CONTRIBUTORS: Shari L. Barkin, MD, MSHS,a Elena Fuentes-Afflick, MD, MPH,b Jeffrey P. Brosco, MD, PhD,c and Arleen M. Tuchman, PhDd aDepartment of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee; Departments of bPediatrics and Epidemiology and Biostatistics, University of California, San Francisco, California; cDepartment of Pediatrics, University of Miami, Miami, Florida; and dDepartment of History, Vanderbilt University, Nashville, Tennessee Address correspondence to Shari L. Barkin, MD, MSHS, 8232 Doctor’s Office Tower, 2200 Children’s Way, Nashville, TN 37232-9225. E-mail: shari.barkin@ vanderbilt.edu Accepted for publication Sep 21, 2010 doi:10.1542/peds.2010-2050 Unintended Consequences of the Flexner Report: Women in Pediatrics

The 1910 Flexner report is recognized as a critical compo- toured medical schools throughout the country to gather nent of the transition to the current model of medical edu- information about current standards of education. His re- cation. Within a decade of the report’s publication, the cur- port, which was considered provocative when it was issued riculum of nearly every American medical school included 2 in 1910, indicted the quality of medical education in most years of basic science education and 2 years of clinical American medical schools. The recommendations focused apprenticeship. By midcentury, the practice of medicine fo- on rigorous entrance requirements, longer periods of cused on acute care visits and technologically sophisticated study, and more attention to the basic and clinical sciences. procedures performed in hospitals. As we mark the 100th The principles in the report enshrined an educational model anniversary of the Flexner report, it is also important to draw attention to one of the unintended consequences of that favored the laboratory over the bedside, the hospital Flexner-era reforms, namely, the near elimination of women over the home, and the physician-as-researcher over the in the physician workforce between 1910 and 1970. In this physician-as-practitioner.1,2 The Flexner report by itself did essay we briefly trace the history of women in medicine in not transform medical education in the United States, al- the decades surrounding the Flexner report and suggest though it has come to symbolize Progressive-Era reforms some implications for the future of pediatrics at a time that led to our current system. The ideas reflected in the when women outnumber men. report, which had been promoted by leaders in medical education since the late19th century, fit neatly into broader THE FLEXNER REPORT: AN OVERVIEW In the late 19th cen- trends in American medicine, such as the increasing appre- tury, there were hundreds of medical schools in the United ciation of science, the growing complexity of medical prac- States, and the quality of medical education varied substan- tice, and the newfound power of organized medicine.3 tially. Generally, medical schools offered minimal training in basic science, and few schools provided their students with FEMALE PHYSICIANS IN THE 19TH CENTURY: PREVENTION the opportunity to acquire clinical skills. Concerned about AND PUBLIC HEALTH In the period just before the Flexner this situation, the American Medical Association worked report, female physicians had a significant presence in with the Carnegie Foundation to hire a professional educa- many parts of the United States. When all-male medical in- tor, Abraham Flexner, to review the state of medical educa- stitutions refused to admit them, women created their own tion in the United States. Flexner chose the Johns Hopkins schools and hospitals, some of which rivaled all-male phy- Medical School as the model educational system, and he sician institutions in prestige and health outcomes.4 Eventu-

