demonstrated, it was largely a strategy to artificially
restrict the supply of physicians and thereby to raise their pay.
Through the accreditation power the detailed character of the training
was imposed upon medical schools reducing the opportunities for innovation.
The power to accredit medical schools was acquired as a result of a study
sponsored by the Carnegie Foundation. The AMA needed the public interest
credibility of the Carnegie Foundation to achieve its goals. A survey of medical
schools previously carried out by the AMA itself had not received the political
support it desired. It therefore encouraged and supported the Carnegie Study.
And, ultimately to a high degree, the AMA controlled the study.
The Carnegie Foundation commissioned Abraham Flexner to carry out the study.
As Reuben Kessel states
Flexner's work consisted of a grand inspection tout of the medical schools of the time-- ,
some were evaluated in an afternoon�-to determine how they produced their outputs.
His model of how doctors should he produced was the medical school of
Johns Hopkins University. There was no attempt to evaluate the output of medical
schools; there was no investigation of what their graduates could or could not do.
Nor was there any discussion of what a graduate of a medical school should be able
to do, or of the possibility of raising standards of medical education through stiff
licensure examinations. The entire burden of improving standards was to be burnt
by changes in how doctors should be produced--that is, how students, facilities, and
faculty ought to be combined to generate physicians. He implicitly ruled out all
production functions other than the one he observed at Johns Hopkins.
It is a paradox that a group ostensibly so concerned as the AMA with the qualifications
of doctors for the practice of medicine failed to be disturbed by Flexner's lack
of qualifications for the task he undertook. Flexner was neither a phvsician nor a
scientist, and had no qualifications as a medical educator. He had an undergraduate
degree in arts from Johns Hopkins and had operated a small, private, and apparently
profitable preparatory school in Louisville for fifteen years. It is unlikely, if not inconceivable,
that he would have been accepted in a court of law as an expert
witness in the field of medical education before he undertook his studv.7
Virtually all the work Flexner undertook had already been done by the AMA,
and N. P. Colwell, the secretary of the AMA's Council on Medical Education at
the time, accompanied Flexner in some of his inspections and provided him with
the results of the AMA's previous labors.` Indeed Flexner spent many hours at the
Chicago headquarters of the AMA. It was clearly recognized that Flexner, or more
properly the Carnegie Foundation, had a comparative advantage over the AMA in
publishinp an attack on the medical schools of the time. The Carnegie Foundation
was comparatively invulnerable to a self-interest charge.
Kessel quotes from an article by Bevan entitled "Cooperation in Medical Education and
Medical Service" from the Journal of the American Medical Association, 1173.
[I]f we could obtain the
publication and approval of our work by the Carnegie Foundation for the Advance-
ment of Teaching, it would assist materially in securing the results we were attempting
to bring about.
Reuben Kessel goes on to say,
As a result of the implementation of the Flexner report, medical education
became considerably more expensive and exhibited relatively little variation from
school to school. To this day, there probably is less variation in medical training
than in almost any other field. The implementation of Fiexner's recommendations
made medical schools as alike as peas in a pod. In their first year medical students
almost invariably took anatomy, biochemistry, and physiology; in the second, microbiology,
pathology, and pharmacology. The next two years consisted of supervised
contacts with patients in the major clinical specialties of a teaching hospital. Often
this training pattern was written into state laws.
Kessel notes that Flexner was even more severe than the AMA is downrating medical schools.
In 1906 the AMA's Council on Medical Education rated 82 schools Class A; Flexner in
1910 rated only 72 as Class A. One of the schools put out of business by the Flexner
report was one that his brother, a distinguished physician, had graduated from.
The implementation of the Flexner report has, until relatively recently, sharply
The implementation of the Flexner report has, until relatively recently, sharply
reduced experimentation in the training of physicians. As a result, there was a
hiatus of over forty years in the search for better curricula and teaching methods, and
in the utilization of the talents of scientists outside of medical schools for the training
of physicians. It is only in recent years, in the decade of the 1960s, that the fetters
imposed by the Flexner report have been loosened. As a consequence, medical
education is currently in a state of flux, and the number of electives open to
medical students has increased enormously. In addition, the economic cost of
acquiring the MD degree has started to decrease, because some medical schools have
relaxed their requirements for a bachelor's degree as a condition for admission.
Moreover, as a result of student pressure, medical schools have increased their
willingness to substitute undergraduate courses for preclinical courses.
One consequence of Flexner's use of the Johns Hopkins medical school as the ideal
is that the practice of working resident physicians unreasonably long hours was
also copied from Johns Hopkins. Charles A. Czeisler of the Harvard Medical School
says in the October 24th, 2009 issue of Science New,
that the tradition of working resident physicians in shifts as long as 24 hours was
established in the 1890's at Johns Hopkins by William Halsted. It seems that Halsted
had a cocained addiction that may have influenced his judgment as to how long a
physician-in-training can safely work.
Czeiler notes that after working 24 hours straight resident physicians are 168 percent
more likely to be involved in a car crash driving home. A 2006 Harvard Work-Hours
Health and Safety Group reported that 20 percent of resident-physicians admitted to
having made a fatigue-related mistake that injured a patient. Five percent of the
resident physicians confessed to having made a fatigue-related mistake that resulted
in a patient's death. With there being about one hundred thousand physicians in
training in the U.S. that is quite a death toll.
(To be continued.)