Lecture Twelve: The Flexner Report

Once the AMA and William Welch orchestrated an alliance of Progressive reformers, corporate interests, and state medical licensing agencies, it was time to sanctify the cogs of a new medical system.  That is what the Flexner Report is all about, a survey of US medical schools largely scripted by the AMA, conducted by a little known educator working for the Carnegie Corporation named Abraham Flexner, and financed by complicit corporations.  The Report entirely transformed the American healthcare system into one that focused on lab rats over clinicians, number measurement over patient-centered care, and a dogmatic top-down system run entirely by the AMA and financed by corporations.  The report closed most medical schools and required the surviving one to use corporate funds to transform into lab-based institutions.  Students would now be taken out of the clinical realm and be placed in the classroom and lab where they would learn about tests and drugs and German medicine, transforming healthcare into more of a technical field than one of critical thinking, humanism, and dynamic science.  Those who complied received higher salaries and status.  Those who did not were excluded from the healthcare landscape.  Poor William Osler protested from England, but his vision for medical care evaporated once the report's findings became the new norm.

Transcript

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Let's talk a little about the Flexner Report, the most important thing that ever happened in American medical care, and yet something that nobody has ever heard of. Really curious, right? So in 1910, the Carnegie Foundation uh paid an unknown educator named Abraham Flexner to survey both the American and Canadian medical schools, God knows why Canada was included, and to rank them. And the alleged purpose of this was to uh create a progressive report card, essentially. Which schools should survive, which schools can be changed over to the new German model of care that emphasized basic science and laboratory research with full-time faculty, period. And you know, this had been going on already, obviously. The AMA already did three school surveys, but they never published them. And all this was kept under wraps. The AMA's alliance with corporate interests, with licensing agencies, uh, with progressive reformers was also never exposed. So the fact that the Carnegie Foundation did this seemed to be a spontaneous move. But you know, the AMA felt as though if it was the spearhead organization to do this, it would be seen as having ulterior motives, which of course it did, but it didn't want the world to see that. It wanted this to be a progressive, uh, a progressive report that all the world appreciated. And so it stayed out of it, at least on the surface. So the the AMA laid the foundation for revolutionary revamping of the medical education system by surveying all the schools, as we talked about, and it established a norm for what constituted a passing grade. But ranking the schools meant nothing without some teeth, whereby graduation from one of these certified schools impacted pragmatic outcomes, such as the ability of graduates to be licensed. I mean, what was the point, right? There's no way schools were going to care about this survey or even make what would turn out to be incredibly expensive and school-altering changes if it was not going to translate into something palpable. So, given that the rubric to determine the quality of schools reflected their compliance with the German model, schools would require massive funding for transformation. And unless schools believed that that funding was going to mean something, why would they do that? You know, once you accept corporate money, and the schools weren't so ignorant not to know this, once you accept corporate money, you owe the corporation something. And the schools wanted to maintain their autonomy, essentially. So behind the scenes, the AMA orchestrated an alliance between academia, corporate philanthropies, and medical licensing agencies. The um largest progressive medical organization was the AMA at the time, and the two largest corporate uh philanthropies were the Rockefeller and Carnegie Institute, and progressive reformers were working behind the scenes to assure that state licensing could be tied to the changes that the AMA had already fairly covertly expressed would be in the works if this report came out and could lead to changes. Once the report achieved the blessing of the progressive press and state licensing agencies, it would be the hammer to assure that the nation's white Orthodox doctors fell into the AMA orbit and essentially became vassals of the AMA. Vassals meaning they had to follow the AMA rules if they were going to be able to practice medicine. And of course, it also meant that the AMA could extirpate, remove all the quote-unquote quack doctors it had been trying to get rid of for all this time. This included not only the homeopaths and osteopaths, um, but also um anyone not white and male. Yes, all the all but two African-American schools were axed, and as we'll discuss, the two that were saved were saved with certain uh changes that had to be made to them whereby