Simar Bajaj - 2020 Near Scholar

2019-20 JOHN NEAR GRANT Recipient Wealthy White Men Only: Examining the American Medical Association’s Use of “The Flexner Report” as Propaganda to Reform Medical Education Simar Bajaj

Wealthy White Men Only: Examining the American Medical Association’s Use of the Flexner Report as Propaganda to Reform Medical Education

Simar Bajaj 2020 John Near Scholar Mentors: Ms. Katy Rees, Mr. Mike Pistacchi, Ms. Meredith Cranston April 15, 2020

Bajaj 2 The AMA promotes the art and science of medicine and the betterment of public health.

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—The mission statement of the American Medical Association

Founded in 1847, the American Medical Association (AMA) has long been dedicated to the idea of medicine as a public good. Service, along with science, makes a doctor a doctor; humanity, rather than technical skill, makes a physician a physician. Medicine has always been the care of people, not diseases. Indeed, the Hippocratic Oath, the first text on medical ethics written in the fifth century BCE, reflected this notion of a physician’s duty to his patients, to “do no harm” to them. That celebrated three-word phrase has served as a guiding beacon for physicians across millennia.

From its beginning, the AMA sought to reform medical education to coincide with this vision of medicine as a public service. In the nineteenth century, however, the decentralized Association had neither the meaningful social influence in the United States nor the ability to 2

shape medical education policy. The nation was plagued with commercial medical schools more interested in collecting tuition than providing quality education, yet the AMA could do nothing 3

to stop them. Without any legal power, the AMA tried using principled arguments to bring about changes in medical education, but its success was hampered by public awareness that the Association was powerless to compel medical schools to reform.

The AMA responded to its failures by reorganizing in 1901 and creating a permanent Council on Medical Education (CME) in 1904, which henceforth published annual reports on the

1

The American Medical Association, last modified 2020, accessed April 4, 2020.

2

​Robert Hudson, "Abraham Flexner in Perspective: American Medical Education 1865-1910," ​Bulletin of the

History of Medicine​ 46, no. 6 (November 1, 1972): 555, ​accessed April 4, 2020​.

​E. Brown, ​Rockefeller Medicine Men: Medicine and Capitalism in America​ (Berkeley, CA: University of California Press, 1980), 65.

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Bajaj 3 4

state of American medical education. The AMA’s biggest weapon in this crusade for reform was the ​Journal of the American Medical Association​ (JAMA). The ​Journal,​ however, only appealed to physicians, not touching the American collective consciousness. To catalyze reform efforts, the AMA turned to the Carnegie Foundation, an independent organization not plagued with claims of bias, and Abraham Flexner to perform an extensive report on medical education.

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Helping reduce the number of American medical schools to half of what they once were, the Flexner Report represented the pinnacle of the AMA’s efforts at medical education reform, but it professionalized medicine by shutting down schools for women, African Americans, and the 6

working classes. The 1910 Flexner Report served as an instrument of propaganda from the American Medical Association meant to enforce its singular view of medicine as a profession open only to middle- and upper-class white men.

Historical Context His contemporaries as well as historians lauded Abraham Flexner for his contributions to medical education as he rid the nation of proprietary medical schools and, as a result, of ill-trained physicians. Indeed, at Flexner’s death in 1959, an obituary from ​The New York Times asserted that “no other American of his time has contributed more to the general welfare of his 7

country and humanity.” Alan Chesney, former dean of Johns Hopkins Medical School, similarly

​Arthur Bevan, "Cooperation in Medical Education and Medical Service," ​Journal of the American Medical Association​ 90, no. 15 (April 14, 1928): 1173, ​accessed April 4, 2020​.

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5

​Hudson, "Abraham Flexner," 556.

6

​Michael Schudson, "The Flexner Report and the Reed Report: Notes on the History of Professional Education

in the United States.," ​Social Science Quarterly​ 55, no. 2 (September 1, 1974): 351, accessed April 4, 2020.

​"Abraham Flexner Is Dead at 92; Revolutionized Medical Schools," ​The New York Times​ (New York City, NY), September 22, 1959, accessed April 4, 2020.

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Bajaj 4 praised “Mr. Flexner’s epoch-making investigation” in 1963 while George Corner, a pioneer physician and historian at the Rockefeller Institute, commended how Flexner had “shaken 8

American medical education to its very roots” in a book published in 1965. In all their romanticization of Flexner’s revolutionary report, historians overlooked the complex effects the Flexner Report had on excluding various disadvantaged peoples from a profession in medicine.

Flexner’s role in medical education received more scrutiny in the 1960s and 1970s, however, as historians explored his biases against African Americans as well as the lower classes, women, and other disenfranchised groups. At the height of the civil rights era and second-wave feminism, historians began reevaluating the Flexner Report, going beyond political 9

history to explore the social history of the time. Historians looked for voices and alternative perspectives that had not been previously recorded. With this new focus came a fresh review on Flexner’s actual effect on medical education. In 1973, Gerald Markowitz, professor of history at John Jay College, and David Rosner, professor of sociomedical sciences at Columbia, wrote that the Flexner Report scuttled women’s and historically black medical schools to aggregate power 10

in the hands of a few institutions catering to an exclusionary vision of medicine. Howard Berliner, former chair of the Health Policy and Management department at SUNY Downstate, decried the Flexner Report as a distraction from the genuinely significant changes in medical

​Alan Chesney, ​The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle​ (Baltimore, MD: Johns Hopkins Press, 1963), 3:105; George Corner, ​Two Centuries of Medicine: a History of the School of Medicine​, University of Pennsylvania (Philadelphia, PA: J.B. Lippincott, 1965), 221.

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​Thomas Bonner, "Abraham Flexner and the Historians," ​Journal of the History of Medicine and Allied

Sciences​ 45 (January 1990): 5, accessed April 4, 2020.

​Gerald Markowitz and David Rosner, "Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine," ​American Quarterly​ 25, no. 1 (March 1973): 104, JSTOR. 10

Bajaj 5 history, such as the efforts to reform medical education before Flexner as well as the impact of 11

philanthropic foundations in eliciting reform. In a book published in 1985, Kenneth Ludmerer, professor of history at Washington University in St. Louis, decried the impact of the Flexner Report in excluding underrepresented minorities from having even a chance at entering the 12

medical profession. These and other historians’ perspectives marked a remarkable shift away from the previous unadulterated praise of Flexner.

Over the years, historians have debated whether the Flexner Report was a truly revolutionary work or a symptom of the growing reform of the time, and whether scholars should 13

judge Flexner in light of present-day values or relative to the beliefs of his day and age. Focus on the AMA’s surreptitious collusion with Flexner, however, remains primarily a recent phenomenon. For years the debate has focused on Abraham Flexner, but, in addition to scholars studying the report’s architect, due focus must be given to the Association’s self-serving influence on the Flexner Report, using it as propaganda to professionalize medicine.

The AMA and Medical Education Reform: Organizational Predominance In its eagerness to reshape medical education, the American Medical Association railed against proprietary medical schools, lambasting them as responsible for creating a glut of

​Howard Berliner, "New Light on the Flexner Report: Notes on the AMA-Carnegie Foundation Background," Bulletin of the History of Medicine​ 51, no. 4 (Winter 1977): 608, ​accessed April 4, 2020​.

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12

​Kenneth Ludmerer, ​Learning to Heal: The Development of American Medical Education​ (New York: Basic

Books, 1985), 120.

​Hudson, "Abraham Flexner," 545; Kenneth Ludmerer, "Commentary: Understanding the Flexner Report," Academic Medicine​ 85, no. 2 (February 2010): 195, accessed April 4, 2020; Ann Steinecke and Charles Terrell, "Progress for Whose Future? The Impact of the Flexner Report on Medical Education for Racial and Ethnic Minority Physicians in the United States.," ​Academic Medicine​ 85, no. 2 (February 2010): 237, accessed April 4, 2020; ​Edward Halperin, Jay Perman, and Emery Wilson, "Abraham Flexner of Kentucky, His Report, Medical Education in the United States and Canada, and the Historical Questions Raised by the Report," ​Academic Medicine 85, no. 2 (February 2010): 207, ​accessed April 4, 2020​.

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Bajaj 6 incompetent physicians. Unaffiliated with any university, proprietary medical schools were operated for profit, with one physician-owner splitting up tuition among lecturers. As a result, the AMA derided these proprietary medical schools, which had no significant entrance 14

requirements and offered no laboratory or clinical work, as “diploma mills.” In his report, Flexner commented that department chairs at these proprietary schools were nothing more than objects to be bought or sold and that “the man who had settled his tuition bill was thus practically 15

assured of his degree, whether he had regularly attended lectures or not.” Proprietary medical schools had transformed medicine into a simple business transaction where competence and scholarship lost all importance. Accordingly, the quality of medical education varied dramatically throughout the nation, making it difficult for consumers to distinguish between “pseudo-physicians” and legitimately trained ones. Proprietary schools also challenged the AMA because, funded exclusively by student tuitions, they answered to no one, pursuing their own 16

independent program of medical education. Proprietary schools’ autonomy and low academic standards threatened the AMA’s organizational predominance.

The AMA, therefore, sought to eliminate proprietary medical schools in order to reduce the number of American physicians and to professionalize medicine. At the time, doctors were compensated no better than mechanics. The ​New York State Journal of Medicine​ complained that 17

“there is a handsome income for a few, a competence for the many, a pittance for the majority.”

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​Ludmerer, "Commentary: Understanding," 193.

​Abraham Flexner, ​Medical Education in the United States and Canada​ (New York City, NY, 1910), 7, accessed April 4, 2020​.

15

​Mark Hiatt, "Around the Continent in 180 Days: The Controversial Journey of Abraham Flexner," ​Pharos​ 62, no. 1 (Winter 1999): 21.

16

​Hiatt, 22; "The Economics of Medicine," ​New York State Journal of Medicine​ 9, no. 12 (December 1909): 481, ​accessed April 4, 2020​.

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Bajaj 7 Compared to other professional occupations, doctors viewed themselves as destitute, unable to enjoy respectable social standing or wealth. However, the AMA recognized that, with fewer medical schools, there would be fewer doctors, allowing those remaining to command greater status and financial stability. Placing physicians on a sounder financial footing would, a 1905 18

JAMA article claimed, elevate the authority of doctors and the AMA as a whole. The Flexner Report thus sought not only to support the top institutions but also to eliminate the institutions that were weaker in terms of finances, equipment, and faculty. In fact, Flexner would send drafts of his report to the “better” institutions to have them make corrections, but he did not give this 19

same opportunity to weaker schools. The Association had no interest in helping to reform proprietary medical schools and thus to improve public access to care. Instead, the AMA measured its success “in the rising status of the doctor, in the excellence of the leading schools,” according to Rosemary Stevens, University of Pennsylvania professor of history and sociology 20

of science. Despite its claim that medical education was a public service, the AMA proved more interested in wielding education to professionalize medicine and to increase its organizational power.

The AMA’s desire for medical education reform was also part of a drive for scientific medicine. In its push for supremacy, the AMA sought to eliminate dissenting medical sects, such 21

as homeopaths, eclectics, osteopaths, and others. Indeed, the nineteenth century was marked by

18

​Markowitz and Rosner, "Doctors in Crisis," 88.

​James Burrow, ​Organized Medicine in the Progressive Era: The Move toward Monopoly​ (Baltimore, MD: Johns Hopkins University Press, 1977), 47.

19

​Rosemary Stevens, ​American Medicine and the Public Interest​, updated ed. (Berkeley, CA: University of California Press, 1998), 60.

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21

​Hiatt, "Around the Continent," 23.

Bajaj 8 the AMA’s efforts to create a monopoly of its “regular” physicians, which would result in a monopoly of medicine under the Association. The AMA wanted to refashion medicine in its own allopathic image: scientific methods would reign supreme, and the “quacks” would be expelled from the profession. These dissenting medical sects, however, had a significant following and were considered, in the words of former UCLA professor of health policy Richard Brown, 22

“relatively at least, as effective as and certainly less dangerous than most regular doctors.” To the AMA, these dissenting medical sects instead offered a haven to the most ill-trained physicians, with the dean of Tulane University School of Medicine calling them “the greatest foe 23

to the medical profession.” The AMA sought out medical education reform because it would allow it to assert control over these dissenting sects and force them to follow only practices endorsed by the AMA. As a result, in 1907, the AMA inspected and rated the 33 medical schools run by dissenting medical sects despite having no authority over them. The AMA’s bias against non-allopathic schools led to it being decried for its “Czar-like methods” by a spokesman for homeopathy and for leading a “conspiracy to seize control of medical education” by the editor of 24

the ​Eclectic Medical Journal​. In 1908, future AMA secretary Alexander Craig declared that the goal of medical education reform should be to determine the minimum requirements needed to keep medicine safe for the public, yet the AMA seemed more motivated by consolidating its

22

​Brown, ​Rockefeller Medicine,​ 74.

Stanford Chaillé, "The Practice of Medicine as a Money-Making Occupation," ​New Orleans Medical and Surgical Journal​ 49, no. 11 (May 1897): 608, accessed April 4, 2020.

23

"The Chicago Meeting of the Council and Legislative Committee of the A.M.A.," ​The Journal of the American Institute of Homeopathy​ 2, no. 4 (April 1910): 247, accessed April 4, 2020; ​Burrow, ​Organized Medicine,​ 44.

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power in medicine. In trying to stamp out variation in the profession, the AMA’s goal of scientific excellence and exclusivity came at the expense of its view of medicine as a public service.

Surreptitious Collusion between the AMA and the Carnegie Foundation A part of the medical establishment, the Council on Medical Education recognized that the reform it could spearhead on its own was limited, so it needed to obtain assistance from an outside organization that could lend an air of credibility and impartiality. As it was, the CME’s findings would always be taken lightly because the Council was an institution trying to police 26

itself. Indeed, with every report published, critics blamed the CME for its self-serving bias. For the most part, the public did not believe the Council could be even-handed and fair. The CME also could not be blatant with its criticisms because doing so would be politically disastrous for 27

the American Medical Association. With doctors judging doctors, there was a need to exercise restraint and be diplomatic.

Therefore, the AMA sought out the Carnegie Foundation to survey medical education and to provide an independent viewpoint to bolster its reform efforts. Established in 1905 by industrialist and philanthropist Andrew Carnegie, the Carnegie Foundation for the Advancement 28

of Teaching was designed to give out pensions to college professors. However, a year after the Foundation was established, its first president, Henry Pritchett, revised the organization’s charter

25

Stevens, ​American Medicine​, 70.

26

​Berliner, "New Light," 606.

27

​Hudson, "Abraham Flexner," 556.

28

​Ludmerer, ​Learning to Heal​, 171.

Bajaj 10 away from pensioning and towards the evaluation of higher education, a greater purpose in his 29

eyes. Pritchett approached the legal profession to initiate law school reforms but was promptly 30

rebuked in his efforts. The AMA’s invitation for the Carnegie Foundation to help reform medical schools thus came at an especially fortuitous time, and Pritchett immediately agreed to this mutually beneficial relationship. The Carnegie Foundation would have an opportunity to build its reputation in education while the Association could elicit reform through an organization separate from the medical establishment. Because the public would see the Carnegie Foundation as an impartial body, Pritchett’s organization would not need to be diplomatic in its criticisms. In fact, the AMA saw a report from the Carnegie Foundation as something that “would do much to develop public opinion,” as recorded in the December 28, 31

1908, CME meeting minutes. By seeking out the Carnegie Foundation’s help, the AMA sought to maneuver the public into joining the Association’s crusade for reform.

To conduct this study, Pritchett selected layperson Abraham Flexner, a former 32

headmaster of a Louisville secondary school. It is unclear how the Carnegie Foundation, which had always selected subject matter experts, chose Flexner. Even “Flexner himself was surprised 33

by the request,” according to Ludmerer. Flexner’s connections to the medical establishment

Steven Kanter et al., "Henry Pritchett and His Introduction to the Flexner Report of 1910," ​Academic Medicine​ 85, no. 11 (November 2010): 1778, accessed April 4, 2020.

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30

​Berliner, "New Light," 605-606.

31

Memorandum, "Council on Medical Education, AMA Minutes of Meeting," December 28, 1908, Minutes of the Business Meetings of the Council on Medical Education and Hospitals: 1907-1917, AMA Library, Chicago, IL, quoted in ​Berliner, 606.

32

​Ludmerer, "Commentary: Understanding," 194.

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​Ludmerer, 194.

Bajaj 11 through his brother Simon Flexner, the first director of the esteemed Rockefeller Institute, and his 1908 publication ​The American College,​ a critique of American higher education, may have 34

endeared him to Pritchett. However, Flexner was an unpopular choice among the Carnegie Foundation trustees as they felt a more prominent outsider or a non-AMA-affiliated health care 35

professional would be better suited to author this report. Layman Abraham Flexner nonetheless remained at the helm of the report.

With no background in medical education, Flexner relied on the AMA to guide his thinking and writing. Before examining the nation’s medical schools, Flexner visited Chicago in late 1908 to consult with the secretary of the AMA and to read previous reports prepared by the 36

CME. The Association ensured that the impressionable Flexner knew its positions and its requirements for his report, aiming to influence Flexner’s view of medical education and thus removing independence from the equation. However, the AMA did not limit its collusion to only educating Flexner about Association standards; it played a crucial role during the writing process as well. Secretary of the CME N.P. Colwell accompanied Flexner on many of his school inspections, and Flexner regularly consulted JAMA’s editor who was on the record lambasting 37

medicine’s “absurdly crowded conditions.” While writing his report, Flexner sought mentors and confidants among AMA officials whose ulterior motives certainly shaped Flexner’s view of

​Thomas Bonner, "Searching for Abraham Flexner," ​Academic Medicine​ 73, no. 2 (February 1998): 162, accessed April 4, 2020; Abraham Flexner, ​I Remember: The Autobiography of Abraham Flexner​ (New York, NY: Simon and Schuster, 1940), 109-110.

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35

Hiatt, "Around the Continent," 19.

36

Hiatt, 20; ​Flexner, I Remember,​ 114.

​George Simmons, "Medical Education and Preliminary Requirements," ​Journal of the American Medical Association​ 42, no. 19 (May 7, 1904): 1205, accessed April 4, 2020.

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Bajaj 12 the medical schools he visited. The AMA sought to convert Flexner to its vision of medical education and thus control the message of his report.

In particular, the AMA exerted its influence over Flexner through Pritchett, who served as a liaison between the Carnegie Foundation and the CME. From the beginning, Pritchett intended for the AMA to impress its values of medical education upon whomever he chose to write this report. In the CME’s 1908 meeting minutes, Pritchett agreed that his “foundation would be guided very largely by the Council’s investigations” and that “no more mention should 38

be made in the report of the Council than any other source of information.” The Carnegie Foundation was a puppet that the CME commanded in order to shape public sentiment around medical education. Further, their coordination needed to be kept in the utmost secrecy so that nobody could connect the Carnegie Foundation’s report to the AMA. In a letter from Pritchett to Arthur Bevan, the director of the CME, Pritchett wrote that “we have only taken up the matter 39

and gone on with the examination very much as you were doing.” The AMA did not seek out the Carnegie Foundation to provide a truly independent report. Instead, the Flexner Report was meant to be a republishing of the medical establishment’s previous findings. On top of that letter’s blatant declaration of collusion, Pritchett outlined Flexner’s report for him even before 40

Flexner had set foot in a single school. Pritchett, for instance, directed how the first section of the Flexner Report would describe the minimum requirements for schools and have specific sections regarding medical education for women, dissenting medical sects, and African

38

​Memorandum, "Council on Medical​,” quoted in ​Berliner, "New Light," 606.

39

Henry Pritchett to Arthur Bevan, November 4, 1909, Carnegie Foundation Archives, New York City, NY, quoted in ​Berliner, 606.

40

​Kanter et al., "Henry Pritchett," 1778.

Bajaj 13 41

Americans. The road map and major points of the Flexner Report were predetermined because the AMA knew exactly what it needed from the Carnegie Foundation’s report. It thus came as no surprise that Flexner’s critiques and suggestions lined up almost perfectly with what the medical 42

profession had been publishing for years prior. In his autobiography, Flexner claimed he was an 43

“unfettered lay mind.” With his views shaped by the medical establishment, Flexner instead reiterated the CME’s talking points.

