Abraham Flexner was a reformer of education, particularly in the area of medicine. He devoted much of his life to education, attempting to gain a better understanding of its place in society.1 It could be said that he changed the face of medical education in America with his 1910 report Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching.2 I would like to explore results on both sides regarding Flexner's impact on medical policy and as a result, medical care.
Good as it was, Flexner's report also may have been a part of the reduction of natural products in the U.S. healthcare environment between 1910 and the 1960s. That gap became obvious to policy makers when David Eisenberg's study, Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use, demonstrated the amount of money that Americans spent out of pocket on "complimentary and alternative healthcare." We will explore this after considering Flexner's work in more detail.
If one considers the centennial commemorative of Flexner's work in a 2010 special edition of Academic Medicine, medical education improved. In it, Dr. Steven Kanter, the editor-in-chief, gave summary of the essays reflecting upon the past 100 years of a post Flexnerian world.3 Kanter's summary focused upon balance as a common feature among the essays. Dialectics ranged from curricular content and the length of medical training, to the contrast between a "disease management" and "population-based health improvement."4 Other areas of balance included professional or scientism and humanism, rural and urban care, lab time and patient time, and "the integration of formal knowledge of the basic, clinical, and social sciences with clinical experience."5 Refreshingly, Lambert et al. argued for a balance between "standardized" and "personalized" scientific knowledge.5 The fundamental message was that Flexner was focused upon balance, as were the "Neo-Flexnerians" who published essays in the Centennial Celebration in Academic Medicine.
But, was Flexner balanced in his approach to seeking balance and improving education according to his worldview? Notorious for his harsh descriptions, Flexner also took rather extreme positions. Consider this section of the report, this one justifiably addressing the Georgia College of Eclectic Medicine and Surgery of Atlanta:
"The school occupies a building in which, in respect to filthy conditions, has few equals, but no superiors, among medical schools. Its anatomy room, containing a single cadaver, is indescribably foul. The pathological and histological "laboratory" contains a few dirty slides and ordinary microscopes . . . nothing more disgraceful calling itself a medical school can be found anywhere."2
Carnegie Foundation published and funded the 1910 Flexnor Report, which carved out and cleaned up national healthcare policy with respect to education and the medical profession, but at what cost? It was devastating for some. They were those who used competing medical models often with better results and stronger economics than the chemical-surgical focus of the medical schools supported by the report. Medical care in the U.S. was altered in such a way that indigenous knowledges as employed by eclectic physicians who used Native American traditional medicine were deleted from the standard of care.
Five criteria for evaluating schools were used by Flexner in order to develop his work. Here are those criteria: a) entrance requirements and adherence to them, b) the size and training of the faculty c) the sum and allocation of endowment and fees to support the institution d) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, and e) the relationships between the school and its associated hospitals. There were other criteria used to develop the Flexner Report such as full-time teaching faculty, pathological analysis of the human body and a physiochemical analysis of the human body.2 There are no records of who was involved with the process for developing the criteria.
What we know is that Flexner, an educator with no background in medicine, investigated 69 schools in 90 days. Here are the results of his work. Within three years of the release of the Flexner Report, 25 medical schools closed. Altogether, because of the earlier efforts and then the release of the Flexner Report the number of medical schools dropped from 650 to 50. Private hospitals declined in number from an estimated 2,441 in 1910 to 1,076 in 1946. 6 The 22 homeopathic medical schools that flourished in 1900 dwindled to just two in 1923. By 1950 all schools teaching homeopathy were closed. If a physician did not graduate from a Flexner approved medical school, he couldn't find a job. New licensing laws required that medical schools be certified. Further:
Schools that admitted Afro-Americans did not pass (except for two that admitted only Afro-Americans).
Schools admitting Jews got lower than average grades (resulting in a 30 percent reduction in Jews graduating)
Schools that admitted women got lower than average grades resulting in a 33 percent reduction in women graduating7
Schools that were "commercial institutions" (able to function entirely by student fees) did not pass.
By 1925 10,000 herbalists were out of business.
While Flexners ideals are espoused in reflection pieces upon him, it is also clear from the reults how the document was used. Conventional medical systems in America effectively excluded indigenous forms of medical knowledge from 1910 until the 1960s.
The Eisenberg's study, Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use 8, showed that the US had began to recover from the losses created by the Flexner report. In 1990, there was an estimated 425 million visits to providers of unconventional therapy exceeding the 388 million visits to primary care physicians. Moneys spent were approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. $12.8 billion was spent out of pocket annually for all hospitalizations in the United States.8 The nation awoke from the sedating slumber of a Flexnerian ideal that had clouded the critical thought sphere.
Not long after Eisenberg published his landmark study, on Friday, December 6, 1996 the FDA announced the reclassification of acupuncture needles from class III (premarket approval) to class II (special controls). They identified the acupuncture needle as "a device intended to pierce the skin in the practice of acupuncture. The device consists of a solid, stainless steel needle. The device may have a handle attached to the needle to facilitate the delivery of acupuncture treatment."9 Thus, the experimental status was removed from acupuncture needles.
Growth and change continued. On March 7, 2000, President William Jefferson Clinton gave executive order 13147, forming the White House Commission on Complimentary and Alternative Medicine Policy.10 Medical schools began including a consideration for nutrition and natural products.
Flexner is arguably the grandfather of the "site visit" in medical education and higher education. The benefits of his work are clear, the U.S. has one of the strongest medical education systems in the world. The American public was divested of a more rich a plural form of medical care. Powers that be noticed in 1990 after Eisenberg's study that people have mode complex needs than the corporate-technological forms of medicine. That trend was present all along and gained momentum during the sixties. Later studies that Eisenberg conducted have demonstrated that the growth of a plural medical system continues.
Flexner A. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. . Boston, MA1910.
Kanter SL. A Letter to Those Who Read This Issue in 2110. Academic Medicine. 2010;85(2):181-2 10.1097/ACM.0b013e3181cfbf6f.
Prislin MD, Saultz JW, Geyman JP. The Generalist Disciplines in American Medicine One Hundred Years Following the Flexner Report: A Case Study of Unintended Consequences and Some Proposals for Post-Flexnerian Reform. Academic Medicine. 2010;85(2):228-35 10.1097/ACM.0b013e3181c877bf.
Irby DM, Cooke M, O'Brien BC. Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine. 2010;85(2):220-7 10.1097/ACM.0b013e3181c88449.
Mark D. Hiatt MD, M.S., M.B.A. and Christopher G. Stockton, M.S.M. The Impact of the Flexner Report on the Fate of Medical Schools in North America After 1909. Journal of American Physicians and Surgeons. 2003;8(2).
Starr P. The social transformation of American medicine. New York: Basic Books; 1982.
Eisenberg DM, Kessler RC, Foster C, Norlock FE, Calkins DR, Delbanco TL. Unconventional Medicine in the United States -- Prevalence, Costs, and Patterns of Use. N Engl J Med. 1993 January 28, 1993;328(4):246-52.