By: Henry S. Pritchett
Source: Pritchett, Henry S. Introduction to Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Abraham Flexner, ed. Bulletin Number Four. New York: The Carnegie Foundation for the Advancement of Teaching, 1910, vii–viii, x–xi, xiii–xvi.
About the Author: Henry S. Pritchett (1857–1939) received a bachelor's degree in 1875 from the Collegiate Institute at Glasgow, Missouri. In 1895, he received a doctorate in astronomy from the University of Munich. Pritchett was a professor of astronomy at Washington University, superintendent of the United States Coast and Geodetic Survey, and president of M.I.T. He was president of the Carnegie Foundation for the Advancement of Teaching from 1905 to 1930.
Medical education in the United States prior to 1910 was woefully inadequate. Aspiring doctors might not receive any formal medical education at all, outside of an apprenticeship with a practicing physician. Of those who did receive training, many attended small, commercial medical schools lacking in equipment and quality instructors. Quacks and charlatans employing dubious methods were common. Significant advances in medical science meant that expensive equipment and facilities were necessary to conduct satisfactory medical education. Smaller schools with modest budgets were unable to meet these new standards, yet a lack of regulation allowed these "diploma mills" to continue to operate.
The American Medical Association (AMA) began preliminary efforts to study and correct some of the problems of medical education. The AMA Council on Medical Education was established in 1904. It produced a 1905 report indicating that, of the 155 medical schools in the United States and Canada, only five required students to have at least two years of college prior to admission. The Council also devised a classification ranking scheme by which medical schools could be evaluated.
In 1907, Dr. Arthur Dean Bevan, chairman of the AMA Council, asked Henry S. Pritchett, the Carnegie Foundation president, to consider the topic. Pritchett immediately saw the subjects as educational rather than medical—these were schools and should be evaluated from the standpoint of education. He was able to convince the Carnegie Foundation's executive committee and trustees of his view, and in 1908, the study was authorized. Pritchett intended the general public to be the audience for the report, rather than solely the medical profession.
Abraham Flexner was chosen to head the study. He visited every medical school in the United States and Canada and evaluated each on the following criteria: entrance requirements, faculty qualifications, size of budget, quality of facilities, and relationship with a teaching hospital. He found, in many cases, deplorable conditions,especially among smaller, for-profit schools. Some schools had no equipment or facilities beyond classrooms, outfitted with only blackboards and chairs. Many medical schools lacked qualified instructors and meaningful entrance requirements. The situation was ripe for change.
The publication of the report, and its subsequent treatment by the press, resulted in a public uproar. As awareness of the problems grew, so did the demands for change. Many schools closed, while others received complete overhauls. Schools that were small, for-profit, or that adhered to non-traditional (today referred to as "alternative") approaches were most likely to close. The result of these closures was the reduction in the number of physicians, as Flexner had recommended. There also followed an increase in admissions standards, and an overall improvement in the quality of medical education.
One significant effect of the report was the elimination of most medical schools serving female and minority students. Some critics have faulted the report for the resulting homogeneity among doctors. Critics have also questioned the qualifications of Flexner, a high-school principal with no medical training, and his high-speed approach that sometimes left only a single afternoon to visit a school. Others have alleged undue influence by the AMA and a possible financial motivation for the recommendations—fewer doctors meant higher incomes for those already in the profession.
The general picture of medical education today reflects Flexner's recommendations. Medical schools are generally non-profit institutions, an integral part of a college or university, and associated with a teaching hospital. Medical schools adhere to accepted standards of admission and instruction.
Primary Source: Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching [excerpt]
SYNOPSIS: In this excerpt, from the report's preface, Henry S. Pritchett, president of the Carnegie Foundation for the Advancement of Teaching, presents the results of the study, together with his recommendations for improving medical education. Pritchett advocates for fewer, but higher quality, medical schools that operate within a university or college.
Colleges and universities were discovered to have all sorts of relations to their professional schools of law, of medicine, and of theology. In some cases these relations were of the frailest texture, constituting practically only a license from the college by which a proprietary medical school or law school was enabled to live under its name. In other cases the medical school was incorporated into the college or university, but remained an imperium in imperio, the college assuming no responsibility for its standards or its support. In yet other cases the college or university assumed partial obligation of support, but no responsibility for the standards of the professional school, while in only a relatively small number of cases was the school of law or of medicine an integral part of the university, receiving from it university standards and adequate maintenance. For the past two decades there has been a marked tendency to set up some connection between universities and detached medical schools, but under the very loose construction just referred to.
