may become a superior resident physician, and actually have less leisure for his professional problems than if he spent but half a day in the hospital and were never expected back until the next morning. Finally, there is an objection which weighs heavily with many men of high spirit, namely, that under this plan the university says to him, "You alone of our professors can I not trust to perform your university duties, if I give you full opportunity and full freedom." This, I am persuaded, stamps the plan as a temporary expedient for the present correction of existing abuses, which were being outgrown more slowly than those who had the interest of medical education deeply at heart wished. So long, however, as the university can not trust the professor of medicine or the professor of surgery with that freedom which is the most prized possession of the university teacher, just so long is it acknowledged that these men are not in the full sense university professors. Two other plans seem to me to deal with the problem in a constructive, and not a destructive, spirit, and to be more likely of ultimate success. One is the German method, unfortunately inapplicable here with our strict separation into classes, which deprives the student of the choice of his own professor. When the professor derives his income, not from a fixt salary, but from the fees of his students, he has an effective stimulus toward taking his university duties seriously. This, however, seems scarcely worth discussing in this country, tho freer interchange of students between institutions would be wholly desirable. A second constructive plan, compatible with the constitution of our medical schools, I wish to suggest for your consideration and criticism. It contains but one element of difference from ordinary academic practise. The five essential points in it are as follows: I. That the clinical teachers he chooses because of their possession of the same qualities which govern choice for other university positions, and which are the qualities I have already described at the beginning of this discussion. Such selections should be absolutely without geographical limitation, the best man being called wherever he may be found. This is becoming more and more the rule in America, in place of the former custom of choosing the most successful local practitioner. It is, in my opinion, ninetenths of the solution of the entire problem, whatever plan of dealing with outside engagements may be adopted. 2. The provision of adequate facilities for laboratory investigation, hand in hand with clinical training, for every member of the department staff. This means a hospital with a varied service, with abundant autopsies, and with laboratories of the several. types already mentioned, under the exclusive control of the head of the clinic. Lack of laboratory facilities to become investigators, rather than love of the dollar, has been the chief reason for the sterility of American clinicians in the past, and those that have proper facilities today are proving the enthusiasm for productive research which the young medical men of this country possess. Consulting offices should be provided in the hospital for the older members of the staff and a small, never a large, private service. 3. Salaries sufficiently ample to make outside practise for a living unnecessary, especially for the younger men who show ability as investigators. Such men should be kept out of practise until research becomes a fixt habit. Salaries should be proportioned to the time given to teaching and research. It is possible that some plan similar to the profit-sharing plans of our most highminded business enterprises could be worked out, which would emphasize the essential team-work of modern hospital care of private patients; but I dread any arrangement which increases the importance of the private ward service of the hospital. 4. Entire freedom for every member of the staff to develop into practitioner, consultant, teacher or investigator, as may best suit his bent, each to contribute to the department what he can give; but original appointment, reappointment, and promotion alike to be for true university accomplishment. Here is where the ideal must be enforced, not by prohibitions and the limitation of freedom. 5. The one distinction which I would make from ordinary university practise is based upon the fact that the hospital clinic is in the nature of a monopoly put into the hands of the professor and which contains the potentialities of exploitation for private gain. This should not be tolerated in a university. Neither should exploitation of the professor by his institution be possible. In my opinion abuse of their positions by clinical teachers can be most easily controlled by making all appointments term-appointments, not even the professor to hold his chair for life. The reason for life tenure for the university professor is, that the older he grows in the university service, and the more valuable in his devotion to his subject, the less capable he becomes of earning his living in any other way. The professor of medicine or surgery, on the other hand, by virtue of his very position, acquires an increasing money value. The more illustrious he becomes, as the university should wish him to become, the greater is his potential earning power. If he is free to make his choice, it is no hardship that at the end of each three to five years it should be possible