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The Flexner Report and “Flexner Report II”: Deciding How and What You’ll be Taught in Medical School

Those embarking on a career in medicine or medical research are doing so at a time of tremendous change and challenge. In the span of 4 years, how are medical schools to simultaneously teach the exponentially expanding body of knowledge garnered by medical and basic science research, introduce students to new technologies and drugs that are revolutionizing diagnostic and therapeutic options, and train physicians to work effectively in an increasingly complex health care system? Last year the Carnegie Foundation for the Advancement of  Teaching published a book based on an in-depth study and blueprint for a major overhaul of medical education entitled Educating Physicians:  A Call for Reform of Medical School and Residency by Molly Cooke, David Irby, and Bridget O’ Brien, three well credentialed medical educators (Jossey-Bass, San Francisco, 2010).

This
study is compelling because it follows a template established a century
earlier when the Carnegie Foundation carried out a study that
revolutionized American medical education. Known as the Flexner Report,
it established the basis for the curriculum and the standards for
medical education that continue to the present day. To understand the
changes called for in the 2010 Carnegie Foundation study, it is
necessary to review the 1910 Flexner Study, including why it was done,
what it reported, and the structure it created.


The Flexner Report

Why it was done. In the early 20th century, there was
grave and widespread concern about the quality and standards of the 155
medical schools in North America. Many were small, proprietary
institutions and, even among those associated with universities, the
instruction, faculties, students, administrators, and clinical training
were often of poor quality. Consequently, in 1908 the American Medical
Association Council on Medical Education approached the Carnegie
Foundation and asked their help in surveying and restructuring American
medical education.  For this task, the Carnegie Foundation chose Abraham
Flexner, a non-physician professional educator from Louisville who was
pioneering the concept that education should be marked by small classes,
personal attention, and hands-on teaching. Before starting on his
in-depth study of all 155 schools, Flexner visited the recently
established Johns Hopkins Medical School and, from his discussions with
leading physicians at that institution, adopted Hopkins as a model for
comparison with the other schools.

What Flexner reported.

The following quotation from Flexner’s 1910 book-length study reflected
his general assessment of the level of education:  “Each day students
were subjected to interminable lectures and recitations. After long
mornings of dissection or a series of quiz sections, they might sit
wearily in the afternoon through 3 or 4 or even 5 lectures delivered in
methodical fashion by part time teachers.  Evenings were given over to
reading and preparations for recitations. If fortunate enough to gain
entrance to a hospital, they observed more than participated.”

Flexner
found a handful of schools worthy of praise for their fine programs,
including Harvard, Western Reserve, Michigan, Wake Forest, McGill, and
Toronto, but reserved his highest praise for Hopkins, “the model for
medical education.”

What Flexner proposed to remedy the situation is summarized by Cooke et al. as follows:

  • High
    admissions standards, including requiring a bachelor’s degree with a
    strong science focus, rather than merely a high school degree as was
    typical at the time.
  • A university-based medical school to train
    students to think like scientists, furnishing two years of basic science
    instruction instead of a mere eight months of lectures.
  • Two years of supervised clinical experience by university-based physicians in a teaching hospital.
  • Experience in investigation through supervised immersion in laboratories and clinical settings.
  • Instruction by physician-scientists who could move effortlessly from the research laboratory to the bedside and back.

Flexner
strongly recommended that medical schools employ full-time clinical
professors, who would become “true university teachers barred from all
but charity practice, in the interest of teaching.”

How things changed.
The impact of the report and the sustained changes it produced are
remarkable. It succeeded in establishing a single model of medical
education that continues to the present day. The recommendations of the
report were implemented through certification accreditation and
licensing procedures throughout the United States and Canada. By 1920
almost half of all American medical schools had merged or closed and the
number of medical students had decreased from 28,000 to fewer than
14,000. Quality became more important than quantity. On the negative
side, medical education became very expensive and access to medical
education was severely restricted for women, African-Americans, and
other minorities, which continued until the 1960s.

The Flexner II (2010) Report

Why it is needed. Flexner
emphasized in his original report that “scientific inquiry and
discovery, not past traditions and practice, should point the way to the
future in both medicine and medical education.” Expansion in the
knowledge base for the practice of medicine, advances in pedagogy, the
complexity of health care, the changing role of the physician in health
care, and the financial cost of medical education are among
the key factors that dictate a major overhaul in how doctors are
prepared for their careers.

How the new study was conducted.
The new study represents 4 years of effort by 3 faculty members at the
University of California, San Francisco School of Medicine: Molly Cooke,
M.D., is a professor of medicine; David M. Irby, Ph.D., is vice-dean
for education; and Bridget C. O’Brien, Ph.D., is a researcher in the
Office of Medical Education. The investigators visited 11 of 130 medical
schools and teaching hospitals currently accredited by the Association
of American Medical Colleges and 3 non-university teaching hospitals.
These institutions were considered to represent a cross section of
institution types and geographic location. Each visit lasted
approximately 3 days and included in-depth interviews and focus groups
involving students, house staff, program directors, deans, and others.

What was found.
The investigators reported that they observed in aggregate “a
remarkable system of healthcare, and along with it an exceptional
educational program for preparation of physicians.” They also observed
significant shortcomings:  

In the course of our
fieldwork, we saw many instances of foundational knowledge poorly linked
to experience; well-thought-out, integrated teaching subverted by
inappropriate assessments; and missed opportunities for allowing
learners to participate in the important nonclinical roles physicians
play within health care and more broadly in society.

The strengths and weaknesses are discussed in detail and make for interesting reading.

Recommendations for change. The findings of the group led them to recommend 4 goals for medical education.

1.    Standardize learning outcomes and individualized learning processes

  • Set clear, progressive expectations for learning outcomes, and assess competencies over time
  • Establish common competency domains across the UME-GME-CME continuum, with appropriate developmental benchmarks for learners
  • Individualize
    learning within and across levels, allowing flexibility in approach to
    learning and offering opportunities to pursue areas of interest beyond
    core learning outcomes

2.    Integrate knowledge and clinical experience, roles, and responsibilities

  • Closely
    connect formal knowledge and clinical experience, including provisions
    of early clinical immersion and later revisiting of the sciences
  • Examine diseases and clinical situations from multiple perspectives
  • Give learners access to different roles and responsibilities of physicians
  • Promote
    learners’ ability to work collaboratively with other health
    professionals to effectively deliver patient care in complex systems

3.    Develop habits of inquiry and improvement

  • Focus on development of both routine and adaptive expertise
  • Engage learners in challenging problems and knowledge-building endeavors

4.    Address professional identity formation explicitly

  • Offer formal ethics instruction, feedback, and reflective opportunities related to professional development
  • Support learner and teacher relationships that advance the highest values of the profession
  • Encourage exploration of the roles of the physician-citizen
  • Create collaborative learning and practice environments committed to excellence and continuous improvement.

Conclusion

The study described in Educating Physicians
is a worthy successor to the original Flexner report. Can the reforms
called for be accomplished? The devil is, of course, in the details, and
the details are largely addressed in this work. The process has already
begun.

For those contemplating or involved in a medical career
(i.e., persons spending 4 years in medical school and a lifetime in
medicine or medical research), Educating Physicians should be required reading.

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