Flexner’s Impact on American Medicine

Medical historian Kenneth Ludmerer, M.D., said, “Don't be disappointed if you don't solve in one weekend what Flexner did in 50 years.” There is more to fix now than in Abraham Flexner's time at the beginning of the 20th century, he pointed out—the whole health care system. Yet, he said he was cautiously optimistic, and quoted the ending of his book Time to Heal: “There is still sufficient opportunity for visionaries to dream and leaders to act.”

Important Points:

Flexner was a high school principal who wrote a report regarding the status of  Colleges in the US. Based on this report and the recommendation of his brother, a physician and pathologist, he was chosen by the Carnegie Foundation to do a study of American Medical Education.

Flexner's concepts are often forgotten

Many boil his life's work as one of the top medical educators into one single Bulletin  4 document (Flexner, Abraham. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, bull. 4. New York: The Carnegie Foundation; 1910, p. xii [Reprinted in Birmingham, AL: Classics of Medicine Library; 1990, p. xii]).

This document tends to fit more the need for justification of the current status quo rather than the integration and innovation current to the time.

Flexner's second report had this statement by him (from Roger Hofford Family L post):

"the imposition of rigid standards by accrediting groups was making the medical curriculum a monstrosity" with medical students moving through it with "little time to stop, read, work or think."

The balance that Flexner attempted has yet to be achieved.

Robert C. Bowman, M.D.


Ranking Medical Schools and FP Residency Programs

Flexner's concepts integrated his understanding of the need for better preparation of high school and college students, where there was perhaps no other more knowledgeable person on the subject. This preparation and improvement were the basis of any medical school progress.  States Education and Medical Education

Unfortunately much of this emphasis has diminished over time, particularly with regard to getting students admitted to medical school that are more likely to choose underserved areas. The key to such admissions in the US or other nations, is improving high school and college education (and middle school). The so-called Flexnerian revolution may have had more impact on high schools and colleges. Not even the reaction to Sputnik is likely to have had as much overall impact on education. More about Flexner concepts at Assessing Community Orientation.

Flexner has always had his critics.

Initially the critics were the medical school faculty in the schools that he recommended closing. Later others differed with his approach and with the bias involved in his reporting. Few took the time and the approach to offer much real critique. Also those familiar with qualitative research realize that certain themes recur in many subjects, or in schools.

Over time critics arose regarding the impact of his recommendations on meeting the needs of underserved areas. Most medical education experts, including Flexner, were dismayed by declines in physicians going to rural areas. With changes in medical education came changes in attitude.

According to Mark D. Hiatt's report http://www.rienstraclinic.com/info/FlexnerPharos.pdf Flexner had never visited a medical school before he began his investigation. He began his visits in January of 1909 and finished April 1910. His aggressive schedule barely allowed him a whole day each for the evaluation of some schools. His efforts were closely linked with the American Medical Association, who provided resources. An AMA official accompanied Flexner throughout most of this period. Some feel that Flexner had inadequate time to do the visits including one stretch of 90 days where he visited 69 schools. Others felt that there were extraordinary influences that biased the report (AMA, Carnegie Foundation, Rockefeller General Education Board). Bias in Flexner Reporting These included pressure to reduce the number of physicians, close all but allopathic schools, and close proprietary medical schools (medical schools as business operations, what a thought!). All of these were accomplished within a short time of the report. See graph at MedSchoolChange.  

Flexner compared each medical school to Johns Hopkins, an institution he (and other influences) considered ideal. Flexner examined the relationships of the medical school to a teaching hospital, the integration of teaching and working facilities into the general organization of fundamental laboratories at the medical school; unifying the medical school faculty and the hospital staff; and, affording professors the freedom to adopt necessary teaching arrangements (i.e. clinical rotations), subject only to concerns for the welfare of patients. Many had put such reforms into place, but Flexner incorporated such reforms.

Clearly Flexner wrote strongly against proprietary institutions, smaller schools, those that did not emphasize science or specialism, and those with little equipment. He considered 5 areas during his visits. Other than this he had little framework to his investigations. These areas included 

  1. school entrance requirements
  2. size and training of faculty
  3. sum available from endowment and fees and budget
  4. quality and adequacy of labs and qualifications and training of lab teachers
  5. the relationships between the school and its associated hospitals

See Assessing Community Orientation for more on the concepts in a different framework.

In the recent reply of LCME to Florida State, medical leaders seem content to focus on these areas. They do not have the advantage of visiting all 150 medical schools, however. LCME and Florida State Medical School

Flexner's report had devastating impact on minority medical schools. Referred to as the Flexner Report on Medical Education, Abraham Flexner's Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (1910), was the catalyst for the closings of many Negro medical schools. Although Negro physicians and nurses fought to overcome the veritable revolution in medicine, new research centers, modern equipment, diagnostic inventions, therapeutic discoveries, and a proliferation of medical literature were awesome hurdles to overcome. The Report consisted of high professional requirements that sounded the end of many Negro medical schools. By 1914, four of six schools had disappeared. The largest one, Leonard Medical School, closed in 1915. It was followed eight years later by the Medical Department of the University of West Tennessee, leaving only Howard and Meharry.  (http://www.mclibrary.duke.edu/hot/blkhist.html#meded Last Modified February 26, 1999). Flexner recommended closing all 3 women's medical schools also.