for the university to say to him, "You have demonstrated that your days of true university usefulness are over, and you must go out to that practical success which you have made certain by your career with us, and a younger man must take your place." This will not rob the community of the mature judgment of men who may have lost any great power of original research, and it will work no hardship on any individual. Furthermore, it will be consonant with that true academic freedom, without which scholarship and search for truth and for mastery over nature will certainly languish. In conclusion let me say that I have taught in three medical schools and in four hospitals, and have been an unpaid instructor, a professor giving part of his time to consulting practise and a well-paid, full-time teacher: therefore, I can speak from some personal experience. I know that the conduct of a large clinical department along university lines requires a man's best thought and effort. Only a small fraction of his time can he spare for outside engagements, professional or other. He must give to teaching and administrative duties, to his staff and his wards, more time than any of his colleagues in the university devote to routine, and he must keep up with an enormous literature and do research besides. To earn any considerable part of his own living is manifestly impossible. But as well say that he must not be a good musician, or a devotee of chess, as to insist that he must never sharpen his wits on a case that has puzzled some physician outside the hospital who wishes his help. If he is to do this, it is unnatural and repugnant to the patient's sense of justice that he should not receive the usual fee for such service. No inconsiderable part of my own knowledge of medicine, upon which I now draw in teaching, has been derived from just such outside engagements. Without them I should today be a far poorer educator of physicians. Had the time I gave to them been devoted to laboratory investigations, it is possible that I should have contributed more to medicine, and should now conduct a more productive clinic, but it is by no means certain. The true investigator is born, not made. He should be shielded from harm at any cost when he is young. Seldom is it wise to burden him with even the executive duties of the head of a department. There should be a place for such rare men in clinical departments, and ample money to support them. For the rest, one man may be valuable to the clinic because of his ability to train students in methods, another for his encyclopedia knowledge, a third for his suggestiveness. Specialists are vital to progress, but all-around men are indispensable for sane teaching. The widest variety of interest will create the strongest department, and men of varied interest can not be produced by any single type of training. For this reason I am of the opinion that, if the liberal support for research provided by the whole time plan could be secured without its limitations, the ends of medical education would be best served. If some men are lost to the university in their prime, none need be kept to outlive his usefulness as a teacher. The clinic might have a younger head, but it would always have his best years. Some men will cut off all outside engagements from choice, and some clinics will require all of the professor's time during the academic year. I would conclude, therefore, that outside professional engagements may be desirable for most members of medical faculties at some period of their careers, and that clinical teachers who engage in some outside practise are necessary in any scheme of medical education. Uniformity of environment is not the distinctive feature of the university, but unity of purpose. JOHNS HOPKINS UNIVERSITY THEODORE C. JANEWAY V NEW DEMANDS ON SECONDARY SCHOOLS THEIR ADAPTATION TO WAR AND AFTER-WAR The secondary schools of the United States have become such an essential part of our democracy and its aims that the disturbances and disarrangements necessarily brought about by the somewhat sudden transition from peace to war can not fail to be reflected in these schools. Our country is just beginning to bend its gigantic energies to the task, and already the effects are felt at home. Hundreds of thousands of young men in all walks of life are enrolled in the prosecution of a stupendous enterprise; strength of brain and brawn is withdrawn from countless tasks and devoted to the immediate and most important object of success. Labor is drawn into new fields in overwhelming numbers; all along the line vacancies result. The gaps need to be filled. Increased production becomes mandatory. Whence comes the deficit? From female help; from the increased productivity of cooperation; and from the rising generation. In all branches of industry and business there has taken place a "moving up" process, with the result that the newspapers are filled with advertisements calling for "boys with a fair education." The Department of Education of New York City has already reported a falling off in registration to the extent of 8,000 children in secondary schools. Before many more months elapse one may expect a still further reduction; especially since the rising cost of living and the withdrawal of adult bread-winners will impose greater burdens upon families, with the consequent result that children must be withdrawn from school for the purpose of increasing the family income. |