PEDIATRICS Volume 126, Number 6, December 2010 1055 Downloaded from www.aappublications.org/news by guest on October 2, 2021 ally, the struggle to integrate all-male institutions paid off. Physicians and other child advocates incorporated new sci- By the 1870s, women could choose from a number of co- entific understandings of germ theory into public health educational institutions in the United States, such as the campaigns to reduce infant mortality rates by promoting University of Michigan and the University of Iowa, as well as breastfeeding, educating parents, and mandating pasteur- a few institutions in Paris and Zurich. In 1892, when Johns ization of milk. The dramatic decrease in infant mortality in Hopkins Medical School agreed to accept women in its in- the 20th century was probably more strongly related to these augural class, women believed that the hardest battles had public health interventions than the efforts of individual physi- been won.4,5 From 1880 to 1900, the number of female phy- cians at the bedside.12 Although male physicians contributed to sicians doubled (to 5.6%), and in some cities such as Boston, these changes, female physicians were disproportionately Massachusetts, and Minneapolis, Minnesota, nearly 1 in 5 drawn to translational policy efforts to address the compelling physicians was female. Although England had 258 female public health issues of the day at a time when they represented physicians and France just 95, the United States could boast only a small proportion of physicians. more than 7000 female physicians.3,6 THE CONSEQUENCES OF THE FLEXNER-ERA REFORMS FOR Female physicians had opened the doors to medical school FEMALE PHYSICIANS Although a number of medical in part by arguing that they possessed unique skills that schools had already implemented the tenets of the Flexner would transform the practice of medicine. Elizabeth Black- report by 1910, Flexner’s role in transforming medical edu- well defined medicine as the caring profession par excel- cation quickly expanded when some foundations decided to lence and insisted that women’s maternal instinct, either distribute funds only to those medical schools that followed potential or realized, endowed them with a unique and nat- the Hopkins model. Many medical schools closed after the ural capacity to heal. Other physicians, such as Marie Zakr- Flexner report was issued, particularly schools that edu- zewska, rejected the biological arguments about women’s cated female, black, and working-class students.1 For exam- unique qualifications to be physicians,7 yet most women gravitated toward such specialties as pediatrics, obstetrics, ple, 5 of 7 historically black medical colleges closed in the 3 gynecology, and preventive medicine. Blackwell, Zakrze- wake of Flexner-era reforms. In 1900 there were 7 women’s wska, and others recognized the need for profound changes medical colleges in the United States; by 1930, only the Wom- in health systems, in part because women and children ex- en’s Medical College of Pennsylvania remained. The propor- perienced high rates of morbidity and mortality, and they tion of women who graduated from medical school de- dedicated themselves to careers that incorporated advo- creased to an all-time low shortly after the Flexner report cacy and public education into clinical practice. This pio- was issued (2.9% in 1915), and the proportion remained 10 neering generation of female physicians joined a relatively below 5% until the 1970s, when radical social forces chal- small, but effective, group of male physicians such as Abra- lenged the barriers that prevented women from studying 13 ham Jacobi, who advocated for health system change to medicine. Overt discrimination at co-educational institu- address the health needs of children, the poor, and other tions, such as gender-based quotas, had succeeded in lim- disadvantaged populations.6,8–10 iting women’s acceptance to medical schools, but the loss of female role models also contributed to the institutionaliza- For example, at the turn of the 20th century, female physi- tion of an unwelcoming atmosphere for female students. cians played a critical role in public health campaigns to Moreover, the Flexner report recommended longer periods reduce infant mortality. The infant mortality rate was con- of study, which may have limited women’s ability to finance sidered an important measure of societal health and well- medical studies. Although the decrease in female medical being, and many US cities reported rates that exceeded 100 students may have been multifactorial, the transformative deaths per 1000 live births in the early 1900s.11 To address dream shared by the pioneering female physicians at the the problem of infant mortality and other public health is- beginning of the 20th century faded within a decade of the sues, female physicians assumed leadership positions in Flexner report. departments of public health and preventative medicine, as exemplified by Dr Josephine Baker, who led New York City’s MARKING THE CENTENNIAL: A HISTORIC JUNCTURE Indi- first Division of Child Hygiene. Dr Baker helped shape health vidual physicians make many decisions that shape their policy for public health practice throughout the United path in medicine: choosing a specialty; deciding whether to States and emphasized the social determinants of health.9 pursue research; selecting a practice setting; and determin-

