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 UNIVERSITY BULLETIN 
 
 NEW SERIES, VOL. XXIII, NO. 20. NOVEMBER 12, 1921. 
 
 UNIVERSITY OF MICHIGAN 
 
 SOME PROBLEMS IN MEDICAL EDUCATION 
 AS THEY CONCERN THE 
 UNIVERSITY OF MICHIGAN 
 
 HUGH CABOT 
 
 ANN ARBOR 
 
 PUBLISHED BY THE UNIVERSITY 
 
SOME PROBLEMS IN MEDICAL EDUCATION 
 AS THEY CONCERN THE 
 UNIVERSITY OF MICHIGAN 
 
 THE ADDRESS OF THE DEAN 
 AT THE OPENING OF THE MEDICAL SCHOOL 
 ON 
 
 SEPTEMBER 27 , 1921 . 
 
Digitized by the Internet Archive 
 in 2017 with funding from 
 
 University of Illinois Urbana-Champaign Alternates 
 
 https://archive.org/details/someproblemsinmeOOcabo 
 
ADDRESS OF THE DEAN AT THE OPENING OF THE 
 MEDICAL SCHOOL 
 
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 I find myself this morning in a difficult position. Difficult for two 
 reasons, firstly, because I am taking up the reins laid down by a great 
 man and secondly, because this is a time when many problems in the 
 teaching of medicine press for solution. There is perhaps more change 
 in the air than is ordinarily the case. In regard to the latter difficulty, 
 one should perhaps not complain since it adds zest and interest to life 
 and we may be sure that no monotony or drabness will surround the 
 next few years of medical teaching. In regard to my first difficulty, the 
 case is far otherwise. To classify Dr. Vaughan as a great man is no idle 
 compliment and the doubtful have merely to look at the monument he 
 has left here for their answer. Many would perhaps be glad to be judged 
 by their intentions, but in the long run, the world will probably judge 
 us by our results and it is reasonable that we should judge Dr. Vaughan 
 by his results. He came here in the early days of organized medical 
 teaching in this country. More than thirty years ago, he became the 
 executive officer in this Medical School and it is strictly accurate to say 
 that this school is his monument. Its policies have been worked out, its 
 faculty has been brought together and stand as the result of his 
 extraordinary executive capacity. 
 
 In the days when it became his duty to decide, it required not only 
 foresight in decision but unusual boldness to undertake the building up of 
 a great medical school without the facilities of a large city. No such 
 schools existed or to the best of my knowledge ever had existed, and 
 the soundness of the proposition that a medical school giving complete 
 instruction in all branches, both pre-clinical and clinical, could be built 
 up in a city of less than ten thousand inhabitants might reasonably be 
 doubted- As a relatively new comer here, I can without bias estimate 
 the position of this school in relation to the other schools of the country 
 and I can say without hesitation that it stands in first rank, that it 
 has always stood high in the character of its pre-clinical instruction and 
 that, with the up-building of the University Hospital, it has stood high 
 in the character of its clinical instruction. The decision made under 
 his administration to retain the clinical teaching in Ann Arbor rather 
 than to allow it to be transferred to Detroit is evidence of great wisdom 
 and great fore-sight. Today discussions concerning the possibility of 
 building up clinical departments in small cities are being answered the 
 
— 4 — 
 
 country over by pointing to the example of the University of Michigan. 
 It means that the policy laid down by Dr. Vaughan has been a convincing 
 success. 
 
 The character and standing of this faculty must be a lasting 
 monument to him as a judge of men. All obstacles which have here 
 been overcome, particularly in regard to the teaching of clinical branches 
 are a lasting monument to his judgment and pre- vision. We may properly 
 regard him as one of the greatest medical educators that this country 
 has ever produced and we may fairly doubt whether we shall be able 
 to direct the policy of this school with equal judgment. 
 
 It is however proper at this time that I should state as clearly and 
 as frankly as possible the fundamental objects which I believe to be 
 comprehended under the term “policy” of this school. A medical school 
 today may be thought of as having three teaching functions and presenting 
 three ideals and facets to the world: 
 
 1. The teaching of undergraduates. 
 
 2. The teaching of graduate physicians and the advancement of the 
 boundaries of medical knowledge. 
 
 3. The teaching of the public in matters of public health and 
 health policy and assisting in working out the relation of physicians and 
 hospitals to the people of the state. 
 
