PREFACE
I began writing the following pages in summer 1965 by constructing the table of contents that appears below unaltered. It was one of the low points in my life and the lowest point of my academic career. Asked to leave the University of Illinois—the only failure in my otherwise reasonably satisfactory academic career—I gratefully accepted a position in Boston University philosophy department created for teaching a summer-semester course in the history of medicine in Boston University School of Medicine in a new accelerated experimental course in medicine. I did not know where to start: the program was hardly developed and I had no background in medicine, in the life sciences, or in their history.[1] My family was absent; I was between homes, staying in a flophouse, with no acquaintance, no books, idling before the semester start. I waited for the semester to begin. Sitting on a bench in a park, I designed the table of contents that appears below to keep myself busy.
The course in the history of medicine that began soon after, incidentally, had an inevitably disastrous ending—due to the poor planning of its place in the curriculum and the excessive submission that medical schools notoriously impose on their students. Unprepared, I expected the students to participate. They were engaged in full-time summer jobs in the school’s hospital. Overworked, they fell asleep in class, as my course was sheer bonus. Also, my teaching was too unusual: I tried to help them learn to write and to develop some theoretical interest when their other courses were crowded with practical information. In addition to smatterings of the history of medicine, I offered rudimentary basics in natural science, particularly biochemistry and nosology (theory of disease). In my second summer there, I faced a rebellion. The students were at a loss: they had no social skills and I had to chair their meeting against me. Their dean, alas, quashed their rebellion without a hearing: he insisted on unconditional submission. Alienated from faculty and students, I resigned. Fortunately for me, the head of the department of philosophy rejected my resignation and won my profound gratitude.
My medical-school experience left me with a part of a first draft of this work. Very negative responses to it made me take a break from writing it. For half-a-century, other business kept me away from it. I am still skeptical about its value, but I like the challenge to keep its youthful exuberance. I cannot judge how outdated it is, as this invites field-study. I think it is regrettably still hardly outdated—as medical education is inflexible.[2] A 1954 American medical-school field report says, no American medical school was planning then any change of curriculum or teaching method.[3] It had then only one professorship devoted to medical education (in the University of Chicago). Its occupant did not respond to that report, he told me, because that reform was an ongoing process. Yet it follows no plan.[4] Any mention of a reform of the American medical education system met with a pious reference to the Flexner reform of the early twentieth century, as if he could object to further innovation. His reform altered anyway. Here is one item of evidence: a recent lead-article in Transactions of the American Clinical and Climatological Association. It says,[5]
Both medical school education (UME) and graduate medical education (GME) for decades have been perceived to be not as coherent or as well structured as they could or should be. Kenneth Ludmerer, in his now classic study of the history of medical education, Time to Heal [1999], showed in painful detail how medical education slowly took a back seat in medical schools and academic health centers (AHCs), first to the focus on the research enterprise and then, more recently, to the focus on re-engineering the clinical enterprise. With professional development and faculty rewards geared towards research and patient care, the education of medical students and the training of residents and fellows went into the academic equivalent of “automatic pilot.”
I will leave all this for a later discussion, except for two general points.
1. Flexner wanted medical students to have some broad education. To that end, he ruled that they acquire bachelor’s degrees first. Courses for this degree became strictly pre-medical.
2. Innovations, especially organ transplants, raised new moral problems. Medical outfits appointed in-house consultants on medical ethics. Soon the job ceased to be full-time: it became an additional task for professors whose job-descriptions wanted a boost.
The next great reform in academic education after Flexner took place in France. It was utterly unplanned as it came as a response to the students’ revolt (May 1968). The greatest discussion of academic education at the time was in Britain, in two detailed, competent, official reports on it: the Robbins Report (1963) and the Rothschild Report (1971) that generated a literature on the topic. The changes that they recommend that are relevant to this study appear below in detailed discussions.
An obvious recent important change in Academe, concerns discrimination (mainly by skin-color, religious affiliation and gender) as well as sexual harassment. Neither is particular to Academe. (The entertainment world comes nearer to this position.) Although these pages discuss injustices, it overlooks these. Let me say a few words on them here, as a mere token.
