Flexner Report

The Flexner Report[1] is a book-length study of medical education in the United States and Canada, written by
Abraham Flexner and published in 1910 under the aegis
of the Carnegie Foundation. Many aspects of the presentday American medical profession stem from the Flexner
Report and its aftermath.

At that time, the 155 medical schools in North America diered greatly in their curricula, methods of assessment, and requirements for admission and graduation.
Flexner visited all 155 schools[3] and generalized about
them as follows: Each day students were subjected to
interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might
sit wearily in the afternoon through three or four or even
ve lectures delivered in methodical fashion by part-time
teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance
to a hospital, they observed more than participated. The
Report became notorious for its harsh description of certain establishments, for example describing Chicagos 14
medical schools as a disgrace to the State whose laws
permit its existence... indescribably foul... the plague
spot of the nation.

The Report (also called Carnegie Foundation Bulletin

Number Four) called on American medical schools to
enact higher admission and graduation standards, and to
adhere strictly to the protocols of mainstream science in
their teaching and research. Many American medical
schools fell short of the standard advocated in the Flexner
Report, and subsequent to its publication, nearly half of
such schools merged or were closed outright. Colleges in
electrotherapy were closed. The Report also concluded
that there were too many medical schools in the USA,
and that too many doctors were being trained. A repercussion of the Flexner Report, resulting from the closure
or consolidation of university training, was reversion of
American universities to male-only admittance programs
to accommodate a smaller admission pool. Universities
had begun opening and expanding female admissions as
part of womens and co-educational facilities only in the
mid-to-latter part of the 19th century with the founding of
co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.

Nevertheless, several schools received praise for excellent performance, including Case Western Reserve,
Michigan, Wake Forest, McGill, University of Toronto,
and especially Johns Hopkins, which was described as the
'model for medical education'.[4]

2 Recommended changes
When Flexner researched his report, many American
medical schools were proprietary, namely small trade
schools owned by one or more doctors, unaliated with
a college or university, and run to make a prot. A degree was typically awarded after only two years of study.
Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be
desired. The regulation of the medical profession by state
governments was minimal or nonexistent. American doctors varied enormously in their scientic understanding of
human physiology, and the word quack ourished.

Background to the report

In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American
medical education. At its rst annual meeting, the CME
adopted two standards: one laid down the minimum prior
education required for admission to a medical school,
the other dened a medical education as consisting of
two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation Flexner carefully examined the situation. Using the Johns
for the Advancement of Teaching to survey American Hopkins School of Medicine as the ideal,[5] he issued the
medical education, so as to promote the CMEs reformist following recommendations:[6]
agenda and hasten the elimination of medical schools that
failed to meet the CMEs standards. The president of the
1. Reduce the number of medical schools (from 155 to
Carnegie Foundation, Henry Pritchett, a staunch advo31) and poorly trained physicians;
cate of medical school reform, chose Abraham Flexner
to conduct the survey. Flexner was not a physician, scien2. Increase the prerequisites to enter medical training;
tist, or a medical educator, although he held a bachelor of
3. Train physicians to practice in a scientic manner
arts degree and operated a for-prot school in Louisville,
Kentucky.[2]
and engage medical faculty in research;
1

3
4. Give medical schools control of clinical instruction
in hospitals
5. Strengthen state regulation of medical licensure

Flexner believed that admission to a medical school

should require, at minimum, a high school diploma and
at least two years of college or university study, primarily devoted to basic science. When Flexner researched
his report, only 16 out of 155 medical schools in the
United States and Canada required applicants to have
completed two or more years of university education.[7]
By 1920, 92 percent of U.S. medical schools required
this of applicants.[8] Flexner also argued that the length
of medical education should be four years, and its content
should be what the CME agreed to in 1905. Flexner recommended that the proprietary medical schools should
either close or be incorporated into existing universities.
Medical schools should be part of a larger university, because a proper stand-alone medical school would have to
charge too much in order to break even nancially.

CONSEQUENCES OF THE REPORT

No medical school can be created without the permission of the state government. Likewise, the size
of existing medical schools is subject to state regulation;
Each state branch of the American Medical Association has oversight over the conventional medical
schools located within the state;
Medicine in the US and Canada has become a highly
paid and well-respected profession.

