Abe Flexner, Where Are You? We Need You!

Abstract

It is just a century since Abraham Flexner was invited by the Carnegie Foundation to evaluate medical education in the U.S. and Canada. After a visit to all of the existing medical schools at that time, Flexner issued a report in 1910 that revolutionized American and Canadian medical schools. The demise of proprietary schools, the solidification of ties between medical schools and universities and the introduction of the laboratory into the curriculum were outcomes that inaugurated the Flexnerian era in medical education. American and Canadian schools became the world's leaders. The educational patterns that emanated from the report dominated medical school curricula for the remainder of the 20^th century. But as science and medicine changed drastically during the past 50 years, medical education has floundered and changed little. Although the environs of clinical education (hospitals and clinics) are dramatically different than 50 years ago, the process of clinical training has barely changed. That education is a science has yet to be fully acknowledged by medicine—witness the lack of continuity of undergraduate, post-graduate and continuing education. Medical education remains an ‘orphan’ supported by clinical practice and research in the same fashion that medical educators are ‘orphans’ in the academic promotions process. There is need for a modern day Abe Flexner—someone to pull the disparate parts together, to shake-up the lethargy and complacency, to streamline medical education into the 21^st century.

Introduction

Almost 100 years have passed since Abraham Flexner was invited by the Carnegie Foundation for the Advancement of Teaching to critique medical education in the U.S. and Canada. Flexner, a school master from Louisville, Kentucky, had spent the 1905–06 academic year in graduate school at Harvard and the following year in Europe focusing on the university-based system of medical education in Germany. On his return to the U.S., he convinced Henry Pritchett, the president of the Carnegie Foundation, and several distinguished members of the Foundation's Board that he was the right person to evaluate medical education in North America. His appointment was likely aided and abetted by his brother Simon, who at that time was the first president of the Rockefeller Institute, admired by Pritchett and Board members and a strong advocate of the Johns Hopkins model of medical education. The story of the Flexner family is an American saga (1,2) and a true example of ‘family values’.

The Flexner Report

From November of 1908 through December of 1909, Flexner visited the 155 medical schools that existed in the U.S. and Canada at that time and speedily drafted a report (3) that had a profound effect on medical education, biomedical research and ultimately on the delivery of medical care in North America through the 20^th century. While the Report was a ‘damning indictment’ of the manner in which American physicians were being trained, particularly in the commercially inspired schools of medicine, so many of the recommendations and reforms urged in the Report had been already implemented in schools such as Johns Hopkins, Pennsylvania, Michigan, Toronto and Harvard—in many instances these schools had incorporated Flexner's standards twenty years previously (4). Among the recommendations in the Report, there are three themes that I would focus upon, as their impact on our current academic structure is profound: 1. Ties between medical schools and universities—the end of proprietary medical schools; 2. Laboratory experience in all of the sciences—investigative science joined to practical training in the education of a modem doctor 3. Medical education, just as elementary and secondary school education should be progressive.

Flexner sought the death of all commercial or proprietary medical schools and urged the linkage of all medical schools with established universities. While this recommendation evolved slowly over the first half of the 20^th century, the outcome of this linkage of medical schools and universities is the modern academic medical center: these centers translate advances in research to quality clinical care (5,6). Academic medical centers are the natural outgrowths of Flexnerian influence.

In a second series of recommendations, Flexner insisted that modern, spacious, well-equipped laboratories be available in each of the basic disciplines (anatomy, physiology, materia medica, etc) and ‘that research untrammeled by near reference to practical ends go on in every properly organized medical school…’ and that research be required of the medical faculty, because only research will keep ‘teachers in condition’. From these recommendations of Flexner evolved the NIH-era of the 50's and the burgeoning of biomedical research that emblemized the second half of the 20^th century in the United States (7). The installation of laboratory sciences into the medical curriculum nurtured the growth of the biosciences, technology, bioengineering that flourish today.

A third set of recommendations in the Flexner Report center around education—both pre-medical and medical school education. Flexner, a champion of the educator John Dewey, felt strongly that medical education has close analogies to primary and secondary education. He agreed with Dewey that ‘the initiative lies with the learner’ and that education involves more than an accumulation of facts but a method of inquiry, thinking and problem solving. Flexner prescribed formal preparation of students before medical school and a full opportunity for medical students to participate directly in patient care during medical training. The paradigm of a comprehensive pre-clinical and clinical curriculum that gradually took hold in all medical schools in North America was constructed from the Flexnerian mold.

