A Solid Building Requires a Good Foundation: The Basic Sciences in the Dutch Medical Curriculum, 1865-1965

Development and organization of medical education in The Netherlands

Nineteenth-century academic medical education in the Netherlands closely resembled that in Germany, the Nordic countries, Austria-Hungary and Switzerland, where it had developed from the work of lecturing university professors in the Middle Ages.¹ In the second half of the 17th century and the first decades of the 18th century, Dutch medical schools ranked at the top of contemporary medical education; for example, Herman Boerhaave (1668-1738) was not only an excellent clinical teacher, but also developed the direct precursor of the ‘discipline-based curriculum,’ later adopted by many American medical schools as well, which dominated medical education until the 1970s.² Boerhaave’s ideal curriculum consisted of a premedical phase (dedicated to mathematics and natural sciences), a preclinical phase (which featured animal and human dissection, post-mortem examinations, artificially produced diseases in animals, and knowledge of medicines) and finally a clinical phase, in which the student would be allowed at the bedside.³ After Boerhaave’s death, his system of clinical education gradually passed into disuse, and by the early 19th century, the French and English medical faculties had widely surpassed the Dutch. Like elsewhere, there was at the time in the Netherlands an extensive ‘second class’ of medical practitioners, predominantly trained by apprenticeship or at so-called ‘Clinical Schools’: rural and urban surgeons, rural and urban general practitioners, physicians who were only allowed to practice on board of ships or in the army, and midwives.⁴ The academically educated physicians, on the other hand, did not consider themselves primarily as practitioners, but rather as learned and well-educated gentlemen, who tried to stay away as far as possible from the more unsavory aspects of medical practice, such as direct physical examination of a patient. Instead, their preferred actions were hearing the patient’s story and, on this basis, prescribing complex and expensive recipes for wealthy clients (the proverbial ‘gilded pills’). If cutting into the patient’s body was inevitable, their role was to instruct the surgeons accordingly. In the decades before academic medicine was connected to the empirical sciences – a process that began around 1830 – the epitome of a learned doctor was a physician who was well versed into the highly speculative and complex theoretical systems (iatrophysics and iatrochemistry). Even excellent clinicians, such as Boerhaave, profoundly engaged in such speculation about the nature and causes of disease. In fact, as medicine lacked a solid scientific foundation, this was the only way to maintain its academic status.⁵

After 1840, the situation gradually improved. Inspired by the development of German scientific physiology and the French clinical school, some academic medical teachers in the Netherlands argued that first, medical science should become more empirically and scientifically based, and second, medical education should be improved and standardized: one type of medical school, one single general qualification (‘unity of licensure’). To this end, in 1849 the Nederlandsche Maatschappij tot Bevordering der Geneeskunst (literally: Dutch Society for the Advancement of the Art of Medicine) was founded. Pressure upon the government resulted in 1865 in new legislation, the Physicians’ Act, which effectively abolished the ‘second class’ of physicians and introduced the ‘one portal system’ of medical education. From then on, everybody who wanted to practice medicine had to pass two rather demanding exams, organized by state committees: a physics exam and a medical exam. The physics exam was encompassing; it included physics, chemistry; botany, ‘natural history of animals and minerals,’ knowledge of drugs ‘as commodities’ (i.e., ‘materia medica’) and also anatomy, comparative anatomy, and physiology.⁶ The medical exam consisted of a theoretical part and a practical part. The theoretical part covered pathology and pathological anatomy, knowledge of herbal medicine, health theory, forensic medicine, general medicine, surgery, and obstetrics, and the preparation of medicaments. Finally, the practical part of the medical exam (called the ‘practical physician’s exam’) both exclusively and comprehensively granted the right to practice medicine: passing the exam was necessary to practice medicine, and once passed, the graduate was allowed to practice medicine ‘in its full extent.’⁷ This was a major innovation, because until then, the right to practice as an academic physician was connected to the Ph.D. degrees in general medicine, surgery, and obstetrics, respectively.

In 1874, the state physics exam was split into two parts, a first physics exam covering the premedical sciences, and a second physics exam covering the preclinical sciences. Four years later, the theoretical part of the medical exam became the responsibility of the individual faculties; only the practical physician’s exam remained under state control, nominally until 1921, though quite soon after 1878 even this became, in practice, a faculty exam. ‘Nationwide’ exams turned out to be too much of a burden for the individual medical faculties, who were required to organize this national exam every fourth year, but were unable to miss their clinical professors for a prolonged period.^6,8,9

Though basically any student could apply for the state exams, no one was legally forced to attend university courses. Yet, it was hard to see how anybody could acquire the knowledge and skills required to pass these exams, except by attending the academic program.¹⁰ The actual arrangement was peculiar: a system of exemptions of the state exams for students who had passed the academic exams was set up. More specifically, obtaining the academic candidate degree – comparable to a Bachelor’s degree – granted exemption for the physics exam; similarly, obtaining the academic doctoral degree – comparable to a Master’s degree – granted exemption for the theoretical medical exam. As the Ph.D. degree no longer granted the right to practice, it soon acquired a purely ornamental status. The non-academic practical physician’s exam, for which no exemption could be obtained, emphasized that the state, rather than academia, was in control of licensure.11 Still, the structure of the medical curriculum itself was not affected by this, as it was considered “the only sequence of disciplines in medical education any sensible human will ever recommend: First, the study of nature in its full extent, but not including humans or animals; next, the study of human and animal anatomy and physiology, and added to this general pathology, general medicine and pharmacology; and finally, the transition to the so-called practical disciplines, and study these in their full extent.”¹² This view illustrates both the rising confidence that the empirical sciences are the ultimate foundation of medicine and the belief that medical education should be compartmentalized – a compartmentalization that both originated from and was maintained by the three staged academic exams (propaedeutic, candidate, and doctoral) and the practical state exam.

One might ask why this elaborate construction of state exams and exemptions was constructed: would it not have been more efficient to just make the academic route the exclusive way to become a doctor? The reasons are twofold. First, the Physicians’ Act was a compromise designed to meet two conflicting concerns: on the one hand the fear that by abolishing the second class of physicians, health care in rural areas would plummet; on the other hand, pressure from a number of leading medical teachers to academize all medical education. Second, in 1865 the Act was announced as temporary legislation, awaiting the statutory regulation of higher education in general. This was actually achieved in 1876 by the Higher Education Act. Two years later, the Physician’s Act was brought into line with the Higher Education Act and renamed the Revised Physicians’ Act.¹³ This Act brought the state exams – with the exception of, at least formally, the practical physician’s exam – under faculty control. As fear of shortage of physicians dominated the discussion which led to the conception of the Revised Act, a dual track system was set up: students who wanted to become doctors could chose between an academic and a non¬academic track. It was an odd construction, for there was only a nominal difference between the two tracks: academic medical students had to pass the academic exams (propaedeutic, candidate, and doctoral) and the non¬academic students the corresponding former state exams (now called first and second physics exam and theoretical-medical exam). But in practice these were exactly the same exams. Indeed, academic and non-academic students attended the same lectures and worked in the same laboratories. Secondary education determined for which track a student was eligible: only students who had attended the ‘Gymnasium,’ the secondary school in which the classical languages were taught, were admitted to the academic track. Students from the other type of secondary school (‘hogere burgerschool’, the equivalent of the German ‘Realschule’) were required to follow the non¬academic track and pass the first and second physics exams and theoretical-medical exam. For students who merely wanted to practice medicine, there was no difference between the tracks; but students in the non¬academic track could not apply for a Ph.D. In other words, students without a classical background – who more often came from middle-or even working-class families – could become practicing physicians, but were denied the ultimate hallmark of academic achievement. Most ironically, over the years it became increasingly clear that the non-classical secondary education prepared students much better for the study of the medical sciences than the classical gymnasium, where little mathematics, and hardly any science was taught.^14,15 In this respect, Abraham Flexner characterized the Dutch gymnasium as “the most conservative secondary school in Western Europe.”¹⁶ Dissatisfaction with this regulation was rampant and many scientifically ambitious non-academic medical graduates went abroad, mostly to Germany or Switzerland, to obtain a Ph.D.-degree. Meanwhile, their classically educated colleagues all too often did not care to pursue the Ph.D.¬degree as it had little benefit in medical practice. This situation persisted until 1917, when the non-academic medical course was abolished and ‘hogere burgerschool’¬as well as Gymnasium-graduates had to follow the academic route.

