Ernest Henry Starling: medical educator.

Medical education in North America changed dramatically during the late nineteenth and early twentieth centuries. Although American medical schools had begun to establish ties with major universities in the 870s,1 few physicians in this country had any meaningful exposure to high quality basic science. According to William G. Rothstein,2 there were 65 medical schools in 860, 75 in 870, 00 in 880, and 60 in 900; in fact, 457 medical schools actually opened during the nineteenth century, but many were short-lived and about 50 were fraudulent.3 Admission standards shortly after the Civil War were often nonexistent1 and most medical schools did not require a high school diploma.2 The standard course of instruction consisted of two identical four-month series of lectures, the second term repeating the first,1 and examinations were usually brief, casual and perfunctory. The Johns Hopkins Medical School, which opened in 893, “became the single most potent influence ever for the dissemination of scientific medical education in America.”4p75 and provided a model for the modern academic health center. With its solid link to the parent university, Johns Hopkins exerted a strong influence on Abraham Flexner, who was commissioned by the Carnegie Foundation for the Advancement of Teaching to review the state of medical education in the United States and Canada. During 909 and 90, Flexner visited all of the 55 medical schools then open in the two countries and wrote a scathing report that exposed the uneven standards of American medical education. Described as “a highly explosive document,”3p980 the Flexner report detailed the sorry state of most American medical schools, which had “multiplied without restraint, now by fission, now by sheer spontaneous generation.”5 The Flexner report forced the closure of many weaker schools and emphasized the role of the university in medical education. An important corollary to its recommendations was strengthening of the ties between clinical training and the basic sciences that were begining to flower at the turn of the twentieth century. The alliance between medical schools and universities begun in the nineteenth and early twentieth centuries exposed American medical students to the high quality basic science that contributed to a century of discovery that has armed the modern physician with a solid understanding of disease. Today, as medicine enters the twenty-first century, we are witnessing a new revolution: the increasing impact of molecular biology on clinical practice. In seeking how best to familiarize students with a rapidly changing basic science in preparation for a career in medicine, it is useful to look back to the turmoil in medical education a century ago. This article reviews the contributions of Ernest Henry Starling, a leading British physiologist during the first decades of the twentieth century, who was a powerful advocate for strengthening the ties between medical education and university-based science.