GOVERNMENT AND NATIONAL AFFAIRS COMMITTEE
Is It Time for a Flexner Report 2.0? Deborah Fletcher, MD and Gregory Jasani, MD
T
he year was 1904 and a mom in rural Louisiana had a sick child with high fever and abdominal pain. She wanted to call the doctor but was worried. This mom had no idea if this person was a doctor, what his training was, and if he could help. But he was all she had and had to trust him. The child worsened overnight, and the doctor was called to the home. He said the young girl had appendicitis and he needed to operate right away. He had ether in his bag and prepared her for surgery on the family dining table. He removed her appendix and left the tube to drain into a pan under the table. She did well and lived well over 100, and loved telling me this story when I was a new attending ED physician. She was lucky to have had one of the well-trained physicians who took care of her in her youth. Around that time the American Medical Association (AMA) had heard many complaints about “quack” physicians and the poor educational quality of medical schools. The AMA had been founded in 1847 with the mission “to promote the art and science of medicine and the betterment of public health.” They wanted to improve public trust in medicine and knew to do that meant having quality training with improved standards of medical education. They organized a Committee on Medical Education (CME) to review the current medical schools and make recommendations on quality improvement for reform. In walks Abraham Flexner. He was hired by the Carnegie Foundation for the Advancement of Teaching to do just that. He visited all the medical schools in North America at that time—155 in total—and found some astounding things. During this process, he chose Johns Hopkins as his “gold standard” for medical education to which he held the other schools to for review. He knew that their education plan included two years of intense coursework followed by two years of clinical training. He also knew of the rigorous training for physicians in Europe, which helped him model some of his ideas. Flexner set out on the mission—visiting and reviewing all 155 medical schools in North America. Imagine what he saw—a huge variety in quality! Across the country, there were no standards but vast differences in admission criteria, graduation criteria, curricula, teachers/ professors, and assessments. He went to rural schools, urban schools, all of them, and documented their standards. Many of the schools were “for profit”—a doctor or group of doctors would get together and open a school to make money. Sadly, the quality of education was not at the forefront of many of these places. They did not follow the same rules or learn the same things across the country—some had shortened degrees of two years, some did not require dissection or research. Some did not even have a full-time teaching physician on staff. Some
Flexner set out on the mission—visiting and reviewing all 155 medical schools in North America. Imagine what he saw.
Abraham Flexner, circa 1910
only allowed the students to observe but not participate. He had criticism of many institutions, large and small. However, he came away from this process with a great understanding of the medical education system and saw positives and negatives and was in a great position to make recommendations. In an excerpt from his 1910 Flexner Report, he states: The striking and significant facts which are here brought out are of enormous consequence not only to the medical practitioner, but to every citizen of the United States and Canada; for it is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate training whatsoever. As a rule, Americans, when they avail themselves of the services of a physician, make only the slightest inquiry as to what his previous training and preparation have been. One of the problems of the future is to educate the public itself to appreciate the fact that very seldom, under existing conditions, does a patient receive the best aid which is possible to give him in >>
COMMON SENSE MARCH/APRIL 2024
39