Thomas Tate.

The American journal of obstetrics and diseases of women and children online

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College of Surgeons of England it is not unduly large. It is true
that surgery has grown enormously in America, but we have a
large country and a large population, and obstetrics has not by any
means obtained the same growth. The public needs competent
obstetricians in all parts of the State. A certain number of men
will qualify themselves to do obstetric surgery safely and success-
fully. These men will become attached to various hospitals through-
out the State, in their maternity departments. The action of
the State Board in causing the establishment of maternity wards
in all hospitals will greatly aid the development of good obstetric
service. These hospitals and their attending obstetricians will
form centers of professional growth, and centers of efficient service
for the population. While the smaller hospitals cannot be the
centers of teaching for a large number of students because they
have not the number of cases seen in the cities, yet these hospitals
will render important service to the State in educating the local
profession and giving relief to patients. The best interests of the
population and of the profession, alike, so far as the development of
good obstetric practice is concerned, will be served by the action of
the State Board in this regard.

There are economic reasons for the renewed interest in obstetrics
as a rational means of conserving the population. The waste
of human life at present is so enormous that the economic value of
human life has become greater. No method of conserving a popula-

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tion can be found so efficient as the proper development of adequate
obstetric service.

Dr. George M. Boyd. — The question of the advance in the
teaching of obstetrics is one of moment and interest. When we
think of the progress that has been made since the days of the rudi-
mentary training us older men received back in the 80*8, theoretical
and without practical instruction, we know that there has been a
great gain in this branch of medicine. I am in accord with what
Dr. Hirst has said. I feel, however, that we must create a standard,
that we must aim as high as possible, and that until we can work
in uniformity, until there exists in each State the same requirement,
it will be impossible to make the progress we desire. I feel that in
the State of Pennsylvania we are a step in advance of some of the
others in first requiring a year of hospital practice and part of that
time given to obstetric work. The difficulty encountered in the
majority of schools teaching medicine is that the student is not under
our direct control; he does not live within the walls of the hospital.
The hospital year provides in a measure for this defect. While the
obstetrical material may be limited in the hospital year the student
is in the hospital and has a practical knowledge of the cases. To
repeat I feel, that in teaching obstetrics the schools should aim at a
standard as high as it can possibly be, and that it should be lived up
to. Even in the small hospital there may be seen a variety of inter-
esting cases. I endorse what Dr. Hirst has said of the importance
of clinical work and the amount of time that should be given to
that part of obstetric teaching. I feel, however, that the didactic
course is important, for there is a large part of the teaching of
obstetrics that cannot be carried out in the clinic. I have enjoyed
the paper and believe that we cannot have a uniformity of teaching
until the same requirements for the practice of medicine exist in
all States.

Dr. Alice Weld Tallant. — It is with great pleasure that we
listen to any proposition for the improvement of obstetrical teach-
in in this country; it is certainly one of the places in which the
greatest need exists, and anything that can be done in this direc-
tion in this State or in any other is for the welfare of the whole
country. It is true as Dr. Hirst has said, that we in America are
far from being able to congratulate ourselves upon the require-
ments in obstetrics. So far as the State of Pennsylvania is con-
cerned we may, at least, congratulate ourselves that there is a
minimum requirement, since so many States do not have even this;
it is something to have the requirement of twelve cases. In regard
to dividing the cases between the undergraduate years and the
interne year, I do not understand that the minimum undergraduate
requirement of six cases carries with it a stipulation that the col-
leges shall not give more than these cases. It is perfectly true that
to see a large number of complicated cases is of great value, but it
is very necessary to emphasize the value of actual contact with the
patient. One may watch a forceps or a version case, but it is
very different to do it oneself; in the same way, many of the cases

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which the students see are a help in certain ways, but not the help
that comes from the work which they have actually done for them-
selves. Dr. Davis takes exception to the out-patient practice. I
feel, however, that the training connected with the out-patient
practice of obstetrics, in which the students meet emergencies,
accept conditions as they find them and bring success out of un-
favorable surroundings, is the kind that will be of the greatest help
to them when they go out as physicians into places in which the
hospitals are not at hand; not only in the foreign field, but in our
own country. It is very easy to practise obstetrics in well-appointed
hospitals, but many of our students are going into the homes of
patients and must make the best of what they find. In our work at
the Woman's Medical College I always feel that the out-patient
work is of the greatest value.

So far as the State requirements are concerned, practically all
our students are already delivering twelve cases in their under-
graduate course, but I do not feel that it can do any harm to have
six more required after they graduate. We lay as much stress as
possible on the practical side; all medical schools dp at present.
I think that the cases conducted during the college years in a certain
way of more value than the same number of cases conducted after
graduation, for the reason that in the colleges the cases are conducted
according to certain teaching principles laid down in the school.
Internes in hospitals do not get as much teaching as they should;
the staff, with the best will in the world, may be unable to teach the
internes who are in the hospitals, so that they are not given ex-
perience under the proper supervision. For that reason I feel that
to increase the requirement in the medical school would be of the
greatest value. The State has made a fine start in requiring the
number of cases that it does, and I have no doubt that it intends to
require more as the years go on, and the sooner it requires more, of
course, the better. Another help in the improvement of obstetrics
would be the establishment of teaching fellowships in colleges, such
as we are offering at the Woman's Medical College this year, whereby
students may obtain special instruction in obstetrics following their
undergraduate training.

These are. the chief points that have occurred to me in following
the discussion thus far. I do feel that our State has made a good
start, but I feel, too, that it needs to go ahead, farther, as I have
no doubt it will. Any increase in the requirements of college training
is to be welcomed in whatever way brought forth.

Dr. John E. James. — I wish to go on record first of all by
stating that I am in absolute accord with the statements which
Dr. Hirst has made. I feel that Dr. Hirst has brought forth a
subject exceedingly timely. The points Dr. Hirst mentions be-
speak an ideal condition for obstetric teaching that must eventually
give higher standards in the teaching of obstetrics in the different
colleges and improve the practice of obstetrics among the general
practitioners of medicine. It is the consensus of opinion among
medical educators that emphasis should be placed upon the value

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of practical training in the thorough equipment of the medical
student. This being true, whether a student can obtain sufficient
bedside instruction in the undergraduate year without the sup-
plementary training in the recognized hospital depends upon the
number of hours which the college curriculum gives the student
and also upon the clinical material available for teaching purposes.
The number of hours devoted to the clinical and didactic instruc-
tion in obstetrics is decidedly below that which it should be. I,
therefore, feel that the law of the State of Pennsylvania in de-
manding the hospital year supplemental to undergraduate study is
a most vitally essential educational adjunct. The greater amount
of practical training we give our students the greater will be the
reduction in mortality and morbidity — and I believe the morbidity
rate is to be considered equally with the mortality — and we shall
see a lessened amount of poor obstetrics among general practitioners.
Many objections will be raised regarding the hospitals to which men
shall go for this supplementary training. The men in charge of
the so-called, maternity hospitals in many instances are not of
sufficient caliber to give the supplemental training. Likewise many
of the hospitals have not sufficient clinical material for instruction.
I believe, however, that the hospitals can be brought up to the
proper standard by the board of licensure or other board legally
appointed. Under present conditions I feel that the position of the
Pennsylvania Board of Licensure in demanding a hospital year is
a most excellent one. I feel that they should go one step farther
and designate by proper control the different hospitals to which
the students should be sent for their supplementary teaching.

Dr. J. M. Baldy. — There is nothing that would give me higher
pleasure than to be able to attain the ideal and to attain it at once.
My experience in the last five years of this work has been that
when I have gone after the ideal I have lost the whole gist of that
which I was after. Idealism is not attained in leaps and bounds,
but by evolution. Now I am in hearty sympathy with all the
essayist has had to say regarding what ought to be. The question
is, can we get, and are we going to get something until we get the
ideal. It must be borne in mind that the teacher in the school
has one viewpoint, that the administrator in the State has another.
The State should prod on the laggard, but should not set a pace
beyond which all can reasonably go. The State is not legislating
done to educate the interne, but to secure the best medical care
for the people of the State. The education of the interne, however,
reacts upon the people of the State, although his education is a
mere incident. I at first thought the solution of this whole matter
was very simple, but many things are to be considered in order to
accomplish results. I think the essayist himself has not thoroughly
understood the Law of Pennsylvania. By it the Bureau of Licensure
is not tied down as are all the other States by hard and fast acts of
Assembly. There is an element of discretion allowing the Bureau
to advance the standard as rapidly as in their judgment is advisable.
If the time has come when the medical schools of the State have

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performed that which the State requires, then the Board of Licensure
will go another step and yet another. That which the State has
been doing in the hospitals has been looked upon in two ways, and
must not be confused. It is supplementing the work of the medical
school. The requirement of the hospital is a minimum of six ob-
stetric cases: so the Act says; a maximum is to be at the discretion
of the Bureau of Licensure. The Bureau is ready to advance to-
ward that maximum if the schools of the State are. The people
of the State are entitled to a proper practice of obstetrics. We are
well aware they are at present abominably served by some of the
men on the hospital staffs. The interne often goes out of the
school infinitely better prepared to give that service than many on
the staffs of many of the hospitals. The State realizes that fully 50
per cent, of the doctors in the State are not fit to teach obstetrics.
This requirement of six cases in hospitals is only a beginning
and whether we shall succeed in our endeavors to standardize the
hospital properly depends upon whether we shall have the back-
ing of such a body as this; we need the backing of the best element
of the profession. The work we are trying to do is not meant to
take the place of the undergraduate school. If I am assured to-
night by any of the teachers of medical schools that they are fully
meeting the requirements of the six cases, within a few days we shall
have under consideration the increase of the requirement to twelve
and when the time is ripe, this will be increased to twenty. I
do not mean that every school must follow; but, if five can do so,
the others will have to, unless they can show us that it is impossible.
It is up to the medical schools to say when the advance shall be
made. The doctors in the State in the small communities need
proper teaching. There should be installed in all hospitals a
certain number of obstetric beds with competent men and then
the community could be educated to go to those beds and not to
the midwife. Dr. Davis struck the keynote. How are we to get
better service to the State if we do not turn out better obstetricians,
and how shall we train these men if they are not given opportunities
after leaving the school. This was illustrated by an incident in
my own town of Danville and is typical of the whole situation:
A young man who had been graduated from the University of Penn-
sylvania Medical School, said to me, "Dr Baldy, what's the use of
your Bureau requiring us to take all the laboratory and scientific work
we have to take at the college, when we never have an opportunity
to use this knowledge." As you give them opportunities they will
develop themselves and will give the towns good obstetrics as well
as good surgeons and they will be teachers themselves to the younger
men who come to them as internes. We cannot accomplish that
in a day or in a year. We are endeavoring to lay so solid a founda-
tion that when the politicians put us out we will have left a heritage
upon which the profession can build forever afterward.

Dr. James Wright Markoe, N. Y. — This subject interests me
greatly. Twenty-six years ago the work of the Lying-in Hospital
in the City of New York started from a peculiar circumstance.

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Connected as I was with the College of Physicians and Surgeons
as house surgeon of the Sloane Maternity Hospital, I found on going
to Boston that they had an out-patient department where they
taught the students practical obstetrics and I came back very
enthusiastic over the idea and presented it to the College of Phy-
sicians and Surgeons, but they said the proposition could not be
carried out. I called attention to the same service done here in
Philadelphia, and still they insisted upon it that it was not prac-
ticable, so I started this thing then with the idea of giving out-
door education in obstetrics. Twenty-six years have gone by.
Through the indoor and outdoor services of that hospital have
passed 100,000 cases; we have educated some six or seven thousand
students although we are not connected in any way with any
institution. Students come to us — undergraduates and graduates
from all colleges and from all States in the United States. They
come because we give them something they cannot get anywhere
else. This may sound egotistical, but it is not, for we have the
most abundant clinical material in New York of any city as it is
the largest city of the United States, and therefore must have more
clinical material. The question comes up in Pennsylvania, of how
to educate the students? My one thought all these years has been
for the medical men, alone in the country who are without aid and
without consultants within easy reach. I want to give such men
a knowledge of obstetrics which will not make them capable of doing
a hysterectomy as perfectly as Dr. Hirst or Dr. Davis will do it,
but will make them competent to take care of any ordinary cases
so that their mortality will be no higher than the general run of the
best maternity hospitals. I believe that it can be done by teaching
these men at the bedside. I do not agree with Dr. Davis that the
out-patient department is of no value. I think the very fact that
a man has to take care of a woman where there is nothing at hand
but water — and very often that is dirty water — is a very great
education. We in the Lying-in Hospital have done this under the
strict supervision of as well-educated instructors as we can get.
By our plan a man goes to a case and is followed in an hour by an
instructor. He is visited every two hours by that instructor, and
if he makes any mistakes they are corrected by the instructor, and
each student sees from twenty to thirty cases in that way. The
first part of their service is given in the hospital where they see a
large number of complicated cases from which they have a good idea
of their duties in the out-patient department. I have had letters
from ex-students saying they would not take a thousand dollars
for the experience gained in the tenement houses. We have reduced
the mortality in these cases managed by our students considerably
below the mortality of the physicians, taking all physicians in the
City of New York. We have a great deal better mortality than the
run of doctors in the City of New York, notwithstanding that
these cases are taken care of by students. When I look back over
those twenty-six years and think of the very few teaching insti-
tutions there were then in the United States and think of the ob-

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stetricians we have sent throughout the towns and cities of this
country, I feel proud of the progress made. I do not belittle the
fact that we must seek much greater progress but if the State of
Pennsylvania, or any other State, will guarantee that their students
graduate with a knowledge of what the fundamental principle of
obstetrics should be by practical bedside instruction indoor and
outdoor it will have accomplished a wonderful amount of work
in the right direction.

