The Flexner Report
The Flexner Report
Standardizing Medical Education in the United States and Canada
By: Abraham Flexner
Source: Abraham Flexner. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin Number Four. New York: The Carnegie Foundation, 1910.
About the Author: Abraham Flexner (1886–1959) was born in Louisville, Kentucky. He attended Johns Hopkins University and graduated in 1886 with a degree in education. He spent nineteen years as a secondary school teacher and a principal before seeking a graduate education at Harvard University and the University of Berlin. In 1908, he was employed by the Carnegie Foundation for the Advancement of Teaching and, in 1910, issued the groundbreaking and controversial Medical Education in the United States and Canada, commonly called The Flexner Report. In his report, Flexner analyzed the status of American medical education and deemed it sorely lacking. The outcome of this body of work was full-scale reform and re-tooling of the medical education system in the United States—from admission standards and academic institution organization to standardization of curriculum across the schools and clinical training of physicians-in-training. Between 1912 and 1925, Flexner was a member of the General Education Board and served as its secretary from 1917 to 1925. He founded the Institute for Advanced Study at Princeton University with Louis Bamberger. Abraham Flexner acted as the head of the institute from 1930 to 1939. He also published numerous treatises on education. The most notable among them were: A Modern School (1916), The Gary Schools (co-authored with F. B. Bachman in 1918), The Burden of Humanism (delivered also as the Taylorian Lecture at Oxford University in 1928), and the well-known Universities: American, English, German (1930).
Abraham Flexner is one of the most well-known names in the history of medical education, since he is considered to have been the catalyst for the transformation and standardization of American medical studies.
During much of the nineteenth century, it generally took little effort to become a physician in the United States. There were three different types of medical education in the America during most of the nineteenth century: an apprenticeship system in which students received direct and practical training from a local physician; a proprietary school system in which groups of students attended lectures given by physicians who owned the schools; and university systems in which students were given training that was both didactic (lecture style) and clinical, through university and hospital affiliations. The latter group received training in a variety of areas of medicine, including scientific, osteopathic, chiropractic, homeopathic, physiomedical, botanical, Thomsonian, and eclectic.
The proprietary schools generally had no formalized entrance requirements, other than an ability to pay tuition. Courses were both brief and general: the typical curriculum entailed two sixteen-week semesters, the second of which was merely a repetition of the first. Instruction was in lecture and text format, with no appreciable academic clinical or laboratory practice. The typical proprietary medical school faculty numbered seven or eight. They usually owned the school and operated it as a profitable venture, hence the name "proprietary school." As a rule, proprietary medical schools had no university or hospital affiliations.
American students seeking a more comprehensive or scientifically based medical education were forced to study in Europe, where the curricula were far more in-depth, and focused more on the scientific and clinical realms. Most American students going abroad chose medical schools in England, Scotland, Germany, or France.
American-trained physicians, because of the lack of standardization in education and training, varied widely in their medical knowledge, therapeutic techniques, philosophies, and abilities to successfully treat illness and injury. There were few licensing examinations and even fewer requirements in order to engage in the practice of medicine.
During the second half of the nineteenth century, the American Medical Association (AMA) was engaged in public efforts to standardize American medical education. Their campaign met with minimal success, since most Americans doubted that any one form of medical education and training was significantly better than another. In addition, the American political philosophy discouraged national regulation of any of the professions.
By the beginning of the twentieth century, clinical and scientific laboratory research had unquestionably proven that previously accepted "medical treatments," such as purging, blistering, and bleeding, were ineffective. There was growing acceptance of public sanitation, the efficacy of vaccination, and the utility of antiseptic surgery in the prevention and treatment of disease.
At the same time, faculty at university-affiliated medical schools asserted that the skills necessary for the practice of scientifically based medicine could not be learned by simple memorization of texts and passive listening to lectures, but could only be gained by the diligent application of the scientific method throughout several years of academic and clinical medical training and education. It was their belief that medical students should be equally schooled in bedside care, laboratory work, and academic studies in order to become skilled physicians.
The AMA undertook a campaign aimed at the closure of all American medical schools that did not move to the new educational standards. In 1904, the AMA created the Council on Medical Education (CME) in order to advance the reorganization of American medical education. The CME created two major goals for implementation: 1) standardization of specific academic and educational prerequisites for medical school entry; and 2) nationwide adoption of the ideal academic medical curriculum. This curriculum involved an initial two years of rigorous training in the laboratory sciences, followed by another two years spent in clinical rotations at a teaching hospital.
In 1908, the CME proposed a complete survey of all American medical schools in order to disseminate information concerning the proposed educational reforms and to gather preliminary data on the various teaching methods currently employed. The CME engaged the Carnegie Foundation for the Advancement of Teaching to conduct the survey. Henry S. Pritchett, then president of the Carnegie Foundation, selected Abraham Flexner to lead the survey.
