The Impact and Implications of the Flexner Report on Medical Education in Korea

Abstract

The recent debate surrounding the expansion of enrollment in Korean medical schools has reignited interest in the Flexner Report, published in the United States in 1910. Historically, medical education in the United States transitioned from small proprietary schools to university-affiliated institutions, emphasizing basic science and clinical experience. The Flexner Report advocated for scientific medicine and led to significant reforms in medical education, including standardization of curricula and strengthened admission requirements. The influence of this report extended to Korean medical education, shaping its curriculum, accreditation system, and emphasis on academic excellence. The expansion of medical school enrollment has led to a crucial dilemma. Should we prioritize the training of physicians who provide practical medical services or continue to emphasize academic medicine as we do now? There has been insufficient discussion of the individualized curricula, necessary investments, and societal efforts to accommodate these changes. It is imperative to move beyond mere enrollment expansion debates and collectively determine the future trajectory of Korean medical education, devising actionable plans to achieve overarching goals.

INTRODUCTION

Recently, there has been a controversy in Korea regarding the expansion of medical school enrollment, which has sparked debate among various stakeholders, including policymakers, educators, healthcare professionals, and the public. Many concerns have arisen regarding the quality of medical education, prompting a reexamination of the century-old Flexner Report from the United States. Although the United States is a global leader in medical education today, its current systematic structure was not attained until the early 20th century.

This paper explores the background and key findings of the Flexner Report, analyzing the state of medical education in the United States at the time of the Report’s publication and its subsequent influence. It also assesses the current landscape of medical education in Korea and the relevance of the Flexner Report in this context. Furthermore, we discuss the lessons that the Flexner Report provides regarding the current situation of medical school expansion in Korea, even a century after its publication.

MEDICAL EDUCATION IN THE UNITED STATES UNTIL THE FLEXNER REPORT

When European immigrants first began to establish colonies in the Americas, medicine and medical education were quite different from their current formats. During the colonial era, medical practice was empirical and medical training mainly comprised apprenticeship. During the 18th century, apprentice medical training became more structured and standardized, leading to early proprietary medical schools in the new independent country.1

After independence, the economic growth of America was surprisingly high, and its population rapidly increased. The growing nation clearly needed more medical practitioners. However, the medical education system in the early 19th century was very different from modern medical education. Many proprietary medical schools were producing more practitioners, but apprenticeship remained a common method for medical training. The curriculum of the proprietary medical schools rarely had order or structure, and the same content was usually repeated every semester for 2 or 3 years. There was no formal assessment during training, nor were there any criteria for admission or graduation.2 Because all proprietary medical schools heavily depended on student tuition, schools always benefited from enrolling as many students as possible. In such circumstances, it was impossible to raise the standards for admission, education, promotion, and graduation. There also were no strict requirements regarding the practice of medicine. During the 19th century, however, medical schools became increasingly affiliated with larger universities, forming a system closer to modern medical schools.1 American physicians and scientists who studied medicine or basic science in Europe, especially in Germany, returned to America and became faculty in those university-affiliated medical schools.3 The drive for educational reform had begun to grow in American medical schools.

At the beginning of the 20th century, there were more than 150 medical schools in America. Some were affiliated with larger universities, such as Harvard and the Universities of Pennsylvania and Michigan. These university-affiliated medical schools pioneered educational reform in the late 19th century.4 The curriculum became more structured and organized, including basic science in the early phase and clinical medicine in the later phase. The length of the curriculum also increased from 2 years to 3 years, and then to 4 years. Experience performing laboratory experiments was emphasized during the basic medical science curriculum. Criteria for admission or graduation became stricter, and formal assessments were included in the curriculum. These university-affiliated medical schools awarded their graduates an MD degree.1 Despite the educational reform in these pioneering medical schools, many proprietary schools had experienced minimal change since the previous century. Proprietary schools unaffiliated with a larger university could not afford laboratory facilities or sufficient full-time faculty. They also could not raise their standards for admission and student promotion due to the fear of losing students to competitor schools. The gap between leading university-affiliated medical schools and proprietary schools became larger than at any other time in history.5

BACKGROUND AND CONTENT OF THE FLEXNER REPORT

The Association of American Medical Colleges (AAMC), established in 1890, led the reform of medical education in the late 19th and early 20th centuries.5 The AAMC was a strong advocate of academic medicine, including research within medical schools, which was only possible in university-affiliated medical schools. The AAMC also recommended raising the criteria for admission into medical schools. This was possible by the end of the 19th century, mostly because overall basic education in America had considerably improved.6

