote themselves to scientific studies • Libraries houses here • 2 prominent medical schools • advancement in nervous system and physiology of pulse • midwifery • vivisections- allowed to undertake live dissection of criminals

9. The Roman Empire • No doctors, but fathers, soldiers, everyday people were self proclaimed healers • immigration of Greek doctors • awkward, foreign, quacks despised for arrogance and greed • 46 BC- julius caesar confers citizenship to all immigrant doctors • 2 schools of thought in medical education • methodists- confined to therapeutics and cure, no interest in pathophysiology • eclecticism- in an effort to explain why, combines greek philospohy of nature with humoral thories of hippocrates

10. Medical Teaching in Rome • highly variable • Galen- the quintissential generalist • superb doctor, learned investigator, teacher of medicine • credited with writing 21 volumes 1000 page text • called for necessity of formal training • Rise of specialties • shortcut to only focusing on one part of medicine • not well respected but half educated charlatans who did not invest in a full education

11. Physicians and Surgeons, the Medici • Friendly relations • “It does not appear that surgeons occupied a lower social position than the doctors for internal diseases as was the case in later times” Plutarch • not well respected • fit for persons of low birth, servants or slaves • affiliated with armies or legions • the Medici

12. Consultations • Commonplace to exchange in a dialogue • heated debates • “In the spirit of emulation like that displayed in a circus or at a pugilistic contest, one endeavors to gain extraordinary fame by his oratory or his dialectics…a structure which his adversary soon levels with the ground.” Priscianus

13. Professionalism in Rome • Doctors often misused their trust to practice adultery and to engage in murder by poison • Galen compared them to robbers • unequal distribution in compensation • few were wealthy, led to bitter competition for patients • free doctors or public servants were respected and granted certain priviledges • no taxes

14. Arabian Civilization • Qu’ran emphasizes benevolence • healthy take care of ill • Growth of hospitals due to donations • 60 hospitals in Bagdhad when London had one • well organized wards, auditoriums for students • where east meets west- renaissance in medical inquiry • studying texts of hippocrates and galen, adding in new observations

15. The Middle Ages: The Influence of Christianity • science stood in direct opposition to christian dogma • diseases were punishments from God • failure of scientific advancement • detriment to medical education • focus on philosophy and theology, lack of practical training • dissections prohibited • Galen’s works persisted and studied

16. Priests in Medicine • Edict of Justinian 529 AD- closed schools • professors vacated and theology dominated by priest teachers • Priests took over teaching of medicine • Nestorian sect of priests gifted in the art

17. Public Hospitals • Credited with foundation of numerous hospitals and benevolent institutions • erection of charitable insitutions such as hospitals became a fashion among distinguished Italian women • crucial role in serving underpriviledged • leper houses, blind, cripples, orphans • Nursing • Distinct social group St. , Leper House Museum

18. Renaissance • Paradigm shift in medical education • increasing prominence of practica- learning about particular diseases/cures • materia medica- ancient pharmacopeia expansion due to efforts by the explorers • Medical art and text explosion • at first only surface inspection, but by 1500, da Vinci and Micehlangelo were dissecting

19. Renaissance England: Non Clinician Physicians • Apothecaries and wise women for the masses • Well respected • physicians reserved for wealthy • Professionalism • “Dr. Slop” and “Dr. Smell-Fungus” • Fled London when Plague hit

20. Barber Surgeons • Barber-surgeons would perform a variety of tasks including, cutting and shaving hair, extracting teeth, lancing boils, setting broken bones and blood-letting as well as amputations • red and white rotating pole outside their shops • In 1745 the Company of Surgeons excluded barber-surgeons from membership.

