THE FIRST ERA OF REFORM
By the time that Abraham Flexner, a research scholar at theCarnegie 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, theUniversity 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’sFederation of State Medical Boards, or risk an unfavorable review that would result in the boards not recognizing the school’s diplomas.