The Report is now remembered because it succeeded in

creating a single model of medical education, characterized by a philosophy that has largely survived to the
present day. An education in medicine, wrote Flexner,
involves both learning and learning how; the student cannot eectively know, unless he knows how. Although
the report is over 100 years old, many of its recommendations are still relevantparticularly those concerning
the physician as a social instrument... whose function is
fast becoming social and preventive, rather than individLess known is Flexners recommendation that medical ual and curative.
schools appoint full-time clinical professors. Holders of
these appointments would become true university teachers, barred from all but charity practice, in the interest of 3.1 Medical School Closings
teaching. Flexner pursued this objective for years, despite widespread opposition from existing medical fac- Flexner sought to reduce the number of medical schools
ulty.
in the U.S. to 31, and to cut the annual number of medical
[8]
Flexner was the child of German immigrants, and had graduates from 4,400 to 2,000. A majority of Ameristudied and traveled in Europe. He was well aware can institutions granting MD or DO degrees as of the date
that one could not practice medicine in continental Eu- of the Report (1910) closed within two to three decades.
rope without having undergone an extensive specialized (In Canada, only the medical school at Western Univeruniversity education. In eect, Flexner demanded that sity was deemed inadequate, but none were closed or
American medical education conform to prevailing prac- merged subsequent to the Report.) In 1904, there were
160 M.D. granting institutions with more than 28,000
tice in continental Europe.
students. By 1920, there were only 85 M.D. granting inBy and large, medical schools in Canada and the United stitutions, educating only 13,800 students. By 1935, there
States have followed Flexners recommendations down were only 66 medical schools operating in the USA.
to the present day. Recently, however, schools have inBetween 1910 and 1935, more than half of all Americreased their emphasis on public health matters.
can medical schools merged or closed. This dramatic decline was in some part due to the implementation of the
Reports recommendation that all proprietary schools
3 Consequences of the Report
be closed, and that medical schools should henceforth all
be connected to universities. Of the 66 surviving MDTo a remarkable extent, the following present-day aspects granting institutions in 1935, 57 were part of a univerof the medical profession in North America are conse- sity. An important factor driving the mergers and cloquences of the Flexner Report:
sures of medical schools was that all state medical boards
gradually adopted and enforced the Reports recommen A physician receives at least six, and preferably dations. In response to the Report, some schools red seeight, years of post-secondary formal instruction, nior faculty members as part of a process of reform and
nearly always in a university setting;
renewal.[10]
Medical training adheres closely to the scientic
method and is thoroughly grounded in human phys3.2
iology and biochemistry. Medical research adheres
[9]
fully to the protocols of scientic research;
Average physician
signicantly;[6]

quality

has

Impact on African-American Doctors

and Patients

increased Flexner viewed blacks as inferior and advocated closing

all but two of the historically black medical schools. His

3
opinions were followed and only Howard and Meharry
were left open, while ve other schools were closed. His
perspective was that black doctors should only treat black
patients and should serve roles subservient to white physicians. The closure of these schools and the fact that black
students were not admitted to many medical schools in
the USA for 50 years after Flexner has contributed to
the low numbers of American born physicians of color
and the ramications are still felt more than a 100 years
later.[11]

based practice. The curricula of DO and MD awarding medical schools are now nearly identical, the chief
dierence being the additional instruction in osteopathic
schools of osteopathic manipulative medicine. The remaining DO schools were adamant in preserving such
training. Before and after Flexnors report, by including these treatment methods in patient care and sometimes foregoing other caustic medical or surgical options
available, clinical outcomes often dramatically improved
morbidity and mortality. This dramatic convergence
of osteopathic and biomedical training demonstrates the
Furthermore, given his adherence to germ theory, he argued that, if not properly trained and treated, African- sweeping eect of the Flexner Report, not only in the closure of inadequate schools, but also in the standardization
Americans posed a health threat to middle/upper class
of the curricula of surviving schools.
[12]
whites.
The practice of the Negro doctor will be limited to his
own race, which in its turn will be cared for better by
good Negro physicians than by poor white ones. But the
physical well-being of the Negro is not only of moment to
the Negro himself. Ten million of them live in close contact with sixty million whites. Not only does the Negro
himself suer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the
ignorant and unfortunate white contaminates him. Selfprotection not less than humanity oers weighty counsel
in this matter; self- interest seconds philanthropy. The Negro must be educated not only for his sake, but for ours.
He is, as far as the human eye can see, a permanent factor
in the nation.[12]

3.3

Impact on Alternative Medicine

When Flexner researched his report, modern medicine

faced vigorous competition from several quarters, including osteopathic medicine, chiropractic medicine,
electrotherapy, eclectic medicine, naturopathy and
homeopathy.[13] Flexner clearly doubted the scientic validity of all forms of medicine other than that based on
scientic research, deeming any approach to medicine
that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that oered training in various disciplines including electromagnetic eld
therapy, phototherapy, eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to
drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all either complied with
the Report or shut their doors.

