Medicine - After Twenty-Five Years Part 2
( Originally Published 1905 )
Twenty-five years ago the staff of this school consisted of the historic septenary, with one demonstrator. Today I find on the roll of the Faculty 62 teachers. Nothing emphasizes so sharply the character of the revolution which has gradually and silently replaced in great part for the theoretical, practical teaching, for the distant, cold lecture of the amphitheatre the elbow to elbow personal contact of the laboratory. The school, as an organization, the teacher and the student have been profoundly influenced by this change.
When I joined the faculty its finances were in a condition of delightful simplicity, so simple indeed that a few years later they were intrusted to my care. The current expenses were met by the matriculation and graduation fees and the government grant, and each professor collected the fees and paid the expenses in his department. Today the support of the laboratories absorbs a much larger sum than the entire income of the school in 1874. The greatly increased accommodation required for the practical teaching has made endowment a vital necessity. How nobly, by spontaneous gifts and in generous response to appeals, the citizens have aided the efforts of this faculty I need not remind you. Without it McGill could not have kept pace with the growing demands of modern methods. Upon one feature in the organization of a first-class school permit me to dwell for a moment or two. The specialization of to-day means a group of highly trained experts in the scientific branches, men whose entire energies are devoted to a single subject. To attain proficiency of this sort much time and money are required. More than this, these men are usually drawn from our very best students, with minds above the average. For a majority of them the life devoted to science is a sacrifice; not, of course, that it is so felt by them, since the very essence of success demands that in their work should lie their happiness. I wish that the situation could be duly appreciated by the profession at large, and by the trustees, governors and the members of the faculties throughout the country. Owing these men an enormous debt, since we reap where they have sown, and garner the fruits of their husbandry, what do we give them in return? Too often beggarly salaries and an exacting routine of teaching which saps all initiative. Both in the United States and Canada the professoriate as a class, the men who live by college teaching, is wretchedly underpaid. Only a few of the medical schools have reached a financial position which has warranted the establishment of thoroughly equipped laboratories, and fewer still pay salaries in any way commensurate with the services rendered. I am fully aware that with cobwebs in the purse not what a faculty would desire has only too often to be done, but I have not referred to the matter without full knowledge, as there are schools with large incomes in which there has been of late a tendency to cut down salaries and to fill vacancies too much on Wall Street principles. And not for relief of the pocket alone would I plead. The men in charge of our Canadian laboratories are overworked in teaching. A well organized staff of assistants is very difficult to get, and still more difficult to get paid. The salary of the professor should be in many cases that of the first assistant. When the entire energy of a laboratory is expended on instruction, research, a function of equal importance, necessarily suffers. Special endowments are needed to meet the incessant and urgent calls of the scientific staff. It is gratifying to know that certain of the bequests to this school have of late been of this kind, but I can safely say that no department is as yet fully endowed. Owing to faulty conditions of preliminary education the medical school has to meet certain illegitimate expenses. No one should be permitted to register as a medical student who has not a good preliminary training in chemistry. It is an anomaly that our schools should continue to teach general chemistry, to the great detriment of the subject of medical chemistry, which alone belongs in the curriculum. Botany occupies a similar position.
But the laboratories of this medical school are not those directly under its management. McGill College turned out good doctors when it had no scientific laboratories, when the Montreal General Hospital and the University Maternity were its only practical departments. Ample clinical material and good methods of instruction gave the school its reputation more than fifty years ago. Great as has been the growth of the scientific half of the school, the all-important practical half has more than kept pace. The princely endowment of the Royal Victoria Hospital by our large-hearted Canadian Peers has doubled the clinical facilities of this school, and by the stimulus of a healthy rivalry has put the Montreal General Hospital into a condition of splendid efficiency. Among the many changes which have occurred within the past twenty-five years, I would place these first in order of importance, since they assure the continued success of McGill as a school of practical medicine.
