Yale J Biol Med. 2011 Sep; 84(3): 269–276.
Published online 2011 Sep.
PMCID: PMC3178858
The Flexner Report ― 100 Years Later
Thomas P. Duffy, MD
This article has been cited by other articles in PMC.
Abstract
The
Flexner Report of 1910 transformed the nature and process of medical
education in America with a resulting elimination of proprietary schools
and the establishment of the biomedical model as the gold standard of
medical training. This transformation occurred in the aftermath of the
report, which embraced scientific knowledge and its advancement as the
defining ethos of a modern physician. Such an orientation had its
origins in the enchantment with German medical education that was
spurred by the exposure of American educators and physicians at the turn
of the century to the university medical schools of Europe. American
medicine profited immeasurably from the scientific advances that this
system allowed, but the hyper-rational system of German science created
an imbalance in the art and science of medicine. A catching-up is under
way to realign the professional commitment of the physician with a
revision of medical education to achieve that purpose.
In
the middle of the 17th century, an extraordinary group of scientists
and natural philosophers coalesced as the Oxford Circle and created a
scientific revolution in the study and understanding of the brain and
consciousness. Thomas Willis, a student of William Harvey, Christopher
Wren, Robert Boyle, and Robert Hooke were synergetic with one another in
a shared scientific exploration. Christopher Wren’s subsequent splendid
achievement in the architectural design of St Paul’s and other
cathedrals resonated with Willis’s delineation of the structure and
function of the brain [1].
THE HOPKINS CIRCLE
A
similar combustion of shared thought and imagination occurred at the
beginning of the 20th century when a group of men who comprised what may
be called the Hopkins Circle joined in a project that altered the
course of medical education in America. They erected an edifice, not of
bricks and mortar, but an edifice that became the system of medical
education that we know more than a century later. Their successful
efforts resulted in the science-based foundation of medical training
that has made the United States the recognized leader in medical
education and medical research today. Much of the credit for this
transformation has been appropriately attributed to Abraham Flexner and
his critique of medical education contained in his Flexner Report of
1910 [2].
The contributions of several other members of the Hopkins Circle should
not be overlooked, nor the importance of the synergy that the Circle
generated underestimated.
The
membership of the Circle affirms a particularly American phenomenon in
which an aristocracy of excellence was not defined by one’s origins or
wealth, although wealth permitted the group’s recommendations to be
successful. The group consisted of a Connecticut Yankee and Yale
graduate, William Welch, the founding dean at Hopkins, a school
established from the fortune of a Quaker merchant, Johns Hopkins. Welch
was in large part the mastermind creator of Hopkins and its extensive
reach and influence in medical education; he was responsible for the
selection of William Osler, the Canadian son of a frontier minister, as
its first chief of medicine. A third member of the group was Frederick
Gates, a Baptist minister and trusted adviser to John D. Rockefeller. He
was galvanized to help improve the scientific and therapeutic store of
medical knowledge that he had recognized as being seriously impoverished
following his reading of Osler’s Textbook of Medicine. Gates
became the intermediary, the go-between, who convinced Rockefeller to
provide his philanthropic resources to achieve the goals of the group [3].
ABRAHAM FLEXNER, THE EDUCATOR AND REFORMER
The
final member of the Circle was Abraham Flexner, a former school teacher
and expert on educational practices whose background and training made
him an outlier in the Circle. He was the sixth of seven siblings in a
Louisville, Kentucky, Jewish family whose father was a struggling but
unsuccessful business man. Education and being well educated had become
the secular faith that replaced religious orthodoxy for Abraham and most
of his siblings. He was able to attend Johns Hopkins University through
a gift and beneficence of his older brother, Simon, who was then a
pharmacist in Louisville and later achieved great eminence as the head
of the Rockefeller Institute. Abraham majored in Greek and Latin and
philosophy at Hopkins, completing his college studies in only two years;
the accelerated course in college was a necessary financial stratagem
for the family. After college, he returned to Louisville, where he
assumed the role as major support of his family by teaching high school;
he reciprocated the kindness of Simon by underwriting his medical
schooling and his sister’s education at Bryn Mawr. His talents as a
teacher generated a large following that facilitated his establishment
of a private high school, where his visionary concepts of education were
instituted and refined. His educational philosophy resembled that of
the progressive model of John Dewey in which students learned by doing,
by solving problems, rather than rote memorization that was the more
common educational motif of the day. It was a philosophy that he would
translate into his transformation of medical education in America [4].
