The Yale System lives! Long live the Yale System.

In February, a group of medical students sat down with a copy of the alumni directory and addressed letters to some 5,000 men and women who had studied medicine before them at Yale. The letters contained a statement of concern about what the students perceived as a shift in educational philosophy and a threat to the Yale System, along with a request for support. The students asked alumni to contact administrators and urge them to place limits on the number of required exams (See “Everyone Loves the Yale System”).

One result of the letter-writing campaign has been the culling of a rich assortment of memories of what it was like to study medicine at Yale in recent years and as long ago as the mid-1930s. More than any other facet of the medical school experience, the Yale System seems to touch an emotional chord.

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It has become clear from the events since February that the Yale System is alive and well. When Deputy Dean for Education Herbert S. Chase Jr., M.D., spoke to alumni leaders about the issue in June, he detailed the efforts to strengthen medical education and mentoring at Yale and ended his presentation by affirming, “Long live the Yale System!” It is a sentiment echoed in many of the letters sent to the student committee. Here, with the permission of the authors, is a selection of those comments.

I agree completely that it would be a sad thing to change the Yale System.

Here is how it was during the years 1937 to 1941. At first, we students did not quite understand the examination system. The professors said take them if you want to, take them home if you want to, return them if you want to. It was a nice surprise, and after taking a few, we learned to use them in various ways to make sure we were learning how to be physicians.

How did the faculty find out whether we were learning what we were supposed to?

Personal attention: All, or most, of the faculty knew us by name. Dr. Winternitz greeted me by name at our first meeting, and most of the others did the same.

Face-to-face conversations: Every afternoon those who were free to do so gathered in the large salon at 333 Cedar Street. We were treated by the faculty ladies to coffee, tea, cookies, cigarettes (!) and, in season, fruits. Here we met the faculty, both senior and junior, in small groups, one faculty member and four to six students. We had an hour to an hour and a half of “man-to-man” talks, discussions, even arguments. This happened with such people as Drs. Goodman, Gilman, Blake, Winternitz and most of the others. These get-togethers were at the core of my Yale education. There is no way I can exaggerate their importance in gathering solid knowledge of and feeling for medicine.

Clinical rounds: On rounds in the clinical years, we were with the senior faculty most of the time, again with free discussions of diagnosis and treatments.

I still think of my four years at Yale with gratitude and amazement that so many wonderful people were there to guide me. They were the best four years of my life.
Bjorn Lih, M.D. ’41

The Yale System is a good system that helps establish self-responsibility early. Preceptorships and frequent counseling are probably much more useful than exams, though I think exams should be offered, too. They are a good learning experience and help to emphasize what the faculty feels is important. Grading without counting the grade is tedious for faculty but useful for students. Require taking the exam and grade it, but don’t count the grade.
Henry H. Jones, M.D. ’43 December

As a member of the Class of 1943, I am shocked by the medical education you have described at Yale since my day. Self-assessments, working “at your own pace,” taking time off for “community service” and spending “quality time with family” have no place in medical education!

The school’s responsibility is to teach you the scientific facts you must know to diagnose and treat the sick. It has nothing to do with “community service” unless you work in the ER and go out with the interns to see sick people and bring them back to the hospital or deliver babies, as we did.

In my day we had exams and took them—no self-evaluations (they are obviously prejudiced). We had to complete a research project approved by the head of the department in which we did it, and have it published.

What you are taught, learn and retain in medical school will make the difference between life and death for some patient of yours in the future. It’s a great responsibility, and one of which you will have to face and bear the consequences.

There is “no quality time for family” while you’re in med school nor when you are out practicing. Your patient comes first.

If I were in charge, I would see to it that you graduate knowing what you should, with periodic exams, class attendance taken, final exams and a research project with published paper.

