Summary

It is hard to underestimate the impact of the Flexner Report (1910) and how it shaped the entire US healthcare system. We live with the results of the Flexner report every day. The report professionalized medical education, raised standards, and improved the quality of medical education. However, the report also closed many medical schools, emphasized science over patient care, and reduced the number of Black doctors.

The Flexner report significantly reduced the number of doctors, resulting in an overwhelmingly white male population of doctors. Blacks and women were excluded. The report directly led to the current shortage of black doctors. 

Flexner’s ideas emphasized laboratory science and scientific discovery over patient care—a shift that still shapes American medicine to this day.  This shift fueled U.S. leadership in medical innovation but left deep scars on equity and access to healthcare. To see why, we need to revisit 1910—an era of snake-oil salesmen, weak public health systems, scientific skepticism and widespread scientific racism. In that setting, the Flexner Report became a turning point for American medicine.

Flexner was an educator who studied classical philosophy and later medical education in Europe. He strongly believed in small, more professional schools based on a science education. His model was the elite Johns Hopkins School of Medicine.

The Flexner report was groundbreaking.  The issuing of the Flexner report in 1910 was a defining moment in US medicine. It stressed scientific medicine over improving the general health of society. Flexner’s legacy is mixed. The AAMC renamed its Flexner award in light of his racist and sexist views. (AAMC)

Who was Abraham Flexner?

Abraham Flexner was not a physician. Flexner was a teacher and educational expert. He taught at Louisville High School and created his own school to use his methods. He believed in practical education, learning by doing, rather than memorization.

He was the sixth of seven siblings in a Louisville, Kentucky, Jewish family whose father was a struggling but unsuccessful businessman. He attended Johns Hopkins University. And majored in Greek, Latin, and philosophy. He completed his studies in two years to save money. Flexner then taught high school for 4 years and then founded his own experimental school at 26.

His educational ideas resembled those of John Dewey: students learn by doing rather than memorization. He founded a successful private school in Louisville and grew his reputation. He sold his school and used the money to pursue a doctorate in philosophy from Harvard. As part of his Phd, he traveled to schools in Europe to study the education of Americans in European medical institutions.

He published a book called “The American College,” which brought him to the attention of Henry Pritchett, head of the Carnegie Foundation, who offered him a job. Pritchett believed a professional educator would do a better job at reforming medical education than a doctor.

Upon commission, he spent a lot of time reading about German education and the scientific methods. He toured all 155 medical schools open at the time in the US and Canada.

Flexner held racist views like many at the time

Flexner reflected the common racist views of the time. Flexner believed that the purpose of Negro medical education was to administer hygiene to the Negro race. The goal was to limit the spread of diseases, like hookworm and tuberculosis, to whites. He believed that black physicians should treat only black patients. He believed that only two of seven Black medical schools should remain open: Howard Medical School and Meharry Medical College.

It was also the time of “Scientific Racism.” Scientists tried to prove that Blacks were biologically inferior to whites. Scientists famously measured the size of black and white skulls to determine brain power.

Later, physicians conducted racist experiments on Black people, like the Tuskegee Syphilis experiment and the stealing of the DNA of Henrietta Lacks. All in the name of science.

What did Flexner say about African American physicians?

Flexner discusses Negro medical education in a 2-page chapter called “The Medical Education of the Negro” on pages 180-181.

His writing in the report illuminates his racial views. Let’s take a closer look.   

“The negro must be educated not only for his sake, but for ours.”

Some of the passages in the report are shocking by today’s standards on race. In one passage, he argues that Blacks are ignorant and easily “taken in.”

“The pioneer work in educating the race to know and to practise fundamental hygienic principles must be done largely by the negro doctor and the negro nurse. It is important that they both be sensibly and effectively trained at the level at which their services are now important. The negro is perhaps more easily ” taken in ” than the white; and as his means of extricating himself from a blunder are limited, it is all the more cruel to abuse his ignorance through any sort of pretense. A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous.”

“The practice of the Negro doctor will be limited to his own race, which in its turn will be cared for better by good negro physicians than by poor white ones.”

 He did touch on Black medical schools.

“The negro needs good schools rather than many schools,- schools to which the more promising of the race can be sent to receive a substantial education in which hygiene rather than surgery, for example, is strongly accentuated.”

“Meharry at Nashville and Howard at Washington are worth developing.” “The upbuilding of Howard and Meharry will profit the nation much more than the inadequate maintenance of a larger number of schools.“

Flexner also suggests that donors and supporters invest in the two remaining medical schools.  We estimate that both schools, if fully funded, would have been three times larger than their current size.  Black medical schools were starved of funds by the government and philanthropy and lacked support from the Black community.  

“The subventions of religious and philanthropic societies and of individuals can be made effective only if concentrated. They must become immensely greater before they can be safely dispersed.”

Of the seven medical schools for negroes in the United States,¹ five are at this moment in no position to make any contribution of value to the solution of the problem above pointed out; Flint at New Orleans, Leonard at Raleigh, the Knoxville, Memphis, and Louisville schools are ineffectual. They are wasting small sums annually and sending out undisciplined men, whose lack of real training is covered up by the imposing M.D. degree.

Flexner mirrored the common views on race and sex at the time. 

What was the Flexner report in detail?

So what was the actual Flexner report, and what were the implications?  

In 1910, the Carnegie Foundation sponsored a report called  “Medical education in the US and Canada.” The report came to be called the Flexner report. The report was a landmark review of medical education on the US.  The report led to modern medical education.

