Medicine, Harvard and Yale: One Problem, Two Answers

In 1907 the late Dr. Harvey Cushing, the foremost brain surgeon of his era, declined an invitation to join the faculty of the Yale Medical School on the grounds that its hospital was "no damn good." Five years later Cushing came to Harvard as Professor of Surgery and remained in that post until 1932, when he reached Harvard's retirement age of 62. When Dr. Thomas F. Fulton, Professor of Physiology at the Yale Medical School, heard of his retirement, he rushed to Boston to offer him a professorship in Neurology at Yale. Cushing immediately accepted.

Many of the problems which faced the Yale Medical School when Cushing made his first, brusque refusal of their teaching offer have been solved since the 1930's. Other dilemmas have arisen and now face medical schools throughout the country.

George Packer Berry, Dean of the Harvard Medical School, has pointed out that "the period from 1910 to 1950 is referred to so often as the 'golden age of medicine' that I sometimes wonder if we have forgotten that all that glitters is not gold." The inundation of a teaching programs by a tidal wave of new facts tends to submerge the medical student and to obscure for him the principles of medical science.

The difficulty is one of developing students' education on two fronts, Berry said. The first is the factual background essential to good medicine; the second is the perspective and creativity necessary to treat patients as human beings with complex sets of problems, rather than as isolated sets of symptoms.

In addressing themselves to this problem, the Medical Schools of Harvard and Yale do seem to agree that the scientific content of a doctor's training must crowd his education out of the picture. "The Medical School must not be a trade school," Dean Berry has said, for "medical education is good only when it is good education."

Teachers, then methods

Harvard and Yale also seem to agree that no curriculum or method of instruction can be any better than the men who implement it. "If one thing has been learned from our experiment over 30 years," said Vernon W. Lippard, Dean of the Yale Medical School, "it is that teachers and their attitudes are more important than curriculum structure and methods."

Apart from their agreement on fundamentals, however, the two Medical Schools have developed widely differing approaches to medical education. "The Yale Plan," which has evolved over a period of 28 years, is particularly unorthodox in four respects.

In the first place, Yale is the only one of the nation's 80 medical schools which requires a doctoral dissertation based on original research. By the end of his third year, at the least, each student presents an original hypothesis to the faculty member under whom he chooses to work. From that point on, the School provides facilities and guidance exactly as it would for any other graduate student.

While the quality of the dissertations varies widely, "many, perhaps ten per cent over the years, would be acceptable to the same pre-clinical department if presented by its candidates for the Ph.D. degree," according to Dean Lippard.

In answer to those who feel that the time of the students would be better spent if they saw more patients instead of working on research, Dean Lippard contends that "the four-year period as a medical student is the time to develop attitudes and to gain basic knowledge. Experience in dealing with large numbers of patients will come later." Since Yale also hopes to give many students the incentive to enter a career in academic medicine, it strongly encourages those who wish to engage in additional research.

Although Yale students normally get their degrees in four years, the School does permit them to take up to six years. Many, when they become interested in a particular research project, take a year or two off to pursue it further. At present, for instance, five men who have completed their first two years of Medical School are spending this year investigating some aspect of medical research.

A second unique aspect of the "Yale Plan" is the absence of required examinations. Although exams are offered two or three times during each course to aid the student in review and self-evaluation, not a single course requires them. Faculty members simply present reports on each student at the end of every course, and since almost all instruction is carried out in small groups, Yale feels that faculty members are acquainted with each student intimately enough to evaluate his work. "Frequent examinations," says Dean Lioppard," "are not only undesirable but are unnecessary."

Tests and competition

The only tests with everyone does have to take are those of the National Board of Medical Examiners. Students may present themselves for these two tests, which cover pre-clinical and clinical medicine respectively, during their second or third year. Yale strenuously attempts to eliminate an atmosphere of competitive strain, even on the National Board exams, and does not base recommendations or awards on the scores which students make.

This absence of excessive competition has helped to create a sense of casualness among the Yale students which many observers find lacking in the exam-ridden, tense and intense Harvard environment. The Yale attitude may be augmented next fall with the completion of the Harkness Memorial Hall, which will have accommodations for 300 students, including also a sundeck, small gymnasium, and lounges and club-rooms, Hitherto many Yale students, like Harvard men at present, have been forced to live in rooming houses because of inadequate dormitories.

A third respect in which the "Yale Plan" is unique is the lack of fixed course requirements. Students who can demonstrate competence in the field of knowledge covered by a course are encouraged to accept special assignments, such as participation in instruction or research in the field, or ore excused from attendance and given additional time for elective work.

Electives emphasized

Finally, the "Yale Plan" is unique in its emphasis on elective courses. "It has been a basic policy in this programs," Dean Lippard has said, "that the student should not be under such pressure to attend required exercises from eight to five daily for four years that he has no time for pursuit of special interests." The Medical School has therefore included fewer than the usual scheduled hours in the curriculum. The student may choose to attend several electives or none, and he receives no credit. The brilliant student may take as many as he is interested in, and the man who learns slowly may spend additional study in the basic courses.

While many of the elective courses are highly specialized, Dean Lippard points out that intimate contact with a faculty member whose investigative interests have carried him into a limited field can be an exciting experience for a student; "and we believe," he says, "that he should be excited as well as taught."

But despite the unorthodox features of the "Yale Plan," Dean Lippard insists that "there is nothing unique or ingenious about it. The material covered is in most respects similar to that in other American medical schools, and the methods of instruction are those which have been considered satisfactory in fields of graduate study other than medicine for centuries."

Harvard balanced

If the essential emphasis of the Yale Plan is stimulating of students' incentive to learn, coupled with an unusual degree of freedom to pursue their interests, Harvard may be said to emphasize the development of prospective doctors as creative, liberally educated men capable, in Dean Berry's words, of "curing the patient and not just treating the disease."

To achieve this aim, Harvard places strong emphasis on the enormous and varied hospital facilities at its command. As at Yale, the first two years of the student's program are concerned chiefly with pre-clinical training in such subjects as anatomy, pharmacology, and physiology, while the last two are devoted to the actual care of patients in hospitals. Pre-clinical training is relatively independent of the environment in which, it is undertaken, but clinical training requires well-equipped hospitals.

Harvard is especially fortunate in being located in Boston, since the city has long been noted for a strong tradition of medical excellence and outstanding hospital facilities. The Medical School shares in the use of 14 of these hospitals, which have a total bed-capacity of 4053, 922 of which are available for teaching purposes. Four hospitals--the Massachusetts General, Peter Bent Brigham, Children's, and Boston Lying In--are affiliated exclusively with Harvard. They have a total bed-capacity of 1702, 1098 of which are always available for teaching.

It would be hard to overemphasize the importance to the teaching program of Harvard's 257 full-time and 624 part-time instructors. The latter, in particular, provide the student with a working knowledge of the economic, social, and personal problems of patients. The part-time instructor, moreover, is more plentiful in large cities.

Perhaps the most unique feature of Harvard's medical program is the stimulating rivalry between the hospitals. Since Harvard students apply to take their clinical training at the hospital of their choice, the hospitals compete to attract outstanding students with outstanding doctors.

Yale facilities

It would be a misconception, however, to assume that merely because New Haven is smaller than Boston that the medical facilities open to Yale are automatically inferior to those of Harvard. Grace-New Haven Community Hospital,1