training was sufficient to secure the license. During the last 15 or 20 years, however, the States have found it necessary to secure medical-practice acts in an effort to guarantee to the public that only those having a satisfactory training in medicine should be permitted to assume the responsibility for the care of the sick. Registration is now required in all States, and in most States certain definite qualifications are demanded before the physician can secure a license to practice. In most States the licensing boards are empowered to fix standards of preliminary and medical education. As shown in Table 4, on page 199, 25 States now require one or two years of collegiate work as the minimum standard of preliminary education and refuse to recognize medical colleges which do not come up to certain defined requirements regarding teachers, laboratories, and hospital equipment. In about 30 States, colleges which conform to such requirements are listed as "reputable" or "in good standing," and only graduates of such colleges are eligible to take the board's examination for license. All others are referred to as "not recognized," "not reputable," or "not in good standing."

NONRECOGNITION OF MEDICAL COLLEGES.

While in 1904 only 2 or 3 States were in any way refusing to recognize low-grade medical colleges, now diplomas issued by such colleges are not recognized in at least 30 States. This action by State licensing boards is the only legal power by which inferior medical colleges may be forced to make the needed improvements or to close their doors. Of the 107 medical colleges which were in session during the past year, 21 are not recognized in from 24 to 32 States. Because of the requirement of two years of collegiate work as the minimum standard of preliminary education in 7 States, graduates of only 32 colleges may invariably count on being eligible to register in these 7 States. In 6 of these States graduates of 65 colleges are eligible for registration if the student has completed two or more years of work in an approved liberal-arts college prior to entering the medical school. Before choosing a medical college, therefore, a student should be sure he has the required preliminary education and that the college of his choice is recognized in all States.

The question is, How may the student secure the information needed on these matters? Some medical colleges advertise extensively in the newspapers and in popular magazines, and send out announcements and circulars containing very glowing, if not misleading statements. It is essential, therefore, that before choosing a medical school, the prospective student should secure further information from impartial and reliable sources, so that he may be sure he is not

1 See Jour. Amer. Med. Assoc., May 23, 1914, p. 1650.

enticed into a poorly equipped institution to find on graduation that his diploma is not recognized in a large number of States.

An important matter which the student is always bound to consider is the expense. But it is well for him to know that to enter a low-grade medical college because the fees may be a little lower is poor economy. The truth is that in the same length of time, and often for even lower fees than he would pay in the poorly equipped institutions, he may acquire his education in some one of the bestequipped medical schools in the land. This refers particularly to the medical departments of State universities. On the other hand, the student should know that even if some of the better schools do charge higher fees, nevertheless, they spend on each student per year several times the amount of money that the student pays in tuition. Here, again, it would be poor economy to enter a lowstandard college which depends on students' fees alone for its income, when for a few additional dollars each year he can enter a thoroughly equipped institution and get a far better medical training. Even should he be required to work his way through college in whole or in part, the opportunities for doing so are, as a rule, greater in the better than in the lower standard colleges. Generally, however, worthy students who are poor in purse are the very ones who appreciate not only the value of money, but also the value of the medical course they are getting. Such students are seldom beguiled into a poor college by alluring and misleading advertisements. On the other hand, many such students are found to be working all or part of their way through some of the highest grade institutions.

In order that the student may be thoroughly informed in any and all of the foregoing matters it would be well for him not only to secure the announcements of a number of colleges among which he may be able to choose, but also to secure reliable information from other sources. He should read the reports on medical education by the various standardizing agencies referred to in this article. At the present time, in order to be eligible to practice medicine in all States, the student must have completed two or more years of work in a standard liberal-arts college. He should then obtain his training in a medical school of unquestioned standing.

The student must bear in mind that in his preliminary and medical training he is laying the foundation for the rest of his life. If a year or two more is needed to enter one of the better medical colleges, he may count it as time well spent, since he is all the more sure of having laid a solid foundation. The medical profession in this country is extremely overcrowded, but there is always room for physicians who are thoroughly competent.

ALL-TIME CLINICAL PROFESSORS.

Those who have noted the marked development of laboratory instruction in medicine, following the employment by the colleges of expert, all-time professors in those branches, can readily appreciate the developments which would follow the securing of all-time professors in the clinical branches. It is now clearly recognized that those who are the best teachers in medical colleges are those whose life work, whose chief interest, is the welfare of the medical students. Medical teaching of the highest type is simply impossible when the teacher is dependent on his active practice for a livelihood and can give only fragments of his time to teaching.

That teachers of the laboratory branches should give their entire time to teaching and to a certain amount of research in the medical school is no longer disputed. That there needs to be a general reorganization of clinical teaching is also clearly understood. That clinical teachers should entirely refrain from the practice of their profession, however, is certainly not desirable. The experience gained from a general contact with patients in their homes and under varying conditions is one of the important qualifications of a good clinical teacher. It prevents him from falling into the unsympathetic, machine-like routine methods of the hospital. On the contrary, his practice keeps alive within him the bond of sympathy and consideration for the patient, a matter which every medical student should be taught to keep in mind. It is a qualification, meanwhile, which counts much in the development of a successful practice.

It is quite evident, therefore, that the need is for some method whereby the clinical professor's practice will be so limited as to prevent it from interfering with his duties as a teacher. For several years a number of medical colleges-notably those of Leland Stanford, Yale, Washington University (at St. Louis), and the Universities of California and Pennsylvania-have limited the practice of some of their clinical teachers to consultations in the hospital. The results have been excellent.

