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100 Years After Flexner: Medical Education Ushers In New Era of Reform

New York, NY

One hundred years ago, a scathing indictment of American medical schools known as the Flexner Report led to sweeping reforms in physician education.

A century later, medical education is again in need of major change - and not only because of national health reform.  Despite everything they do so well, medical schools have not kept pace with the ever-evolving needs of the society they serve.

The centennial of Abraham Flexner’s landmark report, coupled with rapid and dramatic changes in health care, offers an opportunity to review just how far medical schools have come, and, more importantly, where they need to go next.

In 1908, the Carnegie Foundation for the Advancement of Teaching hired Abraham Flexner to produce a critique of American medical education. Flexner, a former high school teacher who started his own experimental school at 26, spent the next 16 months visiting all 155 medical schools in the U.S. and Canada.

In his report, Flexner deemed two-thirds of schools to be “hopeless.” The majority were proprietary, operated more for profit than for education, with no uniform standards.  Sixty percent required their students to have only an elementary school education; a mere 12 percent
required two years of college.

It is difficult to imagine how barren medical education was 100 years ago.  Flexner found squalid classrooms lacking even chairs, desks, and blackboards.  Teachers, of questionable training themselves, were routinely tardy or absent.  Teaching was essentially “uninstructive” - heavy on long, droning lectures and short on dissection, lab work, or other hands-on experience.

In the two decades following Flexner’s report, more than 70 medical schools closed.  College education became the standard prerequisite for medical school admission, and two years of science followed by two years of clinical experience became the standard “2 + 2” curriculum taught by full-time faculty.

We are indebted to Flexner for the reforms he sparked.  But the problems of Flexner’s times are not today’s problems.  Today, science is uniformly well taught as the underpinning of medical practice, and strict licensing and accrediting processes are in place.

But in the last 100 years, the complexity of health care content and delivery has increased enormously, and the patient population is far more heterogeneous in origin, age and disease burden.  Science and technology are advancing so rapidly that new practices must be
incorporated much more quickly.

In short, it is time for a new era of reform.

First, we must teach medical students how to work as part of a team, with nurses, physician assistants, and other health professionals. Medicine is no longer the sole province of the all-knowing doctor – it is a collaborative activity that requires professionals from different
disciplines to do the job well.  Yet this is not how the vast majority of medical students are trained.

Second, we must integrate the teaching of science and clinical medicine in medical school, medical residency and beyond.  The Flexnerian “2+2” model served us well in simpler times but it no longer meets the needs of learners or practitioners in a rapidly changing scientific world.
Medical students should start seeing patients at the outset of their education, and science should be taught and reinforced throughout the four-year curriculum.

Third, we must expand beyond the Flexnerian hospital-based rotation model as the exclusive way to learn clinical medicine.  It does not reflect current medical practice, does not teach important principles of continuity, and does not promote optimal mentoring and professional

Good health care is more than the provision of clinical services. Today’s doctors must learn new content and skills, including quality improvement, patient safety, communication, health economics, and the social determinants of health.

Finally, we must strive for a medical school student body and professional workforce that more closely resemble the society we serve - racially, ethnically, and socio-economically.  This will require medical schools to re-examine their admissions criteria and processes.

Flexner recognized that medical education must respond to changes in both science and society in order to meet its mission.  Because of Flexner and several generations of outstanding medical educators, our country has a strong medical education foundation.  We must now build upon that foundation and realign medical education with the needs of the public so that we can fully serve the public health.

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