they would not actually be medical schools. All the schools that took that educated women were axed. Um schools that educated anyone other than white male Orthodox doctors were excluded. There were a few women and African-Americans going to normal Orthodox schools, but I don't think the AMA was really concerned about that. So, why Abraham Flexner? Who the heck was this guy? In fact, Abraham Flexner was the person who would be least likely to create a survey and go looking at medical schools. He was not a doctor, he never had any medical training. He actually was an educator. He had gone to Hopkins for at least part of his education and also studied extensively in Germany. Um, his brother, Simon Flexner, was a major research scientist at Hopkins and clearly William Welch's understudy and likely best friend. Um Flexner at the time was uh closing up a failed school that in Indiana that he had started. He he felt that the German model of education was the only model that counted. This top-down model where experts told people what to do, where students did not question their teachers, where there was a single dogma that needed to be memorized. This was the German system. Um, again, this is why Einstein left Germany, because uh he, as he wrote, um, that the Germans have no interest in people actually learning. Um, but this is the system that Flexner tried to institute in Indiana. It failed miserably, and hence uh he was given a job with the Carnegie Foundation, uh, likely due to the persuasion of William Welch, who also worked with the Carnegie Foundation and Simon Flexner. Um, and it was probably believed that uh Flexner was very malleable and would do what he was told. I read many letters written by Flexner to William Welch during this period, and my God, this guy felt William Welch was God. He he basically viewed him as a grandfatherly figure, um, talked to him about how the German model would change the world in medicine. He thanked Welch for all his good work. It was kind of weird reading these letters. Um, so Carnegie Foundation was given the task of uh surveying all the schools, sending out Flexner. Now, Flexner didn't go alone, he actually took um Dr. Calwell, who, as we talked about, was the head of the AMA's uh education committee and who had orchestrated the AMA's three school surveys. But this did not become uh public knowledge either. So they they went to all the schools and they summarized their findings in a 1911 report that uh we now call the Flexner Report. This report came out, received massive acclaim. I read all sorts of newspaper headlines and articles, front page stuff. You know, the medical system's corrupt, it's gonna be changed, this is what we're gonna do. Progressive reformers talked about how this was the best thing that ever happened. The AMA stayed quiet, but the AMA was um, of course, the repository of the power that this disciplinary tool offered it. Because what Flexner did was to mimic, basically copy the results of the AMA surveys. Um schools that were felt to be beyond redemption, including, like I said, all the homeopathic, most of the African-American, all the women schools were given failing grades and uh advised to shut down immediately. Um the schools that were already acceptable, and there were just a few, like Hopkins and Harvard, uh, were offered money to maintain their lab facilities and to maintain full-time faculty. Money that was going to be given mostly by the Rockefeller Foundation. Um, interestingly or not, the Carnegie Foundation, which endorsed this study. The schools that were in the middle uh were told that they would need to completely revamp, create lab facilities, lower their number of admissions, have full-time faculty, and accept corporate money with the stipulation that they were only going to have a few years to make these changes or that money would be withdrawn. And not all the schools accepted this, especially like the proprietary schools, the ones that basically existed uh from tuition and had minimal standards, um those guys fought back to some extent, although they didn't have a leg to stand on because they didn't have they didn't have good criteria for graduating their students. And even if they said they were going to change, this report's complete denunciation of their ability to change uh basically doomed them. And when I was looking through letters, uh several letters between uh the Carnegie Foundation uh and AMA Secretary George Simmons, and by the way, these letters are hidden in the AMA archives, they weren't for public consumption, uh, show that several schools sued both the AMA and Carnegie Foundation for slander. Uh and and Simmons uh said, quote, the only way these schools have to defend themselves is to enter suit. For the sake of publicity, I wish this this school, and he's in this letter talking about St. Louis Medical School, which is one of the proprietary schools, I wish this school would follow up the suit. What is needed now is to enlighten the public, to get people interested in medical education. And given the fact that this report received endorsement by state medical boards, by the press, by the public, by the media, um, and that even many Orthodox doctors promoted it, it was very