During the past year another plan has been suggested by the General Education Board, which has donated $1,500,000 to the Johns Hopkins University Medical Department to provide for placing the chairs of medicine, pediatrics, and surgery on a salaried basis. The holders of these chairs are to be paid definite salaries and will be free to practice as they may desire, but any fees collected are to go into the university treasury. Gifts of $750,000 and $500,000 for a like purpose have been given to Washington University Medical School at St. Louis and to Yale Medical School. This plan apparently has never been tried either in this country or abroad and pre

sents some difficulties. There is a question as to the rank of a man who can be secured to give full time to college work and receive no compensation outside of a salary that is small compared with the incomes of leading practicing physicians.

The plan proposed by the General Education Board is commented on in an editorial in one of the leading medical journals,1 extracts of which are as follows:

That the teaching of the clinical branches must be put more nearly on the basis of the teaching of the fundamental subjects, and that full-time teachers must be assigned to these subjects, is becoming more or less generally recognized. It is believed, however, that a large number of men engaged in practice will also be needed to give part of their time to teaching and research, though the number will probably not be so large as at present. When, however, the question is raised as to the rank of the man who can be secured to give full time to the college work and receive no compensation outside of the salary, there is considerable difference of opinion. If a man of exceptional ability has worked his way to the head of a department, does he disqualify himself for the position if he declines to give up the emoluments of general practice? Will not the attempt to restrict great clinical teachers to a salary result in the medical schools being compelled to accept men of less commanding ability and power? If a great clinician is willing to give half or two-thirds of his time to research and instruction, but wishes to reserve two or three hours a day for consulting work for which he can readily secure large fees, is there any real advantage gained in compelling him to surrender these fees to the university?

An important economic problem is involved here which can not at this time be discussed at length. It is important to say, however, that by placing the clinical chairs on a salaried basis it may become as difficult for the medical colleges to secure and retain the services of the best talent in the clinical departments as it is for our schools of technology and engineering to keep on their faculties the most skilled engineers, who are drawn away from teaching by the large emoluments offered by the commercial world. If the public service is of great value, are not the greater emoluments justifiable? Is it not the very experience these men gain in their public service which makes them so desirable on the faculties of the teaching institutions? It is an important question, therefore, whether it is best either for the public or for the college to restrict the work of these men.

A different plan, proposed by one of our leading educators, would place the principal burden of teaching in the clinical branches on the younger men, who would devote themselves for 10 or 15 years to teaching and research exclusively, at a modest but adequate and gradually increasing salary. The sum which it is proposed to pay to the clinical heads under the plan just discussed would support four or five men of this type. At the end of 10, 12, or 15 years some of these men by reason of their exceptional opportunities would have gained the knowledge and experience which would prove their exceptional ability as teachers. The college would thereby be enabled to make the wisest choice of those to be granted professorships or to be placed at the head of the various clinical departments. For these younger men there would be a constant inducement to strive for the higher positions open to them. And whether they reached the desired goal or not, they would be prepared by a broader knowledge and experience to render a larger service to humanity as strong consulting practitioners, so that, as a rule, they could demand at once large fees, and in this way secure adequate reward for their years of service to education. They would still retain their connection with the medical schools, however, giving a large amount of their time to research and teaching, for a small compensation.

1"A New Departure in Clinical Teaching," Jour. Amer. Med. Assoc., Mar. 14, 1914, p. 853.

There are some who feel that the latter plan possesses many advantages: It securse the undivided time and energy of men for teaching and research in the most productive period of their lives, and it effects an ideal pension system, or rather makes unnecessary any pension system. It closely approximates the actual practice in the clinical departments of the German universities, where, as a rule, one contentedly serves an apprenticeship for many years at a meager salary because of the hope of a large reward in honor and financial return on attainment of a professorship, which rarely comes to a man in Germany under 45 or 50. A large part of the best research work, and by far the greater part of the teaching in the German medical schools, has always been done by the younger men of this type.

In the annual report of the Council on Medical Education to the house of delegates of the American Medical Association,1 among other comments on this subject the following statements are made:

In clinical work the head of the department and his associates must be three thingsfirst, great physicians in their special field; second, trained teachers; and third, research workers. The medical school very properly demands that their clinical teachers be men who are recognized as authorities in their special fields, both by the profession and by the community. In the organization of a clinical department this fact must not be lost sight of, and whatever plan is adopted must make it possible for the clinical teachers to remain the great authorities in their special fields both in the eyes of the profession and of the public.

The plan adopted by the German universities has been on the whole most satisfactory. There, a professor in a clinical department is in every sense a university professor, just as much as the professor of chemistry or of physics. His university work commands his time. He must allow nothing to interfere with his teaching, his clinical work in the hospital, or his research, and he devotes on the average quite as much time to his university work as does his colleague in chemistry or in mathematics. In addition to this, however, he devotes some time each day to private practice by which he maintains his position before the profession and the public as a great specialist. This can be done without neglecting his university position. In fact, if he does not remain the great physician, he ceases to be of as much value either to his students or to his university. On the other hand, if he should neglect his university work because of the time he devoted to private practice, his services should be dispensed with.

A special committee composed of prominent clinical teachers is preparing a report on this important problem, which will doubtless. be published during the next year. It will be awaited with interest.

2

GRADUATE COURSES IN PUBLIC HEALTH.

Graduate courses in public health have been established in connection with ten medical schools leading to a degree of doctor of public health (Dr. P. H.), certified sanitarian (C. S.), master of science in public health (M. S. (P. H.)), or master of public health (M. P. H.). The course is for one year except at the Universities of Colorado, Michigan, Minnesota, and Wisconsin, where the course for the doctorate covers two years. Wisconsin gives a diploma in public health (D. P. H.) for a one-year course. The University of Cali

1 Jour. Amer. Med. Assoc., July 4, 1914, p. 86.

2 Or hygiene (University of Pennsylvania).