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Abraham Flexner’s Lasting Effects on in the United States and Canada

Julie H. Schiavo Louisiana State University Health Center, New Orleans Associate Librarian https://orcid.org/0000-0002-9205-6145

Corresponding Author: Julie H. Schiavo Louisiana State University Health Sciences Center, New Orleans School of Dentistry Library 1100 Florida Avenue New Orleans, LA 70119 (504) 941-8162 [email protected]

Word Count Text: 3,648 Word Count Abstract: 149 2

Abraham Flexner’s Lasting Effects on Medical Education in the United States and Canada

Abstract

In 1910, a document produced by an American educator changed the course of medical education ushering in a new philosophy based on the scientific method, active learning, and competency-based education. Abraham Flexner’s report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, was a groundbreaking study undertaken to improve the quality of medical education and ensure capable, competent physicians and surgeons in the United States and Canada. However, the

Flexner Report was not without consequences, both intended and unintended. A large majority of schools examined by Flexner did not meet the standards by which he judged them. Nearly half of the schools in the report closed; most of those were programs dedicated to medical education for

African Americans, women, and working-class students changing the demographics of the medical profession in ways that it has only recently begun to remedy. 3

Abraham Flexner’s Lasting Effects Medical Education in the United States and Canada

Abraham Flexner, a former high school principal, published a document in 1910 that changed the structure of medical education in the United States and Canada. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of

Teaching, commonly known as the , is still as revolutionary and controversial as it was immediately after its publication. It can be credited as the vehicle which introduced, among other things, three concepts that are considered vital to modern medical education: scientific method, active learning, and competency-based education. The Flexner Report is an example of

Progressive Era doctrine of physicians and educators asserting professional status and setting themselves apart from the general public [1]. Controversy regarding the report questions the originality of Flexner’s research and decries its racist, sexist, and classist themes.

The education of future medical doctors has evolved and drastically changed. Earliest forms of medical education were based on a master and apprentice relationship involving no formal schooling or regulation. In time, spurred by new scientific discoveries and theories of health and illness, a more formalized system of lectures and demonstrations developed and later travelled to what would become the United States [2]. The first medical school in the United States, the

College of Philadelphia was established in 1765 as a natural progression of learning at a large public hospital [2, 3]. As time went on, medical colleges were established throughout the United

States with varying degrees of success and quality. According to Ludmerer [4] and Weiss and

Miller [5], in the mid-19th century a model of medical education known as the proprietary school became very popular. The proprietary school was owned by a single practitioner or a small faculty was designed to generate a profit for the owners. These schools had few, if any, entrance requirements, short courses and terms, and mostly didactic instruction including lectures, 4 readings, and memorization. Research, laboratory work, and clinical work were rarely involved in the educational process. Proprietary schools depended upon student fees for operating costs and profit therefore it benefited the owners to admit the largest number of students possible.

Johns Hopkins University School of Medicine, opened in 1893, was grounded in the German model of education using the scientific method and scientific techniques [4].

Origins of the Flexner Report

Abraham Flexner was one of nine children born of Jewish immigrants who settled in

Kentucky in the late nineteenth century. His father, Moritz Flexner, who received an extensive education in Germany before he moved to the United States, instilled in his children a love of learning and the importance of education. Abraham and his brothers attended school part of the day and worked in the evening. As each son graduated and entered a profession, he paid for the education of his younger brothers and sisters Abraham eventually opened a school in Louisville that specialized in getting students admitted into the best colleges. He eventually left the school to pursue further studies at Harvard and then Berlin [6,7].

Flexner was hired by Henry Pritchett to perform a study of both proprietary and university affiliated medical schools operating in the United States and Canada on behalf of the Carnegie

Foundation for the Advancement of Teaching. The study was to include two parts. The first part would describe the history of medical education in the United States and Canada, minimum requirements for medical schools to operate, and how medical could evolve. The second part of the report would include a description of each medical school [7,8]. As an educator rather than a physician, Flexner seemed to be an unlikely choice for the project. It is proposed by Bonner that

Flexner was hired to produce the report based on the president of the Carnegie Foundation Henry

S. Pritchett’s belief that Flexner could write well, that they shared the belief in a traditional 5 education, and because Flexner was well connected to . Pritchett had developed the framework for the report; he did not expect Flexner to so fully grasp the business of medical education nor did he expect the resulting report to be as groundbreaking as it became

[6]. Employing an outsider to medical education to perform the reviews was advantageous in advancing Flexner, Pritchett, and the American Medical Association’s (AMA) agendas [9].

Weiss and Miller contend that Flexner was employed because the ethical structure of the AMA prevented them from publicly criticizing fellow physicians, therefore to mandate change and still appear impartial, they required a non-physician without connections to the organization [10].

