Daily MOS: Lights and Shadows of the Flexner Report

image source: aamc.com

How would you imagine modern medical education took shape? Lots of meetings and committees? The brightest minds in medicine arguing over foundational courses? Deliberating the split between hours of residency and hours spent crying over the mountain of debt?

Nah. It was like one dude with half a masters degree.

Today’s Moment of Science… the Flexner Report.

In colonial and early American history, medical school was more like medical apprenticeship. You’d learn from the last guy who’d learn from the guy before him, and eventually you passed your kit of leeches and cocaine onto the next guy. Medical schools of various stripes started forming in the late 1700s. The shift from an apprentice system to a formalized academic one was all but glacial.

There were 13 medical schools by 1820 in the US. Apprenticeships were often expanded to three years to include theoretical studies. By the late 1800s though, the number of medical schools had exploded. Standards from one school to the next were nonexistent.

The American Medical Association (AMA) was formed in 1847, remaining somewhat toothless until the turn of the century. At that point, they incorporated and set the most basic of guidelines for educational requirements. They were good, but they lacked detail. How should a school educate someone so the AMA would agree they were a doctor? Who was to say what that education looked like?

Abraham Flexner, apparently.

An innovative educator who became wealthy running a private school, he wrote the book The American College. The president of the Carnegie Foundation fucking loved the book. The foundation was funding the AMA’s research into the state of medical education. By coincidence, I’m sure, Flexner was hand-picked for this research and sent out to inspect all 155 medical schools in operation in the US at the time.

He stepped foot into medical school for the first time in order to tell them how to run it.

The idea of sending in someone with an educational background wasn’t without merit; they saw the issue as one of educational standards, not medical or scientific knowhow. But also, it was a matter of confirmation bias; Flexner’s ideas were what they already wanted to implement. So when the Flexner Report shook things up in 1910, Flexner was really just the outside guy who came in to play the heavy.

Some of the ideas are so enshrined in medical education now that it’s odd to think that someone had to recommend any of it. Have a set amount of undergraduate science education before medical school. Practice medicine using the scientific method. Implement state licensure for doctors. Groundbreaking shit, Flex.

His recommendations went beyond telling some mainstream medical schools to straighten up and fly right. Which, yeah, some of them totally had to do. Other fields reformed entirely. Osteopathy was less than reputable at the time. But rather than scream that bone manipulations were the only cure for your health, the osteopaths said “idk, let’s try science?” They got some of their schools completely in line with the new standards. A doctor graduating with a DO in the US today has virtually indistinguishable training from an MD.

Medicine still kinda sucked at the time though, so it’s not a surprise that the science based stuff had competition- sometimes in house- from utter lunacy. Homeopathy, naturopathy, magnetic therapy, eclectic medicine, and my personal favorite, chiropractic? Sure, keep teaching it, but the AMA wouldn’t call your graduates ‘doctors’ anymore. So.

The Flexner Report reformed medicine and undeniably made the curriculum more rigorous, consistent, and based in science. Ideas from the report are still foundational to medical education today.

But he was just one dude a hundred years ago with, perhaps, a more than standard share of shit for brains.

At the time, only seven schools accepted and educated Black doctors. In the wake of the Flexner Report, five of them were closed.

He suggested that Black doctors should only work on Black patients, their education should be limited to hygienic matters as opposed to surgery, and that they were to be subservient to white doctors. He also stated that they were educating Black people not just for their own sake, but because Black people were infected with diseases and by educating Black doctors, they could protect the white people.

That racist little pissant preferred bullhorns to dog whistles.

At the start of his research, there were 155 medical schools in the US. After the hack and slash campaign was through, we were down to 66. It took decades before mainstream medical schools were desegregated. The percentage of Black doctors and other people of color in medicine has made slow progress pushing against the outsized influence of the Flexner Report.

For better and for worse, the effects of one guy with half a masters degree is still being felt in medicine to this day.

This has been your daily Moment of Science, wondering how many things in history one guy with an idea fucked up for absolutely everyone for a goddamn century.

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About SciBabe 375 Articles
Yvette d'Entremont, aka SciBabe, is a chemist and writer living in North Hollywood with her roommate, their pack of dogs, and one SciKitten. She bakes a mean gluten free chocolate chip cookie and likes glitter more than is considered healthy for a woman past the age of seven.

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