The report originated in Flexner’s exposure to European, especially German, medical education, which was heavily science-based at the time. He followed American medical students training in Europe.

The report is divided into two parts: part one has fourteen chapters, which suggest reforms to the US medical education system, and part two has state-level data on doctors. Part one is the most important. Flexner discusses the current state of US medical education but quickly shifts to his ideal program. He uses Johns Hopkins Medical School as a model program. He then discusses the need for two years of science education followed by two years of hospital training.

In his report, Flexner deemed two-thirds of schools to be “hopeless.” The majority were proprietary, operated more for profit than for education, with no uniform standards. Sixty percent required their students to have only an elementary school education, while only 12 percent required two years of college.

How did it impact Medical Education and Medical Schools?

The report found fertile ground in the US at the time. Backed by the Carnegie Foundation, philanthropists, and other donors, the report changed medical education. The report stresses science-based education, laboratory work, and practical training in hospitals. The report recommended higher qualifications for entering medical students, including having 2 years of education in the sciences.

State medical boards and elite medical schools followed his recommendations, while many smaller medical schools closed. The remaining medical schools got smaller and more elite. The limited number of admission slots were reserved for white men. The remaining medical schools rejected black and female applicants.

How did it affect Black medical schools

The report directly led to the closure of 5 out of 7 Black medical schools in the US. However, other sources estimate the number of schools closed as high as thirteen(13) black medical schools (JAMA Network). Both the Flexner report and the JAMA network agree that at least five schools were closed. Many of the eight remaining schools in the JAMA article were closed before the report or had few graduates. But it is fair to say that at least 50% of the small, new schools would have reopened, expanded, grown and improved, if not for the Flexner report.

In addition, no new Black medical school opened between 1920 and 1987, when the Morehouse School of Medicine in Atlanta opened, and later the Drew-King School of Medicine in California.

If Black medical schools had continued and grown, there would be an additional 10,000 to 30,000 Black doctors, all with the benefits. And if HBCUs opened additional medical schools at a rate similar to white schools, the number of African American physicians would have increased dramatically.

The JAMA Network research paper highlights the loss at 10,000 to 30,000 Black doctors.

What is the long-term impact? What was Flexner’s legacy?

The biggest long-term impact of the report was to improve the quality of medical education.  The medical school curriculum shifted to a science-based approach. The change led to the US leading the world in medical research, new drugs, and advanced treatments. Almost every medical school applicant studies science in college. The standard pre-med course schedule includes calculus, biology, organic chemistry, and physics.

Second, he emphasized science-based approaches to medicine.  Science and the scientific method became the basis for medicine in the US.  His ideas led to the development of the modern pharmaceutical industry and some of the largest pharmaceutical companies in the world. His ideas also led to the formation of the FDA, which approves drugs, and the NIH, which conducts basic medical research.

Third, the report professionalized medical education and tilted medical education toward research and discovery. The US has some of the best hospitals in the world: Cleveland Clinic, Sloan Kettering, Johns Hopkins. Today, rich people travel from everywhere in the world to seek treatment in US hospitals.

But there were some downsides to the report

The report effectively limited the number of doctors in the US. The number of US doctors was reduced dramatically from XXX to YYY. By 1930. To this day, the US has one of the lowest per capita rates of doctors among OECD countries. The results were a drastic reduction in the number of doctors over the next 100 years. 

Physicians became almost exclusively male and white as students competed for a limited number of remaining spots at a smaller number of medical schools. The report limited the number of Black and female physicians.

Second, the report emphasized science over patient care. At the time, there were many home remedies but few cures with a foundation in science. Flexner’s report changed how we measure successful treatments.

Finally, the report led to the closure of Black medical schools, damaging Black healthcare for generations.  also limited the number of Black doctors and the number of female doctors between 1920 and 1970.  It took the civil right movement and the feminist movement to undue the damaging effects of the report.  But we still live the repercussions today.

Criticisms of Flexner’s report

Scholars look back on the Flexner report as one of the most important milestones in modern medicine. However, there are critics of the report.

Flexner overemphasized science rather than service. He emphasized expanding medical knowledge over service and general health and welfare.  

Another critique is that the Flexner Report overlooks “the ethos of medicine in its blind passion for science and education. What was the cost of our success, and who has borne that burden?”

His apparent oversight of the service role of the profession may also have played into his fierce and critical opposition to Winternitz’s Institute of Human Relations [13]. Social involvement of the physician was unimportant for the physician as envisioned by Flexner. Quote

“How else to explain the seemingly unexplainable Tuskegee experiments, the Henrietta Lacks tissue culture tragedy, the many occurrences in which the physician as scientist has ta”

Flexner had critics at the time. Some believe medical education would become detached from the common man. Others thought his pursuit of scientific knowledge sacrifices the welfare of patients.

Flexner’s model was also influenced by sponsors and philanthropy, and money.

Did Flexner overlook the core purpose of medicine? General welfare and “first do no harm?”

Summary

The Flexner report, in 1910, forever changed the US health care system. It improved the quality of our healthcare, bringing it up to European standards. But it also limited the number of physicians and closed black medical schools. Flexner also emphasized scientific research over patient care. We are living with its impact.

Sources

The Flexner Report ― 100 Years Later (Yale)

100 Years After Flexner: Medical Education Ushers In New Era of Reform (Macy Foundation)