Equally with the school as an organization, the teacher has felt deeply the changed conditions in medical education, and many of us are much embarrassed to know what and how to teach. In a period of transition it is not easy to get orientirt. In some subjects fortunately there is but the single difficulty—what to teach. The phenomenal strides in every branch of scientific medicine have tended to over-load it with detail. To winnow the wheat from the chaff and to prepare it in an easily digested shape for the tender stomachs of first and second year students taxes the resources of the most capable teacher. The devotion to a subject, and the enthusiasm and energy which enables a man to keep abreast with its progress, are the very qualities which often lead him into pedagogic excesses. To reach a right judgment in these matters is not easy, and after all it may be said of teaching as Izaak Walton says of angling, "Men are to be born so, I mean with inclinations to it." For many it is very hard to teach down to the level of beginners. The Rev. John Ward, Vicar of Stratford-on-Avon, shortly after Shakespeare's day made an uncomplimentary classification of doctors which has since become well-known:—"first, those that can talk but doe nothing; secondly, some that can doe but not talk; third, some that can both doe and talk; fourthly, some that can neither doe nor talk—and these get most monie." Professors similarly may be divided into four classes. There is, first, the man who can think but who has neither tongue nor technique. Though useless for the ordinary student, he may be the leaven of a faculty and the chief glory of his university. A second variety is the phonographic professor, who can talk but who can neither think nor work. Under the old regime he repeated year by year the same lecture. A third is the man who has technique but who can neither talk nor think; and a fourth is the rare professor who can do all three—think, talk and work. With these types fairly represented in a faculty, the diversities of gifts only serving to illustrate the wide spirit of the teacher, the Dean at least should feel happy.
But the problem of all others which is perplexing the teacher today is not so much what to teach, but how to teach it, more especially how far and in what subjects the practical shall take the place of didactic teaching. All will agree that a large proportion of the work of a medical student should be in the laboratory and in the hospital. The dispute is over the old-fashioned lecture, which has been railed against in good set terms, and which many would like to see abolished altogether. It is impossible, I think to make a fixed rule, and teachers should be allowed a wide discretion. With the large classes of many schools the abolition of the didactic lecture would require a total reconstruction of the curriculum and indeed of the faculty. Slowly but surely practical methods are everywhere taking the place of theoretical teaching, but there will, I think, always be room in a school for the didactic lecture. It is destined within the next ten years to be much curtailed, and we shall probably, as is usual, go to extremes, but there will always be men who can present a subject in a more lucid and attractive manner than it can be given in a book. Sir William Gairdner once remarked that the reason why the face and voice of the teacher had so much more power than a book is that one has a more living faith in him. Years ago Murchison (than whom Great Britain certainly never had a more successful teacher of medicine) limited the lecture in medicine to the consideration of rare cases, and the prominent features of a group of cases, and to questions of prognosis which cannot be discussed at the bedside. For the past four years in the subject of medicine I have been making an experiment in teaching only by a weekly examination on a set topic, by practical work in the wards, in the out-patient room and the clinical laboratory, and by a weekly consideration in the amphitheatre of the acute diseases of the season. With a small class I have been satisfied with the results, but the plan would be difficult to carry out with a large body of students.
The student lives a happy life in comparison with that which fell to our lot thirty years ago. Envy, not sympathy, is my feeling towards him. Not only is the menu more attractive, but it is more diversified and the viands are better prepared and presented. The present tendency to stuffing and cramming will be checked in part when you cease to mix the milk of general chemistry and botany with the proper dietary of the medical school. Undoubtedly the student tries to learn too much, and we teachers try to teach him too much—neither, perhaps with great success. The existing evils result from neglect on the part of the teacher, student and examiner of the great fundamental principle laid down by Plato—that education is a life-long process, in which the student can only make a beginning during his college course. The system under which we work asks too much of the student in a limited time. To cover the vast field of medicine in four years is an impossible task. We can only instil principles, put the student in the right path, give him methods, teach him how to study, and early to discern between essentials and non-essentials. Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offence in the pathway of the true student. And it is not so Utopian as may appear at first blush. Ask any demonstrator of anatomy ten days before the examinations, and he should be able to give you a list of the men fit to pass. Extend the personal intimate know-ledge such as is possessed by a competent demonstrator of anatomy into all the other departments, and the degree could be safely conferred upon certificates of competency, which would really mean a more thorough knowledge of a man's fitness than can possibly be got by our present system of examination. I see no way of avoiding the necessary tests for the license to practise before the provincial or state boards, but these should be of practical fitness only, and not, as is now so often the case, of a man's knowledge of the entire circle of the medical sciences.