inary education came largely as a voluntary movement on the part of medical colleges, since their adoption of the higher standards preceded the action taken by state boards. Nevertheless, these boards are now supporting the better class of medical colleges, which make it certain that reasonable standards of preliminary and medical education are to prevail in the United States. This action by the state boards, furthermore, induced other colleges to adopt the higher standards which for financial or other reasons were not willing to do so voluntarily. Only a few more states need to secure legislation providing for better educational standards. Then-and the time is not far distant-all medical schools will have to adopt reasonable standards or cease to exist. Then also every medical school graduate will be better equipped not only to present more acceptable qualifications for the license to practice medicine, but also-and this is far more important— he will be able to render better care to his patients.

EXAMINATIONS FOR LICENSE TO PRACTISE AND

HOSPITAL INTERNESHIP.1

By JOHN M. BALDY, M.D., Philadelphia, President of the Bureau of Medical Education and Licensure of the State of Pennsylvania.

Examinations for License to Practise.

It has always appeared to me that State Boards have greatly misconceived their duties as regards the function of examinations for license to practise medicine. Educationally, we have primary and secondary school work, followed by college work, as preliminary; this is followed by the work in the medical school, and finally by the interneship in a hospital, prior to the state examination. Each one of these sub-divisions begins and ends as an entity and each one is competently taught and competently passed prior to entering upon the succeeding one. In passing from the high school to the college, it is assumed on the presentation of properly certified credentials that the detail of the high school work has been competently performed, the teachers have been of proper competency and the result has been passed on competently; the same may be said of the college work which follows, on entrance to the medical school; and the same ought to be said of the work done in the medical school, on entrance to the state medical examination. No State Medical Examining Board thinks, when examining an applicant for the practice of medicine, of re-examining him in the A B C's nor in reading, writing or arithmetic. No State Examining Board thinks it necessary to pass upon his qualifications in history, geography and the higher branches. Physics, chemistry, biology and languages are not taken into consideration in state medical examinations. If this be true of the work up to the medical school work, and can be done safely, then why should it not be applied equally well to the work done in the medical school itself?

Some years ago, when there was no supervision whatever over the medical schools, when there was no standardization of medical schools and when State Boards well knew that the majority of

medical schools did not teach medicine properly, the situation was an entirely different one. At the present time medical schools are standardized. The weaker ones are rapidly eliminated. Proper departments with proper equipment are well in hand; competent teachers with competent and sufficient numbers of assistants are engaged; the State inspects the schools and assumes responsibility as to their curriculum and teaching force. This being true there is no more reason that the details of their work should be reviewed by the State Examining Board for Licensure than there is that the State should review the preliminary work of the primary or the secondary schools or the college. The function of the State briefly stated is to determine whether or not the applicant wishing to practise medicine is competent to begin to do so. In determining this it is none of the function of the State to test whether or not the applicant knows all the details of all the various fundamental sciences necessary for the preparation for graduation. An applicant having been graduated from a competent and standardized medical school may fairly be presumed to know the facts of the basic sciences. The point the State should demand to know is whether or not he can correlate these facts sufficiently to make him a safe practitioner: not a finished practitioner but sufficiently safe to be allowed to begin practice. This to me is the entire function of the State in these matters and beyond this there is no necessity to go.

It is utterly impossible for any student to learn in the short time devoted to the study of medicine all the facts of all the fundamental sciences. It is equally impossible for him to carry in his mind all of the facts that he does learn in order that they may be available at an examination at some indefinite time in the future. I may state further that it is not even desirable that he should remember them all. Study does not predicate the remembrance of everything one has studied. The value of study is the training it has given the mind and the learning of general principles and principal facts which have a practical applicability to future work. Many men perfectly competent to begin the practice of medicine have been rejected and unfairly

handicapped by a non-recognition of these plain and fundamental facts. Consequently I am a strong believer that the State in its licensing examinations should not examine in the fundamental sciences directly but that it should confine its tests in regard to the knowledge of these sciences to practical questions of practice, which questions cannot be answered unless the applicant understands the general principles and main facts of the underlying sciences.

For instance, I am strongly opposed to asking pure anatomical questions, physiological questions and questions on inorganic and organic chemistry. The examiner who cannot formulate his pathological questions so as to demonstrate the knowledge of physiology of the one answering them, is an incompetent examiner and has mistaken his calling. The examiner who cannot put his surgical questions in such a manner as to demonstrate the knowledge of anatomy of the one answering the questions, is similarly disqualified as an examiner. No man uses organic or inorganic chemistry in the practice of medicine. The chemistry which is in daily use by him and which he should understand thoroughly is physiological chemistry and the examination questions should be confined to this subject. It is perfectly fair to presume that the man who can answer his surgical questions, his pathological questions, his biochemical questions, understands a sufficiency of the three underlying sciences for all practical and theoretical purposes. If the State is to go into the details of all these subjects then there is no reason why it should not reach further back and test out the applicant as to whether or not he understands all of the intricacies of physics, of geography, of reading, writing and arithmetic, and even of the A B C's. There must come a point when it is perfectly safe to cease testing a man's knowledge of elementary subjects and from the State viewpoint I am very emphatic in my belief that that point is reached as indicated above.

Hospital Interneship.

To demand a year or more of time of a young man just leaving the medical school after having undergone all the sacrifices neces

sary to his medical education, is a serious matter, especially when we consider the age at which the average medical student leaves the medical school. Consequently, when the State demands an interneship of a period of time in a hospital it is bound to see that the hospital providing this interneship is capable of returning to the interne a competent quid pro quo for his time and his sacrifice. This means the standardization of hospitals just as medical schools have been standardized and are still in process of being standardized.

It is not the intention to discuss in detail the organization of all departments of a hospital; this has been done many times by others well qualified so to do and a fair understanding obtains as to these matters. Rather is it the intention in a general way to call attention sharply to those departments which really go to make up a true hospital but which, in the course of a systematic and fairly exhaustive inspection of over two hundred hospitals, including State-owned hospitals, the Pennsylvania medical authorities have found to be very generally ignored; or, if in existence at all, were in such a large number of instances found to be so poorly developed as to be worthless for the purpose of proper and efficient scientific work, either as aid to proper and accurate diagnosis or as useful for instruction of an interne.

The question then primarily arises, what is a hospital? From the viewpoint of the interneship it is utterly impossible to consider many institutions at the present time calling themselves hospitals, under this designation. In constructing a true hospital certain scientific departments should first be provided for; the balance of the hospital should be built around these departments. Principally these departments are: the pathological and clinical laboratories, the X-ray department, the anesthetic department, the morgue and the autopsy room, and a competent system of record-keeping throughout the whole institution. These things are as necessary as is a kitchen, a laundry, a superintendent's office, a boiler house, the medical and surgical wards or any other essential department and no institution should be dignified with the name of hospital without each and all of them being competently provided for. It were supererogation to