Flexner Report

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.

History
In the late 19th century, what came to be called allopathic emerged. 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."

Recommended changes
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:
 * 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, 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 (p 28). According to Hyatt and Stockton, by 1920 92% of USA medical schools required this of applicants.
 * The length of medical education be four years, and its content should be what the CME agreed to in 1905.
 * Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.

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:
 * A physician receives at least 6, and preferably 8, years of post-secondary formal instruction, nearly always in a university setting.;
 * The quality of medical education is invariably high.
 * Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry. Medical research adheres fully to the protocols of scientific research;
 * No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
 * Each state branch of the American Medical Association has oversight over the medical schools located within the state;
 * Medicine in the USA and Canada becomes a highly paid and well-respected profession;
 * The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report.
 * Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.

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 osteopathic medicine
When Flexner researched his report, allopathic medicine faced vigorous competition from several quarters, including osteopathic medicine, naturopathic medicine, eclectic medicine, physiomedicalism, herbal medicine and homeopathic medicine. Flexner clearly doubted the scientific validity of all forms of medicine other than the allopathic, deeming any approach to medicine that did not employ drugs to help cure the patient as tantamount to quackery and charlatanism. Medical schools that offered courses in bioelectric medicine, eclectic medicine, naturopathy, homeopathy, or "eastern medicine," for example, 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.

When Flexner researched his Report, the USA contained a number of medical schools training osteopathic, naturopathic, chiropractic and homeopathic practitioners. Because doctors of osteopathy (D.O.s) often had practices whose scope was similar to that of M.D.s, Flexner insisted that the training of DOs be held to the same standard as that of MDs. Osteopathic medical schools had fought hard over the years for their independence from allopathic medicine, and resented being included in Flexner's report, which concluded that the standards of osteopathic schools were in fact substantially lower. As a result of the Report, the American Medical Association (AMA) expected all osteopathic medical schools to close. Instead, through a series of internal revolutions, the American Osteopathic Association (AOA) brought a number of its schools into compliance with Flexner's recommendations.

Before the Flexner report, osteopathic and allopathic training had little in common. As a result of the Flexner report, American osteopathic medical schools today teach 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 allopathic 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.

Further Readings

 * Beck, Andrew H., 2004, "The Flexner Report and the Standardization of American Medical Education," Student JAMA 291: 2139-40.
 * Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press.
 * Flexner, A., 1910. Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
 * Gevitz, Norman, and Grant, U. S., 2004. The D.O.s (2nd ed.). Baltimore: The Johns Hopkins University Press. ISBN 0-8018-7834-9.
 * Goodman and Musgrave, "How The Cost-Plus System Evolved."
 * Hyatt, M. D., and Stockton, C. G., "The Impact of the Flexner Report on the Fate of Medical Schools in North America After 1909."
 * Kessel, Reuben, 1958, "Price Discrimination in Medicine," Journal of Law and Economics 1:
 * Starr, Paul, 1982. The social transformation of American medicine. Basic Books.
 * Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education. Univ. of Wisconsin Press.
 * Dale Steinreich, 2004, "100 Years of Medical Robbery"

Rapport Abraham Flexner