The Flexner Report ― 100 Years Later

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HiSTORiCAl PERSPECTivES iN MEDiCAl EDuCATiON

The Flexner Report ― 100 Years Later

Thomas P. Duffy, MD

Yale School of Medicine, New Haven, Connecticut

The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the bio - medical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchant - ment with German medical education that was spurred by the exposure of American edu - cators and physicians at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system al - lowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is under way to realign the professional commit - ment of the physician with a revision of medical education to achieve that purpose.

In the middle of the 17th century, an cathedrals resonated with Willis’s delin - extraordinary group of scientists and natu - eation of the structure and function of the ral philosophers coalesced as the Oxford brain [1]. Circle and created a scientific revolution in the study and understanding of the brain THE HOPKINS CIRCLE and consciousness. Thomas Willis, a stu - dent of William Harvey, Christopher Wren, A similar combustion of shared Robert Boyle, and Robert Hooke were syn - thought and imagination occurred at the be - ergetic with one another in a shared scien - ginning of the 20th century when a group tific exploration. Christopher Wren’s of men who comprised what may be called subsequent splendid achievement in the ar - the Hopkins Circle joined in a project that chitectural design of St Paul’s and other altered the course of medical education in

To whom all correspondence should be addressed: Thomas P. Duffy, MD, Yale School of Medicine, 333 Cedar Street, New Haven, CT 06510; Tele: 203-785-4744; Fax: 203-737- 4344; E-mail: [email protected].

Keywords: Abraham Flexner, William Welch, William Osler, Simon Flexner, Johns Hopkins, William Gates, William Pritchett, German Medical Training, full-time system, Carnegie Foundation, John D. Rockefeller, Theodor Billroth, medical professionalism 269 270 Duffy: The Flexner report ― 100 years later

America. They erected an edifice, not of background and training made him an out - bricks and mortar, but an edifice that became lier in the Circle. He was the sixth of seven the system of medical education that we siblings in a Louisville, Kentucky, Jewish know more than a century later. Their suc - family whose father was a struggling but un - cessful efforts resulted in the science-based successful business man. Education and foundation of medical training that has made being well educated had become the secular the United States the recognized leader in faith that replaced religious orthodoxy for medical education and medical research Abraham and most of his siblings. He was today. Much of the credit for this transfor - able to attend Johns Hopkins University mation has been appropriately attributed to through a gift and beneficence of his older Abraham Flexner and his critique of med - brother, Simon, who was then a pharmacist ical education contained in his Flexner Re - in Louisville and later achieved great emi - port of 1910 [2]. The contributions of nence as the head of the Rockefeller Insti - several other members of the Hopkins Circle tute. Abraham majored in Greek and Latin should not be overlooked, nor the impor - and philosophy at Hopkins, completing his tance of the synergy that the Circle gener - college studies in only two years; the accel - ated underestimated. erated course in college was a necessary fi - The membership of the Circle affirms a nancial stratagem for the family. After particularly American phenomenon in which college, he returned to Louisville, where he an aristocracy of excellence was not defined assumed the role as major support of his by one’s origins or wealth, although wealth family by teaching high school; he recipro - permitted the group’s recommendations to cated the kindness of Simon by underwrit - be successful. The group consisted of a Con - ing his medical schooling and his sister’s necticut Yankee and Yale graduate, William education at Bryn Mawr. His talents as a Welch, the founding dean at Hopkins, a teacher generated a large following that fa - school established from the fortune of a cilitated his establishment of a private high Quaker merchant, Johns Hopkins. Welch school, where his visionary concepts of ed - was in large part the mastermind creator of ucation were instituted and refined. His ed - Hopkins and its extensive reach and influ - ucational philosophy resembled that of the ence in medical education; he was responsi - progressive model of John Dewey in which ble for the selection of William Osler, the students learned by doing, by solving prob - Canadian son of a frontier minister, as its lems, rather than rote memorization that was first chief of medicine. A third member of the more common educational motif of the the group was Frederick Gates, a Baptist day. It was a philosophy that he would trans - minister and trusted adviser to John D. late into his transformation of medical edu - Rockefeller. He was galvanized to help im - cation in America [4]. prove the scientific and therapeutic store of The success of the school and money medical knowledge that he had recognized obtained from its subsequent sale were as being seriously impoverished following Flexner’s ticket out of Louisville; in the his reading of Osler’s Textbook of Medicine . next few years, he pursued an MPhil at Gates became the intermediary, the go-be - Harvard in philosophy and journeyed to tween, who convinced Rockefeller to pro - Europe, where he visited schools in Great vide his philanthropic resources to achieve Britain, France, and, particularly, Germany. the goals of the group [3]. His continental seasoning was focused upon university medical education in these countries, paralleling the then common ABRAHAM FLEXNER, THE EDUCATOR practice of young American physicians in AND REFORMER completing their medical studies abroad. It The final member of the Circle was was out of his practical experience as an Abraham Flexner, a former school teacher educator in America and his exploration of and expert on educational practices whose pedagogical strategies in Europe that he Duffy: The Flexner report ― 100 years later 271

distilled his critiques of and correctives for FLEXNER AND THE GERMAN SYSTEM OF MEDICAL EDUCATION American schooling in his book, The Amer - ican College . Flexner and his expertise Flexner prepared for his task by im - came to the attention of Henry Pritchett, mersing himself in the literature of medical head of the Carnegie Foundation, upon education, and he specifically identified reading The American College . At the time, Theodore Billroth’s book Medical Educa - the Foundation had identified improvement tion in the German Universities [5] as his of health care in America as the primary major primer. Throughout his life, he was an focus of its philanthropic concern. To ardent proponent of the German pedagogic achieve this purpose, the foundation mem - style of medical education. He was resolute bers correctly surmised that improvement in his belief that medicine was a scientific in the very sorry state of medical schooling discipline that could be best realized by in America was necessary; they invited using the German model as the prototype in Abraham Flexner to survey the quality of America. This was a system in which physi - medical schools throughout America and cian scientists were trained in laboratory in - Canada and provide suggestions for their vestigation as a prelude and foundation for improvement. clinical training and investigation in univer - Flexner was an unorthodox and sur - sity hospitals. All physicians had a respon - prising candidate for the task he was asked sibility to generate new information and to undertake. Flexner himself was quizzi - create progress in medical science, with as - cal about the summoning, suspecting that signment of this task to both laboratory and he was being confused with his brother, clinical scientists. Science, as the animating Simon. At the time of the job offering, the force in the physician’s life, was the overar - former high school teacher had never been ching theme, the zeitgeist, in Flexner’s con - in a medical school. This shortcoming ception of the ideal physician. might have seemed an insurmountable im - Flexner also sought the advice of mem - pediment for successful performance of his bers of the AMA Committee and the Carnegie assigned task, but the choice of a non- Foundation; he particularly listened to the physician was purposeful on the part of counsel of William Welch at Hopkins, who Pritchett and his associates. They perceived had now assumed a leadership role, an almost the problem of medical education as a grandfatherly one in all things educational in problem of education and believed a pro - American medicine. Flexner’s enchantment fessional educator was better qualified to with things German would have been bol - address this dimension of the problem. stered further by Welch’s counsel since the They also had preconceived ideas concern - German model of medical education was al - ing what changes needed to be made in ready in place at Hopkins in the aftermath of medical schools to allow these ideas to be Welch’s earlier European visits. Hopkins’ stu - introduced. The ideas Flexner popularized dents spent their first two years in the basic were those that had already been developed laboratory sciences before progressing to their within medical schools before the turn of clinical training on wards in a university hos - the century. Pritchett and colleagues also pital. The quality of the student body was as - were concerned that antagonisms would be sured by requiring that all students had a generated by the report, which might be university education prior to admission to less vengeful if a non-physician were the medical school. It is no wonder that Flexner object of the resentments. An unflattering chose Hopkins as his gold standard with but not necessarily inaccurate description which all other schools were compared in his for Flexner’s assignment was that he was survey of American medical schools. His def - to be the hatchet man in sweeping clean the inition of excellence had already been con - medical system of substandard medical ceived of and implemented by the other schools that were flooding the nation with members of the Hopkins Circle. Welch had poorly trained physicians. voiced these ideas 10 years earlier. 272 Duffy: The Flexner report ― 100 years later

