From Wilderness to Wards: How the Flexner Report Revolutionized Modern American Medicine
Report Contents
Abraham Flexner’s 1910 report exposed horrific deficiencies in North American medical education.
Part I:
"In the first [part of the report] the history of medical education in this country and its present status are set forth...and a forecast of possible progress in the future is attempted."
—Henry Pritchett, "Medical Education in the United States and Canada," Introduction, 1910.
Table of Contents of Part I of the Flexner Report, "Medical Education in the United States and Canada," 1910
Setting Standards
He demanded stringent university-level prerequisites, condemning loopholes that circumvented legitimate high standards.
"The medical school cannot...provide laboratory and bedside instruction on the one hand, and admit crude, untrained boys on the other.
By the very nature of the case, admission to a really modern medical school must at the very least depend on a competent knowledge of chemistry, biology, and physics. Every departure from this basis is at the expense of medical training itself...It is clear that if [this basis] is to become the common minimum basis of medical education, some recognized and organized manner of obtaining it must be devised: it cannot be left to the initiative of the individual without greatly impairing its quality."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 2, 1910.
Modern Medical School Requirements, Kate Talerico, The Brown Daily Herald, February 17, 2016
"The medical schools under discussion agree to accept at face value only graduation diplomas from 'approved' or 'accredited' high schools...We have concluded that a two-year college training, in which the sciences are 'featured,' is the minimum basis upon which modern medicine can be successfully taught."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 3, 1910
Flexner mandated integrated laboratories, rejecting didactic lectures to ensure rigorous scientific foundations.
"Didactic treatment is hopelessly antiquated; it belongs to an age of accepted dogma or supposedly complete information, when the professor 'knew' and the students 'learned.' The lecture indeed continues of limited use. It may be employed in beginning a subject to orient the student, to indicate relations, [and] to forecast a line of study in its practical bearings... Text-books, atlases, charts, occupy a similar position."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 4, 1910
"The medical laboratories [on the other hand] must be manned, equipped, and organized ... [with] proper quarters for caring for an abundant and varied supply of animals."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 4, 1910
Well-equipped bacteriology laboratory class at Howard University, 1900, Library of Congress.
"The discreditable showing made by our commercial medical schools must not, however, be permitted to obscure the fact that we have at this date perhaps thirty institutions well equipped to teach the medical sciences in laboratories usually of modern construction...Twenty years ago we had not one."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 5, 1910
Lab + Clinic: 2+2
Furthermore, he championed hands-on bedside clinical training inside university-controlled teaching hospitals, proposing his revolutionary "2+2" curriculum.
Class in bacteriology, School of Hygiene and Public Health, Johns Hopkins University, early 20th century, Rockefeller Archive Center
"The study of medicine must center around disease in concrete, individual forms.
The ease with which the clinics and the laboratories may...illuminate each other is an incontestable advantage to both. It is difficult to imagine effective teaching of pathology, for example, under conditions where the operating-room, the medical clinic, and the autopsy do not constantly contribute specimens and propound queries to the laboratory; and assuredly the teaching of medicine and surgery cannot proceed intelligently without constant intercourse with the laboratories.
Any disintegration of hospitals and laboratories is harmful to both,—and to the student, in shaping whom they must cooperate."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 5, 1910
"It remains, then, in the first place to teach the student how to get from the direct study of the patient himself whatsoever data remain to be collected.
He will then possess two sets of facts: one in a way indirectly obtained, through microscopic or other study of excretions, secretions, tissues, etc.; the other set procured directly at the bedside.
He must learn the art of combining them; he must see them together as the total picture of the situation with which he is called on to deal. Upon this inductive process all intelligent therapeutic procedure is based."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 6, 1910
Knowledge workflow in translational medicine. New devices and treatments from basic research are incorporated into the clinical practice, and the knowledge collected during clinical practice is to identify new research, Oxford University Press: "The semantic web in translational medicine: Current applications and future directions," November 2013
"Both [the laboratory and the bedside] supply indispensable data of coordinate importance...and in either case [data] must be interpreted in the light of all other pertinent facts in hand.
The scientific character of the procedure depends not on where or by what means facts are procured, but altogether on the degree of caution and thoroughness with which observations are made, inferences drawn, and results heeded. The essence of science is method,—the painstaking collection of all relevant data, the severe effort to read their significance in connection.
