**2.4 Medical education between the seventeen and nineteen centuries in the United States**

During the 17th to 19th century, and in the same line, the history of medical education took similar strides in the United States. The early 1750s saw informal classes in anatomy that were unstructured and run by doctors who traveled to Europe bringing back with them a series of anatomy lectures that were taught to gentlemen who could afford the fees of a reputable practitioner. The beginnings showed apprenticeship system where apprentices were trained in doctors' offices who had their private venture, in menial and pharmaceutical therapies. Although emulating the British medical system in practice and educational institutions, the American educational system remained unstructured and without formal legislation. The first theory and practice College of Philadelphia was founded by John Morgan in Philadelphia in 1765, and New York in 1768 [10]. Many more schools of medicine grew between 1810 and 1840 resulting in twenty-six new medical schools, and grew even more and doubled until 1876. Teaching at these institutions was at its beginning, and barely founded with some inexpensive anatomy benches and with little investment in teaching that was focused on didactic methods, except for the anatomy sessions. A school diploma was the license to practice after a brief, oral examination as no state boards were yet in place. During this period, teaching circumstances were not ideal with minimal clinical facilities and didactic teaching in badly lighted amphitheaters [10, 11].

In the United States, the beginnings of the 1800s showed the opening and merging of many medical schools including the medical department of King's College and the medical department of Harvard College. During the midst of the 19th century (1835), the American situation of unsuitable distorted mode of education endured protests from different medical education institutions in request of legislations and improved structured standards of education to earn a degree in medicine. These protests ended with the formation of the American Medical Association in 1847 that committed the profession to the requirement of suitable education and standards for the degree.

In the 1850s onward, the time for change was achieved by the dissolution of the preceptorship system where the medical schools of Harvard, Yale, Pennsylvania, became independent of the institutions with which they were legally united. At the time of commercial exploitation, schools were controlled by owners of these institutions and bestowed professorships by common agreement, segregating and dividing fees, along proprietary lines. These independent irresponsible conditions remained as such until the eighties. During this time, medical education was based within medical schools, using didactic methods of teaching that were focused on the chemical, biologic and physical sciences, and personal contact between teacher and student, and between student and patient were lost [12].

This time of medical institutions' wide spreading was associated with the new medical discoveries and the invention of the stethoscope in 1816, that came into fruition in the establishment of the first bachelor's degree at John Hopkins Medical School in 1893. This was the first school with adequate preparations of well-equipped laboratories run by modern faculty and hospital training for physicians. The school provided a standard for medical schools with a scientific curriculum [12].

The conditions of medical education were criticized calling for reforms of medical education. In 1910, Abraham Flexner, an educator, and not a physician, issued his report on the state of medical education after a comprehensive review of and visits to schools of medicine [13]. In his report, he declared that medical education in the USA and Canada must be an educational system by instituting standardized quality education that is university-based only and underpinned by a scientific foundation. Additionally, the report emphasized that students must be educated to be qualified and granted a degree in medicine [14]. This revolutionary report resulted in a decline in the number of commercial medical schools, and the establishment of the residency training and specialization and sub-specialization among American doctors by the 1930 and 1940s, and the foundation of four years' education that are completed with internship and residency programs and board examinations. The role of basic sciences flourished after the Flexner report (1910) which provided the grounds for designing undergraduate medical curriculum followed by clinical experiences and in academically oriented hospitals [15].

The publication of Flexner report was a turning point in medical education: the preclinical and clinical divide [10, 12, 14]. This divide of preclinical and clinical medical education that started in the 20th century showed another form of shortcomings in educational programs. With this polarity, the delivery of basic sciences teaching was more focused on scientific facts rather than the context of medical practice. Additionally, there were notions of poor retention of basic knowledge as students started clinical experiences as described by Pawlina [16].

By the 1960s and 1970s and after the transformative changes that were initiated by the Flexner report, medical education in schools has evolved from a haphazard, unstructured classes for interested gentlemen form to a scientific model of the late 20th century and early 21st century [12]. By the 1980s, education became more structured and clinical training was instituted and delivered by attending physicians in hospitals, ambulatory settings, and physicians' offices. However, training was not well served because physicians did not have enough time to train students and there were recommendations for more change in future doctors' education and training.
