How the Flexner Report Changed Medicine

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0:15Hey and welcome to the podcast I'm Josh and there's Chuck and Jerjer Binks is here too And this is Stuff You Should Know About the Flexner Report That's right This was a suggestion by my wife Oh, that's a good one Yeah, Emily, of course, everyone knows if they listen to the show, is an organic gardener and an herbalist. She said, has long asked me to do one on the Flexner Report, which is a report written in 1910 that did a lot of things, basically kind of revamped how medicine worked in the United States moving forward in medical school in particular. Right. But Emily was interested because another thing it did, a byproduct, was it basically completely squashed what we would now call alternative medicine, homeopathy, basically saying it has zero value and we're not doing that anymore.

1:12It sure did, Biff. Yeah. And it was also racist and sexist. It was definitely of its time. This is a document produced in 1910 for sure. Yeah, it definitely stinks of eugenics and all that. Yeah. So it's one of those weird things where like you can see it from all sides because it did a lot of good. And it also maybe didn't do some good in certain areas. Yeah, for sure. And there's there's not many people who are like, no, the Flexner report sucks. It was all bad because it if you enjoy being treated successfully for cancer, you can pretty much thank the Flexner report for that. But at the same time, yeah, if you believe that there are alternative therapies that are as good or better than medications, then, yeah, you probably don't like that part of the Flexner report.

2:03But I think on the whole, it was a good thing. there seems to be now among, you know, thinking people who don't just wade and wallow in dogma, saying like we need a new Flexner Report for the 21st century because it's basically run its course. And now, again, it's become dogma and we need to do something about that. Right. I think that's a great setup. And maybe we should paint a little bit of a picture about what medicine and medical school look like in the United States pre-Flexner Report. It was bad. It was bad. I guess quickly we should say that Europe was doing it right before we were. Yeah.

2:41In France, especially, they had some pretty top notch medical schools where they embrace real science and were practicing medicine on people like as practice in colleges and stuff like that. But in the United States, that was around 1850. In the U.S. in 1850, they had 52 medical schools. this is what 50 60 years before the flexner report and medicine was not you know to be a doctor was not some prestigious thing medicine was a trade uh if you were associated with the university at all as a medical school it was a two-year program the the curricula was very very broad they were super underfunded even at places like harvard they had to pay for their own teaching supplies.

3:25And those were the good ones that were attached to universities. Yeah. I mean, there were plenty of diploma mills. There were a lot of proprietary medical schools where it was just some people got together and created a for-profit school where they would teach you how to become a doctor, but they were not doing a very good job of it. And your admission requirement was the ability to pay the tuition fees, essentially. Yeah, for sure. You might have like redundant classes that literally went over the same things. You might not have your hands on a scalpel ever. You might not have an exam ever. You may not see patients.

4:07You might not have any contact with another human being at that medical school. It'd be kind of like if you went to go skydive and in the class before you go skydive, they just talk about how hard the ground can be if you hit it. And then they take you up in a plane and push you out. It's similar to something like that. That's good. Thanks. I like it. But then, everybody, the Civil War came around in the 1860s and there was wartime doctoring happening. and after the Civil War, people came out of that saying, we're in trouble, everybody. Like, the doctoring wasn't so great in this war and we need to fix this.

4:48Well, what I interpreted is that they went out and got real world experience and realized, like, the stuff they learned at school was not preparing them for actual medicine. Oh, yeah. I mean, I think it was a little bit of both. I think the person who had their leg chopped off unnecessarily complained. and I think the doctor who did the chopping might have complained as well. Right. They didn't teach me that patients complain in medical school. So yes, regardless, by the 1860s, it was quite clear that American medicine was lacking tremendously and that the main reason for that was that the doctors who were practicing medicine had virtually no actual training in medicine.

