Flexner Report

The Flexner Report on medical school curriculum was instrumental in changing the profession of medicine in North America. This document was submitted by Abraham Flexner in 1910 as the culmination of his personal investigation of each medical school operative at that time". Financed by a group of physicians, educators, and philanthropists, the report, entitled "Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching" was published as a bulletin of the Carnegie Foundation.

Flexner's report included his conclusions and collected data after he had "evaluated all 155 medical schools in the United States and Canada" by interviewing faculty, reviewing financial records, and making site visits to the facilities. These schools ranged from university affiliated 4 year programs with strict admission requirements (for example, 2- 4 years of college), that offered student doctors extensive laboratories for science education and hospital wards of patients to afford clinical experience , to diploma mills that had no formal admission standards, no laboratory teaching in science, no hands-on clinical training and no criteria for graduation other than successful payment of fees.

Flexner and the Carnegie foundation valued modern medical training that was based in laboratory science and couched in the learned atmosphere of the university, and made this bias clear even in its introduction. Further, the report emphasized that the public had no means to distinguish the qualified from the unqualified physician, and emphasized the unacceptable quality of most of the schools reviewed. Beyond the individual welfare of patients, depicted as the "unwitting" victims of newly minted physicians who were sent out from the inadequate schools to learn their skills by trial and error, the Flexner Report insisted that the entire community suffered or benefited according to the quality of its physicians, arguing that it was these community physicians who were responsible for setting standards of public sanitation and hygiene for each community. The tone of much of the report is scathing, describing entire schools as "filthy" or "utterly hopeless" and repeatedly stressing the concept that the public welfare was jeopardized by the "inadequately trained physician". Since this bulletin was widely circulated, it is easy to understand why popular demand for the reform of medical education followed its publication.

Medical education in the 19th century

The 19th century saw the germ theory of disease, histology, and major advances in chemistry and pharmacology all applied to Medicine. during this same time, the westward expansion of the United States and the Civil War, and Reconstruction, were responsible for a wide regional variation of culture in the United States, from relatively affluent Eastern cities that had established university systems based on a European model, to frontier towns that lacked any institutions of higher education. The former Confederate states were generally poverty stricken after the Civil War, and the educational system there was segregated according to race.

In the USA, requirements at different medical schools varied tremendously. Only a minority of medical schools were affiliated with universities, there were dozens of small "proprietary" schools of medicine that were administered by physicians in private practice. Medicine was viewed as a trade by many physicians, and teaching in a medical school- or running one, was seen by these businessmen-physicians as a legitimate source of revenue. With the westward expansion of the United States over the 19th Century, the frontier areas held relatively few educated people, and there were different standards set as towns and cities grew than existed in the more established areas in the East.

Although women did not receive the right to vote in public elections until 19XX, some managed to become physicians, and there were such things as "Women's Medical Colleges" besides coeducational schools of medicine. Johns Hopkins, which was lauded in the report, was unusual in that it started as a coeducational school, as a group of women provided the final funding needed to start it. Although some black Americans attended nonsegregated medical schools, most black physicians graduated from a few schools that were called "Negro Medical Schools".

Even now, the Flexner Report is a historically important document as it captures a description of medical education of its time.

Recommendations for professional medical education

The report advised cutting the number of schools from 155 to 31, and argued that doing so would increase rather than decrease the quality of medical care in the two countries. The demographics of the schools were analyzed so as to leave no major region of the United States without a school of medicine. Part of that analysis looked at "sects" of medicine, so called allopathy, homeopathy etc. Flexner stated that modern medicine belonged to none of these sects, but was a discipline in which knowledge was rationally applied to cure disease, in contrast to pre-conceived generalizations regarding diseases and their cures, like allopathy (dislike cures like) or homeopathy (cures of similars). He quoted the great American physician of the day, Sir William Osler

A new school of practitioners has arisen which cares nothing for homeopathy and still less for so-called allopathy. It seeks to study, rationally and scientifically, the action of drugs, old and new."(Flexner report, page 162)

Sectarian Schools

Although there were no sectarian schools in Canada, 32 were identified in the United States:

• 15 homeopathic
• 8 eclectic
• 1 physiomedical
• 8 osteopathic.