Furthering the collusion between the two organizations, the AMA vigorously defended Flexner’s findings from widespread attack after its publication in 1910. Many prominent medical journals denounced the report as hasty and criticized Flexner for being a layperson without sufficient medical background. For instance, the ​Hospital Bulletin​ declared Flexner was filled 44

with “conceit of Herculean proportions.” Likewise, the ​Denver Medical Journal​ decried the Flexner Report as “full of errors” and made of “pure, unadulterated cussedness, raw malice, and percolated venom” while the ​New York State Journal of Medicine​ condemned Flexner for 45

seeking to “wipe out institutions with the stroke of a pen.” William Osler, one of the founders of Johns Hopkins Medical School, asserted that Flexner had “a very feeble grasp” of medicine, a particularly scathing criticism given that Johns Hopkins was the only medical school Flexner

41

​Halperin, Perman, and Wilson, "Abraham Flexner," 204.

42

​Brown, ​Rockefeller Medicine,​ 146-47.

43

​Flexner, ​I Remember​, 111.

“Summary of Reactions to the Flexner Report,” ​Charlotte Medical Journal​, 1910, quoted in John Felts, "Abraham Flexner and Medical Education in North Carolina," ​North Carolina Medical Journal​ 56, no. 11 (November 1995): 537, accessed April 4, 2020.

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“Summary of Reactions to the Flexner Report,” ​Charlotte Medical Journal​, 1910, quoted in Felts, 537; "The Carnegie Foundation," ​New York State Journal of Medicine​ 10, no. 11 (November 1910): 484, accessed April 4, 2020.

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Bajaj 14 46

unequivocally praised. An editorial from JAMA, however, offered overwhelming, wholehearted support of the Flexner Report. The ​Journal​ praised the report’s neutrality without acknowledging any relationship between the Carnegie Foundation and the AMA. This report is evidently the result of an enormous amount of painstaking work and is worthy of most careful study. Coming from an agency outside and independent of the medical profession, it is sure to have a most profound influence on medical education in general, and claims of partiality or prejudice cannot be made against it. … If the conditions revealed by this extensive investigation are given a wide publicity, the result 47

to medical education can be only good.

In this ostentatiously laudatory editorial, the AMA sought to bolster the Flexner Report’s credibility in the wake of continual attack, reminding readers of the Carnegie Foundation’s supposed independence and of Flexner’s “painstaking work.” Despite the Flexner Report being so intertwined with the Council’s previous findings, “urging reforms along the same lines” in Director Bevan’s own words, the JAMA editorial board refused the possibility of any bias.

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Given the AMA’s extensive collusion with the Carnegie Foundation, holding Flexner’s hand along the way, the Flexner Report rings more like a piece of AMA propaganda, attempting to manipulate public opinion in favor of the Association’s program of medical education reform.

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​Chesney, ​The Johns​, 3:177.

​"The Carnegie Foundation Report on Medical Education," ​Journal of the American Medical Association​ LIV, no. 24 (June 11, 1910): 1949, ​accessed April 4, 2020​.

47

48

​Bevan, "Cooperation in Medical," 1175-76.

Bajaj 15 Matching the 1907 CME Report with the 1910 Flexner Report Every year from its founding, the Council on Medical Education presented its findings regarding medical education reform at the annual meeting of the American Medical Association.

These initial reviews led to the closure of only a handful of medical schools though. Despite their limited impact, the CME’s findings served as the backbone for the Flexner Report, with Flexner 49

studying these reports and praising them in his autobiography as “creditable and painstaking.”

In 1907 in particular, having visited every American medical school, the Council published its first medical school directory as Flexner would repeat only a few years later. More generally, the 1907 CME report bore many striking parallels with the 1910 Flexner Report: both demanded a prominent role for state licensing boards in reforming medical education, and both believed that 50

publicity was necessary to effect change. Unlike the Flexner Report, however, the results of the 1907 CME report were never issued publicly and were only read by state licensing boards and the AMA. Nevertheless, the numerous ideological similarities between the two reports suggest how closely the Association and the Carnegie Foundation coordinated with one another. The 1910 Flexner Report served as a mere elaboration on the Council’s own 1907 findings, belaboring the same AMA program concerning medical education reform.

In seeking to combat the overproduction of physicians, the Flexner Report and the 1907 CME report similarly railed against proprietary medical schools. These reports argued that commercial medical schools were incapable of teaching students properly and posed a danger to society. Neither minced words: the 1907 CME report demeaned schools as “no better equipped

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Flexner, ​I Remember​, 114.

​Report of the Council on Medical Education,​ 10, 1907, accessed April 4, 2020​; Flexner, ​Medical Education​, ix; Flexner, 173.

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Bajaj 16 to teach medicine than is a Turkish-bath establishment or a barbershop” as well as “a menace [that] should not be recognized” while the Flexner Report asserted that these enterprises “can be called schools or institutions only by courtesy” and that it was “important to destroy commercial 51

schools.” Furthermore, both reports claimed that running a medical school for profit was mutually exclusive to running a valuable medical school. The 1907 CME report commented on how “it costs more to educate a medical student than he can pay in the way of fees. Medical 52

education must secure state aid and private endowment.” The Flexner Report agreed that “endowment or taxation alone can meet this burden. … But in no case are the fees adequate to 53

support all the essential departments on a substantial basis.” For medical education, the CME and Flexner both mandated a large endowment and governmental support. Proprietary medical schools, which subsisted on student fees alone, could not attempt to provide a proper education in the eyes of these reports.

Both the 1907 CME report and the Flexner Report also placed great emphasis on a scientific, research-intensive approach to medical school. They insisted on high entrance requirements with a strong foundation in the sciences, specifically mandating one year in biology, chemistry, and physics before starting medical school. In medical schools themselves, both reports recommended that professors see no patients and devote themselves entirely to teaching and research. The 1907 CME report discussed the importance of “trained instructors paid to devote their entire time to teaching and research,” and the Flexner Report underscored the

51

​Report of the Council,​ 11; ​Report of the Council​, 11; Flexner, ​Medical Education,​ 6; Flexner, 282.

52

​Report of the Council,​ 11.

53

​Flexner, ​Medical Education,​ 135.

Bajaj 17 importance of full-time professors who “brought order out of chaos” and “have no other income 54

but their salaries” because they do not see patients. Flexner argued that, by focusing on research instead of patient care, these full-time professors would remain at the forefront of the field and advance medicine, all the while becoming better teachers. While a scientific basis for medicine was not a revolutionary idea, the specific means through which both reports wanted to achieve such a goal were remarkably similar.

Both reports also lamented a didactic style of teaching, advocating for a more hands-on approach to learning medicine. As a result, they criticized the lack of proper equipment and facilities at proprietary schools because this paucity inhibited quality medical education. The 1907 CME report ordained that “the weakest point in the equipment and teaching facilities of medical schools is, naturally, the lack of laboratories” while the Flexner Report condemned how proprietary schools “usually lack a clinical laboratory in which students may work” and “the failure to provide clinical laboratory space thus keeps instruction to the level of passive 55

demonstration.” Laboratories were paramount to both reports because the alternative was an inefficient sermonic pedagogy. The 1907 CME report noted how many schools “are little more than quiz classes, in which men are drilled” to pass exams while the Flexner Report attacked 56

how “the actual emphasis falls on the didactic teaching and the quiz-drills” at these schools.

With regard to medical school structure, they therefore argued for a medical school curriculum based on two years of instruction in the basic sciences, learning in the laboratory, and two years

54

​Report of the Council,​ 14; Flexner, ​Medical Education​, 137; Flexner, 138.

55

​Report of the Council,​ 14; Flexner, ​Medical Education​, 113.

56

​Report of the Council,​ 11; Flexner, ​Medical Education​, 84.

Bajaj 18 of clinical work, learning from patient care. Although standard practice now, this program of medical education was quite novel for its time when four-year medical schools were virtually 57

nonexistent, yet both reports forcefully advocated for its adoption and standardization.

While it remains possible that the AMA merely inspired Flexner or that these similarities are only coincidental, the numerous parallels between these two reports suggest deliberate collusion between the CME and the Carnegie Foundation. In context of Pritchett’s aforementioned statement that the “foundation would be guided very largely by the Council’s investigations” in the CME’s meeting minutes, the resemblance between the 1907 CME report 58

and the Flexner Report suggests that the AMA had a formative influence on Flexner. Further, these similarities indicate that the AMA actively and successfully biased the purportedly independent Flexner Report.

The Flexner Report as Effective Propaganda The late nineteenth and early twentieth centuries represented the pinnacle of the Progressive Era, and the Flexner Report is a reflection of this impulse of reform as well as evidence of the scientific management theory that had enveloped the United States at the time.

From Upton Sinclair’s impact on the meatpacking industry with ​The Jungle​ to Lincoln Steffens’ effect on political reform with ​The Shame on the Cities,​ investigative journalists revealed public 59

injustices to elicit reform. Written in the context of this muckraking tradition, the Flexner

57

​Ludmerer, ​Learning to Heal,​ 74.

58

​Berliner, "New Light," 606.

59

​Ludmerer, "Commentary: Understanding," 193.

Bajaj 19 Report was such effective propaganda because Flexner linked the report to data and science while also offering an alarmist, vitriolic perspective of medical education.

Flexner’s Claim to Science Flexner staunchly believed in the power of data and science to solve medical education.

Indeed, medical historian Thomas Bonner described how Flexner “was motivated like many in his time by a high idealism about science; and he was robustly optimistic about medicine’s 60

future.” In writing his report, Flexner propagated the publicly held belief that science could be used to solve all problems, effectively wielding this tool to silence opposition and assuage the public’s concerns regarding the legitimacy of his report.

While proposing a scientific basis for medical education, Flexner periodically used data tables and researched figures to add credence to his report. For instance, Flexner cited professor Friedrich Paulsen’s ​German Universities​ when arguing for moving away from the American average of one doctor for every 568 people to the German average of one doctor for every 2,000 61

people. Flexner contended that the result of such an action would be a doctor four times better than before, a seemingly reasonable conclusion for the public. Flexner also wanted to reduce the number of medical schools from 155 to 31, which would leave twenty states without a medical 62

school, in order to bring the annual output of physicians from 4,442 to 2,000 (See Fig. 1).