The American Medical Association (AMA), founded in 1847, aimed to protect physicians’ rights nationwide, initially focusing on the exclusion of unqualified practitioners and promotion of trained physicians.7 By the late 19th century, most states required formal medical education for licensure. This was possible due to the growing public trust in scientific medicine during the late 19th and early 20th centuries. Subsequently, this period was called the “Progressive Era” in American history.5 In 1904, during the “Progressive Era,” the AMA established the Council on Medical Education to evaluate medical schools. After conducting a 2-year investigation, the AMA Council on Medical Education asked the Carnegie Foundation for the Advancement of Teaching to conduct an independent evaluation of medical schools. The Carnegie Foundation appointed Abraham Flexner (1866–1959) to lead the evaluation process, and the Council on Medical Education supported Abraham Flexner during his 2-year investigation (1909–1910).8

Flexner’s report was originally titled “Medical Education in the United States and Canada.”9 It had two sections. The first section addressed the ideal principles of general medical education and the practical issues of real-world American medical education. The second section provided details about medical schools in the United States and Canada. Flexner himself adopted two major principles for medical education.8 He argued that medicine should be and already was “scientific medicine.” Therefore, science (e.g., physics, chemistry, and biology) is—and should be—the basis of modern medicine, and scientific methodology is the core of medical practice. To realize the first principle in medical education, he emphasized the experiential learning of medical students in the laboratory and clinic, which the well-known educationist John Dewey (1859–1952) called “learning by doing.” This educational philosophy and the corresponding movement were later termed “progressive education.”4

Based on these education principles, Flexner evaluated medical schools using five criteria: admission requirements, number of faculty members, financial support, laboratory facilities, and clinical facilities.9 The leading university-affiliated medical schools already met these criteria, whereas the smaller proprietary medical schools were the main targets of harsh criticism regarding their educational environments. Flexner strongly argued that all the proprietary medical schools should be closed, except when they were high-quality university-affiliated medical schools.

THE INFLUENCE OF THE FLEXNER REPORT ON MEDICAL EDUCATION IN THE UNITED STATES

The public’s response to publication of the Flexner Report was sensational.8 Remember, this was the “Progressive Era” when public trust in scientific medicine was stronger than ever. The public could not accept that many schools still did not teach scientific medicine and produce scientific physicians. Most medical educators, many of them in university-affiliated medical schools, also fully supported the report; most of the proprietary medical school staff members were outraged by the harsh criticism they received. However, the drive for further educational reform had become unstoppable and continued to accelerate.

After the Flexner Report, the era of medical philanthropy began.10 Extensive funding from national foundations, including the General Educational Board, Carnegie Corporation, and Rockefeller Foundation, poured into American medical schools, along with local support and individual donations. From 1902 to 1934, an estimated 154 million dollars were donated to medical schools; this amount was almost equal to half of the total amount supporting higher education during that period. The financial support was crucial for expanding laboratory facilities and recruiting more full-time faculty. However, the support was exclusively directed to university-affiliated medical schools, which made it extremely difficult for proprietary medical schools to survive during educational reform.

As an overall consequence of educational reform, the number of medical schools decreased from 160 at its peak in the early 1900s to 76 by 1930. Conversely, the average number of students in each school almost doubled; the total number of graduates every year remained relatively steady (between 3,500 and 4,500). However, because the total population was increasing, the number of physicians per capita decreased by one third (from 173 to 125 per 100,000 population) during the period.11

Because most of the smaller proprietary medical schools closed in the early 20th century, it became much more difficult to enter medical school, especially for women, Black individuals, and people with low income.12 Many of the sectarian medical schools that had accepted women and Black individuals had closed with the other proprietary schools. During the period of educational reform, admission requirements became stricter, and tuition became more expensive due to increasing overall cost of education. Medical professionals themselves became part of the upper class of society. Medical education also sought academic excellence over educational equity or training a sufficient number of physicians to serve the community and public. After the educational reform in the early 20th century, academic medicine based on rigorous research and academic excellence became the gold standard for medical education in the United States for the next 100 years.