5:30There was lectures, textbooks, that's basically it. So there were There was a part of the progressive era, this actually, this push to create a movement to make medicine in America better. And by focusing on the medical school education, that came around in about the 1870s. It was led by Harvard. Yeah. But really, Johns Hopkins University was the one that really hopped on it. Yeah, for sure. Like Harvard got the ball rolling for a couple of decades. And by the time Johns Hopkins opened in 1893, they became kind of the standard for the American model moving forward, which, as you see, was based on the German model.

6:14Right. You had to have a first of all, you had to have a college degree just to get in. And that was previously not necessarily the case. No. Secondly, they had full time faculty. They were medical scientists, so they weren't doctors on the side as well. They were just fully employed to teach. And they had a four-year, like a full four-year course of study where it was hands-on and a lot of laboratory work. Yeah. And yes, where they were actually working with patients or assisting other actual doctors in working with patients. Like it wasn't just like sit there and listen to this lecture. Yeah.

6:52Yeah, that was and that essentially that Johns Hopkins model is what became the model for American medical school. And there's a lot of there's a lot of talk at parties if you stop and listen about whether this would have happened on its own or not. Yeah. And for the most part, it seems that, yes, this progressive era movement would have gotten there eventually. Yeah, because it was a good idea. The Flexner Report helped it happen on a dime because not only did it show to everybody else this is the way to do it, it also said this is very expensive and here's how we need to get the money for it and did get the money for it.

7:33Like that's how it was implemented. Yeah, for sure. The American Medical Association was founded in 1847. And one of the reasons, and, you know, again, this is stuff that I learned from sort of Emily's urgings. One of the reasons the American Medical Association was founded to begin with was like on a mission to squash homeopathy. It says so in its charter. And when the AMA was founded, they discouraged any association or communication with those kinds of doctors and had a code of ethics. It was a clause in there known as a consultation clause that said, if you even talk to a quote unquote non-regular practitioner, then you're going to lose your license to practice medicine.

8:20They carved out exemptions for Massachusetts and New York because it was homeopathy was really, really, really popular at the time among the elite, wealthy Americans, like the major politicians, the corporate leaders. I think it was Rockefeller. I think it was Rockefeller that was under the care of a homeopathic doctor for like 50 years. Wow. So they carved out exceptions for those two states for a while until they were able, you know, all those people died off basically and they were able to completely squash it. Right. Rockefeller died. So I guess the homeopathy didn't work. Well, he lived another like 48 years after being told he didn't have long to live, I think.

9:02Oh, wow. So homeopathy works. Case closed. So, yes, I think that you've really put your finger on it. The AMA became the arbiter of what qualifies as medicine in the United States thanks to this Flexner report. It basically strengthened all of its position. And yes, they were the driving force behind this initially. They went to the Carnegie Foundation and said, hey, you got a lot of money. Why don't you help us figure out how to change American medical education in the exact way we want it? and we'll help you figure out who to do that with. We like the Johns Hopkins model. We basically want a report that says the Johns Hopkins model is great.

9:47Let's get an outsider in here. And that is how Abraham Flexner enters the story. Yeah, and you know, this is not to say that he was like cooking the books or anything like that. And this is all a sham, but that was just sort of, the AMA was definitely after that. Well, one of the reasons he was selected is he was already a person, an educator, who espoused exactly this kind of stuff, just not necessarily as it applied to medical education. He just wasn't exposed to medical education at the time, but he was an educational philosopher and theorist, and he was fully on board with that kind of thinking.

10:21Yeah, I mean, he wrote a book. I guess we should say he did go to Johns Hopkins, but not for medicine. I think he studied classic civilizations, and he was a teacher in his hometown in Louisville, Kentucky. Eventually, he was a private school headmaster that he founded the school. And after earning a degree in psychology from Harvard, he wrote a book called The American College, which was sort of the Flexner Report of the university system as a whole. And this guy named Henry Pritchett, who was the president of the Carnegie Foundation at the time, was like, yeah, like Josh of Clark of the future will say, this is this is our guy.

