To the conspiracy-minded alternative health practitioner, everything was great until the Flexner Report was published. Humanity was crushing diseases with herbal remedies and natural potions until 1910 when the 鈥渕edical-industrial complex鈥� came together 补苍诲听聽We are now afflicted by Rockefeller medicine, where ill citizens are hooked on expensive drugs that never heal them and the truth about the benefits of herbs is being hidden by paid-off politicians and academics.
This alleged fall from paradise can all be blamed on the original sin of that darn Flexner Report.
I would wager that most of the people hurling insults at this century-old book have never actually read it; I did, because I wanted to know what the fuss was all about.
The Flexner Report was commissioned because the state of medical education in the United States and Canada was dire. A young educator was hired to visit all of North America鈥檚 medical colleges and report back, which led to much-needed changes and some unfortunate consequences.
And, yes, he did have some harsh words for what he called 鈥渢he unconscionable quacks.鈥�
A medical degree聽补苍诲听a free trip to Europe!
There is a reason why leeches and purging agents are now rarely used in medicine: the discipline has evolved over the millennia, and Abraham Flexner found himself at the beginning of a new and exciting era.
Medicine in the Western tradition began with Hippocrates and Galen. It began with dogma. 鈥淔acts,鈥� Flexner wrote in his report, 鈥渉ad no chance if pitted against the word of the master.鈥� Those who despise modern medicine will claim it has remained dogmatic to this day; but while practitioners can be set in their ways and new findings can linger before they are adopted, we are far from the pontifical medicine of old.
With the rapid development of anatomy in the 1500s, medicine moved from dogma to empiricism. This meant that instead of doctors simply parroting what they had been taught by the rock stars of their field, they would learn from their own experience. They would observe and they would treat accordingly. This approach was more welcoming to discovery, but it was still hard for doctors of that era to properly disentangle diseases that superficially looked the same.
What propelled the discipline forward was science. We came to realize that the human body obeys the laws of biology: it grows, reproduces itself, and dies in predictable ways, and by understanding this underlying biology, the doctor would be better able to prevent and treat disease. Scientific research fed clinical practice, and the medical student, no longer limited to watching, would聽do聽as well.
Like medicine, medical training itself had changed over the centuries. It started as a system of apprenticeship, where a trainee became indentured at a young age to a doctor and ran his errands. Eventually, he would get to learn the secrets of his master鈥檚 trade. In Europe, the teaching of medicine would move to the lecture halls, which were host to anatomy demonstrations, and many American students would cross the Atlantic to benefit from this enrichment in Paris or Edinburgh. It wouldn鈥檛 take long before American doctors saw a way to sprout a similar system stateside and reap its financial benefits.
They were called proprietary schools. They were privately owned, with their teachers splitting the profits among themselves. They could rent a cheap hall, get some inexpensive benches, and recruit students who didn鈥檛 even have a high school diploma. 鈥淎 school that began in October,鈥� Flexner wrote, 鈥渨ould graduate a class the next spring.鈥� Their facilities were poorly stocked, with barely-existing laboratories. The money that didn鈥檛 end up in the founders鈥� pockets was used to make all sorts of wild promises in the advertising material. One of these medical colleges swore it would gift its graduates a trip to Europe!
Following this explosion in questionable proprietary medical schools in the mid-1800s, change was thankfully afoot, but something major was needed around which this change could crystallize.
Quality over quantity
The Flexner Report鈥檚 actual title is聽Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching.聽It was commissioned by industrialist Andrew Carnegie鈥檚 policy and research foundation. Much has been made of the report鈥檚 ties to Carnegie and to Rockefeller, whose own foundation alongside eight others would pour a lot of money to implement the solutions proposed in the Flexner Report. Flexner鈥檚 brother, Simon, was also a friend of John D. Rockefeller, Jr, and he directed the Rockefeller Institute for Medical Research for more than three decades. Seen through our modern lens, this friendly alliance between medical education and capitalistic interest can trigger a fair amount of skepticism, if not outright conspiracy theories. It was in the wealthy elite鈥檚 interest to downplay the impact of social disparities on health and to promote the simpler idea that the human body was a machine whose broken parts could be mended by the right science-informed technician. But as we鈥檒l see, the report itself did not stick to this narrow viewpoint.
Abraham Flexner, whom the Carnegie Foundation recruited for this massive work, was not a doctor; he was a teacher. Born in Louisville, Kentucky, Flexner studied Greek, Latin and philosophy as an undergrad at Johns Hopkins, and this university made a profound mark on him. It would become the template for Flexner鈥檚 medical education revolution.
After teaching high school, Flexner opened his own private preparatory school, which served as a laboratory for his educational convictions. After receiving a Master鈥檚 degree in philosophy from Harvard, exploring Europe, and writing a book on American education, he was recruited by the head of the Carnegie Foundation. His mission: to tour the 150 medical schools in the United States and Canada and report back in writing on what their problems were and how to solve them. Already, the deceptive marketing of many of these schools and their deficient scientific education was known; Flexner was to document it. His report was scathing.
Flexner wrote of the dissection rooms where cadavers were as dry as tanned leather. He denounced the medical colleges claiming to have access to a hospital for their students when that was not the case. Many schools did not have full-time faculty and lacked proper laboratories. At the North Carolina Medical College, in Charlotte, Flexner was told that asking about laboratories was futile: their students were 鈥渁ll thumbs,鈥� better suited to be farmers.
His year-and-a-half survey of North America resulted in a three-tiered list of medical colleges.
