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MEDICAL EDUCATION IN THE US AND CANADA ~ 1910
This subdirectory contains bio and background information on Abraham Flexner (author of Carnegie Bulletin #4) and
four commentaries on various aspects
of Carnegie Bulletin #4
(i.e., the Flexner Report)
Excerpted and recontextualized
from primary and secondary sources
1. Abraham Flexner Bio and background
2. Commentary on the Flexner Report excerpted from Wikipedia
3. The Flexner Report & the Standardization of American Medical Education ~
Journal of the American Medical Association JAMA. 2004;291:2139-2140
4. Medical Nemesis ~ A report on Catholic social theorist Ivan Illich’s theories as related in his book
5. The Amazing Logistics of Flexner's Fieldwork by Mark D. Hiatt, MD, MBA
Association of American Physicians and Surgeons (AAPS) 2000
~ Bio and Background ~ Abraham Flexner 1866-195 [complied from various sources]
Abraham Flexner was born in Louisville, Kentucky, the child of German immigrants. He spoke German, and as an adult studied and traveled in Europe. His brother, Simon Flexner, MD, was a physician employed by the Rockefeller Foundation.
Flexner graduated from Johns Hopkins University in 1886 as a teacher. He taught school for four years and then opened a preparatory school in Louisville in 1889 that he owned and operated for 15 years. In 1905 he began his post-graduate studies in professional education at Harvard and the University of Berlin, specializing in developing and administrating graduate schools education and professional training programs. To research professional educational systems in other countries, he traveled extensively in England, Germany, France, and Canada. He was well aware that in continental Europe, an extensive and specialized university education was required before anyone could practice medicine. He saw universities not as popular institutions reflecting the desires and whims of society but as intellectual leaders. "Universities must at times give society not what society wants, but what it needs".
As research fellow in 1908 at the Carnegie Foundation for the Advancement of Teaching in New York City, Flexner’s first impact on American education took the form of "Germanizing" American medical education. In effect, Flexner believed that medical education in the US should be based on the model and practices of continental Europe, which is to say a university-degree-based education in basic and advanced sciences, with an extensive clinical training element in diagnosis and performance of medical and surgical procedures. Flexner rejected the scientific validity of all healing arts other than western or ‘biomedicine’. Any practice of medicine that did not advocate the use of ‘chemical’ treatments such as vaccines to prevent and cure illness were quackery in his opinion. His policy recommendation reflected in a quote by him in his final report: “If the sick are to reap the full benefit of recent progress in medicine, a more uniformly arduous and expensive medical education is demanded.” 1
After finishing his landmark study of medical education in 1910, Flexner investigated prostitution in Europe. He was also known as an ‘able fund raiser’. Thru his personal and professional relationships with philanthropists he secured a $1.5 million gift from the Rockefeller Foundation’s General Education Board to his alma mater -- the German-oriented Johns Hopkins University.
In 1913 he left the Carnegie Foundation and joined the educational board of the Rockefeller Foundation General Education Board (GEB) as its assistant secretary. After four years, he was promoted to principal executive officer and ran the operations of the Board for eight years in partnership with its president, Wallace Buttrick. As the resident intellectual and educator on the Board, Flexner's directed the dispersal of millions of dollars of medical education endowment funds to institution that promoted ‘chemical’ (pharmaceutical medicines) and surgically-oriented medicine in the United States. Over the next 47 years, the Rockefeller Foundation’s GEB contributed $96 million to medical schools to Johns Hopkins and other university medical schools that disregarded naturopathy, homeopathy and all other forms of ‘alternative’ or non-MD practice of healthcare disciplines (such as midwifery), favoring only those that taught its practitioners to depend exclusively on the use of prescription drugs and surgery.
In the 1930s, Flexner served as first director of the Institute for Advanced Study at Princeton.
Overview & History: Flexner and the Carnegie Foundation for the Advancement of Teaching’ report on Medical Education in the United States and Canada
In 1904 the American Medical Association created an in-house committee known as the “Council on Medical Education”. This later became a stand-alone organization known as the Association of American Medical Colleges. The AMA-CME developed more restrictive standards for medical education that required additional years of didactic and clinical training. The Council also called for ‘irregular’ medical schools to be closed down, a recommendation that was an extension of the efforts going back to the 1820s to make it illegal to practice of any non-allopathic form of medicine. In 1908 the AMA asked the president of the Carnegie Foundation, Henry Pritchett, to underwrite a major study of medical schools in the United States and Canada (see link to Pritchett’s ‘Introduction’ to the original Carnegie report (bulletin #4). Pritchett was a staunch advocate of medical school reform and chose Flexner, a researcher at the Carnegie Foundation for the Advancement of Teaching, to conduct the survey.
[link: Henry S. PRICHETT. April 16,1910: The Foundation is under the greatest obligation in the preparation of this report to leading representatives of medicine and surgery in this country for their cooperation and advice. The officers of the various medical associations and of the Association of American Medical Colleges have furnished information which was invaluable and have given aid in the most cordial way. We are particularly indebted for constant and generous assistance to Dr. William H. Welch of Johns Hopkins University, Dr. Simon Flexner of the Rockefeller Institute, and Dr. Arthur D. Bevan, chairman of the Council on Education of the American Medical Association. In addition, our acknowledgments are due to Dr. N. P. Col well, secretary of the Council on Education of the American Medical Association, and to Dr. F. C. Zapffe, secretary of the Association of American Medical Colleges, for most helpful cooperation. I wish to acknowledge also our indebtedness to a number of eminent men connected with various schools of medicine who have been kind enough to read the proof of this report and to give us the benefit of their comment and criticism. .
From January 1909 to April 1910, Flexner visited 167 medical colleges and post-graduate programs in the U.S. and Canada seeking data on five points for each school:
(1) entrance requirements and adherence to them
(2) size and training of the faculty
(3) amount of tuition, endowments and fees to support the institution
(4) quality of the laboratories and qualifications of the laboratory instructors
(5) relationships between the school and hospitals used as sites for clinical training
By his own admission, Flexner had “no fixed method or procedure” and used no standard questionnaire. As a layman, he had never: “[set] foot inside a medical school” and “knew neither anatomy, physiology, nor psychology enough to warrant embarking on a highly specialized bit of experimentation.” Although this obviously conflicted with the scientific medicine Flexner claimed to promote, he himself admitted that it’s “inconsistency never bothered me.”
The plan called for Flexner to travel to and comprehensively evaluate each campus of 167 geographically dispersed institutions scattered over the entire North American continent. The actual number of site visits was even greater (175), since some schools maintained separate campuses in different cities. According to the itinerary in his footnotes [see addendum] he would have had only a fraction of a day to travel and evaluate each of the 167 institutions. Although 16 months were allotted to the fieldwork, the majority of the visits occurred in only in eight months.
He made 157 or 90 % of his site visits in approximately 240 days. His pace was even more amazing in April 1909, when he investigated 31 schools in 30 days in six western states (Colorado, Illinois, Iowa, Missouri, Nebraska, and Utah). Flexner often visited schools when they were not in session and toured some institutions unaccompanied by school officials. On one occasion bribed the janitor to open the laboratories; when he didn’t see any microscopes or other apparatus, he concluded that the school had no laboratory equipment. He never checked with the director or considered other possibilities, such as locking up valuable equipment.
The logistical challenge of visiting multiple schools in such a limited period of time was complicated by frequently returning to his home base in New York, where he stayed for many months at a time. Train travel was fastest, but still took one to three days in each direction. Excluding weekends, the train-dependent Flexner would have had only 0.71 of a 12-hour day per school.
Flexner readily admitted that his tour of medical schools was "swift," and that he finished his inspections "within less than a year." His explanation of these methods was his personal maxim of Ambulando discimus or "we learn by going about". His strong negative report on American medical education was quickly picked up by the Hurst and other publishing empire and syndicated all across the country as a front-page story. As a result, about half of the medical schools in the United States were forced to close. This included all that taught non-AMA approved methods and nearly all that accepted women and minorities.
As of 2010, the recommendations in the Carnegie Foundation’s “Medical Education in the United States and Canada” will have defined both medical education and medical practice as an intensely hierarchical product under their exclusive control for 300 million people for an entire century. However, the underlying research for this power-broker document was undertaken at the request of the AMA and all the parameters were established by the AMA’s Council of Medical Education and the AMA’s sister organization the Association of American Medical Colleges. Unfortunately for us all, its conclusions have never been questioned by the public, the unbiased scientific community or reexamined by other health professionals or policy-makers.
It was not until 1975 that anyone publicly questioned society’s blanket acceptance and dependence on AMA defined, drug and surgery centric healthcare. When someone finally did,it came from an unlikely source -- a Catholic social theorist by the name of Ivan Illich. His book Medical Nemesis subjected the allopathic practice of medicine in the US to detailed scrutiny. Illich was the first to introduce the concept of iatrogenic disease to the public. He argued against the routine medicalization of life.
In this context, medicalization is usually defined as “the process by which health or behavioral conditions come to be defined and treated as medical issues. The term refers to the process by which certain events or characteristics of everyday life become medical issues, and thus come within the purview of doctors and other health professionals to engage with, study, and treat.” [Wikipedia: definition of ‘medicalization]
Since 1910 many aspects of normal biology, including normal childbirth and anticipated natural death (example: elderly or terminally ill persons) have become intensely medicalization. Ivan Illich was convinced this caused more harm than good and had turned the entire population of the United States into lifelong patients. Mortality and morbidity statistics in his book also showed the ‘shadow side’ of medicalization, in the shocking extent of post-operative side-effects and drug-induced illness in now rampant in advanced industrial societies that depend solely on drugs and surgery for all their healthcare needs.
Title Page for:
MEDICAL EDUCATION IN THE UNITED STATES AND CANADA
A REPORT TO
THE CARNEGIE FOUNDATION FOR THE ADVANCEMENT OF TEACHING
BY ABRAHAM FLEXNER
INTRODUCTION BY HENRY S. PRITCHETT,
PRESIDENT OF THE CARNEGIE FOUNDATION
576 FIFTH AVENUE NEW YORK CITY
BULLETIN NUMBER FOUR
The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation. Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.
The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. This was a reversal of a trend by universities, which had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.
In the late 19th century, what came to be called modern medicine emerged after a struggle with other forms of medicine such as homeopathy. This new medicine was grounded in antiseptic surgery, the germ theory of infectious disease (which informed a large number of effective public health measures), and the scientific method, including evidence-based medicine and clinical trials. In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education.
At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.
At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: “Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated.” The Report became notorious for its harsh description of certain establishments, for example describing Chicago's 14 medical schools as “a disgrace to the State whose laws permit its existence... indescribably foul... the plague spot of the nation.”
Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.
The length of medical education be four years, and its content should be what the CME agreed to in 1905.
Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.
Less known is Flexner's recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become "true university teachers, barred from all but charity practice, in the interest of teaching." Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner's recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.
Consequences of the report
To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:
A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;
Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry
Medical research adheres fully to the protocols of scientific research;
Average physician quality has increased significantly;
No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;
Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;
Medicine in the USA and Canada becomes a highly paid and well-respected profession……….
The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;
The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 90 years old, many of its recommendations are still relevant—particularly those concerning the physician as a "social instrument... whose function is fast becoming social and preventive, rather than individual and curative."
Closure of many medical schools
According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.
Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.
American medicine becomes a less diverse profession
At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the Leonard Medical Center, the oldest four-year medical school in the country for African-Americans. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.
Impact on alternative medicine
When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physio-medicalism, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physio-medicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.
Impact on osteopathic medicine
Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.
Beck, Andrew H. (2004), "The Flexner Report and the Standardization of American Medical Education", JAMA: the Journal of the American Medical Association 291 (17): 2139–2140, doi:10.1001/jama.291.17.2139, PMID 15126445
Barzansky, B.M.; Gevitz, N. (1992) (w), http://books.google.co.uk/books?hl=en
Beck, Andrew H., 2004, "The Flexner Report and the Standardization of American Medical Education", Student JAMA 291: 2139–40.
Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press. ISBN 0801871247.
Flexner, A., 1910. Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
Goodman, John C., and Gerald L. Musgrave, 1992. "How The Cost-Plus System Evolved". Patient Power. Washington, D.C.: Cato Institute,W67.
Kessel, Reuben, 1958. "Price Discrimination in Medicine", Journal of Law and Economics 1 (Oct., 1958): 20–53.
The Flexner Report & the
Standardization of American Medical Education
Medical education in the United States today is strikingly standardized and demanding. It was not always so. Prior to the widespread implementation of educational reforms, medical training was highly variable and frequently inadequate. It was not until the early decades of the 20th century that a "uniformly arduous and expensive" system of medical education was instituted nationally.
Throughout the second half of the 19th century, the American Medical Association (AMA) lobbied for the standardization of American medical education.
However, by the turn of the 20th century, a series of scientific breakthroughs had altered the values held by the public and the medical profession: clinical and laboratory research had exposed the irrationality of "heroic" treatments (such as blistering, bleeding, and purging)
The AMA sought to eliminate schools that failed to adopt this rigorous brand of systematized, experiential medical education. "It is to be hoped that with higher standards universally applied their number will soon be adequately reduced, and that only the fittest will survive," the editors of JAMA declared in 1901.6
In 1904, the AMA created the Council on Medical Education (CME) to promote the restructuring of US medical education. At its first annual conference, the CME outlined its 2 major reform initiatives: standardization of preliminary education requirements for entry into medical school and national implementation of an "ideal" medical curriculum, consisting of 2 years of training in laboratory sciences followed by 2 years of clinical rotations in a teaching hospital.7 In 1908, the CME planned to undertake a survey of medical education in the United States to promote the organization's reformist agenda and to hasten the elimination of medical schools that failed to adopt the CME's standards. The CME requested the Carnegie Foundation for the Advancement of Teaching to lead the undertaking. Carnegie Foundation president Henry Pritchett, a staunch advocate of medical school reform, chose the schoolmaster and educational theorist Abraham Flexner to head the survey.8-9
In the 1910s, state licensing boards began to force medical schools across the United States to implement heightened admission standards and stricter curriculum requirements.10 In 1912, a group of licensing boards formed the Federation of State Medical Boards, which voluntarily agreed to base its accreditation policies on academic standards determined by the AMA's CME. Consequently, the CME's decisions "came to have the force of law."11 During these same years, philanthropic foundations began making large contributions to promote medical research and education at a select group of leading medical universities.12-13 By the 1930s, the combined efforts of state licensing boards, philanthropic foundations, and the AMA's CME resulted in the eradication of America's proprietary medical colleges and the standardization of the laboratory- and hospital-based research medical university model that Flexner advocated in his report.3
Medical Nemesis by Ivan Illich ~
Report on interesting, anit-medicalized healthcare monopoly by a catholic theologian – from Wikipedia
The Catholic social theorist Ivan Illich subjected contemporary western medicine to detailed attack in his Medical Nemesis, first published in 1975. He argued that the medicalization in recent decades of so many of life's vicissitudes — birth and death, for example — frequently caused more harm than good and rendered many people in effect lifelong patients. He marshalled a body of statistics to show what he considered the shocking extent of post-operative side-effects and drug-induced illness in advanced industrial society. He was the first to introduce to a wider public the notion of iatrogenic disease.  Others have since voiced similar views, but none so trenchantly, perhaps, as Illich. 
Through the course of the twentieth century, healthcare providers focused increasingly on the technology that was enabling them to make dramatic improvements in patients' health. The ensuing development of a more mechanistic, detached practice, with the perception of an attendant loss of patient-focused care, known as the medical model of health, led to criticisms that medicine was neglecting a holistic model.The inability of modern medicine to properly address some common complaints continues to prompt many people to seek support from alternative medicine. Although most alternative approaches lack scientific validation, some, notably acupuncture for some conditions and certain herbs, are backed by evidence.
Medical errors and overmedication are also the focus of complaints and negative coverage. Practitioners of human factors engineering believe that there is much that medicine may usefully gain by emulating concepts in aviation safety, where it is recognized that it is dangerous to place too much responsibility on one "superhuman" individual and expect him or her not to make errors. Reporting systems and checking mechanisms are becoming more common in identifying sources of error and improving practice. Clinical versus statistical, algorithmic diagnostic methods were famously examined in psychiatric practice in a 1954 book by Paul E. Meehl, which controversially found statistical methods superior. A 2000 meta-analysis comparing these methods in both psychology and medicine found that statistical or "mechanical" diagnostic methods were generally, although not always, superior.
