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1 Abraham Flexner's Lasting Effects on Medical Education in the United 1 Abraham Flexner’s Lasting Effects on Medical Education in the United States and Canada Julie H. Schiavo Louisiana State University Health Sciences 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 Flexner Report, 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 Johns Hopkins University. 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 science 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 teaching hospital [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
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