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Revolution in American Medicine

Until Johns Hopkins opened a century ago, most medical students were taught in "trade schools" which, because they were set up to turn a profit, often accepted high school graduates who would have had trouble getting into a liberal arts college. After two, at most three, years of attending typically repetitious lectures by part-time teachers, students were free to apprentice themselves to older doctors or simply hang out a shingle, even if they had never laid a hand on a patient.

Hopkins earned its reputation by radically transforming medical education and the practice of medicine and medical research. With the opening of the Hospital in 1889, followed four years later by the School of Medicine, Hopkins ushered in a new era marked by rigid entrance requirements for medical students, a vastly upgraded medical school curriculum with emphasis on the scientific method, the incorporation of bedside teaching and laboratory research as part of the instruction and integration of the School of Medicine with the Hospital through joint appointments. The new model also created standardized advanced training in specialized fields of medicine with the creation of the first house staff fellowships and post graduate internships.

To wage this revolution, Hopkins recruited four impressive young physicians, William H. Welch, William Osler, William S. Halsted and Howard Kelly - the so-called Big Four - by offering them rare and tempting research opportunities. The basic scientists and later the clinicians were free to do research by having a full-time salary, a departure from the tradition of employing part-time local practitioners to teach classes.

Another innovation assured higher quality applicants: rigid entrance examinations after prerequisite college education, heavy on basic science - chemistry, physics, biology - and rigid entrance examinations, were expected of all students who ventured into a Hopkins medical school classroom.

Classes were small and involved hands-on training with patients, a departure from the old lecture format. From the start, talented women were permitted to enroll, breaking a prohibition that many older schools held for decades. Medical research by both faculty and students was fostered as part of the educational process and as integral to patient care. The "clinician-scientist" became a Hopkins hallmark.

Study was rigorous and lasted four years, including unprecedented hours of bedside learning at the side of experts, original research projects guided by respected clinicians, and extensive laboratory training.

Then came postgraduate education in the Hospital for interns and residents, an innovation that became the model for the postgraduate clinical education of the 20th century. Hopkins' "products" soon were in demand across the country.

The Hopkins reforms in American medical education were pushed further after 1910, when the Carnegie Foundation asked educator Abraham Flexner to survey the 150 medical schools then operating in the United States and Canada. Flexner found only five that he thought were adequate, and he held up Hopkins as the model.

"The influence of this new foundation can hardly be overstated," Flexner wrote.

"It has finally cleared up the problem of standards and ideas and its graduates have gone forth in small bands to found new institutions or to reconstruct old ones."

In fact, Washington, Vanderbilt, Iowa, Duke and Rochester universities patterned their medical schools directly after Hopkins; Duke went so far as to hire all but one of its first chairmen and chiefs of service from the Hopkins faculty.

In turn, Johns Hopkins had modeled itself largely after German universities, where medical science was highly valued and laboratories were well equipped. Few facilities like this were available in the United States in the late 19th century, but slowly, with Hopkins in the vanguard, the belief spread that medicine would not advance unless doctors were firmly grounded in basic science and applied research methods to the study of disease.

It was perhaps fortunate that the opening of The Johns Hopkins Hospital was delayed for 13 years after the opening of the University in 1876. These years gave Daniel Coit Gilman, the University's first president, a chance to get a program of postgraduate education well established.

The delay also gave William H. Welch, the first professor at the School of Medicine, time to get Pathology up and running before the wards opened. The emphasis on research was well established before a single patient was admitted. The bacteriologic era came into full bloom during those years, as well. Robert Koch discovered the tuberculosis organism in 1881, launching a new awareness of the role of germs in disease, which strongly influenced the practice of medicine.

The School of Medicine opened four years after the Hospital and, in retrospect, this gap, too, was an advantage, for it gave the innovative residency system time to get firmly established. When the first medical students came along, they could easily be incorporated into the wards. One other great benefit emerged from the delays. They gave William Osler the time he needed to write his classic textbook, The Principles and Practice of Medicine.

For years, Hopkins has been the top medical school in the amount of competitive research grants awarded by the National Institutes of Health.

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