An Education….About Medical Education
In the early 1900s, the American Medical Association(AMA) formed the Council on Medical Education(CME) to restructure medical education. Why? Because it was a hodgepodge of inconsistency. The AMA wanted better doctors, better medical education, and better quality of care. Why? Because it was necessary to ensure the safety and care of the public. The CME, with the support of the Carnegie Foundation, decided to perform a survey of all medical schools in North America (of which there were 155) in an effort to find the standard they sought. Abraham Flexner, an esteemed educator (and unapologetic racist), was selected to execute the survey. Flexner ultimately settled on six institutions which he believed set the standard the AMA was seeking. His recommendations became known as the Flexner Report. His number one choice was Johns Hopkins, the medical model that continues to be followed today, 100+ years after his report. Substandard institutions were either absorbed by larger centers of education or closed down completely. Ultimately, the 155 medical schools were whittled down to 31 which had more rigorous admission requirements and standardized curricula.
As a result of the actions initiated by the AMA, medical education in the U.S. and Canada subsequently became the best in the world. This is exactly how education should function. Strive for the best to be the best. Everyone will not succeed; that is to be expected. If 100% of individuals could accomplish a set goal, surely one must question just how valuable the goal. One aspect of achievement is the work invested; the accomplishment gives one a sense of pride for a job well done. Isn’t that acknowledgement the reward? Isn’t the Olympics about those who have achieved excellence in their sport and recognition for that triumph? It takes years to attain that level of success. Because nothing worth having ever comes easy.
Today, there appears to be a paradigm shift occurring in which truncated “accomplishments” are rewarded with degrees, titles, job offers, financial compensation, etc. False equivalence to earned success when it is, in fact, not comparable. Time spent pursuing one’s honorable goals is ridiculed by others. As one who has lectured frequently on the value of education, this laissez faire mentality angers me. As a descendant of slaves who would be lynched for daring to learn how to read, this lackadaisical approach to education as a whole offends me. Online “Doctorate” degrees abound. Programs that are non-standardized, non-vetted, without oversight of any legitimate accrediting body and without stringent admission criteria exists in multiple disciplines, including health care. No one wants to do the work. No one wants to make the sacrifices. No one wants to pay the price. Let’s just find the alternate, easier pathway to obtain that all important but superfluous “degree” that is not worth the toilet paper on which it is written. Paper that would be worth more if I wiped my a** with it.
Education is about investment. Investment in ourselves. Investment in our craft. Investment in our future. Like all meaningful investments, the return is delayed. Patience is a virtue in such situations. We know there will be a return…with interest. That interest is the knowledge gained. That is the value of medical education, which by itself can do nothing. However, when that education is absorbed, incorporated, processed and utilized, it becomes knowledge. And that knowledge can then be shared with our next generation of physicians. It is the gift that keeps on giving. Do not allow others(insert corporate medicine here)to demean it. Do not take it for granted. Do not abuse it. Honor it. It deserves no less. Surely if the forefathers of medicine saw its value 100+ years ago, how can we not? Most importantly, respect those within it who have paid the price so that they could fulfill the objectives set by the AMA one hundred years ago–to ensure the safety and care of the public.
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The Flexner Report merits reading. It is sevel hundred pages, ten chapters or so. It is toe-curlingly bigoted, by the way. The chapters on the Negro Physician and the Female Physician are at the back, and are best left unread.
Flexner had never been to a medical school until he began his research on this book. His perspective is that of the new modern 20th century educator. Apparently his personal studies did not include personal improvement in writing style. He is woefully boring to read. This makes it for some dry going in the book, and explains why everyone refers to the Flexner Report, but nobody’s read it.
His next undertaking was to produce an academic study on prostitution in Europe. Apparently he traveled about the European cities and towns alone, studying prostitution making notes, not in the company of Mrs. Flexner.
A read of this lugubrious tome shows why Mrs. Flexner wasn’t too concerned. Prostitution In Europe, by Abraham Flexner is far more woefully boring than the Medical Education text. It may well be the dullest book that I have attempted to read; I gave up within fifty pages.
But enough of Flexner. His hypotheses included the idea that the standard of medical education involved countless thousands of hours in mind-numbing, irrelevant lectures; with little mentoring and practical guidance in the practice of medicine. I’ll have to say that his Report interrupted that process for a short while (See Care of the Patient by Peabody as an example.) Medical education has slid back into a stodgy and mind-numbing process, even worse perhaps than the pre-Flexner days. Medicine lived in the world of Science in 1900; it has achieved presence in the world of Technology, which is far from the model of the scientific doctor.
American culture dislikes and distrusts education and intelligence. Many complain about the sorry state of childhood education and college. The fundamental cause is that most Americans don’t see the benefit of expertise by detailed study of a certain thing, and mistrust those who have done so. Smarties can be seen on the Big Bang Theory, and boy are they weirdos.
The late John Taylor Gatto expounded on this in Mass Weapons of Education, I think it was. When one compares the esteem for higher education in the United States with that of places like Tokyo and Peking – and Hanoi, Baghdad, Beirut and Marseilles – one can find a far more rational and encouraging environment than the esteem for Education at home.
The reasons for this are far too lengthy to approach here; but many countries abroad rather pity us for our senility.
Perhaps the AMA can guide us to a new Renaissance in medicine; but I fear we will become more like Honduras and Turkey than the post-Flexner America.
Excellent piece Doctor Newman. The AMA rarely gets the credit it deserves for establishing the professional order we enjoy today out of the chaos of the pre-Flexner era.
Sadly the AMA has changed.
The AMA is an imperfect organization. Like many others, they have made mistakes. But this? This they got right. The fact that U.S. and Canadian medical education remain exceptional is a testament to their very wise decision. We have to be willing to give credit where credit is due.
IMO, the negative changes in medical training that we are witnessing today I attribute almost completely to the business of medicine interfering with a well-established process.
The AMA was co-opted by several greater forces in the environment. One of the most powerful forces was the factory paradigm, which started at the end of the Civil War, and supported a national realignment to improve the utility of the lower classes: immigrants and people of color. they often fit poorly into the factory model. Certain persons such as the execrable Frederick Winslow Taylor approached the labor force as animate machines, the industrialist’s controllable capital. Even though his Efficiency Movement and “The Principles of Scientific Management” were rejected by the informed and enlightened business community as inefficient, Taylor’s dreadful approaches have finally made it: to own the medical industry and control its living capital as effectively as any other machine.
I consider the AMA to be nitwit collaborators in this movement. The idea of pulling up the ladder when you have made it to the top, assumes that you will make it up the ladder in the first place. Doctors bought into the idea of pulling up the drawbridge when the chosen had crossed into the castle, because they thought that they were implicitly members of the “chosen.”
Wrong.
I find your perspective a bit optimistic. That’s cool.