From Wilderness to Wards: How the Flexner Report Revolutionized Modern American Medicine
Flexner's Process
"At Flexner’s first council meeting [in late 1908], he heard...Pritchett’s plan...for a study divided into two parts.
The first would... lay down the minimum requirements for study, equipment, and finances...
The second... would survey each medical school in the United States and Canada... with a view to rooting out those with weak or inadequate programs."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002.
The investigation would prioritize the interests of the public and prospective students over the survival of inadequate institutions
"In the preparation of this report the Foundation has kept steadily in view the interests of two classes...first, the youths who are to study medicine and to become the future practitioners, and, secondly, the general public, which is to live and die under their ministrations."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
"Harvard Medical School Class of 1888," a school later deemed favorable by the Flexner Report, Harvard Medical School, June 1888
Despite having no background in medicine, Flexner prepared voraciously.
Portrait of Theodor Billroth, Dr. Gerrit van Schalkwyk
"In the month between his hiring and the start of his first survey...he had done a prodigious job of familiarizing himself with the literature on medical training, reading such classics as...The Medical Sciences in the German University."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002.
The English translation of "Lehren und lernen der medicinischen wissenschaften" ["The Medical Sciences in the German Universities"] (1876) by Theodore Billroth in 1924.
Flexner audited schools alongside the AMA’s Dr. N.P. Colwell, ensuring his scientific findings carried the weight of the medical establishment, making his 'revolution' impossible for failing schools to ignore.
The Four Doctors (left to right: William Henry Welch, William Stewart Halsted, William Osler, and Howard Atwood Kelly), 1906, John Singer Sargent, Johns Hopkins School of Medicine Portrait Collection
"Colwell's reports were creditable and painstaking documents,... [but] had to be extremely diplomatic, because they were prepared by a committee of physicians about medical schools, the faculties of which consisted of their fellow physicians...
Whereas [Colwell] was under the necessity of proceeding cautiously and tactfully, I was fortunately in a position to tell the truth with utmost frankness.
Having finished my preliminary reading, I went to Baltimore...where I talked at length with Drs. Welch, Halsted, Mall, Abel, and Howell, and with a few others who knew what a medical school ought to be, for they had created one."
—Abraham Flexner, "Abraham Flexner: An Autobiography," 1960
"[Flexner] particularly listened to the counsel of William Welch at Hopkins...since the German model of medical education was already in place at Hopkins in the aftermath of Welch’s earlier European visits."
—Thomas P. Duffy, Yale Journal of Biology and Medicine: "The Flexner Report ― 100 Years Later," September 2011
"Reminiscences of the early days of the medical school," William H. Welch on the German Roots of Johns Hopkins (1932), Johns Hopkins Medical Archives.
William H. Welch with the First Graduating Class of The Johns Hopkins University School of Medicine, 1897, The Rockefeller University
"Hopkins’ students spent their first two years in the basic laboratory sciences before progressing to their clinical training on wards in a university hospital. The quality of the student body was assured by requiring that all students had a university education prior to admission to medical school.
It is no wonder that Flexner chose Hopkins as his gold standard with which all other schools were compared in his survey."
—Thomas P. Duffy, Yale Journal of Biology and Medicine: "The Flexner Report ― 100 Years Later," September 2011
In early January 1909, Abraham Flexner embarked on his rigorous, revolutionary evaluation of North American medical education.
"The pace of Flexner's trips to distant cities over a period of sixteen months staggers the imagination... stopping at ninety-eight cities and making 174 separate visits to [all 155 US and Canadian] medical schools."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002.
Map Showing the Actual Number, Location, and Distribution of Medical Schools [at the Time] in the United States and Canada, "Medical Education in the United States and Canada," 1910
Pace and Precision
"Flexner's findings, furthermore, were sent to each school, which was given an opportunity to correct any misstatements of fact."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002.
In each visit, the following points were investigated:
"(1) Entrance requirement...
(2) Attendance and Teaching staff...
(3) Resources available for maintenance...
(4) Laboratory facilities...
(5) Clinical facilities..."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
Points' Rationale
...and he would also interrogate the local state medical board examiners.
"The outside examiners...fall far short of enforcing a high...standard. The examiner, even where distinctly well intentioned, as in Kentucky, never gets sufficient control.
The schools do not want the rule enforced, and the boards are either not strong enough or not conscientious enough to withstand them.
Besides, the examiners lack time, machinery, and encouragement for the proper performance of their ostensible office. They are busy men: here, a county official; there, a school principal; elsewhere, a high school professor."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
What Flexner discovered was shocking.
Flexner's Discoveries
Of course, some institutions were not happy with his prodding.
Robert S. Brookings, Board Chairman of Washington University, was initially indignant at the Report but later reconciled with Flexner, 1905, Richard E. Miller
"A considerable number of colleges and universities take the unfortunate position that they are private institutions and that the public is entitled to only such knowledge of their operations as they choose to communicate.
[However,] the attitude of the Foundation is that...the public is entitled to know the facts concerning their administration and development.
We believe, therefore, that in seeking to present an accurate and fair statement of the work and the facilities of the medical schools of this country, we are serving the best possible purpose which such an agency as the Foundation can serve; and, furthermore, that only by such publicity can the true interests of education and of the universities themselves be subserved."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
Anson Phelps Stokes, Secretary of Yale University, who openly thanked Flexner for his advice on Yale Medical School
His general consensus was that:
New York Post-Graduate Medical School and Hospital advertisement, 1894, Period Paper
"The advertising methods of the commercially successful schools are amazing...The school catalogues abound in exaggeration, misstatement, and half-truths. The deans of these institutions occasionally know more about modern advertising than about modern medical teaching. They may be uncertain about the relation of the clinical laboratory to bedside instruction; but they have calculated to a nicety which 'medium' brings the largest 'return'."
—Abraham Flexner, "Medical Education in the United States and Canada," 1910
"Flexner's report showed that although most of the nation's medical schools claimed to adhere to progressive, scientific principles of medical education, only a very few had the financial resources, laboratory and hospital facilities, and highly trained faculties necessary to do so."
—Andrew H. Beck, Journal of the American Medical Association: "The Flexner Report and the Standardization of American Medical Education," May 5, 2004
By auditing 155 schools, Flexner exposed a landscape of fraudulent standards and inadequate facilities, setting the stage for the specific medical mandates in his final report.