The Forgotten Chapter of the Flexner Report

Spend a few cursory hours reading or writing about U.S. medical education and you’ll bump into the “Flexner Report” and its author Abraham Flexner. If you’re reading this blog, it’s safe to assume you’re somewhat familiar with the report and its impact on medical education. The report’s influence has been debated for generations—some point to the report as the main impetus for educational reform, others caution against assigning an overly large causative role. Few today can debate the report’s distinctly negative consequences for historically black medical colleges.  Still, any reasonable assessment acknowledges the report as a significant milestone in U.S. medical education.

220px-Picture_of_Abraham_FlexnerBut for all the supposed familiarity with the report by those who love to reference it, one portion has been largely forgotten and seldom cited—chapter 11 dealing with state medical boards.  I re-read this chapter recently. What struck me most in revisiting the text was Flexner’s juxtaposition of praise and criticism of state medical boards. I found myself momentarily flashing back to 10th grade English, Julius Caesar and Marc Anthony’s funeral oration: “I come not to praise Caesar but to bury him.”

Okay, that may have been a bit much so let me be clear. I’m not accusing of Flexner of being disingenuous or damning state medical boards with faint praise…but he does take the reader on a bit of roller coaster. The opening sentence of chapter 11 set forth the inherent potential for medical boards to bring about pronounced, positive changes to medical education: “The state boards are the instruments through which the reconstruction of medical education will be largely effected.”

Remember, at the time of Flexner’s writing, U.S. medical education featured a wide disparity in the quality of schools (e.g., entrance requirements, facilities, faculty, clinical training, etc) with most schools being private, proprietary endeavors operating without any university and/or hospital affiliations. (These schools were the main target of Flexner and many other educators.) For Flexner, the greatest service state medical boards could provide involved “crushing” the outlier schools proliferating on the fringes of medical educations…what he deemed “notoriously incompetent institutions.”

reportFlexner identified three weapons at the disposal of state medical boards—all of which derived from their statutory authority bestowing varying degrees of oversight/influence on education within their state. These powers included…

  1. Mandating preliminary education requirements for physicians (e.g., 1-year college course work prior to matriculating medical school)
  2. Authority to recognize/approve acceptable medical schools
  3. Authority to require an examination as a condition for medical licensure

Flexner viewed the latter as particularly critical. He characterized the licensing exam as the “lever” with the potential to raise medical education and the profession as a whole. He wasn’t subtle about this either. You can almost sense a Machiavellian relish at the thought of what can be done to those substandard proprietary schools when he writes, “…the power to examine is the power to destroy.”

But then, almost as if he were awakened from his dream of an imagined medical school future, Flexner grumpily catalogs all the nagging contemporary realities of medical regulation…and there were admittedly many that frustrated the reform-minded educator.

Flexner’s lamentations

The composition of state medical boards troubled Flexner greatly—too often they were “not strongly constituted.” He lamented that membership too often featured politically-motivated appointments and that medical school faculty were prohibited from serving.

While a champion of the medical licensing examination, Flexner lamented the boards’ reliance upon written exams and the booming industry in preparation materials (“State Board Questions and Quiz-compends”). For Flexner, only a “practical” exam touched the “heart of the matter,” i.e., the ability and fitness of the physician to treat patients safely. At the time of his report, only Minnesota and Ohio were experimenting with practical exams.

State boards were poorly resourced. Flexner lamented the lack of staff—often just a single person, the board secretary—and inadequate funding. “A bureau properly organized cannot live on small fees.” His list continued, citing the persistence of sectarian (homeopathic, eclectic) licensing boards, unreasonably diverse states laws regulating the practice of medicine, etc.

And yet despite the gloomy depiction throughout much of this chapter on the role of medical boards, Flexner still found reason for optimism. “Despite imperfect and discordant laws and inadequate resources, the state board has abundantly justified itself.” He sensed a motivating esprit de corps and pointed to signs of collaboration (e.g., reciprocity agreements) as reasons for hope.

While he didn’t cite it as a basis for optimism, the greatest hopefulness stemmed from a simple fact: state medical boards were the only entities with the statutory authority to compel change. The Association of American Medical Colleges (AAMC) could promote high standards for education; the AMA Council on Medical Education could survey and categorize schools into Class A, B, C institutions…but only state medical boards could embed best practices and classification systems into law.

It seems that Flexner’s laments on state medical boards stemmed directly from his recognition that they were the 600 lb. gorilla that could bring the future he envisioned just a little closer.

The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards.