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The ''Flexner Report'' is a book-length landmark report of medical education in the United States and Canada, written by
Abraham Flexner Abraham Flexner (November 13, 1866 – September 21, 1959) was an American educator, best known for his role in the 20th century reform of medical and higher education in the United States and Canada. After founding and directing a college-prep ...
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 Flexner report has been criticized for introducing policies that encouraged
systemic racism Institutional racism, also known as systemic racism, is a form of racism that is embedded in the laws and regulations of a society or an organization. It manifests as discrimination in areas such as criminal justice, employment, housing, healt ...
. 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 Science is a systematic endeavor that builds and organizes knowledge in the form of testable explanations and predictions about the universe. Science may be as old as the human species, and some of the earliest archeological evidence ...
in their teaching and research. The report talked about the need for revamping and centralizing medical institutions. Many American medical schools fell short of the standard advocated in the ''Flexner Report'' and, subsequent to its publication, nearly half of such schools merged or were closed outright. Colleges in
electrotherapy Electrotherapy is the use of electrical energy as a medical treatment. In medicine, the term ''electrotherapy'' can apply to a variety of treatments, including the use of electrical devices such as deep brain stimulators for neurological dis ...
were closed.
Homeopathy Homeopathy or homoeopathy is a pseudoscientific system of alternative medicine. It was conceived in 1796 by the German physician Samuel Hahnemann. Its practitioners, called homeopaths, believe that a substance that causes symptoms of a d ...
, traditional
osteopathy Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques in ...
,
eclectic medicine Eclectic medicine was a branch of American medicine that made use of botanical remedies along with other substances and physical therapy practices, popular in the latter half of the 19th and first half of the 20th centuries. The term was coined by ...
, and physiomedicalism (botanical therapies that had not been tested scientifically) were derided. The Report also concluded that there were too many medical schools in the United States, and that too many doctors were being trained. A repercussion of the ''Flexner Report'', resulting from the closure or consolidation of university training, was the closure of all but two "negro" medical schools and the reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. Universities had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of
co-education Mixed-sex education, also known as mixed-gender education, co-education, or coeducation (abbreviated to co-ed or coed), is a system of education where males and females are educated together. Whereas single-sex education was more common up to ...
al
Oberlin College Oberlin College is a private liberal arts college and conservatory of music in Oberlin, Ohio. It is the oldest coeducational liberal arts college in the United States and the second oldest continuously operating coeducational institute of highe ...
in 1833 and private colleges such as
Vassar College Vassar College ( ) is a private liberal arts college in Poughkeepsie, New York, United States. Founded in 1861 by Matthew Vassar, it was the second degree-granting institution of higher education for women in the United States, closely foll ...
and Pembroke College.


Background

In 1904, the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's sta ...
(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 two years training in human
anatomy Anatomy () is the branch of biology concerned with the study of the structure of organisms and their parts. Anatomy is a branch of natural science that deals with the structural organization of living things. It is an old science, having i ...
and
physiology Physiology (; ) is the scientific study of functions and mechanisms in a living system. As a sub-discipline of biology, physiology focuses on how organisms, organ systems, individual organs, cells, and biomolecules carry out the chemic ...
followed by two years of clinical work in a
teaching hospital A teaching hospital is a hospital or medical centre that provides medical education and training to future and current health professionals. Teaching hospitals are almost always affiliated with one or more universities and are often co-located ...
. Generally speaking, the council strove to improve the quality of medical students, looking to draw from the society of upper-class, educated students. In 1908, seeking to advance its reformist agenda and hasten the elimination of schools that failed to meet its standards, the CME contracted with the
Carnegie Foundation for the Advancement of Teaching The Carnegie Foundation for the Advancement of Teaching (CFAT) is a U.S.-based education policy and research center. It was founded by Andrew Carnegie in 1905 and chartered in 1906 by an act of the United States Congress. Among its most nota ...
to survey American medical education. Henry Pritchett, president of the Carnegie Foundation and a staunch advocate of medical school reform, chose
Abraham Flexner Abraham Flexner (November 13, 1866 – September 21, 1959) was an American educator, best known for his role in the 20th century reform of medical and higher education in the United States and Canada. After founding and directing a college-prep ...
to conduct the survey. Neither a physician, a scientist, nor a medical educator, Flexner held a
Bachelor of Arts Bachelor of arts (BA or AB; from the Latin ', ', or ') is a bachelor's degree awarded for an undergraduate program in the arts, or, in some cases, other disciplines. A Bachelor of Arts degree course is generally completed in three or four yea ...
degree and operated a
for-profit school For-profit education (also known as the education services industry or proprietary education) refers to educational institutions operated by private, profit-seeking businesses. For-profit education is common in many parts of the world, making up m ...
in
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. He visited every one of the 155 North American medical schools then in operation, all of which differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Summarizing his findings, he wrote: The Report became notorious for its harsh description of certain establishments, describing Chicago's fourteen medical schools, for example, as "a disgrace to the State whose laws permit its existence . . . indescribably foul . . . the plague spot of the nation." Nevertheless, several schools received praise for excellent performance, including
Western Reserve The Connecticut Western Reserve was a portion of land claimed by the Colony of Connecticut and later by the state of Connecticut in what is now mostly the northeastern region of Ohio. The Reserve had been granted to the Colony under the terms o ...
(now ''Case'' Western Reserve),
Michigan Michigan () is a state in the Great Lakes region of the upper Midwestern United States. With a population of nearly 10.12 million and an area of nearly , Michigan is the 10th-largest state by population, the 11th-largest by area, and t ...
, Wake Forest,
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,
Toronto Toronto ( ; or ) is the capital city of the Canadian province of Ontario. With a recorded population of 2,794,356 in 2021, it is the most populous city in Canada and the fourth most populous city in North America. The city is the anch ...
, and particularly
Johns Hopkins Johns Hopkins (May 19, 1795 – December 24, 1873) was an American merchant, investor, and philanthropist. Born on a plantation, he left his home to start a career at the age of 17, and settled in Baltimore, Maryland where he remained for most ...
, which was described as the 'model for medical education'.


