医院对于医生的训练具有极其重要的价值。在现代高等医学教育中，医院处于医学教 育的中心地位，亦是保证医学教育质量的关键要素。医院在当代医学教育中如此重要，但 追溯历史发现，医院成为医学教育的必要组成部分实际上经历了极其漫长、艰辛且复杂的 历程，期间伴随着临床医学知识的增加、医院的转型等，这种演变历程较为明显地体现在 美国医学教育的发展中。从北美殖民地时期，美国的医学教育是在缺乏医院作为有效支撑 的基础上进行的，医学教育的发展速度极为缓慢。20 世纪初，美国医学教育扭转颓势，医 学教育质量迅速提升，美国医学教育之所以在短时间内取得巨大的成功，与 19 世纪末 20 世纪初医学院为应对临床教学的困境相继建立教学医院密切相关。医学院拥有教学医院后， 医院成为临床医学课程的教学基地，医学院拥有了临床课程的教学空间、临床课程的教学 资源（医院内丰富的病例）、临床课程的师资队伍，医学院进而实施了行之有效的临床教 学方法，临床教学自此成为医学院的正式教学安排，医学院临床教学质量迅速提升。教学 医院的兴起体现了美国医学教育中临床教学的重大变革，美国教学医院的兴起在高等教育 史中意义重大，但学界关于教学医院的兴起历程及其对医学教育的意义尚未给予充分的探 讨。本研究立足整体视野，以宾夕法尼亚大学医学院、约翰·霍普金斯大学医学院、哈佛 大学医学院、哥伦比亚大学内外科医生学院、华盛顿大学医学院为典型案例，探讨了教学 医院兴起的原因，梳理了美国教学医院的兴起历程，总结教学医院兴起的意义与影响。研究得出以下结论：

首先，美国教学医院的兴起主要受到了学科发展的引领、领袖人物的推动、大学医学院的建立、医院的转型这四方面的影响。教学医院兴起的动力因素是临床医学学科的兴起。 从 19 世纪开始，由于外科学与病理解剖学的发展，颠覆了过去一直流行的体液学说，疾 病不再被认为是体液的失调，而是人体局部的损伤，疾病的症状与器官病变有密切的关系。 随之而来的是，关于病变器官的临床诊断知识及技术不断增加，临床医学学科日趋成形。 临床医学的教学区别于传统的医学教学，它需要新型的教学空间，且此空间必须拥有丰富 的教学病例，需要专业的临床师资队伍。临床教学的所有需求，唯有拥有丰富病例、且以 医疗为主题的医院才能满足。19 世纪末 20 世纪初，由于医学科学化的进程导致了医院的 转型，医院由收容空间转变为医疗空间，成为实施临床课程教学的理想场所。与此同时， 在大学医学院中，医学院成为大学的专业学院，在大学的支持下，一批高等医学教育领袖 人物说服医院董事会履行医院的教育培训责任，为医学院临床课程的教学建立教学医院。

其次，美国教学医院的兴起过程，主要经历了三个发展阶段，教学医院的萌芽期、教学医院的建立期及教学医院的发展期。在每一个阶段，医学院与医院的关系呈现出不同程 度的变化，此种变化直接影响了医学院临床课程的教学安排。在教学医院的萌芽期，医学 院使用医院进行教学，但临床教学能否顺利开展取决于医院董事会的态度，此时期，医学 院的临床教学并不稳定，临床教学并没有列入医学院的正式教学安排。在教学医院的建立 期，以宾夕法尼亚大学医学院、约翰·霍普金斯大学医学院为例，医学院拥有了教学医院， 临床课程教学成为医学院的正式教学安排。不仅如此，约翰·霍普金斯大学医学院在临床 课程教学中，施行了临床实习制度，大幅度地提升了霍普金斯大学医学院的临床教学水平， 提高了医学生的培养质量，临床实习制度被弗莱克斯纳称为临床教学的理想范式。在教学 医院的发展期，哥伦比亚大学医学院、哈佛大学医学院、华盛顿大学医学院以约翰·霍普 金斯大学医学院为典范，与附近的医院协商，使其成为医学院的教学医院，在他们的影响 下，1920 年教学医院在美国广泛出现，1926 年，全美所有医学院施行了临床实习制度， 临床课程的教学计划成为全美医学院的正式教学安排，医学院临床教学模式逐渐形成。

最后，教学医院兴起后，美国的临床医学课程的教学发生了巨大的变化。临床教学中教师与学生的身份发生了变化，临床教学中教学方式发生了转变，临床教学中人际关系模 式发生了演变，临床教学中学生的学习资源比以往更加丰富， 临床教学中学生的学习时 间大为拓展，这些变化皆成为提升美国医学教育质量的关键。教学医院的兴起，使医学院 的课程更加完整，课程符合现代医学的发展趋势。教学医院兴起后，对于医院来说，是医 院发展医学教学功能与医学研究功能的正式开始，医院不再将其功能局限于医疗救治，医 院拥有了有组织的教学医疗团队，医务人员对患者的日常护理达到了最高效率。

Hospitals are of paramount value for the training of doctors. In modern higher medical education, although the length of time medical students spend in hospital training varies from country to country, hospitals are at the centre of medical education and are a key element in ensuring the quality of medical education. Despite the importance of hospitals in contemporary medical education, the history of hospitals as a necessary part of medical education has been a long, arduous and complex journey, accompanied by an increase in clinical knowledge and the transformation of hospitals, an evolution that is more evident in the development of medical education in the United States. From the colonial period in North America, medical education in the United States was also based on the lack of hospitals as an effective support, and the pace of development of medical education was extremely slow. In the early 20th century, American  medical education turned the tide and the quality of medical education rapidly improved. The reason for the great success of American medical education in a short period of time is closely related to the establishment of teaching hospitals in succession by American medical schools in the late 19th and early 20th centuries in response to the teaching of clinical medicine.With a teaching hospital in the medical school, the hospital became the teaching base for clinical medicine courses, solving the long-standing dilemma of teaching clinical courses in US medical schools. The quality of clinical teaching at the School of Medicine has rapidly improved. The emergence of teaching hospitals represents a major change in clinical teaching in American medical education and is significant in the history of higher education, but the emergence of teaching hospitals in the United States and their significance for medical education have not been fully explored. This study takes the University of Pennsylvania School of Medicine, Johns Hopkins University School of Medicine, Harvard Medical School, Columbia University College of Physicians and Surgeons, and the University of Washington School of Medicine as typical cases to explore the reasons for the emergence of teaching hospitals, to sort out the history of the emergence of teaching hospitals in the United States, and to summaries the significance and impact of the emergence of teaching hospitals. The study draws the following conclusions:

Firstly, by looking at the emergence of teaching hospitals in the United States, this study found that the emergence of teaching hospitals was influenced by four main factors: the development of the discipline, the promotion of leaders, the establishment of university medical schools, and the transformation of hospitals. The driving factor in the emergence of teaching hospitals was the emergence of the discipline of clinical medicine. From the 19th century onwards, as a result of developments in surgery and pathological anatomy, which overturned the doctrine of humour that had been popular in the past, disease was no longer considered to be a disorder of the humour, but a localized injury to the body, the symptoms of disease were closely related to organ lesions. With this has come an increase in clinical diagnostic knowledge and techniques, and the discipline of clinical medicine is taking shape and occupying an important place in the medical discipline. The teaching of clinical courses differs from traditional medical teaching in that it requires a new teaching space that is rich in teaching cases, a professional clinical faculty, and a new teaching methodology for the teaching of clinical subjects that emphasis the active participation and hands-on practice of medical students. All the needs of clinical teaching could only be met by the modern hospital, which became the ideal place to implement the clinical curriculum in the late 19th and early 20th centuries, as the scientific process of medicine led to the evolution of the hospital into a modern hospital, with medical treatment as its main theme. At the same time, the medical school became a specialist college of the university and, with the support of the university, a group of leading figures in higher medical education worked to persuade hospital boards to fulfil the hospital's responsibility for education and training by establishing teaching hospitals for medical schools.

Secondly, the process of the emergence of teaching hospitals in the United States has gonethrough three main stages of development; the budding period of teaching hospitals, the establishment period of teaching hospitals and the development period of teaching hospitals. At each stage of the development of teaching hospitals, the relationship between medical schools and hospitals in the US showed different degrees of change. During the nascent period of the teaching hospital, medical schools used hospitals for teaching, but the success of clinical teaching depended on the attitude of the hospital's board of trustees. During this period, clinical teaching in medical schools was unstable, and teaching programme for clinical courses were not included in the formal teaching schedule of medical schools. During the period of the establishment of teaching hospitals, in the case of the University of Pennsylvania School of Medicine and Johns Hopkins University School of Medicine, the medical schools had teaching hospitals and clinical courses became part of the formal teaching schedule of the medical schools.

In addition, the Johns Hopkins School of Medicine implemented a clinical clerkship system in the teaching of clinical courses, which significantly improved the level of clinical teaching at the Hopkins School of Medicine and the quality of medical student training, and the clinical clerkship system was described by Flexner as the ideal paradigm for clinical teaching. During the development of teaching hospitals, Harvard Medical School, Columbia Medical School and Washington University School of Medicine, for example, all used the Johns Hopkins University School of Medicine as a model and negotiated with nearby hospitals to make them teaching hospitals for their medical schools. Under their influence, teaching hospitals became widespread in the United States in 1920, and in 1926, clinical internships for medical students, were established in all medical schools in the United States, and clinical courses became a formal teaching programme in medical schools.

Finally, the teaching of clinical medicine in the United States has changed dramatically since the rise of the teaching hospital. Changes in the identity of teachers and students in clinical teaching, changes in teaching styles in clinical teaching, changes in interpersonal patterns in clinical teaching, greater availability of learning resources for students in clinical teaching, and a significant expansion in the time available to students in clinical teaching have been key factors in improving the quality of medical education in the United States. The emergence of teaching hospitals has resulted in a more complete medical school curriculum that is in line with modern medical trends, and the US medical school curriculum has since become a "2+2" model, a "basic medicine curriculum + clinical medicine curriculum". The rise of the teaching hospital was the official beginning of the development of the teaching and research functions of the hospital, which no longer confined its functions to medical treatment, but had an organized teaching and medical team, and the medical staff was able to provide maximum efficiency in the daily care of patients