From Wilderness to Wards: How the Flexner Report Revolutionized Modern American Medicine
The Man, The Moment
By the 20th century, American medical training was still a profitable and dangerously unregulated trade.
The AMA's Failure (1904)
In 1904, Council on Medical Education of the American Medical Association (AMA) faced the crisis of lenient standards and proprietary greed.
American Medical Association logo, ama-assn.org
"Physical laboratory, Johns Hopkins University," informally deemed the gold standard of medical schools by Flexner, 1903, Library of Congress
"The Council...set an 'ideal standard' for training doctors: a high school education, two years of laboratory science, two years of clinical work, and a year of hospital practice or internship."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002
Even against this minimal standard the council rated half of America's schools as less than 'satisfactory'... [but was] unable to demand that all schools comply at once for fear of splitting the association."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002
"The St. Louis College of Physicians and Surgeons," a school later deemed unfavorable by the Flexner Report, National Institutite of Allergy and Infectious Diseases
Knowing it lacked the power to enforce higher scientific standards itself, the AMA sought an outside ally to force a revolution.
"A meeting in the early days of the Carnegie Foundation for the Advancement of Teaching," Carnegie Medal of Philanthropy
"The council moved to 'obtain the publication and approval of [its] work by the Carnegie Foundation for the Advancement of Teaching,' a step that would 'assist materially' in bringing about change."
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002
The AMA partnered with the Carnegie Foundation for impartial legitimacy
"Some medical schools now sheltered by institutions of learning are disreputable as well as inefficient. In this matter the attitude of the trustees of the Carnegie Foundation is uncompromising. They will admit [to the Foundation] no college or university...which either sustains or shelters a... medical school unfit for the training of men in modern medicine."
—"The Carnegie Foundation for the Advancement of Teaching: Fourth Annual Report," October 1909
"[The president of the Carnegie Foundation for the Advancement of Teaching, Henry] Pritchett [agreed] that while the foundation's [new] study would be 'guided' by the council's previous investigations, the council itself would not be mentioned so as 'to avoid the usual claims of [professional] partiality.'"
—Thomas Neville Bonner, Johns Hopkins University Press: "Iconoclast: Abraham Flexner and a Life in Learning," 2002
Portrait of Henry Smith Pritchett, Santa Barbara Independent
Columbia University College of Pharmaceutical Sciences, Pharmaceutical lecture hall, Wisconsin Historical Society
"What I have in mind is not a medical study, but an educational one. Medical schools are schools and must be judged as such...Henceforth, these institutions must be viewed from the standpoint of education."
—Henry Pritchett, "Henry S. Pritchett: A Biography," 1943
Pritchett realized standardizing medicine required an outsider untouched by the establishment's financial greed.
Who Was Abraham Flexner?
Abraham Flexner was initially an educator
"After receiving his bachelor's degree from Johns Hopkins in 1886, [Flexner] founded his own private high school, which drew the attention of Charles Eliot, President of Harvard University.
His experiences at Harvard and travels in Europe led him to write a book on the American College system."
—Jordan M. Prutkin, Yale University: "Abraham Flexner and the Development of the Yale School of Medicine," 1999.
Abraham Flexner, 1890-1910, Library of Congress
"The American College; A Criticism,"
1908, Library of Congress
"While in Germany, [Flexner] had been writing a book, The American College, that was severely critical of American higher education and strongly supportive of [European] university ideals.
In the fall of 1908, Abraham Flexner returned to New York...He was forty-two years old, unemployed... and, as he put it later, eager to make 'a layman’s contribution to education.'"
—Ellen Condliffe Lagemann, Wesleyan University Press: "Private Power for the Public Good: A History of the Carnegie Foundation for the Advancement of Teaching," 1983.
Flexner wanted to work at the Carnegie Foundation and... secured an introduction to Pritchett from Ira Remsen, the president of Johns Hopkins and a Foundation trustee."
—Ellen Condliffe Lagemann, Wesleyan University Press: "Private Power for the Public Good: A History of the Carnegie Foundation for the Advancement of Teaching," 1983.
Flexner's progressive background and disdain for rote learning aligned with the Foundation's educational mission.
"Though my acquaintance with schools, school systems, and colleges was slight...I was fully...convinced that all were in need of thoroughgoing reform."
—Abraham Flexner, "Abraham Flexner: An Autobiography," 1960.
Left to right: Ira Remsen in 1909, Abraham Flexner in 1910, National Library of Medicine
Though not a doctor, Flexner's passion for strict standards prepared him to ruthlessly inspect these failing, profit-driven schools.
"This is a layman's job, not a job for a medical man."
—Henry Pritchett in "Abraham Flexner and the Development of the Yale School of Medicine," 1999.
"Pritchett wanted the focus of the report to be on education, not medicine."
—Jordan M. Prutkin, Yale University: "Abraham Flexner and the Development of the Yale School of Medicine," 1999.
Teacher-led high school classroom, early 20th century,
National Education Policy Center
"Dr. Pritchett...had taken much the same line that was advocated in my little book...He asked me whether I would like to make a study of medical schools. As our family resources had been depleted during the preceding three years, I was, I confess, prepared to do almost anything of a scholarly nature."
—Abraham Flexner, "Abraham Flexner: An Autobiography," 1960.
Backed by Carnegie, Flexner's bombshell report would soon mandate scientific standardization, permanently transforming American medicine from a careless trade into a globally respected profession.