From January 1909 to April 1910, Flexner, accompanied by Dr. Nathan Colwell, a medical doctor affiliated with the AMA, visited 155 medical schools to assess their ability to produce capable physicians trained in the of medicine. The resulting document, Medical

Education in the United States and Canada: A Report to the Carnegie Foundation for the

Advancement of Teaching, more commonly known as the Flexner Report, was published in 1910 and quickly embraced by the medical community and the general public. Barzansky, quoting

Flexner’s autobiography states, “he had no ‘fixed method of procedure’ and that he ‘never used a questionnaire.’ He did, however, review areas that he described as ‘decisive points’ as to the

‘quality and value’ of the medical school” [10]. These points included entry requirements, quality of the faculty, funding and budgets, quality of laboratories, and the relationship between the school and a hospital. Flexner built his standards upon the German model of education epitomized by Johns Hopkins University, Flexner’s alma mater: a well-equipped school, with a curriculum taught by dedicated physician-educators, and attached to an exemplary [4,8,6,11,12]. 6

Flexner drew on his background as an educator, skill as a writer, and philosophies of education to advance several educational, organizational, and empirical theories that are still embraced by modern medical education [8]. His educational theories included active learning with multiple pedagogies such as bedside teaching, laboratory work, clinical experience, and case work in addition to didactic lectures; he felt integration of the basic and clinical sciences were vital to the practice of medicine. Flexner appealed to medical schools to increase admission standards by requiring students to have at least two years of college courses prior to admission.

He also believed in a continuum of medical education involving postgraduate work and medical schools must have an affiliation with both a university and a hospital in order to provide adequate training opportunities. Flexner held that education should be provided by dedicated full-time faculty without clinical responsibilities. He believed the cost of an education should not dictate the quality of education and medical schools must have a large annual budget and an endowment high enough to ensure the continuation of high quality education. He strongly advocated for evidence-based medical education, the scientific method, and lifelong learning, providing a foundation for modern medical education. He also had strong beliefs regarding medicine as a part of modern science - based on facts but still involving uncertainty. Flexner believed that preventive and community medicine are important to public health and medical school was a necessary, vital, public good [4,7].

Standards and Evaluations

The Flexner Report appeared at a pivotal point in the development of medicine and healthcare. Problems in medical education had become evident and revolutionary discoveries such as germ theory, aseptic techniques in surgery, diagnostic laboratory procedures, and new equipment led to an obvious deficit in the education of some physicians. Some educational 7 reform to improve the education of physicians and rank medical schools in the United States and

Canada prior to 1910 occurred before the Flexner Report, including changes enacted by several organizations, such as the Association of American Medical Colleges (AAMC), the Illinois State

Board of Health, and the American Medical Association (AMA) [4,7,10,13]. Yet, it is widely held that the Flexner Report “laid the foundation for total reform” [8], “transformed the nature and process” [14], and “initiated a revolution” [1] in medical education.

Twenty years before the Carnegie Institute hired Flexner to write the report, the membership of AAMC established several requirements for schools to attain membership including a prescribed period of classwork, laboratory time in the basic sciences, and written or oral examinations [10]. One year later, the Illinois State Board of Health issued a report that included a five-item list of problems in medical education that were reflected in Flexner’s report. This list included students having too little preliminary education leading to problems comprehending necessary scientific principles, too much didactic work, too little clinical work, too few practical exams, and too short a period of coursework [10].

The AMA Council on Medical Education developed an “ideal standard” of medical education in 1905 that included prerequisite education, basic science and clinical courses, a four- year curriculum, and an additional year [10]. Both the AMA and AAMC developed a grading system based 10 categories which later became the basis of Flexner’s individual evaluations of schools: performance on state board examinations, admission prerequisites, length and quality of coursework, buildings, laboratories, training in dispensaries, training in hospitals, dedicated faculty teaching basic sciences, extent of for profit activities, and access to libraries, museums, and teaching aids [10]. 8

Many researchers propose that the Flexner Report was simply a vehicle to accelerate the changes in education put forth by the AMA and that the close relationship between Flexner, the

Carnegie Foundation, and the AMA prevented truly fair evaluations [5,7,15]. Weiss and Miller call into question Flexner’s methods of inspecting schools reporting that his inspections were haphazard and certainly not as accurate and detailed as proposed in Pritchett’s laudatory introduction to the report [5]. University of North Carolina’s medical school administration reported Flexner and the AAMC had decided the fate of the program prior to his visit; as a result, his visit consisted of only a half-hour meeting and no tour of the facilities [5]. Weiss and Miller posit that the main intent of Flexner Report was to reduce the number of schools and close proprietary schools thereby ensuring the medical profession was inaccessible to working-class and minority men and women [5].