10:59Because did you see the way he came at the regular universities? Like, wait till he finds out what's happening in medical schools. Exactly. And then one of the other reasons that he was such a great candidate because he was an outsider and a non-physician is that they were quite aware that there was going to be a lot of blowback, that there was going to be a lot of bruised egos and stepped on toes. And that somebody outside of the profession would be less likely to suffer, say, like a professional injury or being ostracized for the rest of their career. Yeah, Flexner was like, I don't care what you think of me, doctors.

11:35That's right. So he started out by researching the European models, the American models. Like I said, he was really impressed with the German model. Yeah. And in fact, a couple of years after the American and Canadian, as we'll see Flexner report, he published a European version which critiqued, well, Europe, basically everybody but Germany. He was very uncritical of the German system. And we also need to point out some of the bad things he said. There were several anti-Semitic passages in the European version of the Flexner Report because he was so enamored of how the Germans did their medicining.

12:14Yeah, that German model also inspired the guy who founded Johns Hopkins Medical School, William Welch. And that was essentially, so essentially the Flexner Report said the Johns Hopkins model is what we want. Johns Hopkins said the German model is what we want. And the Germans said, yeah. Ja. Ja, da. Yeah. No, that's Russian. Das Boot, that's German. Nice, what else? um the Heimlich Maneuver yeah that's it Bratwurst Cider okay yeah all that stuff Oktoberfest but with a K should we take a break yeah all right you're gonna think did you say yeah yeah we're gonna think of some more German words or Deutsche words and we're gonna be back with more on what Flexner said right after this

13:32Chuck, I could only come up with one more, and it was strudel, but it's the best one. Mm, yeah. Oh, wait, Frankenstein? Yeah. That's it. Do you see that new Frankenstein movie? The Bride? No, no, no. What's his name? It's a new Frankenstein movie. I don't know. The Rock? Who? No, the director, Guillermo del Toro's Frankenstein. Oh, no. What did you think of it? It was pretty good. I got a little bored, but everyone said it was really great. I think I was distracted. Maggie Gyllenhaal is redoing The Bride in a really strange, like out there kind of fashion that looks interesting. Yeah, I saw that.

14:13I thought it seemed super interesting and I love mags. So I'm down. Okay, well, that's fine. I'll allow it. So back to the Flexner Report. He started that research in 1908. I think the thing came out in 1910, like we said. But he went around all over the place. He went to 155 medical schools, 148 of which were in the United States. Seven were in Canada. Spends a couple of days there with his nose turned up. And he did this for about 18 months. Yeah, just to be clear here, this guy was not phoning this in. He definitely took the assignment and did it to, like, he did it. Like, all of those 155 medical schools in the U.S.

14:56and Canada, that was every medical school in the U.S. and Canada, including ones that taught alternative medicine and black medical schools in the United States. So, like, he definitely went through the paces. It wasn't just like a, yeah, let's look at Johns Hopkins and here's my report. Yeah, for sure. And you mentioned the black medical schools because they come up pretty front and center here in a minute. Yeah. But Johns Hopkins was, like, the gold standard, so that was his comparison point for all of them. He looked at everything. He looked at how they financed their school. He looked at how big the classrooms were, how many teachers they had per student, what like admissions, what it took to get in, what they were actually teaching, laboratory stuff, facilities, kind of everything.

15:43And what he came out with was one of three determinations in the end for each school. The school is good. You can stay. You can keep your doors open. Your school is not so great, but you show promise. So maybe if you have some more funding and you change these things, you can be OK. And then, I'm sorry, please close your doors forever. Yeah, there was a lot of them that he categorized as hopelessly deficient. A lot. Most, in fact. Yeah. And it wasn't just like him being a snooty butthead. Like, as we said, like the medical schools in the United States were, in a lot of cases, hopelessly deficient.

16:22And that's a problem when you're producing doctors, you know? So he did make a pretty good case that there were a lot that were hopelessly deficient. But the deficient ones, they actually had different rankings. For example, Iowa State University's medical school, he basically said they know what they're wanting to do, but the hospital associated with it is too small. And your clinical faculty, the people who are supposed to be doing research and teaching medicine to the students, they all have their own private practices because they have to support themselves. So if you gave this group enough funding, they could create a top-notch medical school in the Johns Hopkins model.

