Commentary

Commentary: Understanding the Flexner ReportKenneth M. Ludmerer, MD

Abstract

In this commentary, the author discussesmedical education reform beforeAbraham Flexners 1910 report, MedicalEducation in the United States andCanada, the reforms for which Flexnercampaigned, and the reports impact onthe future of the discipline. To honorFlexners contributions to medicaleducation, the author then exposes themyths that surround Flexners ideals and

accomplishments 100 years later. Theauthor argues that Flexners achievementlies in how he transformed medicaleducation reform into a broad socialmovement, aligning it with John Deweyspopular progressive educationmovement, and in how Flexnersucceeded in establishing the universitymodel as the standard for all medicalschools. The author also argues that

Flexner, at the most fundamental level,stood for academic excellence and publicservice in medical education. Thisdedication, the author argues, isFlexners greatest legacy and acommitment that should continue toshape the future of the discipline.

Acad Med. 2010; 85:193196.

No individual has been more closelyidentified with American medicaleducation than Abraham Flexner. In1910, he wrote Medical Education in theUnited States and Canada,1 the famousmuckraking report for the CarnegieFoundation for the Advancement ofTeaching. This report put forth the JohnsHopkins University School of Medicineas the ideal of what a medical schoolshould look like. After publication of thereport, Flexner became the unchallengedarbiter of educational reform in Americaand helped create a system that eventoday is associated with his name.

Yet for nearly a century, Flexner hasbeen misunderstood. Regularly, he isboth credited and blamed for things hedid not do, and some of his greatestcontributions remain unappreciated.This commentary will shatter themythology surrounding the man anddescribe what his accomplishments infact were. In my view, Flexners role asthe most prominent medical educatorAmerica has ever produced remainssecure. However, his memory will behonored more fully by an accurateunderstanding of his ideals andaccomplishments.

American Medical Education Priorto the Flexner Report

In the mid-19th century, the notoriousproprietary school model reigned as thedominant vehicle for medical instructionin America.2 The typical medical schoolwas owned by a small faculty of 8 or 10who operated the institution for profitand measured its success with financialresults, hence the term proprietaryschool. Entrance requirements werenonexistent, and the courses taught weresuperficial and brief. The typical path to amedical degree consisted of two 16-weeksets of lectures, the second term identicalto the first term. Instruction was almostwholly didactic, including lectures,textbook readings, and enforcedmemorization of the innumerable facts.Laboratory and clinical work were not tobe found. The schools were not affiliatedwith universities nor were the facultyinvolved in research activity.

Yet in the mid-19th century, a revolutionin American medical education wasalready under way. This revolution beganamid the birth of experimental medicinein Europe and the migration of Americanmedical graduates to France3 andGermany4 to acquire the latest scientificknowledge and, more important, anunderstanding of scientific methodologyand technique. In the 1870s, the firstlasting reform occurred as HarvardMedical School, the University ofPennsylvania School of Medicine, and theUniversity of Michigan Medical Schoolextended their course of study to threeyears, added new scientific subjects to thecurriculum, required laboratory work ofeach student, and began hiring full-time

medical scientists to the faculty. In 1893,the Johns Hopkins University School ofMedicine opened, immediately becomingthe model by which all other medicalschools were measured. There, a collegedegree was required for admission, afour-year curriculum with nine-monthterms was adopted, classes were small,students were frequently tested, thelaboratory and the clerkship were theprimary teaching devices, and a brilliantmedical faculty made medical research aswell as medical teaching part of itsmission. In the 1880s and 1890s, medicalschools across the country started toemulate these pioneers, and a vigorouscampaign to reform American medicaleducation began. By the turn of thecentury, the university medical schoolhad become the acknowledged ideal, andproprietary schools were already closingbecause of the lack of applicants.

At the heart of the transformation ofAmerican medical education was arevolution in ideas concerning thepurpose and methods of medicaleducation. After the Civil War, medicaleducators began rejecting thetraditional notion that medicaleducation should inculcate factsthrough rote memorization. The newobjective of medical education becamethat of producing problem solvers andcritical thinkers who knew how todiscover and evaluate information forthemselves. To achieve this goal,medical educators deemphasizedtraditional didactic teaching methodslectures and textbooksand beganspeaking of the importance of self-education and learning by doing.