Despite some changes in legislation, the structure of the Dutch medical curriculum was in 1965 still very much the same as in 1878.17,18 The general outline was: [1] an essentially premedical (propaedeutic) year, which was spent in the Faculty of Mathematics and Sciences, in which physics, chemistry and biology were taught as separate sciences; [2] two candidate years in which the preclinical sciences were taught – by preclinical scientists
– as if the student would become a scientific researcher in any one of these disciplines; [3] two doctoral years in which clinical theory was extensively taught, including pharmacology, pathology, and microbiology; and [4] two practical clinical years (clerkships) in which the student would become acquainted in practice with all clinical departments.19 Teaching of both clinical theory and clinical practice aimed to be exhaustive, for students could start working as general practitioner immediately after graduation (i.e., without any further postgraduate training). In practice, the medical faculties had only very limited control over what happened to the student during the clerkship years, and, as they considered professional education outside the scope of their responsibility, they did not care very much either.²⁰

While the structure of the medical curriculum did not show major changes, its content evolved with the development of the individual disciplines. Innovations often boiled down to adding new disciplines, in particular new medical specialties, to the program. The first formal effort at a more fundamental curriculum change occurred in 1936, when the Sociaal Hygiënische Commissie (‘Social Hygienic Committee’) published a preliminary report on medical education. In this report, the role of the premedical sciences (chemistry, physics, and biology) in particular was challenged.²¹ The Committee proposed that the curriculum be restructured in order to enable students to focus on the human organism right from the beginning, with corresponding early introduction to the bedside. It was also recommended that some new disciplines, such as philosophy and psychology, should fill the space made available by reducing the premedical sciences. Probably as a consequence of the imminent World War II, none of the proposed improvements was implemented. Immediately after the war, a second, more ambitious, effort at reorganization was made, this time encompassing the whole of higher education. A large State Committee was established, divided into sections, of which Section K dealt with medical education. In its Report, which appeared in 1949, the members of Section K expressed the view that the primary aim of medical education should be to properly educate the general practitioner.²² As this education was viewed as deficient, proposals were made to introduce a plethora of new disciplines, such as sociology, psychology, philosophy, the history of medicine, general health science, general microbiology, and general pharmacology. Being overly ambitious, the report can be seen as a recipe for failure. Yet, some tentative efforts to break the compartmentalization between the premedical, preclinical and clinical parts of the curriculum ensued. For example, at a small scale, preparatory clinical lectures were introduced in the last preclinical year, and parts of the premedical sciences were integrated into physical and chemical physiology. This can be construed as a ‘rooftile’¬curriculum, i.e., an organization in which advanced parts of earlier disciplines overlap, in time, with early parts of later disciplines. However, in spite of the weight of the Committee, its major proposals were not adopted: The 1921 Academic Statute – which formalized the 1878 structure of the curriculum – remained in effect, basically unchanged, until 1968.²³

Thus, the first two decades after World War II witnessed few changes in the Dutch medical curriculum. In two senses, however, pressure on the curriculum increased: first, the medical sciences evolved at an increasing speed, without any system of filtering out the developments worthwhile including in the curriculum and those not; second, during the 1950s, and increasingly so in the 1960s, the number of students applying for medical education increased considerably. As medical faculties could not select their students and, until the second half of the 1960s, also not limit the number of students admitted, dissatisfaction with the state of affairs increased concomitantly. By 1965, enough momentum had accumulated to release a cascade of educational innovations within a relatively short time span (no more than a decade). We will give a concise overview of these developments.

Shortcomings of the Dutch medical curriculum

First, the medical curriculum was “educationally insufficient” in the sense that it was dominated by inferior instructional (didactic) formats: excessive reliance on and exaggerated faith in the utility of lectures and far too little practical work in the laboratories (in the preclinical phase) and in the hospitals (in the clinical phase).^19,24 For example, it was not unusual for students in Amsterdam to have lectures, six days a week, without interruption, from 8 o’clock till 12 o’clock, to be followed by special courses in the afternoon.²⁵ This amounted to approximately one lecture hour for each laboratory hour, whereas Pearce, Welch, and Howell already advocated a ratio of one lecture hour to six laboratory hours.²⁶ Van Rijnberk (1875¬1953), an Amsterdam-based physiology professor who wrote many editorials about medical education between 1913 and 1946, presents a hierarchy of instructional formats, in descending order of importance: practical courses (laboratory experiments and dissections), demonstrations, theoretical lectures, and self-study from books.²⁷ This hierarchy is in line with Abraham Flexner’s view: he also emphasizes “learning by doing” and prefers, for example, dissection to demonstration, and demonstration to anatomy lectures.²⁸ Flexner, in his 1925 comparison of European medical schools, characterized Dutch medical education as follows: “unrelieved demonstrative lecturing,” “complaints are rife that students are passive,” “all students hearing the same lectures… individuality does not disclose itself.”²⁹

Forty years later, the situation had hardly improved, theoretical lectures and self-study still being the predominant didactic formats.³⁰ The curriculum was also insufficient as it failed to achieve its formal aims: to prepare students for both scientific research and future medical practice (i.c. general practice). Students who wanted to be well-prepared for future practice were overly arrested in their progress, they were faced with the task to acquire in-depth knowledge of a large number of specialized scientific medical subjects, knowledge not necessary for everyday general practice.³¹ On the other hand, pre-candidate education was insufficient for students who aimed at a scientific career, because it was stuffed with scientific facts, but did not foster students’ scientific attitude.³² In the late 1950s, basic science education of Dutch medical students was characterized as “extensive but shallow by necessity.”³³ Partly, this was inevitable, due to the large number of disciplines included in the curriculum and the autonomy of individual teachers. On the other hand, it also was deliberately arranged this way: The 1949 Report of Section K of the State Commission re¬emphasized the view that medical education should be extensive, rather than profound. Graduates should be able to enter general practice immediately.²² Subject matter coverage should be exhaustive; students’ achieving in-depth conceptual understanding was a major issue. Flexner considered Dutch medical education too broad to be a proper basis for a scientific researcher, and particularly criticized the absence of elective courses.²⁹ In the mid-1960s, the tradition to require “almost encyclopaedic factual knowledge” of students in every single discipline was criticized: it did not make sense because current knowledge would soon become obsolete and replaced by new factual knowledge.³⁴ Around the same time, the undue emphasis on the scientific aspects of medical education was called “sanctimonious,” for while the faculty payed lip service to science, a majority of medical students was forced to fake interest in it.³⁵

How can it be that Flexner’s critical comments were still relevant forty years later? Apparently, the curriculum was highly resistant to change. For one thing, it lacked ‘internal dynamics’: there was no coherent philosophy of medical education to generate new ideas or innovations, and no advancing views. The aim to educate students to ‘practice medicine on a scientific basis and in its full extent’ did not change over the years, though it did become increasingly more fictitious. Whether or not a topic was included in the curriculum often depended upon a corresponding chair being part of the medical faculty. For example, though he considered pathological chemistry an important scientific discipline, Van Rijnberk doubted whether it could be included in the medical curriculum: it would be hard to find a teacher who was an expert in both biophysics and biochemistry.³⁶ If there were any dynamic forces on the curriculum, they came from outside; for example, in 1935, the Secretaries of State of the Departments of Education, Arts, & Sciences and Social Affairs explicitly asked the Sociaal Hygiënische Commissie to investigate whether the contribution of the premedical sciences could be decreased and the preclinical sciences could focus more on the human being – that is, increase their relevance for medical students. Though the government’s primary aim was to achieve budget cuts by decreasing the length of the medical course, rather than to improve medical education, the investigation can be seen as an initiative for curricular change.³⁷

This lack of internal dynamics was also reinforced by a third factor, the extreme compartmentalization of the curriculum. The gap between the self-contained premedical, preclinical, and theoretical clinical sciences and clinical practice was all but insurmountable. Premedical and preclinical teachers, in particular, had almost absolute power in determining the content of their courses; moreover, invariably, they were both teacher ÿa1nd examiner. Usually they were well aware of the latest developments in their own discipline, but they were hardly interested in the practical applications of their courses for clinical medicine.³⁸ This situation was maintained because the Faculty of Mathematics and Sciences, rather than the Faculty of Medicine, was in charge of the first year (propaedeutic) program. As late as 1965, a committee charged with preparing a proposal for curricular reform – the Conventscommissie voor de Faculteit der Geneeskunde at Utrecht University – complained that students were unable to integrate the premedical sciences into the preclinical subjects, and that the first year program was predominantly viewed as a hurdle to be taken. Students’ aim was to pass the exams, rather than to acquire lasting knowledge.¹⁷ In addition, the gap between the preclinical and clinical part of the curriculum was experienced by most students as absolute. As soon as the student entered the (theoretical) clinical phase, the scientific approach was abandoned in favor of a completely case-based approach. Students were often bewildered by this abrupt transition. Implicitly, the message was: forget what you have learned until now. You will hardly ever need it in your future career as a physician.¹⁷ Yet, from an academic point of view, the separation between the preclinical and clinical sciences was “almost sacrosanct” and the curriculum was described as completely dis-integrated.^34,35 In this respect, little had changed in sixty years, for in 1901 it was already argued that students buried their knowledge of anatomy and physiology directly after their candidate (or second physics) exam, never to dig it up again.³⁹ Once in the clinic, they focused on the clinical tricks and the practical basis of diagnosis and therapy. The clinicians who supervised them had also withdrawn from anatomy and physiology, and even from the clinical laboratory: “My clinic is my laboratory,” they would proudly say, “I don’t need an additional one.”³⁹ The extreme compartmentalization of Dutch medical education did not escape Flexner as well, for he observed its “total divorce of theoretical clinical instruction from practical experience of whatever kind.”²⁹

One reason behind this compartmentalization was the extreme reluctance of those responsible for medical education to admit students who had even the slightest gaps in their preclinical or theoretical clinical knowledge in the wards.⁴⁰ Obviously, the structure of the academic course, with its division in phases – propaedeutic, candidate, and doctoral – supported the compartmentalization. Moreover, within the phases, disciplines were also self-contained as a consequence of the belief of many professors that every individual science should be taught and examined as if there were no other disciplines and no other exams at all, and as if these sciences were devoid of any practical applications.^41,42 Even within disciplines, teaching was compartmentalized: For example, it was not uncommon for laboratory work in anatomy to be completely disconnected from the corresponding explanatory lectures. In some cases, laboratory experiments preceded the theoretical basis by six months.⁴³ This problem of fragmentation was highly persistent: in the 1960s, it could occur that renal physiology was taught by the physiologist a year or so before the anatomy of the kidney was dealt with by the anatomist. After the candidate exam, the pathologist would teach the pathology of the kidney, to be followed, again after a gap of several months, by the clinical aspects of renal diseases, to be taught by the internist. The ‘logical’ sequence from normal to abnormal and from structure to function would not necessarily be observed as well, for in some cases the internist might precede the pathologist by several months. Finally, the surgeon demonstrated kidney surgery. “How can a medical student be expected to construct a clear picture, based on conceptual understanding (italics ours) of the normal function and pathology of the kidney, having learned about these organs in such a fragmented and haphazard way?”⁴⁴

A fourth shortcoming was curriculum overload. Complaints concerning curricular overload can be traced back to 1883, when it was noticed that duration of the student years and the difficulty of the study for medical students had increased, largely as a consequence of three requirements, which were, taken together, incompatible:
[1] that physicians should be able to practice medicine “in its full extent,” [2] that every physician would be able to work independently on scientific problems, and [3] that the level of both study and exams would be high.45 However, in the late nineteenth and early twentieth century, overload was compensated for, so to speak, by a particular form of curricular inefficiency: medical students had too much unscheduled time, particularly in the second and third year of medical school, which were assigned for the better part to anatomy and physiology, which was probably too much.⁴⁰ Basically, only seven months each year were effectively used for teaching and studying.⁴⁶ Teachers could still afford to be unselective in terms of what they wanted the students to learn, which students perceived as “throwing books at us.”⁴³ During the long holidays, students were expected to study these books, but they were probably not very motivated to do so. Thus, curricular overload may have been limited to certain parts of the academic year, in particular the months immediately prior to the examinations. As the exams were until the 1960s exclusively individual, long holidays were necessary for teachers to perform the “endless series of (oral) exams.”⁴⁷ Lack of scheduled time had an additional drawback: it decreased students’ commitment, which was aggravated by the fact that students who flunked were permitted to repeat exams over and again, basically interminably.⁴⁸

Initially, teachers could alleviate problems of overload to some extent by removing obsolete topics and decreasing the (sometimes excessive) amount of time dedicated to other subjects. Descriptive anatomy, for example, contained a lot of “dead wood.”⁴³ Bachmeyer, an outsider to Dutch medical education, proposed in the early 1950s that one year at least could be cut from the program by introducing practical clinical work earlier and eliminating many of the lectures, a recommendation that was reiterated twenty years later.^18,19 Quite consistently over the years, though, the balance between addition of new and removal of obsolete subjects in the curriculum was tilted towards the addition side, as new knowledge accumulated at a faster rate than old knowledge could be done away with.^35,49 Rigid adherence to the criterion of completeness and the requirement that the curriculum should deliver fully prepared general practitioners prevented any attempt at curricular differentiation.⁵⁰ Thus, by 1960, the actual duration of the average student’s medical study surpassed the nominal duration of seven years by approximately one year and a half.⁵¹ That students were well aware of the problems is illustrated by the fact that, in the early 1960s, medical students at Utrecht University opposed against abolishing lectures and practicals on Saturdays: they were afraid that adopting Saturdays as holidays would increase the duration of the already lengthy medical course.⁵²

What probably strikes most if one views Dutch medical education in an international context is the excessive length of the pre-clerkship course, including the theoretical-clinical phase. Whereas in the early twentieth century most students saw their first patient at the beginning of their fifth year, around the mid-1960s, this had increased by one year, and even after five years preparation, when they entered the ward they were given hardly any responsibility at all. To emphasize the contrast, an international review observed that in nearly every country, the medical student comes into contact with the patient in the beginning of the third year, and that there is “much talk of making this contact begin earlier.”⁵³

Finally, despite all intentions, the medical curriculum poorly prepared students for medical practice. In the nineteenth century, too few patients were available; due to the low quality of medical care at the academic hospitals, only people who could not afford to go elsewhere were treated there. Other hospitals were not involved in medical education. In the twentieth century, the quality of care in academic hospitals improved, the primary problem now being too many clerks present at understaffed wards. Thus, there was insufficient room for practical clinical skills training, even during clerkships, and young graduates generally lacked the skills necessary to work independently as a general practitioner. A survey in the 1930s showed that they felt themselves inadequately prepared for medical practice.⁵⁴ Graduates were expected to learn practical skills while practicing medicine. A practical (post-graduate) clinical year, often proposed but never implemented, was viewed by some as a solution to the long-standing problem of insufficient practical training. We know of no proposals to introduce practical skills training in the undergraduate course before 1965. Whatever pressure was exerted on the curriculum, the need to introduce practical clinical courses before the clerkships did not arise.

The inability to attack the problems of educational insufficiency, compartmentalization, lack of internal dynamics, curricular overload, and length caused the Dutch medical curriculum in the early 1960s to compare unfavorably to medical education in several other countries. Particularly striking was the low output rate: only 69% of students who started the study graduated, which was low in comparison to the medical course in other European countries, were it often approached 90%.^51,55 Starting in the early 1960s, the number of students that enrolled exploded, from approximately 750 each year in the 1950s to over 1400 in 1965. As any applicant who had successfully completed the H.B.S. or the gymnasium (provided he or she attended the science department of these schools) was legally entitled to enter the medical faculty without the need to pass admission exams, this number was expected to further increase. In addition, increasing awareness of educational developments in other parts of the world also contributed to the perceived inadequacy of the Dutch medical curriculum.18 The results of three world conferences on medical education in 1953, 1959, and 1966, the flow of literature on curricular and educational reform elsewhere, and teacher’s personal contacts with new medical schools or programs, contributed to increased feelings of discontent and desire for change. In the early 1960s, there was a surplus of physicians in the Netherlands; consequently, a number of doctors who saw no professional future for themselves in the Netherlands went (temporarily) for employment to the U.S., where they were faced with curricula that were much further developed and integrated than the traditional Dutch medical course. Probably, their enthusiastic reports also contributed to the desire for curricular innovations.^30,56 Finally, the prevailing reform ‘spirit’ in society at large in the 1960s may have instigated junior faculty (e.g., at Utrecht University in 1965) and even students (at Amsterdam University, also in 1965) to initiate projects for curricular reform.

Premedical education from 1865-1965

Until 1876, only one preparatory school granted direct access to the university: the gymnasium, in which approximately half of the instruction time was devoted to the classical languages. This was not a serious problem for, at the time, the purpose of any academic education was to prepare students for their position as member of the ‘learned class,’ rather than for a scientific profession. Thus, the lack of training in mathematics and sciences of graduates of the gymnasium was not viewed as a serious drawback: This deficit could easily be made up in the propaedeutic year, the first year at university. In fact, the primary function of the premedical or propaedeutic year was to compensate for the deficient gymnasium course. For example, the 1867 State Commission responsible for the state exams declared:

“There is no need for a physician to be a mathematician, physicist, chemist, botanist or zoologist in the extended sense of the word; to achieve his full education, however, he should devote himself for some time to mathematics, physics, chemistry, zoology, and botany. In due course, he can forget the details of what he learned in these courses, even though he will continue to receive the benefits of his studies for his further development, because these disciplines have taught him to observe accurately, and to arrive at the appropriate decisions on basis of these observations. What he has learned will be infinitely more valuable for him than having his memory stuffed with facts and words: he has learned to see, think, compare, judge!”⁵⁷

Until the Higher Education Act came into force in 1876, the propaedeutic program consisted of mathematics, physics, chemistry, botany, and zoology, with mandatory testimonia – i.e., exams not represented on the diploma – for comparative anatomy and knowledge of minerals. By this Act, mathematics was transfered from the propaedeutic year to the last two years of the gymnasium. This school was split into a liberal arts and a scientific department, the latter adopting some science – though at the time mostly of the ‘natural history’ type – in the curriculum. In addition, the mandatory testimonia in the propaedeutic year for natural history of minerals and comparative anatomy were abolished. Natural history of minerals was integrated with chemistry and probably limited to a little knowledge of soil conditions, which was considered relevant for the prevention of epidemics. Comparative anatomy in the strict sense was moved to the candidate (preclinical) phase. Consequently, the propaedeutic program at the beginning of the last quarter of the nineteenth century consisted of physics, chemistry, zoology, and botany.