21. Master Apprentice Relationship “The first few years are mostly spent doing small tasks and waiting at table…until [the apprentice] gradually becomes accustomed to wielding the razor, opening veins, applying plasters and at most bandaging a wound or a fracture, and he may, in addition now and then be permitted to see a few operations performed by his master.”--Swedish apprentice, 1737 • Contractual obligation • Set period • “faithfully and honestly by day and night, holiday and work day” • Learn manual skills to supplement university education • Precursor to modern day residency • Organization into surgical guilds- often were monopolies

22. Hermmanus S. Booerhaave • Turn of 18th century at University of Leiden, Netherlands • famous for • bedside instruction entered into medical school curricula • mediastinitus due to esophageal rupture • started first internship

23. Clinical Teaching • End of 18th century • Students required to “walk the wards” for 6 months before getting a degree • few patients wanted to be “practice material” • Hospitals for sick poor provided main opportunity for learning • Charite Hospital in Berlin

24. Crimean War 1854-56 Armed with newly invented telegraph, British outraged by hospital conditions Sent Florence Nightingale to revamp the ward—mortality rate declined from 40% to 2% within 2 years

25. Industrial Revolution • Proliferation of universities • Medical journals published • Lancet, 1823 • Guilds replaced by new societies that grew from hospital dining clubs • Formal education requirement • Increasing importance of physical exam • Invention of stethoscope Laennec • Body snatching due to cadaver shortage • Burke and Hare scandal

26. William S. Halsted • Graduate, Johns Hopkins Medical School • emphasized need for standardization for surgical training due to wide variation • credited with starting first US residency

27. Johns Hopkins Surgical Residency • All male • “residents” lived in hospital 24/7 • marriage forbidden or strongly discouraged • residency still the exception, not the rule What the Family Looked Like in 1892- Johns Hopkins Class

28. Internship • Bedside method of teaching in practice in France and England • US in 1800’s • “house physician” would pay their teachers fifty to 75 dollars to serve in the hospital • Term intern coined after civil war University of Pennsylvania- first medical shool (1765) and first to open a teaching hospital (1874)

29. Residency • Driven by need for specialization • First used to describe any resident physician • Later in 1889, referred to those who completed internship and chose a special field

30. Impact of WWII • Medical developments • Antibiotics • PCN- Fleming • Anesthesia • first cardiac operations • Wartime • great need for surgical trainees led to proliferation of residencies

31. The Flexner Report, 1910 • “Germanized” medical education • Studied North American medical schools • Apalled by conditions • Closed 50 medical schools • Exception- alma mater, Johns Hopkins “the one bright spot, despite meager endowment and missing clinics.” • Rockefeller board • Funded schools that refuted alternative medicine and adopted surgery and chemical oriented medicine Abraham Flexner 1866–1959

32. Women in Medicine • Self taught American teacher • First woman to become a doctor • Graduated at top of her class • Moved to London and founded School of Medicine for women • Women not admitted to University of Pennsylvania until 1915 • Harvard in 1947 • 1970 class action lawsuit of discrimination against every medical school in the US • Women enrollment often limited to 5% Dr. Elizabeth Blackwell 1821-1910

33. “the Match” • 1940’s chaotic internship programs • 1951 centralized matching system • NRMP- National Residency Match Program • Originated with town square meetings to fix apprentices to masters 2 elated students on Match Day 1996

34. NRMP Antitrust Lawsuit • Filed by Paul Jung • gastroenterology fellow at Johns Hopkins • matching program discourages competition • salary effect? • Effect on academic teaching hospitals if lawsuit is successful?

35. Financing GME • Medicare • Direct payment (DME) • direct cost of training physicians (salary, etc) • Indirect payment (IME) • additional operating costs that teaching hospitals incur in patient care (sicker patients, cutting edge therapies) • Residency proliferation between 1985 and 1996 • Lucrative business for hospitals to have residents as cheap labor • 1996 Balanced Budget Act • Capped number of residents qualifying for DME • Phased in reduction of IME payment

36. Residency Work Hour Reform • Sleep deprivation research • Focus on medical error • Media influence • ACGME- July 2003 • bills in Congress

37. The Romance of Medicine “The moral training to keep a confidence inviolate, to act promptly on a sudden call, to keep your head in critical moments, to be kind and yet strong-- where can you, outside medicine, get such training as that?” Arthur Conan Doyle, 1910