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
Dream Cures

• 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?

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 doctors 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 dialecticsa 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

• Quran 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
• Galens 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 tableuntil 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 wardmortality 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 1800s
• 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 18661959
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

• 1940s 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