Dr. Ludmerer is professor, Department ofMedicine, Washington University School of Medicinein St. Louis, St. Louis, Missouri.

Correspondence should be addressed to Dr.Ludmerer, Washington University School of MedicineCampus Box 8066, 660 South Euclid Avenue, St.Louis, MO 63110; telephone: (314) 362-8073; fax:(314) 362-8015; e-mail: kludmere@dom.wustl.edu.

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Through laboratories and clinicalclerkships, students were to be activeparticipants in their learning, ratherthan passive observers. A generationbefore John Dewey, medical educatorswere espousing the ideas of what latercame to be called progressiveeducation.

Learning by doing greatly increased thedemands on medical schools, for the newteaching methods were extremely costlyto implement. Thus, this intellectualrevolution gave rise to an institutionalrevolution. The proprietary medicalschool model was abandoned, and theuniversity medical school standard wascreated. Funds were raised, newlaboratories and facilities were built,clinical facilities were acquired, andfull-time faculty members interested inresearch were hired. Medical schools,which had existed as autonomousinstitutions during the proprietary era,began to establish close affiliations withuniversities and hospitals.

In the early 1900s, however, much workremained to be done. The chiefproblem was that medical schoolslacked the funds and clinical facilitiesto implement fully their new ideas ofhow to teach medicine. For lack ofresources, desired reforms often wentundone. It was unclear whether furtherdevelopment would continue along thesame gradual, evolutionary path thathad been occurring since the middle ofthe previous century or whether moreradical, dramatic changes were to come.It was also unclear what form theinstitutional structure of Americanmedical education would ultimatelyassume. Should there be one uniformstandard of excellence for all schools, orwould it be acceptable to have differenttiers of medical schools, each with itsown mission and standards? Shouldresearch be conducted at all schools, orshould there be a group of practicalschools that concentrated on goodteaching rather than investigation?Must all schools be university affiliated,or could a school of independent statusstill function effectively? There were avariety of fiercely competing modelsof how best to conduct medicaleducation, each of which hadresponsible advocates. This was thesetting for the Flexner Report.

The Flexner Report

How Flexner came to the attentionof the Carnegie Foundation for theAdvancement of Teaching is not known.Flexner himself was surprised by therequest, thinking perhaps that HenryPritchett, president of the CarnegieFoundation, had confused him with hisyounger brother Simon, director of theRockefeller Institute for MedicalResearch. Pritchett possibly learned ofAbraham Flexner through his first book,The American College, which appeared in1908 and was a criticism of the lectureand elective system of Americanuniversities. Flexner, theretofore anobscure educator and former headmasterof a private high school in Louisville,became a powerful spokesperson formodern methods of medical teaching anda very loyal friend to academic medicine.

It is well known that during hisinvestigation, Flexner was coached by hisbrother Simon, William Welch of JohnsHopkins, and members of the AmericanMedical Associations Council onMedical Education. However, it is notwell known that Flexner had alreadydeveloped a sophisticated educationalphilosophy that emphasized theimportance of experiential learning(learning by doing) at every level ofstudy. It is also not well known thatFlexner began his study with theconviction that universities andprofessional schools had the duty topromote original investigation, notmerely to teach. Flexner had developedthese ideas from his experiences as acollege student at the Johns HopkinsUniversity, where he was profoundlyinfluenced by Daniel Coit Gilman, thefirst president of the university, and byhis study of educational theory.5,6 Thus,Flexners conceptual framework hadalready been developed before joining theCarnegie Foundation. Welch and theothers merely provided the details as theypertained to medicine.

After visiting each of the 155 medicalschools in the United States and Canada,Flexner prepared his report. The resultingdocument published in 1910 is regularlycited for its caustically entertainingdescriptions of the weaker medicalschools, particularly those proprietaryschools that had not yet closed. However,the lasting significance of the report liesin Flexners discussions of the principlesof modern medical education. This part

of the report remains the most notabletheoretical discussion of medicaleducation ever written.

Flexners views on medical education

A detailed analysis of the full report hasbeen provided elsewhere.2 However, it isimportant here to summarize the maincomponents of Flexners educational views.