17:04That was kind of like that deficient category, the varying degrees of how much money you would need and whether you're headed in the right direction. Yeah, for sure. The way he wrote in what was called Carnegie Foundation Bulletin No. 4 or Medical Education in the United States and Canada, a.k.a. Flexner Report, was that very muckraking style. It's not the kind of report you would. People wouldn't write it this way today because he did get a little. It seems like he enjoyed sort of the put downs and coming up with new ways of saying how bad a school was. So people would write it that way today, unfortunately.

17:47Well, you're probably right. One of them, he said, apparently the inexcusable degree of ignorance begins just where the ability to pay fees leaves off. Oh, yeah. And so he was basically taking them to task over low admission requirements, if any. But he didn't say low admission requirements. He also used the word reeks, which you don't usually see in academic studies. Yeah. He said that the osteopathic schools in the United States, there are eight of them, that they reek of commercialism, that they attract students with a mass of hysterical exaggerations that confidently appeals to the crude boys or disappointed men and women whom it successfully exploits.

18:26Yeah. We should say osteopathy is an accepted form of medicine in the United States now, but a lot of people still view it as a pseudoscientific alternative medicine. Yeah. I mean, he had a sight set on them, on chiropractors, on all kinds of things that a lot of people put a lot of great value in today. So he was off base on some stuff for sure. But again, this was 1910. So of the underfunded medical schools, and this was a problem, too. This is actually one of the things that befell black medical schools, as we'll see in a minute. If you were underfunded, that was it. Sorry. Yeah. No amount of funding is going to bring you up.

19:09Well, maybe some amount of funding is going to bring you up to speed, but we need that money to bring other medical schools that are closer up because we can bring more of them up to snuff or we can bring fewer up to snuff and basically get the ones that are the least funded. His whole premise was just close those poorly funded ones because they're just not going to be able to do this. Yeah. And, you know, he was probably on to something there because there was a glut of bad schools. And his quote was, the curse of medical education is the excessive number of schools. The situation can improve only as weaker and superfluous schools are extinguished.

19:45Like I said, it was Canada and the U.S. Canada fared much better. Our northern friends up there, of the seven Canadian medical schools, he only recommended one foreclosure. So one-seventh of them. That's right. The 148 medical schools in the United States, more than half of them he recommended closing. And I think it ended up being more than that even, right? Yeah, he actually recommended reducing the full number of schools in the U.S. and Canada from 155 down to 31. Yeah. That's four fifths. So, yeah, I mean, like he was basically a hatchet man. They brought him in to basically get rid of competing, poorly funded, poorly run medical schools.

20:33He said if you're a proprietary medical school, it doesn't matter what you're doing, you're closed. He saw med school as a public trust, that it should be publicly funded, ergo they should be associated or attached to public universities. And that the reason that doctors were being produced was to help society along. that you should not have a board or stockholders to whom you are really kind of beholden to so they would affect your decision making. No, you needed to be beholden to science and ideally to patients, although he didn't put much emphasis on that part. Yeah. And we'll talk about that at the end.

21:11So every single proprietary school was immediately on the list, basically, from the jump. Like if you weren't affiliated with the university, you had no hope for surviving this. all the holistic or what we call alternative medical systems were completely shut down. Five of the seven black medical schools were recommended for closure. I think Howard University in D.C. and Meharry Medical College right here in Georgia, he thought might be salvageable. But there are a couple of chapters in there. Chapter 14, specifically, the medical education of the Negro was the title of that chapter, where he shows a real disdain for black medical schools.

21:54He said they were wasting money, small sums of money annually, that undisciplined men whose lack of real training is covered up by imposing MD degrees. And he basically ended up saying like, close most of these. And my suggestion is just to make black medical schools to train black doctors to treat Black patients only, and they should really just concentrate on hygiene. Yeah, they should focus on public health in order to keep Black people from spreading disease to white people. That was essentially his take on the purpose for the existence of Black doctors. Out of 346 pages in the initial version of the report, chapter 14 was two pages long.

