For Reforming Medical Education the Flexner Report at The

The Flexner Report at the Century Mark: A Wake-Up Call for Reforming Medical Education

Mike Mitka Online article and related content current as of April 22, 2010. JAMA. 2010;303(15):1465-1466 (doi:10.1001/jama.303.15.1465)

http://jama.ama-assn.org/cgi/content/full/303/15/1465

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The Flexner Report at the Century Mark A Wake-Up Call for Reforming Medical Education

Mike Mitka cal Education came up with the stan- Michigan in Ann Arbor, said the train- dards that Flexner used to assess the ing of medical students was much dif- ROM JANUARY 1909 TO APRIL 1910, various schools.” ferent 100-plus years ago. “Most medi- a high school principal named The model for quality medical edu- cal schools were proprietary—where a FAbraham Flexner visited all 155 cation was a properly equipped medi- team of physicians basically opened up medical schools in the United States and cal school with dedicated physician- a store front and called it ‘Doctor Jones’ Canada to assess their ability to pro- educators attached to a top-of-the-line Medical School,’ offering a year or 2 of duce physicians rigorously trained in lectures, some anatomy, and an appren- allopathic medicine. The book-length ticeship with someone.” summary of his findings, published in These schools were ill equipped. 1910 by the Carnegie Foundation, Many students were admitted having served as the catalyst for a reform move- only a high school education and the ment that changed medical education necessary tuition money. Teaching was and still influences the way medicine mostly didactic, emphasizing text- is practiced in North America a cen- book readings and memorization. In ad- tury later. dition, many of these schools issued The effort that produced the Flexner medical degrees for completion of stud- report (http://www.carnegiefoundation ies in nonallopathic disciplines such as .org/sites/default/files/elibrary homeopathy, hydropathy, and eclec- /Carnegie_Flexner_Report.pdf), for- tic medicine (botanical-based thera- mally known as Medical Education in the pies). Flexner also argued that the pro- United States and Canada: A Report to duction of too many graduates with the Carnegie Foundation for the Advance- medical degrees suppressed salaries and

ment of Teaching (Bulletin No. 4)[New Blackstone Studios/AMA dampened the profession’s ability to at- York, NY: Carnegie Foundation; 1910], Abraham Flexner and his 1910 report exposed tract the best and brightest students. came about during the Progressive Era, the poor quality of many US and Canadian Flexner was blunt in his assess- a time in which many believed sci- medical schools and helped accelerate the ments. For example, he described the city modernization of physician training. ence, technology, and education could of Chicago as “the plague spot of the solve society’s ills. teaching hospital. These schools country” for medical education. In tour- The Carnegie Foundation, which was (Flexner’s ideal was Johns Hopkins Uni- ing Chicago’s National Medical Univer- founded during this time to improve versity) would train students who had sity, a night school enrolling 150 stu- education, funded Flexner to survey the been selected for their superior qualifi- dents apparently owned by its dean, medical schools, accompanied on his cations. Training would be based on the Flexner wrote, “The school occupies a travels by Nathan P. Colwell, MD, sec- scientific method, and students would badly lighted building, containing noth- retary of the Council on Medical Edu- learn by doing, spending most of their ing that can be dignified by the name of cation of the American Medical Asso- time in the laboratory and the clinic. equipment. There had been no dissect- ciation (AMA). Such institutions, Flexner found, were ing thus far (October to the middle of “The AMA came into existence in few in number and were mostly con- April), anatomy being didactically 1847, in part to have standards to pro- centrated on the US eastern seaboard. taught. . . . There is a large room called tect the public, so when you went to see Flexner also found an appallingly the chemical laboratory, its equipment a physician, his license indicated that high number of second-rate schools, ‘locked up,’ the table spotless. ‘About ten’ he had a certain minimum of medical many run by profit-motivated private oil-immersion microscopes are claimed education,” said J. James Rohack, MD, physicians. Howard Markel, MD, PhD, —also ‘locked up in the storeroom.’ AMA president. “The Council on Medi- a medical historian at the University of There is not even a pretense of any-