Medical positivism. Flexner describedmedicine as an experimental disciplinegoverned by the laws of general biology.It [the human body] is put together oftissues and organs, in their structure,origin and development not essentiallyunlike what the biologist is otherwisefamiliar with; it grows, reproduces itself,decays, according to general laws.1(p53)

Rigorous entrance requirements. Sincethe preclinical courses of medical schoolwere sciences at the second, not theprimary, stage,1(p24) medical schoolsneeded to establish and enforce entrancerequirements. At minimum, these shouldconsist of two years of college withpreparation in biology, chemistry, andphysics. A medical school, Flexner wrote,cannot provide laboratory and bedsideinstruction on the one hand, and admitcrude, untrained boys on the other.1(p22)

The scientific method. Flexner pointedout that the scientific method of thinkingapplied to medical practice. By scientificmethod, he meant the testing of ideasby well-planned experiments in whichaccurate facts were carefully obtained.The clinicians diagnosis was equivalentto the scientists hypothesis; bothdiagnosis and hypothesis needed to besubmitted to the test of an experiment.The practicing physician and thetheoretical scientists are thus engaged indoing the same sort of thing, even whileone is seeking to correct Mr. Smithsdigestive aberration and the other tolocalize the cerebral functions of thefrog.1(p92) Flexner argued that mastery ofthe scientific method of problem solvingwas the key for physicians to managemedical uncertainty and to practice in themost cost-effective way.

Learning by doing. There was but onereliable way for students to learn bothmedical facts and the scientific methodof thinkingto spend most of their timein the laboratory and clinic rather than inthe amphitheater. On the pedagogicside, he wrote, modern medicine, like

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all scientific teaching, is characterizedby activity. The student no longermerely watches, listens, memorizes; hedoes.1(p53) Flexners scorn for didacticinstruction pervaded the report.

Original research. Original research wasa core activity at Flexners model medicalschool. Research, untrammeled by nearreference to practical ends, will go on inevery properly organized medical school;its critical method will dominate allteaching whatsoever.1(p59) Flexner sawresearch as critical, not only for the newknowledge that would be produced butalso for the stimulation, excitement, andcritical rigor that research would bring toteaching. To Flexner, the best teacherswere usually men of active, progressivetemper engaged in research; thoseuninterested in solving problems tendedto be perfunctory teachers.1(p56) Thus,his ideal medical school had to be part ofa vigorous university with a large staff offull-time professors, in the clinical as wellas scientific departments.

How to develop the proper system ofmedical schools

Flexner recommended a drasticreduction in the number of schools in theUnited States and Canada from 155 to 31.Only a few schools should be retained;the vast majority should be eliminated,either through extermination orconsolidation into stronger units. Allsurviving schools would be of one typeuniversity schools committed to medicalresearch and academic excellence.

Flexner recognized that medical schoolscould be first-rate only if they were wellfunded. Accordingly, the subject ofobtaining strong financial support andmodern laboratories and hospitalfacilities received detailed andimpassioned discussion in his report. Healso defined medical schools as publictruststhat is, as public servicecorporations to be run for the benefit ofsociety, not private businesses to beoperated for the profit of theirstockholders. What made the commercialschools so despicable to him was thatthey placed their owners interests abovethe interests of the public. Flexnersindignation and moral outrage, coupledwith his sensational journalistic style,made the report an elegant example ofProgressive Era muckraking journalism.

Significance of the FlexnerReport

Conceptually, the Flexner Report saidnothing new about how physiciansshould be trained. Everything in it hadbeen said by academically inclinedmedical educators since the 1870s.However, the report brought concernsabout medical education to generalattention that previously had been voicedonly within the medical profession. Ittransformed the professions effort toreform medical education into a broadsocial movement similar to otherreform movements of Progressive EraAmerica. There is little doubt that theextraordinary development of medicaleducation that occurred in the yearsimmediately following the report wouldhave occurred without this catalyst.

