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Public Health Classics Public Health Classics This section looks back to some ground-breaking contributions to public health, reproducing them in their original form and adding a commentary on their significance from a modern-day perspective. This month, Charles Boelen reviews Abraham Flexner’s 1910 report to the Carnegie Foundation for the Advancement of Teaching on medical education in the United States of America and Canada. Selected sections of the report are reproduced below. A new paradigm for medical schools a century after Flexner’s report Charles Boelen1 Abraham Flexner’s report, commissioned by the Carnegie The value of the Flexnerian paradigm Foundation, was a remarkable attempt to improve the quality Almost a century after the report, we may question whether the of medical education in North America (1). It was based on sound principles, which may appear trivial today: medical Flexnerian paradigm is still relevant to meet the challenges of schools should be university based and their educational today. Does it sufficiently prepare medical schools to respond programmes should have a solid scientific basis. Almost a optimally to society’s needs and the requirements of health century later, its influence on medical schools is still felt systems? Clearly, the report has stimulated generations of worldwide. medical educators to design medical curricula based on a better In his report, Flexner demonstrated both vision and understanding of the scientific foundations of life and disease. courage. He was a strong advocate for the adoption of high However, we need to acknowledge that its scope needs to be standards in the preparation of future physicians. In suggesting considerably widened if we are to understand better the basic that physicians should practise medicine with a critical mind, determinants of health and expect medical schools and medical always searching for evidence for the appropriateness of their education in general to play a more proactive role in health decisions, he broke away from the then-current approach of development. physicians, who displayed arrogance and ignorance. He had The emphasis on the biomedical and hospital-centred great hopes for physicians, expecting their function to become model of the Flexner report has contributed to shaping many ‘‘social and preventive, rather than individual and curative’’. medical educational programmes in a reductionist fashion. As a In keeping with his principles, he suggested a drastic result, there is little room for the social, psychological, and reduction in the number of medical schools in the USA from economic dimensions of health and the better use of the wide 155 to 31, arguing that those not meeting the proposed spectrum of health resources beyond medicine and its standards and not offering society the high-quality doctors it physicians. Too many Flexner followers have regarded his deserves should close down. He condemned ‘‘commercial’’ thinking as exhaustive and have not questioned his recom- schools, which produced lots of ill-trained doctors and mendations. They should, however, have applied Flexner’s introduced the concept of social need, with the corollary that own critical approach and considered a wider core of principles a school should be ‘‘a public service corporation’’. and approaches which could enable medical schools to fulfil Such observations and his suggested remedial actions their mission better in meeting people’s health needs. were certainly relevant but were ahead of the current thinking. Although the recommendations in the report had the Nevertheless, his recommendations for the ‘‘reconstruction’’ of great merit of focusing on the search for excellence in the medical education have been generally applied to medical preparation of future physicians, they may have also diverted schools in North America and subsequently across the globe. attention away from other aspects affecting the impact of Strict policies on student admission into medical school, a strong educational strategies on the way physicians practise and health emphasis on basic sciences in the educational programme, the services are organized and delivered — the very things a use of a university hospital for ample clinical exposure, and the reformed medical education system was supposed to improve. availability of ‘‘laboratories’’ and appropriate facilities are some It may be that Flexner made the implicit assumption that good of Flexner’s criteria which have been widely used to assess the medical education is the beginning of a cascade of events that quality of medical education. The essence of his recommenda- would eventually determine the quality of medical practice, the tions is clearly perceptible in most of the evaluation and distribution of the medical workforce, the performance of accreditation systems now in use throughout the world. health services, and eventually the health status of people. To 1 International Consultant in Health Systems and Personnel (formerly Coordinator of Human Resources for Health, World Health Organization, Geneva, Switzerland). Correspondence should be addressed to Dr Boelen at 585 route d’Excenevex, 74140 Sciez-sur-Le´man, France (email: [email protected]). Ref. No. 02-0252 592 Bulletin of the World Health Organization 2002, 80 (7) Molecular epidemiology of tuberculosis my dismay, this assumption is still widely held today. Even if should demonstrate how these products contribute to not openly expressed, the impression is too often given that improving quality, equity, relevance, and cost-effectiveness medical education is a cornerstone in health, whereas it should in health services. The concept of ‘‘social accountability’’ can be seen as one important part interacting with others in the be defined as ‘‘the obligation [of medical schools] to direct their health system. In my opinion, Flexner’s report is at least partly education, research and service activities towards addressing responsible for sustaining the former view. the priority health concerns of the community, region and/or The reality is that the majority of forces acting on nation they have the mandate to serve. The priority health physicians’ behaviours (e.g. career choices, establishment of concerns are to be identified jointly by governments, health practices, participation in quality-improvement programmes, care organizations, health professionals and the public’’ (3). existence of a reward system, conducive working environment, Medical schools could be grouped into categories and general performance of a health system) are poorly according to their degree of social accountability. Consistent correlated with the endeavours of medical educators. How- with Flexner’s view, the setting of standards and informing the ever, medical schools and medical educators could certainly public how medical schools meet the standards are important play a significant role in ensuring that medical education issues. Standards should be established to help assess the levels contributes to a greater extent in meeting the priority health by which medical schools respond to societal needs, by concerns of people, individually and collectively. To do this, following up their graduates and ensuring that they perform as they would need to have a strategic vision of the principal well as expected. This is now being seen as a natural extension factors interacting in the health system, which influence of the educational mission of medical schools. It would imply people’s health and the attitudes of health professionals. They that they will eventually engage in health system research — would also need to be willing to take action related to these which is beyond their current educational activities — to factors, going beyond their current educational strategies. This influence the future working environment in which their would require a fundamental shift in mindset in those graduates will function and that such research activities should responsible for the design or redesign of institutions as well be designed and implemented in partnership with other as of action programmes. People’s health needs need to be stakeholders, such as policy-making bodies and professional taken as a starting, and not as an end point. associations. Interestingly enough, in his report Flexner does hint at In reading his report, I think that Flexner would some important factors influencing the wider health context, sympathize with this new approach. He refers to ‘‘educational presumably having been aware that they may affect the impact patriotism’’ to depict the moral obligation of medical schools to of the educational reforms he advocates. For example, he do their utmost to serve the public interest. When applied to refers to concepts such as the ‘‘patriotism’’ of institutions, the the medical profession, he calls this ‘‘medical patriotism’’. He role of the medical profession, the need for a fair geographical therefore encourages both universities and medical associa- distribution of medical manpower, and general accountability tions to share a common vision and commitment in putting the to the public, but elaborates only briefly on them and only social cause ahead of their private interests. His concerns for an through the perspective of medical education. Obviously, his equitable distribution of well-trained physicians in under- reflection on a reform process in medical education was not staffed areas and for fair access of black citizens to medical based on a rigorous approach to health systems. Although I education — with
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