Friday, October 26, 2012

A hundred years of Flexner

Many sources describe the state of Medicine and Medical Education in the USA around the turn of the 20th Century as overcrowded, extremely poor and variable, driven by profits and dreams of riches with practitioner licenses handed out by poorly run Registration Boards via easily scammed exams. [1] [2] [3]

The US AMA was looking to properly regulate the profession and. while doing so, increase their power and influence and drive out of business competing “medical sects”.

This “cleaning of the Augean Stables” started well before 1904 and the AMA’s Council on Medical Education (CME) first proposals, pitched to, and taken up by, the Carnegie Foundation for their first report on “The Professions” in 1910.

That the Carnegie Foundation’s report [4] was original or the cause of a Revolution is ISM/FSM propaganda. They are peddling The Big Lie in an elaborate Con. They also confuse and conflate Medical Education with Medical Practice. While Education is necessary for good Practice, much more is needed.

Flexner wasn’t a medical practitioner, but a 40yo ex-teacher, his claim to fame a book on reforming College Education in the USA written after 2 years in Europe. This book, and perhaps his brother teaching at John Hopkins, adopted as the “model” for Medical Education, got him hired by the Carnegie Foundation to write the CME requested report.

He was then hired by Rockefeller’s General Education Board where he worked for 15 years as head of the “Division of Studies” before losing an internal power struggle. He then went on to setup and head for 10 years the “Institute of Advanced Studies” (IAS), who hired the likes of Einstein. [5]

Rockefeller’s General Education Board funded the CME/Carnegie Foundation reforms over the next 20 years and should be acknowledged as bringing about the revolution. Quite quickly the number of “schools” was reduced from 155 to 31, growing to around 60 in the next 2 decades.

ISM/FSM cite the 1910 report by Abraham Flexner as their primary source, to understand their ideas and proposals, Flexner must be discussed.

Not only do ISM/FSM take just his some of his recommendations as the entirety of his writing, they leave out the context of this long-running Healthcare Reform.  Flexner/CME recommended Medical Registration Boards examine students only from approved Institutions with approved curricula of Theory, Lab work and Clinical Training: a rubber-stamp of the AMA CME’s work.

Perhaps what especially draws ISM/FSM to Flexner is the immoderate language, matching their own, succinctly described as: excoriating most of them in the colorful language of his muckraking contemporaries. [6]

There are three questions to answer about Flexner’s report: Is it still relevant? What would he say today? and What did he mean by “Scientific Medicine”? 

Importantly, Flexner only addressed a specific, limited question: “How should we teach Medicine?”.
A limited form of the more important question of Practice: How do we create a competent, ethical and self-sustaining Medical Profession? Still as pertinent and unsolved today as then.

Notably, Flexner and the CME like ISM/FSM, did not offer proof of the benefits America would see from their proposals. It was American Medicine that desperately needed reform, not Everyone, Everywhere as ISM/FSM are now advocating.

ISM/FSM relying on a century old report is quaint. Like teaching management with century old texts: e.g. Taylor’s “Scientific Management”. While containing some truths they, like Flexner,  don’t address today’s problems nor include the results of 100 years of thinking, research and real-world trials.

We can’t know what Flexner may have written today, but we do know what his employer, the Carnegie Foundation, thinks. In 2010 they published “Educating Physicians: A Call for Reform of Medical School and Residency” [7]. It makes 7 key recommendations and sets goals, but again limited to education, not all Professional Practice.

If ISM/FSM wish to cite a Carnegie Foundation report,  good practice suggests that would be the current report, not one that’s ancient, irrelevant and stale.

The Flexner/CME vision of “Scientific Medicine” is not Science as we know it today. We have a very different view after Popper’s Falsifiability Theory, Gallup’s Sampling Theory, Controlled Trials and around 2 decades of “Evidence Based Medicine”.

More importantly, back then, just as now, “Scientific Medicine” was most observed in advertising with iconic images like white-coats, microscopes and “machines that go bing!”. 

The majority of Flexners’ writing was about the Practice of Medicine, not Education and Certification. The most important principle espoused by Flexner was: licenses bear a uniform value, unmentioned by ISM/FSM.

Taken to its logical conclusion, as in Aviation, this requires on-going competency testing and regular complete re-certification, not once-off testing giving a lifetime certification. With the sum of Medical Knowledge increased 30-1,000 fold in the last century, how could the Flexner/CME syllabus and recommendations apply today?

A finishing quote from: 100 Years Later, the Flexner Report Is Still Relevant, Lawrence Diller. Project MUSE [8]

The professionalism of medicine is again in question...
The hundred-year anniversary of the Flexner Report should remind physicians and the public alike that physicians do not become “professionals” merely by obtaining a medical degree. The field must collectively maintain worthy standards for itself that warrant the label.

[1] The AMA, NMA, and the Flexner Report of 1910, Ololade Olakanmi 
the Writing Group on the History of African Americans and the Medical Profession 

[2] Diseases of Men:  Sexual Health and Medical Expertise in Advertising Medical 
Institutes, 1900-1930 , PhD Dissertation, Suzanne Michelle Fischer.



[5] Bio of Abraham Flexner, from IAS.

[6] Reclaiming the American Library Past: Writing the Women in
Chap 11. Pratt Institute Library School: The Perils of Professionalisation, Barbara B Brand

[7] Summary of Educating Physicians: A Call for Reform of Medical School and Residency


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