1910-2010: Flexner’s Legacy
OVERVIEW OF MEDICAL EDUCATION IN THE 20TH CENTURY
Medicine in the 20th century advanced at an unprecedented rate. Following Flexner’s ideals medical schools were mostly able to accommodate such rapid change, always striving to be at the forefront of discovery and innovation. Despite, or perhaps because of these efforts, medical education again came under fire. The educational system was criticized for stressing scientific knowledge over biological understanding, clinical reasoning, practical skill, character growth, compassion, and integrity, all of which are integral parts of the profession.
THE “PUBLISH OR PERISH” CULTURE, THE COMMERCIAL ATMOSPHERE OF TEACHING HOSPITALS, AND THE FOCUSES OF MEDICAL TEACHERS
When Flexner encouraged research as a fundamental part of medical education, he did not intend for academic hospitals to place laboratory research over teaching. In fact his intentions were quite the opposite. At the beginning of the 20th century, when Flexner made such suggestions, investigation or research was combined with clinical teaching and patient care because most research was directly related to the physical examination of patients. After 1960, research became more about molecular investigation in labs than about patient related studies. Such a shift often meant that medical students were spending more time in labs than with patients at the cost of maximizing their clinical education.
Also jeopardizing clinical education was the fact that the majority of the teachers students encountered no longer had the clinical knowledge to pass onto their students. These faculty members spent limited time with the patients and considered the practice of medicine as second to teaching in their careers. On the other hand clinical teachers often had a limited understanding of modern biomedical science because they saw little academic reward in learning new practices to teach. These teachers were also caught between the pressures of providing first rate care for paying patients and balancing teaching and giving students hands on experience. These predicaments are still very much part of medical education today although some steps have been taken to remediate such concerns.
As was stated in an article in the September 2006 issue of the New England Journal of Medicine, “students may learn from this culture that health care as a business may threaten medicine as a calling.” The “culture” mentioned refers to the commercial atmosphere and pressure found in teaching hospitals. From the marketing of pharmaceutical companies to the view of medical students as “products” in the “see one, do one, teach one” mentality, this environment does little to improve and more to hinder the education of the next generation of physicians.
In 1925, fifteen years after the publication of his report, Flexner voiced a concern that still resonates today; he said that “scientific medicine in America- young, vigorous, and positivistic- is today sadly deficient in cultural and philosophic background.”
While the reforms implemented at the suggestion of Flexner and other reformers of the time undoubtedly raised the standards of medical schools and made it more difficult for students to acquire a medical degree, some lasting effects of this reform proved to be undesirable by the end of the 20th and the beginning of the 21st century. This should come as no surprise, as clearly in the last 100 years things have changed. The circumstances under which students pursue medical careers have changed. The science and technologies faced by both students and physicians have not only changed but are continuously evolving. In short, what it means to practice medicine has changed greatly since Flexner’s time. Institutions of medical education and the next generation of medical students must follow his lead and make the necessary reforms designed for the current era of medicine.