The
success of the school and money obtained from its subsequent sale were
Flexner’s ticket out of Louisville; in the next few years, he pursued an
MPhil at Harvard in philosophy and journeyed to Europe, where he
visited schools in Great Britain, France, and, particularly, Germany.
His continental seasoning was focused upon university medical education
in these countries, paralleling the then common practice of young
American physicians in completing their medical studies abroad. It was
out of his practical experience as an educator in America and his
exploration of pedagogical strategies in Europe that he distilled his
critiques of and correctives for American schooling in his book, The American College. Flexner and his expertise came to the attention of Henry Pritchett, head of the Carnegie Foundation, upon reading The American College.
At the time, the Foundation had identified improvement of health care
in America as the primary focus of its philanthropic concern. To achieve
this purpose, the foundation members correctly surmised that
improvement in the very sorry state of medical schooling in America was
necessary; they invited Abraham Flexner to survey the quality of medical
schools throughout America and Canada and provide suggestions for their
improvement.
Flexner was an unorthodox
and surprising candidate for the task he was asked to undertake.
Flexner himself was quizzical about the summoning, suspecting that he
was being confused with his brother, Simon. At the time of the job
offering, the former high school teacher had never been in a medical
school. This shortcoming might have seemed an insurmountable impediment
for successful performance of his assigned task, but the choice of a
non-physician was purposeful on the part of Pritchett and his
associates. They perceived the problem of medical education as a problem
of education and believed a professional educator was better qualified
to address this dimension of the problem. They also had preconceived
ideas concerning what changes needed to be made in medical schools to
allow these ideas to be introduced. The ideas Flexner popularized were
those that had already been developed within medical schools before the
turn of the century. Pritchett and colleagues also were concerned that
antagonisms would be generated by the report, which might be less
vengeful if a non-physician were the object of the resentments. An
unflattering but not necessarily inaccurate description for Flexner’s
assignment was that he was to be the hatchet man in sweeping clean the
medical system of substandard medical schools that were flooding the
nation with poorly trained physicians.
FLEXNER AND THE GERMAN SYSTEM OF MEDICAL EDUCATION
Flexner
prepared for his task by immersing himself in the literature of medical
education, and he specifically identified Theodore Billroth’s book Medical Education in the German Universities [5]
as his major primer. Throughout his life, he was an ardent proponent of
the German pedagogic style of medical education. He was resolute in his
belief that medicine was a scientific discipline that could be best
realized by using the German model as the prototype in America. This was
a system in which physician scientists were trained in laboratory
investigation as a prelude and foundation for clinical training and
investigation in university hospitals. All physicians had a
responsibility to generate new information and create progress in
medical science, with assignment of this task to both laboratory and
clinical scientists. Science, as the animating force in the physician’s
life, was the overarching theme, the zeitgeist, in Flexner’s conception
of the ideal physician.
Flexner also sought the advice
of members of the AMA Committee and the Carnegie Foundation; he
particularly listened to the counsel of William Welch at Hopkins, who
had now assumed a leadership role, an almost grandfatherly one in all
things educational in American medicine. Flexner’s enchantment with
things German would have been bolstered further by Welch’s counsel since
the German model of medical education was already in place at Hopkins
in the aftermath of Welch’s earlier European visits. Hopkins’ students
spent their first two years in the basic laboratory sciences before
progressing to their clinical training on wards in a university
hospital. The quality of the student body was assured by requiring that
all students had a university education prior to admission to medical
school. It is no wonder that Flexner chose Hopkins as his gold standard
with which all other schools were compared in his survey of American
medical schools. His definition of excellence had already been conceived
of and implemented by the other members of the Hopkins Circle. Welch
had voiced these ideas 10 years earlier.
