Kanter, Steven L. MD
Dear Reader of 2110,
As you celebrate the 200th anniversary of the Flexner Report1 and contemplate its meaning in the context of your time, I thought it would be important for you to have access to a set of reflective articles that illuminate the report's significance at the 100-year mark. Those articles are in this issue of Academic Medicine, along with commentaries from leaders of the major organizations - the Carnegie Foundation for the Advancement of Teaching, the Association of American Medical Colleges, and the American Medical Association - that played a role in the generation of the Flexner Report in 1910.
I hope that these articles and commentaries will complement your reading of the original version of Flexner's report and will add breadth and depth to your understanding of the challenges that faced academic health centers in the early 21st century. These articles can enrich your sense of academic medicine at that time period and help you understand the struggles of those who worked in medical schools and teaching hospitals during that era. Examining points of contention, the opposing forces that defined them, and the efforts of those who strove to balance such forces can offer uniquely focused insights into the hopes and desires, as well as the trials and tribulations, of the time.
In fact, in this issue of the journal, you will find that balance is a pervasive theme that weaves its way through most, if not all, of the articles. Each mention of balance highlights a point of contention, for which the academic medicine community seeks a rational, beneficial, or useful position between opposing forces.
For instance, several authors seek balance in the education of physicians, expressing concerns that range from curricular content to the length of medical training to broader educational goals. Prislin et al. write of the need to balance the medical curriculum between a “focus on disease management” and an “emphasis on population-based health improvement,” while Irby et al. discuss the need to balance “the integration of formal knowledge of the basic, clinical, and social sciences with clinical experience.” Lambert et al. argue that educators must strike a balance between “standardized and personalized scientific knowledge” for learners across the continuum from premedical education to continuing professional development.
Rabow et al. discuss the need for curriculum managers to balance attention to “professional formation” with a necessary emphasis on cognitive expertise. They believe that seeking a balance between “the values of humanism and science is an important future challenge.” Doukas et al. support this notion, stating that curriculum designers should “balance the needs and rigors of becoming a physician-scientist with the humanistic skills to better care for one's patients.”
Muller et al. extend the discussion to service, emphasizing the need to achieve a healthy balance between the “focus on science in medical school curricula... [and] the importance of service” in the training of physicians. And, Shomaker questions the balance “between the mass of information that we have decided that trainees should absorb to be well trained and the time commitment and expense incurred by trainees.”
Busing et al. underscore the value of Flexner's report to inspire generations of educators to revisit important issues in education: “Whether it is a question of bias toward the inner city hospital or the rural clinic, time in the lab or time with the patient, academic grades or interpersonal acumen, a reflection on Flexner's work underscores the need to review and, if necessary, rebalance medical education.”
Other authors seek equipoise in patient care. An important issue in 2010, in the context of a national debate about health care reform in the United States, is the struggle to determine an effective balance between the numbers of primary care physicians and specialist physicians. Prislin et al. write about the need to balance “the generalist and specialist composition of the physician workforce” and also to balance “the physician workforce so that the provision of such care to all segments of our population will be possible at an affordable cost.” Muller et al. note that “an imbalance of primary care providers contributes to higher health care costs and poorer outcomes.” Busing et al. quote the rationale for the Future of Medical Education in Canada Project, which notes the necessity to balance “generalists and subspecialties” to meet health care needs in Canada.
Prislin et al. go so far as to warn that “our ability to provide affordable, equitable, efficacious, and high-quality care to the American people in the 21st century hangs in the balance.”
Flexner, too, sought balance. Curry and Montgomery discuss Flexner's recognition of the importance of a well-trained physician to balance “scientific medicine” with a “cultural and philosophic background,” while Halperin et al. mention Flexner's attitude toward “teachers who preserved the balance and connection between science and pragmatism.” Hafferty and Castellani, in discussing the increasing complexities of professionalism, point out that Flexner was concerned about the balance between family and work.
As Gunderman introduces all the articles in this special issue of the journal, he invokes the notion of balance at least a half-dozen times as he writes of “the creative tension between continuity and change” and the balance between “minimal levels of competence and creativity,” “specialism and generalism,” and “professional and personal life,” among others.
There are, of course, struggles in the early 21st century that I have not mentioned above. For example, in biomedical research, there is a natural tension between allocating fixed resources to pursue basic versus applied studies.2 As research becomes necessarily more collaborative, medical school promotion and tenure committees must balance the value of intellectual independence with the ability to function productively as a member of a team. Academic health centers seek an appropriate balance among a number of competing forces in their relationships with industry, while deans and hospital presidents work hard to find appropriate and effective ways to manage conflicts of interest and conflicts of commitment for themselves and those whom they supervise. Practitioners who adhere to different philosophies of medicine clash over how much evidence of effectiveness a licensed professional should require to recommend a treatment.3
Although the articles in this issue can provide only a sampling of the struggles that existed in the early 21st century, I am confident that they tell important stories that will help you in the 22nd century to achieve greater clarity about how academic medicine evolved over the first 100 years after Flexner's report. And I believe that a critical examination of the struggles of the early 21st century, and the way we sought to balance the opposing forces of our time, will help you as you grapple with academic medicine's most vexing issues at the beginning of the 22nd century.
Obviously, I cannot know the specific controversies of your day or the details of the problems that you struggle with. However, I am sure that you, too, will seek balance in dealing with your century's issues, for every generation seeks such balance. And so, as you prepare to celebrate the 200th anniversary of the release of the Flexner Report, I wish you a rational, ethical, and satisfying equipoise in dealing with the most important challenges of your time.
I wish to thank Richard Gunderman for serving as the guest editor of this issue's collection of articles related to the Flexner Report and for applying his expansive intelligence and keen insight to the development of the collection. Also, I thank Mary Beth DeVilbiss, senior staff editor, and the entire professional editorial staff of Academic Medicine for their extensive efforts to ensure that the articles, commentaries, and special features in this issue provide a cohesive and integrated perspective on Flexner, his report of 1910, and key events in the ensuing century.
Steven L. Kanter, MD