August 21, 1913] 



NATURE 



639 



T 1 



A CRITICISM OF MODERN METHODS OF 

 MEDICAL EDUCATION. 1 

 HE report drawn up by Mr. Flexner for the 

 Carnegie Foundation is a sequel to the 

 report on medical education in the United States 

 and Canada issued in 1910. Primarily intended 

 for the guidance of medical education in the 

 United States, the report deals so fully with con- 

 ditions in Germany, Austria, France, England, 

 and Scotland, and adopts so critical an attitude 

 towards them, that it must compel the attention 

 not only of those directly concerned, but of edu- 

 cational authorities everywhere. 



The report opens with an historical sketch of 

 the rise of modern medicine, and is followed by 

 a chapter on the number and distribution of 

 physicians in the countries under review. We 

 learn that the medical profession is overcrowded 

 both in countries like Austria and Germany, where 

 the practitioner is educated entirely on a high 

 university basis, and in countries like our own, 

 where medical qualifications of varying standards, 

 some undeniably low, are obtained partly in 

 universities and partly in proprietary schools 

 under the control of the medical and surgical cor- 

 porations. A later chapter in the report shows 

 how quackery flourishes in Great Britain and 

 Germany, a phenomenon Mr. Flexner attributes 

 solely to the laws which permit it. Incidentally 

 he remarks upon the inconsistency of British law 

 which throws all manner of restrictions upon 

 properly qualified men of science in experimenta- 

 tion upon the lower animals, but allows medical 

 and surgical practice upon human beings without 

 evidence as to training, competency, or skill, pro- 

 vided only the practitioner does not assume an 

 unearned title. 



From a purely educational point of view the most 

 interesting part of the report is that which deals 

 with the nature and standard of the medical 

 preliminary examinations, and with the position 

 of the preliminary sciences, physics, chemistry, 

 and biology. The conditions in Germany, France, 

 and Great Britain are closely reviewed, and much 

 valuable information is collected. The German 

 system of secondary-school leaving certificates, 

 and the somewhat similar French system, are 

 favourably considered ; the want of method, multi- 

 plicity, and low standard of some of the British 

 medical preliminaries receive severe condemnation. 

 The work of the General Medical Council in 

 raising the standard of the preliminary is acknow- 

 ledged, but the condition of secondary-school 

 education in England, though improving, is still 

 lamentably poor, proprietarv interests in the 

 medical schools, and even in the universities, 

 constitute a formidable barrier to progress, and 

 the General Medical Council is not vested with 

 sufficient legal authority to enforce everything it 

 deems desirable. 



The existence in Great Britain of proprietary 



1 " Medical Education in Europe " A Report to the Carnegie Founda- 

 tion for the Advancement of Teaching. By Abraham Flexner. With an 

 Introduction by Henry S. Pritchett. Pp. xx+357. (New Vork City : 576 

 Fifth Avenue, 191 2 ) 



NO. 2286, VOL. 91] 



interests in the teaching of medicine meets with 

 severe criticism throughout the report ; again and 

 asjain vested interests are held responsible for in- 

 efficient teaching, low standards, and other evil 

 influences. While we can agree with the author 

 in many of his strictures, it must be remembered 

 that the proprietary conditions have often been 

 the only ones possible in a country which prides 

 itself upon the voluntary character of its institu- 

 tions. It must be remembered, too, that this re- 

 port is drawn up for an educational body in tin- 

 United States, where the proprietary medical 

 school is a source of much scandal. The presi- 

 dent of the foundation, in an introduction to the 

 report, states that if the lowest terms upon which 

 a medical school can exist abroad were applied 

 to America, three-fourths of the existing American 

 schools would be closed at once. 



Mr. Flexner advocates the omission of physics, 

 chemistry, and biologv from the overcrowded 

 medical curriculum, and would have them taught 

 in the secondary schools. Much of this part of the 

 report is a plea for the development of efficient 

 secondary schools in which higher mathematics, 

 the sciences, and German must replace the time- 

 honoured classics. 



Laboratory development is found to be very 

 uneven in Great Britain as compared with 

 Germany. Anatomy is too much drilled into the 

 students by repeated lectures and demonstrations ; 

 more practical work is necessary, but is largely 

 restricted by insufficiency of material. British 

 physiology receives a high tribute, but is hampered 

 by the student's lack of preliminary training in 

 physics and chemistry, and by the anti-vivisection 

 laws. Pharmacology barely exists but for a few 

 notable exceptions. Pathology suffers by the 

 separation of its laboratories from the post-mortem 

 departments of the hospitals, by lack of funds 

 for research, and by sentimental objections to 

 pathological experimentation which carry great 

 weight in hospitals chiefly supported by voluntary 

 contributions. 



Clinical instruction, the medical curriculum, and 

 the position and standard of the professional ex- 

 aminations are each considered separately in the 

 case of Germany, Great Britain, and France. 

 Clinical education in England is essentially prac- 

 tical, and at graduation the English product is 

 more dexterous than the German, but the latter is 

 held to have received the more stimulating scienti- 

 fic training, and one which will eventually carry 

 him further. The English graduate lacks ideas, 

 the German lacks practice. 



Criticism is abundant and frankly bestowed. 

 The clinical school in Great Britain is accused of 

 being unproductive of research, and wanting in 

 scientific ideals. The German clinician and the 

 British physiologist seek advancement by scienti- 

 fic achievement. The English medical man is able 

 and practical, makes a good physician and surgeon, 

 but is empiric, and only occasionally a contributor 

 to scientific knowledge. 



The report is bound to excite adverse criticism, 

 for it is often detailed and very frank. It is the 