Dr. Alexander Marcy, Jr. — Personally I have been very much
interested in listening to the papers read and to the discussion
following. The sentiment has been quite in keeping with our idea
in New Jersey as to what should be required before a license to
practise medicine shall be granted. I am free to confess that
Pennsylvania at the present time is just a little in advance of New
Jersey along this particular line. We in New Jersey have hereto-
fore been leaders in medical licensure and in our requirements,
and I think our law at present is second to none in the country,
excepting in some particulars. I think Pennsylvania has rather
"put it over on us" in this matter of hospital standardization and
requirements for the teaching of obstetrics. This year, however,
after July i, we do require in New Jersey a year of interneship
before a person will be allowed to come before the Board for ex-
amination. We have not, however, stipulated the number of
hours he should take in practical obstetrics or the number of cases
he shall attend before he comes before the Board. From what I
have heard to-night I think we shall have to amend our law, and I
think we shall make the number of cases twenty-five.

Dr. Adolph Koenio, of the State Bureau of Medical Education
and Licensure, Pittsburgh: I did not intend to make any remarks
here to-night, but came simply to listen and to gain some ideas.
I do feel, however, that I should commend the statements which
Dr. Davis has made here to-night; they appeal to nle as being good
common sense and in keeping with the situation as it exists at the
present time. It is an easy matter to say that we should have things
idealistic. I am thoroughly in accord with everything that Dr.
Baldy has said. As a Bureau, we are absolutely a unit on these
things, believing that they are evolutionary. Such an example
of inefficiency on the part of an obstetrician as was mentioned
by Dr. Hirst is an arraignment against the college graduating such

I regret that the Bureau of Medical Education and Licensure has
no way of sizing up the personal equation of a candidate or of in-
vestigating his ingenuity. That is something which should be
done by the college, and I believe is now being done. Twenty to
thirty years ago or less the intellectual status of a candidate for
the study of medicine was never inquired into by the colleges.

I am thoroughly in accord with the requirements regarding ob-
stetrical experience in the hospitals. The Bureau is standardizing
them and investigating their ability to give the opportunity for
the acquisition of such experience. An approved hospital stands

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between the school and the general practitioner. If the college
thinks the present number of required cases right the Bureau I
am sure will not object. These hospitals carry the graduate to the
time when he will be upon his own responsibility — even though he
may not have the highly qualified teacher to supervise, he still has
some one to fall back upon when he gets into trouble. That is a
condition very much better than the old situation.

I am very glad to be here and to have heard what has been said,
and I am heartily in accord with most of the sentiments expressed,
especially so with what Dr. Baldy has said.

Dr. Richard C. Norris. — I think this meeting has been well
worth while; it has clarified the atmosphere, and has given us all,
clearer ideas of what this law established by the State means.
Every one will agree, that the higher the college raises its standard
in obstetric teaching the better. Unless internes are properly
trained in their early experience in obstetrics, they cannot expect
to be masters in the art and science of that branch. The orthopedic
man, the eye man, the general surgeon, the internist, the laboratory
— all clamor for the same advance in their departments while the
roster is crowded beyond the student's endurance, and there must
come a time when medical students, to be better educated along
all lines, will have to use the hospitals for a final yeay of instruction
and experience. The State says to the obstetric-teaching institu-
tion, raise your standards as high and rapidly as you will, and we
will meet them. They are doing their best now, and they will do
better. When we come to study the relationship of the State law
as to the year's interneship in the hospital, the paramount question
at issue to my mind is the advantage to the community. The
matter must be viewed in its relation to the teaching institution,
to the student, to the community and to the doctor. As. Dr.
Baldy has said the matter is in process of evolution, and no State,
not even Pennsylvania, could at once make a law that would meet
all these conditions and satisfy every one concerned. Dr. Baldy
has also brought out the essential point of the benefit not only to
the student, but to the doctor. You will remember that in the
earlier days the great surgical operations came to Agnew and Gross
who had established teaching centers and developed their art.
Those conditions no longer prevail. Hospitals now exist in each
community, and have created able surgeons. Where there is a
hospital there is a need for a surgeon; when there is a maternity
there is need for an obstetrician, and that need will create the sup-
ply. So I can see that hospitals compelled by the State to have
obstetrical departments, will find the morale, the skill and the
experience of their obstetrical staffs increasing rapidly just as surgery
has been developed in those hospitals in the recent past. There is
no question to my mind that this movement is one to uplift the
educational standards of our State in regard to the student and the
doctor. If obstetric surgery is developed to its highest point it
must be done in our hospitals. Let a man leave his school having
seen a large number of Cesarean sections, unless he has had personal,

Online LibraryThomas TateThe American journal of obstetrics and diseases of women and children → online text (page 10 of 123)