HISTORY OF MEDICAL EDUCATION IN KOREA

Before analyzing the impact of the Flexner Report on medical education in Korea, it is important to consider how historical, philosophical, cultural, social, political, and economic contexts have shaped the background of medical education. The history of medical education in Korea spans approximately 100 years since the introduction of western medicine. According to data from the Korean Medical Association, medical education in Korea evolved through several phases: the adoption of western medicine before 1910; the period of Japanese colonial rule from 1910 to 1945; the emulation of American medical education from 1946 to 1960; and the establishment of American-style medical education from 1961 to 1976. During the progression from the 1970s to the 1990s, concepts of educational methodology and evaluation began to be actively introduced; as Korea entered the 2000s, earnest discussions began regarding the identity of Korean medical education.13,14

Japanese-style western medicine was formally introduced to Korea under Japanese colonial rule, but after Korean liberation, the dominant influence on the establishment and implementation of medical education shifted from Japan to the United States.

Unlike the United States, where a student must complete a 4-year degree program to enter medical school, Korea introduced a 6-year program for medical schools. This was due to circumstances similar to the colonial era, when secondary education was not well-established and only a tiny fraction of students progressed to university. The familiarity and preference for the Japanese imperial university model, which includes a 6-year medical education program with 2 years of pre-medical education, overshadowed the unfamiliar American-style medical school model. In the 1990s, it was necessary to restructure the higher education system by categorizing graduate education into general and professional graduate schools, similar to the system in the United States. However, this reorganized medical school system did not persist, and it eventually reverted to the previous academic system.15,16

Rapid economic growth in Korea led to increased demand for healthcare in the 1960s; new medical schools were established, resulting in a total of 41 schools and an annual admission capacity of 3,300 students in the 1990s. A reduction in the admission quota for medical schools in Korea began to be formally discussed during the pharmaceutical division struggle in 2000. After this struggle, in an effort to fulfill the promise to reduce medical school admissions, the Ministries of Health and Welfare and Education agreed to decrease medical school admissions by 10%. This led to a gradual reduction in medical school admissions, totaling 351 places by 2007. Since then, medical school admissions have been maintained at 3,058 places for 18 years.15

In 2020, the government announced plans to increase medical school admissions and establish public medical schools. However, these plans were postponed due to opposition from the medical community. Nevertheless, the shortage of physicians in some specialties, collapse of essential medical services, and disparities in healthcare across regions have prompted reconsideration of expanding medical school admissions.

INFLUENCE OF THE FLEXNER REPORT ON MEDICAL EDUCATION IN KOREA

Standardized curriculum

Flexner proposed that a 4-year medical education program would be ideal, consisting of 2 years of basic science and 2 years of clinical training; this format has been largely maintained and continues to serve as the standard curriculum for most medical schools in the present day. The Flexner Report argued that science and medicine are inseparable, and that clinical medicine should be based on a solid foundation of basic science. It also emphasized hospital-based practice and active participation in patient care during clinical education.1

This approach helped to standardize medical education, but it has been criticized for several reasons. First, there is no integration between basic and clinical medicine. This led to a disconnect when transitioning from basic medical sciences to clinical medicine. There was also criticism that the biomedical model received excessive emphasis, leading to abandonment of patient-centered holistic care. To address these criticisms, integrated basic-clinical education programs have been introduced, along with efforts to strengthen humanities and social medicine education, such as communication skills and ethics.17

Accreditation evaluation

The Flexner Report served as the foundation for standardized accreditation systems in medical education. It presented criteria for medical school accreditation, laying the groundwork for subsequent medical school accreditation evaluations.

In Korea, the need for medical school accreditation began to be recognized in the 1970s and 1980s, when many medical schools were established, and the quality of medical education became a major concern within the medical community. Although the introduction of accreditation prevented indiscriminate establishment of medical schools, it was not solely driven by this concern. Instead, the introduction of accreditation was part of ongoing efforts to enhance the overall standard of medical education in Korea, influenced by experiences in countries such as the United States, United Kingdom, and Australia with regard to implementing successful accreditation systems. The increased discussion of medical school accreditation by the Council of Deans from 1990 to 1992 was also prompted by concerns about the continued establishment of medical schools. These concerns led to resolutions opposing the establishment of new medical schools, supported by major medical organizations including the Korean Medical Association.

The Accreditation Board for Medical Education in Korea was founded in 1998 as a voluntary organization but gradually gained strong support from the medical community. It successfully evaluated all 41 medical schools from 2000 to 2004. In 2004, it was renamed the Korean Institute of Medical Education and Evaluation (KIMEE) and received government recognition for its accreditation efforts. In 2014, the Ministry of Education officially recognized KIMEE as an Institute for Accreditation of Higher Education Evaluation. Consequently, in the certification conducted by KIMEE, Seonam University School of Medicine was not accredited; it eventually closed in February 2018.18

Rigorous academism

The Flexner Report proposed the integration of medical research and education, advocating for research-based education to advance medical knowledge. To Flexner, the need for medical schools to produce an appropriate number of doctors for society was secondary. He had chosen the most rigorous academic model, and the direction of medical education in Korea also focused on academic medicine.