Effects on Medical Education and Medical Schools

The publication of the Medical Education in the United States and Canada: A Report to the

Carnegie Foundation for the Advancement of Teaching had a rippling effect on medical education that reaches to modern times. Results of the Flexner Report were immediate due to the acceptance and enthusiasm for change by the AMA, AAMC, and the general public [7].

Several medical schools across the country were able to alter their curriculum to conform to

Flexner’s standards but many could not and closed soon after. Of the 155 schools visited by

Flexner only 85 of them remained open by 1922 [8,10,16,17]. Of the schools that closed, the majority were dedicated to the education of female, African American, or working-class students

[18]. Flexner asserted that for the good of the country, the United States needed “fewer and better doctors” [2]. He advocated that to standardize medical education and improve the quality of physicians, the medical student must first be homogenized [2] and, therefore, according to 9

Bailey [13] and Steinecke and Terrell [17] the phrase fewer and better was soon understood to signify wealthy, privileged, urban, white, men from the northern part of the country. Bailey [13] also states Flexner argued that high standards for medical colleges should not be compromised in order to accommodate working-class or rural students, going so far as to speak out against the academic calendar being arranged to coincide with the practices necessary to operate a farm.

Medical Education for African Americans

The Flexner Report drastically changed access to medical education for African Americans; his beliefs of the role, value, and abilities of African American physicians described in the report have had lasting effects on medical education and medicine in general. Hunt argues “… the influence of the Flexner Report shaped black medical school admissions from the first world war until the 1960s” [19]. Created during the time after the Plessy v Ferguson verdict, the Flexner

Report demonstrated the racist views of many in the United States [17]. Miller and Weiss discuss the Flexner Report as one of the two key events that caused the medical profession to be segregated [20]. They consider the Flexner Report “A muckraking exposé of medical education that was sponsored covertly by the AMA and overtly by the Carnegie Foundation for the

Advancement of Teaching” [20]. As Bailey states, “The latent white supremacy embedded within Flexner’s report continues to color medicine more than 100 years later” [13].

The Flexner Report was the first to publicly acknowledge the existence of medical schools who admitted African American students and graduated African American medical doctors [21].

However, Flexner demonstrated the negative attitudes directed to African American physicians in the two page chapter, “The Medical Education of the Negro”. He begins the chapter with assertion: “The medical care of the negro race will never be wholly left to negro physicians.

Nevertheless, if the negro can be brought to feel a sharp responsibility for the physical integrity 10 of his people, the outlook for their mental and moral improvement will be distinctly brightened”

[2]. He asserts that African American health is important not only for themselves but also for the white race: “The physical well-being of the negro is not only of moment to the negro himself.

Ten million of them live in close contact with sixty million whites” [2]. Flexner also stresses that the African American physician should be limited to hygiene and public health; advanced medicine and surgery should be left to the white physician. He maintains that the African

American physician should dedicate his life to serving other African Americans in rural areas

[17,19,21]. “If at the same time these men can be imbued with the missionary spirit so that they will look upon the diploma as a commission to serve their people humbly and devotedly, they will play an important part in the sanitation and civilization of the whole nation” [2].

Prior to 1910, an African American student who wished to pursue medicine could attend one of seven schools in several parts of the country. These schools were either operated by missionaries or were proprietary, generally not well funded, and provided an education that was not equivalent to the elite schools that only admitted white students. Only two of the seven schools survived the fallout of the Flexner Report: Howard and Meharry [16,21]. “Of the seven medical schools for negroes in the United States, five are at this moment in no position to make any contribution of value…” [2]. He believed that Howard and Meharry were able to improve enough to meet the standards he set for white institutions with help and a large infusion of money [21]. “Meharry at Nashville and Howard at Washington are worth developing, and until considerably increased benefactions are available, effort will wisely be concentrated upon them”

[2].

The futures of both Howard and Meharry were very much in jeopardy as the schools attempted to meet the standards set by the Flexner Report in the atmosphere of institutionalized 11 racism of the time. Although the Carnegie Foundation endorsed the continuation of these two medical schools, the philanthropic organization did not offer financial assistance to either institution [21,22]. While the requirement of a large budget and endowment was often within reach of many schools educating white men through the charitable contributions of alumni, philanthropic organizations, and even donations by faculty. For instance, Washington University

School of Medicine, when faced with an evaluation below the standard they expected to receive from Flexner, embarked on a total reorganization of the school and it’s faculty. This reorganization was accomplished, in a large part, through financial contributions of the President of the Corporation Board of Washington University, Robert Brookings [25]. Such resources and donations were not available to Howard and Meharry [22,23,24]. According to Epps, in many cases, Howard University applied for funds from the same sources, such as the General

Education Board, as white institutions but were consistently denied funding for nearly 20 years

[22]. Both universities set a standard mirroring the Flexner Report’s admission requirement of at least two years of college level study focused on the sciences and forgien languages. However, such an education was largely unavailable to African Americans resulting in a significant decrease in enrollment for the schools further complicating an already dire financial situation

[22,23,24].