In an address delivered in 1901 at the tween the practicing physician and the basic 200th anniversary of the founding of Yale scientist. Flexner’s task was greatly facili - College, Welch spoke on “The Relation of tated by the coalescence of all of this energy Yale to Medicine” [6] and described the mu - invested in improving medical education in tual benefit that a union of the university and America. medical school created. He emphasized the need for well-equipped and well-supported THE FLEXNER REPORT laboratories and a body of well-paid teachers thoroughly trained in their special depart - Equipped with extensive book knowl - ments. He was bold enough to state that edge and not a few prejudices and precon - there could be no nobler work for a univer - ceptions, Flexner demonstrated near sity than the promotion of medical studies. superhuman industry and energy in carry - William Osler voiced the same prescriptions ing out his review of American/Canadian for medical education in his farewell ad - medical education. He crisscrossed the dress, “L’envoie,” delivered in 1905, shortly United States and evaluated institutions before leaving Baltimore to assume the from the point of view of an educator and Regius Professorship at Oxford [7]. Osler not a medical practitioner. Questions re - echoed Welch’s message and included a garding the clinical facilities available for salvo to German medical schools and the teaching purposes were few and brief to the rigor of their scientific training. He said one dean and professors of the clinical depart - of his ambitions during his tenure at Hop - ments. Flexner was mainly interested in the kins was to build up a great clinic on Teu - extent to which the school enjoyed rights or tonic lines, not on those previously followed merely courtesies in the hospitals identified in America and in England, but lines that in the school catalogue. Admission stan - had proved so successful on the continent dards, physical facilities, especially well- and which had placed the scientific medicine equipped laboratories, and instruction by of Germany in the forefront of the world. physician scientists were the other major Osler also made a very significant con - criteria for judging the quality of the edu - tribution to the realization of Flexner’s task cation offered. Schools were assigned to by helping to create the Interurban Clinical one of three categories on the basis of his Club in 1905 [8]. The purpose of this organ - evaluation: A first group consisted of those ization was the exchanging of ideas and the that compared favorably with Hopkins; a nurturing of fellowship among medical pro - second tier was comprised of those schools fessors in the leading Eastern medical considered substandard but which could be schools. Its aims included several goals that salvaged by supplying financial assistance Flexner’s conception of medical education to correct the deficiencies; and a third group also incorporated; scientific investigation of was rated of such poor quality that closure disease was promoted, and methods of was indicated. The latter was the fate of teaching were to be shared and improved. one-third of American medical schools in The club was largely responsible for the de - the aftermath of the report. A majority of the velopment of the scientific base of Ameri - medical schools were rated as defective can medicine. It was the springboard to with low admission standards, poor labora - eminence for department and divisional tory facilities, and minimal exposure to heads of the leading medical schools in clinical material. Medical education at the America. These were the individuals who turn of the century was a for-profit enter - forged institutional philosophies and stan - prise that was producing a surplus of poorly dards of excellence in medical schools trained physicians. The enactment of state throughout the next century. The era of the licensing laws put teeth into the indictments clinical scientist in America dates from this of the report. Flexner sounded the death organization; its members were academic knell for the for-profit proprietary medical physicians who became the vital link be - schools in America. Duffy: The Flexner report ― 100 years later 273

