Beyond Flexner: Medical Education in the Twentieth Century (Contributions in Medical Studies)
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For decades, educators, historians, and social commentators accorded major responsibility for the reform of medical education in the United States to the Flexner Report of 1910. More recently, historians have begun to challenge the impact of the Report and the desirability of the changes attributed to it. This volume takes the themes articulated in the Report and traces their development. With each theme being discussed by a specialist in the subject area, the book provides a comprehensive review of medical education in the twentieth century.
These themes, many of which have not been discussed in other books, include the basic sciences, the clinical curriculum, women in medicine, black medical education, and sectarian medical education. In addition, the volume includes chapters on the evolution of the health care delivery system, trends in financing medical education, the use of outpatient settings for clinical education, the current status of the medical curriculum and needed changes, and health manpower needs. The work concludes with a chapter discussing the current proposals for change and how they relate to the problems and reforms of the Flexner era. The work will be of interest to medical school administrators, policy makers, and faculty members as well as to practicing physicians.
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Beyond Flexner: Medical Education in the Twentieth Century (Contributions in Medical Studies) Review
This is an absolutely excellent specimen of academic-technical writing! Dense with objective facts, it easily remains a fascinating read. Simply as non-fiction literature, despite its specialized focus, this is one of the very best books written. At the same time, it is satisfying at a specialist level with 33 pages of notes & judiciously selected bibliography. I warmly recommend the book to any serous-minded person who mightbe interested in the history of the systems and the physicians we rely on for our helathcare. I consider it fundamental reading for anyone who hopes to understand the historical or current healthcare problems we face.
The topic of healthcare (and the sub-topic on the training of doctors) is highly politicized and divisive - it "made" a US President. But by some miracles of recruitment and editing, Barzansky and Gevitz have assembled a collection of "chapters" by strong scholars that manages to address all the difficult problems and competing interests without descending into contentious pleading for one "side" or the other. Not a single dud item!
As a political "conservative" working in Canada's hospital industry, I had several corrections made to my misperceptions and yet never felt that "my" views were dealt with unfairly. I suspect that a "liberal" reader will have both experiences similarly.
Introduction
Abraham Flexner (1866-1959) was a "high school" principal, who became interested in medical training and competence as an outsider. He was supported by the Carnegie Foundation to conduct a survey of Medical Schools in Canada and the USA; this "Flexner Report" was very frank and caught the attention of the schools: "Medical Education in the United States and Canada", appearing in 1910. In the years following, huge changes transformed medical education in both countries.
Flexner is credited or blamed with the trends in medical education since his 1910 "Report"; but the trends were already underway when he wrote and his Report was a catalyst that speeded them up. The collection discusses many dimensions of the change since and in relation to the Report.
1. Abraham Flexner in Historical Perspective (Hudson)
Flexner, sponsored by the Carnegie Fnd, with the support of the AMA & AAMC, articulated ideas in his "Report" from Europe/Germany and in NA medical circles accepted. Med deregulated 1830-1870-1890 many bad schools. Importance of knowledge & science became apparent - universities became centres. Flexner recc: 1.fewer 2.better med schools, 3.college pre-req, 4.scientific approach, 5.research MDs, 6.university hosp, 7.state licensure. Flexner did not say all MDs must research or that clinical skill not vital; nor did he say Johns Hopkins model shd be copied.
2. The Growth and Divergence of the Basic Sciences (Barzansky)
Pre-1900 curriculum was repetitional, not graded. Flexner's "basic" sciences: anatomy [hist & embryo], physi'y [physio-bio-chem], pharmac'y, path'y, bactri'y, from biology, chemistry, physics. MD shd develop a scientific "spirit" w experiential learning in labs. Over the 20thC med-ed lab work grew in time but became mere exercise unrelated to MD work. MD salaries and growth of special sciences led to non-MD (i.e. PhD) as med-ed teachers. Need to integrate basic sci learning with goal of clinical competence. Reaction to rote labs and PhDs brought organ-system and problem-solving curricula, w basic depts serving med-ed goals. Stat of hours devoted to basic science varied over 20thC.
3. Clinical Education since Flexner or Whatever Became of William Osler? (Atwater)
The role of the practioner in medical education has declined since 1910. Factors: 1_university control of hospitals and full-time teachers, 2_technology and specialism, 3_financial control by bureaus, 4_economic prosperity and public support. Changes in a_Hospital enormous and high-tech, b_Curriculum overload and selection c_Patients of all classes d_Clinical teachers specialist or non-practitioners and declining physician authority e_Students less responsibility and focus on post-grad specialties.
4. Women in Medicine Since Flexner (Walsh)
The "heyday" until 70s for women in medicine was mid-19thC. However, [as w all med schools] quality was poor. Flexner recommended fewer but high-quality schools. School numbers fell dramatically and women were invited to apply to the remaining ones; however open and covert attempts to exclude women from med sch kept the number of women MDs low [until in 2005 women>men].
In 1971 a medical text was published including girlie pictures and locker-room humour (Becker et al. Anatomical Basis of Medical Practice) withdrawn from publication after objections from a Dr Ramey objection [feminist or obscenity issue?]
