Page:Carnegie Flexner Report.djvu/124

106 with astonishment, if not with resentment, that facilities made up of insecure and disconnected privileges scattered here and there through the hospitals, public and private, of a community now large, now small, do not satisfy the fundamental requisites of clinical discipline surpervening upon modern laboratory work; or that a surgical clinic is no substitute for a clinic in internal medicine. The regeneration of clinical education is therefore apt to proceed somewhat slowly: the sources from which well trained clinical teachers can be drawn are few; the places in which they can be freely utilized are equally restricted. Students trained in the laboratories on modern lines enter clinical departments still more or less unconverted. The result is at best a half-result, yet upon it progressive amelioration in large measure depends.

Once more a few schools meet the specifications set forth in the preceding chapter. We there urged that the backbone of clinical instruction must be a pedagogically controlled hospital best developed on its medical side. The exact status of the hospital may indeed vary: a proper footing has been obtained now through coördinate and coöperative endowment, again through state support in connection with the state university, at times through a really effective affiliation. The crucial points are these: (1) the hospital must be of sufficient size; (2) it must be equipped with teaching and working quarters closely interwoven in organization and conduct with the fundamental laboratories of the medical school; (3) the school faculty must be the sole and entire hospital staff, appointment to which follows automatically after pointment to the corresponding school position; (4) the teaching arrangements to be adopted must be left to the discretion and judgment of the teachers, subject only to such oversight as will protect the welfare of the individual patient.

As long ago as 1869 the department of medicine of the University of Michigan began in a remodeled dwelling-house, capable of accommodating twenty patients, the development of a university hospital on fundamentally sound lines. From this modest beginning a teaching hospital of two hundred beds has now grown up, every patient available for the purposes of instruction, in so far as his own welfare permits. The staff of the hospital is the faculty of the school; the ward service in his own department is the laboratory of the professor. Ward rounds and amphitheater clinics are used for demonstrative teaching; but, better still, students are assigned to individual cases, which they work up at the bedside and in the clinical laboratory. An isolation ward is provided for infectious diseases; a lying-in ward is administered by faculty obstetricians and senior students; recently a psychopathic hospital, thoroughly modern in construction and management, has been made available. Difficulties, of course, of a serious nature have been encountered; the state by a liberal policy has minimized them. Ann Arbor is a small residential town; it is necessary to attract or