Aftermath of the Flexner Report

From the vantage point of almost a century of retrospective observation since the issuance of the Flexner Report, I would contend that the evolvement and maturation of academic medical centers and the growth and sophistication of the biological sciences (e.g., molecular biology, genetics and immunology) have been progressive and continual (Figure 1). In contrast, medical education has lingered and stagnated at its 1950's level. While the pre-clinical curricula in medical schools now incorporate ‘the new sciences’, the format of educational programs has changed little, integration of the biological and social sciences so integral to medicine is so rarely attempted, and the silo approach that has each pre-clinical department doing ‘their thing’ remains dominant. Most stagnant is the clinical curriculum—the structure of clerkships has changed little in the last 50 years, in spite of the drastic changes in the ‘school house’—the wards, clinics and private offices employed for student instruction. In reality, medical education was ‘thalidomized’ in mid-century while the other ‘legs’ of the classical three-legged stool of medical academia thrived.

Fig. 1.

The Aftermath of Flexner During the 20^th century, academic medical centers developed and matured progressively, the basic sciences burgeoned, while medical education stagnated at mid-century.

Medical Education as a Science

Why is this? Why did medical education stagnate during the last half of the 20^th century? One reason is that as physicians we fail to recognize or acknowledge that medical education is a science. The premise that ‘all doctors are teachers’ falsely pervades our culture. After all, ‘doctor’ is derived from ‘docere’, the Latin ‘to teach’. Education is a science. In his clinical experiments with Aplysia (the giant marine snail) the Nobel laureate, Eric Kandel, isolated neuronal units to decipher the molecular biology of both short-term and long-term (memory) learning. Kandel and his colleagues observed the gill withdrawal reflex of Aplysia and how that reflex is modified in the two forms of learning (8,9). In brief, these seminal observations on the molecular biology of short- and long-term learning have been extended by Kandel and many other neuroscientists to the mammalian hippocampus and learning in higher animals (10). While this brief summary does a disservice to the brilliance of this experimental work, suffice it to say, learning (including medical learning) has a molecular basis.

The neuronal units that house the molecular pathways of learning are the loci for the physiology of learning. Just as with other biological processes, when the molecular processes go awry, pathological disorders result. Most of us are familiar with common learning disorders, such as dyslexia or attention deficit disorders, but in fact, there are many other types of learning disorders currently being elucidated. The clinical field is still in its nosological stage. As the molecular science of learning and memory is refined, the clinical science of defining learning disorders and devising therapeutic approaches matures.

An example of a learning variant encountered while working closely with medical students over the past 20 years deals with students whose native language is Spanish and second language is English. One group of such students must translate the lecture, tutorial and other curricular material from English to Spanish before responding in class. These students commonly have difficulty with standardized examinations such as the National Boards. Other students with the same background with Spanish as their native language and English as their second language overcome the ‘two language center’ phenomenon and readily manage texts, lectures and other didactic information in English while maintaining fluency in Spanish. Kim and colleagues reported on this ‘language learning disorder’ and using functional MRI, demonstrated that in the individuals who translated material back to their native language the language sensitive areas in the cortex (Broca area) are spatially separate, unlike the other group where the language areas coalesce (11). I point out this ‘language learning disability’ as one example of the multiple learning disorders we encounter among a very intelligent medical student population. Medical education is a science with its own molecular basis, physiology, pathophysiology and clinical entities.

What Would Abe Recommend?

If there were to be a Carnegie Foundation study of current-day medical education, what might its Abraham Flexner recommend? Flexner would observe the striking discontinuity of the several levels of medical education—the absence of a planned, organized progression as the student moves from undergraduate medical education, then graduate medical education and for the duration of professional life, continuing medical education. Flexner would address the need to develop links between the organizations responsible for accrediting these discontinuous segments, recommend pedagogical methods that thread through the entire spectrum of medical education and emphasize that the competencies developed in medical school are the building blocks for life-long learning. Abe Flexner would scold the organizations responsible for the accreditation of the several levels of medical education and the leaders of these organizations for the poor communication between the bodies. Flexner would be especially critical of the proprietary aspects of continuing medical education (12).