Recommended changes

To help with the transition and change the minds of other doctors and scientists, John D. Rockefeller gave many millions to colleges, hospitals and founded a philanthropic front group called " General Education Board" (GEB). When Flexner researched his report, many American medical schools were small "proprietary" 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 with laboratory work and dissection optional. Many of the instructors were local doctors teaching part-time. Regulation of the medical profession by state governments was minimal or nonexistent. American doctors varied enormously in their scientific understanding of
human physiology The human body is the structure of a human being. It is composed of many different types of cells that together create tissues and subsequently organ systems. They ensure homeostasis and the viability of the human body. It comprises a head ...
, and the word "quack" was in common use. Flexner carefully examined the situation. Using the
Johns Hopkins School of Medicine The Johns Hopkins University School of Medicine (JHUSOM) is the medical school of Johns Hopkins University, a private research university in Baltimore, Maryland. Founded in 1893, the School of Medicine shares a campus with the Johns Hopkins Hospi ...
as the ideal, he issued the following recommendations: # Reduce the number of medical schools (from 155 to 31) and the number of poorly trained physicians; # Increase the prerequisites to enter medical training; # Train physicians to practice in a scientific manner and engage medical faculty in research; # Give medical schools control of clinical instruction in hospitals # Strengthen state regulation of medical licensure Flexner expressed that he found Hopkins to be a "small but ideal medical school, embodying in a novel way, adapted to American conditions, the best features of medical education in England, France, and Germany." In his efforts to ensure that Hopkins was the standard to which all other medical schools in the United States were compared, Flexner went on to claim that all the other medical schools were subordinate in relation to this "one bright spot." Flexner believed that admission to a medical school should require, at minimum, a
high school A secondary school describes an institution that provides secondary education and also usually includes the building where this takes place. Some secondary schools provide both '' lower secondary education'' (ages 11 to 14) and ''upper seconda ...
diploma A diploma is a document awarded by an educational institution (such as a college or university) testifying the recipient has graduated by successfully completing their courses of studies. Historically, it has also referred to a charter or offici ...
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. By 1920, 92 percent of U.S. medical schools required this of applicants. Flexner also argued that the length of medical education should be four years, and its content should be what the CME agreed to in 1905. Flexner recommended that the proprietary medical schools should either close or be incorporated into existing universities. He stated that medical schools needed be part of a larger university since a proper stand-alone medical school would have to charge too much in order to break even financially. 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 traveled 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 demanded that American medical education conform to prevailing practice in continental Europe. By and large, medical schools in Canada and the United States followed many of Flexner's recommendations. However, schools have increased their emphasis on matters of
public health Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the det ...
.


Consequences of the report

Many aspects of the medical profession in North America changed following the ''Flexner Report''. Medical training adhered more closely to the scientific method and became grounded in human physiology and
biochemistry Biochemistry or biological chemistry is the study of chemical processes within and relating to living organisms. A sub-discipline of both chemistry and biology, biochemistry may be divided into three fields: structural biology, enzymology and ...
. Medical research aligned more fully with the protocols of scientific research. Average physician quality significantly increased.


Medical school closings

Flexner sought to reduce the number of medical schools in the US. A majority of American institutions granting MD or DO degrees as of the date of the Report (1910) closed within two to three decades. (In Canada, only the medical school at Western University was deemed inadequate, but none was closed or merged subsequent to the Report.) In 1904, there were 160 MD-granting institutions with more than 28,000 students. By 1920, there were only 85 MD-granting institutions, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the US. Between 1910 and 1935, more than half of all American medical schools merged or closed. The 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 MD-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. In response to the Report, some schools fired senior faculty members as part of a process of reform and renewal.