unlikely that any of these schools were going to win any lawsuits. So, again, how do you have teeth? The teeth were in the state licensing organizations. They had the AMA through its lobbying efforts, through its local medical societies and through progressive reformers, had basically shored up almost all the states, that these states would only grant licenses to doctors who graduated from AMA-approved schools and who belonged to an AMA-endorsed medical society. This is the AMA's dream, right? That now every Orthodox doctor in this country had to comply. If a doctor was deemed uh to be problematic by the AMA or by its local agencies, if it was reprimanded, it would lose its license. If it did not graduate from the right school, it would lose its license. And by the way, from what I could read, the doctors who had already graduated from failing schools but who were members of local AMA affiliated organizations were allowed to grandfather in to this new reality. Poof, just like that, half the nation's medical schools closed within five years of the report. Understand that by reducing the number of doctors, which is what this did, the prestige and salary of the remaining doctors increased, which was one of the AMA's primary goals. And the AMA's control over the entirety of the physician-based healthcare system was enshrined. You cannot get away with being a doctor in America after 1911 without bowing to the AMA and following the AMA's code of ethics, its medical racial script, its um its German-based philosophy of care, and its uh its focus on laboratory medicine. I read through tons of letters from both Abraham Flexner and these foundations, especially the Rockefeller Foundation, uh, about the way this whole process would work out. And you know, if you read through the Rockefeller Foundation year after year, their their um letters, you see kind of how they were going to do this. In one letter, looking back at the report, Flexner states how the Rockefeller Foundation money reformed some of the country's more prestigious schools while turning its gaze away from others that could have potentially been redeemable. But he did suggest that once a few schools gained prestige and funding by instituting reforms, other was followed suit. He wrote, quote, by expending a few millions, you will incite others to do the rest. Don't bother about the total cost. Do one thing well, and emulation may be counted on to do the rest. That is a lesson of history. It is a lesson of science, unquote. So the lesson of history and science to him is once schools saw that this was happening, that they better darn well accept money from these corporate foundations, or they were doomed that they would do it. So basically, what Flexner was saying is let's pay money to the big schools. Um, you know, the Harvard Yale, you know, when I looked through what who Rockefeller was paying, they were paying most of their money to the big schools. I'm doing it tens of millions of dollars they were given to these big schools to shure up their lab facilities and their full-time faculty, and then they would start giving money to the smaller schools who basically had to beg them for the money. I read a lot of letters that show the begging process, so it was kind of sad actually, but this is what had to happen in the new reality. And it should be noted that the logistics of the funding all were siphoned through the AMA. The uh the the Committee of Education, the one running run by Calwell, um, actually worked with the foundations to assure that the schools get the money, the ones that deserved to get the money. And so the the AMA was right on top of all this. So we're so were these foundations like Rockefeller and Carnegie who by the way, Rockefeller gave $50 million to this effort initially. That was his first check. Um, and more to come. And Carnegie gave a lot too. So so were they giving out this money because they were just wanted to fix the medical system, make it more in line with the German model that they felt was so much better. Um or did they have something to gain? You know, I'm a cynic. So I I view the latter. I read through all these Rockefeller Foundation archives. I couldn't see that they were doing this for any pecuniary advantage, but of course, they did gain a lot. They made a ton of money from these research institutes. They they invested in them, uh, they made money from the drugs that came out, and they were part of this huge profit-driven uh change in our system. Just one little caveat is that Rockefeller was still seeing a homeopath during this whole time. His doctor was a homeopath who in the future was not going to be able to practice medicine with a license. We still have homeopaths now, but they are not licensed doctors. And it seems like Rockefeller was the main guy who was orchestrating this. A letter that um Abraham Flechner wrote many years later in 1955, uh, looking back at the ramifications of his report, notes that while Carnegie Foundation paid for this study, quote, Mr. Carnegie declined to use its conclusions in reorganizing medical education in the United States. It was Mr. Rockefeller who took hold of this important problem and assured that the General Education Board was provided with