The long-term consequences of Flexner’s report were significant and have resulted in systematic inequality and disenfranchisement of African Americans in medical education [23].

Flexner asserted that the African American community would be better served by a few good doctors rather than many ineffective doctors [2,17,21]. His vision of an African American doctor focused on the health and hygiene of the African American population, along with the assertion that surgery and other advanced medical specialties should be left to white physicians, 12 resulted in far fewer African American doctors pursuing research or academic leadership

[23,26,27]. As Halperin et al. describe, the number of African American physicians did, indeed, drop drastically and remains below expectations currently. “Fewer black physicians meant fewer physicians for the black community, fewer role models for students, and fewer black alumni to press the case for increased enrollment” [7]. The United States Census Bureau reported in 2018, that 13.4% of the American population self-identified as Black or African American [28] yet, according to Jaschik, in 2016 the percentage of African American matriculants in medical school was 7.1%, an increase of only 1.1% since 1980 [29]. Jaschik goes on to say that of all African

American medical school applicants, only 35.4% of them are accepted [29]. Recent research by

Campbell et al. has found that if the five medical schools dedicated to educating African

Americans had not closed, they could have provided medical education to approximately 27,000 to 35,000 students. This number would result in 29% of all physicians graduating in 2019 would be African American [24].

Medical Education for Women

Prior to 1910, women in the United States were able to enter medical schools across the country. As a result of these opportunities, more than 7000 female physicians were practicing in the United States in 1900, a significantly higher number than in England or France [18]. There were seven women’s colleges and various co-educational opportunities but by 1930 only the

Women’s Medical College of Pennsylvania remained [4,18].

Flexner included a chapter of his report to address medical education for women. This chapter consisted of three paragraphs and a chart, the contents of which had a dramatic and lasting effect on women in medicine. “Medical education is now, in the United States and

Canada, open to women upon practically the same terms as men. If all institutions do not receive 13 women, so many do, that no woman desiring an education in medicine is under any disability in finding a school to which she may gain admittance” [2]. Flexner continues, “Women have so apparent a function in certain medical specialties and seemingly so assured a place in general medicine under some obvious limitations…” [2]. However, based on data he compiled of the number of women in medical school from 1904-1909 that showed a slight decrease of women in medical school, he determined that women were not interested in the study of medicine. “Now that women are freely admitted to the medical profession, it is clear that they show a decreasing inclination to enter it” [2].

Flexner concluded the chapter with an assertion that money should not be dedicated to the survival of women’s medical colleges; he believed that the opportunities found in co-educational colleges were equal for men and women [13,30]. Research by Walsh [30] and Burrow &

Burgess [31] shows that this was not the case. Walsh [30] discusses events after Cornell Medical

College absorbed the women’s medical college at New York Infirmary in 1900. Seventy women entered Cornell but three years later, only ten remained after the administration of Cornell deliberately created barriers for the women students such as requiring them to attend two years of classes at the Ithaca campus, 250 miles away from New York City. Burrow and Burgess describe the experiences of women entering Yale University School of Medicine [31]. Yale

University agreed to admit “a limited number” of women in 1915 provided a sum of $1,000 could be raised to refit the building to include women’s bathrooms. These women were required to be “graduates of recognized colleges for women who can meet the special requirements in sciences and languages.” Men, however, were not yet required to be college graduates nor was there a limit on the number of men admitted annually. Despite these barriers, one of the three women admitted to Yale University School of Medicine in 1915, Louise Farnam MD, PhD, 14 graduated as valedictorian of her class. Before 1970, Yale had increased admissions of “six to eight” women annually; a new policy enacted that year raised that number to 29 in an effort to

“achieve balance” [31].

After the publication of the Flexner Report, the quantity of women graduates of medical colleges decreased to 2.9% in 1915. The number of women graduates stayed below 5% until

1970 [18]. Recently, large strides have been made by women in achieving equality in medical education with AAMC reported in 2017 that 50.7% of students admitted to medical school were women [32].

The Flexner Report ushered in a new era of medical education leaving behind apprenticeship and ensconcing it into the university setting. These changes resulted in better educated physicians and the practice of medicine based in scientific facts and research rather than folk remedies. Such reforms did not come without great cost that still negatively affects medicine to this day. It ensured that medicine became a profession of wealthy, white men by constructing nearly insurmountable barriers for African American and women. The Flexner Report was a product of its time, demonstrating prejudices of the past yet modern educational concepts still in use today.

Acknowledgements

The author would like to thank James Thomas, PhD. for his wisdom and guidance during the creation of this manuscript

Declaration of Interest:

The author declare no conflicts of interest. 15

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