That’s the way it was and should be as far as I’m concerned.
Sophie Trent Stevens, M.D. ’43

The most important piece of information that I learned in medical school, I learned on my first day when Dean Winternitz welcomed us and outlined the next four years for us. He stated that if we were going to succeed in medicine, we should not close our books upon graduation, but should remain students for the rest of our lives. This advice made the practice of medicine for 53 years very enjoyable for me.
A. Reese Matteson, M.D. ’44

My father, John P. Peters, M.D., moved my mother, pregnant with me, to take a position at Yale as professor of medicine in 1921. He was one of the founders of the Yale System and an ardent supporter of it. I first learned of it as a child. For a number of evenings each spring he would close himself into his study to read the written exams given at the end of the second year and read by the Yale faculty. The only marks were pass and fail.

I entered medical school at Yale in June of 1942 under this system. In June of 1943, all but 10 of the students in our class were inducted into the armed services. The faculty stood firm in its protection of the Yale System for the students, privates first class or midshipmen in the Navy. We had the freedom, even under the military, to learn the fundamental lesson that we were responsible for our own education and should continue so for the rest of our lives. We did OK—I got the highest mark in the country in anatomy on the national boards but missed a significant number of lectures and decided not to do any dissection below the knee. We could make sensible judgments, as have now at least 80 classes of Yale medical students.

I had the opportunity to serve on the faculty of two medical schools at their inceptions—the University of North Carolina in 1952 and the University of California, San Diego, in 1969. In both of these schools, a significant number of the early faculty were Yale graduates, and we took segments of the Yale System with us. It is hard for faculty who have not had the privilege of working the system to accept the fact that students can take significant responsibility for their own education. More importantly, if marks and silly tests are not imposed, they will work collegially to educate one another.
Richard M. Peters, M.D. ’45

Northwestern has a modified Yale System and it works well. However, I strongly support the traditional Yale System established in 1921. It not only sets Yale apart—as a graduate school—from other medical schools that act like trade schools but affords freedom of expression and development of lifetime learning habits that are essential to the practice of good medicine.
B. Herold Griffith, M.D. ’48

The Yale System is all right for some students, but there is a significant number of poor students who slip through the cracks and make poor physicians. I think the Yale System should be abandoned. I think that the mandatory thesis requirement should also be abandoned, although I won the Keese Prize for the best thesis in 1948. The sum of the world’s medical knowledge is so great that the students should spend all their time on their medical studies unless they are in the M.D./Ph.D. program.
David E. Morton, M.D. ’48

I am voting for the Yale System as it was in 1950. It was good for me and seemed to be for my classmates. I’ve enjoyed a 36-year career in academic medicine—been the head of two departments, president of my professional society, written a lot of papers—so what’s to change?
Malcolm A. Bagshaw, M.D. ’50

The Yale University School of Medicine formed a model for our development of the new School of Medicine at the University of California, San Diego, from 1964 to 1968. All educational systems need constant surveillance and updating but maintenance of the outstanding and unique qualities is equally important.
Robert N. Hamburger, M.D. ’51 March

Your letter addressed to my late husband, Henry M. Williams, M.D., arrived here today and I read its contents with great interest. One line in particular piqued my attention and aroused a memory. The line is in the second paragraph: “Instead, students have been expected to make responsible decisions about the best use of their own time.”

In his very early days as a medical student at Yale, my husband found that his poor eyesight caused him to take unconscionable amounts of time getting through Gray’s Anatomy. He soon saw that if he were ever to graduate, let alone finish reading the book, something drastic would have to be done.

Here is what he came up with: he sat down and copied—in his own handwriting—the entire Gray’s Anatomy. Then using his own copy, able to read it swiftly and easily, looking back and forth between sections, he was able to read and comprehend the whole thing. I don’t believe he ever forgot a word of it.

I would call this action “responsible and self-driven,” and would place it above “optional self-assessments throughout their body system modules” any time.

