Summary of ‘The Evolution of Medical Education and Licensing’
by Robert Craig
Phyllis Allen wrote on The Evolution of Medical Education and Licensing 1540 – 1858 (Vol 1 No4, JHMAS). It outlines the way medical education and medical practice has developed in Britain and the Commonwealth which influences the present structure of health services in Australia. I added a paragraph to include the role of the Society of Apothecaries in the origins of modern pharmacists and general practitioners which had been omitted by Phyllis Allen. Variations in the USA and Europe, as well as developments in more recent years with the globalisation of the medical market come from a recent paper by Eugène Custers and Olle Cate: The History of Medical Education in Europe and the United States, With Respect to Time and Proficiency Academic Medicine March 2018; vol 93.
Such a history offers explanation for many assumptions underpinning regulations regarding training, practice and provision of health services in Australia. Before the seventeenth century medical education in England was dominated by the two universities, Oxford and Cambridge. The method was Mediaeval Instruction through study of theological commentary and verbatim knowledge of the classical texts (especially Hippocrates and Galen). Scholarship was assessed by capacity to argue and debate these texts with no practical exposure to disease or surgery. This system provided significant income for the universities but few useful physicians and no surgeons or apothecaries. Those who wished to practice medicine studied abroad especially at Padua and later in the protestant Dutch Schools such as Leiden. However, to practise in England applicants had to obtain university degrees at considerable expense and with bureaucratic hurdles called incorporation. Henry VIII who reigned from 1509 to 1547, not only broke with Rome and created the Church of England, but also took on the Universities’ unregulated control of ineffective medical education. He licensed the Royal College of Physicians in 1518 to raise standards and founded practical medical training by establishing three medical lectureships and Regius Professors of Physic in Oxford and Cambridge. He compelled them to include teaching dissections at regular intervals in their courses and made the initial steps of unification between surgeons and physicians by requiring Barber Surgeons to provide the bodies and dissection demonstrations in this ‘Elizabethan Code’ of medical training. Contemporaneously John Caius founded 20 lectureships at his college (Gonville) in Cambridge.
Surgeons had followed a different route. Arising from a split from the Barber’s Guild in1368. Henry VIII formalised their right to incorporation to practice in 1540 by giving a charter to the Company of Barber Surgeons. However, the absence of a pragmatic time-limited curriculum ensured that there was little change and students still had to go abroad to study medicine. A report in 1623 showed all Henry’s regulations were being ignored. Charles I tried to reform the code of practice, with the help of Archbishop Laud, to ensure demonstration dissections but the ‘Caroline Code’ continued to require Galenic and Hippocratic study whilst adding more practical medical instruction. This had the unfortunate effect of extending the time to graduate MD to fourteen years, much of which was spent in outdated study. However, it remained profitable to the universities and ensured long incorporation lists and large fees but the requirement to study overseas
persisted and surgery and physic continued as a separate trade and profession. However, by 1663, Gresham College, an institution funded by the City of London financiers and merchants in cooperation with the newly formed Royal Society with its many Physician Members, was incorporated to enable the licensing of Physicians. This allowed the scientific and philosophical glitterati who founded modern medicine in England such as Willis, Wren, Radcliffe, Harvey, Bacon and Hobbes to lecture small groups of students and offer demonstrations with the intent of producing empirically inspired doctors . They promoted scientific interest, observation, research and the drive to collect and classify against the prevailing rigid but profitable conservatism of the day. The surgeons were granted the right to license as practitioners in 1745 and by 1820 St Thomas’s, St Bartholomew’s, St George’s and The Middlesex Hospitals had private schools attached to teach would be practitioners with or without a Doctor of Medicine degree.
The Society of Apothecaries arose out of the Guild of Pepperers, but it was not until 1617 that it split from the Grocers Company. Many members were likely to have gained knowledge of the characteristics of materials from involvement in alchemy and examining biological fluids chemically. It was they who held the right to prepare medicines independently and by prescription of physicians. This was the guild which developed into pharmacists and the future General Practitioners, whose previous apprenticeship training was beneath the dignity of university recognition. The Society of Apothecaries gained the right to license medical practitioners in 1815.
However, it was not until the 1830s that apprentice surgeons were required to have a medical license before commencing surgical studies. In 1858 the Medical Act codified the requirements for the institutions who could licence medical practitioner with the aim of a designing and overseeing a training that would provide a safe practitioner on graduation. Pharmacists were excluded from medical practice by this act, and dentists continued to practice without licence or regulation.
In Europe gradual change occurred from similar origins by different routes. The conflict between practical competence, reputation and experience and the scholarly university study of classical learning and commentary was evident, though contact with the millennial golden age of learning in medicine and mathematics from Arabia was more likely to percolate through from the South with the Islamic control of North Africa and the Iberian Peninsula.
France followed a similar path to England and Scotland. Germany and the Netherlands, (possibly due to the more radical reformation) focussed less on the old ways and university regulations and degrees. They were more influenced by competency through experience and apprenticeship. They assessed their students by the recommendation of their masters and patients but the concept that exposure was sufficient rather than a testing of competence allowed for much variability in the years and quality of training. As a new country the United States started with little or no regulation. Unlike Europe, medical training was developed piecemeal often only requiring brief apprenticeships, usually but not exclusively, in hospital. Until the twentieth century there were no nationally accepted experiential or academic qualifications needed to obtain a licence to practice through one of the numerous competing institutions. William Osler (1849-1919) at Johns Hopkins Hospital in Maryland was arguably the founder of the gold standard to be followed by the rest of the world through a structured postgraduate residency training of seven or eight years in a well-funded teaching hospital. This innovation leapfrogged through the idea arising from 1858 of making a doctor safe to practice independently on graduating. Osler introduced the concept of competence testing of practical procedures particularly for special roles.
Since 1950, with the development of an international market for medical professionals there has been increasing standardisation of the content of training and competency in identified professional activities and academic knowledge in addition to requirements for a good professional standing. The expansion of technology as well as biological sciences and the dependence on other health practitioners in the provision of health services suggest it is time to reconsider a root and branch reform comparable to the Elizabethan Code of Henry VIII or the 1858 Medical Act to train personnel to service the complex needs of individual and public health services and to consider whether the aim to provide a safe practitioner using a single core training has outlived its usefulness.