1056 BARKIN et al Downloaded from www.aappublications.org/news by guest on October 2, 2021 PEDIATRICS PERSPECTIVES ing how to balance home and work. Before the Flexner-era 2. Hudson RP. Abraham Flexner in perspective: American medical edu- reforms, female physicians generally made different cation 1865–1910. Bull Hist Med. 1972;46(6):545–561 choices than their male counterparts; women were more 3. Starr P. The Social Transformation of American Medicine. New York, NY: Basic Books; 1982 likely to choose specialties that emphasized prevention and 4. Morantz RM, Zschoche S. Professionalism, feminism, and gender the translation of science into improvements in public roles: a comparative study of nineteenth-century medical therapeu- health. When traditional career paths were closed to tics. J Am Hist. 1980;67(3):568–588 women, they took advantage of the opportunities available, 5. Bonner TN. To the Ends of the Earth: Women’s Search for Education in Medicine. Cambridge, MA: Harvard University Press; 1992 and some female physicians became leaders in fields such 6. Walsh MR. Doctors Needed: No Women Need Apply—Sexual Barriers as occupational health, child health, and maternal health. in the Medical Profession, 1835–1975: New Haven, CT: Yale University Despite these gender differences in practice patterns, how- Press; 1977 ever, women did not have a major impact on American med- 7. Tuchman AM. Science Has No Sex: The Life of Marie Zakrzewska, M.D. Chapel Hill, NC: University of North Carolina Press; 2006 icine in the late 19th century, partially because they repre- 8. Bittel C. Mary Putnam Jacobi and the Politics of Medicine in sented such a small proportion of physicians, even at their Nineteenth-Century America. Chapel Hill, NC: University of North Caro- peak. Today, a century after the Flexner report, we have lina Press; 2009 witnessed a gender revolution in medicine, and women con- 9. Morantz-Sanchez R. Sympathy and Science: Women Physicians in American Medicine. Chapel Hill, NC: University of North Carolina Press; 14 stitute more than half of American medical students and 2000 15 more than 70% of residents in pediatrics. 10. More ES. Restoring the Balance: Women Physicians and the Profes- As today’s pediatricians revisit the history of foremothers sion of Medicine, 1850–1995. Cambridge, MA: Harvard University; 1999 such as Drs Blackwell and Zakrzewska, they may draw in- 11. Brosco JP. The early history of the infant mortality rate in America: “a reflection upon the past and a prophecy of the future.” Pediatrics. spiration from the strength and creativity that these women 1999;103(2):478–485 showed in the face of daunting institutional barriers. Physi- 12. Meckel R. Save the Babies: American Public Health Reform and the cians in the 21st century could tap into the pioneers’ commit- Prevention of Infant Mortality. Baltimore, MD: Johns Hopkins Univer- sity Press; 1990 ment to translational science and public health and search for 13. Ludmerer KM. Learning to Heal: The Development of American Medical ways to create new career choices that allow physicians to Education. Baltimore, MD: Johns Hopkins University Press; 1996 effectively address the social determinants of health. 14. Riska E. Towards gender balance: but will women physicians have an impact on medicine? Soc Sci Med. 2001;52(2):179–187 REFERENCES 15. Althouse LA, Stockman JA 3rd. Pediatric workforce: a look at general 1. Ludmerer KM. Commentary: understanding the Flexner report. Acad pediatrics data from the American Board of Pediatrics. J Pediatr. Med. 2010;85(2):193–196 2006;148(2):166–169

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

PEDIATRICS Volume 126, Number 6, December 2010 1057 Downloaded from www.aappublications.org/news by guest on October 2, 2021 Unintended Consequences of the Flexner Report: Women in Pediatrics Shari L. Barkin, Elena Fuentes-Afflick, Jeffrey P. Brosco and Arleen M. Tuchman Pediatrics 2010;126;1055 DOI: 10.1542/peds.2010-2050 originally published online November 8, 2010;

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Downloaded from www.aappublications.org/news by guest on October 2, 2021 Unintended Consequences of the Flexner Report: Women in Pediatrics Shari L. Barkin, Elena Fuentes-Afflick, Jeffrey P. Brosco and Arleen M. Tuchman Pediatrics 2010;126;1055 DOI: 10.1542/peds.2010-2050 originally published online November 8, 2010;

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Pediatrics is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. Pediatrics is owned, published, and trademarked by the American Academy of Pediatrics, 345 Park Avenue, Itasca, Illinois, 60143. Copyright © 2010 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 1073-0397.

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