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During the last half of the nineteenth century, medical schools grew significantly in number and enrollments, as did all institutions of higher education. Many medical schools added optional fall and spring sessions to compete with the private courses and provide additional training for their students. Faculty members were appointed in the clinical specialties, which led to the expansion of the curriculum to include courses in the specialties and the replacement of the repetitive course with a graded one. After the Civil War, enrollments in higher education grew significantly, especially in professional schools. The number of students enrolled in all institutions of higher education increased from 32,000 in 1860 to 256,000 in 1900. The 1860 enrollments, which consisted almost entirely of men, comprised 3.1 percent of the white male population between 18 and 21 years of age. The 1900 enrollments, which included many women in colleges and normal schools, comprised 5.0 percent of the white male and female population between 18 and 21 years of age. In 1860, 51 percent of the students were enrolled in colleges and universities, 44 percent in medical, law, and theological schools, and 6 percent in normal schools. In 1900, 41 percent were enrolled in colleges, 33 percent in professional schools, and 27 percent in normal schools. A higher standard of living and greater access to education led many students to enter college directly from secondary school, according to a study of 20,000 graduates of 11 well-established colleges. The study found that the median age at graduation, between 22 and 23 years, changed very little between the late eighteenth century and 1900, but that the range of ages became smaller over the period. This indicated that students had more preliminary education and were less likely to delay attending college. The admission standards of the colleges remained low. Most did not require a high school diploma. Entrance requirements included Latin and mathematics, plus Greek for admission to the classical course. Equivalents were widely accepted. Most students did not meet even these requirements.

During the first half of the twentieth century, American medical education underwent drastic changes. Greater costs of operation and the requirements of licensing agencies forced many medical schools to close and most of the others to affiliate with universities. The surviving medical schools were able to raise their admission and graduation requirements, which was also made possible by the rise in the general educational level of the population. The growth of the basic medical sciences led to the development of a new kind of faculty member whose career was confined to the medical school. During the first half of the twentieth century, the educational level of the population rose significantly. The proportion of the 17-year-old population with high school educations increased from 6.3 percent in 1900 to 16.3 percent in 1920, 28.8 percent in 1930, and 49.0 percent in 1940. The number of bachelors’ degrees conferred per 100 persons 23 years old increased from 1.9 in 1900 to 2.6 in 1920, 5.7 in 1930, and 8.1 in 1940. Between 1910 and 1940, the number of college undergraduates more than tripled. Because the number of medical students did not increase, medical schools were able to raise their admission standards. At the same time, many new professions competed with medicine for students. Between 1900 and 1940, dentistry, engineering, chemistry, accounting, and college teaching, among others, grew significantly faster than the traditional professions of medicine, law, and the clergy. Graduate education also became an alternative to professional training. Between 1900 and 1940, the number of masters’ and doctors’ degrees awarded, excluding medicine and other first professional degrees, increased from 1,965 to 30,021, or from 6.7 to 13.9 percent of all degrees awarded. Colleges and universities decentralized their organizational structure to deal with the increasingly technical and specialized content of academic disciplines. They established academic departments that consisted of faculty members who shared a common body of knowledge and taught the same or related courses. Departments were given the responsibility of supervising their faculty members, recruiting new faculty, and operating the department’s academic program. By 1950, departments existed in most of the sciences, social sciences, and humanities.

The professionalization of academic medicine occurred in the clinical as well as the basic science curriculum. Full-time clinical faculty members replaced part-time faculty members in the wealthier schools. Medical specialties, many of which were rare outside the medical school, dominated the clinical courses. Clinical teaching, which was improved by more student contact with patients, occurred primarily in hospitals, whose patients were atypical of those seen in community practice. The growing importance of hospitals in medical education led to the construction of university hospitals. Early in the century, some leading basic medical scientists called for full-time faculty members in the clinical fields. They noted that full-time faculty members in the basic sciences had produced great scientific discoveries in Europe and had improved American basic science departments. In 1907, William Welch proposed that “the heads of the principal clinical departments, particularly the medical and the surgical, should devote their main energies and time to their hospital work and to teaching and investigating without the necessity of seeking their livelihood in a busy outside practice” Few clinicians endorsed this proposal. They found the costs prohibitive and disliked the German system of medical research and education on which it was based. Medical research in Germany was carried on, not in medical schools, but in government research institutes headed by medical school professors and staffed by researchers without faculty appointments. All of the researchers were basic medical scientists who were interested in basic research, not practical problems like bacteriology. Although the institutes monopolized the available laboratory and hospital facilities, they were not affiliated with medical schools, had no educational programs, and did not formally train students, although much informal training occurred. For these reasons, their research findings were seldom integrated into the medical school curriculum, and German medical students were not trained to do research. German medical schools had three faculty ranks. Each discipline was headed by one professor, who was a salaried employee of the state and also earned substantial amounts from student fees. Most professors had no institute appointments and did little or no research.