Flexner’s Report provided a comprehensive roadmap for schools, state education, medical education, state licensure, public health, scientific research, public hospitals, and the elimination of several competitors of allopathic medicine. 

Other history and impact of Flexner and early US medical education efforts at    How The Cost-Plus System Evolved http://www.ncpa.org/w/w67.html Excerpted From: John C. Goodman and Gerald L. Musgrave

The following are some of the common quotes from Flexner from his Report, and then a final one in 1925. Flexner died in 1959, having seen much of what he hoped to accomplish. His work in follow up with many of the medical schools was considerable.

Regarding Inadequate Facilities   Where any criticism is attempted of inadequate methods or inadequate facilities, no reply is more common than this: "Our institution cannot be judged from its financial support. It depends upon the enthusiasm and the devotion of its teachers and its supporters, and such devotion cannot be measured by financial standards." Contributor: Murray, T. J. Source: Flexner, Abraham. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, bull. 4. New York: The Carnegie Foundation; 1910, p. xii [Reprinted in Birmingham, AL: Classics of Medicine Library; 1990, p. xii].

Problems with universities serving the underserved and keeping up facilities continues today. See Howard University ACGME Accreditation

Regarding Service to the Underserved    "The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but...this argument is insincere, and that the excuse which has hitherto been put forward in the name of the poor boy is in reality an argument in behalf of the poor medical school." Contributor: Murray, T. J. p. xi

Methods of Instruction      In methods of instruction there is...nothing to distinguish medical from other sciences. Out-and-out didactic treatment is hopelessly antequated; it belongs to an age of accepted dogma or supposedly complete information, when the professor "knew" and the students "learned." The lecture indeed continues of limited use. It may be employed in beginning a subject to orient the student, to indicate relations, to forecast a line of study in its practical bearings; from time to time, too, a lecture may profitably sum up, interpret, and relate results experimentally ascertained. Subject: Medical education Contributor: Murray, T. J. pp. 60-1

About Physician Numbers     The country needs fewer and better doctors; and...the way to get them better is to produce fewer. p. 17

Foundations of Medical Education      The development...suggested for medical education is conditioned largely upon three factors: first, upon the creation of a public opinion which shall discriminate between the ill trained and the rightly trained physician, and which will also insist upon the enactment of such laws as will require all practitioners...to ground themselves in the fundamentals upon which medical science rests; secondly, upon the universities and their attitude towards medical standards and medical support; finally, upon the attitude of the... medical profession towards the standards of their own practice and upon their sense of honor with respect to their own profession. p. xiii       This is still true from the perspective of the medical schools. Of course the creation of a public opinion that discriminates between ill trained and rightly trained physicians is still subject to the yellow press of yesterday as well as the headline hunters of today. The grounding in science and support and standards is still true. Note that the failure to mention the needs of the public continues. Only in the past few years has the AMA added equality in access to its recommendations. 

Rural Doctors and Need For Quality    The small town needs the best and not the worst doctor procurable. For the country doctor has only himself to rely on: he cannot in every pinch hail specialist, expert, and nurse. On his own skill, knowledge, resourcefulness, the welfare of his patient altogether depends. The rural district is therefore entitled to the best trained physician that can be induced to go there. p. 44   Note, Flexner was highly biased against country doctors who were often trained in preceptorships. Remember than until the advent of the Model T, few people ever got more than 20 miles from home. Having rural doctors trained by preceptorship then did meet access needs, although the quality depended on the preceptor. Now that today's preceptors are some of the most well-trained and experienced health professionals, preceptorship training is quite different. Osler had a different view than Flexner in some areas, but both tended to support rural needs.

Medical School Attitudes Toward Rural People      It might conceivedly become the duty of the several states to salary district physicians in thinly settled or remote regions--surely a sounder policy than the demoralization of the entire profession for the purpose of enticing ill trained men where they will not go. p. 16   Not much different than a similar address at Why Doctors Don't Go

Importance of Hands-On Training   Abraham Flexner, 1925 The student is to collect and evaluate facts. The facts are locked up in the patient. To the patient, therefore, he must go. Waiving the personal factor, always important, that method of clinical teaching will be excellent which brings the student into close and active relation with the patient: close, by removing all hindrance to immediate investigation; active, in the sense, not merely of offering opportunities, but of imposing responsibilities. Contributor: Huth, Edward J.Source: Flexner, Abraham. Medical Education: A Comparative Study. New York: Macmillan; 1925 [As cited in Wartman W. Medical Teaching in Western Civilization: A History Prepared from the Writings of Ancient and Modern Authors. Chicago: Year Book Medical Publishers; 1961, pp. 227-8].     It seems that Flexner was against the preceptorship method of training, but not against learning on actual patients. Unfortunately in today's medical education students and residents have greatly restricted access to actually making decisions on patients. Rural preceptorships are a great source of such interactions. Even Flexner might have to change his mind on this when presented with the facts.Osler also agreed with hands-on training and would be appalled at modern day medical education methods and facilities

Family L post 1/2003

I also find myself going back to Osler and Flexner. Initially I thought of Flexner as the villain most responsible for maldistribution. After all his medical school reforms did destroy the sources of most rural physicians and also greatly limited the training of minorities since 3 of 5 medical schools for blacks closed (Ludmerer, Time to Heal). He also seemed to be a  pawn in the hands of the elite colleges, foundations (Carnegie), and associations (American Medical Association). These certainly seemed to be in a conspiracy to eliminate the competition, not only other medical schools, but other forms of health care in the nation at that time (homeopathy, etc.).

Over time I have had a chance to examine what Flexner's concepts were instead of how they have been applied by others. He is now a hero and visionary in my eyes, despite what they have done to his concepts later. One of my first applications of my perception of Flexner's concepts resulted in an unexpected call from my dean, only my second contact with him. I made a table comparing Flexner's concepts, the LCME critique of Florida State, and Florida State's defense and posted it on my web site. You must understand that a rural medical education web site such as mine is rarely visited. It is buried 4 subfolders deep in the UNMC web sites. Yet somehow someone at the LCME found this table and called my dean to have me remove this critique of them. In his defense is that he stated that it would make his life easier if it were not there. I had to decide whether to dig in or let this pass. I decided that my impact would be minimal and might actually cause problems for Florida State or the new model of medical education which we desperately need. Now that FSU has been accredited, it is time to explain things to my dean and others. Of course the new medical school in line in northern Ontario is worried about dealing with the LCME.... Will the Canadian inspectors be different? In the mean time several new osteopathic schools have opened with similar missions. It is my hope that accreditation becomes a learning process for both site visitors
and sites.

One of the thought pieces that has influenced me greatly is a discussion of the Five Generations of American Medical Revolution, by Garrison. In this he discusses the first generation of radicals, a second generation who make the proposals palatable. A third generation always shifts to the side that seems to be winning. A fourth generation of bureaucrats that applies the new methods without understanding their concepts and a fifth generation that digs in and opposes any changes, sometimes distorting the original
reforms in an effort to maintain the status quo.

Flexner was more like a first and second generation person. The press and medical associations insured that the third generation went along with his proposals. Osler was placed in this position by Garrison in his landmark article. Osler was more like Lincoln, one who was above generational labeling, one who who stood for fundamental concepts such as freedom and truth and liberty. Osler was one who stood for students working directly with patients in real practice settings working with teachers who truly cared about growing doctors.

Interestingly I think Flexner and Osler would be in agreement today regarding rural preceptorships. Rural preceptorships have become the best medical education. Both believed that the quality of education was related to the preparation of the student before medical school, the ability of the trainee to make decisions and work directly with patients, the quality of the faculty, and their devotion to teaching.

The sad fact is that the medical schools, LCME, ACGME, and the rest have to deal with an American environment that is anti-Oslerian and perhaps anti-service oriented. We know that the characteristics and qualities of a student before medical school have perhaps the greatest influence on this person as a physician (academics, service, career choice, etc.) Perhaps it is impossible to uphold the standards with changes in the environment. Maybe we will need changes in education and communities before the situation will improve.

Osler and Rural Practice

Robert C. Bowman, M.D.

Addendum on Medical Education and Flexner

1) Student Characteristics - In the rural and underserved circles, we have
often pushed the student characteristics model, intrinsic factors that
drive a student to pursue rural and underserved areas, rural background,
minority background, service orientation, lower socioeconomic origin,
maturity, etc.

2) Training Characteristics - We have not examined other factors in
training that might actually drive people into rural practice. We know that
procedures are a part of rural practice. We know through research that
residents that do more ob months go into rural practice more often. It also
seems that we are becoming more and more limited in our capacity to train
in procedures and full service practice, the kind needed in rural and
underserved areas.

I predicted that our accelerated rural training program would have
difficulty dislodging residents from Omaha after 7 years of Omaha-based
training, 3 years medical school, 3 years residency, and a 1 year
procedural fellowship. After all, the research notes that the longer the
urban based training, the less rural graduation (moving from 1 to 2 or 3
years of residency).

Thankfully I was wrong, probably for both reasons above. The selection of
the accelerated candidates was rural background and rural interest and
maturity. The training was primary care intensive as much as possible,
including extra efforts in the M-1 and M-3 year and throughout training. We
added as much procedural orientation as we could do, thanks to stellar
efforts by Jim Stageman, facing great local obstacles, especially in
obstetrics volume. In addition the residents did 2 - 4 months of rural
rotations, and perhaps more importantly, significant rural moonlighting and
also formed a group mentality, even going out into rural practice in 2
person teams.

Perhaps the 3rd item is also key: being trained together exchanging
support and expectations too.

I think that when residents are trained intensively and together and
specifically in full service primary care for underserved areas, they will
not be satisfied unless they get the opportunity to do what they have long
desired and have trained for!

Robert C. Bowman, M.D.

Other Flexner on the web http://jama.ama-assn.org/cgi/content/full/291/17/2139



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