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The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and 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. 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.
Additional recommended knowledge
In the late 19th century, what came to be called allopathic medicine emerged after a struggle with other forms of medicine. Allopathic medicine was grounded in antiseptic surgery, the germ theory of infectious disease (which implied a large number of effective public health measures), and the scientific method including clinical trials. The American Medical Association sought to eliminate medical schools that were not fully committed to allopathic medicine. In 1904 the 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 2 years training in human anatomy and physiology followed by 2 years of clinical work in a teaching hospital. 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."
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. There is no evidence that the mass of Americans were dissatisfied with this situation.
Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal, he boldly recommended that:
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 travelled 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 USA 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.
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:
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 more than 90 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 Hyatt 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 4400 to 2000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within 2-3 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 28000 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 M.D. 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.
American medicine becomes a less diverse profession
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 middle 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 6-8 years of university education, and were often simply denied admission to medical schools affiliated with universities. At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continuted to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. 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. The Flexner report recommended the closure of several African American Medical schools. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.
Impact on alternative medicine
When Flexner researched his report, allopathic medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physiomedicalism, naturopathy and homeopathic medicine. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, 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 (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of osteopathic and allopathic medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. 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.
|This article is licensed under the GNU Free Documentation License. It uses material from the Wikipedia article "Flexner_Report". A list of authors is available in Wikipedia.|