These objects are promoted in some directions by the laboratory appliances that eke out our defective senses; even so, however, we do not escape or rise superior to these same senses."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 6, 1910
2+2 M.D. Curriculum, Emory University School of Medicine, 2026
"The four-year curriculum [will fall] into two fairly equal sections: the first two years are devoted mainly to laboratory sciences,—anatomy, physiology, pharmacology, pathology; the last two to clinical work in medicine, surgery, and obstetrics."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 4, 1910
Crushing Commercialism
Flexner revealed that relying on student fees incentivized corruption, necessitating a severe reduction of commercial schools.
Standards and State Boards
He demanded uniform scientific standards for all healing sects, empowering state licensing boards with the authority to ruthlessly close down incompetent institutions.
"The public is equally concerned in [a doctor's] right preparation... whatever he call himself, allopath, homeopath, eclectic, osteopath, or whatnot. It is equally clear that he should be grounded in the fundamental sciences upon which medicine rests."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 10, 1910
"The south, for instance, may well rest for a time, if every state will at once restrict examinations for license to candidates actually possessing the M.D. degree, and require after, say, January 1, 1911, that every such degree shall emanate from a medical school whose entrance standards are at least those of the state university.
Such legislation would suppress the schools that now demoralize the situation; it would concentrate the better students in a few solvent institutions to which the next moves may safely be left. Elsewhere, every available agency should be employed to bring examining boards to reinterpret the word 'equivalent' and to adopt efficient machinery for the enforcement of the intended standard.
Equivalent means 'equal in force, quality, and effect.' The only authorities competent to pass on such values are trained experts."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 11, 1910
Texas State Board of Medical Examiners Application for William August Richardson, 1933, Texas Medical Center Library
Codifying Prejudice
However, his biased assessments regarding women and African Americans reflected a deeply prejudiced climate.
Woman's Medical College of Pennsylvania, the world's first institution established specifically to train women in medicine, Drexel University Libraries
"Medical education is now, in the United States and Canada, open to women upon practically the same terms as men...No woman desiring an education in medicine is under any disability in finding a school to which she may gain admittance.
Woman has so apparent a function in certain medical specialties and seemingly so assured a place in general medicine under some obvious limitations that the struggle for wider educational opportunities for the sex was predestined to early success.
Now that women are freely admitted to the medical profession, it is clear that they show a decreasing inclination to enter it."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 13, 1910
"The practice of the negro doctor will be limited to his own race, which in its turn will be cared for better by good negro physicians than by poor white ones.
But the physical well-being of the negro is not only of moment to the negro himself. Ten million of them live in close contact with sixty million whites. Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors."
—Abraham Flexner, "Medical Education in the United States and Canada," Chapter 14, 1910
Meharry Medical College, a historically black college, 1917, Public Domain
Part II:
Targeting specific regions, he exposed putrid dissecting-rooms, inadequate equipment, and mercenary financial motives.
"The second part of the report gives in detail a description of the schools in existence in each state of the Union and in each province of Canada."
—Henry Pritchett, "Medical Education in the United States and Canada," Introduction, 1910.
The full Part II is below. Explore specific 1910 institutions' states and Flexner's recommendations with [Ctrl + F]
Part II of the Flexner Report, Organized Alphabetically By State
"Medical Education in the United States and Canada," 1910
The Report stressed that...
Map Showing the [Flexner-Recommended] Number, Location, and Distribution of Medical Schools in the United States and Canada,
"Medical Education in the United States and Canada," 1910
"The object of the Foundation in undertaking studies of this character is to serve a constructive purpose, not a critical one. Unless the information here brought together leads to constructive work, it will fail of its purpose."
—Henry Pritchett, "Medical Education in the United States and Canada," Introduction, 1910
...but
"The very disappearance of many existing schools is part of the reconstructive process...[and] our hope is that this report will make plain once for all that the day of the commercial medical school has passed."
—Henry Pritchett, "Medical Education in the United States and Canada," Introduction, 1910
Flexner’s bombshell eradicated substandard institutions, catalyzing our modern, rigorous medical system; but it had a horde of negative consequences for black, female, low-income, and non-allopathic doctors and medical schools.