Flexner Report
Encyclopedia
The Flexner Report is a book-length study of medical education in the United States
United States
The United States of America is a federal constitutional republic comprising fifty states and a federal district...

 and Canada
Canada
Canada is a North American country consisting of ten provinces and three territories. Located in the northern part of the continent, it extends from the Atlantic Ocean in the east to the Pacific Ocean in the west, and northward into the Arctic Ocean...

, written by the professional educator Abraham Flexner
Abraham Flexner
Abraham Flexner was an American educator. His Flexner Report, published in 1910, reformed medical education in the United States...

 and published in 1910 under the aegis
Aegis
An aegis is a large collar or cape worn in ancient times to display the protection provided by a high religious authority or the holder of a protective shield signifying the same, such as a bag-like garment that contained a shield. Sometimes the garment and the shield are merged, with a small...

 of the Carnegie Foundation
The Carnegie Foundation for the Advancement of Teaching
Founded by Andrew Carnegie in 1905 and chartered in 1906 by an act of the United States Congress, the Carnegie Foundation for the Advancement of Teaching is an independent policy and research center, whose primary activities of research and writing have resulted in published reports on every level...

. 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
Science
Science is a systematic enterprise that builds and organizes knowledge in the form of testable explanations and predictions about the universe...

 in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, 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
Oberlin College
Oberlin College is a private liberal arts college in Oberlin, Ohio, noteworthy for having been the first American institution of higher learning to regularly admit female and black students. Connected to the college is the Oberlin Conservatory of Music, the oldest continuously operating...

 in 1833 and private colleges such as Vassar College
Vassar College
Vassar College is a private, coeducational liberal arts college in the town of Poughkeepsie, New York, in the United States. The Vassar campus comprises over and more than 100 buildings, including four National Historic Landmarks, ranging in style from Collegiate Gothic to International,...

 and Pembroke College
Pembroke College (Brown University)
Pembroke College in Brown University was the coordinate women's college for Brown University in Providence, Rhode Island. It was founded in 1891 and closed in 1971.-Founding and early history:...

.

History

In 1904 the AMA
American Medical Association
The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

 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
Anatomy
Anatomy is a branch of biology and medicine that is the consideration of the structure of living things. It is a general term that includes human anatomy, animal anatomy , and plant anatomy...

 and physiology
Physiology
Physiology is the science of the function of living systems. This includes how organisms, organ systems, organs, cells, and bio-molecules carry out the chemical or physical functions that exist in a living system. The highest honor awarded in physiology is the Nobel Prize in Physiology or...

 followed by two years of clinical work in a teaching hospital
Teaching hospital
A teaching hospital is a hospital that provides clinical education and training to future and current doctors, nurses, and other health professionals, in addition to delivering medical care to patients...

. 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 Flexner to conduct the survey.

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 Harvard
Harvard Medical School
Harvard Medical School is the graduate medical school of Harvard University. It is located in the Longwood Medical Area of the Mission Hill neighborhood of Boston, Massachusetts....

, Western Reserve
Case Western Reserve University
Case Western Reserve University is a private research university located in Cleveland, Ohio, USA...

, Michigan
University of Michigan Health System
The University of Michigan Health System is the wholly owned academic medical center of the University of Michigan in Ann Arbor. UMHS includes the U-M Medical School, with its Faculty Group Practice and many research laboratories; the U-M Hospitals and Health Centers, which includes University...

, Wake Forest University School of Medicine
Wake Forest University School of Medicine
The Wake Forest School of Medicine is the medical school of Wake Forest University, located in Winston-Salem, North Carolina. It is affiliated with North Carolina Baptist Hospital and Wake Forest University Physicians, forming part of the Wake Forest Baptist Medical Center system...

, McGill
McGill University
Mohammed Fathy is a public research university located in Montreal, Quebec, Canada. The university bears the name of James McGill, a prominent Montreal merchant from Glasgow, Scotland, whose bequest formed the beginning of the university...

, University of Toronto
University of Toronto
The University of Toronto is a public research university in Toronto, Ontario, Canada, situated on the grounds that surround Queen's Park. It was founded by royal charter in 1827 as King's College, the first institution of higher learning in Upper Canada...

, and especially Johns Hopkins
Johns Hopkins University
The Johns Hopkins University, commonly referred to as Johns Hopkins, JHU, or simply Hopkins, is a private research university based in Baltimore, Maryland, United States...

 - the latter was described as 'model for medical education'.

Recommended changes

When Flexner researched his report, many American medical schools were "proprietary", namely small 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 government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished.

Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal, he boldly recommended that:
  • Admission to a medical school should require, at minimum, a high school
    High school
    High school is a term used in parts of the English speaking world to describe institutions which provide all or part of secondary education. The term is often incorporated into the name of such institutions....

     diploma
    Diploma
    A diploma is a certificate or deed issued by an educational institution, such as a university, that testifies that the recipient has successfully completed a particular course of study or confers an academic degree. In countries such as the United Kingdom and Australia, the word diploma refers to...

     and at least two years of college
    College
    A college is an educational institution or a constituent part of an educational institution. Usage varies in English-speaking nations...

     or university
    University
    A university is an institution of higher education and research, which grants academic degrees in a variety of subjects. A university is an organisation that provides both undergraduate education and postgraduate education...

     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 (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.
  • The length of medical education be four years, and its content should be what the CME agreed to in 1905.
  • 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.


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 was demanding 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
Public health
Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals" . It is concerned with threats to health based on population health...

 matters.

Consequences of the report

To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
  • 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
    American Medical Association
    The American Medical Association , founded in 1847 and incorporated in 1897, is the largest association of medical doctors and medical students in the United States.-Scope and operations:...

     has oversight over the conventional medical schools located within the state;
  • Medicine in the USA and Canada becomes 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."

Closure of many medical schools

According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting MD
Doctor of Medicine
Doctor of Medicine is a doctoral degree for physicians. The degree is granted by medical schools...

 or DO
Doctor of Osteopathic Medicine
Doctor of Osteopathic Medicine is a professional doctoral degree for physicians in the United States. Holders of the MD degree, Doctor of Medicine, have the same rights, privileges and responsibilities as osteopathic physicians in the United States.The American Osteopathic Association’s Commission...

 degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none 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 institution, 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. This 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.

One of the consequences of Flexner's advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper-class white males. The small "proprietary" schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities. While many such doctors continued to practice, they did so under proscribed circumstances and for less pay. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form.

Impact on alternative medicine

When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, eclectic medicine
Eclectic medicine
Eclectic medicine was a branch of American medicine which made use of botanical remedies along with other substances and physical therapy practices, popular in the latter half of the 19th and first half of the 20th centuries....

, naturopathy and homeopathy
Homeopathy
Homeopathy is a form of alternative medicine in which practitioners claim to treat patients using highly diluted preparations that are believed to cause healthy people to exhibit symptoms that are similar to those exhibited by the patient...

. 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 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 complied with the Report or shut their doors.

Impact on osteopathic medicine

Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association
American Osteopathic Association
The American Osteopathic Association is the representative member organization for the over 78,000 osteopathic medical physicians in the United States...

 (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations and producing an evidence-based practice. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine
Osteopathic Manipulative Medicine
Osteopathic Manipulative Medicine is the application of the distinct osteopathic philosophy, structural diagnosis and use of Osteopathic Manipulative Technique in the diagnosis and management of the patient. OMM takes into account the physical and mental health of a patient, and how either aspect...

. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.

Further reading

  • Beck, Andrew H., 2004, "The Flexner Report and the Standardization of American Medical Education", Student JAMA 291: 2139–40.
  • Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press. ISBN 0801871247.
  • Flexner, A., 1910. Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
  • Gevitz, Norman
    Norman Gevitz
    Norman Gevitz, PhD is a medical historian. He has written numerous books and papers on the history of medicine in the United States and England. He is perhaps best known for his book, The D.O.s, about osteopathic physicians in the United States. He is currently a professor at the New York College...

    , and Grant, U. S., 2004. The D.O.s (2nd ed.). Baltimore: The Johns Hopkins University Press. ISBN 0-8018-7834-9.
  • Goodman, John C., and Gerald L. Musgrave, 1992. "How The Cost-Plus System Evolved". Patient Power. Washington, D.C.: Cato Institute, W67. Part I Part II Part III

  • Kessel, Reuben, 1958. "Price Discrimination in Medicine", Journal of Law and Economics 1 (Oct., 1958): 20–53.
  • Starr, Paul, 1982. The Social Transformation of American Medicine
    The Social Transformation Of American Medicine
    The Social Transformation of American Medicine is a book written by Paul Starr and published by Basic Books in 1982. It won the 1984 Pulitzer Prize for General Non-Fiction as well as the Bancroft Prize.Capers Jones wrote,...

    . Basic Books. ISBN 0465079350.
  • Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education. University of Wisconsin Press
    University of Wisconsin Press
    The University of Wisconsin Press is a non-profit university press publishing peer-reviewed books and journals. It primarily publishes work by scholars from the global academic community but also serves the citizens of Wisconsin by publishing important books about Wisconsin, the Upper Midwest, and...

    . ISBN 0299117502, ISBN 0299117545.

External links

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