THE FULL TIME SYSTEM IN ucation of students to that effect as more im - ACADEMIC MEDICAL SCHOOLS portant priorities, although he reverenced The Flexner Report was embraced as the centrality of scientific knowledge in that the definition of the academic model that regard. His mentee, Harvey Cushing, voiced was to characterize American medical edu - the same sentiments, basing his reservations cation up to the present. Its success was im - on his background of several generations of portantly assured by the huge financial gifts practicing physicians. Their voices were of the Rockefeller and Carnegie Founda - hushed by the irresistible seduction of large tions ― this single model of medical educa - sums of money tied to implementation of the tion required large sums to support the full-time system. Osler’s voice also was near scientific focus at its core. The powerful silenced and no longer a force in this matter stimulus of philanthropy money also af - following his move to Oxford at the time fected the fashion in which medical faculty this controversy was taking place. William would live their lives in academic medicine; Welch, the Carnegie and Rockefeller foun - this was the important introduction of the dations, and Abraham Flexner were suc - full-time system in medical schools. Med - cessful in the task they had set out to ical professors were to be freed from any accomplish. major responsibilities for patient care and could dedicate their lives to research and THE FLEXNER REPORT ― THE teaching. It was the example established in PATH NOT TAKEN German universities during the 1880s, where the practice was observed by Welch, The success of the reorganized medical who became a major proponent of the inno - training has been awesome in the breadth vation. The advancement of knowledge was and depth of understanding and discovery. to trump all other involvements in the aca - Its achievements are so evident that enu - demic physician’s life. Provision of an ade - merating them is somewhat unnecessary. quate salary for the full-time faculty would The Puritan ministers and their descendents guarantee that fees generated from patient would be dumbstruck by so much that has care would not be pursued and distract from been realized; Frederick Gates would reel on research. A McGhee Harvey, chairman of learning of the uncoding of the human the Department of Medicine at Hopkins at genome, which has become the newest sec - mid-century, believed that no single event ular Bible of science for many. The Hopkins had a more profound effect upon medical Circle was responsible for creating a path - education and medical practice than this way that has taken mankind to the stars. movement. Still, a question can be raised, needs be But the full-time system was not with - raised, as to the cost incurred by this jour - out its serious critics. The most vocal chal - ney, filled as it unquestionably is, with mar - lenger and naysayer was William Osler, who vels. Did the Hopkins Circle take the was subsequently seconded by Harvey profession down a pathway that threatened Cushing. Osler believed that the focus of the loss of what should be non-negotiable such physicians would be too narrow, they for all physicians, academic or not? Did the would live lives apart with other thoughts Flexner Report overlook the ethos of medi - and other ways [9]. He was apprehensive cine in its blind passion for science and ed - that a generation of clinical prigs would be ucation? What was the cost of our success, created, individuals who were removed from and who has borne that burden? Review of the realities and messy details of their pa - medical care in the last century documents tients’ lives. Osler believed that the Flexne - that the trust and respect that were extended rians had their priorities wrong in situating to the profession 50 years ago have been the advancement of knowledge as the over - substantially eroded. There has been a fall riding aspiration of the academic physician. from grace of our vaunted profession [10]. He placed the welfare of patients and the ed - Physicians have lost their authenticity as 274 Duffy: The Flexner report ― 100 years later

trusted healers. We have become derelict in of ideals. Oslerian wisdom regarding the pri - many realms. Bioethicists are strident in macy of patient beneficence is not evi - drawing attention to the major moral failing denced. Patients were primarily viewed as of the profession in the last century; its fail - serving the academic purposes of the pro - ure to address and care for the problem of fessor. These attitudes were not of apparent pain ― this an omission by a group that has concern for Flexner or his advocates. ready and singular access to the means for Flexner’s identification of Billroth’s text as resolution of pain. The $14 million SUP - his most important influence is also trou - PORT study to understand and improve care bling. The book contains several anti-Se - for patients at the end of life found that more mitic passages that are very offensive for all than 40 percent of families were unhappy readers and especially disturbing for a Jew - with the fashion in which their loved ones ish reader. It was a work for which Welch were cared for as they died [11]. The dis - also had great admiration. In his preface to a content with doctor’s errors, doctor’s si - translation published in 1924, he described lence, doctor’s experimentation, and the the book as a work of enduring value, char - crass monetary orientation of the profession acterized by a breadth of view as sound and is legion. The profession appears to be los - as needful today as when it was first pub - ing its soul at the same time its body is lished in 1876. Flexner and Welch must have clothed in a luminous garment of scientific been aware that its prejudiced views had led knowledge. to near riots over its depictions of Jews and This is especially ironic because the the superiority of pure German racial stock. Teutonic heritage that provided the template Flexner’s journey from Louisville to the for Flexner’s plan also contains a cautionary aristocratic Hopkins Circle may have re - message for him, for his Circle, and for all of quired adaptations and moral accommoda - us. It is the tale of Faust and the irresistible tions that ultimately made their way into his allure of knowledge in exchange for one’s prescriptions for American medical educa - soul. The Carnegie Foundation unwittingly tion. His apparent oversight of the service recast Goethe’s drama by selecting Flexner role of the profession may also have played as the main character in their version of the into his fierce and critical opposition to Win - play. Flexner may be in part excused for his ternitz’s Institute of Human Relations [13]. omission of any consideration of a physi - Social involvement of the physician was cian’s healing role and how education unimportant for the physician as envisioned should foster that art; he was an educator by Flexner. whose philosophy was shaped by a patholo - gist and their shared immersion in the Ger - THE FLEXNER REPORT AND THE man tradition and by his reading of RESTITUTION OF MEDICAL Billroth’s Medical Education in German PROFESIONALISM Universities . This was a world of hyper-ra - tionalized medicine that Flexner investi - The Flexner Report set American med - gated during his early sabbatical years icine on a course that was fueled by the en - post-Louisville phase and to which he re - ergy of scientific discovery. Those turned for a second time after his comple - discoveries have immeasurably improved tion of the Flexner Report in 1910. Two the lives of all human beings, and it is diffi - years later, he published a European version cult to cavil in the face of such accomplish - of the report with a critique of medical edu - ments. But the oversights of Flexner and his cation in France, Britain, and Germany [12]. associates need not have occurred if these His uncritical description of the German sys - leaders had recognized the primary role of tem is surprising, especially for a modern physicians as beneficent healers; the delicate reader in retrospect. The German clinic is balance of patient care and research could described as being surcharged with energy have been pursued with mutual benefits for and ideas, but there is little if any mention both sides. As it was, the science of medi - Duffy: The Flexner report ― 100 years later 275