approximately $50 million to start reforming medical education. And like I said, we see this. Letters written to the president of Harvard. Well, we have $10 million for you if you do this, this, and this by this date. Um the uh 1918 uh uh General Education Board annual report stated, quote, students of medical education are no longer in doubt as to what a modern medical school ought to have. It needs endowment funds, fully controlled laboratory and clinical facilities, and teaching and research staffs in the main clinical as well as laboratory branches. In other words, without funding and without AMA endorsement, schools could not graduate approved medical graduates because no longer would it be acceptable to come out of a school that did not have this formulaic approach, this German-induced approach. So, I mean, not everyone sat and just accepted this, but in general, it was endorsed across the board. It was progressive, it seemed reasonable, it was scientific, it was according to the press, um uh it was done by a non-AMA source. So, and and the corporations were willing to, there was so my cynicism's gonna come out. They were just so good and big-hearted to give their money away to these schools to to try to make medicine better in this country. Forget, forget what their motives were or the AMA's motives. So, so poor William Osler, right? This is like his nightmare. He's he's back in England, powerless. All his friends at Hopkins were fired. His entire program he set up at Hopkins was disassembled. There was no longer any clinical part. Now students were gonna sit in the classroom for two years and then go to hospitals and never see a doctor outside the hospital, which by the way is the case today. Nothing has changed since Flexner. Um, and he couldn't do a darn thing about it. He, the most, the most um successful and popular doctor in the country, his words meant nothing against this. And I could not see anywhere, and I did a massive search anywhere that his protests were were put into the press at all. You know, again, the press could put in what they want, and unless people um saw what Osler said, who's who's gonna even know or even care? Osler said that the report is seeking to create, quote, a set of clinical prigs, the boundary of whose horizon would be the laboratory, and whose only human interest was research, forgetful of the wider claims of a clinical professor as a trainer of the young. He said that this was um this was formulaic, it was it was the wrong way to go, that the German system was absolutely not concerned with the patient or with the art of medicine, um that critical thinking would die, that humanism would die, that Flexner's report was just going to basically, and he didn't use this word, obviously, but basically create robots who are gonna follow protocol and do what they're told. Um, welcome to medicine in the 21st century, but that that was the goal of of this report, and Osler saw right through it. But again, his um his words and also the words of people like uh Francis Peabody from Harvard, who we mentioned before, who said the same thing. I mean, he said, we're gonna create basically non-thinking drones from this report, whose only uh whose only uh allegiance was to the AMA. You know, it turns out they were both very prescient about this, but nobody listened because this was considered a big progressive move to fix the medical system. Um and and likely not all Orthodox doctors supported this, especially the ones who were worried about where they went to school. But again, by Gip grandfathering them in, they were included in the umbrella and they probably shut up. Because you just don't read anything negative. And as we'll show in the next lecture, even in the African-American press, nothing negative was said about this report. It's it's fascinating, um, the lack of pushback. Um, and the report within five years took hold. Again, read I read through Rockefeller Foundation documents up through 1925. They were already talking about allocating money, which schools were making it, which schools were making their requisite changes, which schools probably were not going to make it. Um, school presidents were writing to the Rockefeller Foundation, scared to death, pleading with them. The power dynamic has shifted so dramatically that now the AMA, which controlled this massive Amount of money and which controlled the ability of schools to graduate licensed doctors. Now the AMA had so much power. Just that quickly, right? In 1900, it was nothing. It was a feckless organization with nothing. And now it had this massive power to reshape the landscape. It's really doubtful the AMA had an ideological backbone. It obviously believed in the medical racial script. It believed in German medicine to some extent, although not all Orthodox doctors did. But now it created this new algorithm that would be universal. So every school would have the exact same curriculum as it does today. Every school would test their students the same way. And the only actual clinical science it would uh it would endorse would be in the hospital itself. And this and every school uh needed to uh get money from these foundations to do this and thus basically not complain because complaining