Flexner of 2006 would cite the massive body of scientific knowledge accumulated during the last 50 years and the impact of that knowledge on the process of medical education and learning as a whole. Modern medical educators must understand how individual adults learn, the assessment tools used to evaluate not only individual learning but the several methods of teaching as well as the individual student's ability to reason and problem solve. He would be astonished by the advances in electronic technology and its application to medical education. In essence, Flexner would envision ‘medical education’ as a specialty not unlike cardiology or neurology (Figure 2). If medical education necessitates a set of skills, a core of knowledge that requires constant updating, he would reason ‘why not establish a cadre of ‘specialists’ who bring the advances in education to the training of our medical students, residents and practicing physicians?’ It is time that such teachers as clerkship directors, training program (residency) directors and the directors of continuing medical education in hospitals be encouraged to acquire formal ‘specialty’ training, enroll in fellowship programs or even earn advanced degrees in education.

Fig. 2.

Medical Education as a Specialty Medical education should be regarded as a specialty, and leaders in medical education should acquire advanced training. Examples: MEd = Master of Education; MBA = Master in Business Administration, JD = Doctor of Law; Cardiology fellowship, Plastic Surgery residency; MMS = Master in Medical Science; MPH = Master in Public Health; MPP = Master in Public Policy.

Among the other recommendations the modern day Flexner might make is ‘look around you—apply the education instruments you are using in the clinical arena’. We encourage comparative clinical trials of drugs, procedures and other therapeutic approaches yet never apply this principle to medical education. In a similar fashion, we review medical outcomes both in hospitals and ambulatory environments, then modify or alter the clinical approach if the outcomes are not up to standards. We fail to apply similar approaches to medical education. Flexner would ask: ‘is it not time to compare different education techniques to the approaches to clinical education?’ As an educator, he would urge that process of outcome analysis and clinical trials are very applicable to medical education.

Summary

Advancements in the biological sciences and their translation to patient care are the hallmark of 20^th century medicine. While our knowledge of molecular biology and our abilities to treat disease in academic medical centers increased incrementally during that century, parallel and analogous progress has not characterized medical education. Medical education is a science to be treated as other clinical sciences. Flexner would urge that we apply processes now employed in clinical practice to medical education. The ‘new Flexner Report’ will so stimulate medical education—its organization, teachers and methodologies—so that its ascendancy matches that of the biological sciences and clinical services.

DISCUSSION

Friesinger: Nashville: Thank you very much. I have two questions as a follow up to Dr. Peabody's comment about stirring up the profession. I think the profession ought to feel some urgency about this, as you suggest, sort of a Flexner II by 2010. That would be the centennial of bulletin IV. Talking with my colleagues who are in a position of responsibility and authority, I don't get the idea that the thing is really brewing at a very fast pace. So first question is: is that true, that we are still pretty indolent, and the second has to do with the idea that even Flexner, in all his visionary wisdom, could probably not have predicted this tremendous specialization and sub-specialization and sub-sub-specialization and the length of medical training. So, as a philosophic approach to reform, must we not put the pre-doctoral and post-doctoral experiences in some kind of context as a collaborative and continuous experience, rather than truncated as they are now by awarding the M.D. degree as if it is the end of medical education.

Arky: Boston: I agree with your comments. The answer to your first question is: no, there does not seem to be a ground swell to bring about much reform. Some of my colleagues who follow will show some attempts at reform. Secondly, I had actually intended to talk about the discontinuity in medical education and the steps that should be taken to correct that. Currently, continuing medical education has a semblance to what went on a century ago in general medical education; that is, it is too proprietary and needs reform. I agree with you that the pre-doctoral and post-doctoral experience should be collaborative and continuous.

Michael Thorner: Charlottesville: I really enjoyed your presentation. I was just going to make the comment that this group has been concerned for a long time with the dying breed of the clinical investigators. In the last two or three years, Dr. Zerhouni, the Director of NIH, has taken a new approach to actually revamp and start from scratch again to encourage people to do clinical investigation, including taking non-doctors, or non-medical people, and teach them to do clinical investigation. So, I agree with you that this requires starting from scratch again.

Cimino: New York: Twenty years ago, Harvard Medical School tried an experiment called The New Pathway, where they did a randomized, controlled trial of teaching medical students in the traditional way and in a new, fairly radical approach. I wonder if you are familiar with that experiment and if so, could comment on the lessons learned by the change in approach and also the lessons learned about how to do those kinds of experiments.

Arky: One of the reasons I am here is that when we started the New Pathway, we did not build in the appropriate assessment processes. If you ask whether after twenty years we have produced a different product, a better product or a product with value-added benefits, I cannot provide a definitive answer. I am biased and feel strongly that any educational experiment should not be initiated without built-in assessment processes.