Beyond Flexner

Beyond Flexner: The Social Mission of Medical Education in the 21st Century

Principal Investigators:
Fitzhugh Mullan, MD
Jennifer Lee, MD

BACKGROUND

In 1910, the Carnegie Foundation published Medical Education in the United States and Canada, by Abraham Flexner subsequently known as the Flexner Report.  This document catalyzed enormous and important changes in medical education in the United States.  The report was highly critical of the state of American medical education and advocated the swift closure of the majority of schools in the country, most of which were proprietary, poorly resourced, and, in Flexner’s judgment, graduating completely incompetent physicians.

The impact of his report was extraordinary.  In the two decades following its publication, the majority of medical schools in the country closed (from 160 in 1900 to 76 in 1930) and the number of medical graduates fell from 5,200 to an all time low of 2,600 in 1919.  The report had the greatest impact on schools that were dedicated to the education of African Americans and women.  Flexner recommended that the five of the seven black medical schools be closed and, by 1923, only Meharry Medical College and Howard University Medical Department were left standing.  In consequence, less than 3% of entering medical students between 1920 and 1964 were African American.  Flexner argued that there was no need for medical schools that were dedicated to the education of women and recommended that all three of these schools be closed and they were.

The schools that survived Flexner were largely university based and firmly committed to medical science for the basis of medical education -- tying medical education to what has now become the academic health center.  Flexner created this foundation for the best of reasons – to rescue American medical education from the unprincipled, commercial, dangerous state in which it existed at the beginning of the twentieth century.  This foundation and the Flexner Report on which it was built, however, has had long standing consequences that Flexner surely never envisioned.  While there is understanding today of the impact of Flexner on the education of African Americans and women, much less is known or has been articulated about other limiting aspects of Flexner’s influence.  

Flexner could not have predicted what the twenty-first century research university would become, but by embedding medical education in the forbearer of that institution, he ordained that medical school applicants would have to have the academic and financial capabilities required by that institution.  The accreditation standards that developed around medical schools have likewise become demanding and specific to the point of creating an extraordinary consistency between US medical schools -- a characteristic seen by many as an indication of quality and strength, but a model which is also characterized by relatively inflexible institutions.  

The skills, proclivities, finances, and ambitions of today’s students are all subject to this orthodoxy and the Flexnerian model is so pervasively accepted that it is rarely examined or challenged.  Chronic problems with the nation’s medical work force including where medical school graduates work, what specialties they choose, and how many are from minority populations rarely receive scrutiny from this perspective.

As we celebrate the centennial of the Flexner Report, an important question often not asked is, what is the legacy that the Report leaves to us in regard to the social mission of medical education?  Broadly defined, the social mission is the ability of medical education to address problems of equity in health.  Foremost among these are well-established disparities between well-to-do communities and poorer communities, urban communities and rural ones, the population in general and underrepresented minorities, and the ability of the country to meet the primary care needs of its citizens.  In many of these areas, the Flexnerian model has not shown a particularly effective course.  In some areas, the standardization and its attendant rigidities may have prevented innovations or modifications in medical education that would have promoted the social mission of medical education.  

The continued focus of medical admissions on science accomplishments to the exclusion of other skills and the overwhelming focus on science competency in medical school admissions and education have governed who gets the opportunity to study medicine and what values they take into practice with them.  The educational costs associated with the Flexnerian medical school have made it more difficult for less affluent students to attend.  The growth of the academic health center as an incubator of and enthusiastic customer for technology has imprinted values in generations of students.  This imprint tends to keep them close to the medical center in specialty and in geographic choice after they graduate.  This tendency often frustrates efforts to improve access to care across the country.  

None of these observations is meant to fault Flexner.  But a full examination of the Flexner legacy in relation to some of the country’s enduring health care problems would be an important addition to the conversation that is taking place around the centennial.  

THE STUDY

The W.K Kellogg Foundation has awarded a grant to the Department of Health Policy of the George Washington University School of Public Health and Health Services to study the unintended consequences of the Flexner Report in regard to health equity in the United States and to explore models of medical education that go beyond Flexner in addressing the social mission of medical education.  The Study will comprise the following activities:

Formation of an Advisory Committee: An advisory committee of twelve individuals will be assembled to bring multiple perspectives to the question of moving beyond the Flexnerian legacy in regard to the social mission of medical education. These individuals will be chosen broadly for their experience in the field as well as for their perspectives on population health, social development, and education.  Advisory committee members will be asked for guidance in framing the project at the beginning and also to participate in site visits in the subsequent activity.

Site Visits: Six programs will be selected for their creative approach to medical education geared toward meeting the social mission of medical education.  A team of approximately three individuals consisting of individuals from the GW staff and Advisory Committee members will participate on each site visit.  The site visitors will conduct a series of interviews and focus groups to provide a closer look at innovative educational programs, including how they came to be, obstacles to implementation, evaluative efforts, and future prospects. Each site visit team will produce a report focusing on social mission outcome.  

Publications: Articles based on the site visits, conference papers, and overall research will be prepared for placement in scholarly journals and as will essays for op-eds and other general audience commentaries.

Website: Early in the project, a website will be developed in which current articles, reports, news stories, and legislative activities pertinent to the social mission will be posted and made widely available.  Additionally, the case studies, as they become available, will also be posted on the website.  

OUTCOMES

The overall outcome of the project will be the development and articulation of a series of creative and experience-based ideas pertinent to the social mission of medical education.  The literature in this area is thin; discussion of these areas in medical education and health policy is random and not captured by any organization, movement, or department.  The Beyond Flexner Study is intended to provide information and perspective in a period in which many new and expanded medical schools have opened or are in a planning phase.  New federal legislation will provide many more Americans with health care coverage, and the role of medical schools in meeting the oncoming need is under active policy debate.  The Study will add information and perspective to that debate.