While working with our medical school on curricular reform, an often-mentioned piece of literature is the Flexner Report. Most, if not all, of those on the committees know what this is and what it entails. However, those with whom I have discussions about the reform outside of the committees are often left dumbfounded. Many understand the need to reform medical curricula, but far less know the history of its structure in the United States.
Prior to the 20th century, American medical education was dominated by three systems. These included an apprenticeship system, a proprietary school system, and a university system. Lack of standardization inevitably resulted in a wide range of expertise. Additionally, the best students left the United States to study in Paris or Vienna. In response, the American Medical Association established the Council on Medical Education (CME) in 1904. The council’s goal was to standardize medicine and to develop an ‘ideal’ curriculum. They requested the Carnegie Foundation for the Advancement of Teaching to survey medical schools across the United States.
Abraham Flexner, a secondary school teacher and principal not associated with medicine, led the project. In one and a half years, Flexner visited over 150 U.S. medical schools, examining their entrance requirements, the quality of faculty, the size of endowments and tuition, the quality of laboratories, and the teaching hospital (if present). He released his report in 1910. It was found that most medical schools did not adhere to a strict scientific curriculum. Flexner concluded that medical schools were acting more as businesses to make money rather than to educate students:
“Such exploitation of medical education […] is strangely inconsistent with the social aspects of medical practice. The overwhelming importance of preventive medicine, sanitation, and public health indicates that in modern life the medical profession is an organ differentiated by society for its highest purposes, not a business to be exploited.”
In response, the Federation of State Medical Boards was established in 1912. The group, with the CME, enforced a number of accreditation standards that are still in use today. They implemented a curriculum with two years of basic science curriculum followed by two years of clinical rotations as their ‘ideal’ curriculum. The quality of faculty and teaching hospitals were to meet certain standards, and admissions requirements were standardized. As a result, many of these schools shut down. Prior to the formation of the CME, there were 166 medical schools in the United States. By 1930, there were 76. The negative consequence was an immediate reduction in new physicians to treat disadvantaged communities. Those with less privilege in America also found it more difficult to obtain medical education, creating yet another barrier for the socioeconomically disadvantaged in America. Nonetheless, the report and its followup actions were key in reshaping medical curricula in the United States to embrace scientific advancement.
Today, medical schools across the country embrace the doctrines established 100 years ago. Most schools continue to follow the curriculum previously imposed. Scientific rigor is a key component. However, medical educators are currently realigning curricula to embrace modern components of medicine and to focus on the service component of medicine that is central to the doctor-patient relationship.
In 2010, the Commission on Education of Health Professionals for the 21st Century was launched, one century after the release of the Flexner Report. By the turn of the 21st century, gaps within and between countries were glaring. Health systems struggle to keep up with new infectious agents, epidemiological transitions, and the complexities and costs of modern health care. Medical education has once again become fragmented. There is a mismatch between aptitude and needs of populations. We focus on hospitals over primary care. Leadership in medicine is lacking. The interdisciplinary structure of medicine requires that we no longer act in isolated professions. As a result, a redesign of the curriculum is required.
The Commission surveyed the 2420 medical schools and 467 public health schools worldwide. The United States, India, Brazil, and China, each having over 150 medical schools, were the most heavily sampled. In contrast, 36 countries had no medical schools. Across the globe, it cost approximately US$116000 to train each medical graduate and $46000 for each nurse, though the number is greatest in North America. There is little to no standardization between countries, similar to the disjointed nature within the United States in the early 20th century. The globalization of medicine thus requires reform.
Reform of medical education did not stop with Flexner. After the science-based curriculum introduced by the report, the mid-20th century saw a focus on problem-based learning. However, a new reform is now required that seeks a global perspective. A number of core professional skills were recommended by the Commission, and these must be implemented in medical curricula across the globe.
Within the United States, medical educators seek to reform curricula to be more in-line with the global perspective of the modern era, focusing more on global health initiatives and service learning. Additionally, health care reform in America will bring with it new challenges, and medical school curricula must keep up. How this will be accomplished is still under heavy discussion.
When considering any reform, it is helpful to remind oneself of its historical context. In this case, the disjointed structure within the United States at the time of Flexner parallels the disjointed global structure of the world seen today. Though changes will be of a very different nature, motivations remain the same.