Though Flexners discussion containedno new educational ideas, he did what nomedical educator had done before herelated the discussion of medicaleducation to the discussion of publiceducation. Flexner, who had studiedphilosophy and psychology for theirrelevance to educational matters, hadbecome familiar with the work of JohnDewey, the famous educationalphilosopher. He understood that Deweywas advocating the same approach toelementary teaching as medical educatorswere promoting for medical teaching. AsFlexner described the modern principlesof medical learning, he cited Dewey as hisultimate authority. Flexner thusdemonstrated the unity in viewpointbetween medical educators and JohnDewey. He realized that progressiveeducation involved concepts that weregeneralizable to all educational levels.2

The greatest significance of the FlexnerReport was its impact on shaping themedical school as an institution. Flexnerespoused a model system of medicaleducation in which all schools were to beof the same kind university-based,research-oriented schools patternedafter the Johns Hopkins UniversitySchool of Medicine. Only the mostuncompromisingly academic model for amedical school was acceptable to him.There was no room in his system forpractical, non-research-based schools,even if they happened to providerespectable teaching. This is precisely thesystem that was ultimately created, andmedical schools soon became much morehomogeneous than before. Herein lies

Flexners most important influence onthe subsequent course of medicaleducation in the country.

Two years after the report, Flexnersnewfound fame catapulted him into theposition of assistant secretary, and latersecretary, of John D. Rockefellersmammoth foundation, the GeneralEducation Board. In this capacity, hechanneled tens of millions of dollars ofRockefeller money into medical schoolsin an attempt to implement his vision ofmedical education, and he persuadedother philanthropists to support medicaleducation as well. In his report, Flexnerdescribed in great detail the financialneeds of scientific medical schools. Hespent much of the rest of his life helpingto solve the problem of funding this new,expensive system of medical education,becoming academic medicines greatestfund-raiser.

Dispelling Myths About theFlexner Report

Myths concerning Abraham Flexnerabound. The most common myth is thatlittle or nothing had happened inAmerican medical education untilFlexner arrived on the scene. Accordingto this myth, Flexner, in one swoop,pulled antiquated medical schools,kicking and screaming in resistance, intothe 20th century. Ironically, scholars forover a generation have been trying todispel this myth. They have pointed outthat the Flexner Report represented apoint along a continuum of developmentand that the report had been preceded foryears by considerable strengthening ofthe schools.2 Nevertheless, the myth haspersisted. Physicians, educators, medicalschool administrators, university officials,foundation officers, and others continueto popularize the fiction that little hadtranspired in medical education untilFlexner, in one stunning blow,modernized an anachronistic system.This myth deserves, once and for all, tobe dispelled.

The report itself has frequently beenmisunderstood. Because of its strongemphasis on scientific medicine, it hasoften been accused of ignoring thedoctorpatient relationship and thehumane aspects of medical care. Exactlythe opposite was the case. Science,Flexner wrote, was inadequate toprovide the basis of professional practice.

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The practitioner needs insight andsympathy, and here specific preparationis much more difficult.1(p26) In lateryears, Flexner felt that the medical coursehad become overwhelmed with science tothe exclusion of the humanistic aspect ofmedicine, and he seemed frustrated thatsuch a system of medical education hadcome to be identified with his name.He wrote in 1925, Scientific medicinein Americayoung, vigorous andpositivisticis today sadly deficient incultural and philosophicalbackground.7(p18)

Another common misperception is thatthe report denigrates the importance ofpreventive medicine. According toFlexner, doctors must remember thatdirectly or indirectly, disease has beenfound to depend largely on unpropitiousenvironment. These conditionsa badwater supply, defective drainage, impurefood, unfavorable occupationalsurroundingsare matters for socialregulation, and doctors have the dutyto promote social conditions thatconduce to physical well-being.1(pp67 68)

Flexner maintained that the physiciansfunction is fast becoming social andpreventive, rather than individual andcurative.1(p26)

Many have faulted the Flexner Reportfor fostering a crowded, inflexiblecurriculum. Here again, the criticismshave resulted from a misunderstanding ofwhat Flexner actually wrote. In discussingthe medical school curriculum, Flexnerdecried the absurd overcrowdingproduced by 4,000 hours of prescribedwork. He warned medical educatorsagainst too much rigidity. Medicalschools, he argued, must be trusted witha certain amount of discretion.1(p76) Hebelieved that the endeavor to improvemedical education through iron-cladprescription of curriculum or hours is awholly mistaken effort.1(p76)

