In the United States a sentinel occurrence was the Flexner report in 1910, supported by the Carnegie Foundation for the advancement of teaching. Flexner essentially took medical education out of the closet of mystery and outlined the need for trained fulltime academic teachers in medical schools, emphasizing the need for libraries, laboratories for anatomy and science, lecture rooms, and access to a hospital where students could learn by being in contact with physicians treating “real” patients.
Now I won't bore you with more details about the history of the schools because I want to outline for you briefly the education of a physician and surgeon at the beginning of the twentyfirst century. It is important to recognize that, until that last quarter of the twentieth century, most medical students were male, whereas now a significant percentage of women graduate with M.D. degrees.
The requirements for entering medical school vary slightly from college to college, but the basics are pretty much the same. Except for the rare program that combines undergraduate and medical school in a single facility for only six years to the M.D. degree, most undergraduate college students will be required to achieve a Bachelor of Arts or Science degree (B.A. or B.S.) and usually a good grade point average (A's and B's) and in the top ten percent of their graduating class or higher. This does not take into account the many programs established throughout the United States to help minorities get into medical school, and for many years special emphasis has been placed on recruiting African American, Native American, and other minority groups to fill a noticeable cultural and ethnic gap in the physician force of today. Although the premedical courses may stress the inclusion of biology, physics, inorganic and organic chemistry, and zoology, the medical schools are also seeking well-rounded individuals with an additional knowledge of literature, history, English, and philosophy. In addition to the grades of an applicant, the medical schools usually require recommendations from teachers and community leaders and a personal interview, as well as the scores from the Medical College Admission Test. To all this I must add that many Medical Schools only accept 5% of the applicants, and students may have to take further postgraduate studies or work in laboratories or hospitals to make their application “look better” before reapplying. Getting into a medical school is only the first hurdle!
Most medical colleges have a four-year curriculum divided into two sections, the first two years being preclinical, namely, the studying of the science of medicine, and the last two years being the clinical years, where the student learns by being in contact with patients and practicing physicians.
The first year, the student is bombarded with a massive amount of information in Embryology (about the development and formation of embryos), Gross Anatomy (which usually involves dissecting a human cadaver under the careful instruction and guidance of the professor, while memorizing all the parts!), Microscopic Anatomy (seeing what the tissue looks like under a microscope—i.e., brain cells, kidney cells, skin, bone), Physiology (functions of the parts of the body—i.e.,, how a muscle works, why kidneys can excrete waste, how the stomach functions and produces acid), and Biochemistry (the study of the chemistry of life processes, i.e., how cortisone is produced, sex hormone production, thyroid function). And that's not all; the first year student also studies Cellular and Molecular Biology (how things work at the cellular level and, even smaller, the molecular level), Neuroscience (the study of brain and spinal cord, and nerve anatomy and physiology), Genetics (the study of genes, heredity, and variation) and then a broad introduction to medicine and society.
The students that complete the first year (and who don't throw in their marbles and go into some other business) can look forward to the interesting second year and a whole new set of courses. These include Microbiology (the study of microorganisms like Staphylococcus and the germs that cause TB or syphilis or a sore throat), Immunology (your body's defense system to help fight off disease), Nutrition, Pathology (the study of abnormal anatomy — i.e., cancer, pneumonia, diabetes mellitus), and Pharmacology (the study of all the drugs used today, like digitalis, pain medicines, and hormone replacements). Then there's Epidemiology (the study of the causes of disease), Introduction to Clinical Medicine (such as how to use a stethoscope to listen to the heart or lungs and how to use an otoscope to look into ears), Family Practice Introduction, and a course of behavioral sciences. Some programs also have lectures in Alternative and Complementary medicine (modalities including psychosocial interactions and the more unusual nonWestern medical practices like acupuncture, diet therapy, meditation, etc.).
So you've survived the first two years, somehow, and are then ready to see your first live patient. Quite a frightening experience for most young physicians-to-be! The last two years of medical school introduce you to the various specialties of medicine (the surgical ones, which we shall discuss in the next chapter). They are Medicine, General Surgery, Pediatrics, Obstetrics and Gynecology, Neurology and Neurosurgery, Ophthalmology (eyes), Psychiatry, Radiology, Orthopedics, Ear, Nose and Throat (Otorhinolaryngology), Anesthesia, Preventive Medicine, and Urology. Additional studies for the fourth year may include Prenatal Obstetrics, Ambulatory Surgery, Emergency Room Medicine, Geriatrics, and Primary Care.
And you graduate and get your M.D. degrees to the sounds of “gaudeamus igitur” and all that stuff, and usually someone reads the Hippocratic Oath, and now you're a doctor. Unfortunately, those are just the very basics, which don’t really prepare you for much because you haven't had enough clinical experience. Most United States medical students take the National Board Examinations before they get their degree, and this helps them to get licenses in states other than where they went to medical school. But in most cases the new doctors go on to get further training in a specialty of their choice, such as Family Practice, Emergency Room Medicine, Radiology, or a host of other interesting areas. We will discuss the surgical specialties in Chapter IV.
Oh! You might reflect on the fact, that while you are sweating away in medical school, most of your college buddies are well established in some business, making a living, and raising a family. (Some medical students are married, but it creates a great stress on the family, and the husband or wife usually needs to support the student for many years.) It's a difficult period to go through and yet, for the individual fascinated by medicine and intent on helping others, it never becomes tedious or boring. After these four years, the new physician may opt for additional training, so that many doctors don't even start their own practices until they are almost thirty years old!
Chapter 4
INTRODUCTION TO SURGICAL SPECIALTIES
When I was young in college, to feel good I had to lie,
To other guys who often seemed much cleverer than I
So I went off to med school, and determined I would find
A specialty that I could use to give me peace of mind.
And after four hard years I found my niche in general surgery
Where I could talk to patients and not be accused of perjury.
And when I meet old college pals (on benches in the park)
I can truly say I always have the final cutting remark.
When the physician has completed his studies for an M.D. degree, he may decide that he wants to go on into a surgical specialty. This will require him to enter into a postgraduate training program called a residency (sometimes including a first year called an internship) and may spend as many as six to eight more years expanding his knowledge and experience. He is generally taken on as a special