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.
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.
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.
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.