 1. POLICY IN REGARD to TEACHING OE UNDERGRADUATES. 
 
 I may say at once that unless I gravely mistake the temper of 
 this faculty no fundamental change is contemplated. Clearly the most 
 debatable and debated question is that of so called “full time” instruction 
 in the clinical branches. Here no change of policy is contemplated 
 since it is more than two years since this faculty voted its approval 
 of the theory involved. This is not the time nor the place to re-state 
 the argument concerning full time teaching but it is proper that our 
 position should be made clear at the outset. 
 
 The theory of full time teaching in the clinical branches is relatively 
 simple and concerning it there is little difference of opinion. That it 
 is a desirable method, most will agree and this agreement has come from 
 the clear demonstration of the unsatisfactory character of part time 
 teaching in these branches. It will be generally admitted that part 
 time teaching involves a dual allegiance, one to the university and one 
 to the individual himself and this divided allegiance has resulted in 
 teaching somewhat less than satisfactory. That the difficulty is widely 
 
— 5 — 
 
 recognized and generally admitted is clear since most of the great 
 medical schools in the country are experimenting with such full time 
 teaching in some form. 
 
 But, it is not over the theory of full time instruction but over 
 the practice that doubt and difficulty has arisen. It is undoubtedly true 
 that today there is no well demonstrated plan of full time teaching in 
 clinical branches which is regarded as satisfactory by a large number 
 of those competent to an opinion. Discussions of the matter have been 
 considerably impeded by the failure to draw a distinction between the 
 application of this principle to medical schools situated in large cities 
 and its application to those situated, as we are, in small cities. But 
 the difference is very real and cannot be omitted from any discussion 
 without seriously compromising the soundness of the conclusion. The 
 employment of part time teachers for all the clinical branches is a 
 relatively simple matter and comparatively more satisfactory in those 
 schools situated in large cities with quantities of clinical material at hand. 
 If, however, part time teaching has been unsatisfactory in the group 
 just referred to, it has been far more unsatisfactory here. The teacher 
 must here stretch himself thinner and thinner over the field he is 
 required to cover and may in the end fail to achieve success either as 
 a teacher or as a practitioner of medicine. Thus, clearly the problem 
 is one of paramount importance and we must bring to it our best 
 judgment applied always with patience and respect. 
 
 It is my own well considered opinion that full time instruction in 
 clinical subjects will not achieve its best results if the character of the 
 instruction is essentially altered from that given in the past by the 
 schools employing part time services. If as the result of full time 
 teaching, we are to see it fall into the hands of those who are essentially 
 scientists unfamiliar with the art of medicine, I shall be unwilling to 
 admit that we are doing our full duty to the student. We must, I believe, 
 continue to attract to these teaching positions men of experience both 
 in the science and in the art of medicine. If this premise be admitted, 
 it follows necessarily that the most difficult question is one of financing. 
 We shall require men who have achieved distinction and are able to 
 command relatively large incomes- That the Medical School can properly 
 afford to offer them salaries equal to their earning capacity as practitioners, 
 I do not believe, but it must be prepared to offer them something 
 approaching their market value or in the long run they will not come. 
 
 As I have already intimated there is no general agreement as to 
 how the principle of full time teaching shall be put into practice. Many 
 
— 6 — 
 
 methods are being tried. Some of them are far reaching and some of 
 them are very moderate and hesitating. The fact of the matter is 
 that there is no body of experience entitling anyone to pass final judgment 
 in this matter. All are experimenting and the more methods that are 
 tried in good faith, the sooner we shall be able to accumulate a body 
 of fact entitling to an opinion. 
 
 But if we are to experiment we must try the method in a reasonable 
 way such that our conclusions will be entitled to weight. Enough 
 departments must be put on full time to allow drawing of sound 
 inferences and at the same time the school must not so far commit 
 itself as to lose its flexibility and be unable to adapt itself to reasonable 
 changing conditions. It would indeed be a bold man who would assert 
 that he was sure of the best method to utilize “full time” in the clinical 
 branches. In working out this experiment on the basis which I have 
 stated, it is essential that the university should respect its commitments 
 and no agreements expressed or implied can properly be disregarded. 
 Futhermore, we must at all times keep our minds open and preserve a 
 decent respect for the opinions of others. 
 
