Book Review

Becoming a Physician: Medical education in Britain, France, Germany, and the United States, 1750–1945

N Engl J Med 1996; 334:1275May 9, 1996

Article

Becoming a Physician: Medical education in Britain, France, Germany, and the United States, 1750–1945
By Thomas Neville Bonner. 412 pp. New York, Oxford University Press, 1995. $35. ISBN: 0-19-506298-1

The history of medical education, as Theodor Puschmann observed in his classic account of the subject (A History of Medical Education from the Most Remote to the Most Recent Times. London, H.K. Lewis, 1891), is not only a key to the understanding of medicine as a whole but also an important aspect of the broader history of civilization. If this view is granted, it is strange indeed that we have had to wait nearly a century for a competent successor to Puschmann's often-cited work. In the past 25 years, some excellent collections of essays and several good national histories of medical education have appeared, but no work of synthesis such as this one by Professor Thomas Bonner of Wayne State University has made its way onto our bookshelves.

Bonner, an accomplished historian who has also been president of three universities, has published books about American doctors learning medicine in Germany and the education of women in medicine, among other subjects. This book is a work of considerable scholarship, based on a wide reading of German, French, British, and American sources, and is cogently presented. Whereas Puschmann was concerned especially with the theoretical basis of medicine, hardly ever pausing to probe what was actually taught by professors or learned by students, it is Bonner's great strength to focus on the conditions for learning in the four key Western societies in the two centuries between 1750 and 1945.

Bonner makes a very good case that the late 18th century was far more important in the history of medical education than previously recognized. He clearly describes a turbulent and creative period in the last decades of that century when many of the features we have come to recognize in late-20th-century medical education were taking shape. Clinical education in the medical schools came to take the place of the apprenticeship in all but the English-speaking countries as the 19th century progressed. By the end of that century, as science became increasingly laboratory-based and the theory of medicine could no longer be satisfactorily taught by a preceptor, the apprenticeship had been replaced by the clinical clerkship, a form of apprenticeship in which students work with many preceptors rather than with just one or two. The importance of science has recently been downplayed by some historians of medicine, but Bonner believes it was crucial to the transformation of medical education at the end of the 19th century and even earlier in universities in the German-speaking part of Europe.

A constant refrain in this excellent book is the persistence of national differences in shaping the social and scientific movements in medical teaching. For instance, Bonner describes a variety of second-class physicians — surgeon-apothecaries, Wundärzte, and officiers de santé — who were the doctors for a large segment of the populations in their respective countries. Recurring questions were what kind of medical education and how much of it could be expected of such country practitioners who lacked a good general education and would earn only a meager living. Although in North America we steadfastly refused to call our medical practitioners anything but doctors, Bonner is quite correct in drawing the parallel between our country doctors and the so-called second-class practitioners in the European countries.

By using a comparative method, Bonner has made an important contribution to our understanding of the shaping of medical education in the past and the influence of that history on medical schools today. We now know more about the conditions that students in the past faced both in and out of the classroom, how their learning was organized, and their sex and social class. No longer can we say that the history of medical education is a backwater of studies that merely glorify a school or a national system of medical education. With this book, we finally have a worthy successor to Puschmann's work.

Gert H. Brieger, M.D.
Johns Hopkins University School of Medicine, Baltimore, MD 21205