22:39And that is shocking in and of itself. But the Flexner report was essentially the first document about medicine and medical school that even acknowledged the existence of black medical schools. Up to this point, they were totally invisible, completely ignored. So the fact in a really silver lining to the cloud way of looking at this, the fact that Howard University and Meharry Medical College in Georgia made the cut was really substantial. Like that was a that was sadly a really big positive for black medical schools, unfortunately. Yeah, for sure. You know, I mentioned sexism to the AMA and the Carnegie Foundation were also not too hot on the idea of the three women's medical college colleges even existing.

23:32And Flexner himself basically came out and said, I don't think women can withstand the mental rigors of being a doctor. He never met Elizabeth Blackwell. Yeah, no kidding. And he literally said, you know, women make better patients than doctors. This is the 1910s. Yeah, it's not like 1810. So, yeah, so this was, I mean, I guess on the other way of approaching this, too. So we've talked about everything that he was giving the hatchet to. He had a version of what made an ideal medical education. And again, it was based on the German model, which the Johns Hopkins model was based on. And he essentially said, so you need to have rigorous instruction.

24:17You need to have rigorous admissions requirements and you have to enforce them too. And in doing so, he basically said, you're going to weed out candidates who aren't, they can't make the cut for this new kind of doctor. So that meant you had to have money to even get started because this new model was so much more expensive than the old model. Tuition, I think, needed to increase three to four times just to start to meet the funding for this. So you just out of the gate had to have money to even try to apply to medical school. And then the academic requirements meant that even if you had money, if you didn't have what it took to like really dedicate yourself to learning this stuff, you were going to fail out too.

25:07So in that sense, it took doctors from being just ordinary tradespeople and said, these people are responsible for keeping the population of the United States healthy. And we're making sure that they are up to the task in return. They're rich now. That's right. And, you know, you know, part of it was as medical school was expensive was because or ended up being more expensive is because they needed better facilities. They need a better equipment. I know we already mentioned that teachers were working part time as doctors just because they had to make a living. But one of his big key recommendations was you have to have a full time faculty that is just doing biomedical research like they're not doctoring on the side.

25:52And in order to come up with this kind of money, it was expensive. The idea of medical philanthropy really, really took off because, you know, Johns Hopkins is one thing. But if you wanted to have more than one Johns Hopkins-like model out there, you had to lay out this roadmap of basically, you know, starting in 1910 and over the next few decades and continuing today, these huge foundations were created. And also local groups just donating money to make sure the Flexner Report was enacted, like the Rockefeller Foundation. They gave hundreds of millions of dollars to get these programs going across the country.

26:31Yeah, and it worked. But again, it took hundreds of millions of dollars and I think 1910 money too. Should we take a break? Let's take a break. All right. We'll be right back with the closing act of the Flexner Report.

27:07so we're back um one of the results we talked about was all these schools shutting down i think more within 10 years i'm sorry within five years of the reports released more than 50 of the medical schools in the united states shut down and 20 years on only 76 of the original 148 in the united States remained. Like you said, five of the seven black medical schools, 80 percent of the alternative medicine programs were shut down. And the handful of schools that had admitted women were either shut down or not admitting women anymore for a while. Right. So like this was a huge impact on the way that doctors were created in the United States.

27:52And again, the profession of doctoring in the first place. And it happened very quickly, as you just mentioned. And there are a lot of positives to it, but there are a lot of criticisms to the outcomes too. One of the big ones is the impact that the Flexner had on producing black doctors in the United States. I saw an estimate that had all seven of the black medical schools stayed open and been funded so that they could follow this model. Another 30 ,000 doctors, black doctors would have been produced in the United States between 1910 and 2012, I think, which is a big deal because apparently right now 2 % of American doctors are black, but the percentage of the black population in the American population overall is 13%.