5. Abraham Flexner and the Black Medical Schools (Savitt)
At least 15 "black" medical schools were founded by black MDs in the late 19thC; two have survived but the others closed after median 8 yrs (mean 12 yrs); unable to sustain the finances related to quality expectations [false that difficulties were black-specific; see Hudson and Gevitz next]
6. The Fate of Sectarian Medical Education (Gevitz)
Ordinary mainstream M.D. medicine is "allopathic" (allo- a different health state follows treatment [term invented mid19thC abusively by Hahnemann infra]). "Sectarian" is any non-allopathic: homeopathy (Samuel Hahnemann 1755-1843), eclectic (Wooster Beach 1794-1868), [chiropractic, naturopathic, Chinese CTM, etc.] and DO osteopathy (Andrew Taylor Still 1828-1917) of which the theory stresses a holistic approach esp musculo-skeletal manipulation. The trends after Flexner to upgrade medical training were sidestepped by DOs because they did not then use drugs or invasion. The other sects did use drugs but could not keep up to the increasing standards and schools disappeared. But DOs continued with low standards improving only so much and fast as survival allowed. Then during WW II, they de facto filled in for the MDs who went to the forces (which did not want DOs). And as DOs' techniques expanded after 1945, they accepted the challenges to improve training so that they are similarly trained and functioning; both MD&DO are now accepted in the USA but not in most other places. [DO is a not merely a fancy chiropractor; USA-level medical training is very similar to the MD (as some DOs lament)]
7. American Health Services Since the "Flexner Report" (Anderson)
The history of the organization of health services in the US falls into three periods. 1875-1930 Infrastructure development and patient-pays free markets, physician quality doubtful rapidly improved; 1930-1965 3rd party insurer or employer left some people without affordable care and the CCMC (Ctt Costs Med Care), physician and hosp accreditation, and professional hosp administration, system controls; costs now growing too rapidly; "group practice/HMOs; 1965-future Medicare/Medicaid legislation begins a rapid growth of government oversight and controls; cost-plus funding for services proves "irresponsible"; new structures put quality at risk; seeking a way to incentivize low-cost high-quality; DRGs tried; reaction against specialization in favour of generalists; physicians will lose control over payment and system.
8. Trends in the Financing of Undergraduate Medical Education (Perloff)
USA - Federal govt interest in Med Ed (want more quality and quantity of MDs) was expressed from the 1940s on by attempts to provide funding to Med Schools for Med Ed, but faculty resisted/refused, because they wanted to prevent erosion of their academic freedom to control the curriculum and to keep numbers of MDs low (higher incomes), and until then Med Sch funding was private and from tuitions; starting in the 1950s the Govt tried a compromise by funding biomedical research which provided indirect revenues to the Med Schs, but it filled Med Schs w research-oriented profs who did not give the best clinical training, and when research funds began to decline in the 70s, the MedSchs needed another source; in the 80s, clinical reimbursements (ultimately Fed) were still generous, so this led to "Practice Plans" (at LHSC = GFTs) in which MDs joined a pool so that their billings went to support the MedSch and research before they got paid, but this led to a focus on revenues and constant clinical activity away from education and also away from a social responsibility ethic that had been part of medicine, so grads were shaped wrong.
9. Trends in the Use of Outpatient Settings for Medical Education (Barzansky & Perloff)
The normal work of physicians was once in the place of their patients, in ambulatory settings. Before 1920, this was reflected in the educational methods of the schools. But as hospitals became internally more specialized w the dominance of departmentalized science, the ambulatory patient was less interesting to the learned faculty who favoured more acute cases of the diseases under study, and clinics too miscellaneous, busy, and superficial for teaching; teaching became focussed on the inpatient units with student in rounds; after 1920 this led to the narrowing concept of the outpatient and the care there provided became less of a focus and unsystematic so that it was of little use in educating MDs; MDs who did not have outpatient training were incompetent to practice everyday med, and by 1950 this led to a search for solutions: preceptorships (apprenticeships), comprehensive care programs, (HMO settings), opportunities or programs stressing rural or general exposure to med care.
10. The Medical Curriculum: Developments and Directions (Baldwin)
There are many motives to change curriculums: MDs want to improve their profession, changes in the kind or number needed as health delivery systems and team structures change, not to mention technology and the specialization reqd by knowledge growth leading to content selection and greater program length. Attempts have been through internal adjustments, integration of content, ambulatory setting. General trend is a distance between the medical teacher and students, with a need to teach ethics explicitly and concerns about how to evaluate "loner" students. While many of the curriculum changes are logical responses to the evolution already discussed, there is a concern that the students are not being helped to become healers.
11. Will the Supply and Distribution of Physicians be Appropriate for the National Needs in the Year 2000? (Kindig & Movassaghi)
[USA specific and dated numbers, avg 20 numbers per page not counting tables, but gives good feel for the degree of complexity] Some elaborate attempts have been made to forecast medical manpower (GME_NAC, and BHP) using "needs" or "supply" forecast models rather than demand; with a surplus predicted. Interim results are surprisingly accurate, though the negatives of the supposed surplus are being offset by other factors (oddly the article makes no mention of demographics). Gives a good idea of the complexity and limitations of forecasting medical manpower.
12. Abraham Flexner: Lessons from the Past with Applications for the Future (Barzansky)
Synthesizing review of the main points of the book; then an overview of "current" plans for Med Ed reform as in four actual proposals: AMA-CME, AAMC-GPEP, Ebert-Ginzberg, Macy Fnd. All agree that changes in healthcare delivery systems are affecting MedSchs: financing methods, delivery modes, new knowledge. Proposals: choose rounded students, avoid narrow curricular specialization, emphasize teaching, link med sch experience to pre and post education. Levers of change: licensure (the MedSch offers a degree, but the state [through Boards] authorizes practice) can use diff evaluation tools to support the perceived needs, financing (MedSch funding from research 20% and practice 40%) supplement to reward innovation in "model" institutions (like Johns Hopkins - Flexner); ambulatory (inpatients too acute for med ed) clinics in hospital construction, content overload (accelerating growth of knowledge) use computers to manage. Successful adaptation of the MedSch will require environmental support, acceptance of a problem, innovation in financing and program/logistic design.
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