In an address
delivered in 1901 at the 200th anniversary of the founding of Yale
College, Welch spoke on “The Relation of Yale to Medicine” [6]
and described the mutual benefit that a union of the university and
medical school created. He emphasized the need for well-equipped and
well-supported laboratories and a body of well-paid teachers thoroughly
trained in their special departments. He was bold enough to state that
there could be no nobler work for a university than the promotion of
medical studies. William Osler voiced the same prescriptions for medical
education in his farewell address, “L’envoie,” delivered in 1905,
shortly before leaving Baltimore to assume the Regius Professorship at
Oxford [7].
Osler echoed Welch’s message and included a salvo to German medical
schools and the rigor of their scientific training. He said one of his
ambitions during his tenure at Hopkins was to build up a great clinic on
Teutonic lines, not on those previously followed in America and in
England, but lines that had proved so successful on the continent and
which had placed the scientific medicine of Germany in the forefront of
the world.
Osler also made a very
significant contribution to the realization of Flexner’s task by helping
to create the Interurban Clinical Club in 1905 [8].
The purpose of this organization was the exchanging of ideas and the
nurturing of fellowship among medical professors in the leading Eastern
medical schools. Its aims included several goals that Flexner’s
conception of medical education also incorporated; scientific
investigation of disease was promoted, and methods of teaching were to
be shared and improved. The club was largely responsible for the
development of the scientific base of American medicine. It was the
springboard to eminence for department and divisional heads of the
leading medical schools in America. These were the individuals who
forged institutional philosophies and standards of excellence in medical
schools throughout the next century. The era of the clinical scientist
in America dates from this organization; its members were academic
physicians who became the vital link between the practicing physician
and the basic scientist. Flexner’s task was greatly facilitated by the
coalescence of all of this energy invested in improving medical
education in America.
THE FLEXNER REPORT
Equipped
with extensive book knowledge and not a few prejudices and
preconceptions, Flexner demonstrated near superhuman industry and energy
in carrying out his review of American/Canadian medical education. He
crisscrossed the United States and evaluated institutions from the point
of view of an educator and not a medical practitioner. Questions
regarding the clinical facilities available for teaching purposes were
few and brief to the dean and professors of the clinical departments.
Flexner was mainly interested in the extent to which the school enjoyed
rights or merely courtesies in the hospitals identified in the school
catalogue. Admission standards, physical facilities, especially well-
equipped laboratories, and instruction by physician scientists were the
other major criteria for judging the quality of the education offered.
Schools were assigned to one of three categories on the basis of his
evaluation: A first group consisted of those that compared favorably
with Hopkins; a second tier was comprised of those schools considered
substandard but which could be salvaged by supplying financial
assistance to correct the deficiencies; and a third group was rated of
such poor quality that closure was indicated. The latter was the fate of
one-third of American medical schools in the aftermath of the report. A
majority of the medical schools were rated as defective with low
admission standards, poor laboratory facilities, and minimal exposure to
clinical material. Medical education at the turn of the century was a
for-profit enterprise that was producing a surplus of poorly trained
physicians. The enactment of state licensing laws put teeth into the
indictments of the report. Flexner sounded the death knell for the
for-profit proprietary medical schools in America.
THE FULL TIME SYSTEM IN ACADEMIC MEDICAL SCHOOLS
The
Flexner Report was embraced as the definition of the academic model
that was to characterize American medical education up to the present.
Its success was importantly assured by the huge financial gifts of the
Rockefeller and Carnegie Foundations ― this single model of medical
education required large sums to support the scientific focus at its
core. The powerful stimulus of philanthropy money also affected the
fashion in which medical faculty would live their lives in academic
medicine; this was the important introduction of the full-time system in
medical schools. Medical professors were to be freed from any major
responsibilities for patient care and could dedicate their lives to
research and teaching. It was the example established in German
universities during the 1880s, where the practice was observed by Welch,
who became a major proponent of the innovation. The advancement of
knowledge was to trump all other involvements in the academic
physician’s life. Provision of an adequate salary for the full-time
faculty would guarantee that fees generated from patient care would not
be pursued and distract from research. A McGhee Harvey, chairman of the
Department of Medicine at Hopkins at mid-century, believed that no
single event had a more profound effect upon medical education and
medical practice than this movement.
