States. Some boards have the legal power to establish such relationships, but arbitrarily refrain from doing so, thereby placing an undue hardship on physicians who desire to remove to or from those States. Based on the instances in which reciprocal relations have been established, the physician's chance of becoming re-registered without further examination is about one in three. In actual practice, however, his chances are much less than that, owing to the other conditions which State boards are compelled to fix because of the wide variance of standards. Such conditions by State boards are very essential, however, since a poorly administered rule regarding reciprocal registration would seriously lower educational standards. Universal reciprocity will be impossible so long as such widely varying standards of medical licensure are maintained. Meanwhile, thousands of physicians are annually subjected to an unnecessary hardship. It has therefore been suggested1 that an examination given under Federal authority, without infringing in the least on the examination given by the various States, would in time come to be cheerfully accepted by the States as sound proof of the qualification of the physician who passed it. The nearest approach to such an examination at present is that required of medical officers in the United States Army, Navy, and Public Health Service. Such an examination might be thrown open to any physician on payment of a reasonable fee, whether he is to serve as a Government official or not. Eventually, no doubt, all the States would recognize this Government examination. In five States at the present time those who have served as officers in the Government medical service are eligible to receive licenses without further examination. These States are Alabama, California, Colorado, Illinois, and North Dakota. There still remain 8 States in which there are two or three boards, instead of one, concerned with the licensing of physicians. These States, and the number of boards in each, are: Arkansas, 3. District of Columbia, 3. Louisiana, 2. Maryland, 2. The authority of the two boards in Delaware is centralized in a medical council; that of the three boards of the District of Columbia is centralized in a board of medical supervisors; and that of the three boards of New Hampshire, in the regent-the State superintendent of public instruction. In the other 5 States, however, the entire machinery for examining and licensing physicians is duplicated or triplicated and placed in the hands of two or three separate and independent boards. This confusion has repeatedly resulted in a prac 1 "The Use of the Government Medical Services in Raising the Standard of Medical Education," Quar terly of the Federation of State Medical Boards of the United States, April, 1914, p. 235. tical annulment of educational standards. It has repeatedly happened that candidates who could not secure licenses from one board have readily passed the "examination" of another. STANDARDS OF MEDICAL PRACTICE. The question of the standards of medical practice is educational. In effect the State asks: Has the practitioner had the training by which he is enabled to recognize the disease he is called upon to cure? If not, his treatment is mere guesswork and is as apt to do harm as good. Successful treatment of any disorder depends largely upon an accurate knowledge of what is causing that disorder. In all leading countries it is recognized that to secure an adequate training in diagnosis and treatment of diseases requires hard study for five or six years beyond the high-school education-this training to be secured in well-equipped laboratories, in dispensaries, and in hospitals. Such is the training now required by the majority of the medical colleges in the United States. Dr. F. M. Crandall, of New York, states the case as follows: * * * The medical laws are but a part of the general educational laws of the State. These laws are wide in their application, and cover many professions and diverse conditions. There is nothing exceptional in the laws covering medical practice. They are at the farthest possible remove from class legislation. They are simply a part of the great educational system of the State. The medical profession has upheld the hands of the State educational authorities, whose aim has been to enact a broad and consistent system of just and equitable laws. A State educational system has, therefore, been built up, of which the laws controlling medical practice are an integral part. The medical profession approves the system which requires the same general professional education of all its members. The specialist upon the eye and the specialist upon the throat, the physician and the surgeon, must each undergo the same training and must pass the same State examination. One may select any specialty he chooses and may adopt any method of treatment which his educated judgment dictates. He may use large doses or small, massage or electricity. What the State requires for one body of practitioners it should not abate in favor of another. We may properly demand that every man and woman who enters upon the practice of the healing art should have adequate education. Here we are on ground that can not be misjudged or misrepresented. We ask no favors or special privileges. We are not the ones who are seeking to bring half-educated practitioners in by the back door. We simply ask equal requirements for all. RELATION OF MEDICINE TO GENERAL EDUCATION. Medical education is necessarily closely related to, or in a sense a part of, the system of general education. Heretofore, in the administration of entrance requirements the deans of medical colleges had most to do with high schools, which fortunately have been fairly well standardized. Now that medical colleges have advanced their entrance requirements to include one or more years of collegiate work, there comes the question: What is "collegiate" work? It is a well-known fact that there are colleges so called which in reality are teaching little else than secondary school courses. In an effort to prevent the higher requirements adopted by medical colleges from interfering with the proper development of high schools, the Council on Medical Education, in its "Outline of the Essentials of an Acceptable Medical College," has inserted a clause that "college work should not be considered as such unless it has been preceded by a completed course of study in a standard four-year secondary school or its full educational equivalent." It is believed that observance of this rule will aid materially in the administration of the requirement of "college work." It will at once eliminate the short-cut secondary school colleges which endeavor to crowd the work of several years into three or four and, it is hoped, will help in the work of standardizing our colleges of liberal arts. The Council on Medical Education is now preparing for its own guidance a list of liberal arts colleges in which courses considered as essential prerequisites to the study of medicine are properly taught. No liberal-arts college will be included in the list which does not require for admission the completion of a standard four-year high-school course or its full educational equivalent. ENTRANCE TO COLLEGE BY EXAMINATION. The weakest point in the administration of satisfactory entrance requirements to medical