cine eclipsed the active witnessing of our pa - last 10 years following the revisions in the tients. Edmund Pellegrino’s lament was medical curriculum that recent re-evalua - proven true that doctors had become tions have called for. neutered technicians with patients in the A similar revision of Christopher service of science rather than science in the Wren’s cathedral occurred near the end of service of patients. How else to explain the the 17th century. The Oxford Circle wit - seemingly unexplainable Tuskegee experi - nessed severe damage to Wren’s signature ments, the Henrietta Lacks tissue culture edifice when the Great London fire threat - tragedy, the many occurrences in which the ened the cathedral. The distinguished gar - physician as scientist has taken precedence dener, diarist, architect ,and polymath John over the physician as healer. But this lesion Evelyn assisted with the plans to repair the is not restricted to situations in which pa - cathedral. He also made an important gift to tients are used as experimental subjects ― the corpus of scientific knowledge with the it pervades the fashion in which so much of later donation of the anatomical tables to the medicine was taught and practiced in the last Royal Society [16]. These were micro-dis - century. This lapse has not escaped our pa - sections of the arterial, venous, and neuro - tient population nor our critics who have logical systems mounted on pine tables; they richly documented the poverty of profes - were the work of Padua anatomist Joann sional ideals now current in medicine. They Leonius, whom Evelyn had witnessed dis - have called for a new Flexner Report, a cen - secting during Evelyn’s study of anatomy. tennial taking stock, to address the short - Anatomists later recognized that the delicate comings in medical education that have arborizations of the three systems were vir - occurred in the aftermath of the original re - tually super imposable upon one another. port. Dr Tom Inui, an internist and medical Very recent studies, only doable as a result educator, was enlisted by the AMA to spend of modern molecular techniques, have iden - a year in this investigation [14]; Molly tified the inter-dependence of the vascular Cooke and her associates undertook the and nerve systems. They are not only struc - same task for the AMA and performed a turally related. There is constant cross-talk mini-version of the Flexner initiative by vis - between them with shared growth factors, iting 10 medical schools throughout Amer - receptors, and specialized cells. During em - ica [15]. Everyone is a proponent of what is bryogenesis, the nerves and vessels impose now happening in many medical schools. the directions of growth that become the Major emphasis is being placed upon the vascular and nervous systems that Harvey professional formation of students and spe - and Willis originally described; failure of cific core competencies. Practice-based coordinated interaction of these vital sys - learning, a Flexner initiative, is supple - tems results in death or maldevelopment of mented by courses in patient communica - the embryo [17]. tion, medical ethics, and medical humanities. Departments of medical educa - CONCLUSION tion are now part of medical faculties that train their members to incorporate these There was maldevelopment in the struc - ideals into their courses. The coming cen - ture of medical education in America in the tury has received a bounteous richness of aftermath of the Flexner Report. The pro - medical accomplishments thanks to Flexner; fession’s infatuation with the hyper-rational a system of education that was conceived world of German medicine created an ex - more than a century ago still remains a vi - cellence in science that was not balanced by brant system. There is in place an edifice a comparable excellence in clinical caring. that is the envy of the entire world, but it is Flexner’s corpus was all nerves without the a structure that has required a re-molding in life blood of caring. Osler’s warning that the light of its too-narrow focus. The original ideals of medicine would change as “teacher Hopkins edifice has been rebalanced in the and student chased each other down the fas - 276 Duffy: The Flexner report ― 100 years later

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