But
the full-time system was not without its serious critics. The most
vocal challenger and naysayer was William Osler, who was subsequently
seconded by Harvey Cushing. Osler believed that the focus of such
physicians would be too narrow, they would live lives apart with other
thoughts and other ways [9].
He was apprehensive that a generation of clinical prigs would be
created, individuals who were removed from the realities and messy
details of their patients’ lives. Osler believed that the Flexnerians
had their priorities wrong in situating the advancement of knowledge as
the overriding aspiration of the academic physician. He placed the
welfare of patients and the education of students to that effect as more
important priorities, although he reverenced the centrality of
scientific knowledge in that regard. His mentee, Harvey Cushing, voiced
the same sentiments, basing his reservations on his background of
several generations of practicing physicians. Their voices were hushed
by the irresistible seduction of large sums of money tied to
implementation of the full-time system. Osler’s voice also was near
silenced and no longer a force in this matter following his move to
Oxford at the time this controversy was taking place. William Welch, the
Carnegie and Rockefeller foundations, and Abraham Flexner were
successful in the task they had set out to accomplish.
THE FLEXNER REPORT ― THE PATH NOT TAKEN
The
success of the reorganized medical training has been awesome in the
breadth and depth of understanding and discovery. Its achievements are
so evident that enumerating them is somewhat unnecessary. The Puritan
ministers and their descendents would be dumbstruck by so much that has
been realized; Frederick Gates would reel on learning of the uncoding of
the human genome, which has become the newest secular Bible of science
for many. The Hopkins Circle was responsible for creating a pathway that
has taken mankind to the stars. Still, a question can be raised, needs
be raised, as to the cost incurred by this journey, filled as it
unquestionably is, with marvels. Did the Hopkins Circle take the
profession down a pathway that threatened the loss of what should be
non-negotiable for all physicians, academic or not? Did the Flexner
Report overlook the ethos of medicine in its blind passion for science
and education? What was the cost of our success, and who has borne that
burden? Review of medical care in the last century documents that the
trust and respect that were extended to the profession 50 years ago have
been substantially eroded. There has been a fall from grace of our
vaunted profession [10].
Physicians have lost their authenticity as trusted healers. We have
become derelict in many realms. Bioethicists are strident in drawing
attention to the major moral failing of the profession in the last
century; its failure to address and care for the problem of pain ― this
an omission by a group that has ready and singular access to the means
for resolution of pain. The $14 million SUPPORT study to understand and
improve care for patients at the end of life found that more than 40
percent of families were unhappy with the fashion in which their loved
ones were cared for as they died [11].
The discontent with doctor’s errors, doctor’s silence, doctor’s
experimentation, and the crass monetary orientation of the profession
is legion. The profession appears to be losing its soul at the same time
its body is clothed in a luminous garment of scientific knowledge.
This
is especially ironic because the Teutonic heritage that provided the
template for Flexner’s plan also contains a cautionary message for him,
for his Circle, and for all of us. It is the tale of Faust and the
irresistible allure of knowledge in exchange for one’s soul. The
Carnegie Foundation unwittingly recast Goethe’s drama by selecting
Flexner as the main character in their version of the play. Flexner may
be in part excused for his omission of any consideration of a
physician’s healing role and how education should foster that art; he
was an educator whose philosophy was shaped by a pathologist and their
shared immersion in the German tradition and by his reading of
Billroth’s Medical Education in German Universities. This was a
world of hyper-rationalized medicine that Flexner investigated during
his early sabbatical years post-Louisville phase and to which he
returned for a second time after his completion of the Flexner Report in
1910. Two years later, he published a European version of the report
with a critique of medical education in France, Britain, and Germany [12].