and to other colleges is in the so-called "equivalent-examination" method. The examination is needed to test the knowledge of the occasional student whose courses in the secondary school are not regularly taken, but who may have covered as much ground as the graduates. This method of admitting students, however, has been taken advantage of by some "colleges" and an "easy" examination has been provided in order to admit large numbers of students who otherwise could not qualify.1 THOROUGH AND RELIABLE EXAMINATIONS ESSENTIAL. The chief evil of the examination method lies in the multiplicity of agencies having to do with such examinations, where there could well be only one in each State. To ascertain the actual value of any 1 The fraudulent methods by which an institution provided credentials for students seeking admission to a medical college in Chicago were discovered to be as follows: A set of questions with the answers filled in were furnished each "student," who was told to take them home, memorize the answers, and return in two weeks to take the "examination," where, of course, the same questions would be asked. In one instance, at least, when the time for the "examination" came around, the farce became even more ridiculous. The examiner deputized the preparatory school officer to conduct the examination; this he proceeded to do in the easiest manner for himself and for the students. Examination paper was given out and the students were instructed to take it home, write out the answers that had already been furnished them, and return the written papers the next day. Thus they did not even need to memorize the answers to the questions asked. Following this farce, nevertheless, these "students" were furnished with affidavits signed in the presence of a notary public, by a county superintendent of schools of an adjoining State, setting forth that these "students" had "passed" examinations in the required branches of the highschool curriculum.-Jour. Amer. Med. Assn., Feb. 7, 1914, p. 477. examination there is a fairly reliable and simple test, which should be applied: Require documentary evidence as to when and in what school or schools the preliminary preparation was obtained. It is practically impossible for a student to pass an examination which actually proves that he has the equivalent of a standard high-school course, unless he can show evidence of four years or more of attendance in secondary schools, private tutoring, or of other legitimate means of preparation. For example, no student could pass a fair examination in algebra unless he has actually studied algebra. So when a student is found to have attended high school only one or two years and yet easily passes an "examination" in all the subjects of a complete four-year high-school course, then it can be seen at once that something is wrong either with the examination or the examiner. A routine method of verification of every credential presented by the student, whether it be a diploma or a certificate of examination, should be adopted by every well-regulated college. In the enforcement of the four-year high-school standard, therefore, the medical colleges have been urged to secure for each student direct from the principal of the secondary school attended, a statement showing the courses taken by the student, the number of weeks covered in each course, the number of periods per week, the length of the period in minutes, and the final grade obtained. This simple routine procedure secures official and reliable evidence of the work done by the student, and without it no accurate idea can be obtained regarding his work. ADMINISTRATION OF ENTRANCE REQUIREMENTS. One of the best evidences that improved standards of preliminary education for entrance to medical colleges are becoming effective is that already fears are being expressed in some quarters that the standards may become so exacting as to hinder some well-qualified students from gaining admission. Most of the "fears," however, have emanated from medical colleges which are conducted more as business enterprises than as educational institutions-colleges whose methods of admitting students have so far exceeded the utmost bounds of "liberality" as to render void any entrance standard. The motives back of complaints from such sources are so apparent as to make the complaints unworthy of notice. In several instances, however, misgivings have been expressed from the most sincere motives, lest the entrance requirements to medical schools be made so rigid as to work a hardship in individual cases. Such statements have made it clear, however, that the speakers were in entire sympathy with the higher standards. Such statements are opportune as a warning rather than an indication that the rigidity feared is already being experienced. In fact, the requirements suggested by the 73226°-ED 1914-VOL 1—————14 Council on Medical Education and other standardizing agencies are not inflexible, and the care of the exceptional cases is purely a matter of common-sense administration. The standard meanwhile is (a) completion of a standard four-year high-school education or its actual educational equivalent and, in addition, (b) one or more years of collegiate work equal to that taken in standard colleges of liberal arts, this collegiate work to include courses in physics, chemistry, and biology. The student is strongly urged also to secure a reading knowledge of French or German. A common-sense, conscientious enforcement of that standard is all that is asked. Legal bodies the State licensing boards, for example-must fix and without discrimination adhere to a minimum requirement, and of course the closer an institution hugs to the minimum line the less room will there be for flexibility. CHOICE OF A MEDICAL SCHOOL. The choice of a medical school by the prospective medical student has perhaps never been so easy in this country as at the present time, since never before has there been so much reliable information available for his guidance. And there has never been a time when a careful and wise choice was so important; never have there been so many pitfalls or misleading paths for the unwary. MEDICAL KNOWLEDGE MORE EXTENSIVE AND COMPLETE. Up to a decade or two ago the training secured in any medical college was deemed sufficient to give the physician a start in his life work. That was before the days of the microscope in the practice of medicine and before the discovery of the microbic origin of many diseases. Then two years of teaching by such odd moments as busy doctors could spare from their practice was not looked upon as inadequate. At the present time, however, medicine is based on scientific knowledge, and without this knowledge the physicians of the future will be a failure. To get this knowledge the student needs a better preliminary education than formerly and must secure his medical education in a college which gives a four or five year course, which has a corps of expert, salaried teachers, expensively equipped laboratories, and an abundance of clinical material in dispensaries and hospitals. STATE REQUIREMENTS MORE EXACTING. Only a decade or two ago anyone was at liberty to begin medical practice in almost all States, there being no provision by law for standards of education or proficiency. Even in the few States in which registration was required almost any evidence of medical |