The Flexner Report And Medical Education

Robert Siegel talks to Paul Starr of Princeton University about the Abraham Flexner Report, which critiqued American medical training. This is the centennial year of that report. Before his report, most medical schools were run like barber colleges, and Flexner more or less made medical schools get into the university system or shut down.

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ROBERT SIEGEL, host:

This is ALL THINGS CONSIDERED from NPR News. I'm Robert Siegel.

This is from Abraham Flexner's description of kind of American school that he reported on 100 years ago. The schools, he wrote, were essentially private ventures, money making in spirit and object. Income was simply divided among the lecturers. No applicant for instruction who could pay his fees or sign his note was turned down. Secretarial school or barber college or anyone-can-learn-to-draw art school? None of the above. Flexner was describing medical education in the United States and Canada.

The report that he issued for the Carnegie Foundation published in 1910 led to the reform of medical schools. And in this centennial year of the Flexner report, we've invited Paul Starr, professor of sociology and public affairs at Princeton University, to talk about it. He's written extensively about the history of American medicine. Welcome to the program.

Professor PAUL STARR (Sociology and Public Affairs, Princeton University): Good to be with you, Robert.

SIEGEL: First, who was Abraham Flexner?

Prof. STARR: Abraham Flexner, curiously enough, was not a doctor. His brother, Simon Flexner, was a very distinguished physician. He was, however, an expert in education. He played an important role in the reform, not only of medical education, but much more broadly of scientific research.

SIEGEL: How did the Flexner report of 1910 change American medical education? What did he find and how did people react to it?

Prof. STARR: Well, during the 19th century, Americans were distrustful of expertise. There were, through the mid 19th century, no effective medical licensing laws, no regulation of medical practice or medical education. And so the whole field was thrown open to all kinds of practitioners of various medical sects and various kinds of entrepreneurs, who set up schools as money-making ventures, just as Flexner said in the passage you quoted.

SIEGEL: There were some medical schools affiliated with universities, but then there were these proprietary schools all over the country.

Prof. STARR: Yes. Medical schools at universities had themselves gone through a major transformation in the late 19th century with the introduction of laboratory sciences and other more advanced fields, but many other schools had not undergone that transformation. They were still back in the old-fashioned mode.

SIEGEL: I was looking at Flexner's autobiography, which he published in 1940, and he was recalling some of the incidents of his study trip. And one of them, he says, I recall that when in Salem, Washington, I asked the dean of the medical school whether the school possessed a physiological laboratory. He replied, surely, I have it upstairs, I'll bring it you. And he went up and brought down a small sphygmograph, an instrument designed to register the movement of the pulse, he said, or to test blood pressure, I guess. That was passing for medical school early in the last century.

Prof. STARR: Yes, because, again, there had been no regulations. So, many schools had no laboratories whatsoever. Things were changing already at the time when Flexner did his report. And sometimes people attribute the entire change that medicine underwent to Flexner, but that's not true. Licensing laws were being strengthened. People were aware that changes needed to take place, and Flexner helped to consolidate a movement that was already underway.

SIEGEL: Some of the reforms that Flexner proposed that seem like no-brainers today, but medical schools should be for college graduates, for example.

Prof STARR: Uh-huh.

SIEGEL: Or there should be some kind of experience with dissection, actual looking at the body while you're in medical school.

Prof. STARR: Yes. All of those things made a great deal of sense, but at the same time, what they meant is that there would be new financial obstacles because medical education would become more expensive. It would become more exclusive and that was, on the whole, a necessary change. Unfortunately, it did result in a decline in the supply of doctors and that had very long term, unfortunate consequences for America.

SIEGEL: So we're witnessing sometime early in the 20th century a change from a well-intentioned, good-natured local physician, who didn't have much training, frankly, to a kind of a trained scientist with a real medical degree.

Prof. STARR: That was the vision. That was Flexner's idea that science had to be brought to the bedside. And his report played a very positive role in doing that.

SIEGEL: Was the Carnegie Foundation so influential that a report from an educator who'd been sent around the country to look at medical schools could have that much influence on the way the country trained doctors?

Prof. STARR: I think what you have to bear in mind is that at that time in 1910, American society was undergoing a revolution, in many different respects, as a result of science. The airplane had just been invented. The automobile was coming into use. The telephone was coming into use. People were seeing everyday life transformed by science and technology. They began to have more faith in science than they had before. And the old distrust of professionals as monopolists that ran through the 19th century began to dissipate. And instead, people began to place their trust in science. I think that's why Flexner had so much influence.

SIEGEL: Paul Starr, thanks so much for talking with us today.

Prof. STARR: Thank you.

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