Page:Carnegie Flexner Report.djvu/114

96 and fourth year students in clinical work is severely reprehensible, -an infallible indication of deficient clinical material, imperfect teaching organization, or of both. As for the rest, there can be no fixed rule. Important, mainly, is it that the student be brought into immediate and increasingly responsible contact with the disordered machine.

Let us consider briefly the dispensary first. The classes are divided into small rotating sections, each with regular appointments in every one of the dispensary departments. The sections, in charge of separate instructors, should not contain more than ten students apiece—rather fewer would be even better. The student is trained at once to take the patient's history, to make the physical examination, to examine blood, sputum, etc., and on the basis of all the facts thus amassed to make a diagnosis and suggest a course of treatment. The instructor stands by, to correct and to stimulate by question, criticism, or suggestion. Everything is a matter of record, and the student's work is thus part of, in a sense the basis of, the complete dispensary records. In the surgical out-patient department, bandaging, stitching up a wound, administering anesthetics, quickly fall to his lot. Schools favorably located in large cities are able to develop considerable out-patient obstetrical work. Thus the student not only amplifies his experience, but learns to combat the conditions under which he will subsequently be called upon to work. He should, of course, in justice to his charge, be accompanied by an instructor, though in the weaker schools this is by no means always arranged. Even so, however, out-patient obstetrical work, though an experience, is not a discipline: it does not dispense with the necessity of careful training in method under ideal hospital conditions. The young physician will never learn technique and the importance of technique properly except in the maternity hospital; having learned them there, his problem in practice is to secure the essentials even amidst the most unpromising environment. In certain of the specialties—dermatology, ophthalmology—the bulk of the direct instruction received is in the dispensary service. To some extent, of course, the conditions observed in them come under repeated observation in the medical clinics of both third and fourth years; full mastery of a specialty belongs of course to the postgraduate years. But the student must be sufficiently at home to help himself in emergencies and to know when and whence to seek further assistance.

The fourth year is spent in the hospital under precisely the same conditions. The class is again broken up into small groups. Each student gets by assignment a succession of cases, for a full report upon each of which he is responsible; he must take the history, conduct the physical examination, do the microscopical and other clinical laboratory work, propound a diagnosis, suggest the treatment. For this