His uncritical description of the German system is surprising,
especially for a modern reader in retrospect. The German clinic is
described as being surcharged with energy and ideas, but there is little
if any mention of ideals. Oslerian wisdom regarding the primacy of
patient beneficence is not evidenced. Patients were primarily viewed as
serving the academic purposes of the professor. These attitudes were not
of apparent concern for Flexner or his advocates. Flexner’s
identification of Billroth’s text as his most important influence is
also troubling. The book contains several anti-Semitic passages that are
very offensive for all readers and especially disturbing for a Jewish
reader. It was a work for which Welch also had great admiration. In his
preface to a translation published in 1924, he described the book as a
work of enduring value, characterized by a breadth of view as sound and
as needful today as when it was first published in 1876. Flexner and
Welch must have been aware that its prejudiced views had led to near
riots over its depictions of Jews and the superiority of pure German
racial stock. Flexner’s journey from Louisville to the aristocratic
Hopkins Circle may have required adaptations and moral accommodations
that ultimately made their way into his prescriptions for American
medical education. His apparent oversight of the service role of the
profession may also have played into his fierce and critical opposition
to Winternitz’s Institute of Human Relations [13]. Social involvement of the physician was unimportant for the physician as envisioned by Flexner.
THE FLEXNER REPORT AND THE RESTITUTION OF MEDICAL PROFESIONALISM
The
Flexner Report set American medicine on a course that was fueled by the
energy of scientific discovery. Those discoveries have immeasurably
improved the lives of all human beings, and it is difficult to cavil in
the face of such accomplishments. But the oversights of Flexner and his
associates need not have occurred if these leaders had recognized the
primary role of physicians as beneficent healers; the delicate balance
of patient care and research could have been pursued with mutual
benefits for both sides. As it was, the science of medicine eclipsed the
active witnessing of our patients. Edmund Pellegrino’s lament was
proven true that doctors had become neutered technicians with patients
in the service of science rather than science in the service of
patients. How else to explain the seemingly unexplainable Tuskegee
experiments, the Henrietta Lacks tissue culture tragedy, the many
occurrences in which the physician as scientist has taken precedence
over the physician as healer. But this lesion is not restricted to
situations in which patients are used as experimental subjects ― it
pervades the fashion in which so much of medicine was taught and
practiced in the last century. This lapse has not escaped our patient
population nor our critics who have richly documented the poverty of
professional ideals now current in medicine. They have called for a new
Flexner Report, a centennial taking stock, to address the shortcomings
in medical education that have occurred in the aftermath of the original
report. Dr Tom Inui, an internist and medical educator, was enlisted by
the AMA to spend a year in this investigation [14];
Molly Cooke and her associates undertook the same task for the AMA and
performed a mini-version of the Flexner initiative by visiting 10
medical schools throughout America [15].
Everyone is a proponent of what is now happening in many medical
schools. Major emphasis is being placed upon the professional formation
of students and specific core competencies. Practice-based learning, a
Flexner initiative, is supplemented by courses in patient communication,
medical ethics, and medical humanities. Departments of medical
education are now part of medical faculties that train their members to
incorporate these ideals into their courses. The coming century has
received a bounteous richness of medical accomplishments thanks to
Flexner; a system of education that was conceived more than a century
ago still remains a vibrant system. There is in place an edifice that is
the envy of the entire world, but it is a structure that has required a
re-molding in light of its too-narrow focus. The original Hopkins
edifice has been rebalanced in the last 10 years following the revisions
in the medical curriculum that recent re-evaluations have called for.
A
similar revision of Christopher Wren’s cathedral occurred near the end
of the 17th century. The Oxford Circle witnessed severe damage to Wren’s
signature edifice when the Great London fire threatened the cathedral.
The distinguished gardener, diarist, architect ,and polymath John Evelyn
assisted with the plans to repair the cathedral. He also made an
important gift to the corpus of scientific knowledge with the later
donation of the anatomical tables to the Royal Society [16].