Disparities in quality of care given are often an additional cause of controversy. For example, elderly mentally ill patients received poorer care during hospitalization in a 2008 study. Rural poor African-American men were used in a study of syphilis that denied them basic medical care.
The Amazing Logistics of Flexner's Fieldwork ~ Mark D. Hiatt, MD, MBA
Originally published in the Medical Sentinel 2000;5(5):167-168.
Copyright © 2000 Association of American Physicians and Surgeons (AAPS).
Dr. Hiatt is a resident in diagnostic radiology at the University of Virginia in Charlottesville, Virginia.
His e-mail is firstname.lastname@example.org.
Phileas Fogg had won his wager, and had made his journey around the world in eighty days. To do this he had employed every means of conveyance - steamers, railways, carriages, yachts, trading-vessels, sledges, elephants. The eccentric gentleman had throughout displayed all his marvelous qualities of coolness and exactitude. But what then? What had he really gained by all this trouble? What had he brought back from this long and weary journey?
Jules Verne Around the World in 80 Days
The Flexner Report(1) is one of the most cited evaluations of medical education in the twentieth century. Published in 1910 by the Carnegie Foundation, the Report arose from research conducted by Abraham Flexner, who claimed to have visited and objectively evaluated 155 graduate and twelve postgraduate medical schools in the United States and Canada. His recommendations have met with high regard in the ensuing nine decades,(2,3) but the underlying research has gone virtually unquestioned. The suspect motives and means behind the Report, as well as its equivocal legacy, have been described elsewhere.(4) This article explores in greater depth the amazing logistics of Flexner's fieldwork.
Abraham Flexner began his evaluation of North American medical education in December 1908. He first conducted a literature review for one month since he was, by his own admission, a layman with a "very sketchy notion of the main functions of the various departments" of a medical institution(5) who had "never had [his] foot inside a medical school."(6) Then, notwithstanding his further concession that he "knew neither anatomy, physiology, nor psychology enough to warrant [his] embarking on a highly specialized bit of experimentation," Flexner commenced his fieldwork in January 1909, claiming to have visited in the following 16 months each of the 167 institutions he evaluated in accord with a personal maxim Ambulando discimus ("We learn by going about").(6)
Yet, the quality of this learning is questionable given certain peculiar features of Flexner's going about. First, Flexner had a large number of institutions (167) to visit and evaluate, and the actual number of site visits (175) was even greater since three schools maintained separate campuses in different cities* and Flexner revisited five other schools in different months.** Second, the many campuses Flexner had to visit were, of course, scattered about the continent. Third, this logistical challenge of visiting multiple geographically dispersed schools in a limited period of time was further complicated by Flexner's inclination to return often to his home base in New York, as he disclosed, to "set [his] facts in order."(6) Finally, a traveler in 1909 would have been much like the fictitious Phileas Fogg of Jules Verne's Around the World in 80 Days for whom, just a few decades prior to Flexner's journey, the train --- not the airplane --- was the fastest available means of transportation. In light of these peculiarities, Flexner's itinerary contained some periods during which the early twentieth-century traveler had to move at an impressive pace.
Flexner himself admitted that his tour of schools was "swift," acknowledging that he finished inspections "within less than a year."(6) Although 16 months --- from January 1909 to April 1910 --- were allotted to the fieldwork, the majority of the visits occurred in only half of this time: in eight months, Flexner made 157, or 90 percent, of his 175 site visits.
Flexner visited 96 of these schools in his first five months of fieldwork. Specifically, in January 1909, according to footnotes in the Report, Flexner traveled to six states (Alabama, Georgia, Kentucky, Louisiana, Mississippi, and Tennessee) to visit 15 schools.*** In the following month (February 1909), he traveled to Georgia, North Carolina, South Carolina, and Virginia to visit 11 schools. In March, he traveled to the District of Columbia, Maryland, Michigan, New York, Ontario, Pennsylvania, Quebec, and West Virginia to visit 22 schools. In April, he traveled to Colorado, Illinois, Iowa, Missouri, Nebraska, and Utah to visit 31 schools.**** Finally, in May 1909, he traveled to California, Manitoba, Minnesota, North Dakota, Oregon, Vermont, and Wisconsin to visit 17 schools.
