13 The Flexner Report

The 1910 Flexner Report is credited by many as responsible for putting in place a science-based foundation for medical training in the United States. Abraham Flexner was a former schoolteacher and student of educational philosophy, very heavily influenced by German approaches to medical education, that required physicians to be trained as laboratory scientists before entering the hospital and beginning their clinical training ^[1]. Flexner studied educational methods throughout Europe and, on his return, was invited to survey the quality of medical education in America and Canada. Flexner used the well-established and highly successful Johns Hopkins University Medical School as his benchmark, and found that many of the schools across the country — especially those running courses for profit — were substandard. Flexner recommended the closure of one-third of all medical schools, and the radical reform of many others ^[2]. He then secured enormous funds, mostly from the Rockefeller and Connie foundations, to rebuild almost the entire infrastructure of medical training. New medical schools were built, faculty members were freed up to concentrate on academic medicine, research, and teaching, and an emphasis was placed on the advancement of medical knowledge (above, even the welfare of patients and the education of students) ^[3].

Although Flexner’s recommendations were widely accepted by the medical establishment — not least because of the boost to the profession’s social standing that accompanied the enormous injection of funds — they also came in for some criticism. William Ostler suggested that the emphasis on laboratory work would reduce doctors’ clinical skills and empathy, and that ‘patients were primarily viewed as serving the academic purposes of the professor’ ^[4]. Flexner also betrayed some troublingly racist and anti-semitic views. His report led to the closure of 46 medical schools, mostly in rural locations, and including all but two African-American medical colleges ^[5]. His view was that the poor health of African-Americans was a threat to white Americans, and that the education of African-American doctors was necessary, not least for the protection of the white American population.

The Flexner report shifted American medicine rapidly from being an exploitative, pastoral, cottage industry, into a coherent, rational, and objective professional discipline. But this came at some considerable cost. In Thomas Duffy’s retrospective on the report in 2011, for example, Duffy argues that;

‘Edmund Pellegrino’s lament was proven true that doctors had become neutered technicians with patients in the service of science rather than science in the service of patients. How else to explain the seemingly unexplainable Tuskegee experiments, the Henrietta Lacks tissue culture tragedy, and many occurrences in which the physician scientist has taken precedence over the physician as healer’ ^[6].

Flexner’s ‘infatuation with the hyper-rational world of German medicine created an excellence in science that was not balanced by a comparable excellence in clinical caring. Flexner’s corpus was all nerves without the lifeblood of caring’ (ibid). This approach, though, seems not to have hurt the medical profession’s social standing, and may have been a necessary step in securing its monopoly over healthcare. Bryan Turner has suggested that the report may have brought about a significant decline in competition from other healthcare providers, including homeopaths ^[7]. He also suggests that the sudden decline in the number of doctors and medical educators that flowed from the closure of so many schools, significantly increased the status and pay of those who had achieved accreditation, whilst, at the same time, establishing new accreditation frameworks that could be applied to other professions in future (ibid). What is clear, is that by the time Talcott Parsons at Harvard and Alexander Carr-Saunders at the London School of Economic were exploring what constituted an ideal-type profession, much had been learned about the tripartite relationship that now existed between medicine, the patient, and the state.