Meanwhile the requirements of medical education have enormously increased. The fundamental sciences upon which medicine depends have been greatly extended. The laboratory has come to furnish alike to the physician and to the surgeon a new means for diagnosing and combating disease. The education of the medical practitioner under these changed conditions makes entirely different demands in respect to both preliminary and professional training.…
No effort has been spared to procure accurate and detailed information as to the facilities, resources, and methods of instruction of the medical schools. They have not only been separately visited, but every statement made in regard to each detail has been carefully checked with the data in possession of the American Medical Association, likewise obtained by personal inspection, and with the records of the Association of American Medical Colleges, so far as its membership extends. The details as stated go forth with the sanction of at least two, and frequently more, independent observers.…
The striking and significant facts which are here brought out are of enormous consequence not only to the medical practitioner, but to every citizen of the United States and Canada; for it is a singular fact that the organization of medical education in this country has hitherto been such as not only to commercialize the process of education itself, but also to obscure in the minds of the public any discrimination between the well trained physician and the physician who has had no adequate training whatsoever. As a rule, Americans, when they avail themselves of the services of a physician, make only the slightest inquiry as to what his previous training and preparation have been. One of the problems of the future is to educate the public itself to appreciate the fact that very seldom, under existing conditions, does a patient receive the best aid which it is possible to give him in the present state of medicine, and that this is due mainly to the fact that a vast army of men is admitted to the practice of medicine who are untrained in sciences fundamental to the profession and quite without a sufficient experience with disease. A right education of public opinion is one of the problems of future medical education.
The significant facts revealed by this study are these:
- For twenty-five years past there has been an enormous over-production of uneducated and ill trained medical practitioners. This has been in absolute disregard of the public welfare and without any serious thought of the interests of the public. Taking the United States as a whole, physicians are four or five times as numerous in proportion to population as in older countries like Germany.
- Over-production of ill trained men is due in the main to the existence of a very large number of commercial schools, sustained in many cases by advertising methods through which a mass of unprepared youth is drawn out of industrial occupations into the study of medicine.
- Until recently the conduct of a medical school was a profitable business, for the methods of instruction were mainly didactic. As the need for laboratories has become more keenly felt, the expenses of an efficient medical school have been greatly increased. The inadequacy of many of these schools may be judged from the fact that nearly half of all our medical schools have incomes below $10,000, and these incomes determine the quality of instruction that they can and do offer.
Colleges and universities have in large measure failed in the past twenty-five years to appreciate the great advance in medical education and the increased cost of teaching it along modern lines. Many universities desirous of apparent educational completeness have annexed medical schools without making themselves responsible either for the standards of the professional schools or for their support.
- The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation; but the facts set forth in this report make it evident that this argument is insincere, and that the excuse which has hitherto been put forward in the name of the poor boy is in reality an argument in behalf of the poor medical school.
- A hospital under complete educational control is as necessary to a medical school as is a laboratory of chemistry or pathology. High grade teaching within a hospital introduces a most wholesome and beneficial influence into its routine. Trustees of hospitals, public and private, should therefore go to the limit of their authority in opening hospital wards to teaching, provided only that the universities secure sufficient funds on their side to employ as teachers men who are devoted to clinical science.
In view of these facts, progress for the future would seem to require a very much smaller number of medical schools, better equipped and better conducted than our schools now as a rule are; and the needs of the public would equally require that we have fewer physicians graduated each year, but that these should be better educated and better trained. With this idea accepted, it necessarily follows that the medical school will, if rightly conducted, articulate not only with the university, but with the general system of education. Just what form that articulation must take will vary in the immediate future in different parts of the country. Throughout the eastern and central states the movement under which the medical school articulates with the second year of the college has already gained such impetus that it can be regarded as practically accepted. In the southern states for the present it would seem that articulation with the four-year high school would be a reasonable starting-point for the future. In time the development of secondary education in the south and the growth of the colleges will make it possible for southern medical schools to accept the two-year college basis of preparation. With reasonable prophecy the time is not far distant when, with fair respect for the interests of the public and the need for physicians, the articulation of the medical school with the university may be the same throughout the entire country. For in the future the college or the university which accepts a medical school must make itself responsible for university standards in the medical school and for adequate support for medical education. The day has gone by when any university can retain the respect of educated men, or when it can fulfil its duty to education, by retaining a low grade professional school for the sake of its own institutional completeness.…
The development which is here suggested for medical education is conditioned largely upon three factors: first, upon the creation of a public opinion which shall discriminate between the ill trained and the rightly trained physician, and which will also insist upon the enactment of such laws as will require all practitioners of medicine, whether they belong to one sect or another, to ground themselves in the fundamentals upon which medical science rests; secondly, upon the universities and their attitude towards medical standards and medical support; finally, upon the attitude of the members of the medical profession towards the standards of their own practice and upon their sense of honor with respect to their own profession.
These last two factors are moral rather than educational. They call for an educational patriotism on the part of the institutions of learning and a medical patriotism on the part of the physician.
