thus both wasted. As a rule, services rotate every three or four months; the hospitals sometimes provide clinical laboratory space in which students work.[1] All these institutions possess supplementary facilities. In general, however, supplementary clinical opportunities are of fragmentary and precarious character; the medical school has as such no uniform constitution, nor is a single department an organized entity; clinical clerks may be employed by one teacher for three months, only to be spurned by his successor in the service at the close of his brief term. Fresh pathological material may be procured by giving a faculty appointment to a coroner's physician, while the professor of pathology scours the city in vain for admission to a dead-room; instead of compact departments pulling as a whole towards a definite goal, a halfdozen professors of medicine and surgery stand on an equal footing, each compelled to conform to conditions imposed by the hospital on the staff of which he is a transient sojourner, or holding the whip-handle over his own school, because the school cannot antagonize the clinical professor without imperiling its clinical opportunities correspondingly. The normal relation of school and teacher is inverted. The question is not, "Who is a good teacher?" but rather, "Who controls a hospital service?" In a large city, the curtain rises on a dozen hospitals, each already provided with a staff, and several medical schools, each requiring a faculty of men who can bring as their dower "clinical facilities." There is a lively competition: at once, every holder of a hospital service finds himself a potential professor of medicine, surgery, or whatnot. When the scramble is over, the counted spoils appear in the catalogue in the form of a list of the hospitals "open to students of this school." The hospital appointments are therefore valuable "plums." They give the holders the call in the matter of school rank; and school positions are still in most places of substantial commercial value. It happens, in consequence, that the schools under discussion are put together of two dissimilar pieces: the laboratory branches are of one texture, the clinical branches of another. The laboratory men are imported; their productivity has been increased by crossing the breed. The clinical men are local[2] and, with some notable exceptions, contentedly non-productive. There is little intercourse across the line in either direction. The redeeming feature of these schools is, then, simply the amount and variety of clinical material that their students see.
The plane drops once more as we leave behind these large schools and approach the next class. Conditions now become rapidly worse through aggravation. Hospital management becomes increasingly unsympathetic or unintelligent, thus keeping the schools on the anxious bench. In truth, not much can be expected. "Amongst the
- ↑ In a few services a continuous term prevails for the time being, — sometimes by arrangement among the teachers themselves, sometimes by way of personal compliment to an individual. Welcome as such improvements are, they are far from curing the trouble.
- ↑ One can in a few lines give a complete list of schools that can and do go outside the local profession to procure clinical teachers: Johns Hopkins, University of Michigan, University of Virginia, Yale, Tulane (in medicine), University of Pennsylvania, and Washington University. These institutions have imported perhaps a score or two of clinical teachers; there are almost 4000 more clinical professors in the United States and Canada who are practising local doctors.
