Say the name Abraham Flexner, and a torrent of useless fact pours forth. He was the author of a work published in 1910 that became the backbone of American medical education: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. We’ve all heard of that report, but few of us have read it. Here’s a link to the work. This cruel report closed many medical schools and crushed the incomes of many medical educators; restruc- tured the medical curriculum to that which we easily recognize today; and not coincidentally, rocketed his alma mater, Johns Hopkins, to the front of the pack of New Scientific Medical Schools.
It’s been largely unread, I expect, because of the windy and pedantic style of Flexner. He was not a doctor; he was a headmaster of a novel school in the Midwest who was an innovator in a new American style of education. He did have something to say, quite a bit to say – but taking 364 pages to say it, and say it again, leaves quite a pile to pick through.
He could make sex boring! That’s proven – in 1914, he wrote a report for John D. Rockefeller, Jr., on the suppression and regulation of prostitution in Europe. It’s a real eye-roller, to keep by the bedside not for titillation but insomnia.
But the Flexner report on medical education turned the tide of modern American medicine towards scientific understanding and scrutiny of hu- man health and disease. Sadly, over time, his work has given rise to bad ideas and habits in medical education. We changed in 1910 and it was pain- ful. We do not want to change again.
Flexner describe three methods of the development of medical training through history: mentorship, didactic lectures, and the scientific method.
If one saws through his ponderous prose, Flexner offers quite astute ob- servations:
We have seen how an empirical training of varying excellence, se- cured through attendance on a preceptor, gave way to the didactic method, which simply communicated a set body of doctrines of very uneven value; how in our own day this didactic school has capitulated to a procedure that seeks, as far as may be, to escape empiricism in order to base the practice of medicine on observed facts of the same order and cogency as pass muster in other fields of pure and applied science. The apprentice saw disease; the didactic pupil heard and read about it…
The Flexner report treated the didactic medical schools harshly. Stu- dents did not see patients in these schools. Instead, they paid an enormous amount of money to attend lectures about disease. That criticism should make our current educators squirm, but they are thankfully ignorant of Flexner’s material beyond what can be asked in a quiz about the History of Medicine.
After a century, not only is medical education back to the didactic method, now dolled up with colorful and interactive PowerPoint and such; the undergraduate education of the aspiring physician has been relegated into a purposeless exercise of pre-med studies. This field of study is less for education than for advertising – the packaging of the candidate into a blandly inspiring applicant to the twelve or twenty medical schools which he or she finds unique.
The danse macabre of finding the best students is equally frustrating for the medical institution. Every criterion – GPA, MCAT, experience, recom- mendations – are top-notch. Limited individuality can peek through – what school will turn down the Olympic silver medalist in the 400 meters? A prodigy cellist? The deans, after all, need to have something to chat about during faculty meetings.
These unique, innovative and inspired learners are promptly dropped into a didactic grind far more enveloping than Flexner’s bete noir, didactic schools, which were closed a century ago. Fortunately, these eager learners know and are practiced in the way of didactic education. The title of the course is not very relevant. What goes in the Permanent Record, is. Those that never learned this critical aspect of the undergraduate curriculum have been sifted out.
Should medical education stray very far from its consensus homogeneity in the US, there are standardized medical licensure tests which the students are prepped for. Of course, these examinations are check-box examina- tions, very much like the medical school grind. What else can they do to measure students? Good students are, by definition, good at these things. Actual comprehension is still extra credit but not required reading.
Dmitry Orlov, an insightful critic of American education, has discovered that the entire US “teaches to the test.” The concept of teaching how to han- dle the unfamiliar seems lost to the American educational system. Orlov is a scientist, born in Leningrad, USSR, into an academic family, and immi- grated to the United States at the age of 12. He is not a professional educa- tor. His only qualification to comment on American education is that he has experienced both; and he can think.
The Soviet education system was generally quite excellent. It pro- duced an overwhelmingly literate population and many great spe- cialists. The education was free at all levels, but higher education sometimes paid a stipend, and often provided room and board. The educational system held together quite well after the economy col- lapsed. The problem was that the graduates had no jobs to look for- ward to upon graduation. Many of them lost their way.
The higher education system in the United States is good at many things – government and industrial research, team sports, voca- tional training… Primary and secondary education fails to achieve in 12 years what Soviet schools generally achieved in 8. The massive scale and expense of maintaining these institutions is likely to prove too much for a post-collapse environment. Illiteracy is already a problem in the United States, and we should expect it to get a lot worse.
America has a particular, pathological type of illiteracy that is actively fostered by the medical schools. It is the “lint-roller” approach to education. Pick it up superficially long enough to pass the test. Then discard.
American medical schools have universally become more didactic than they ever were before Flexner’s Great Purge. Individual thinking is actively discouraged. We want no independent thinkers at bedside, but guideline- followers, memorizers and reciters and scribes. There is a reason that the mythic Dr. Gregory House was troubled; he was incapable of not-thinking when it was indicated. Flexner’s scientific physician would be met with a great deal of concern by the residency program directors. A bright young doctor, that one – but residency is the time to learn the guidelines!
The nimble student must, to excel, have a powerful forgetting machine. Most American students, especially those having experienced higher educa- tion, have world-class forgetting machines. For goodness sake, of what use is it to remember the names of the various regions of the adrenal cortex, and the hormones made there? That’s taking up space in the brain for other things.
Apparently, the experience of active medical practice was driving the lo- cal medical doctors to stray off into their own experience in seeing patients; experience not offered by randomized, double-blinded studies shown to have statistical significance, and hence superstition.
Now that the various board certifications are not achieved but rather rented on a fixed-term basis, subject to renewal by re-entering the didactic learning machine, there is no escape from the monolith that has grown again from the roots of medicine a century after Flexner’s astute and wordy attack.
We need a new Flexner for the 21st Century to revitalize medical educa- tion. It will not happen; that will interfere with the greater order of the medical industry. We could even make do with the old Flexner of the 20th Century. But we have forgotten who he was, except for something about a report.