Flexner highlights 'abysmal' condition of medical education

April 15, 2005

The cost of medical education was recently featured in an article in the perspective section of The New England Journal of Medicine (2005;352: 117-119). This prompted me to remember a report written in 1910 about medical education that was to change the course of medical education radically.

The cost of medical education was recently featured in an article in the perspective section of The New England Journal of Medicine (2005;352: 117-119). This prompted me to remember a report written in 1910 about medical education that was to change the course of medical education radically.

Medical education in the United States prior to the 1800s was mostly based on apprenticeship, with possibly some study in Europe. Formal medical education in the United States was conceived to be primarily an arm of the established schools of education.

The apprenticeship program, having long been the origin of medical education prior to the mid 1700s, was only to be supported and developed at the time. A student could spend 1 year in medical education, study mathematics and philosophy, and receive both a bachelor's degree and a doctor's degree.

These high ideals were soon to fall by the wayside with the development of proprietary institutions. These schools were privately owned and most often had no tie to organized institutions, which at least would often provide certain established standards and ideals, albeit not always perfect.

Between 1810 and 1840, 26 new medical schools were opened in the United States. From 1840 to 1876, 46 more were founded. By 1900 the United States had 427 medical schools, although some were short-lived and others were on the verge of extinction. By 1903, 157 medical schools had survived.

Chicago led the way in the development of medical schools, having approved 39 medical colleges throughout its history. By 1900, however, only 14 still survived in the Windy City.

During the late 1800s, the medical community, working together with the American Medical Association, began to develop standards of medical care, including: 1) a student should have a preliminary degree before beginning medical school; and 2) there should be requirements for an MD degree.

Although these goals were set in motion during the late 1800s, they still had not been uniformly fulfilled by 1900. Some schools had 6-month courses, others like Northwestern had a 3-year medical school curriculum, and Harvard Medical School in 1901 required an academic degree for admission.

Medical societies also felt pressured by the plenitude of physicians. Pennsylvania had one physician per 636 residents, Colorado had one in 328, Maryland one for 658, and Oregon one for 646. The thought at the time was that one per 1,500 was the proper ratio of physicians to patients. The overriding thought at the turn of the 20th century was to educate fewer physicians.

The Carnegie Foundation for the Advancement of Teaching was established in 1905 with an endowment to be expended for the benefit of teachers in the United States, Canada, and Newfoundland.

After the initial trustee's meeting, it was decided to focus on medical education as its first topic of study. For this task, the trustees asked Abraham Flexner (1866–1959), a schoolmaster from Lexington, KY and brother of Simon Flexner (1863–1946), who was then director of Rockefeller Institute, to evaluate the 148 medical schools in the United States and the seven medical schools in Canada and to report their findings to the foundation.

Beginning in early 1909, Abraham Flexner visited all of the 155 schools during a 16-month train tour. During this time, Flexner's personal maxim, ambulando discimus (we learn by going around), was forever at the tip of his tongue.

His report, issued in 1910, is one of the most important medical education publications of the 20th century. Flexner looked at the following factors at each institution:

In general, Flexner found that the medical education in the United States was very poor, so poor that he used the term "abysmal."

Flexner's major recommendations included: