Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Academia Gets Its Share of Blame

In 1910, Abraham Flexner produced a book-long report on reforming medical education, under the sponsorship of the American Medical Association and the funding of the Carnegie Institution. The report was a product of the progressive era of reform which ended the Gilded Age, and can fairly be described as the handbook of a revolution in American medicine. The book had an impact on closing 106 of the 160 medical schools in the United States and Canada. To Flexner that was a disappointment; he thought only 31 were worth saving. To be a good doctor, in his opinion, required between six and eight years of scientific training. The quality of student, as well as the quality of schools, was important, justifying a vast shrinkage of the student body. He liked research and unleashed an avalanche of medical research which subsequently transformed medical care in a hundred ways.

Having said all that, it must be acknowledged, Abe Flexner had been educated in Germany, and his efforts mainly crystallized the transfer of German academic medicine to America, and from here onward to the world. What's being acknowledged is that for a time, German Medicine was far ahead of us, in an environment where we aspired to be the leaders.

Flexner was a charismatic figure, supported by American Medical Association reports from its Council of Medical Education, the wealth of the Carnegie Institution, and the enormous resources of the Rockefeller Foundation. American academic medicine pointed to the example of the Johns Hopkins Medical School, formed before the ferment of pre-World War I, and now being given prominence by Teddy Roosevelt, Woodrow Wilson and the rest of the muckraking era who aspired to replace the Gilded Age with something better. America was aching to take charge of something, had great gobs of philanthropic money at its disposal, and the wind in its sails. Abraham Flexner was a towering figure, all right, but he was not a physician, an academic, or a scientist. He was more the agent of revolution than its originator, ending up as the patron saint of several political factions, individually fighting academic wars with each other. He was, in short, a rain-maker.

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Abe Flexner, the Rainmaker {bottom quote}
German Model for Medical Schools

Abe Flexner and his book aimed to reduce the number of medical schools from 160 to 31, demanding the survivors look like German schools. This was not so strange; like Japan and China today competing with America, Flexner wanted to compete with Germany more than he wanted to worship it. The students of his dreams were required to be college graduates, the curriculum was to be four years along with two years of science followed by two years of hands-on learning. If the school could afford it, the professors would be on a full-time salary, free of any need to practice in order to make a living. On this last point, many begs to differ, arguing you have to get on a boat to learn how to sail one. There were many echoes of the ferment to come, in the upheavals of the 1960s, and the Humboldt's University of Berlin was the source of quite a few, in both cases.

Immediately there arose a town-and-gown competition. The gown group had the point they could afford the time to do some research. The town group had the point you couldn't teach doctors if you weren't one, yourself. The distinction is probably best understood by comparing medical students with law students. Both were originally taught by practitioners; schools were late arrivals. Many lawyers have remarked that a law school graduate now knows almost nothing about the practice of law until he joins a firm which teaches it to him. A medical student (post-Flexner) can do a pretty good job with most medical problems, the day he graduates. The practicing physicians have retreated into specialty training; a doctor has trouble becoming a specialist if he didn't have the right residency. The rest of the awe-inspiring march of medical progress in the Twentieth century, is the consequence of pouring unbelievable amounts of money into the system, thereby attracting a glittering array of talented medical students. Some of the talents are unbelievable. My own medical school, as an example, has a symphony orchestra made up of students in their spare time, performing on a truly professional level for their own amusement. In a sense, all of this was due to Flexner. In another sense, Flexner himself had little to do with originating it.

Now, forget the yellow journalism, or muckraking, quality of what I am about to relate. A book was recently published relating that a particular medical school was able to support its operations without touching a penny of medical student tuition for ten consecutive years. Instead, the tuition money was transferred to the University's undergraduate schools, and the medical school subsisted on research and other funds. The undergraduates continue to protest about rich doctors, while the medical students complain about going a hundred thousand into debt -- to pay their tuition. But forget that part. The most undesirable situation it reflects is that for ten years, the school was totally able to exclude any parent and student influence in an area that unfortunately has a growing power over events, the school's finances. If the students, families, and alumni of a university have no power to influence its decisions, who do have such power?

Originally published: Sunday, April 12, 2015; most-recently modified: Sunday, July 21, 2019