The Flexner Report is a book-length study of medical education in the United States and Canada, written by Abraham Flexnerand published in 1910 under the aegis of the Carnegie Foundation. Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.
The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. The report talked about the need for revamping and centralizing medical institutions. Many American medical schools fell short of the standard advocated in the Flexner Report and, subsequent to its publication, nearly half of such schools merged or were closed outright. Colleges in electrotherapy were closed.
Homeopathy and natural medicines were derided; some doctors were jailed.
The Report also concluded that there were too many medical schools in the United States, and that too many doctors were being trained. A repercussion of the Flexner Report, resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. Universities had begun opening and expanding female admissions as part of women’s and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.
In 1904 the American Medical Association (AMA) created the Council on Medical Education (CME) whose objective was to restructure American medical education. At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. Generally speaking, the council strove to improve the quality of medical students, looking to draw from the society of upperclass, educated students. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME’s reformist agenda and hasten the elimination of medical schools that failed to meet the CME’s standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Abraham Flexner to conduct the survey. Flexner was not a physician, scientist, or a medical educator, although he held a bachelor of arts degree and operated a for-profit school in Louisville, Kentucky.
At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: “Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated.” The Report became notorious for its harsh description of certain establishments, for example describing Chicago’s 14 medical schools as “a disgrace to the State whose laws permit its existence… indescribably foul… the plague spot of the nation.”
Nevertheless, several schools received praise for excellent performance, including Western Reserve (now Case Western Reserve), Michigan, Wake Forest, McGill, Toronto, and especially Johns Hopkins, which was described as the ‘model for medical education’.
To help with the transition and change the minds of other doctors and scientists, Rockefeller gave more than $100 million to colleges, hospitals and founded a philanthropic front group called “General Education Board” (GEB).
When Flexner researched his report, many American medical schools were small “proprietary” trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state governments was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word “quack” flourished.
Flexner carefully examined the situation. Using the Johns Hopkins School of Medicine as the ideal, he issued the following recommendations:
- Reduce the number of medical schools (from 155 to 31) and poorly trained physicians;
- Increase the prerequisites to enter medical training;
- Train physicians to practice in a scientific manner and engage medical faculty in research;
- Give medical schools control of clinical instruction in hospitals
- Strengthen state regulation of medical licensure
Flexner even expressed that he found Hopkins to be a “small but ideal medical school, embodying in a novel way, adapted to American conditions, the best features of medical education in England, France, and Germany.” In his efforts to ensure that Hopkins was the standard to which all other medical schools in United States were compared, Flexner went on to claim that all the other medical schools were subordinate in relation to this “one bright spot.” Flexner believed that admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education. By 1920, 92 percent of U.S. medical schools required this of applicants. Flexner also argued that the length of medical education should be four years, and its content should be what the CME agreed to in 1905. Flexner recommended that the proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even financially.
Less known is Flexner’s recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become “true university teachers, barred from all but charity practice, in the interest of teaching.” Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner demanded that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner’s recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.
To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
- In a very short time, medical colleges were all streamlined and homogenized (all the students were learning the same thing)
- A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
- Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;
- Average physician quality has increased significantly;
- No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
- Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;
- Medicine in the US and Canada has become a highly paid and well-respected profession.
The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. “An education in medicine,” wrote Flexner, “involves both learning and learning how; the student cannot effectively know, unless he knows how.” Although the report is over 100 years old, many of its recommendations are still relevant—particularly those concerning the physician as a “social instrument… whose function is fast becoming social and preventive, rather than individual and curative.”
Flexner sought to reduce the number of medical schools in the U.S. to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting MD or DO degrees as of the date of the Report (1910) closed within two to three decades. (In Canada, only the medical school at Western University was deemed inadequate, but none was closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institutions, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. The dramatic decline was in some part due to the implementation of the Report’s recommendation that all “proprietary” schools be closed and that medical schools should henceforth all be connected to universities. Of the 66 surviving MD-granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report’s recommendations. In response to the Report, some schools fired senior faculty members as part of a process of reform and renewal.
Flexner viewed blacks as inferior and advocated closing all but two of the historically black medical schools. His opinions were followed and only Howard and Meharrywere left open, while five other schools were closed. His perspective was that black doctors should only treat black patients and should serve roles subservient to white physicians. The closure of these schools and the fact that black students were not admitted to many medical schools in the US for 50 years after Flexner has contributed to the low numbers of American born physicians of color and the ramifications are still felt more than a century later.
Furthermore, given his adherence to germ theory, he argued that, if not properly trained and treated, African-Americans posed a health threat to middle/upper class whites.
When Flexner researched his report, “modern” medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, electrotherapy, eclectic medicine, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than that based on scientific research, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including electromagnetic field therapy, phototherapy, eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all either complied with the Report or shut their doors.
Although almost all the alternative medical schools listed in Flexner’s report were closed, the American Osteopathic Association (AOA) was able to bring a number of osteopathic medical schools into compliance with Flexner’s recommendations and produce an evidence-based practice. The curricula of DO and MD awarding medical schools are now nearly identical, the chief difference being the additional instruction in osteopathic schools of osteopathic manipulative medicine.
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