Sixteen were in tier one, requiring at least two years of college for admission and doing their best to meet the standard set by the Johns Hopkins Medical School. Fifty were salvageable and required of their student applicants a high school diploma. The rest, mostly found in the south of the United States, was a complete loss, in his opinion. 鈥淔or the law, if enforced, would stamp them out.鈥� (In case my colleagues are curious, he admired 不良研究所鈥檚 own medical school, calling it 鈥渆xcellent鈥� and being impressed by its anatomical and pathological museums, as well as its library. Its medical budget at the time was a mere $77,000.)
Flexner鈥檚 short-term solution to the proliferation of inadequate, for-profit medical schools was to shut them down and fund the ones that had stricter standards and that were affiliated with a university. He recommended quality over quantity, with fewer but better equipped schools graduating fewer physicians that were better trained. His influential book-length report was used to justify an influx of $154 million in the medical education system over the course of nearly two decades.
While prioritizing quality is commendable, the consequences of the Flexner Report were not all positive. Almost all women鈥檚 and historically Black medical colleges聽, and women were nearly eliminated from the physician workforce until the 1970s. Medical schools were consolidated in large urban centres and required more money and education to get in, which meant that middle- and upper-class white men had an easier time becoming physicians. And closing a bad medical college in the American South might have been smart in the short term, but if it was not replaced by a better school, it simply created an educational desert.
But if the Flexner Report was focused on improving聽尘别诲颈肠补濒听education, why are so many homeopaths and naturopaths mad about it?
Made-up minds
In chapter 10 of his report, Flexner goes for the jugular of what he calls the 鈥渕edical sects.鈥� Those were competing philosophies of medicine, like homeopathy, osteopathy, and eclectic medicine (a plant-based approach). Flexner correctly observes that unlike the doctor who wants facts and not dogma, 鈥渢he sectarian [鈥 begins with his mind made up.鈥� He denounces the contradiction in many of the best sectarian colleges, where students underwent two years of chemistry, biology, and physics, before entering clinical training and suddenly being introduced to a pseudoscientific principle that contradicted what they had just learned.
Flexner was not single-handedly responsible for shutting these colleges down. In the ten years before the publication of his report, the 22 homeopathic colleges in the U.S. were trimmed down to 15. Much like the scientific revolution changing medicine, the Flexner Report did not begin the transformation but simply galvanized it.
Yet, Flexner, perceived as the hatchet man that tore down much of the medical education infrastructure, has become a lightning rod for misconceptions and bad arguments. He is sometimes accused of having denigrated the value of public health, which is simply false. In his report he writes of bad environmental conditions that breed disease, such as a contaminated water and food supply. The good doctor鈥檚 role, he writes on page 68, 鈥渋s equally to heal the sick and to protect the well. The public health laboratory belongs, then, under the wing of the medical school.鈥� To make the point even clearer, Flexner notes that 鈥渢he physician鈥檚 function is fast becoming social and preventive, rather than individual and curative.鈥�
And while a hyperfocus on science as the answer to medical problems can lead to inhumane treatment (and certainly had a role to play in eugenics and unconscionable medical experiments like Tuskegee鈥檚), Flexner understood the importance of care. His ideal doctor required 鈥渋nsight and sympathy鈥� in order to heal. That priority may have gotten lost in the implementation of his plan, but it is present in the report, black on white.
When the sectarians he condemns criticize his report, they often claim that he transformed medicine from a holistic view of the entire body into a myopic practice that only focused on broken body parts. This is a convenient argument for them. As scientific research nourished clinical practice, our body of medical knowledge grew, forcing doctors to specialize. But there is no real growth in so-called alternative medicine. There is no聽苍别别诲听to specialize when you believe there is only one true cause to all diseases. Whether it鈥檚 an alleged chiropractic subluxation or a blockage of the supposed life force called qi, it鈥檚 just an obstruction. All these practitioners need to do is find the source of the blockage and declog the pipe, much like a plumber. As Flexner pointed out, though, this is not science but dogma masquerading as knowledge.
As for the loss of holism in medicine, it still exists in family medicine, and especially in group practices, where integrating knowledge from specialties is commonplace. But given the incredible amount of knowledge generated in scientific medicine, it is absurd to expect every doctor to know everything.
The Flexner Report of 1910 was an imperfect catalyst that helped move medicine into its science-informed era. It would take many more decades, though, before the randomized controlled clinical trial was adopted as a gold standard for determining the worth of a treatment or preventative. The report also exacerbated inequalities in access to medical education in an attempt to reward the most rigorous institutions. Nonetheless, it argued that the best place for medical education was not in a privately owned and poorly regulated makeshift school but in a university, where foundational research could provide new solutions to the healer.
The kind of quackery that Flexner decried has not really gone away, despite what he predicted, and its practices certainly have not been criminalized.聽Osteopathy聽raised its standards in the United States and became, for all intents and purposes, equivalent to medicine. Homeopathic colleges are rare but聽their hyperdiluted concoctions聽are still widely available. Some dubious professions, like naturopaths, have acquired an unearned legitimacy in some states and provinces, and the concept of integrative medicine鈥攐f adding junk practices to actual medicine to get some sort of best of both worlds鈥攈as unfortunately made聽massive strides in academia.
The battle against medical sectarianism has not been won. There is a lot of work left to do.
Take-home message:
- The Flexner Report, published in 1910, crystallized a revolution in North America toward teaching a type of medicine that was strongly influenced by scientific discoveries
- The claim that Flexner downplayed the importance of public health and preventive medicine in his report because he was working for the Carnegie Foundation is simply false
- The claim that medicine stopped treating the whole person after the Flexner Report came out but that natural healers still do is false: family medicine is holistic; medical specialties exist because of our increased knowledge; and natural healing practices have no need to specialize since they often believe there is one true cause to every disease, which is wrong