60

​Bonner, "Abraham Flexner," 8.

61

Flexner, ​Medical Education,​ 14.

62

Flexner, 151.

Bajaj 20

Figure 1: Medical schools at the time of the Flexner Report (left) and medical schools Flexner suggested stay open (right). Abraham Flexner, ​Map Showing the Actual Number, Location, and Distribution of Medical Schools,​ 1910; Abraham Flexner, ​Map Showing the Suggested Number, Location, and Distribution of Medical Schools​, 1910. Flexner, ​Medical Education​, 152-53.

These numbers, however, were not arbitrary as Flexner spent several pages calculating how many doctors each American region needed annually based on its population, urbanization, potential future vacancies, etc. Similarly, Flexner categorized the various costs of a medical school, such as class materials, library books, professor’s salary, and even the janitor’s salary, to determine that a medical school cannot provide proper instruction for “less than $10,000 to 63

$15,000 per annum.” Case studies and school budgets helped Flexner further drive home the 64

importance of having sufficient funding to deliver proper medical education. In addition, the second part of the Flexner Report centered around collecting data on every school from its entrance requirements to its laboratory quality. Flexner’s thoroughness and attention to detail shone through as he not only raised quite specific estimates but also offered the reasoning to

63

Flexner, 129.

64

Flexner, 134.

Bajaj 21 back them up. Flexner sought to use data to solve the social ill that was poor medical education, hoping to achieve reform through the power of research.

Not only did the scientific means with which he created his report endear him to the public, but also his overwhelming support of the sciences played a critical role in his report’s success at propaganda. Flexner’s dogma for medical education was that it must be governed by modern science where decisions were made by fact and investigation rather than hoax and mere empiricism. Before medical school, he advocated for a minimum of two years of undergraduate education during which students would gain a background in fundamental sciences (biology, chemistry, physics) so that they could effectively study second-tier sciences (anatomy, physiology, pathology, etc.) in medical school. In his report, he declared that medical students should be “trained to regard the body as an infinitely complex machine,” seeking to understand it 65

through experimentation alone. Flexner’s qualm with the quiz-drills so popular in proprietary medical schools stemmed from his belief that didactic learning created rote-memorizers for doctors. Flexner greatly preferred the critical thinkers produced, in his eyes, only by academic medical school Johns Hopkins. Throughout his report, Flexner thus prioritized logical reasoning and research-based medicine because a scientific basis for medical schools would create these critical thinkers. He believed in the scientific method’s employment in all aspects of a physician’s life, including patient care, so he wanted ​every​ medical school to have a research and 66

a lab component. This purist view entirely refuted the possibility of a more practical, clinical-focused medical school no matter if the school was otherwise qualified. Flexner’s timely

65

Flexner, 63.

66

​Flexner, 59.

Bajaj 22 claim to science resulted in his findings being enthusiastically accepted because society, in the words of professors Markowitz and Rosner, was “beginning to view technology and science as a 67

new religion.” Science seemed to offer objective, ideal solutions for the nation’s problems, so the public rewarded any association with “science,” no matter how dubious. The Flexner Report effectively mobilized the collective consciousness because it relied on the infallibility of science, the sentiment that science could be used to solve societal ills.

Flexner’s Acerbic Style Wielding his words as weapons, Flexner also unabashedly stripped down nearly every medical school in ways that lent themselves to media and academic attention. Deliberately provocative and not necessarily based on facts, Flexner’s language led him to be sued for 68

$150,000 for libel and to have his life repeatedly threatened. In Flexner’s autobiography, he dramatically described the impact of his report, pronouncing that “such a rattling of dead bones 69

has never been heard in this country before or since.” Flexner was more than willing to employ similarly flamboyant yet acerbic language in his descriptions of schools, contributing to the striking popularity of his report. He regularly called schools “criminally inadequate,” “utterly 70

wretched,” “indescribably foul,” and “dirty and disorderly beyond description.” More specifically, he called Mississippi Medical College “a stock company,” California Medical College “a disgrace to the state whose laws permit its existence,” St. Louis College of Physicians and Surgeons “one of the worst in the country,” and the College of Eclectic Medicine and

67

​Markowitz and Rosner, "Doctors in Crisis," 92.

68

​Flexner, ​I Remember​, 131.

69

​Flexner, 131.

70

​Flexner, ​Medical Education,​ 163; Flexner, 321; Flexner, 205; Flexner, 297.

Bajaj 23 71

Surgery as “nothing more disgraceful calling itself a medical school can be found anywhere.”

He described all 155 medical schools he visited in detail, yet only a handful of these schools

received a mostly positive description. By naming names, detailing every single medical school, Flexner ensured that no school could hide behind anonymity.

Flexner’s deliberately inflammatory comments about nearly all the nation’s medical schools ensured that every newspaper, whether at the national or local level, would have headlining news to report about his work. Indeed, from the ​Brooklyn Daily Eagle​ to ​The Chicago Tribune​ to the ​El Paso Herald​, the Flexner Report made front-page news across the country.

When printing lines from the Flexner Report, newspapers were often careful to put quotes, 72

fearing libel lawsuits otherwise. For instance, the ​Washington Post​ published “Too Many Physicians: Carnegie Foundation Assails Medical Colleges. Would Abolish Majority: Investigator Arraigns Large Number of Institutions for Tinning Out ‘a Host of Poorly Educated 73

and Ill Trained’ Medicos—Called a ‘Menace to the Country’—Chicago ‘Plague Spot.’” The San Francisco Examiner​ similarly ran “Three-quarters of Doctors ‘Quacks’: Scientific Inquiry

by Carnegie Foundation Finds Almost All Are Illy Trained. Schools Many and Poor: Nation Has 74

Four Times the Physicians It Needs; Noted Institutions Blacklisted.” Meanwhile, the ​New York

71

​Flexner, 249; Flexner, 190; Flexner, 256; Flexner, 205.

72

​"The Carnegie Foundation," 484.

​"Too Many Physicians: Carnegie Foundation Assails Medical Colleges. Would Abolish Majority: Investigator Arraigns Large Number of Institutions for Tinning out 'A Host of Poorly Educated and Ill Trained' Medicos -- Called a 'Menace to the Country' -- Chicago 'Plague Spot.,'" ​The Washington Post​ (Washington, DC), June 7, 1910, ​accessed April 4, 2020​.

73

​"Three-quarters of Doctors 'Quacks': Scientific Inquiry by Carnegie Foundation Finds Almost All Are Illy Trained. Schools Many and Poor: Nation Has Four Times the Physicians It Needs; Noted Institutions Blacklisted.," San Francisco Examiner​ (San Francisco, CA), June 6, 1910, ​accessed April 4, 2020​.

74

Bajaj 24 Times,​ the nation’s most esteemed publication, dedicated a front-page to Flexner headlining “Factories for the Making of Ignorant Doctors: Carnegie Foundation’s Startling Report that 75

Incompetent Physicians Are Manufactured by Wholesale in This Country.”

Figure 2: Front pages of ​The New York Times​ and ​The Brooklyn Daily Eagle.​ “Factories for the Making of Ignorant Doctors: Carnegie Foundation's Startling Report that Incompetent Physicians Are Manufactured by Wholesale in This Country,” 1910, Newspapers.com; “Too Many Ill-Trained Doctors Say Carnegie Investigators: In Severe Criticisms of Medical Schools of North America Abraham Flexner States That the 155 Institutions Should Be Reduced to 30—Brooklyn Physicians Combat His Assertions,” 1910, Newspapers.com.

​"Factories for the Making of Ignorant Doctors: Carnegie Foundation's Startling Report that Incompetent Physicians Are Manufactured by Wholesale in This Country," ​The New York Times​ (New York City, NY), July 24, 1910, ​accessed April 4, 2020​.

75

Bajaj 25 The profound impact of the Flexner Report was evidenced by the 15,000 copies distributed, an 76

extraordinarily high number for a technical research report. With its sensationally abusive criticisms, the Flexner Report captured newspaper editors and readers everywhere.

Flexner’s sharp, uncompromising critiques mobilized the American public for medical education reform because he personalized the deleterious impacts of poor medical schools to his readers. In the introduction of the Flexner Report, Pritchett made it clear that the public had a right to know the circumstances of American medical education, and Flexner subsequently laid out, in no uncertain terms, the dire state of affairs. After repeatedly emphasizing how medicine is a “public service corporation” designed for the good of the people, Flexner demonstrated that, because of proprietary schools, medical education had become nothing more than a business run 77

by greedy physicians motivated solely by profit. Flexner wrote how even the school catalogs “abound in exaggeration, misstatement, and half-truths,” claiming that the medical school deans 78

were more adept in marketing than education. Rather than teaching the next generation of physicians to faithfully serve the country, these schools sought to enroll as many students as possible, Flexner argued. Flexner ruthlessly lambasted the “mercenary concerns that trade on ignorance and disease” and created a popular sentiment of disgust for these proprietary school 79

owners who put their business over the public good. The scathing tone that pervaded Flexner’s writing helped his report gain traction, which ultimately spurred governmental action to implement the reforms the AMA had been eyeing since its founding.

76

Ludmerer, ​Learning to Heal,​ 84.

77

​Flexner, ​Medical Education,​ ​154.

78

Flexner, 19.

79

Flexner, 89.

Bajaj 26 Enactment of Medical Education Reform Two years after the Flexner Report was published, state licensing boards came together to form the Federation of State Medical Boards. The Federation based its medical school accreditation requirements entirely on the CME’s standards of medical education, guidelines 80

which had been largely ignored prior to the publishing of the Flexner Report. After about 65 years, the AMA finally had the legal power to enact its reforms. The AMA’s influence was so profound that the Association’s judgment of a medical school led to the state licensing board 81

offering accreditation or not, regardless of the school’s actual merits. As a result, these licensing boards began requiring medical schools around the nation to enhance their admission and education standards if they wanted to stay afloat. These more rigorous licensing requirements increased the length and cost of medical education, leaving many medical schools in a Catch-22. The medical schools could either raise requirements, which would fatally diminish enrollment, or fail to comply, which would result in the state licensing boards not recognizing 82

their diplomas. After all, the AMA’s intention was not to reform medical schools but to close as many as possible in order to professionalize the field.