 On the other hand however, this experiment is entitled to an honest 
 trial. Here we have elected a method whereby the whole weight of 
 financing this work does not fall upon the tax payer but is borne in 
 part by the legitimate income of the hospital. It is my judgment that 
 by distributing the burden in this way, it will not bear too heavily 
 upon the school and is far more likely to succeed than any other yet 
 attempted method. 
 
 I do not need to remind you that the plan has been much criticised 
 but most of the critics have not faced the problem and offered no solution 
 unless it be that we should ask the tax payer to assume the whole burden 
 which suggests that they really desire failure and regard this as a most 
 convenient method of getting it. There has been much loose talk about 
 the state’s interference in the practice of medicine, apparently in entire 
 disregard of the fact that the state has been gradually insinuating itself 
 into the practice of medicine for two generations. It has been alleged 
 that the competition thus introduced is unfair when as it seems to me, 
 it is far less so than under the system of part time when with all the 
 advantages which accrue from a university connection, the clinical staff still 
 competes with its less fortunate brothers. We have even been accused 
 of attempting to commercialize medicine when in fact this is clearly 
 an attempt to uncommercialize it. The utmost limits of commercialized 
 medicine were reached in the days, happily now passing, when some 
 
— 7 — 
 
 medical schools with a faculty of purely part time teachers were nothing 
 more nor less than feeders for the consulting rooms of the faculty. This 
 is commercialized medicine, if you please. Our proposition is precisely 
 the reverse- The method suggested for the conduct of the University 
 Hospital has been criticised on the ground that it would deprive physicians 
 of their patients and ruin their practice. If one looks carefully at this 
 proposition, it at once appears to have no basis in fact. If half of 
 the physicians of the State of Michigan were to send to the University 
 
 Hospital one patient a year, we should be unable to cope with the 
 
 number. In these discussions, it has I think been overlooked that this 
 university is an institution of the State and that it must be conducted 
 
 with due and proper regard for that fact. Beyond question, the physicians 
 
 are entitled to consideration but so also are the sick and the tax payer. 
 We are not prepared to admit that the physician is entitled to exclusive 
 consideration in the working out of this problem but we propose that he 
 shall have every consideration and every respect. We are prepared 
 to consider any suggestion and any criticism which is constructive and 
 which is an honest attempt to aid in the solution of the problem. We 
 are not hide-bound in our opinions and do not say that the method 
 here adopted is the only one or the best one. 
 
 2. the) teaching oe physicians and the advancement oe the 
 
 BOUNDARIES OE KNOWLEDGE. 
 
 It is clearly one of the great duties of the Medical School to be 
 prepared to assist physicians not only in the management of any particular 
 patient but in the general management of disease. One might I think 
 properly regard the Medical School as a reference library in the diagnosis 
 and treatment of disease. W'e should be prepared to put at the disposal 
 of physicians the knowledge here accumulated and advise them upon 
 those methods which in our opinion are sound and those which are not 
 sound. Only in this way will the Medical School discharge its duties 
 to the public and maintain a sound relation to the great body of those 
 who must care for the sick of the country. 
 
 But if we serve no other purpose than to teach our students wisely 
 and to present the problem of modern medicine skillfully to our brother 
 physicians, we should lose sight of one of the great functions which is 
 properly to be expected of us, namely research. Research requires for 
 its proper prosecution a highly special environment and it is rare ihat 
 the physician with a private practice can at the same time carry on 
 
— 8 — 
 
 far reaching investigations of medical problems. It is the duty of the 
 Medical School to see to it that an atmosphere congenial to research 
 exists and that a reasonable proportion of its funds are at the disposal 
 of those who have both the ability and the desire to work in this field. 
 The University will do well to make congenial abiding places for those 
 with investigative minds though having perhaps little or no capacity to 
 achieve distinction in the turmoil of the world. Such men allowed to 
 grow up under the proper surroundings may well contribute more to the 
 sum of human knowledge and to the alleviation of human ills than 
 many of their more practical minded brothers- 
 
 3. INSTRUCTION OF THE PUBLIC ON QUESTIONS PERTAINING TO PUBLIC 
 
 health. 
 