Homeopathic

Of the homeopathic schools, only five required so much as a high school diploma for entrance and 2 had no educational pre-requisites at all. Several schools were noted to have adequate laboratory facilities, these included the school associated with Boston University, the New York Homeopathy College and the Hahneman School of Philadelphia.

In contrast, several homeopathic schools in Illinois, Kentucky, Missouri, and Michigan were condemned as "utterly hopeless" (p.160), with managers "unfit for any educational purpose" and inhabiting physical plants that were both "filthy and neglected". Flexner also criticized the overall lack of "clinical material" (meaning patients) available to students, claiming that some schools were restricted to amphitheater teaching, rather than offering bedside teaching in wards.

Interestingly, the report mentions that the number of schools and the enrollment of students in the homeopathic schools was markedly reduced from ten years previously. In 1900 the graduating classes totaled 413 (from 22 schools), and, by 1910, were cut "almost in half" to 246 (from the 15 remaining schools).

Eclectic

Of the 8 eclectic schools, one, in New York City, required the Regents High School diploma for entry, the others had nominal requirements. Three of the schools were described as having some modest assets, but the "remaining five eclectic schools are without exception filthy and almost bare." The laboratory equipment at all of these schools was dismissed as not remotely resembling the equipment claimed in their catalogs. In assessing the eclectic schools exposure of students to clinical material in the form of patients, he stated "of the schools under discussion, none has decent clinical opportunities", and went on to claim that what the 3 best of the 8 schools had was "criminally inadequate", the "other five schools have literally nothing at all".

The eclectic schools, like the homeopathic schools were dwindling in numbers at the time of his assessment, with two schools closed since the height of ten in 1901, and overall enrollment down to 413 from 1014 in 1904.

Osteopathic

The 8 osteopathic schools "fairly reek with commercialism", Flexner complained, quoting brochures that claimed"...our graduates earn in a single month what they formerly able to earn by a full year's work". Although Flexner was uniformly critical of schools that promoted careers in medicine to prospective students on the basis of finances, he analyzed each school's finances with an accountant's eye. Whereas other sorts were condemned for poverty, the osteopathic schools were roundly criticized for making a profit from their students. He noted that the 8 schools collected over $200,000 annually from their students, and the the instruction furnished for this sum is "inexpensive and worthless"(p166)

Even though the osteopathic "sect" relied on spinal manipulation as a uniform treatment, this did not excuse them from enabling their students to make a diagnosis, he argued,and that the short course of 3 years, the lack of laboratory facilities was woefully inadequate to do so. He found particular fault with the "fatally defective" teaching in anatomy, which he argued should be the cornerstone of a school that emphasized spinal manipulation.

University affiliation

Neither Abraham Flexner or the Carnegie Foundation was neutral towards educational philosophies in medicine. "For profit" schools, for which the term "proprietary" was coined, were deplored and academic education in a University setting of a "higher calling" was openly admired. Mere affiliation was not enough to earn the Carnegie Foundation's approval, the President of the Foundation, Henry S. Prtchett, argued that a University must support a medical school at a high level of educational standards and provide first class physical and laboratory facilities in his introduction to the report. His language was blunt to the point of being inflammatory: " There is a certain minimum of equipment and a certain minimum of educational requirement without which no attempt ought to be made to teach medicine. Hitherto not only proprietary medical schools, but colleges and universities, have paid scant attention to that fact. They have been ready to assume the responsibility of turning loose upon a helpless community men licensed to the practice of medicine without any serious thought as to whether they had received a fair training or not" (page xii, Introduction. Flexner Report.)

Hospital for clinical training

Flexner stated that a hospital for clinical training was as important to a medical school as a laboratory for training in chemistry or pathology. Just as he specified that adequate laboratories were well equipped and supervised, he specified that the appropriate hospital was to be under the direction of the medical school.

Impact of the Flexner Report

"Although reform in medical education was already under way, Flexner's report fueled change by criticizing the mediocre quality and profit motive of many schools and teachers, the inadequate curricula and facilities at a number of schools, and the nonscientific approach to preparation for the profession, which contrasted with the university-based system of medical education in Germany."

Association of American Medical Colleges

Formed in response to the report, the American Association of Medical Colleges (AAMC) reflected the common approach of Flexner-compliant schools.

Many Medical Schools Closed

Johns Hopkins University was lauded in the Flexner Report. Some homeopathic schools, such as Hahnemann, converted to the new model.