From January, 1909, through April, 1910, Abraham Flexner1 traveled throughout the United States and Canada on a trip that revolutionized North American medical education. He visited every one of the existing 155 medical schools and, by the end of 1910, had published his report detailing the resources and practices of all these schools.2 Startlingly, he also recommended closing 120 of them3. The report, commissioned by the Carnegie Foundation for the Advancement of Teaching, begins by projecting needs for well-educated physicians and then articulates the educational resources and standards necessary before proceeding to detail the specifics of each school. He critiqued not only the admissions processes, academic curricula and resources but also the challenges in funding and the recruitment and retention of faculty. Finally, he recommended exactly which medical schools should be closed and which should remain open in each state and province. The resultant improvements in education have lasted to the present day but, unfortunately, no longer adequately serve the needs of aspiring surgeons.
Flexner divided the schools into three categories depending on the standards outlined in the first part of the report. In the first were those already meeting or about to meet all the standards. In the second were “almost rans”, those able to meet the standards with reasonable and obtainable improvement. The remaining schools were lumped into the third and final category as essentially hopeless, with no reasonable expectation of ever meeting the standards.
Subsequently, large numbers of schools were closed (although not 120) and the ones that remained increasingly adopted what has come to be known as the “Flexner Curriculum”, essentially still in use today. While identified as the “Flexner” curriculum, Flexner simply describes, with appropriate citations, curricula originating in Berlin and Vienna (including a paper by a certain Theodore Billroth4) which had already been summarized by the American Medical Association5 and the Association of American Medical Colleges6. This curriculum was already a standard in more than a dozen schools at the time, most famously Johns Hopkins.
In this landmark paper Flexner includes a lengthy section on the educational prerequisites (college level instruction) needed for successful medical education. He then covers in logical detail the progression of instruction and laboratory work in the necessary basic sciences. Building on anatomy and physiology in the first year, he progresses to pharmacology, pathology, and bacteriology in the second year. There is an excellent discussion of the need for, ideals of, and difficulties with obtaining hands-on experience for students during their clinical third and fourth years. A fifth year and the role of “internes” is also covered. The educational goals, methodologies, and obstacles he details remain amazingly relevant in 2017.
So why would one say that Flexner is failing the contemporary medical student, especially the modern surgical student? The problem lies in the assumptions of his report which were, in fact, appropriate for that time. Flexner discusses at some length physician to population ratios in various towns and states and projects future needs for well-trained physicians. Implicit in his discussion is that these physicians are all General Practitioners, seeing all types of patients, performing minor surgeries, delivering babies, etc. He mentions specialists largely in assuming that they provide the instructional and research core of the major university medical schools.
Today, however, only vestiges of the General Practitioner remain. The military anoints General Medical Officers after a medical degree and an internship. Many states will still license graduates of LCME accredited medical schools to “Practice Medicine and Surgery” after their internships. However, no insurance company, medical facility, clinic or hospital will credential a physician who is not board certified or eligible. Unfortunately, residency training was not part of Abraham Flexner’s calculus.
Therein lies the crux of the problem. Newly minted medical graduates today are not expected to “hang out their shingle” and begin their careers; in fact, this is not really an option. Instead they are expected, indeed required to evaluate, select, apply to, be accepted to, and succeed in residency programs. To make matters worse, this process begins well before graduation. The fourth year in Flexner’s Curriculum was supposed to be devoted to refinement and honing of the medical knowledge and skills acquired in the first three years. Now it has increasingly and haphazardly become devoted to the pursuit of a residency position with little to no change in the medical school curricula to support that pursuit.
Compounding this, a student’s decisions about their elective fourth year usually need to be made well before the end of the third year. It is important to remember that in the days when surgical specialty training followed the completion of 2-5 years of general surgery, as many as 60% of surgical interns changed their minds about the surgical specialty they eventually pursued. To give our medical colleagues their due, they continue to require a broad-based medical residency prior to applying to most medical specialty training. This allows more exposure to those disciplines before deciding on a specialty. Surgery, however, has become increasingly fragmented into academically and clinically isolated disciplines. Today’s students interested in surgery are therefore expected to choose a surgical specialty in the middle of their third year of medical school, often before they’ve even rotated on any surgical services.
Clearly the “Flexner” surgical education, now often constricted to a 6-8 week rotation on only one or two surgical services during (and not prior to) their third year fails to address the needs of aspiring surgeons in two basic ways. The first is the need for structured exposure to all, or as many as possible, of the various surgical specialties across their full spectrum of practices. Although the acquisition of surgical knowledge and skill by the average medical student would be a laudable effect, the most important objective would be to allow students to assess their true affinity and suitability for potential careers in those specialties. Second and more pressing is the need for expeditious timing. Given the schedule for residency applications, core surgical curricula should be completed by the beginning (January or February) of their third year for the student to constructively finalize their fourth year rotations.
The current and future generations of surgical students, from their first year of medical school through their chief residency deserve an integrated curriculum that provides not only the academic structure and breadth of the “Flexner Curriculum” but also a rational basis and modern algorithm for selecting and succeeding in a contemporary surgical specialty.
- Flexner was a rising iconoclastic educator, who went on to found the Institute for Advanced Studies at Princeton, who had already published a critique of college education in America in 1908.
- Flexner, A: Medical Education in the United States and Canada; The Carnegie Foundation; Bulletin No. 4; New York; 1910 (http://archive.carnegiefoundation.org/pdfs/elibrary/Carnegie_Flexner_Report.pdf)
- ibid, p.151
- Billroth, T; Uber das Lehren und Lernen der Medicinischen Wissenschaften; Vienna, 1876
- Report of Curriculum Committee, Council on Education, Am Med Assoc; Bulletin of the Am Med Assoc; Sept, 1909.
- “What Constitutes a Medical Curriculum?”; Association of American Medical Colleges; 1909