Downloaded from www.jama.com at University of Toronto on April 22, 2010 MEDICAL NEWS & PERSPECTIVES thing else. Classes in session were all tak- versity in New York City, points out that process,” Fox said. “Each department ing dictation.” Ultimately, Flexner con- the conversion to the modern came over of the medical school could devote its cluded that only 31 of the 155 schools the protests of many in medicine. “You energies to education, research, and pa- he visited should remain open. had these elite researchers and special- tient care rather than having to spend In the United States, the Flexner re- ists who wanted to eliminate the unsci- it on just generating clinical income.” port caused a sensation, selling about entific medical schools, and local prac- 15 000 copies and garnering headlines titioners who saw their practices OTHER CONSEQUENCES across the country. The AMA, academ- threatened by competition from top But there were downsides attached to ics, the public, and state legislators used school graduates and from licensing by Flexner’s legacy as well. Improving the findings in the report to accelerate the AMA, which may not have viewed medical education meant lengthening the closing of questionable facilities, and their training as sufficient,” Rosner said. the time of study and raising tuition by 1922, only 81 US medical schools “A compromise was reached in which the rates. Medical schools soon became the remained. The number of graduates de- older physicians were grandfathered in enclaves of those who could afford the creased by half, from more than 5000 to continue to practice medicine, regard- training—mostly upper-class white annually to about 2500. less of the quality of their schooling, males. The closing of substandard Darrell G. Kirch, MD, president and while the remaining schools would pro- schools, or their mergers with other in- CEO of the Association of American duce highly trained practitioners, but in stitutions, eliminated many of the Medical Colleges, lauded the Flexner smaller numbers as to limit competi- schools that had been training women report’s legacy. “If you read the re- tion, especially in more rural areas.” and minorities. The cutback in the num- port, you can see how much we needed ber of graduates boosted the income of that kind of sweeping revolutionary BEYOND THE REPORT practicing physicians, but it also lim- change; the conditions of many medi- Flexner personally contributed to the ited workforce supply, which has led to cal schools were just abysmal,” Kirch rise in quality of medical education. The ongoing concerns about physician short- said. “What grew up out of that report reforms that were instituted following ages, especially in underserved areas. was truly spectacular. I do not believe the report’s release cost money, and Markel cautioned against “present- it is an exaggeration to say that many while states increased their support, ex- ism” and the inclination to view his- of the miracles of modern medicine are tra funds were still needed. To par- tory through today’s prism. He does not directly attributable to Flexner, as he tially fill that economic void came phil- think Flexner intentionally advocated brought medical schools back to the anthropic organizations, including the medical school reform to harm women heart of the universities.” Rockefeller Foundation. In 1917, John or minorities. “I do not believe he was Indeed, Kenneth M. Ludmerer, MD, D. Rockefeller Jr appointed Flexner as bigoted, especially with his back- professor of history and biostatistics at assistant secretary of his foundation’s ground as a child of immigrant Eastern Washington University in St Louis, said General Education Board. Flexner European Jews. Flexner found schools Flexner specifically wanted medical showed a knack for convincing the that were inferior and underfunded, re- schools to have university ties. “Be- wealthy with philanthropic tenden- gardless of whom they were teaching,” fore Flexner came along, there was quite cies to contribute to the foundation, Markel said. “The real issue is that the a lot of debate of what a medical school from which he disbursed millions of good old days were not that good any- should look like as an institution; ev- dollars in grants to leading medical way, and to put it all on his lap is too eryone liked the university model, but schools to modernize and improve their much. American society was harsh and many thought it was not practical be- equipment and facilities (Markel H. closed to women and blacks and re- cause it was expensive,” Ludmerer said. JAMA. 2010;303[9]:888-890). “Flexner mained that way for decades.” “There was talk of having a tiered sys- always called himself the humble ser- Ludmerer also downplays a direct tem with schools like Johns Hopkins vant of powerful men, but he knew link between Flexner, his report, and providing hard research and others what he needed to do to achieve his own malicious consequences. Instead, Lud- teaching practical medicine. Flexner goals,” said Markel. “He had to get the merer suggests a different view of the came along and said all schools needed right people in line, including philan- educator. “Flexner was a champion of to follow the university system; they did thropists, organized medicine, deans, excellence, and it is the most lasting of not all need to be the same, but they and elite medical institutions.” his accomplishments,” Ludmerer said. needed to have the same value system Daniel M. Fox, PhD, president emeri- “It is this identity and value of who we and commitment to research.” tus of the Milbank Memorial Fund and are as physicians and as a profession, While the past 100 years have seen im- a Flexner historian, said income from of increasing knowledge. That, I think, pressive improvements in medical edu- outside the medical schools and their is timeless and something we are in his cation and medical practice, David Ros- teaching hospitals was vital in trans- debt for, even as we disagree with the ner, PhD, MPH, professor of history and forming the medical landscape. “The specifics of his recommendations and sociomedical sciences at Columbia Uni- Rockefeller money jump-started the actions.” ᮀ

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