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2010 marks the centennial of the publication of the Flexner report . YJBM commemorates this anniversary with two articles from our archives: One chronicles the expansion of Yale’s medical school in the wake of the report’s publication; the other is a personal reminiscence written by Flexner for YJBM some 50 years ago. Together, these articles invite a reconsideration of an important moment in the history of 20th century American medical education.
At the beginning of the 20th century, the United States could boast some 150 medical schools nationwide. Most claimed to provide their students with training in anatomy, physiology, and newer laboratory sciences such as bacteriology; however, standards and quality of instruction, facilities, and access to clinical training varied widely from school to school. Many were organized as proprietary schools with no formal university affiliation. Abraham Flexner, appointed by the Carnegie Foundation at the behest of the American Medical Association, visited each U.S. school (as well as several Canadian institutions) to obtain a firsthand account of the state of medical education.
The Flexner report, based on his extensive touring of medical institutions, was published in 1910. Flexner found the majority of schools either wholly lacking in educational “rigor” or in need of significant improvement. As such, he devoted considerable space to criticizing contemporary medical education in the United States. Indeed, the highly publicized report sounded the death knell for more than half of U.S. medical schools in the 20 years that followed the report’s initial publication.
Despite his strongly worded critique of U.S. medical schools in general, the report did praise several medical institutions, including those affiliated with the universities of Michigan, Wake Forest, Harvard, and Johns Hopkins. Flexner considered the latter an ideal model for medical education: a formal college education requirement for admission coupled with a four-year, progressive medical curriculum placing substantial emphasis on clinical and basic sciences.
When Flexner visited Yale, he found medical education in favorable, though not ideal, conditions. The articles that follow show the personal commitment Flexner subsequently made to improving Yale's medical campus.
In an examination of Abraham Flexner’s relationship with the Yale University School of Medicine, Jordan M. Prutkin argues that Flexner figured centrally in the growth of the school. The paper highlights the importance of private foundations in the financing of education and research in a period before the federal government became a major grant source for medical schools. While Flexner sought to articulate a blueprint for systematic reform across the United States, his involvement at Yale reveals that implementing change could be a surprisingly personal, piecemeal affair. Prutkin’s article documents the changes realized at Yale post-Flexner, but also provides a fascinating “local” look into the tentative first steps toward academic medicine as we know it today.
The compilation of universities, hospitals, and medical schools into a single academic institution evolved gradually in the decades following the Flexner report. The second article, written by Flexner to honor former Yale medical school Dean Milton Winternitz, illustrates one such moment of changing relations between Yale University, the medical school, and the New Haven Hospital. With the medical campus in need of both greater revenue and access to patients for clinical training and research, reformers like Flexner and Winternitz worked to extend the hospital privileges of academic physicians and, later, medical students. Colorfully remembered by Flexner and examined in greater detail by Prutkin, both articles reflect on this transitional moment in the evolution of “modern” university hospital-based care.
Since its initial publication, the Flexner report has been viewed as a pivotal moment in the emergence of a rigorous, “scientific” medical education curricula. Yet with the passage of time, our understanding of the report’s impact and role in medical education has been both broadened and qualified. While it undoubtedly articulated and raised modern standards of a “scientific” medical education, the resultant medical school closures curtailed opportunities for African Americans, ethnic minorities, women, and other underprivileged groups to enter the medical profession. A colorful exchange between Flexner and Yale President Arthur Hadley, contained in Flexner’s eulogium for Winternitz, offers off-handed yet revealing insight into considerations of race, religion, and class at one university in the early 20th century.
Lastly, while few schools met Flexner’s standard, several schools did, which reveals that educational reform in America did not come in one fell swoop. Rather, the report publicized and galvanized financial and philanthropic support for developments in medical education already under way at some medical schools. In this regard, the Flexner report was less a singular force of reform than a well-publicized statement of what many medical reformers already desired.
Ludmerer K. Learning to Heal: The Development of American Medical Education. New York: Basic Books; 1985.
Cooke M, Irby D, Sullivan W, Ludmerer K. American Medical Education 100 years after the Flexner Report. New Engl J Med. 2006;355(13):1339-44.