 Though it may be a somewhat novel conception, it seems to me 
 clear that the medical school, particularly of a State University, must 
 do its share in the work of disseminating sound opinion on medical 
 questions. There is today a large and growing group of agencies part of 
 whose function is the dissemination of knowledge concerning public 
 health. With these agencies and perhaps particularly with the public 
 health officers and public health associations, it is clearly the business of 
 the University through its medical department to co-operate to the fullest 
 extent. If we are prepared to admit that there can be no sound public 
 health without as an antecedent a sound public opinion then there is a 
 great work for the university and one to which it must be prepared to 
 give considerable time. In so far as it has officers competent to speak 
 with authority and trained in the business of transmitting information to 
 the less informed, these officers should be at the disposal of the state and 
 public health agencies to assist in the great campaign for building up and 
 strengthening of public health. 
 
 As a part of this function and one which at the moment is of great 
 importance is the dissemination of knowledge in regard to the soundest 
 and best relationship between the medical profession and the public. 
 It appears to be true that at the present time this subject is attracting 
 more attention than at any other time, certainly for many years. With 
 the growing complication of the field of medicine have arisen difficulties 
 in adjustment between the profession and the public. The expense of 
 the practice of medicine to the physician has enormously increased and 
 has in more or less direct ratio increased the expense to the patient. 
 This has given rise to much discussion. That the public has a real case 
 
— 9 — 
 
 in its desire to obtain medical care at a reasonable price is true. But 
 it is even more true that the medical profession is entitled to great 
 consideration and should properly be regarded as the best witness con- 
 cerning the difficulties surrounding any new adjustment. It is not 
 necessary here to go into the suggested remedies which have included 
 various forms of compulsory health insurance and various remedies 
 classified under the very vague phrase of “state medicine.” I desire 
 only to point out that it is my opinion that the State Medical School 
 should be prepared to bear its part in this discussion and I desire to 
 take this opportunity of making clear the position which this school 
 will take in the present discussion. Any proposition for the amelioration 
 of real ills in the present adjustment which leaves out of account or fails 
 to give great importance to the maintenance of the present relationship 
 between the physician and the patient is in my judgment doomed to 
 failure in this democracy. It is the essence of the American spirit that 
 it desires freedom of choice and though such choice may not always be 
 wisely made, any attempt to curtail such choice will meet irresistible 
 opposition and will fail, furthermore it appears to me clear that no 
 proposition looking to change can be successful which will result in the 
 deterioration of the standing of the medical profession in the community. 
 The standing of the physician in the community has always been a high 
 one and he has been looked to as an almost public official whose concerns 
 were less personal and more public than those of most of his brethren 
 Now, any proposition to change present conditions which will importantly 
 alter this relation, which will make the medical profession one of lesser 
 dignity and lesser importance, though it might temporarily appear to 
 remedy the ills, would in the end defeat its own purpose and have a 
 disastrous effect upon the public health. Unless the medical profession 
 be encouraged to continue in the future as in the past and unless the 
 individual physician continues to regard himself as having duties to 
 others far greater than to himself, advancement in medicine will be 
 less rapid, our ability to deal with disease will improve less certainly 
 and we may well see our civilization fall because of the failure to cope 
 with the diseases with which it is constantly menaced. I think I may 
 safely say that this faculty will be found upon the side of the medical 
 profession, that it is will always sympathize with the demands of the 
 public for improved medical service but that it will cast the weight 
 of its influence in favor of those changes which maintain the dignity of 
 the profession and oppose those which reduce the profession to hirelings 
 of the state, of the community or of the corporation. I take your time 
 
— 10 — 
 
 to make these statements because there has, I think, been misapprehension 
 in the minds of the physicians of this state as to the views held by this 
 faculty. This misapprehension I desire to correct to the end that the 
 most cordial relation may exist between this faculty and the medical 
 profession. 
 

V.