One hundred years ago Abraham Flexner wrote a book-length study of American medical education that dramatically transformed the education of doctors.
The influence of the 1910 Flexner report, "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching," was profound, so much so that the American medical education system is described still by an adjective—"Flexnerian."
In his report, Flexner established the foundations for an educational system whose predominant features are still in existence (see What Flexner Wrought).
In the February Academic Medicine, leaders in medical education looked back on what Flexner accomplished. Nine commentaries from educational leaders consider the historical context in which Flexner made his observations and recommendations, as well as their impact today on the culture of medicine, the structure and financing of medical education, and physician training.
Several commentaries focus on how Flexner has impacted such contemporary issues as training of minority clinicians, the distribution of generalists versus specialists, and training in public health.
A common thread throughout is that the Flexnerian model of medical education may now be in for changes nearly as profound as those Flexner proposed 100 years ago.
Psychiatrist Darrell Kirch, M.D., president and CEO of the Association of American Medical Colleges, addressed changes under way in the culture of medicine and in the way health care is organized and financed that make the Flexnerian model of training obsolete.
In his essay, "The Flexnerian Legacy in the 21st Century," Kirch argued that current realities call for a collaborative culture for which physicians are not prepared by traditional medical training, which has emphasized, since Flexner's time, individual excellence and achievement.
"[A]n underlying theme of many articles in this issue is that the medical education community's response to the Flexner report—and the individualistic, expert-centric culture to which it gave rise—may now work against the collaboration needed for greater integration across the medical education continuum, highly networked teams in discovery research, and inter-professionalism in clinical care," Kirch wrote. "The question, as many authors suggest, is not whether medical education is being true to Flexner, but whether academic medicine is responding to the implications of post-Flexnerian education and whether it is able to embrace the cultural change needed to address 21st-century health care needs."
Kirch noted that Flexner's model of the European university, focusing on individual professional achievement and individual acquisition of factual knowledge, has led over time to faculty members' becoming essentially "free agents" in each of academic medicine's mission areas, with corresponding proprietary references to "my lecture," "my grants," and "my clinic."
"However, a different reality faces us now," Kirch wrote. "For example, with scientific knowledge growing exponentially, an individualistic culture works against the integration and sharing of new knowledge needed in each mission area, particularly medical education.
"Moreover, as medical education moves toward outcome-based assessment, having knowledge is no longer sufficient. Students and physicians must also be able to apply that knowledge to everyday clinical situations. Just as important, young physicians must be able to effectively interact with patients, patients' families, and other health care professionals, as well as respond to the complex organizational demands of the health care system. Further, they must commit to lifelong learning that includes the ability to self-reflect and assess their own performance."
Two psychiatrists who reviewed the commentaries in Academic Medicine agreed that there is much about the Flexnerian model that is enduring and much that is in need of change.
Barbara Schneidman, M.D., M.P.H., a clinical professor of psychiatry and behavioral sciences at the University of Washington School of Medicine and past vice president for medical education at the AMA, said Flexner's most powerful influence was on the standardization of education—for good and for ill.
"There were programs that were quite rigorous and others that were short and involved minimal or nonexistent clinical time," she told Psychiatric News. "One negative outcome of this standardization was to cut off the main pipeline for enrolling and training women as physicians. Because most women were denied internships and hospital privileges, women medical students trained in ‘irregular apprenticeships.’ But more rigorous criteria [resulting from standardization] gave medical schools a reason to reject women applicants since it was known that it would be exceedingly difficult for these women to get hospital positions after medical school."
On the positive side, Schneidman pointed to Flexner's push for a process by which to accredit medical schools, now embodied in the Liaison Committee on Medical Education (LCME). "The LCME has standards for performance, structure, and function, but because there are so many variations among the schools, the standards allow for flexibility and creativity within them," she said.
The movement toward assessment of "competencies" is easily the most significant change under way in medical education, Schneidman said.
"This movement could provide the flexibility needed to remain educationally rigorous but provide more variation within the medical education process," she said. "If there are predetermined competencies for satisfactory completion of medical school, perhaps an advanced student could finish within three years instead of four, thus saving one year of tuition. Or a student with diverse interests or who needs some extra time could finish med school in five years in order to satisfy the competencies."
She added that there is also significant interest in looking at the criteria for admission into medical school. "Should there be a greater emphasis on the social sciences and humanities instead of such a strong focus on hard-science subjects like physics, which may not be useful for many practicing physicians?"
Psychiatrist Steven Schlozman, M.D., co-director of medical student education in psychiatry at Harvard and associate director of training for child psychiatry training at Massachusetts General Hospital, emphasized that the clerkship experience no longer mirrors the way medicine and psychiatry in particular are practiced.
"Clerkships still focus for the most part on inpatient, hospital-based medicine, whereas medicine is increasingly outpatient oriented," he told Psychiatric News. "This is especially the case for the majority of psychiatry clerkships, which are, first of all, far too short for the epidemiologic burden of psychiatric illness and, secondly, often very poorly representative of what psychiatry looks like today.
"When Flexner wrote his report, psychiatry was asylum-based for the most part," he said. "As the primary psychiatric experience at many medical schools continues to be short and in inpatient settings, students continue to believe that psychiatric patients rarely function highly and that there is virtually no longitudinal follow-up or real benefit to longitudinal care. There are data showing that students cling to these notions in part because of the clerkship experience and in part because of what they are told by their teachers who happen not to be psychiatrists and therefore experienced psychiatry just as they did.
"As with other fields, psychiatric educators must collaborate with other disciplines to offer the teaching in a longitudinal, outpatient setting that is patient centered," Schlozman said. "Also, the role of mentorship is often celebrated and was central to Flexner's vision, yet there is decreasing time for ‘routine’ clinical mentorship in the office or on the wards."
Schlozman is also a member of the APA Council on Medical Education and Lifelong Learning and chair of the Workforce Committee for the Executive Committee of the American Association of Directors of Psychiatric Residency Training.
The commentaries on the Flexner Report are posted at <http://journals.lww.com/academicmedicine/toc/2010/02000>.