I believe my husband would have signed the petition.
Eileen M. Williams, widow of Henry M. Williams, M.D. ’52

At the time I went to medical school, Yale was known as and truly was the only adult medical school in the country. When a large number of students failed Step I of the USMLE 15 years ago, I suspect the deficit was in the faculty or curriculum, not the students or the system. Through the years there have been initiatives to change the system, in many cases coming from faculty members who were threatened by the failure of students to come to their lectures. Instead of looking to themselves to make their lectures worth going to, they blamed the system. In my day, the worthwhile lectures were crowded; the poor lectures were met with near-empty halls, the students choosing the library instead. I suspect the same is true today.

In the real world Yale medical school graduates have always excelled. Please preserve Yale as the truly adult medical school.
Edward J. Gerety, M.D. ’54

Abandoning or even eroding the Yale System will result in Yale graduates being as devoid of curiosity and as boring as most physicians.
Jack Peter Green, M.D. ’57

American education has tended toward narrower, more nearly vocational goals for decades, and that narrowing of focus has always characterized most medical education. You have only to go onto the wards of any hospital to hear discussions of disease management and treatment that seem wholly ignorant of the underlying pathophysiology and unconcerned about the broader context of the symptom under discussion.

Yale has been the blessed exception, and as residency programs—even Yale’s own—seek standardization around some national standard that essentially commodifies physicians and their knowledge and services, the tradition of medicine as broad and unending, self-directed learning is all that promises a worthwhile future to an embattled profession.
David A. Carlson, M.D. ’58

I credit the Yale System with molding the most crucial part of my medical training and fostering the independence of spirit, curiosity and investigatory instincts that are integral to my professional functioning as an academic clinician, investigator, teacher, writer and thinker. Had I been forced to take tests, I would never have graduated; I was too busy absorbing and learning. Yale is a wonderful place to begin a medical career.
Robert N. Taub, M.D. ’61,Ph.D.

I found the Yale System without exams to be more stressful than the pre-med school at Johns Hopkins with frequent exams. There at least you knew where you stood. I strongly favor the old Yale System with its emphasis on original research and the need to write a paper on the topic.
Charles B. Anderson, M.D. ’62

The traditional Yale System is an invaluable asset. Please protect it!
Richard L. Heppner, M.D. ’67

Having mandatory exams will destroy our great traditions. I chose Yale in 1968 over many “cut-throat” institutions, including Harvard and Columbia P&S, because of educational freedom. I flourished in this environment. Yale is at the top because of this educational freedom. Please keep it going!
Joseph L. Renda, M.D. ’68

The Yale System was made for me. I have been greatly influenced by the learning patterns and intellectual disciplines I developed in my four years at Yale, and I am the physician I am largely because of this system. I felt I got a “Swiss cheese” education. It was full of holes and there were many things I hadn’t learned, but I spent most of my days there actively learning, stimulated by whatever I encountered on my serendipitous path that day.

I am a clinical cardiologist, in private practice in one town for my entire 27 years of practice. I follow my patients long term, because the biggest impact I have on their lives is not in the procedures I do but in the care of their chronic diseases. I have chosen to ignore the wishes of our HMOs and of the current generation of family practitioners in this regard, and I have an exceptionally large practice of patients, for whom I often have been the only constant in their care. What I bring to them is largely a product of this Yale System. I read all of the major cardiology journals cover to cover each issue. I know I am the only practicing cardiologist in my state who attends the national meetings in my field every year without exception. I think about the puzzles of cardiac disease and its treatment, I challenge presenters at meetings, I debate the issues with my peers and I bring the day’s harvest of these endeavors to each of my patients every day. I love what I do. I doubt all this would be so were it not for my having attended Yale. I was a good student in college, but Yale medical school, and particularly the trust and freedom of its system, opened doors in my brain I never dreamed existed, and I have inhabited them every day of my life since.
Michael Toren, M.D. ’69

The Yale System worked very well for me. I am eternally grateful!
Jerome H. Meyer, M.D. ’72