Discrimination causes untold damage.[6] Exploitation looks tempting. This is an illusion: as Adam Smith said, it is too costly, since cooperation is more beneficial all round. Karl Marx agreed. Popular though he is, this view of his is not. Advocates of unbridled competition claim that the market will reach freedom from discrimination fastest. It did not. Excuses for this defect amount to toleration of discrimination.[7] When laws against gender discrimination appeared, many employers circumvented them by falsely declaring inferior jobs gender-specific.[8]
You might expect that since academics are better educated than the average citizen is, and since Academic discrimination is costly, the contribution of Academe to the struggle against discrimination should signify. As it is supposedly a pioneer in the struggle for progress, it should be a leader in in that front. To some extent, it is, but its overall record is not what it could and should be. Except that—since discrimination rests usually more on ignorance than on malevolence—all education helps fight it indirectly. I belonged to a minority group—the Jewish people—that suffered violent discrimination that defies the wildest imagination (in and out of Academe). By contrast, the nation I belong to—Israel—excels these days in the discrimination against its own citizens—women, non-Jews and blacks—thus shamelessly defiling the impressive time-honored Jewish record of valiant support and of struggle for justice and humanism (Exodus 21:23; Deuteronomy 21:17). Israel’s current government exploits Academe craftily to further its agenda. Most Israeli intellectuals find this atrocious but are scarcely able to fight it, since there are so many excuses for the Israeli official identification of civil society with traditional congregation that imposes the religious discrimination that deprived of religion proper becomes racist unintentionally but unavoidably. It is hard to expect Israeli Academe to support reform in national affairs before the implementation of some urgently needed reforms in Academic education. But I anticipate myself: this is the topic of the very conclusion of this study.
Medical education today differs from all other parts of higher education in its taking apprenticeship as a part of education; this is due to a complex system of cooperation between medical education and practice. The reform of medical education must involve a much wider social setting than other parts of higher education. For this, I can only direct the interested reader to studies that concern aspects of the system wider than I can consider here.[9]
The only change within Academe that is possibly relevant to the present concern is within philosophy: its improvement is (or will be) due to the current (or future) increase of the recognition of the fallibilist, liberal studies of my teacher Karl Popper. When I began writing these pages, the philosophical literature generally overlooked his output. The exceptions were some baffling denunciations of it and some occasional backhanded compliments. This altered significantly after he died. An interesting comment that semi-officially recognizes change appears as late as in 2016—in the Notes and Records of the Royal Society.[10] It mentions the election of Popper for a fellowship of that Society as a counter-balance to the Rothschild Report, I cannot judge with how much justice.
— Herzliyah, Israel, Summer 2020.
[1] I owe the job offer to my publication, Towards an Historiography of Science, History and Theory, Beiheft 2, 1963; facsimile reprint, Middletown: Wesleyan University Press, 1967; reprinted with corrections in my Science and Its History, Boston Studies in the Philosophy of Science, Vol. 253, 2008. To check the appointment, the faculty of medicine interviewed me. They did not believe my confession of ignorance, since I spoke there of the episode in the history of medical research that I was familiar with—having been involved in it as a patient—and since by sheer luck I guessed correctly what book a faculty member very vaguely referred to.
[2] Sharon A. Levine, “Boston University School of Medicine”, Academic Medicine: 2010 85: 265-8.
[3] Vollan, Douglas D. “Preview of Principal Findings of American Medical Association Survey of Postgraduate Medical Education.” Journal of the American Medical Association 155.4 (1954): 389-392.
[4] Larry Cuban, How Scholars Trumped Teachers: Change Without Reform in University Curriculum, Teaching and Research, 1890-1990, 2000.
[5] Transactions of the American Clinical and Climatological Association, 2005; 116: 311–320, 311.
[6] Adam Smith suggested that perfect competition precludes discrimination. He tried to explain why most societies are les advanced than the Europeans. this led him to options that are these days deemed racist. the same happened to pioneering anthropologist Lewis Henry Morgan. Edward Said became popular as he declared almost all western studies on non-Western cultures. the problem, however, will not go away: why are some societies better off than other?
[7] My Art. “Discrimination; Statistical” in International Encyclopedia of the Social Sciences, 2nd edition, Macmillan Reference USA, 2008.
[8] Judith Buber Agassi, Women On The Job: The Attitudes of Women to Their Work, 1979; Comparing the Work Attitudes of Women and Men, 1982.
[9] Yehuda Fried and JA, Psychiatry as Medicine, 1983; Nathaniel Laor and JA, Diagnosis: Philosophical and Medical Perspectives, 1990.
[10] Neil Calver and Miles Parker, “The Logic of Scientific Unity? Medawar, the Royal Society and the Rothschild controversy 1971-72.” Notes and Records of the Royal Society of London 70.1 (2016): 83-100, 88.
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