These were micro-dissections of the arterial, venous, and neurological
systems mounted on pine tables; they were the work of Padua anatomist
Joann Leonius, whom Evelyn had witnessed dissecting during Evelyn’s
study of anatomy. Anatomists later recognized that the delicate
arborizations of the three systems were virtually super imposable upon
one another. Very recent studies, only doable as a result of modern
molecular techniques, have identified the inter-dependence of the
vascular and nerve systems. They are not only structurally related.
There is constant cross-talk between them with shared growth factors,
receptors, and specialized cells. During embryogenesis, the nerves and
vessels impose the directions of growth that become the vascular and
nervous systems that Harvey and Willis originally described; failure of
coordinated interaction of these vital systems results in death or
maldevelopment of the embryo [17].
CONCLUSION
There
was maldevelopment in the structure of medical education in America in
the aftermath of the Flexner Report. The profession’s infatuation with
the hyper-rational world of German medicine created an excellence in
science that was not balanced by a comparable excellence in clinical
caring. Flexner’s corpus was all nerves without the life blood of
caring. Osler’s warning that the ideals of medicine would change as
“teacher and student chased each other down the fascinating road of
research, forgetful of those wider interests to which a hospital must
minister” [18]
has proven prescient and wise. We have learned that scientific medicine
must travel linked to a professional ethos of caring that has been in
place in our oaths and aspirations. Cross-talk must occur between the
two with a bi-directional bedside to bench dialogue. This creates the
frisson that animates the quest for breakthroughs in a medical realm.
The revisions in medical education that are now taking place are
re-claiming the rightful eminence of the service component of medicine ―
the centerpiece of the doctor-patient relationship. The Flexner model
remains in place, the foundation of the magnificent edifice that is
American medicine.
References
- Zimmer C. The Soul Made Flesh. The discovery of the brain and how it changed the world. New York: Free Press; 2004.
- Flexner A. Medical Education in the United Sates and Canada. Washington, DC: Science and Health Publications, Inc.; 1910.
- Bryan CS. Mr. Gates’s Summer Vacation: a centennial remembrance. Ann Intern Med. 1997;127:148–153. [PubMed]
- Abraham Flexner: an autobiography. New York: Simon and Schuster; 1960.
- Billroth T. The Medical Sciences in the German Universities: with an introduction by William H. Welch. New York: The Macmillan Company; 1924.
- Welch WH. The Relation of Yale to Medicine. Science. 1901;14(361):825–840. [PubMed]
- Osler W. Aequanimitas and other papers that have stood the test of time. New York: Norton; 1963.
- Bliss M. William Osler: A Life in Medicine. New York: Oxford University Press; 1999.
- Harvey AM. The Interurban Clinical Club (1905-1994) The Interurban Clinical Club; 1995.
- Rothman DJ. Medical professionalism ― focusing on the real issues. N Eng J Med. 2000;342:1284–1286. [PubMed]
- Schroeder S. The Legacy of SUPPORT. Ann Int Med. 1999;131:780–782. [PubMed]
- Flexner A. Medical Education in Europe: a report to the Carnegie Foundation for the advancement of teaching. New York: 1912.
- Viseltear A. Milton C. Winternitz and the Yale Institute of Human Relations. Clio Med. 1997;43:32–58. [PubMed]
- Inui T. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges; 2003.
- Cooke M, Irby D, O’Brien B. Educating Physicians: a call for reform of medical school and residency. San Francisco: Jossey-Bass; 2010.
- Hanson CA. The English Virtuoso: Art, Medicine and Antiquarianism in the Age of Empiricism. Chicago: University of Chicago Press; 2009.
- Adams R, Eichmann A. Axon guidance molecules in vascular patterning. Cold Spring Harbor Perspectives in Biology. 2010;2:1875. [PMC free article] [PubMed]
- Chesney A. The Johns Hopkins Hospital, Volume III. Baltimore: Johns Hopkins Press; 1963. p. 182.
Articles from The Yale Journal of Biology and Medicine are provided here courtesy of Yale Journal of Biology and Medicine
No comments:
Post a Comment