3.4

Impact on Osteopathic Medicine

Although almost all the alternative medical schools listed

in Flexners report were closed, the American Osteopathic Association (AOA) was able to bring a number of osteopathic medical schools into compliance with
Flexners recommendations and produce an evidence-

4 See also
Committee of Ten

5 References
[1] Flexner, Abraham (1910), Medical Education in the
United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (PDF), Bulletin
No. 4., New York City: The Carnegie Foundation for the
Advancement of Teaching, p. 346, OCLC 9795002, retrieved June 8, 2015
[2] Goodman, John C.; Musgrave, Gerald L. (1992). Patient
power: Solving Americas Health Care Crisis (PDF). Washington, DC: Cato Inst. pp. 142148. ISBN 0-932790-925.
[3] Cox, Malcolm; Irby, David M.; Cooke, Molly; Irby, David
M.; Sullivan, William; Ludmerer, Kenneth M. (Sep 28,
2006). American Medical Education 100 Years after the
Flexner Report. New England Journal of Medicine 355
(13): 13391344. doi:10.1056/NEJMra055445. PMID
17005951.
[4] Rael MN, Rael NK. The US Health System: origins
and functions. 4th ed. Albany, NY: Delmar Publishers;
1994:11.
[5] UNMCs Flexners Impact on American Medicine
[6] Barzansky, Barbara; Gevitz, Norman (1992). Beyond
Flexner: Medical Education in the Twentieth Century (1.
publ. ed.). New York: Greenwood Press. ISBN 9780313259845.
[7] Flexner & Pritchet 1910, pp. 28
[8] Hiatt, Mark D.; Christopher Stockton (2003). The Impact of the Flexner Report on the Fate of Medical Schools
in North America After 1909 (PDF). Journal of American Physicians and Surgeons 8 (2). Retrieved 24 November 2012.

[9] Beck, Andrew H. (5 May 2004). The Flexner report

and the standardization of American medical education.
(PDF). The Journal of the American Medical Association 291 (17): 213940. doi:10.1001/jama.291.17.2139.
PMID 15126445. Retrieved 24 November 2012.
[10] McAlister, Vivian; Claydon, Emily (2012). The Life of
John Wishart (18501926): Study of an Academic Surgical Career Prior to the Flexner Report. World Journal
of Surgery 36: 6848. doi:10.1007/s00268-011-1407-x.
[11] Sullivan, Louis W.; Suez Mittman, Ilana (February 2010).
The State of Diversity in the Health Professions a Century After Flexner. Academic Medicine 85 (2): 246253.
doi:10.1097/ACM.0b013e3181c88145.
[12] Black Physicians and Black Hospitals (PDF). p. 24.
[13] Stahnisch, Frank W.; Verhoef, Marja. The Flexner
Report of 1910 and Its Impact on Complementary
and Alternative Medicine and Psychiatry in North
America in the 20th Century. Evidence-Based Complementary and Alternative Medicine 2012: 110.
doi:10.1155/2012/647896.

Further reading
Beck, Andrew H. (5 May 2004). The Flexner
report and the standardization of American medical education. (PDF). The Journal of the American Medical Association 291 (17): 213940.
doi:10.1001/jama.291.17.2139. PMID 15126445.
Retrieved 24 November 2012.
Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins
Univ. Press. ISBN 0-8018-7124-7.
Gevitz, Norman, and Grant, U. S., 2004. The D.O.s
(2nd ed.). Baltimore: The Johns Hopkins University
Press. ISBN 0-8018-7834-9.
Starr, Paul, 1982. The Social Transformation of
American Medicine. Basic Books. ISBN 0-46507935-0.
Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education.
University of Wisconsin Press. ISBN 0-299-117502, ISBN 0-299-11754-5.

External links
The Flexner Report (PDF) from the Carnegie Foundation for the Advancement of Teaching
Flexner Report Transformed Med Schools, All
Things Considered, 16 August 2008.
The Flexner Report 100 Years Later (September
2011)

EXTERNAL LINKS

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