The integration of the 1876 Higher Education Act and the 1878 Revised Physicians’ Act formalized access to the medical faculty for graduates from the H.B.S., the non¬classical preparatory school. These students were directly admitted to the non-academic ‘parallel track.’ As they were much better prepared, it took them on the average only one year to pass the propaedeutic exam, whereas most students from the Gymnasium spent two years in the premedical phase. Over the years, the propaedeutic phase increasingly became a replication of the sciences taught in secondary school. For example, it included all of elementary physics (among which, for instance, the theory of continuity of gasses and liquids), all of chemistry (organic as well as inorganic), all of comparative anatomy (including, for example, the development of tertianaschizont), and botany (including, for example, a broad knowledge of cambium and phloem and of plasmolysis).⁵⁸ Not surprisingly, the propaedeutic program was repeatedly challenged; botany, in particular, was probably never taken too seriously. Anecdotes about students’ cheating abound; for example, at botanic identification exams, it was not uncommon for students to help each other by surreptitiously substituting the prepared difficult and exotic plants for well-known, easier to identify specimens. Even bribery – paying the assistant in charge to prepare particular plants for the exam – occurred. It is hard to believe the professors were entirely unaware of this, but in all likelihood, they did not want to flunk students on as obsolete a subject as botany. That is, substantial knowledge of botany was considered superfluous as early as 1870, even for the (few) physicians who still did run a dispensary; for them, a little knowledge of commodities sufficed.59 Still, it would take another century before botany, together with the other premedical sciences, was removed from the curriculum by the revision of the Academic Statute (in 1968).

Physics and chemistry, as premedical sciences, were mostly viewed as auxiliary sciences for the study of physiology.⁵⁹ From the late nineteenth century onwards, proposals were made to remove at least parts of them from the first-year program.^43,60 The most radical proposal was to transfer the entire premedical education to the secondary schools, and dedicate the first semester of the first year in medical school completely to anatomy, with an emphasis on this discipline’s scientific-biological aspects.⁶¹ In the event, all these proposals suffered the same fate: they were ignored. At least in part, this was due to the prevailing spirit of academic conservatism and also to vested interests: the propaedeutic year of the medical curriculum was an important source of income for the Faculty of Mathematics and Sciences. In addition, proponents of the premedical sciences also made themselves heard. Physics, for example, was defended on basis of several arguments: first, it was necessary to understand physical processes occurring in the body; second, it served to make students familiar with the experimental method and enabled them to apply this method, when necessary, to diagnosis or therapy; and third, it contributed to students’ physical thinking.⁶² However, it was also argued that elementary physics should be properly taught in secondary school, and that the medical curriculum should not include a comprehensive course in physics, but capita selecta, for example, in acoustics, radiation (X-rays, in particular), and energy. It should be noted that this was an ideal, not the current practice in the propaedeutic year: in fact, physics, as well as the other premedical sciences, was taught in a self-contained way, largely devoid of medical application, and in the form of a synopsis. This is where academic conservatism comes in: Van Rijnberk, for example, vehemently rejected the notion that practical utility (for medicine as a profession) should be a criterion for inclusion of any subject in the curriculum. If, for example, zoology is taught, then this should be “true” zoology, as it is performed and taught by the zoologist, not “medical” zoology.⁴³ In this respect, Van Rijnberk defended the classic academic ideal of pure scholarship, devoid of any vocational interests, an ideal also strongly supported, in America, by Flexner. Obviously, the fact that the Faculty of Mathematics and Sciences controlled the content of the propaedeutic year effectively prevented that medical physics and medical chemistry, as opposed to pure physics and pure chemistry, was taught. In fact, during the propaedeutic year, medical students attended lectures in chemistry together with physics students and lectures in comparative anatomy and botany together with biology students.^63,64 This organization, which remained formally in effect until 1968, was viewed unfavorably by many, the main complaint being that teachers at the Faculty of Mathematics and Sciences lacked ‘medical feeling’ and that science teachers preferred their own discipline’s students to those in medicine. There were also rumors that this faculty was inclined to employ their ‘second-rate’ teachers for medical students, teachers who acted as ‘drill masters.’⁶⁵

Yet, over the years, the character of the propaedeutic year gradually shifted from making up for deficient secondary education to elaborating upon it. Its primary aim increasingly became to instil in students a scientific attitude or the ability to “think scientifically.” As such, this aim was explicitly mentioned in the 1921 Academic Statute.⁶⁶ Whether it was actually accomplished was quite another matter, however: the Committee-Pekelharing expressed serious doubts in this respect. Though this Committee considered some preliminary education in physics, chemistry, botany, and zoology indispensable, it was not satisfied with the way it was currently taught at medical school, which at the time largely boiled down to reinforcement of knowledge already acquired at secondary school.³² A decade later, the new Academic Statute argued for some reduction of the premedical sciences – it was observed that the curriculum of the gymnasium had recently improved in this respect – but the emphasis should remain on complete elementary physics and complete chemistry (organic as well as inorganic).⁶⁶

Of course, a scientific education worth the name also includes practical laboratory work; hence, the importance of such work for medical students was repeatedly emphasized, and complaints were often voiced. Van Rijnberk, for example, noted that, in contrast with their English peers, Dutch medical students were offered little opportunity for practical (laboratory) work in the premedical sciences.⁶⁵ Over the years, this probably improved somewhat; for example, in the 1950s, at Utrecht University, practical work in medical physics in the first year was scheduled on 16 afternoons.⁶⁷ Most notably, the author here talks about medical, not elementary, physics. Yet, across the board, the quality of the premedical practicals was relatively poor, as they were very much of the ‘cook-book type.’⁶⁸ The laboratory practicals in the premedical sciences were also used as an argument in favor of keeping the propaedeutic year the responsibility of the Faculty Mathematics and Sciences, or, as an alternative proposal, to accommodate the first year of the medical course in a yet to be founded interfaculty – a joint administrative institute of the Faculty of Sciences and the Faculty of Medicine that would be responsible for propaedeutic medical education. This plan was never realized, though.⁶⁹

Thus, propaedeutic year in the first half of the twentieth century witnessed a shift from elementary sciences via a regurgitation of secondary school science to a program featured more by capita selecta with a medical angle from physics, chemistry, and biology. For example, the first-year course in medical physics at the University of Utrecht in the mid-1950s dealt with subjects such as viscosity, surface tension, photography, double refraction, and nuclear physics, with examples of application of these subjects in physiology, diagnosis, or therapy.67 Despite such innovations ‘from within,’ the position of the premedical sciences remained contentious: should they be included in the medical curriculum at all? In 1936, the Sociaal Hygiënische Commissie considered an early orientation of medical students toward their future life in medicine absolutely essential, and recommended, as a start, to divorce first year courses for medical and science students, and to organize separate lectures and practicals for medical students.21 In all likelihood, this would be easier to achieve than a full transfer of the entire first year to the Faculty of Medicine, though this would be the ultimate aim. In fact, though the 1921 Academic Statute affirmed the predominance of the premedical sciences in the first year, it offered limited opportunity to introduce preclinical science in this year’s program; in addition, students were formally allowed to attend lectures and practicals of the second year before they had passed the propaedeutic exam – which was, explicitly for this purpose, renamed the ‘first candidate exam,’ while the former candate exam became the ‘second candidate exam.’ Consequently, some Dutch universities, such as Leiden University, in the 1950s provided introductory courses in gross anatomy and physiology in the first year.⁸² Apparently, students appreciated this early introduction of anatomy and physiology, because it fulfilled their ‘natural’ need to become familiar with the preclinical disciplines in an early stage and enabled them to see the relations between the premedical and preclinical sciences.¹⁹ However, real integration of premedical and preclinical disciplines was precluded, first because the Academic Statute still required that physics, chemistry and biology be taught, as individual disciplines with the explicit aim of developing medical students’ scientific thinking; and second, because two different faculties remained responsible for the first and second year program. By the mid-1960s, however, there was a widespread belief, shared by both students and most teachers, that the premedical year in its current form had become an obstacle to curricular improvement. For example, in 1965, the Conventscommissie expressed the belief that physics, chemistry, and non-human biology had lost their function in medical school long since.¹⁷ Around the same time, students at the University of Amsterdam also wanted the premedical sciences to be removed from the curriculum and to start the first year with physiology and physical chemistry.⁵⁵ Though international comparisons were not as common then as they are today, authors then did not fail to notice that in this respect, Dutch medical education definitely lagged behind that in other European countries, such as Sweden and England.⁵¹