Medical education is not winning the battle for humanism, intellectual curiosity and honesty in its medical students, and the medical profession is suffering for it. Preserving student enthusiasm and encouraging self-education are the strengths of a system which has allowed me the ability to “think better” than most of the colleagues I have worked with since I left Yale in 1977. Ruining it in the name of conformity and standards will land Yale in the middle of the deplorable medical educational system that widely exists today and will ensure that its graduates will be indistinguishable from everyone else.
Robert A Sirota, M.D. ’73

When I was in medical school, I studied constantly; never having the assurance of a passing grade on a test caused a lot of anxiety because I would look at the textbook and see only how much I hadn’t learned. It was impossible to learn all, or even half, of the information in most textbooks. The anxiety was productive and led to actual learning and not cramming before an exam. I don’t think I would have studied as hard if there had been exams. Even now, I find I often study, regardless of whether CME credits are available.
Marie Kelly, M.D. ’74

The Yale System comes with a heavy responsibility for the admissions committee and the teaching faculty.

Not everyone belongs at Yale. It takes a highly self-directed, self-motivated, organized person to be successful there. Thus, the admissions interview is more important than MCAT scores. It is far easier for the faculty to hand out a written test than to truly assess a student through first-hand discussion. I do not believe the Yale System excludes student assessment just because there are no tests or grades. I think the faculty knew very well how we students were doing because they made teaching their priority. Teaching was an end in itself; it was not a part-time inconvenience for the teacher. Many students appreciated optional tests, and self-assessment was quite honest.

Medical students are by nature very competitive. The Yale System tempers the negative aspect of that kind of competitiveness, and fosters a camaraderie which grows into the collegial relationships that doctors maintain throughout their stressful careers. The Yale System prepares students in a manner which more directly relates to the realities, the rigors, the values inherent in the practice of medicine. When I see a patient in my office or in the hospital, it is not a written test that I am taking—I must adhere to the high standard that I set for myself when I am entrusted with the heath care of another human being. This is what the Yale System has taught me.

I am proud to be a graduate of Yale, and I know I could not have gotten the same quality medical education anywhere else.
Alan B. Silken, M.D. ’74

I recommend anonymous, coded, periodic self-assessments to help students assess their progress in learning the minimum. Additional independent study should be encouraged and mentoring should begin early. Not all exams need to be mandatory—but the final, anonymous one should be.
Pamela Zeitlin, M.D. ’83

To this day it has served me well. Don’t kill the system!
Alan M. Reznik, M.D. ’83

Dean Berliner called me into his office in my first year at Yale medical school. He told me that if I had merely wanted to become a doctor, I should have gone to school elsewhere. Yale was interested in producing leaders in medicine, not just good doctors. The 15 minutes he spent with me explaining his rationale for the Yale System were among the most influential in my career and life.

Emphasis at Yale has been on self-directed learning, driven by
excitement and love of medicine. The de-emphasis of competition allowed the blossoming of personal social skills and a personal sense of mission separate from one’s personal success. Now middle-aged, I realize that these lessons were the most important in building successful, happy health care delivery teams. Dean Berliner was right. The place of Yale medical school is to produce leaders, not merely doctors.
Calixto Dimas, M.D. ’85

Becoming a physician means making a commitment to lifelong learning. The dates of graduation from medical school or residency are arbitrary points in a career, useful in marking passage from one stage of training to another. However, they in no way represent the completion of an education. Even if you were able to absorb all of the world’s accumulated knowledge in any one field, your knowledge would be shortly out-of-date as our understanding of human physiology and disease rapidly advances.

The Yale System acknowledges the fact that Yale medical students are intelligent, intellectually curious and self-motivated. I have no examiner sitting above me now, making sure that I achieve a passing grade, but I owe it to every patient to continue to learn and to be the best physician that I can be. I feel that the Yale System helped me to incorporate learning into my everyday clinical activities, as a lifelong process and not just as a means to the end of passing a test.

Please do not let one anomalous year bring down a tradition that has been proven worthy over the decades.
Michael Rothschild, M.D. ’88