After a four-month rest, Flexner resumed his fieldwork to visit another 61 schools in the ensuing three months. Specifically, in October 1909, he traveled to Maine, Massachusetts, New York, Nova Scotia, Ontario, and Quebec to visit 15 schools.
In November, he traveled to ten states (Arkansas, Iowa, Kansas, Mississippi, Missouri, New York, Oklahoma, South Dakota, Tennessee, and Texas) to visit 23 schools. Finally, in December, he traveled to Illinois, Indiana, Kentucky, Maryland, Michigan, New York, and Ohio to visit another 23 schools.
What about the other eight months of relative inactivity? For four consecutive months in the summer (June through September 1909), Flexner visited no schools at all; during March and April 1910, he visited one and two schools, respectively; and in January and February 1910, he visited eight and seven schools, respectively.
In eight months, or approximately 240 days, Flexner had to make 157 site visits to geographically dispersed schools. In performing "a slight operation in mental arithmetic" (to borrow a phrase Flexner used to describe how he evaluated the financial aspects of medical education),(6) 240 days for 157 visits yields 1.5 days, on average, to travel to, and comprehensively evaluate, each campus. The pace quickens, however, when one allots time for weekend repose. In excluding Saturdays and Sundays from the 240 days, Flexner would have had only about 180 working days to travel to and evaluate the schools, or 1.1 days, on average, per visit.
Flexner's pace becomes even more amazing in April 1909, during which he claimed to have investigated 31 schools in six states (Colorado, Illinois, Iowa, Missouri, Nebraska, and Utah), spending about one day for each school. Again, in excluding weekend days, the train-dependent Flexner would have had only a fraction of a day (0.71) per school. Nevertheless, he released his recommendations in June 1910 on the basis of this seemingly rushed research, in spite of the proverb his grandmother had taught him to refrain from leaping to hasty conclusions: So schnell schiessen die Preussen nicht ("The Prussians don't shoot so hastily").(6)
Flexner's rapid pace seems to conflict with the Report's assertion that Flexner spared no effort "to procure accurate and detailed information as to facilities, resources, and methods of instruction."(1) His task was indeed ponderous. Flexner sought data on five points for each of the 167 schools: (1) entrance requirements and adherence to them, (2) the size and training of the faculty, (3) the sum and allocation of endowment and fees to support the institution, (4) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, and (5) the relationships between the school and its associated hospitals.
Flexner's later confession may more accurately reflect the thoroughness and objectivity of his research. He revealed that he used no standard questionnaire and "no fixed method of procedure."(6) He was also prone to return often to his home in New York to "set [his] facts in order."(6) Flexner even toured the facilities of some institutions unaccompanied by school officials. At one school, he bribed the janitor to open the laboratories, wherein he failed to find any apparatus, concluding that the school had none without considering the possibility that it could be locked up elsewhere.(6) Flexner visited other schools when they were not even in session.(7) Although such casual observation conflicts with the scientific medicine Flexner claimed to promote, he himself admitted that "[i]nconsistency never bothered [him]."(6)
Abraham Flexner's evaluation of medical education on the North American continent in the early twentieth century proceeded at a rapid pace. The itinerary that emerges from the footnotes Flexner left in his Report reveals periods during which he would have had only a fraction of a day to travel to and evaluate a school. Either Flexner was strikingly efficient or his efforts lacked thoroughness. In any event, a Report of such repercussions warrants further study of the methods used in its creation. Certainly Flexner, allegedly the promoter of the scientific method in medical education, would have approved of such perusal.
* The University of California maintained "clinical" and "medical" departments in Berkeley and San Francisco, respectively; the American Medical Missionary College, as a "divided school," maintained separate campuses, "part of the work being done in Chicago, part at Battle Creek"; and Laval University maintained departments in Montreal and Quebec.
** Flexner twice visited four Chicago schools (in April and again in December 1909) and one school in Cincinnati (in December 1909 and April 1910).
*** Flexner failed to provide the date of his visit to one of the two Louisiana schools (the Medical Department of the Tulane University of Louisiana). It is assumed that he visited this school in the same month in which he visited the other school in Louisiana.
**** Since Flexner did not provide the date of his visit to the Chicago campus of American Medical Missionary College, it is assumed that he visited this campus when he visited the majority of the Chicago schools. He visited the College's Battle Creek, Michigan campus in February 1910.
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