The Conventscommissie proposed that those parts of the premedical sciences that had no direct bearings on the human organism should be integrated with other subjects in order to make them meaningful to beginning medical students. Subjects specifically mentioned in this respect were medical physics, analytical and organic chemistry, physical chemistry, and botany; zoology, provided that it would be presented as an independent introduction to human biology, could escape this fate and remain an individual discipline. The Conventscommissie also emphasized that, at any time, students should be able to perceive the relationship between what they were being currently taught and their ultimate aim, that is, becoming a physician.¹⁷ Finally, in 1968, the premedical year was formally abolished when Revised Academic Statute came into effect. However, vestiges of non-human biology could be found in the propaedeutic program – the new Statute dropped the term ‘first candidate exam’ and restored the traditional expression ‘propaedeutic exam’ – until well into the 1980s.⁷⁰

Preclinical education

From 1865 until 1921, the preclinical years (the second and third year) were almost entirely devoted to morphology (anatomy, histology, and cytology) and physiology (physical as well as chemical), or, to put it another way, to the sciences that deal with the normally structured and normally functioning organism. Physiology was generally considered the basis of medical science.^59,71 After 1921, parts of general pathology were moved to the preclinical program; at mid-century, pathology in the Dutch medical curriculum started in the second year and extended into the fifth year.⁷² Some relatively minor changes occurred in the 1950s and early 1960s; for example, pharmacognosy was removed from the curriculum, and histology was assigned a more independent position.⁷³ In these years, instruction during the second and third year covered the subjects of gross and microscopic anatomy, physiology, biochemistry, and general pathology.¹⁹ At Utrecht University and Nijmegen University, pharmacology (both lectures and practicals) was also included in the candidate program, but at the other faculties, it was still limited to the theoretical-clinical years (the doctoral program). At that time, disciplines such as health science, psychology, and social medicine had already worked their way into the preclinical curriculum.⁷⁴

A salient feature of the preclinical curriculum, and a relic from the traditional university, was that the preclinical years were basically not graded: Second and third year programs were given every other year, and students just flowed in after they had passed their propaedeutic or first physics exam. Academic freedom enabled students to basically attend the courses in whatever order they wanted, though the universities provided the students with general recommendations regarding the optimal sequence. Probably, most students followed these recommendations, for Flexner observed that the Dutch student was “characterized by his teachers as usually docile and industrious, [and] follows a beaten path with great conscientiousness.”⁹³ It is not clear how long this situation persisted; as the candidate exam was taken at the end of the third year, it may formally never have been abolished at all, though in practice the preclinical years in the 1950s were to a large extent graded. In the 1920s, Van Rijnberk was not happy with the situation, for he believed that anatomy and histology should be dealt with extensively before teaching of physiology and pathology could start. At the time Flexner visited the Netherlands, in practice, academic freedom to attend courses in any order was probably already limited, if only because practicals and courses more and more built on each other.

The basic aim of the preclinical years was that students should built a firm, stable, and extended knowledge base, which could last a lifetime. In 1909, the Committee-Pekelharing listed what preclinical education should achieve in students: A thorough knowledge of human anatomy, of circulation in mammals (before birth and during life), of respiration, muscles, and nerves, of the senses (eye and ear), of digestion and metabolism. In addition, students must be able to operate the microscope in order to know the intricate structure of organs and tissues, to be able to recognize tumors and to understand microscopic changes in diseased organs, and to investigate blood, sputum, and urine. Moreover, they must have some skills in chemical analysis and some knowledge of the substances the human body consists of.⁷⁶

Though the structure of the preclinical years remained largely unchanged, the content of specific disciplines evolved. For example, in pathology, between 1900 and 1940, the emphasis gradually shifted from pure (morphological) pathology to pathological physiology. In general, anatomy had a large share in the preclinical program, with dissection being considered the most informative, but due to capacity constraints not the most practiced, educational format. In the 1960s, compared to other countries, anatomy was still excessively taught in the Netherlands, though the differences between medical faculties were considerable: the number of hours devoted to gross anatomy in the second and third year ranged from 225 (125 lecture hours and 100 practical hours at Utrecht University) to 572 hours (305 lecture hours and 267 practical hours at Leiden University).⁷⁴

In addition to building a firm and stable knowledge base, the preclinical sciences – like the premedical sciences – also played an important role in fostering a scientific attitude in students.²⁵ Probably, Flexner did approve the solid scientific foundation in the biomedical disciplines (in this respect, the Dutch curriculum was modeled after the German system), though he would have rejected the teaching of encyclopaedic scientific knowledge predominantly by means of lectures, as was the practice in the Netherlands at the time. Rather, students should be trained in the scientific method of the basic sciences, which was also the appropriate tool for medical practice, Flexner argued.¹ Nonetheless, the scientific standard of preclinical education was a source of concern over the years. On the one hand, basic science education was too broad for students who ‘only’ wanted to become practicing physicians, on the other hand, it was not sufficiently scientific for students who pursued a research career.⁷⁷ Therefore, the introduction of a dual track system was repeatedly advocated.^39,78-80 In such a system, students would be able to choose between a more vocationally oriented, shorter premedical and preclinical track, and a scientifically oriented track. Initially, the predominant belief was that future practitioners who did not want to engage in scientific research needed less scientific education than the standard medical course provided (i.e., the practitioner’s course could be shortened), but from the 1950s onward the prevailing view was that the then standard curriculum was too much of a professional school, and that students who opted for a scientific career required more – or at least better – instruction in the basic sciences than the program provided for. Thus, it was argued that the scientific standard should be raised, and in the early 1960s, some Dutch medical schools experimented with a mandatory elective in the basic sciences. An important secondary aim of this elective was to spot those students with particular interest in basic science research, who could possibly be recruited as future research personnel.^{24,33,48,81,82} A similar, but more ambitious project was the five-months scientific practical which was inserted between the preclinical and clinical phases in the newly founded Rotterdam Medical School in the mid-1960s.^52,83 Though it was reported that students were enthusiastic about the six-week scientific elective at Leiden University, the Nijmegen scientific elective was not met with unequivocal enthusiasm, one important reason being that the number of holidays was substantially reduced. Students in Rotterdam, many of which “just wanted to become physicians,” in general considered this scientific practical a waste of time and effort and a hurdle to be passed before they could embark on their clinical studies.^48,82,84

In short, preclinical education suffered from the same shortcomings as premedical education some decades earlier: from a scientifically solid and up-to-date course in the late nineteenth and early twentieth century it evolved into a more encyclopaedic ‘stuffed-with-facts’ course in the 1950s and 1960s. Increasingly, the drawback that the courses were compartmentalized, self-contained, organized by autonomous departments isolated from the clinic, and taught in suboptimal instructional formats was felt. Though it was not appreciated by many students, the fact that the basic sciences were taught as if the students would be future anatomists, physiologists, pathologists, etc. was understandable, because the medical course was until the 1970s the only route to become a basic science researcher. But while students who wanted to become practitioners emphasized that they just needed to know the basics of anatomy and physiology, in order to become properly equipped for clinical work, their professors rhetorically asked: “…is it possible to become a physician without knowing the full structure of the human body?,” and: “are not all parts of this body of equal importance?,” the answers, of course, being “no” and “yes,” respectively.⁵⁸ In addition, to defend comprehensive teaching of the basic sciences, an obvious argument was used: “What is irrelevant for practice today, may become routine tomorrow.”⁴¹ As an historical coincidence, on exactly the same day (i.c., March 26, 1921) when Van Rijnberk’s recommendation that physiology should be taught, not on basis of its relationship with clinical medicine, but as if all medical students would be future professors in physiology, was published, W. D. Halliburton in the Lancet expressed sympathy for students complaining of curricular overload and argued that, for physiology in particular, “in the details of its many ramifications one must make a judicious selection, and the choice must naturally first fall on those parts of the subject in which the practical outcome is already realised rather than on those the application of which is still to seek.”^85,86 Over the years, Van Rijnberk stuck to his belief, though in 1938 he sounded less convinced when he considered the inclusion of essentially useless subject matter “a necessary feature of medical education.”⁸⁷ He strongly opposed reducing the amount of anatomy and other preclinical sciences in the curriculum. “Good practice is based on thorough theoretical understanding,” was his adage. Anatomy and physiology, as taught in medical school, will be “the student’s foundation which will last a lifetime.”⁸⁸ “Students know too much of anatomy? That will give the clinicians a good laugh!” Van Rijnberk ironically exclaimed, quoting Petersen.⁸⁹

