Sometimes I wonder if we will ever be better than the physicians who came before us. You know, those names we only see at the end of a quote or engraved into a heavy-looking plaque. Osler, Weber, probably Rendau, too. The doctors of olde. The doctors of legend. Wise faces in sepia-tinged photographs, eyes all-knowing founts of primal medical knowledge. How did they achieve greatness? Where did they learn medicine? And most importantly, can I ever be that good?
Way back when, medical education was simply an apprenticeship. Young, 17th century doctors-to-be would append themselves to a practiced physician with the hope of learning the craft. Experience was paramount; evidence was anecdotal. Undoubtedly, the neophyte would be at the whim of his master, required to complete all manner of menial tasks, perhaps cleaning the bloodletting studio or mixing salves in a back room.
The transition to formalized medical education was gradual, but in 1765 the University of Pennsylvania created America's first medical school. Its initial curriculum included anatomy and chemistry, but also more colorfully named courses like "materia medica" (pharmacology) and "practice of physick" (medicine). Other institutions took root up and down the eastern seaboard, and in 1851, a new establishment sprouted up at the corner of 12th and F in northwest Washington, D.C. It would later relocate and become the Georgetown University School of Medicine we know today.
While all of these establishments had the same broad strokes, in reality, there was little uniformity in their standards. Some schools required only a high school diploma for admission and it took a mere two years to obtain a medical degree, although many followed Georgetown's lead and extended this to three years in the latter part of the 19th century. Curricula also began to incorporate more practical experience, such as gross anatomy and physiology lab.
But this wasn't enough. At least not for Abraham Flexner, who in 1910 wrote a landmark report, formally titled Carnegie Foundation Bulletin Number Four, about the state of medical education. Despite its proper title, the document was a searing criticism of the supposed depths to which medical education in the United States had fallen. Ultimately, he concluded that there were too many medical schools making too many physicians, and doing it poorly. Educational standards were lax and many new doctors were deficient in medical skills.
Post-publication, a number of schools were shuttered. The survivors shored themselves up by requiring at least two years of college for admission, affiliating directly with universities, and extending the length of medical school to a full four years. Thus, in a very real way, the Flexner Report is responsible for the two years of pre-clinical science plus two years of clinical work that have haunted student-doctors for the past 100 years. It assured uniformity and rigor across the board, and the result was a yearly assembly line that produced a phalanx of highly trained physicians. Apparently, Flexner was right about some things.
However, Flexner was also a racist who wanted to ensure that "The practice of the Negro doctor will be limited to his own race." Some of his beliefs are out of touch with today's ideals, including those regarding medical education. Of Georgetown, he wrote:
"The equipment consists of a good dissecting-room, a single fairly well stocked laboratory for pathology, bacteriology, and histology, a fair equipment for experimental physiology, and an ordinary chemical laboratory. There is no library accessible to students, no museum, and no pharmacological laboratory."
Few, if any, present-day medical students would point to these elements as markers of a "good" medical school. Recently, many schools have moved away from the "first patient" ideal of cadaveric dissection. Most students would find the prospect of doing their own pathology, bacteriology, and histology euphemistically amusing. Dahlgren Memorial Library may be called accessible, but basically, the things that made medical schools great in 1910 don't necessarily hold true today.
Over the past few decades, medical schools have been brushing off the cobwebs and firing up the rusty gears of the innovation engine. Around the country, educators are developing new ways to teach, and giving prospective students the opportunity to customize their medical school experience. There is a medical school in New Jersey that spends the first eight weeks training new students to become EMTs. NYU has an accelerated three-year track for students pursuing primary care. UPenn, the sire of U.S. medical education, crams all of its pre-clinical work into 18 months, reserving the third year solely for research. This sort of a la carte approach to education allows prospects to find the program that meshes with the way they like to learn, whether it is more small groups, selfdirected learning, or an increased emphasis on real-world education.
Georgetown has also made significant changes to the curriculum over the past decade, increasing its emphasis on early clinical experience and moving to a systems-based education. Recently, a measure was passed that will convert preclinical classes to a pass/fail system, eliminating the honors, high pass, pass, low pass, and fail delineations that were hated by so many, loved by the top 10 percent in every class. Even more significant are reports that the first two years of medical school will be condensed into just 18 months. These are new tricks for an old school, and proof that our school is steeped in tradition, but not stifled by it.
Of course, those doctors of legend did everything without flipped classrooms, electronic medical records, and the USMLE (despite the fact that many view it as some particularly cruel species of Medieval torture). I imagine they merely read a few books, and skills simply flowed forth like water from the stone. Innate, ingrained medical powers.
Can we ever be that good? Maybe. It's tough to say, because I'm only three years into my education and medical school, whatever the format, only accounts for a small portion of my medical career. After all, what are four years compared to the 20, 30, 40 years I'm going to spend healing and helping? Right now, it's easy to get caught up in the minutiae, all the little facts we puzzle together to get a good score on that test. But do these things really change me? Are they really that formative? I don't know what the future holds but I do know that we are getting a terrific education no matter what. And in a way, these Georgetown years become our brand, our calling card. The deep history. The reputation for innovation. The glossy Blue and Gray.
Daniel Coleman (M'17)
Daniel is a member of the class of 2017 going into Emergency Medicine, with a particular interest in Wilderness Medicine. He founded the GUSOM Writers Group, and is a student editor and writer for In-Training.org. We are grateful for his current and future contributions to Georgetown Medicine magazine. He can be reached at Daniel.Coleman@georgetown.edu.