Tuesday, December 29, 2009

A HUNDRED YEARS OF FLEXNER



When I find myself ranting that today’s healthcare is detached, impersonal, or even industrial, I sober up by recalling that its present style is only a hundred-year-old aberration.

At the turn of the last century, the enterprises calling themselves medical schools ranged from universities to carnival booths. The Illinois Board of Health reported in 1899 that while 179 American and Canadian medical schools featured some version of scientific approach, 26 taught homeopathy [evidently the Board didn't feel homeopathy was scientific], another 26 were “eclectic,” 13 “miscellaneous,” and 13 were outright “fraudulent.”

Industrialists Andrew Carnegie and John D. Rockefeller determined to convert this shaggy variety into a standardized vehicle suited to modern times. Rockefeller’s administrator of philanthropies, Rev. Frederick T. Gates, viewed the human body as the victim of virtual assault by disease. He wrote to Rockefeller,

“The body has a network of insulated nerves, like telephone wires, which transmit instantaneous alarms at every point of danger. The body is furnished with a most elaborate police system, with hundreds of police stations to which the criminal elements are carried by the police and jailed…The body has a most complete and elaborate sewer system…”
           
As a progressive of his time, Gates naturally recommended science as the basis of reformed medical education. Though he encountered little direct opposition, a few instructors expressed qualms. William Osler, professor of medicine at Johns Hopkins University and even today considered the historical patriarch of North American medicine, was one.

Though he revered science, Osler insisted throughout his career that human beings couldn’t be healed by science alone. (His best-known maxim is, “It is more important to know what sort of patient has a disease than what sort of disease the patient has.”) Osler cautioned against any change in medical education that might diminish attention to the patient. His warnings went largely unaddressed, and when he left Johns Hopkins in 1904 for Oxford University, he wrote to a colleague he considered too laboratory-oriented, “Now I go, and you have your way.”

Andrew Carnegie's Foundation for the Advancement of Teaching hired educator Abraham Flexner to critically examine American medical training. Competent and thorough, Flexner visited every medical school in the country. In his final report, issued in 1910, he recommended that curricula and methods be nationally uniform and based on science. Every medical student since then has learned during the first week of freshman year that the Flexner Report marked the birth of modern, scientific medicine, now sometimes called “biomedicine.”

After Flexner published his report, Dr. Osler, who had since been knighted, continued to predict that inordinate focus on science would likely eclipse concern for the patient. He wrote,

“The danger would be of the evolution throughout the country of 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, a leader in the multiform activities of the profession, an interpreter of science to his generation, and a counselor in public and in private of the people, in whose interests, after all, the school exists.”

Bypassing such misgivings, money from Carnegie and Rockefeller—eventually over $100 million—established scientifically-based teaching chairs and facilities at America’s major medical schools. Unfunded institutions soon found competition difficult, and in a few years half of America’s medical schools closed. The industrialists effectively dislodged every competing style. Historically, this happened only yesterday: my own instructors received their training from students of the professors Carnegie and Rockefeller funded.

We’re in debt to Flexner for stupendous advances that ultimately helped devastate infectious disease and successfully treat other acute disorders. Yet if Flexner’s a rose, he bears the inevitable thorn, which I’ll describe in the next blog entry.


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