could mean a diminution of funding. And so every doctor now had to also follow these rules and be beholden to the AMA to join an AMA affiliated society, if not the AMA itself, um, to uh follow practice medicine in a certain very specific way lest they get in trouble. This became American medicine after 1920. Um, Abraham Flexner himself, just as a side note, had an interesting career. He he went on to run uh the Rockefeller Foundation um for quite a while. Um in fact, he he fought hard for the African-American medical schools after his report decimated them. And we'll we'll talk about that next chapter. It's almost like a little redeeming quality of Flexner. He also felt when he's writing in the 1950s that the report had basically destroyed the soul of medicine. That that's what Peabody had said, interestingly, at the time of the report, that the soul of medicine is now destroyed. And just like Osler said, the art of medicine has been destroyed and replaced by protocols and and by you know by by uh fabricated certainty. This is what Peabody said, but so did Flexner in the 1950s, saying that no longer did we have a viable primary care backbone, no longer were doctors getting trained in the humanities in college and having critical thinking skills. He he just condemned the very report that he scripted. But like we said, he scripted a report that was handed to him that had already been done. Uh but he left uh the um the foundation and went on to uh run the institute at Princeton. This was the Institute of Advanced Studies. If anyone doesn't know what that is, it's where um scholars can go and spend several years um basically doing research and learning without having to teach. It's it's out of Princeton. I have friends who went there and said the food was excellent, but they they um they basically could just do stuff. The first person invited to be in this program was Albert Einstein. Um, and Albert Einstein uh tried to get several physicists in who were uh a threat during uh the Nazi era um of getting uh losing their jobs, of being killed. And he appealed to Flexner to use the foundation to get some of them to America, and Flexner said no. Flexner was a Jew, he was a German Jew. Einstein was a German Jew. Um, but Flexner's view of Judaism was very different. He said, we already have too many Jews in this country, we don't need any more. And in fact, when when Einstein appealed to Eleanor Roosevelt to try to appeal to her to get these people over, she wrote back and said, Of course, and Flexner intercepted the letter and ripped it up. He ripped up several of Einstein's letters. And it was later in life, Einstein, who was just the most wonderful man, if you read about him, you just fall in love with the guy. But he said there was only one man in the world he ever hated, and it was Abraham Flexner. The very Abraham Flexner that created the healthcare system in which we live today, and which um has been the subject of great analysis. We'll include one article in our last lecture about someone who looked back on the Flexner report 100 years later and kind of gave it a report card, a failing grade. But but of course, that that's not going to change because the the profitability of our healthcare system uh and the huge increasing salaries of doctors that were never there before all uh flowed from the Flexner Report. It achieved what it wanted to achieve, uh regardless of its effect on patient care, which was not at all its objectives. Nor it should be noted right here that the AMA, like we mentioned before, was a trade association. Its only goal was to improve the salary and prestige of doctors. Patient care was not part of its goal. Never had been, it never explicitly said it would be. The AMA was just trying to help doctors, and it did. So to that extent, it succeeded. Um, so now we'll talk about what it did to African American doctors. I will say that in this class we are not talking about what it did to the Asian community, to the Latino community, to women and women doctors. Those are all huge stories that deserve attention, but we just don't have time in this course. And I will eventually talk about them in a subsequent course, but really important to know that it had a huge impact because along with the report um came uh an uh a support of eugenics. Eugenics was part of the AMA model, the medical racial script basically just easily morphed into the eugenic script, and uh the medical system from then on took on a role to be the arbiter of the of the nation's biologic health, which essentially translated into doing a lot of things looking back that we don't think were very kosher. They certainly were not ethical and they caused a lot of harm to human beings and to groups of people. But again, that's fodder for another talk. And we and what what happened to women in medicine deserves a lot of attention because their schools were wiped out and very few were asked or allowed to go into uh standard medical schools, at least that not at this juncture. That would change later. And um yeah, it's it's um really for most people who are non white males, this this report was a catastrophe. But let's we will talk about how it affected the African American uh physician population next.