By educational patriotism I mean this: a university has a mission greater than the formation of a large student body or the attainment of institutional completeness, namely, the duty of loyalty to the standards of common honesty, of intellectual sincerity, of scientific accuracy. A university with educational patriotism will not take up the work of medical education unless it can discharge its duty by it; or if, in the days of ignorance once winked at, a university became entangled in a medical school alliance, it will frankly and courageously deal with a situation which is no longer tenable. It will either demand of its medical school university ideals and give it university support, or else it will drop the effort to do what it can only do badly.
By professional patriotism amongst medical men I mean that sort of regard for the honor of the profession and that sense of responsibility for its efficiency which will enable a member of that profession to rise above the consideration of personal or of professional gain. As Bacon truly wrote, "Every man owes a duty to his profession," and in no profession is this obligation more clear than in that of the modern physician. Perhaps in no other of the great professions does one find greater discrepancies between the ideals of those who represent it. No members of the social order are more self-sacrificing than the true physicians and surgeons, and of this fine group none deserve so much of society as those who have taken upon their shoulders the burden of medical education. On the other hand, the profession has been diluted by the presence of a great number of men who have come from weak schools with low ideals both of education and of professional honor. If the medical education of our country is in the immediate future to go upon a plane of efficiency and of credit, those who represent the higher ideals of the medical profession must make a stand for that form of medical education which is calculated to advance the true interests of the whole people and to better the ideals of medicine itself.…
In the preparation of this report the Foundation has kept steadily in view the interests of two classes, which in the over-multiplication of medical schools have usually been forgotten—first, the youths who are to study medicine and to become the future practitioners, and, secondly, the general public, which is to live and die under their ministrations.
No one can become familiar with this situation without acquiring a hearty sympathy for the American youth who, too often the prey of commercial advertising methods, is steered into the practice of medicine with almost no opportunity to learn the difference between an efficient medical school and a hopelessly inadequate one. A clerk who is receiving $50 a month in the country store gets an alluring brochure which paints the life of the physician as an easy road to wealth. He has no realization of the difference between medicine as a profession and medicine as a business, nor as a rule has he any adviser at hand to show him that the first requisite for the modern practitioner of medicine is a good general education. Such a boy falls an easy victim to the commercial medical school, whether operating under the name of a university or college, or alone.
The interests of the general public have been so generally lost sight of in this matter that the public has in large measure forgot that it has any interests to protect. And yet in no other way does education more closely touch the individual than in the quality of medical training which the institutions of the country provide. Not only the personal well-being of each citizen, but national, state, and municipal sanitation rests upon the quality of the training which the medical graduate has received. The interest of the public is to have well trained practitioners in sufficient number for the needs of society. The source whence these practitioners are to come is of far less consequence.…
While the aim of the Foundation has throughout been constructive, its attitude towards the difficulties and problems of the situation is distinctly sympathetic. The report indeed turns the light upon conditions which, instead of being fruitful and inspiring, are in many instances commonplace, in other places bad, and in still others, scandalous. It is nevertheless true that no one set of men or no one school of medicine is responsible for what still remains in the form of commercial medical education. Our hope is that this report will make plain once for all that the day of the commercial medical school has passed. It will be observed that, except for a brief historical introduction, intended to show how present conditions have come about, no account is given of the past of any institution. The situation is described as it exists today in the hope that out of it, quite regardless of the past, a new order may be speedily developed. There is no need now of recriminations over what has been, or of apologies by way of defending a régime practically obsolete. Let us address ourselves resolutely to the task of reconstructing the American medical school on the lines of the highest modern ideals of efficiency and in accordance with the finest conceptions of public service.
Barzansky, Barbara, and Norman Gevitz. Beyond Flexner: Medical Education in the Twentieth Century. New York: Press, 1992.
Bonner, Thomas Neville. Iconoclast: Abraham Flexner and a Life in Learning. Baltimore, Md.: Johns Hopkins University Press, 2002.
Flexner, Abraham. Henry S. Pritchett: A Biography. New York: Columbia University Press, 1943.
——. I Remember: The Autobiography of Abraham Flexner. New York: Simon and Schuster, 1940.
Vevier, Charles, ed. Flexner: 75 Years Later: A Current Commentary on Medical Education. Lanham, Md.: University Press of America, 1987.
Wheatley, Steven C. The Politics of Philanthropy: Abraham Flexner and Medical Education. Madison: University of Wisconsin Press, 1988.
Ober, K. Patrick. "The Pre-Flexnerian Reports: Mark Twain's Criticism of Medicine in the United States." Annals of Internal Medicine 126, January 1997, 157–163.
"The Carnegie Foundation for the Advancement of Teaching." Available online at ; website home page http://www.carnegiefoundation.org (accessed March 14, 2003).