Though opinions diverged considerably with respect to the content and extent of the basic sciences, there seems to be agreement that they were poorly taught. The opportunities for hands-on work, in particular, were very limited. This was a long-standing problem, already noted in the late-nineteenth century.⁶¹ Van Rijnberk explicitly added an extra argument in favor of practical laboratory work: it not only provided students with knowledge and fostered their scientific insight, but it also supported the development of fine hand and finger dexterity, as well as eye-hand coordination.⁴² This “learning by doing” was also one of Flexner’s preferred methods of instruction, and, though he was laudatory of teachers as well as preclinical laboratories, he expressed concern about insufficient facilities and resources for teaching in the laboratories.¹

A third problem was students’ lack of opportunity to choose capita selecta in the preclinical sciences, an illustration of Flexner’s observation that “…individuality does not disclose itself” in Dutch medical education.²⁹ Students as well as teachers were familiar with this problem, which in the 1960s re-emerged as the question of ‘electives,’ or ‘curricular differentiation.’ Overload, fear of students’ missing even the slightest knowledge considered necessary to become a good physician, and shortage of teachers probably all contributed to this problem. The situation improved somewhat after 1973, when general practice became an official medical specialty, and the need to prepare all students equally for general practice became somewhat less strongly felt.⁹⁰

Unlike the premedical sciences, the role of the preclinical sciences in the medical curriculum was generally taken for granted. Criticism was limited to the aim of these sciences and, most notably, to the way they were taught. As early as 1874, the belief that in-depth scientific knowledge was necessary to avoid physicians’ reverting to routine behavior and empiricism was challenged.⁹¹ Insofar as scientific knowledge was necessary, societal pressure and competition between practitioners would ensure that physicians would stay informed about scientific progress in the medical domain. Not knowledge for its own sake, but the ability to apply this knowledge in line with scientific methods would be the hallmark of a good physician, who would be, first and foremost, a medical practitioner. Scientific medicine and the practice of medicine, though mutually supportive, have different goals. There is no need for the future physician to be chemist, physiologist, pathologist or anatomist.⁹¹ In any case, students would bury their knowledge of anatomy and physiology directly after their candidate’s exam, never to disinter it again. Once in the clinic, they focused on the clinical tricks and the practical basis of diagnosis and therapy. The clinicians who supervised them had also withdrawn from anatomy and physiology, and even from the clinical laboratory: “My clinic is my laboratory,” they would proudly say, “I don’t need an additional one.” Or: “We educate general practitioners, not scientists.”³⁹

Though the preclinical sciences were seen as requisite for physicians, there were early doubts about the importance of descriptive anatomy, in particular.⁹² Presumably, it contained much “dead weight,” because students were expected to learn whole textbooks by heart, or at least teachers were not very selective in assigning subject matter.⁴³ Besides, there was an overemphasis on factual knowledge and little attention for correlation, neither between the sciences themselves nor between the sciences and medical practice. Again, what strikes most is how long it took for innovation to occur: in the mid-1960s, medical students still had to learn the complete descriptive anatomy, the physiology of all organ systems, and the biochemistry of all metabolic processes.³⁴ Yet, the same author who considered much of this knowledge superfluous, did not recommend a reduction of the basic sciences in general, for, as he argued, “a solid foundation is a primary prerequisite to construct a building,” in which resonate Van Rijnberk’s words of the 1920s. That is, a shift of emphasis was indicated, rather than a reduction.³⁴ But at the time, this belief had grown increasingly obsolete, and a substantial reduction and reorganization of the preclinical curriculum was long overdue.

Premedical and preclinical education after 1965

After a long period of relatively little change the decade between 1965 and 1975 eventually witnessed an accelerated development. In fact, the popular stereotype of the “sixties” as an era of major changes may, with respect to Dutch medical education, not be all that far from the truth. In the decade between 1965 and 1975, four major events occurred that had far-reaching ramifications for the medical curriculum: first, the foundation of a seventh medical faculty (at Rotterdam) in 1965, the first medical school in the Netherlands with a designed, rather than historically developed, curriculum; second, the major revision of the Academic Statute in 1968; third, the establishment of general practice as an individual medical specialty in 1973 – which relieved the medical faculties from the obligation to prepare graduates directly for family practice – and finally, the foundation of the eighth medical school (at Maastricht) in 1974, the first medical school with a problem-based learning curriculum in The Netherlands, and one of the first in the world. For preclinical medical education, the revision of the Academic Statute in 1968 was probably the most important of the four innovations, for it legally permitted medical faculties to break the barriers between the preclinical sciences: whereas until then anatomy, biochemistry, physiology, pathology etc. had to be taught as individual disciplines, the new Statute phrased it quite differently: students in the preclinical years should study the “macroscopical, microscopical, submicroscopical, and molecular structure and development of organisms, especially of man,” and the “functions of living organisms, including chemical and physical aspects.”⁹³ This new conception of preclinical education – in which the premedical and preclinical years were effectively integrated – can easily be seen as a necessary precondition for a curriculum to embody problem-based learning. Today, in the wake of the Maastricht curriculum, all eight Dutch medical schools have either integrated and innovated their entire curriculum, or at least adopted major elements from such programs. Today, unlike in 1965, Dutch medical education no longer compares unfavorably to that in other countries in Europe or North America. In addition, to facilitate developments towards further innovation, many schools have relatively large departments of educational development and research. Consequently, proportionally more contributions from the Netherlands appear in international medical education journals than would be expected on basis of the size of the medical community.⁹⁴

REFERENCES

1. Flexner, A. Medical education. A comparative study. New York: The MacMillan Company; 1925.
2. Papa, F.J., and Harasym, P.H. Medical curriculum reform in North America, 1765 to the present: A cognitive science perspective. Acad Med. 1999;74:154-164.
3. Lindeboom, G.A. Medical education in the Netherlands, 1575-1750. In: O’Malley, C.D. (Ed.). The history of medical education. UCLA Forum in medical sciences, No. 12. (pages 201¬216). Berkeley, CA: University of California Press; 1970.
4. Beukers, H. Medical education in the Netherlands in the nineteenth century. In: Ogawa, T. (Ed.). History of medical education. Proceedings of the 6th International Symposium on the Comparative History of Medicine. Susono-shi, Shizuoka, Japan, September 17-24, 1981. (pages 192-195). Tokio, Japan: Saikon Publishing Company, Ltd. 1983.
5. Van Geuns, J. Het tegenwoordige standpunt der geneeskundige wetenschap, in betrekking tot het onderwijs. Archief voor Geneeskunde. 1842;2:381-389.
6. Editorial. Nederlandsch Tijdschrift voor Geneeskunde, 1865;1(Eerste Afdeeling):214.
7. Wachelder, J.C.M. Universiteit tussen vorming en opleiding. De moderniseringvan de Nederlandse universiteiten in de negentiende eeuw. (page 137). Hilversum, The Netherlands: Uitgeverij Verloren; 1992.
8. Groen, M. Het wetenschappelijk onderwijs in Nederland van 1815 tot 1980. Een onderwijskundig overzicht. Vol. 1: Wetgeving. Civiel effect. Godgeleerdheid. Rechtsgeleerdheid. Indologie. Geneeskunde (pages 307-374). Eindhoven, Netherlands: Technische Universiteit Eindhoven; 1987.
9. Van Lieburg, M.J. De natuurkundige staatsexamens voor medische studenten en de constructie van een natuurwetenschappelijke basis voor de artsenopleiding tussen 1865 en 1880. Gewina, 1995;18:139-180.
10. Groen, M. Het wetenschappelijk onderwijs in Nederland van 1815 tot 1980. Een onderwijskundig overzicht. Vol. 1: Wetgeving. Civiel effect. Godgeleerdheid. Rechtsgeleerdheid. Indologie. Geneeskunde (page 325). Eindhoven, Netherlands: Technische Universiteit Eindhoven; 1987.
11. Beukers, H. Medical education in the Netherlands in the nineteenth century. In: Ogawa, T. (Ed.). History of medical education. Proceedings of the 6th International Symposium on the Comparative History of Medicine. Susono-shi, Shizuoka, Japan, September 17-24, 1981. (page 203).
    Tokio, Japan: Saikon Publishing Company, Ltd.; 1983.
12. Simon Thomas, A.E. Waar zullen de artsen kunnen gevormd worden? Nederlandsch Tijdschrift voor Geneeskunde, 1865;1(Eerste Afdeeling):468.
13. Wachelder, J.C.M. Universiteit tussen vorming en opleiding. De moderniseringvan de Nederlandse universiteiten in de negentiende eeuw. (page 138). Hilversum, The Netherlands: Uitgeverij Verloren; 1992.
14. Burger, H. Onderwijsbelangen. III. Nederlandsch Tijdschrift voor Geneeskunde, 1910;54(Eerste Helft,3):142.
15. Burger, H. Onderwijsbelangen. IV. De Onderwijsregeling in Duitschland. Nederlandsch Tijdschrift voor Geneeskunde, 1910;54(Eerste Helft,4):204
16. Flexner, A. Medical education. A comparative study (page 69). New York: The MacMillan Company; 1925.
17. Conventscommissie voor de Faculteit der Geneeskunde. Nota over de artsopleiding. Utrecht, The Netherlands: Stafconvent Rijksuniversiteit Utrecht; 1965.
18. Thung, P.J. Medical education in the Netherlands: Recent history and developmental trends. Leiden, The Netherlands: Universitair Medisch Centrum; 1970.
19. Bachmeyer, A.C. Medical schools in Western Europe. The Netherlands. J Med Educ, 1952;27(4, Part Two): 64-75.
20. Van Rijnberk, G.A. Hervorming van de opleiding van den geneesheer. (Reactie op een brief van een doktersvrouw). Nederlandsch Tijdschrift voor Geneeskunde, 1918;62(Tweede Helft,22):1731¬1732.
21. Tuntler, J.H. Praeadvies over de opleiding van den arts, uitgebracht aan het hoofdbestuur der Nederlandsche Maatschappij tot Bevordering der Geneeskunst, door de Sociaal Hygiënische Commissie in Maart 1936. Nederlandsch Tijdschrift voor Geneeskunde. 1937;81(42):5019¬5082.
22. De Waart, A. et al. Rapport van Sectie K. In Reinink, H. J. et al. (Ed.), Rapport van de Staatscommissie tot reorganisatie van het hoger onderwijs (pages 243-244). Den Haag: The Netherlands: Staatsdrukkerij en – Uitgeverijbedrijf; 1949.
23. Groen, M. Het wetenschappelijk onderwijs in Nederland van 1815 tot 1980. Een onderwijskundig overzicht. Vol. 1: Wetgeving. Civiel effect. Godgeleerdheid. Rechtsgeleerdheid. Indologie. Geneeskunde (page 358). Eindhoven, Netherlands: Technische Universiteit Eindhoven; 1987.
24. Julius, H. W.. Reorganisatie of hervorming van het hoger onderwijs in de geneeskunde. Utrecht, The Netherlands: Boekhandel H. De Vroede; 1951.
25. Van Rijnberk, G.A. Een en ander over hooger onderwijs in de geneeskunde. VI. De taak van den hoogleeraar. Nederlandsch Tijdschrift voor Geneeskunde. 1916;60(Tweede Helft,16):1365¬1368.
26. Van Rijnberk, G.A. Hervorming van de opleiding van den geneesheer. 3. Pearce’s denkbeelden. Nederlandsch Tijdschrift voor Geneeskunde. 1918;62(Tweede Helft,21):1655-1659.
27. Van Rijnberk, G.A. De geneeskundige opleiding in Europa, bezien door een Americaan.9. Slotbeschouwingen. Nederlandsch Tijdschrift voor Geneeskunde. 1925;69(Tweede Helft,19):2068-2069.
28. Van Rijnberk, G.A. De geneeskundige opleiding in Europa, bezien door een Americaan. 5. De laboratorium-wetenschappen. Nederlandsch Tijdschrift voor Geneeskunde. 1925;69(Tweede Helft, 15):1644-1647.
29. Flexner, A. Medical education: A comparative study. (p. 261) New York: The MacMillan Company; 1925.
30. Greep, J.M. Medische opleiding in de Verenigde Staten. Nederlands Tijdschrift voor Geneeskunde, 1967;111(16):736-744.
31. Winkler, C. Bijlage IV bij het Rapport van de Commissie Korteweg. Nederlandsch Tijdschrift voor Geneeskunde. 1901;37(Eerste Deel,10):516¬520.
32. Pekelharing, C.A. et al. Rapport der blijvende commissie voor het praktische en het aanvullende geneeskundig onderwijs, benoemd door het hoofdbestuur der Nederlandsche Maatschappij tot Bevordering der Geneeskunst, ingevolge het besluit der Algemeene Vergadering van Dinsdag 10 Juli 1906. Nederlandsch Tijdschrift voor Geneeskunde, 1909;53(Eerste Helft,6):357-384.
33. Noach, E.L. De opleiding van onderzoekers in de geneeskundige basisvakken. Nederlands Tijdschrift voor Geneeskunde. 1958;102(I,1):36.
34. Kuijjer, P.J. De betekenis van de niet-klinische vakken voor de geneeskundige opleiding. Nederlands Tijdschrift voor Geneeskunde. 1965;109(I,23):1090-1091.
35. Boerema, I. Vereenvoudiging van de medische studie. Universiteit en Hogeschool. 1965;12:194¬201.
36. Van Rijnberk, G. A. Een en ander over hooger onderwijs in de geneeskunde. V. Voortzetting van het praeclinische onderwijs in de clinische jaren: Clinische physiologie. Nederlandsch Tijdschrift voor Geneeskunde. 1916;60(Tweede Helft,11):903-905.
37. Goudsmit, J. Anderhalve eeuw dokteren aan de arts. Geschiedenis van de medische opleiding in Nederland. (page 82). Amsterdam, The Netherlands: SUA; 1978.
38. Goudsmit, J. Anderhalve eeuw dokteren aan de arts. Geschiedenis van de medische opleiding in Nederland. (page 72). Amsterdam, The Netherlands: SUA; 1978.
39. Winkler, C. Het hooger onderwijs in de geneeskunde in Nederland. De Gids: Nieuwe Vaderlandsche Letteroefeningen. 1901;10:8-11.
40. Salm, A.J. Over de opleiding der artsen. Nederlandsch Tijdschrift voor Geneeskunde.1906;50(Eerste Helft):108-112.
41. Van Rijnberk, G.A. Een en ander over hooger onderwijs in de geneeskunde. II. De verhouding der praeclinische, “theoretische” en “laboratorium”-wetenschappen, tot de eigenlijke geneeskunde. Nederlandsch Tijdschrift voor Geneeskunde. 1916;60(Tweede Helft,8):595-598.
42. Van Rijnberk, G.A. Een en ander over hooger onderwijs in de geneeskunde. IV. Nadere beschouwingen over de beteekenis en inrichting van het praeclinische onderwijs: Het wetenschappelijk peil van de colleges en het nut der practica. Nederlandsch Tijdschrift voor Geneeskunde. 1916;60(Tweede Helft,10):805¬808.
43. Mulder, J. and Van Rijnberk, G.A. Onderwijsvraagstukken. 9. Nog iets over de opleiding van de artsen in Nederland. Nederlandsch Tijdschrift voor Geneeskunde. 1924;68(Eerste Helft,9):894-898.
44. Boerema, I. Vereenvoudiging van de medische studie. Universiteit en Hogeschool. 1965;12:197.
45. Koster, W. Stemmen uit den vreemde. Nederlandsch Tijdschrift voor Geneeskunde. 1883;19(Eerste Afdeeling,12):187-89.
46. Eijkman, K.H. and Van Rijnberk, G.A. Onderwijsvraagstukken. Iets over de studie in de geneeskunde. Nederlandsch Tijdschrift voor Geneeskunde. 1932;76(Tweede Helft,17):1910¬1914.
47. De Langen, C.D. Enkele vragen inzake het geneeskundig onderwijs. V. Het geneeskundig onderwijs aan onze universiteiten. Nederlandsch Tijdschrift voor Geneeskunde.
    1942;86(IV,43):2618.
48. Mertens, A.Th.L.M. Veranderingen in het curriculum van de medische faculteit te Nijmegen. Nederlands Tijdschrift voor Geneeskunde. 1966;110(39):1706-1708.
49. Galjaard, H. De basisvakken en de geneeskunde. Nederlands Tijdschrift voor Geneeskunde. 1977; 121(43):1723-1726.
50. Prakken, J.R. De medische opleiding. Nederlands Tijdschrift voor Geneeskunde. 1966;110(1):2
51. Veeneklaas, G.M.H. et al., Het medisch onderwijs in Scandinavië en Groot-Brittannië. Nederlands Tijdschrift voor Geneeskunde.
    1965;109(28):1281-1284.
52. Binneveld J.M.W. and Vleesenbeek, H.H. Medische Faculteit Rotterdam. Analyse van een experiment. (page 15). Leiden, The Netherlands: H. E. Stenfert Kroese B.V.; 1976.
53. Burnet, E. Medical education and the reform of medical studies. Quarterly Bulletin of the Health Organisation of the League of Nations. 1933;2(11): 684.
54. Pekelharing, C.A., and Hartman, J.C M. De praktische oefening van den jongen arts. Nederlandsch Tijdschrift voor Geneeskunde. 1910;54(Eerste Helft):1844-1848.
55. Wackers, F. J. Th. Het “Werkplan Kernopleiding” van de Medische Faculteit der Amsterdamse Studenten. Nederlands Tijdschrift voor Geneeskunde,1966;110(1):34-37.
56. Eskes, T.K.A.B. Medische opleiding in de Verenigde Staten. XI. De opleiding van arts en vrouwenarts aan de Western Reserve University te Cleveland, Ohio, U.S.A. Nederlands Tijdschrift voor Geneeskunde. 1967;111(23):1047-1051.
57. Van Lieburg, M.J. De natuurkundige staatsexamens voor medische studenten en de constructie van een natuurwetenschappelijke basis voor de artsenopleiding tussen 1865 en 1880. Gewina, 1995;18:139-180 (quote on page 174).
58. Mulder, J., and Van Rijnberk, G.A. Onderwijsvraagstukken. 3. Vakschool of universiteit? Nederlandsch Tijdschrift voor Geneeskunde. 1923;67(Tweede Helft):2664.
59. Sanders, H. De voorbereidende studiën van de geneeskundige en de natuurkundige examens. Nederlandsch Tijdschrift voor Geneeskunde. 1870;6(Eerste Afdeeling):94.
60. Ter Kuile, Th.E. De universitaire medische studie. (p. 14). Amsterdam, The Netherlands: Scheltema & Holkema’s Boekhandel; 1906.
61. Straub, M. De vorming van den geneeskundige. Rede, bij de aanvaarding van het buitengewoon Hoogleeraarsambt aan de Gemeentelijke Universiteit van Amsterdam, op Maandag 18 Maart 1895. (p. 12) Haarlem, The Netherlands: De Erven F. Bohn; 1895.
62. Burger, H.C. Het onderwijs in de natuurkunde aan de studenten in de geneeskunde. Openbare les gehouden te Utrecht op 11 October 1922. Physica: Nederlandsch Tijdschrift voor Natuurkunde. 1923;3:1-10.
63. Querido, A. Doorgaand verkeer. Autobiografische fragmenten. (page 14) Lochem: Uitgeversmaatschappij De Tijdstroom; 1980.
64. Goudsmit, J. Anderhalve eeuw dokteren aan de arts. Geschiedenis van de medische opleiding in Nederland. (page 68). Amsterdam, The Netherlands: SUA; 1978.
65. Van Rijnberk, G.A. Nieuwe banen voor de geneeskundige opleiding. 2. De jongste denkbeelden in Engeland. Nederlandsch Tijdschrift voor Geneeskunde. 1919;63(Eerste Helft,9):652.
66. Smidt, H.J. Het Academisch Statuut. Koninklijk besluit van 15 Juni 1921, Staatsblad No. 88. Met aantekeningen. Tweede, herziene uitgave. Alphen aan de Rijn, The Netherlands: N. Samson N.V.; 1932.
67. Burger, H.C. How much physics? In: Clegg, H. (Ed.), Proceedings of the First World Conference on Medical Education, London, 1953. Held under the auspices of the World Medical Association. (page 133-139). London, UK: Oxford University Press; 1954.
68. Querido, A. De binnenkant van de geneeskunde. Een autobiografie, opgetekend in samenwerking met Jacky Bax en Ruud Overdijk. (page 24). Amsterdam, The Netherlands: Meulenhoff; 1990.
69. De Waart, A. et al. Rapport van Sectie K. In Reinink, H. J. et al. (Ed.), Rapport van de Staatscommissie tot reorganisatie van het hoger onderwijs (page 247). Den Haag: The Netherlands: Staatsdrukkerij en – Uitgeverijbedrijf; 1949.
70. Rijksuniversiteit Utrecht. Studiegids 1980 (page 101).
71. Van Rijnberk, G.A. Nieuwe banen voor de geneeskundige opleiding. 6. Stemmen uit Oostenrijk. Nederlandsch Tijdschrift voor Geneeskunde. 1919; 63(Eerste Helft):1161-1165.
72. Deelman, H.T. Enkele vragen inzake het geneeskundig onderwijs. XX. Over de plaats van het onderwijs in de pathologie aan de universiteit. Nederlandsch Tijdschrift voor Geneeskunde, 1944; 88(I,1/2):3-6.
73. Groen, M. Het wetenschappelijk onderwijs in Nederland van 1815 tot 1980. Een onderwijskundig overzicht. Vol. 1: Wetgeving. Civiel effect. Godgeleerdheid. Rechtsgeleerdheid. Indologie. Geneeskunde (page 351). Eindhoven, Netherlands: Technische Universiteit Eindhoven; 1987.
74. Actualiteit. Artsen-opleiding. Nederlands Tijdschrift voor Medische Studenten. 1964;10:46¬50.
75. Flexner, A. Medical education. A comparative study. (page 131, footnote). New York: The MacMillan Company; 1925.
76. Pekelharing, C.A. et al. Rapport der blijvende commissie voor het praktische en het aanvullende geneeskundig onderwijs, benoemd door het hoofdbestuur der Nederlandsche Maatschappij tot Bevordering der Geneeskunst, ingevolge het besluit der Algemeene Vergadering van Dinsdag 10 Juli 1906. Nederlandsch Tijdschrift voor Geneeskunde, 1909;53(Eerste Helft,6):361.
77. Buning, E.J., and Van Lingbeek, M.S. De geneeskundige opleiding. Nederlandsch Tijdschrift voor Geneeskunde. 1910;54(Eerste Helft):1489-1490.
78. Donders, F.C. Openingsrede van de zes-en-twintigste Algemeene Vergadering der Nederlandsche Maatschappij tot Bevordering der Geneeskunst. Nederlandsch Tijdschrift voor Geneeskunde. 1875; 11(Tweede Afdeeling):229¬248.
79. Koster, W. Hooger-onderwijs-belangen. Nederlandsch Tijdschrift voor Geneeskunde. 1903;(Eerste Deel,6):281-299.
80. Treub, H. Over medische studenten, medisch onderwijs en medische professoren in Nederland. Openingsrede van de twee-en-veertigste Algemeene Vergadering der Nederlandsche Maatschappij tot Bevordering der Geneeskunst. Nederlandsch Tijdschrift voor Geneeskunde. 1891;27(Tweede Deel,2):65-78.
81. Defares, J.G. Aanvulling van de medische opleiding met onderricht op exact¬wetenschappelijk gebied. Nederlands Tijdschrift voor Geneeskunde. 1958;102(II,32):1569.
82. Oort, J. and Hooghwinkel, G.J.M. Onderwijs in wetenschappelijk onderzoek in de medische basisvakken. Nederlands Tijdschrift voor Geneeskunde. 1967;111(15):689-693.
83. Querido, A. Planning for the new medical faculty of Rotterdam. J Med Educ. 1970;45(6):393-402.
84. Binneveld J.M.W. and Vleesenbeek, H.H. Medische Faculteit Rotterdam. Analyse van een experiment. (page 83-85). Leiden, The Netherlands: H. E. Stenfert Kroese B.V.; 1976.
85. Van Rijnberk, G.A. School en leven. Nederlandsch Tijdschrift voor Geneeskunde. 1921;65(Eerste Helft,13):1674.
86. Halliburton, W.D. The importance of the infinitely little. Lancet. 1921(March 26):628.
87. Van Rijnberk, G.A. Efficiency. Nederlandsch Tijdschrift voor Geneeskunde. 1938;82(III,33):3932-3933.
88. Van Rijnberk, G.A. Onderwijsvraagstukken. X. “Efficiency”, het spook der toekomst. Nederlandsch Tijdschrift voor Geneeskunde. 1924;68(Eerste Helft,14):1491.
89. Petersen, H. Anatomie und Physiologie im vorklinischen Unterricht. Ueber die Rolle der Anatomie im Lehrgang des künftigen Arztes. Klinische Wochenschrift. 1928;7(39):1872-1875.
90. Van Der Werff Ten Bosch, J.J. Differentiatie in medisch onderwijs. Nederlands Tijdschrift voor Geneeskunde. 1973;117(6):230-233.
91. Sanders, H. De genees-en natuurkundige afdeeling van het Athenaeum Illustre en het voor haar gevraagde ius examinandi. Nederlandsch Tijdschrift voor Geneeskunde. 1874;10(Tweede Afd.,7):93-98.
92. Ter Kuile, Th.E. De universitaire medische studie. Amsterdam, The Netherlands: Scheltema & Holkema’s Boekhandel; 1906.
93. Thung, P.J. Medical education in the Netherlands: Recent history and developmental trends. (page 5). Leiden, The Netherlands: Universitair Medisch Centrum; 1970.
94. Tutarel, O. Geographical distribution of publications in the field of medical education. BMC Medical Education. 2002;2:3.