Along with the threat of state licensing boards not offering accreditation, Flexner elicited reform through the reward of foundation money. In 1912, Flexner joined the General Education Board, a philanthropic organization run by industrialist John Rockefeller, and had $50 million set

80

​Halperin, Perman, and Wilson, "Abraham Flexner," 208-09.

81

​Ludmerer, ​Learning to Heal,​ 237.

​Paul Starr, ​The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry​, rev. ed. (New York, NY: Basic Books, 2017), 118.

82

Bajaj 27 83

aside to enforce the recommendations outlined in the Flexner Report. Life-sustaining foundation money helped Flexner coerce changes in medical schools. Howard Medical School, for instance, received less funding than Meharry Medical College simply because Howard graduates were more likely to create their own practices in the North than do public health work 84

in the South. With the help of the General Education Board’s bullying, only 79 medical schools 85

of the 155 that Flexner studied were left standing by 1920. About half of the nation’s medical schools either outright shut down or merged with another in the years that followed the Flexner Report. The Flexner Report brought publicity to the subject of medical education reform, leading state licensing boards and the General Education Board to adopt Flexner’s recommendations and professionalize medicine on the AMA’s behalf.

Singular View of Health Care At the time of the Flexner Report, the American Medical Association was exclusively composed of white males of the middle and upper classes, whose plans to reform medicine were influenced by their own insular perspectives. To maximize benefits to its members, the AMA sought to create an artificial shortage of medical personnel, which resulted in the closure of schools for African Americans, women, and the working classes, removing them from the profession. In an attempt to professionalize medicine through medical education reform, the Flexner Report had profound, far-reaching implications on American health care, transforming medicine into a monolithic field accessible only to the privileged.

83

​Stevens, ​American Medicine​, 68.

84

​Thomas J. Ward, ​Black Physicians in the Jim Crow South​ (Fayetteville: University of Arkansas Press, 2010),

85

Schudson, "The Flexner," 351.

33.

Bajaj 28 African Americans Only devoting two pages to African American medical education in his report, Flexner flagrantly dismissed the role of African Americans in medicine. The Flexner Report proclaimed that only Howard Medical School and Meharry Medical College were worth saving while the other five historically black medical schools should be immediately shut down to concentrate resources on those two schools. This mandate closely resembled the suggestions of the Council on Medical Education, which, among all historically black medical schools, gave only Howard 86

an “A” rating in its reports. Flexner acknowledged that Howard and Meharry could not accommodate the number of aspiring African American physicians but entirely dismissed that 87

concern, asserting that African Americans “need good schools rather than many schools.”

Neither he nor the AMA worried about the far-reaching impacts of excluding African Americans from medical training, instead preoccupied with fighting the national oversaturation of physicians. Doctors, however, were not equally represented. In 1910, there was one physician for every 684 people nationally, but there was only one black physician for every 2,883 black 88

people. Flexner’s idealized German ratio of one physician for every 2,000 people had already been well exceeded for the African American population, but Flexner failed to recognize this nuance, leaving African Americans to bear the brunt of the damage. On top of that, Flexner derided all African American doctors as “dangerous” and “essentially untrained,” stating that the only role prescribed for them should be in “hygiene rather than surgery,” public health rather

86

​Ward, ​Black Physicians,​ 21.

87

​Flexner, ​Medical Education,​ 180.

88

​Brown, ​Rockefeller Medicine,​ 154.

Bajaj 29 89

than medicine. Given the Jim Crow segregation and discrimination under which African Americans suffered in the early twentieth century, this circumscribed view of African Americans 90

in health care was unfortunately common, if not even liberal. Perhaps more maliciously, Flexner also declared that society needed African Americans in health care to ensure their communities did not spread diseases to whites: “The negro must be educated not only for his 91

sake, but for ours.” In line with the AMA’s desire to limit competition for health care delivery, Flexner did not want African American physicians in the profession. Flexner’s contemptuous attitude resulted in his demeaning any potential contribution of African Americans in medicine.

As a result, Flexner’s recommendations for medical education reform disproportionately targeted historically black medical schools. The Civil War had concluded a few decades prior, so all black medical schools had been recently founded. These schools thus lacked the large endowment or the generations of alumni donors of most other universities. Additionally, because of white philanthropists’ reluctance to sponsor African American higher education, most medical schools open to African Americans had to be proprietary medical schools, which Flexner deemed 92

unacceptable. There were generally no universities with which historically black medical schools could be associated, and the creation of a university hospital from the ground-up was often financially unfeasible. Nonetheless, university and hospital affiliations were pillars of Flexner’s program for reform. Considering that African Americans were also severely

89

​Flexner, ​Medical Education,​ 180.

90

​Ward, ​Black Physicians,​ 32.

91

​Flexner, ​Medical Education,​ 180.

92

​Ludmerer, ​Learning to Heal,​ 145.

Bajaj 30 disadvantaged by systemic educational inequality at every level from kindergarten to college, Flexner’s stringent medical school admission requirements, such as two years’ college education 93

and training in the sciences, inordinately targeted the African American communities. Flexner failed to account for the histories and disadvantaged positions of historically black medical schools, forcing them to adhere to standards racially biased against them.

By dismissing historically black medical schools, the Flexner Report delegitimized African American physicians already in practice and severely curtailed the training of new black physicians. By 1940, Howard and Meharry were annually producing about 100 physicians, a number that could not even keep pace with the African American physicians leaving the 94

profession every year. Moreover, 1940 mortality rates were 71% higher among the black communities than the white communities; a greater number of African American physicians likely would have made a difference because “nearly all diseases which show excess mortality in 95

the Negro are classed as preventable” according to biological anthropologist Dr. William Cobb.

With his recommendations, Flexner set up a vicious cycle of underrepresentation in medicine among African Americans. Ultimately, fewer African American alumni could fight racial disparities in health care, and fewer African American physicians could serve as mentors for aspiring black physicians. The Flexner Report excluded African Americans from medicine not only in his time but also for several decades thereafter.

93

​Steinecke and Terrell, "Progress for Whose," 239.

94

​Ward, ​Black Physicians,​ 28.

​William Cobb, ​Medical Care and the Plight of the Negro​ (National Association for the Advancement of Colored People, 1947), 5.

95

Bajaj 31 Working Classes Flexner entirely rejected the role of the working class in medicine, advocating for a more expensive vision of medical education that would price them out of the profession. Laboratory equipment, maintaining full-time professors, and upkeep of facilities cost medical schools a great deal, and Flexner knew that medical education would have to become significantly more expensive than it currently was to reach the quality needed to properly train physicians and have patients benefit from medical advances. From advocating for higher tuition to the removal of flexible night schools that allowed students to do work-study, Flexner precluded poor students from the possibility of a career in medicine, forcing them out with his recommendations.

Flexner struck down arguments regarding the importance of the working class in medicine and of the schools that taught them. For one, Flexner rejected that society needed second-tier medical schools to train the working class, callously stating that “it is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate 96

preparation.” However, Flexner ignored the structural inequity that prevented the “poor boy” from receiving the necessary preparation for a career in medicine. The AMA also saw poor medical schools as dangerous because they were bringing in members of the working class into medicine, “encouraging the very kind and class of people the ‘profession’ was trying to keep 97

out” according to professors Markowitz and Rosner. A ruthless pragmatist, Flexner knew that professionalizing medicine entailed raising the profession’s socioeconomic status, which meant ridding the profession of these poor physicians. Shortly after the publication of the Flexner

96

​Flexner, ​Medical Education​, xi.

97

Markowitz and Rosner, “Doctors in Crisis,” 95.

Bajaj 32 Report, a physician from a Tennessee medical school argued in the ​Collier’s Weekly f​ or the importance of heterogeneity in medicine because poorer physicians served poorer populations.

True, our entrance requirements are not the same as those of the University of Pennsylvania or Harvard; nor do we pretend to turn out the same sort of finished product.

Yet we prepare worthy, ambitious men who have striven hard with small opportunities and risen above their surroundings to become family doctors to the farmers of the south, and to the smaller towns for the mining districts. … Would you say that such people should be denied physicians? Can the wealthy who are in a minority say to the poor 98

majority, you shall not have a doctor?

Poorer schools may not have been producing the most qualified physicians, but the physicians they did graduate played an important role in health care, returning home and caring for their underserved communities. Flexner entirely dismissed that argument, holding an idealistic view that paying more for medical education would not deter these students from serving poorer locales: ​“The young graduate will not hesitate to pitch his tent in a sparsely settled neighborhood, if it promises a future. A high-grade and comparatively expensive education will not alter his 99

inclination to do this.” However, biostatistician Raymond Pearl showed in 1920 that the 100

national dispersal of doctors corresponded to the average income of a region.

As expected,

physicians followed the money. ​Rather than employ a more nuanced perspective to ensure

​ ollier's Weekly,​ June 11, 1910, Box 19, Flexner Papers, Library of Congress, Washington, DC, quoted in C Starr, ​The Social,​ 125.

98

99

​Flexner, ​Medical Education​, 15.

100

​Starr, ​The Social​, 125.

Bajaj 33 heterogeneity and diversity in the profession, Flexner sought to indiscriminately bludgeon schools for the socioeconomically disadvantaged.

By pricing the lower classes out of medicine as a profession, Flexner priced large communities out of medicine as a service as well (See Fig. 3).

Small Towns

Large Cities

1906

590:1

492:1

1923

910:1

536:1

Figure 3: People-to-physician ratio for small towns, defined as having 1,000-2,500 people, and large cities, defined as having over 100,000 people, in 1906 and 1923. Paul Starr, ​The Social Transformation of American Medicine​, 2017.

After the Flexner Report, the people-to-physician ratio increased in large cities by 9% but more remarkably in small towns by over 54%. Informed by a social justice view of medicine, AMA President William Pusey acknowledged in 1927 that “as you increase the cost of the license to practice medicine you increase the price at which medical service must be sold,” resulting in fewer people having access to care.