Contrary to widespread popular opinion,the Flexner Report was not envisioned byits author as a final document. Thissolution, he wrote, deals only withthe present and the near future,ageneration, at most. In the course of thenext thirty years needs will develop ofwhich we here take no account. As wecannot foretell them, we shall notendeavor to meet them.1(p143) The

report thus contained much moreflexibility than commonly supposed. Itrecognized that academic medical centerswould need to change as the demandson them changed. Flexners specificproposals were designed only to addressthe problems immediately at hand.

Flexners Legacy

It is impossible to deduce from the reportor his other writings what Flexner wouldsay about the opportunities andchallenges in medical education today.Too much has changed. His focus wasundergraduate medical education and theeducation of general practitioners. Today,trainees spend more time in residencyand fellowship programs than in medicalschool, and specialization has proceededto a degree that would have flabbergastedhim. Flexner constructed an educationalsolution to address the problems posedby acute diseases. Todays challengesresult predominantly from chronicdiseases. Flexner could not have foreseenthe strains that would develop betweenteaching and research, the enormousgrowth of academic medical centersfollowing World War II, the more recentexpansion of the clinical enterprise atmedical schools (and with it the blurringof traditional distinctions betweenacademic medicine and private practice),the emergence of the computer andInternet, and cultural changes thatpromote shorter work hours and lessindependence for trainees. Nor wasFlexner concerned about health caredelivery. In all his writings, he neverwrote a single word on the subject. Heundoubtedly would be dumbfounded bythe possibility of an implosion of thehealth care delivery system, even as thepower and sophistication of medicalpractice have reached unprecedentedheights.

Yet it is certain that Flexner would be atthe vanguard of efforts to reformmedical education today. As hediscussed in his report, medicaleducation is destined to change. Hecharged each generation of medicaleducators with the task of adaptingmedical education to evolvingscientific, professional, and culturalcircumstances. To Flexner, noeducational idea should ever be

considered off limits for review, noeducational strategy or approach toosacrosanct to revise or discard. Heundoubtedly would be disappointedto find so many of his specificrecommendations still current acentury later, even though todaysphysicians face scientific and socialconditions far different from those ofhis own generation.

Flexner would also counsel caution inhow we go about reforming medicaleducation. He would consider any changejustifiable, as long as it fostered excellenceand served the public interest. Hechampioned the highest possibleacademic standards; he detestedmediocrity. He was uncompromising inhis view that medicine is a public trustand that the profession and itseducational system exist to serve. Thesevalues, he argued, are timeless, regardlessof the professional and socialcircumstances of the moment. By andlarge, medical educators since his timehave taken this message to heart. Wecertainly have done our best work inpursuit of this goal. An unswervingcommitment to excellence and servicethis was and continues to be Flexners giftto medical education and the medicalprofession.

Funding/Support: This essay was funded in partby the Josiah Macy, Jr. Foundation.

Other disclosures: None.

Ethical approval: Not applicable.

References1 Flexner A. Medical Education in the United

States and Canada: A Report to the CarnegieFoundation for the Advancement of Teaching.Bulletin No. 4. Boston, Mass: Updyke; 1910.

2 Ludmerer K. Learning to Heal: TheDevelopment of American Medical Education.New York, NY: Basic Books; 1985.

3 Warner JH. Against the Spirit of the System:The French Impulse in Nineteenth-CenturyAmerican Medicine. Baltimore, Md: The JohnsHopkins University Press; 1998.

4 Bonner TN. American Doctors and GermanUniversities: A Chapter in InternationalIntellectual Relations, 1870 1914. Lincoln,Neb: University of Nebraska Press; 1963.

5 Bonner TN. Iconoclast: Abraham Flexner anda Life in Learning. Baltimore, Md: The JohnsHopkins University Press; 2002.

6 Flexner A. I Remember: The Autobiography ofAbraham Flexner. New York, NY: Simon andSchuster; 1940.

7 Flexner A. Medicine: A Comparative Study.New York, NY: Macmillan; 1925.

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