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The Flexner Report The New Schools The Future

In the Beginning . . .

At the turn of the nineteenth century, becoming a physician was relatively simple: either you came from a wealthy family or you encountered a doctor who was impressed by you. No undergraduate degree was necessary! Medical education involved a few years as an apprentice with an established medical practitioner. After which, 'the graduate' may decide to pursue further studies abroad or simply begin a medical practice. A significant number of 'doctors' at the time were charlatans with no training whatsoever.

The Flexner Report

Abraham Flexner was a professional educator who was hired by the Carnegie Foundation for the Advancement of Education to evaluate the condition of medical education in America and to make suggestions for the future. His report was published in 1910 and would stand as the gold standard on medical education for decades.

For his evaluation Flexner visited the medical schools in both the US and Canada. He was not known for mincing his words. Regarding one medical school, he wrote:

" Entrance requirement: Less than a high school education. "

And yet another:

" The school occupies a few neglected rooms on the second floor of a fifty-foot frame building. Its so-called equipment is dirty and disorderly beyond description. Its outfit in anatomy consists of a small box of bones and the dried-up fragments of a single cadaver. A few bottles of reagents constitute the chemical laboratory. A cold and rusty incubator, a single microscope, and a few unlabelled wet specimens, etc., form the so-called 'equipment' for pathology and bacteriology. "

In his report, Flexner concluded that there were too many medical schools, many were substandard, and prerequisites for the study of medicine and the content of medical education had to be defined. He suggested that the minimum requirement for admissions to medical school include a high school diploma and two years of a college or university level science curriculum.

He recommended that medical school be four years long. The first two years would involve the basic sciences with relevant laboratories. The first year would include anatomy, histology, embryology, physiology and biochemistry. The second year would explore pathology, bacteriology, pharmacology and physical diagnosis. The last two years would be clinical. Thus in the last two years learning would occur through experience garnered on hospital wards and dispensaries. Flexner's 'two plus two' solution to medical education formed the bedrock for teaching medicine in North America for decades.

After more than fifty years of following Flexner's recommendations remarkably close, only relatively recently have medical schools turned away from the Flexner Report, probing, exploring, and creating new paths towards medical education.

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The New Schools

The new medical schools based their curricula on body systems. The classic education at the time followed Flexner's prescription, as previously described, thus courses were parallel but independent. This meant that in the same time period, each professor would attempt to present the exponential growth of material with little or no restriction. This resulted, on the whole, with the teaching of information during Flexner's basic science years which was, at best, only slightly relevant to both medical practice and licensing exams.

The body systems approach integrated the various disciplines into an organized framework. For example, a period of time could be set aside to learn about the cardiovascular system. Thus the system would be viewed from the perspective of the various disciplines - anatomy, physiology, etc. This teaching method is more efficient, less repetitive. Decisions must be made regarding the quantity and quality of the information being taught and its relevance to a future practitioner. Some of the older medical schools began adopting a similar integrated approach.

Many new schools use a problem-based approach to education which is discussed elsewhere in this website.

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The Future

Undoubtedly, the future is bright, exciting and full of challenges. The brief historical outline here has not the breadth to illustrate the very dark times in the histories of many US and Canadian medical schools. There were instances when the future was counted in weeks not decades or centuries. And yet the record displays growth, achievement, world-wide recognition, and most importantly, consistent and excellent provision of health-care to our communities.

The challenges, however, are significant. History suggests that the challenges shall be met, handily. The following includes a few of the many issues which medical schools are summoned to face:

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