1910: The Year American Medicine Changed Forever
Medical education in the United States is generally regarded to be the finest in the world, and for that, you can thank Abraham Flexner. In 1910, the Louisville native and education reformer published an in-depth, damning, and eye-opening report on the state of American medical schools. In the quarter-century after the Flexner Report's publication, the entire medical profession was dissected, examined, and reforged, transforming from an unregulated free-for-all to an expert, science-based endeavor.
American medical education was in a sorry state in the early 20th century. More than 160 institutions pumped out 4,400 graduates each year, most of whom were woefully undertrained and received uneven instruction. With no agreed upon standards, many schools focused on pseudoscientific fields like electrotherapy, homeopathy, chiropractic, and naturopathy. For a patient seeking medical attention, there was no standard of care, just a daunting morass.
Seeking to cure this sickness was philanthropist and business magnate Andrew Carnegie. In the waning years of his long and fruitful life, Carnegie dedicated himself to giving away much of his amassed fortune, which tallied near $400 billion in today's dollars. One mission he particularly deemed worthy was improving healthcare in America. As part of this goal, he turned to Abraham Flexner.
Henry Pritchett, head of the Carnegie Foundation, heard about Flexner by reading his first book, The American College, which heavily criticized lectures as a method of teaching. At his own experimental college preparatory school, Flexner promoted hands-on learning and eschewed traditional tests and grades. Impressed, Pritchett tasked Flexner with surveying the quality of medical schools throughout America and Canada and providing suggestions for their improvement.
"An unflattering but not necessarily inaccurate description for Flexner’s assignment was that he was to be the hatchet man in sweeping clean the medical system of substandard medical schools that were flooding the nation with poorly trained physicians," described Thomas P. Duffy, Professor Emeritus of Medicine at Yale University.
Flexner felt overwhelmed by and under-qualified for the mission (he didn't actually have a degree in medicine) but was assured he'd have the full support and confidence of the Carnegie Foundation. He got to work immediately. Over the next two years, Flexner visited 155 medical schools, discovering gross inadequacies galore, but some positives as well. He held Johns Hopkins University in Baltimore, Maryland as the gold standard of medical education, praising its facilities, attached hospital, and professors. There were a variety of "bad apples." For example, of Arkansas' two schools, Flexner was scathing.
"Both... are local institutions in a state that has at this date three times as many doctors as it needs; neither has a single redeeming feature. It is incredible that the state university should permit its name to shelter one of them."
There were many more schools like Arkansas'. Generally, they were purely for-profit, had lax entrance standards, provided little to no patient interaction before graduation, and did not engage in science-based education.
The takeaways from Flexner's 346-page report can be summarized as follows: Drastically reduce the number of medical schools and thus the surplus of poorly-trained physicians. Increase the prerequisites to receive medical training, particularly by requiring a college degree in basic science. Encourage evidence-based practice. Align colleges with medical schools and mandate clinical education in hospitals. Strengthen regulation of medical licenses. Free medical professors from most patient care to permit time for research and instruction. Increase the years of instruction required before graduation.
With significant financial backing from Andrew Carnegie and John D. Rockefeller, Flexner's vision was realized. Licensing was strengthened. Treatments not rooted in science were rooted out. Instruction became far more hands-on. Twenty-five years after its publication, only 66 medical schools operated in the United States.
But there were side effects of Flexner's prescription. The Kentuckian sported both sexist and racist attitudes, and his recommendations set back women and African Americans seeking to become doctors. Most of the remaining medical schools no longer accepted women, and many of the institutions that accepted African Americans shut down. Years later, some also wonder if medical education now trains too many "neutered technicians" who see "patients in the service of science rather than science in the service of patients." As Professor Duffy wrote:
Did the Flexner Report overlook the ethos of medicine in its blind passion for science and education? What was the cost of our success, and who has borne that burden? Review of medical care in the last century documents that the trust and respect that were extended to the profession 50 years ago have been substantially eroded. There has been a fall from grace of our vaunted profession. Physicians have lost their authenticity as trusted healers. We have become derelict in many realms.
Other doctors think there is a need for yet another Flexner report, but this time to fix the systemic issues caused by profit-driven interests in healthcare.
"Students hear institutional leaders speaking more about “throughput,” “capture of market share,” “units of service,” and the financial “bottom line” than about the prevention and relief of suffering. Students learn from this culture that health care as a business may threaten medicine as a calling," a team of doctors wrote in the New England Journal of Medicine.
"No one would cheer more loudly for a change in medical education than Abraham Flexner. He recognized that medical education had to reconfigure itself in response to changing scientific, social, and economic circumstances in order to flourish from one generation to the next."