101

Small towns found themselves increasingly abandoned by

physicians as the money to recoup medical school costs and the status associated with the contemporary doctor could be found only in the city. As the profession lost its socioeconomic diversity, medicine became more homogeneous in terms of physicians as well as patients.

Women While Flexner largely did not address women in his report, he viewed the typical doctor as male, and his bias helped diminish female representation in the field. For instance, Flexner

William Pusey, "The Disappearance of Doctors from Small Towns," ​Journal of the American Medical Association​ 88, no. 7 (February 12, 1927): 506, accessed April 4, 2020.

101

Bajaj 34 saw women’s medical colleges as unnecessary and as depriving coeducational schools of resources. Gender studies scholar Moya Bailey asserted that Flexner failed to consider the 102

“​otherness​ of women” in health care.

Women’s medical colleges offered community and

support in ways that predominantly male coeducational schools could never offer. Considering that both Flexner and the AMA held that women lacked the psychological faculties to become physicians and that, “if middle or upper class, women make better patients than doctors,” it 103

comes as no surprise that Flexner advocated for the closure of all women’s medical colleges.

In his report, Flexner justified this recommendation, asserting that women were not interested in 104

medicine based on declining attendance over the six years prior to his report’s publication.

However, the truth proved more complicated: Flexner ignored social factors that prevented women from pursuing a career in medicine, such as men’s vigorous efforts to keep them out of medicine and medical schools’ prejudice against women on the grounds that marriage would 105

render them useless, inactive physicians.

Women were not necessarily unwilling to go into

medicine, but were increasingly excluded from the profession during the years Flexner looked at, a small sample size of six at that. Women were staying outside of medicine because of the men who argued against their inclusion, not because of general apathy toward the field.

Flexner’s justification that women would still be able to receive a medical education also proved faulty because only a handful of medical schools adopted coeducation after the Flexner

​Moya Bailey, "The Flexner Report: Standardizing Medical Students through Region-, Gender-, and Race-Based Hierarchies," ​American Journal of Law & Medicine​ 43 (2017): 220, ​accessed April 4, 2020​.

102

103

​Brown, ​Rockefeller Medicine,​ 149.

104

Bailey, "The Flexner," 220.

105

​Starr, ​The Social​, 124.

Bajaj 35 106

Report.

Both Flexner and the AMA viewed the archetypal physician as male, as seen through

continuous references to doctors as only “men” in the 1907 CME report and the Flexner Report.

Medical schools instituted gender quotas against females, which, along with discriminatory gender norms, made coeducation realistically unfeasible. With the declining number of female physicians denying women role models and a longer period of study pricing them out of 107

medicine, women found it progressively more challenging to enter the medical profession.

Five years after the Flexner Report was published, fewer than 3% of medical school graduates 108

were women, a historical decline from 4.3% (1880-1904).

Apart from wartime, women would

not make up 5% of physicians until the feminist movement of the early 1970s.

109

The Flexner

Report had profound implications for female representation in medicine and, more generally, gender roles.

Lessons from the Flexner Report In the name of medicine as a public service, the Flexner Report revolutionized American medical education at a time when well-trained physicians were in short supply. Nonetheless, the Flexner Report also served as American Medical Association propaganda to promote its political causes—reducing variety in medicine and professionalizing the field to obtain organizational predominance. Instead of openly working with the Carnegie Foundation, the AMA secretly colluded with Henry Pritchett and Abraham Flexner because the Association recognized that, if

106

​Ludmerer, ​Learning to Heal​, 248.

​Shari Barkin et al., "Unintended Consequences of the Flexner Report: Women in Pediatrics," ​Pediatrics​ 126, no. 6 (December 2010): 1056, accessed April 4, 2020.

107

108

​Barkin et al., 1056.

109

​Markowitz and Rosner, "Doctors in Crisis," 97.

Bajaj 36 portrayed as independent, the report would more successfully mobilize reform. With the Flexner Report, the AMA sought to brazenly manipulate public opinion and proved effective at doing so because of Flexner’s acerbic tone and claim to science garnering mass media attention. The Flexner Report, however, paved the way for institutional changes that persist over a hundred years later, with women not being equally represented in surgical specialties and prescription drugs being overwhelmingly designed for Caucasians rather than the general public. The devastating impacts of the Flexner Report on underrepresented groups reflect not only the success of the AMA in achieving its organizational goals but also the failure of society to prevent these horrific systemic inequities. Prioritizing organizational profit over the public good, the Flexner Report stands as a testament to malignant institutional injustice.

Bajaj 37 Bibliography The American Medical Association. Last modified 2020. Accessed April 4, 2020. https://www.ama-assn.org/.

This primary source reflects the American Medical Association's commitment to advancing medicine for the benefit of humanity. The American Medical Association was founded in 1847 to attempt to reform medical education for the public good. Its mission statement is designed for the public and members alike to understand what the American Medical Association stands for.

Bailey, Moya. "The Flexner Report: Standardizing Medical Students through Region-, Gender-, and Race-Based Hierarchies." ​American Journal of Law & Medicine​ 43 (2017): 209-223.

Accessed April 4, 2020. https://journals.sagepub.com/doi/pdf/10.1177/0098858817723660.

While Abraham Flexner recognized the role of women in medicine, he did not consider the importance of community in women's colleges and misleadingly ascribed the fall in female medical graduates to a lack of interest. Moya Bailey is an assistant professor of women's, gender, and sexuality studies at Northeastern University. Bailey's argument supports how the Flexner Report helped the American Medical Association reform medical education in its own image, one where female physicians played a marginal role.

Barkin, Shari, Elena Fuentes-Afflick, Jeffrey Brosco, and Arleen Tuchman. "Unintended Consequences of the Flexner Report: Women in Pediatrics." ​Pediatrics​ 126, no. 6 (December 2010): 1055-1057. Accessed April 4, 2020. https://pediatrics.aappublications.org/content/126/6/1055.

Advocating for closing all women's medical colleges, the Flexner Report contributed to the diminishing role of women in medicine, which would persist until the 1970s. Shari Barkin, Elena-Fuentes Afflick, and Jeffrey Brosco are pediatricians and professors at Vanderbilt, UCSF, and the University of Miami respectively while Arleen Tuchman is a professor of history at Vanderbilt. The American Medical Association's singular view of health care left little room for women, and the Flexner Report served that vision.

Berliner, Howard. "New Light on the Flexner Report: Notes on the AMA-Carnegie Foundation Background." ​Bulletin of the History of Medicine​ 51, no. 4 (Winter 1977): 604-609.

Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/343847.

While portrayed as an independent creation, the Flexner Report was a product of surreptitious collusion between the American Medical Association and the Carnegie Foundation as the Association sought to mobilize public opinion for medical education reform. Howard Berliner was the chair of health policy and management at SUNY Downstate. The secrecy behind the American Medical Association's efforts to work with the Carnegie Foundation on the report reflects the American Medical Association's desire to utilize the report as propaganda to bring about its vision of medicine.

Bajaj 38 Bevan, Arthur. "Cooperation in Medical Education and Medical Service." ​Journal of the American Medical Association​ 90, no. 15 (April 14, 1928): 1173-1177. Accessed April 4, 2020. https://jamanetwork.com/journals/jama/article-abstract/323106.

This primary source seeks to examine the history of the American Medical Association's push for educational reform, emphasizing the role of the Carnegie Foundation in helping mobilize public opinion. Bevan, the director of the Council on Medical Education, wrote this paper eighteen years after the Flexner Report came out, summarizing the Council's successes at medical education reform for other doctors to appreciate. Bevan offers insight into how the Council on Medical Education used the Carnegie Foundation to bolster its conclusions about medical education reform.

Bonner, Thomas. "Abraham Flexner and the Historians." ​Journal of the History of Medicine and Allied Sciences​ 45 (January 1990): 3-10. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/2179404.

The historiography of Abraham Flexner has shifted away from romanticization and universal admiration to a view that underestimates his role on medical education and challenges his social views. Medical historian Thomas Bonner was president of the University of New Hampshire, Union College, and Wayne State University. Bonner provides context regarding how historians have studied the Flexner Report in the past, focusing more on the man himself instead of the American Medical Association.

———. "Searching for Abraham Flexner." ​Academic Medicine​ 73, no. 2 (February 1998): 160-166. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/9484189.

Henry Pritchett had the American Medical Association educate Abraham Flexner in its views of medical education before giving him an outline of what his report should look like. Medical historian Thomas Bonner was president of the University of New Hampshire, Union College, and Wayne State University. Bonner's paper helps support the argument that the American Medical Association had significant influence over Abraham Flexner and his thoughts on medical education.

The Brooklyn Daily Eagle​ (New York City, NY). "Too Many Ill-Trained Doctors Say Carnegie Investigators." July 10, 1910. Accessed April 4, 2020. https://www.newspapers.com/image/53919324/?terms=carnegie.

This primary source reflects the immense impact that the Flexner Report had on capturing the nation's media, even at the local level. An entire front-page dedicated to the Flexner Report from a newspaper that is primarily focused on covering Brooklyn-related issues demonstrates how effective the Flexner Report was at starting the conversation around medical education reform. ​The Brooklyn Daily Eagle​ offers a representation of the Flexner Report’s media coverage, capturing local and national newspapers alike.

Brown, E. Richard. ​Rockefeller Medicine Men: Medicine and Capitalism in America​. Berkeley, CA: University of California Press, 1980.

Since its founding, the American Medical Association sought to reform medical education, and the Association's desire to overcome dissenting medical sects led to its role in creating the Flexner Report. Brown founded the UCLA Center for Health Policy

Bajaj 39 Research and was a professor of public health at UCLA. Brown's argument supports the view of the Flexner Report as American Medical Association propaganda as Flexner helped the Association enforce its singular view of health care by marginalizing the role of women and African Americans in medicine.

Burrow, James. ​Organized Medicine in the Progressive Era: The Move toward Monopoly.​ Baltimore, MD: Johns Hopkins University Press, 1977.

The American Medical Association sought to professionalize medicine to raise the income and status of its members, which also meant eliminating medical schools for dissenting medical sects. James Burrow is a historian and has published widely on the American Medical Association as well as other aspects of medical history. Burrow's book provides context for why the Association sought to reform medical education and why it used the Flexner Report as propaganda to achieve that goal.

