The modern medical establishment that spends $50,000 or $75,000 upon its fundamental laboratories will, if it is to be equally productive in clinical medicine, spend an equal sum on teaching and investigation during the latter two years,—quite apart from the current maintenance of hospital and dispensary. That is to say, $100,000 to $150,000 will be required at the start to pay the minimum cost of a four-year school of medicine accommodating 250 students and consistently organized along sound lines on both laboratory and clinical sides. The outlay will increase, not decrease, as the school grows, not in number, but in scope and power. The proposed budget may look formidable just now, when compared with the scant provision that has been generally made for medical education in this country under men many of whom have had no real appreciation of what good medical training is, or costs; but as public sentiment and educational intelligence develop, the suggested scale will appear not only modest, but insufficient.
The fees received from such a student body would amount to some $40,000; so that it may be fairly estimated that in such an institution fees will at the utmost pay little more than one-third of the expense, provided that proper hospital and dispensary facilities are already supported by endowment or otherwise. A comforting notion is prevalent that "in time" this proportion will rise, and that losses in attendance due to elevation of standards will eventually be "made up." There is no warrant for this belief. Institutions which have always, or long, operated on a high standard, and thus command an established public, find that expense tends to increase more rapidly than fee income. They persistently seek additional funds that may enable them to push ahead. The number of high standard schools supported will tend to be in some definite relation to the public need; there will be no such disproportion between number and need on a high, as there has been on the low, basis. In other words, the total enrolment will shrink; it will tend to concentrate in fewer schools. Under these circumstances schools which have long enjoyed a comparatively low-grade patronage must cut loose from their past, and begin to cultivate a new clientele. They will probably make slow headway in recovering from the initial shock. Most of them must expire or "merge" before their independent salvation can possibly be worked out. Our conclusion is that established schools, secure of their public on a sound basis, may count on fees to the extent of one-third to onehalf of the expenditure required to conduct a good school of modern medicine; and that as the department becomes more homogeneously developed, the fees will tend to do even less.
It is interesting to compare this hypothetical budget as a whole, and by separate departments, with the actual outlay of our best schools. The Johns Hopkins most nearly represents desirable conditions; for there a teaching hospital belonging to the medical school is supported by adequate and separate endowment, so that clinical facilities impose no burden on the funds of the medical school proper. Moreover, there from the first clinical teachers have been salaried and, in a measure, withdrawn