After the American-style academic system was introduced and medical education became the responsibility of universities following liberation, Korean medical education also focused on producing elite doctors who prioritize academia. Moreover, medical school professors who studied in the United States during and after the Korean War led the development of medical science and technology by introducing advanced American medicine.15,19

The remarkable progress in healthcare within Korea, driven by academically focused medical education, is undeniable. However, recent issues such as doctor shortages in some specialties, the collapse of essential medical services, and the need to address regional disparities in healthcare delivery have prompted reassessment of the current direction.

REFLECTION ON THE CURRENT STATE OF MEDICAL EDUCATION IN KOREA

Healthcare in a country is influenced and determined by the specific history, culture, economy, and politics of the society in which it is implemented; similarly, the system of physician training and medical education can only be understood within the context of the factors inherent to a particular society.

The question of which type of physician to cultivate, one with a solid theoretical and academic foundation or one immediately able to practice, depends on the effects of factors such as a country’s healthcare system, culture, and educational environment. Medical education in countries such as the United Kingdom, Canada, and Australia, where active medical education research is conducted, focuses on training primary care physicians to support their national healthcare systems. Therefore, early exposure to clinical practice, integration of clinical and basic medical education, and an emphasis on problem-solving abilities and competencies are key characteristics. However, in these countries, medical research and development largely depend on a few elite medical education institutions; specialist training is limited to the extent necessary for their healthcare systems. Under such medical education systems, medical humanities are often limited to communication skills and other practical competencies required for clinical practice.20,21

After the Flexner Report, academic aspects of medical education in the United States were emphasized. Despite subsequent remarkable socioeconomic advances by American physicians, the emphasis on elite medical education led to a shortage of primary care physicians in local communities by disrupting the tradition of secondary-level physicians that existed in Europe.21

The medical education system in the United States has a professional school system targeting university graduates; within this system, there has been a consistent emphasis on specialized medical education. The question of whether to cultivate elite physicians who prioritize academia or primary care physicians capable of practical work is a fundamental dilemma in medical education, greatly influenced by each country’s healthcare system.

Although Korea claims that medical schools produce primary care physicians, the actual roles of primary care physicians within the healthcare system are limited. As a result, basic medical education often becomes merely a preparatory stage for subsequent training. Even after they have received such training, most physicians subsequently practice in unrelated fields.22 When discussing the expansion of medical school admissions, a key question must be addressed: “What kind of physicians should we cultivate?” It is essential to redefine the direction of medical education to cultivate the physicians that society truly needs and to address the phenomenon of medical school admissions frenzy prevalent in Korean society.

The proposal to increase admissions by more than 60% of the total capacity is unprecedented. An improperly planned and inadequately prepared expansion of medical school admissions may lead us back to an era of confusion, similar to a century ago. Moreover, it remains uncertain whether increasing the number of physicians who provide care to patients in each region will effectively address the many issues we face, whether the concentration of healthcare resources in metropolitan areas will be alleviated, and whether the increased amount of healthcare will satisfy the heightened expectations of the populace.

Over the century since the introduction of western medicine, medical education in Korea has made remarkable progress, which is commendable. The issue of expanding medical school admissions cannot be separated from the quality and extensive history of medical education accreditation. When enrollment exponentially increases in a short period, maintaining the quality of medical education, as history has demonstrated, is not an easy task.

CONCLUSION

The 1910 Flexner Report had a profound impact on medical education in the United States and beyond, including Korea. The report’s emphasis on higher admission and graduation standards, as well as its advocacy for a more science- and research-based approach to medical education, led to extensive reforms in the field. A standardized medical curriculum, accreditation bodies, and academic medicine in Korea are products of the Flexner Report.

The recent conflict over expanding medical school admissions highlights concerns about the quantity and quality of medical education, who is qualified to become a doctor, and how they should be educated. The challenges of expanding medical school enrollment require careful consideration. However, there is a lack of thorough discussion among the government, medical community, and public regarding the justification for expanding medical school admissions and the necessary investments and efforts. It is imperative to move beyond debates solely focused on increasing admissions and engage in comprehensive discussions about the future direction of medical education. These discussions require building consensus and devising concrete action plans and support measures to achieve these goals.