"The Carnegie Foundation." ​New York State Journal of Medicine​ 10, no. 11 (November 1910): 483-484. Accessed April 4, 2020.

This primary source was written by the editorial department of one of the leading medical journals at the time following the publication of the Flexner Report. The journal article even commented on how Flexner did not give the American Medical Association's Council on Medical Education enough credit for its work. With this article, the ​New York State Journal of Medicine​ sought to attack the Carnegie Foundation for its elitist attitude towards medical education.

"The Carnegie Foundation Report on Medical Education." ​Journal of the American Medical Association​ LIV, no. 24 (June 11, 1910): 1948-1949. Accessed April 4, 2020. https://jamanetwork.com/journals/jama/article-abstract/432064.

This primary source from the ​Journal of the American Medical Association​ lauded praise on the Flexner Report while other journals attacked the report as hasty and not well-prepared. The editorial even commended the report as independent despite the American Medical Association working secretly with the Carnegie Foundation to produce this report. The purpose of this publication was to bolster the image of the Flexner Report among physicians so that it would have the intended effect of mobilizing public opinion in favor of the Association's program of medical education reform.

Chaillé, Stanford. "The Practice of Medicine as a Money-Making Occupation." ​New Orleans Medical and Surgical Journal​ 49, no. 11 (May 1897): 605-614. Accessed April 4, 2020. https://books.google.com/books?id=q-JDAQAAIAAJ&pg=PA605#v=onepage&q&f=fals e.

This primary source reflects how Chaillé viewed dissenting medical sects as a threat to the medical establishment. As the dean of Tulane University Medical School, a school that trained physicians in the allopathic tradition, Chaillé would have likely seen medical schools that taught homeopathy, osteopathy, etc. as competition to his institution.

Chaillé's purpose is likely to rally the medical establishment together in order to combat the growing influence of the dissenting medical sects.

Bajaj 40 Chesney, Alan. ​The Johns Hopkins Hospital and the Johns Hopkins University School of Medicine: A Chronicle.​ Vol. 3. Baltimore, MD: Johns Hopkins Press, 1963.

This primary source underscores how Chesney, dean emeritus of Johns Hopkins Medical School, praised Abraham Flexner in the decades immediately following his report.

Chesney seeks to acknowledge Flexner's immense impact in medical education in this book about the history of Johns Hopkins. As Johns Hopkins was the only medical school to be unequivocally praised in the Flexner Report, it is perhaps less surprising that Chesney would praise the impact of the Flexner Report.

"The Chicago Meeting of the Council and Legislative Committee of the A.M.A." ​The Journal of the American Institute of Homeopathy​ 2, no. 4 (April 1910): 247-248. Accessed April 4, 2020. https://books.google.com/books?id=DUlYAAAAMAAJ. This primary source reflects the belief of the homeopathic community that the American Medical Association sought to subjugate its practice of medicine. The Association and the homeopathic community were on two opposing sides on the debate of the future of medicine. The homeopathic community decried the Association's efforts to assert allopathic medicine because the homeopathic community wanted to ensure its survival.

Cobb, William. ​Medical Care and the Plight of the Negro.​ National Association for the Advancement of Colored People, 1947.

This primary source reflects the disparities between African American and white health care, stemming from unequal medical education: Howard Medical School and Meharry Medical College could not meet the needs of the black population. Cobb sought to bring public awareness about African American health care, showing, for instance, how African American mortality rates were much higher than white mortality rates. Cobb sought to emphasize the needs of the black community for black physicians and advocate for the inclusion of African American students in all medical schools.

"Collier's Weekly." June 11, 1910. Box 19. Flexner Papers. Library of Congress, Washington, DC. Quoted in Starr, Paul. ​The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry.​ Rev. ed. New York, NY: Basic Books, 2017.

This primary source indicates the importance of heterogeneity in medicine because poorer physicians served poorer populations. Writing in a magazine for the general population, the author implicitly charges that the Flexner Report deprived poor people of health care, coming from an elitist perspective. The author is not affiliated with one of the elite institutions Abraham Flexner had suggested remain open, so the author's institution was at risk of shutting down due to the Flexner Report, certainly informing his view.

Corner, George. ​Two Centuries of Medicine: A History of the School of Medicine, University of Pennsylvania​. Philadelphia, PA: J.B. Lippincott, 1965.

In the years that immediately followed Abraham Flexner’s death, Flexner was highly regarded by the historical community for his impactful contributions to medical

Bajaj 41 education. Medical historian and pioneering physician-scientist Dr. George Corner was the first professor of medicine at the University of Rochester. Corner’s writings about Flexner demonstrate how Flexner was, at least initially, universally admired for his work.

"The Economics of Medicine." ​New York State Journal of Medicine​ 9, no. 12 (December 1909): 481-483. Accessed April 4, 2020. https://archive.org/details/newyorkstatejour9190medi/page/481/mode/2up.

This primary source demonstrates the unhappiness doctors felt with the financials of medicine. In comparison to other white-collar professionals, doctors were not compensated enough, and this editorial from one of the nation's leading medical journals seeks to bring light and hopefully change to that matter. The American Medical Association sought to raise the status and thus financial compensation of medicine in the context of most doctors being unsatisfied with the economics of the profession.

“Summary of Reactions to the Flexner Report,” Charlotte Medical Journal, 1910. Quoted in Felts, John. "Abraham Flexner and Medical Education in North Carolina." ​North Carolina Medical Journal​ 56, no. 11 (November 1995): 534-540. Accessed April 4, 2020. https://dc.lib.unc.edu/cdm/compoundobject/collection/nchh/id/1054566/rec/51.

This primary source shows how various medical journals responded negatively to the Flexner Report, attacking Flexner's credentials as well as his acerbic writing style.

Flexner threatened the medical schools that many doctors had graduated from or were faculty at, so criticisms of his report included a personal bias. In the context of many medical journals, such as the ​Denver Medical Journal​ and the ​Hospital Bulletin,​ viciously attacking the Flexner Report, the ​Journal of the American Medical Association'​ s support of the Flexner Report is suggestive of collusion.

Flexner, Abraham. ​I Remember: The Autobiography of Abraham Flexner.​ New York, NY: Simon and Schuster, 1940.

This primary source represents Abraham Flexner's autobiography where he seeks to explain his contributions to medical education to the general public. Offering insights into his thinking while he was writing his famous report, he underemphasizes the impact of his report on marginalized groups in medicine and overemphasizes his independence while writing the report. Flexner perhaps seeks to cement his reputation at the center of medical education reform and preempt any criticism about his intentions.

———. ​Medical Education in the United States and Canada.​ New York City, NY, 1910.

Accessed April 4, 2020. http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf.

This primary source, the Flexner Report, sought to bring about medical education reform in a way that would professionalize medicine, being funded by the American Medical Association but conducted by the Carnegie Foundation. Flexner's vitriolic writing and emphasis on science helped this report appeal to the public consciousness, mobilizing support for eliminating for-profit proprietary medical schools. The Flexner Report served as an instrument for the American Medical Association to recreate medicine in its own image where middle- and upper-class white men reigned supreme.

Bajaj 42

Halperin, Edward, Jay Perman, and Emery Wilson. "Abraham Flexner of Kentucky, His Report, Medical Education in the United States and Canada, and the Historical Questions Raised by the Report." ​Academic Medicine​ 85, no. 2 (February 2010): 203-10. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/20107344.

Abraham Flexner was a pragmatist who focused on lifting the quality of United States medical education rather than accounting for the effects on historically black medical schools. Edward Halperin is the chancellor and CEO of New York Medical College, Jay Perman is the former chancellor for the University System of Maryland, and Emery Wilson is the former dean of the University of Kentucky. While they attempt to provide contextual cover for Flexner's actions, they also articulate how the Flexner Report institutionalized inequity in medicine and helped the AMA professionalize medicine.

Hiatt, Mark. "Around the Continent in 180 Days: The Controversial Journey of Abraham Flexner." ​Pharos​ 62, no. 1 (Winter 1999): 18-24.

Layman Abraham Flexner engaged in a rushed report, much to the irritation of most medical journals of the time. Flexner also acted as a pawn for the American Medical Association, which wanted to professionalize medicine. Mark Hiatt is a member of the Board of Directors of Myndshft, a health care technology company, and has published over 75 articles and book chapters. Hiatt's argument provides insight into how the American Medical Association engaged in collusion with the Carnegie Foundation to put out a less-than-ideal report that reiterated the Association's talking points.

Hudson, Robert. "Abraham Flexner in Perspective: American Medical Education 1865-1910."

Bulletin of the History of Medicine​ 46, no. 6 (November 1, 1972): 545-561. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/4572582.

Without any legal power, the American Medical Association had trouble bringing about reform until they reorganized in 1901, yet even then, the optics of a medical organization criticizing fellow doctors and medical schools meant that the Association had to be measured in its criticisms. Robert Hudson was a professor and the chairman of the history of medicine department at the University of Kansas. His publication explains why the American Medical Association sought out the Carnegie Foundation, an independent organization, to report on the state of medical education in the same fashion that the Association had already done.

Kanter, Steven, Victoria Groce, Beth Littleton, and Richard Gunderman. "Henry Pritchett and His Introduction to the Flexner Report of 1910." ​Academic Medicine​ 85, no. 11 (November 2010): 1777-1783. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/20881820.

Henry Pritchett played an important role in working with the American Medical Association on the Flexner Report, giving Abraham Flexner an outline of the report before Flexner even started surveying schools. Steven Kanter is dean of the University of Missouri-Kansas City; Victoria Groce and Beth Littleton were his research assistants when he was vice dean at the University of Pittsburgh. Richard Gunderman is a professor of medical humanities and health studies at Indiana University. Their argument reflects

Bajaj 43 how little Flexner contributed to the report that bears his name, being guided by the American Medical Association and Pritchett the entire time.

Ludmerer, Kenneth. "Commentary: Understanding the Flexner Report." ​Academic Medicine​ 85, no. 2 (February 2010): 193-96. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/20107341.

In accepting only a research-based medical school, Abraham Flexner, a layman tasked to create a report on medical education, left no room for most historically black medical schools. Professor Kenneth Ludmerer teaches history at Washington University St. Louis and has written a few critically acclaimed books on United States medical education.

