Flexner Report


The Flexner Report is a book-length landmark report of medical education in the United States and Canada, written by Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation. Flexner not only described the state of medical education in North America, but he also gave detailed descriptions of the medical schools that were operating at the time. He provided both criticisms and recommendations for improvements of medical education in the United States.
Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath. While it had many positive effects on American medical education, the Flexner report has been criticized for introducing policies that encouraged systemic racism and sexism.
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 principles 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 for the education of the various forms of alternative medicine, such as electrotherapy, were closed. Homeopathy, traditional osteopathy, eclectic medicine, and physiomedicalism were derided.
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 the closure of all but two black medical schools and the reversion of American universities to male-only admittance programs to accommodate a smaller admission pool.
In Chapter 11, Flexner stressed that the success of medical education reform and the professionalization of medicine relied heavily on the effective legal and ethical functioning of state medical boards. However, he noted that these boards were failing in their mission, stalling progress, and allowing substandard medical practices to continue, thereby jeopardizing public health. This problem persists as a significant issue in the current practice of medicine in the United States.

Background

During the nineteenth century, American medicine was neither economically supported nor regulated by the government. Few state licensing laws existed, and when they did exist, they were weakly enforced. There were numerous medical schools, all varying in the type and quality of the education they provided.
In 1904, the American Medical Association created the Council on Medical Education, 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 upper-class, educated students.
In 1908, seeking to advance its reformist agenda and hasten the elimination of schools that failed to meet its standards, the CME contracted with the Carnegie Foundation for the Advancement of Teaching to survey American medical education. Henry Pritchett, president of the Carnegie Foundation and a staunch advocate of medical school reform, chose Abraham Flexner to conduct the survey. Neither a physician, a scientist, nor a medical educator, Flexner held a Bachelor of Arts degree and operated a for-profit school in Louisville, Kentucky. He visited every one of the 155 North American medical schools that were in operation at the time, all of which differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Summarizing his findings, he wrote:
The Report became notorious for its harsh description of certain establishments. For example, Flexner described Chicago's fourteen 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, Michigan, Wake Forest, McGill, Toronto, and particularly Johns Hopkins, which was described as the 'model for medical education'.
The Report ultimately produced many unintended consequences, and many of the repercussions of the Report are still seen in American medicine today. Minority groups, such as African Americans and women, faced fewer opportunities as a result of the publishing of the Flexner Report. Additionally, many medical schools for alternative medicine and osteopathic medicine eventually closed as a result of the Report.

Recommended changes

To help with the transition and change the minds of other doctors and scientists, John D. Rockefeller gave many millions to colleges, hospitals and founded a philanthropic group called "General Education Board".
In the nineteenth century, it was relatively easy to not only receive a medical education, but also to start a medical school. 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 with laboratory work and dissection optional. Many of the instructors were local doctors teaching part-time. There were very few full-time professors, dedicated to medical education. Medical schools did not receive funding, and their only money came from the students' tuitions. 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" was in common use.
Flexner carefully examined the situation. Using the Johns Hopkins School of Medicine as the ideal medical school, he issued the following recommendations:
  1. Reduce both the number of medical schools and the number of poorly trained physicians;
  2. Increase the prerequisites to enter medical training;
  3. Train physicians to practice in a scientific manner and engage medical faculty in research;
  4. Give medical schools control of clinical instruction in hospitals;
  5. Hire trained, full-time staff for medical education;
  6. Grant medical schools increased funding;
  7. Strengthen state regulation of medical licensure
Flexner 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." To Flexner, Hopkins incorporated the high standards of German medical education, while keeping the American standard of high respect for patients by physicians. In his efforts to ensure that Hopkins was the standard to which all other medical schools in the United States were compared, Flexner went on to claim that all the other medical schools were subordinate in relation to this "one bright spot." In addition to Johns Hopkins School of Medicine, Flexner also considered the medical schools at Harvard, University of Michigan, and the University of Pennsylvania to be strong schools. He said that medical schools that did not meet these high standards must change their approach to medical education or close their doors.
Flexner also 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, in the nineteenth century, 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 prerequisite 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. Furthermore, he stated that medical schools needed to be part of a larger university since 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. During the research of his report, Flexner noted a lack of dedicated, full-time professors. American medical education needed committed professors to teach the next generations of physicians. 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 he had studied and traveled in Europe extensively. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. There were many aspects of German medical education that Flexner, along with other medical educators and physicians who had traveled to Germany, admired, such as their national standards for students and universities, academic freedom, and the expectation of postgraduate training. Furthermore, many physicians who traveled to Europe to receive postgraduate training were impressed with the German dedication to research, innovation, and teaching. 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 followed many of Flexner's recommendations. However, schools have increased their emphasis on matters of public health.