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Flexner

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THE FIRST ERA OF REFORM

By the time that Abraham Flexner, a research scholar at the Carnegie Foundation for the Advancement of Teaching, began his report by traveling to medical schools across the United States and Canada, other organizations had begun to review the medical education system. Among these reviews are reports from the Illinois State Board of Health, the Association of American Medical Colleges (AAMC), and the American Medical Association (AMA) Council on Medical Education.

The reviews of the medical education system at this time were based on the need for reform that had been identified in the second half of the half of the 19th century. Scientific advances made both laboratory and clinical teaching reform necessary in medical schools and also necessitated a premedical education. For these advancements to be incorporated into medical education, medical schools needed to have access to well equipped labs and a modern hospital where students could learn clinical practices.

Out of all the reviews and reports made concerning the inadequacy of an obsolete medical educational system in the early part of the 20th century, the Flexner Report is by far the best known and most influential. Why is this? Flexner’s approach and complete disclosure of issues gave his report an edge over others. The recommendations Flexner made were well grounded and direct in a way that allowed medical schools and medical boards to understand and adhere to his suggestions. Unlike other reformers who attempted to shed light on the ominous situation, Flexner was separated enough from the medical education community that he was able to directly inform the public about issues that were known but not addressed by insiders. Perhaps what truly separated Flexner’s report from others was his appeal for reform on behalf of not only the public but also for the students studying in the poor conditions of many medical schools of the time.

BASIC IDEALS AND RESULTS OF THE FLEXNER REPORT

After having visited medical schools across America and Canada, Flexner made clear his critiques in what would become the guidebook for medical schools for more than a century. He criticized the inferior quality and profit motive of proprietary schools and their teachers and the inadequate facilities and curricula they offered their students. Conceivably the most basic concern Flexner addressed was that while the focus of medical education should be on the accurate diagnosis and application of new scientific understanding to treat patients as prescribed by the diagnosis, most physicians relied on the outdated technique of the memorization of signs and symptoms of diseases and their predetermined treatments.

According to Flexner, medical schools should return to the focus on formal analytic reasoning that served as the basis for America’s first medical schools including the Harvard Medical School, the University of Michigan Medical School, and the School of Medicine at theUniversity of Pennsylvania, in the 1880’s. Flexner openly acknowledged Johns Hopkins University to be what he considered the ideal for medical education. At the time of Flexner’s research, Hopkins required college level premedical courses, employed fulltime faculty members dedicated to research, and offered full access to the university hospital for the purpose of clinical teaching. As a researcher himself, Flexner placed emphasis on the scientific basis of medical practice while also recognizing that there should be a clinical phase of education in teaching hospitals. Flexner also iterated that medical students need the opportunity to learn under the guidance of experienced teaching physicians until they themselves have significant ability, an idea that calls to mind the apprenticeships of earlier centuries. In short, according to Flexner, the ideal medical education incorporated a reliance on science, a use of modern techniques and technologies, and a new age master-apprentice relationship between physicians and students.

There were 160 medical schools in America in 1905, 133 in 1910, and by 1920 only 85 remained open (no Canadian medical schools were deemed inadequate after the publication of the Flexner Report and thus none were closed as a result of its publication). After the implementation of Flexner's reforms, the remaining 85 medical schools had higher entrance requirements, longer terms, and better resources to offer. Only a decade after the Flexner Report was published, 77 out of the 85 medical schools required a minimum of two years of college before admission to medical school. Part of what made the Flexner Report so influential was its potential for practical implementation. State medical boards were able to demand medical school reform. In 1904 the Journal of the American Medical Association wrote that medical schools are “compelled to live up to standards” by the Confederation of State Medical Examining and Licensing Boards, a predecessor of today’s Federation of State Medical Boards, or risk an unfavorable review that would result in the boards not recognizing the school’s diplomas.

 

< Before There Was Flexner ---------- 1910 - 2010: Flexner's Legacy >

Flexner's Search

What did Abraham Flexner consider when evaluating medical schools?

  • Entrance requirements and the enforcement of such requirements
  • The size and ability of the faculty
  • Funding from both endowment and student fees for the support of the school and how these funds were used
  • The quality of the laboratories used for instruction in the first two years of medical education and the training of preclinical teachers
  • Relations between the medical school and surrounding hospitals, specifically access to hospital beds for teaching and the ability for the school to appoint hospital physicians

Flexner's Suggestions

What should be required of the medical education community?

  • Applicants to medical school must have studied biology, chemistry, and physics at the college level- premedical requirements
  • Medical schools should implement curricula with didactic and laboratory courses in anatomy, histology, embryonology, physiology, and biochemistry in the first year of study and pathology, pharmacology, bacteriology, and physical diagnosis in the second year
  • Medical schools must have access to hospitals and dispensaries
  • Students should be as active as possible in patient care and should consult medical literature as a reference
  • Medical schools should employ salaried faculty in the basic and clinical sciences whose job it is to teach students and conduct research
  • State Medical Boards should be responsible for reviewing existing and endorsing new medical schools
  • Finally, Flexner noted bluntly that “medicine is expensive to teach”. Medical schools cannot survive and prosper funded only by student fees, they require the endowment and support of a university. He suggested that medical schools with no means of acquiring this funding should merge with other schools or close, a continuation of a solution reached before the Flexner Report was published