Flexner at 100: A Perspective

Flexner at 100A Perspective Donald A. Chambers The year 2010 marks the hundredth anniversary of the Report on Medical Education in the United States and Canada (1910), written by Abraham Flexner as Bulletin Four of the Carnegie Foundation for the Advancement of Teaching. This report was monumental in helping to define excellence for the next century of medical education. The editors of Perspectives in Biology and Medicine determined that in recognition of the Flexner Report, this year is appropriate to consider emerging trends that are likely to guide and revitalize medical education in the 21st century. That the observations and changes embodied in the Flexner Report have so long endured is a fitting tribute to the wisdom of the medical education reformers at the turn of the 19th century. A major discussion of Abraham Flexner, the man, is beyond the scope of this introduction or of this volume. A number of biographical and autobiographical studies will sate the reader's curiosity (Bonner 2002; A. Flexner 1960). Flexner was born of Jewish immigrant parents in Kentucky in 1866. He began studies at Johns Hopkins University in 1883, seven years after its opening, and graduated two years later, having completed the usual four-year curriculum in two years, [End Page 3] as family funding was only available for that period. Flexner displayed an early passion and ambition to succeed. After Johns Hopkins, he returned to Louisville, taught high school for two years, and opened his own school that prepared wealthy, less ambitious students for university acceptance. The school was a major success and brought recognition and some financial security to Flexner. In 1908 he published a book, The American College, which so impressed Henry Pritchett of the Rockefeller Fund that Pritchett asked Flexner to undertake a study of American and Canadian medical schools. Of interest is that while Flexner was engaged in the aforementioned teaching activities, his brother, Simon, was gaining recognition and fame, first at Johns Hopkins Medical School as a student and colleague of the famed pathologist and Medical Dean, William Welch, and then as Director of the Rockefeller Institute, the first major medical research institution in America. Thus, the Flexner family produced two icons of American medical education (J. T. Flexner 1984). Like no other single person before or after, Abraham Flexner was able to institute changes in the fabric of American medical education and infrastructure because he almost single-handedly controlled the flow of major amounts of monies from American philanthropy as a function of his role as Secretary of the General Education Board (Wheatley 1999). In this capacity, he was also able to supply funding for full-time academic medical faculty, as well as the initiation of what became the Johns Hopkins School of Public Health. Many would observe that this funding was often restricted to a small number of elite universities. By no means were Flexner's views universally accepted. Sir William Osler, Regius Professor of Medicine at Oxford University, took Flexner to task in 1912, disagreeing with the concept and implementation of full-time academic physicians employed by medical schools for hospital teaching and service. In a number of communications, Osler railed at Flexner that a nonclinician like Flexner had neither the knowledge, the experience, or the right to be a decision maker for the clinical enterprise (Bliss 1999). Arguments of this nature are not uncommon, even today. The Flexner Report defined the standards for medical education. It argued that the university is the natural home for medical education and that the years of medical school provide only the beginning of a commitment to continuing, lifelong education. As such, it was instrumental in making medicine a scholarly and learned profession. The Flexner Report demanded an undergraduate premedical liberal arts education as a prerequisite to professional education and regarded the basic medical sciences of anatomy, physiology, biochemistry, microbiology, and pathology as the building blocks upon which clinical medicine rests. As we shall see, the strict dichotomy of basic sciences and clinical medicine is currently breaking down in favor of an early integration of how basic science informs clinical reasoning, an exciting development that arises directly from the biomedical revolution of the 20th century and the...

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