Impact on African-American doctors and patients

The Flexner report has been criticized for introducing policies that encouraged
systemic racism Institutional racism, also known as systemic racism, is a form of racism that is embedded in the laws and regulations of a society or an organization. It manifests as discrimination in areas such as criminal justice, employment, housing, healt ...
and sexism. Flexner advocated closing all but two of the
historically black Historically black colleges and universities (HBCUs) are institutions of higher education in the United States that were established before the Civil Rights Act of 1964 with the intention of primarily serving the African-American community. Mo ...
medical schools. As a result, only Howard University College of Medicine and Meharry Medical College were left open, while five other schools were closed. Flexner's view was that black doctors should treat only black patients and should play roles subservient to those of white physicians. The closure of the five schools, and the fact that black students were not admitted to many U.S. medical schools for the next 50 years, has contributed to the low numbers of American-born physicians of color, and the ramifications are still felt more than a century later. Flexner's findings also restricted opportunities for African-American physicians in the medical sphere. Even the Howard and Meharry schools struggled to stay open following the Flexner Report, having to meet the institutional requirements of white medical schools, reflecting a divide in access to health care between white and African-Americans. Following the Flexner Report, African-American students sued universities, challenging the precedent set by Plessy v. Ferguson. However, those students were met by opposition from schools, who remained committed to segregated medical education. It was not until 15 years after Brown v. Board of Education in 1954 that the AAMC ensured access to medical education for African-Americans and minorities by supporting the diversification of medical schools. Along with his adherence to
germ theory The germ theory of disease is the currently accepted scientific theory for many diseases. It states that microorganisms known as pathogens or "germs" can lead to disease. These small organisms, too small to be seen without magnification, invade h ...
, Flexner argued that, if not properly trained and treated, African-Americans posed a health threat to middle and upper-class whites. The view that Flexner and his report were detrimental to Black medical schools is largely refuted by Thomas N. Bonner, a scholar referred to as a “distinguished historian” by the AAMC. Bonner contended that Flexner worked to save the two Black medical schools that were graduating most of the Black physicians at that time.


Impact on alternative medicine

When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine, electrotherapy,
eclectic medicine Eclectic medicine was a branch of American medicine that made use of botanical remedies along with other substances and physical therapy practices, popular in the latter half of the 19th and first half of the 20th centuries. The term was coined by ...
,
naturopathy Naturopathy, or naturopathic medicine, is a form of alternative medicine. A wide array of pseudoscientific practices branded as "natural", "non-invasive", or promoting "self-healing" are employed by its practitioners, who are known as naturo ...
, and
homeopathy Homeopathy or homoeopathy is a pseudoscientific system of alternative medicine. It was conceived in 1796 by the German physician Samuel Hahnemann. Its practitioners, called homeopaths, believe that a substance that causes symptoms of a d ...
. Flexner clearly doubted the scientific validity of all forms of medicine other than that based on scientific research, 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 electromagnetic field therapy, phototherapy, 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 most 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 The American Osteopathic Association (AOA) is the representative member organization for the more than 176,000 osteopathic medical doctors (D.O.s) and osteopathic medical students in the United States. The AOA is headquartered in Chicago, Illinoi ...
(AOA) brought a number of osteopathic medical schools into compliance with Flexner's recommendations to produce an evidence-based practice. The curricula of DO- and MD-awarding medical schools are now nearly identical, the chief difference being the additional instruction in osteopathic schools of
osteopathic manipulative medicine Osteopathy () is a type of alternative medicine that emphasizes physical manipulation of the body's muscle tissue and bones. Practitioners of osteopathy are referred to as osteopaths. Osteopathic manipulation is the core set of techniques ...
.


Impact on role of physician

The vision for medical education described in the Flexner Report narrowed medical schools' interests to disease, and not on the system of health care or society's health beyond disease. Preventive medicine and population health were not considered a responsibility of physicians, bifurcating "health" into two separate fields: scientific medicine and public health.


See also

* Committee of Ten


References


Further reading

* * Bonner, Thomas Neville, 2002. ''Iconoclast: Abraham Flexner and a Life in Learning''. Johns Hopkins Univ. Press. . * Gevitz, Norman, and Grant, U. S., 2004. ''The D.O.s'' (2nd ed.). Baltimore: The Johns Hopkins University Press. . * Starr, Paul, 1982. '' The Social Transformation of American Medicine''. Basic Books. . * Wheatley, S. C., 1989. ''The Politics of Philanthropy: Abraham Flexner and Medical Education''.
University of Wisconsin Press The University of Wisconsin Press (sometimes abbreviated as UW Press) is a non-profit university press publishing peer-reviewed books and journals. It publishes work by scholars from the global academic community; works of fiction, memoir and ...
. , .


External links


The Flexner Report
(PDF) from the
Carnegie Foundation for the Advancement of Teaching The Carnegie Foundation for the Advancement of Teaching (CFAT) is a U.S.-based education policy and research center. It was founded by Andrew Carnegie in 1905 and chartered in 1906 by an act of the United States Congress. Among its most nota ...

"Flexner Report Transformed Med Schools"
''
All Things Considered ''All Things Considered'' (''ATC'') is the flagship news program on the American network National Public Radio (NPR). It was the first news program on NPR, premiering on May 3, 1971. It is broadcast live on NPR affiliated stations in the United ...
'', 16 August 2008.
The Flexner Report ― 100 Years Later
(September 2011) {{italic title Medical education in the United States Medical education in Canada Osteopathic medicine History of medicine in the United States