Ludmerer's argument gives context to how the Flexner Report came about and indicates the Flexner's Report emphasis on research, which helped make it effective propaganda.

———. ​Learning to Heal: The Development of American Medical Education.​ New York: Basic Books, 1985.

The Carnegie Foundation was set up to determine pensions for college professors but was tasked by the reorganized American Medical Association to study medical education. The resulting Flexner Report was the pinnacle of using science and research to solve societal ills. Professor Kenneth Ludmerer teaches history at Washington University St. Louis and has written a few critically acclaimed books on United States medical education.

Ludmerer contextualizes the formation of the Flexner Report in the history of the Carnegie Foundation and the American Medical Association before emphasizing how the Flexner Report claimed science for itself in an era that worshiped science.

Markowitz, Gerald, and David Rosner. "Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine." ​American Quarterly​ 25, no. 1 (March 1973): 83-107. JSTOR. The American Medical Association sought to reform medical education to increase the compensation of physicians and to eliminate the influence of competing medical sects.

Gerald Markowitz is a professor of history at John Jay College of Criminal Justice while David Rosner is a professor of sociomedical sciences at Columbia. Their argument offers insight into the self-centered reasons why the American Medical Association wished to refashion medical education through the Flexner Report.

Memorandum, "Council on Medical Education, AMA Minutes of Meeting," December 28, 1908.

Minutes of the Business Meetings of the Council on Medical Education and Hospitals: 1907-1917. AMA Library, Chicago, IL. Quoted in Berliner, Howard. "New Light on the Flexner Report: Notes on the AMA-Carnegie Foundation Background." ​Bulletin of the History of Medicine​ 51, no. 4 (Winter 1977): 604-09. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/343847.

This primary source indicates the extent of the collusion between the American Medical Association and the Carnegie Foundation. The two organizations were in bed with one another, with the Association dictating what the Flexner Report would include and this collusion being kept a secret from the public. In the meeting minutes, Henry Pritchett and the Council on Medical Education were free to talk openly and honestly, however.

Bajaj 44

The New York Times​ (New York City, NY). "Abraham Flexner Is Dead at 92; Revolutionized Medical Schools." September 22, 1959. Accessed April 4, 2020. https://timesmachine.nytimes.com/timesmachine/1959/09/22/issue.html.

This primary source is an obituary remembering Abraham Flexner after his 1959 death.

The simple fact that the ​New York Times​ wrote about Flexner's death serves as evidence of the immense respect Flexner commanded among the American public. Seeking to secure Flexner's legacy, the editorial team showered Flexner with praise because of his work in reforming medical education.

The New York Times​ (New York City, NY). "Factories for the Making of Ignorant Doctors: Carnegie Foundation's Startling Report that Incompetent Physicians Are Manufactured

by Wholesale in This Country." July 24, 1910. Accessed April 4, 2020. https://www.newspapers.com/image/20522706/.

This primary source reflects the immense impact the Flexner Report had on capturing the national media. An entire front-page dedicated to the Flexner Report from one of the nation's most esteemed newspapers demonstrates how effective the Flexner Report was at starting the national conversation around medical education reform. ​The New York Times may have quoted Flexner's acerbic writing in its headline to shock the public.

Pritchett, Henry. Letter to Arthur Bevan, November 4, 1909. Carnegie Foundation Archives, New York City, NY. Quoted in Berliner, Howard. "New Light on the Flexner Report: Notes on the AMA-Carnegie Foundation Background." ​Bulletin of the History of Medicine​ 51, no. 4 (Winter 1977): 604-609. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/343847.

This primary source indicates the extent of the collusion between the American Medical Association and the Carnegie Foundation. The two organizations were in bed with one another, with Pritchett noting how the Carnegie Foundation was simply reiterating what the Association had already done. In this personal letter, Henry Pritchett felt free to talk openly and honestly about working hand-in-hand with Arthur Bevan, director of the Council on Medical Education.

Pusey, William. "The Disappearance of Doctors from Small Towns." ​Journal of the American Medical Association​ 88, no. 7 (February 12, 1927): 505-506. Accessed April 4, 2020. https://jamanetwork.com/journals/jama/article-abstract/245302.

This primary source reflects how William Pusey, president of the American Medical Association, negatively viewed how medicine was becoming increasingly expensive.

Pusey's main drive during his tenure as president was combating the growing costs of medical education, which made the medical profession more exclusive. This viewpoint was relatively rare within the American Medical Association because the Association-funded Flexner Report had just professionalized medicine by essentially excluding the working classes from a medical education.

Bajaj 45 Report of the Council on Medical Education​. 1907. Accessed April 4, 2020. https://ama.nmtvault.com/jsp/viewer.jsp?doc_id=ama_arch%2FHOD00003%2F0000002 5.

This primary source contains the Council on Medical Education's own internal findings when it came to medical education reform. The report was presented only at the American Medical Association annual meeting and distributed to state licensing boards.

While the report seeks to extol the important traits of medical schools and the importance of reform, its recommendations are quite measured in that they advocate for helping better poor schools in lieu of closing them down.

San Francisco Examiner​ (San Francisco, CA). "Three-quarters of Doctors 'Quacks': Scientific Inquiry by Carnegie Foundation Finds Almost All Are Illy Trained. Schools Many and Poor: Nation Has Four Times the Physicians It Needs; Noted Institutions Blacklisted."

June 6, 1910. Accessed April 4, 2020. https://www.newspapers.com/image/457663517/.

This primary source demonstrates how newspapers from around the nation, even in California which only had a handful of medical schools at the time, were involved in covering the Flexner Report. The headline attempts to highlight the most damaging findings of the Flexner Report, perhaps to encourage readers to buy the edition. The ​San Francisco Examiner​ offers a representation of the Flexner Report’s media coverage, capturing local and national newspapers alike.

Schudson, Michael. "The Flexner Report and the Reed Report: Notes on the History of Professional Education in the United States." ​Social Science Quarterly​ 55, no. 2 (September 1, 1974): 347-361. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/11630484.

In 1920, ten years after the Flexner Report was published, the number of medical schools in the nation had dropped to 79 from the 155 Abraham Flexner had studied. Michael Schudson is a professor of journalism at Columbia University and has been a Guggenheim Fellow as well as a MacArthur Fellow. Schudson's publication quantifies the demise of medical schools in the years that followed the Flexner Report, helping assess the impact of this seminal paper in medical education.

Simmons, George. "Medical Education and Preliminary Requirements." ​Journal of the American Medical Association​ 42, no. 19 (May 7, 1904): 1205-1210. Accessed April 4, 2020. https://jamanetwork.com/journals/jama/fullarticle/459082.

This primary source from the editor of the ​Journal of the American Medical Association reveals Simmons' thoughts regarding medical education reform. He wanted to professionalize the field because he saw medicine as overly crowded with physicians, leading to vicious competition and poor compensation. As the American Medical Association had little legal power in 1904, articles like this were the primary means through which the Association tried to exhort medical schools to reform.

Starr, Paul. ​The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry​. Rev. ed. New York, NY: Basic Books, 2017.

Bajaj 46 Advocating for a one-size-fits-all medical school, Abraham Flexner not only made medicine a profession for the wealthy but also, as a result, made medicine only readily accessible to the wealthy. Paul Starr is a professor of sociology and public affairs at Princeton, writing frequently about medicine and health care. Contextualized with the American Medical Association's goal of professionalizing medicine, Starr's argument explains how the physician shortage increased the exclusivity of physicians, pricing patients out of having health care.

Steinecke, Ann, and Charles Terrell. "Progress for Whose Future? The Impact of the Flexner Report on Medical Education for Racial and Ethnic Minority Physicians in the United States." ​Academic Medicine​ 85, no. 2 (February 2010): 236-245. Accessed April 4, 2020. https://www.ncbi.nlm.nih.gov/pubmed/20107348.

Flexner's report helped structuralize inequity in medicine because his willingness to accept only a university-affiliated, non-profit medical school with high admission standards led to the closure of most historically black medical schools. Ann Steinecke is a senior director at the Association of American Medical Colleges, specializing in academic affairs, and Charles Terrell was the chief diversity officer at the Association of American Medical Colleges. They provide insight into how Abraham Flexner did not make provisions for African American medical schools, arguing that Flexner was more obsessed with the overall goal of transforming United States medical education, his primary task from the American Medical Association.

Stevens, Rosemary. ​American Medicine and the Public Interest​. Updated ed. Berkeley, CA: University of California Press, 1998.

Claiming medicine as a public service but privately advocating for a goal of scientific excellence and exclusivity, the American Medical Association was more concerned with professionalizing medicine than with improving access to medicine for the public.

Rosemary Stevens is a professor of the history and sociology of science at the University of Pennsylvania. Stevens' argument helps explain the self-centered rationale for why the Association wanted to reform medical education.

Ward, Thomas J. ​Black Physicians in the Jim Crow South.​ Fayetteville: University of Arkansas Press, 2010.

There were numerous parallels between the American Medical Association's previous reports on medical education and the Flexner Report, both of which sought to professionalize medicine through eliminating medical education for women, African Americans, and the working class. Professor Thomas Ward is the chair of the history department at Spring Hill College and has written numerous books, journal articles, and encyclopedic entries on the intersection of health and race in the United States. Ward's argument suggests that Flexner failed to account for the context in which schools for underrepresented populations arose, giving recommendations that ensured their demise in line with the American Medical Association's singular view of medicine.

The Washington Post​ (Washington, DC). "Too Many Physicians: Carnegie Foundation Assails Medical Colleges. Would Abolish Majority: Investigator Arraigns Large Number of

Bajaj 47 Institutions for Tinning out 'A Host of Poorly Educated and Ill Trained' Medicos -- Called a 'Menace to the Country' -- Chicago 'Plague Spot.'" June 7, 1910. Accessed April 4, 2020. https://www.newspapers.com/image/28830414/.

This primary source reflects the immense impact the Flexner Report had on capturing the national media. ​The Washington Post​ put out this article within days of the Flexner Report being published to report to the public this shocking take on American medical education. ​The Washington Post​ offers a representation of the Flexner Report’s media coverage, capturing local and national newspapers alike.

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