The striking and significant facts which are here brought out are of enormous consequences not only to the medical practitioner, but to every citizen of the United States and Canada; for it is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate training whatsoever. As a rule, Americans, when they avail themselves of the services of a physician, make only the slightest inquiry as to what his previous training and preparation have been. One of the problems of the future is to educate the public itself to appreciate the fact that very seldom, under existing conditions, does a patient receive the best aid which is possible to give him in the present state of medicine, and that this is mainly due to the fact that a vast army of men is admitted to the practice of medicine who are untrained in sciences fundamental to the profession and quite without a sufficient experience with disease. A right education of public opinion is one of the problems of future medical education.
The significant facts revealed by this study are as follows:
(1)For twenty-five years past there has been an enormous over-production of uneducated and ill trained medical practitioners. This has been in absolute disregard of the public welfare and without any serious thought of the interests of the public. Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany.
(2)Over-production of ill trained men is due in the main to the existence of a very large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occupations into the study of medicine.
(3)Until recently the conduct of a medical school was a profitable business, for the methods of instruction were mainly didactic. As the need for laboratories has become more keenly felt, the expenses of an efficient medical school have been greatly increased. The inadequacy of many of this school may be judged from the fact that nearly half of all our medical schools have incomes below $10,000, and these incomes determine the quality of instruction that they can and do offer.
Colleges and universities have in large measure failed in the past twenty-five years to appreciate the great advance in medical education and the increased cost of teaching it along modern lines. Many universities desirous of apparent educational completeness have annexed medical schools without making themselves responsible either for the standards of the professional schools or for their support.
(4)The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but the facts set forth in this report make it evident that this argument is insincere, and that the excuse which has hitherto been put forward in the name of the poor boy is in reality an argument in behalf of the poor medical school.
(5)A hospital under complete educational control is as necessary to a medical school as is a laboratory of chemistry or pathology. High-grade teaching with a hospital introduces a most wholesome and beneficial influence into its routine. Trustees of hospitals, public and private, should therefore go to the limit of their authority in opening hospital wards to teaching, provided only that the universities secure sufficient funds on their side to employ as teachers men who are devoted to clinical science.
In view of these facts, progress for the future would seem to require a very much smaller number of medical schools, better equipped and better conducted than our schools now as a rule are; and the needs of the public would equally require that we have fewer physicians graduated each year, but that these should be better educated and better trained. With this idea accepted, it necessarily follows that the medical school will, if rightly conducted, articulate not only with the university, but with the general system of education….
Over a period of eighteen months, Abraham Flexner visited a total of 155 medical schools across the United States. For each institution, he examined five specific areas in depth: 1) the entrance requirements; 2) the size and specific training of the faculty; 3) the extent of both the endowment and the amount of tuition charged per student; 4) the quality and sufficiency of the laboratory facilities; and 5) the availability and affiliation with a teaching hospital whose medical staff would function as clinical faculty. He found very few medical schools possessing the necessary combination of skilled and educated academic and clinical teaching faculty, appropriate hospital and laboratory facilities, and financial resources necessary to support the AMA's CME proposed reform for medical education. Flexner stated, "We have indeed in America medical practitioners not inferior to the best elsewhere; but there is probably no other country in the world in which there is so great a distance and so fatal a difference between the best, the average, and the worst."
Flexner was of the opinion that it would be impossible to raise the performance of the schools most lacking in the five essential areas to the standards of the best equipped institutions He felt that it was better to close the inferior medical schools and concentrate on those showing the most promise for the delivery of a superior education. Flexner said, "The point now to aim at is the development of the requisite number of properly supported institutions and the speedy demise of all others."
One of Flexner's greatest impacts in the support of reform for American medical education lay in his public health approach. It was his contention that the values and ethics inherent in a progressive system of scientific medical education were incompatible with the proprietary approach. Flexner stated, "Such exploitation of medical education is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited."
Shortly after the Flexner Report was published, state licensing boards across the country began to emerge. They required medical schools to implement significantly more arduous pre-admission requirements and far more rigorous curriculum standards. In 1912, the Federation of State Medical Boards was created, and it agreed to utilize the AMA's (CME's) academic standards as its basis for academic accreditation. During this time period, philanthropic foundations began to create large financial endowments aimed at furthering medical education and research at various medical institutions. By 1940, proprietary medical schools no longer existed, and the rigorous medical curriculum desired by the AMA's CME and espoused by Flexner had become the norm.
Rothstein, William G. American Physicians in the Nineteenth Century: From Sects to Science. Baltimore: Johns Hopkins University Press, 1972.
Starr, Paul. The Social Transformation of American Medicine. New York: Basic Books, 1982.
Wheatley, Steven C. The Politics of Philanthropy: Abraham Flexner and Medical Education. Madison: University of Wisconsin Press, 1988.
Beck, Andrew H. "The Flexner Report and the Standardization of American Medical Education." Student JAMA [Journal of the American Medical Association] 291 (2004): 2139-2140.
Billings, J. S. "Ideals of Medical Education." Science 18 (1891): 1-4.