Humphrey, Holly J. MD; Levinson, Dana MPH; Smith, Lawrence MD
Intellectual inquiry—not job training—is the purpose of the university.
—Abraham Flexner, Universities: American, English, German
American medical schools continue to be shaped by and to reflect the ideals espoused by Abraham Flexner1 in his 1910 report, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. Historians generally agree that what Flexner reported was “hardly the beginning of a movement; it was the end of a beginning.”2 At that moment in history, Flexner's report was a culminating incident in a half-century-old series of reforms. One of the most important ideas that Flexner identified from these series of reforms and that he firmly espoused was that a medical school should be part of a university, an affiliation that would immeasurably enrich and strengthen the rigor of the education provided. He specifically noted that universities had resources in terms of endowments, laboratories, clinical training sites, and skilled teachers to provide the intensive and costly, but ideal, environment for medical education. Furthermore, Flexner identified the need for a university to govern medical education, not just as a method of advancing the profession but because of his concept of medical education as a public good.
In this article, we consider the historical underpinnings for the relationship between universities and medical schools. We will further develop this historical point of view by considering the specific elements of a medical school education, as outlined by Flexner. We also explore the relative advantages and disadvantages of close associations between universities and medical schools in the context of the opening decade of this new century and consider, by way of example, both a medical school visited by Flexner (the University of Chicago) and a brand new school in applicant status with the Liaison Committee on Medical Education (LCME) that anticipates welcoming its first students in 2011 (the Hofstra University School of Medicine). These specific snapshots provide an opportunity to reconsider the essential elements of a medical school from the ideas at conception to the bricks-and-mortar reality, the faculty and students, the curriculum and methods of instruction, and the impact on the community. We found remarkable alignment in some ways with the point of view espoused by Flexner and the current plans formulated by medical schools in response to contemporary challenges. Finally, in navigating a way forward in the 21st century, we invite reconsideration of our aspirations and sources of inspiration.
Today, 100 years after publication of the Flexner Report, many raise legitimate questions regarding whether a medical school is a relevant part of a university. Is medical education a public good, and are universities themselves relevant social institutions today? Do the advantages of the historic relationship between medical schools and their universities remain intact, or have both medical schools and their universities evolved in ways that make this relationship more burdensome than helpful, more superficial than authentic, more archaic than dynamic? Do universities continue to have resources to support medical education, or, in fact, are the resources of the university's hospital supporting the university itself? Budgets of the university hospital not infrequently outpace the budget of the entire university by several-fold. Because many if not all medical schools send their students away from their campuses for clinical experience, has the linkage between medical schools and universities attenuated through fragmentation of student experience? Finally, what Flexner hoped to achieve by binding medical schools to research universities was a higher standard of medical education. Whether in fact this linkage continues to be necessary to achieving quality in medical education, when the instruments and metrics of medical pedagogy are well understood and broadly disseminated, is an open question.3
Ties between medical schools and universities have not always been perfect unions, and, in fact, what we describe as “contemporary challenges” to such a relationship often look a lot like historical challenges. Many university affiliations were thrust on medical schools, but concerns about independence were forgotten once medical schools began to experience the financial benefits that this arrangement initially brought them at a time when many medical schools were badly in need of financial support, facilities, and philanthropy.4 Universities, in turn, gained in stature from the presence of medical schools as well as the power and influence of the medical schools' alumni. However, even from the inception, issues emerged. The close linkage of medical schools and universities was conceived ideally as a physical linkage, with medical schools to be sited on university campuses so as to promote interdisciplinary exchange between faculty and students. This physical proximity is by no means a defining feature of every American medical school (or even of most American medical schools), and it certainly does not apply to the location of the affiliated teaching hospitals where students participate in clinical education. The physical distances resulted in isolation and, in some cases, rivalry and jealousy between the medical school faculty and the rest of the university professoriate. Nevertheless, as Ludmerer4 writes, “[A]lthough medical schools often remained isolated from the rest of the university, they adopted university values.”
University Values and Pedagogy in Medical Education
One of those university values was an increasing interest in pedagogy as a subject in itself. It is instructive to consider the most forward-thinking educational philosophies that influenced Flexner's recommendations for medical education, including Flexner's admiration for the theories espoused by John Dewey and the progressive education movement.5 In fact, whereas progressive education theory took hold quite slowly in secondary educational settings, medical education could be said to be one of the strongest and earliest examples of progressive education in practice.4 The tenets of progressive education are outlined below; they have a clear relationship to what Flexner conceived as the ideal format for medical education—exemplified even before 1910 by such programs as the Johns Hopkins Medical School. The elements of experiential learning that characterized the progressive education philosophy include the following6:
* An emphasis on learning by doing
* An integrated curriculum focused on thematic units
* A strong emphasis on problem solving and critical thinking
* Group work and development of social skills
* Understanding and action as the goals of learning, as opposed to rote knowledge
* Collaborative learning
* Education for social responsibility
* The integration of service into the daily curriculum
* The selection of subject content by society's needs
* The use of varied learning resources beyond textbooks
* An emphasis on lifelong learning
It is remarkable how relevant Dewey's work was and continues to be for the way in which medicine—particularly, clinical reasoning—is taught and learned. According to Dewey's educational theory of experiential learning, students employ ideas as hypotheses needing continuous testing and revision, which necessitates that these hypotheses have been accurately formulated in the first place.7 The validity of these hypotheses is then assessed by the consequences that they produce when acted on, and all ideas and hypotheses are tracked and considered through reflective review. In fact, the remarkable relevance of this educational philosophy to medical education raises the question: What influence did examples of medical pedagogy have on the development of Dewey's theories?4
Linkages between universities and medical schools occupied key educational leaders, both before and after the publication of the Flexner Report. In The University of Utopia, Robert Maynard Hutchins,8 president of the University of Chicago from 1929 to 1945, firmly espoused the greater value to students of learning critical thinking skills than of “professional” or “technical learning.” Skeptical of most professional education as lacking in intellectual content, Hutchins made an exception for the study of such disciplines as medicine and law. Students training in these professions should, to his mind, have received strong prior education in the liberal arts so that they can understand the larger context of their future practices.8 Furthermore, the professional schools of the University of Chicago were intended to be devoted to research, and their activities were intended to be integrated with those of departments studying related subjects.9 The University of Chicago's medical school served for Hutchins as an exemplar of the integration of education and research, as well as of close interactions with the other parts of the university, a status achieved by its physical location on the campus. Hutchins writes that “the fact that the school is on the campus, adjoining the disciplines on which its work is based, makes the medical school more definitely a part of the University than any other I have known.”9
Remarkably, the University of Chicago continues to look very much the same as it did in Hutchins' era: The medical school and hospitals occupy the same campus as the college and the graduate programs. In addition, the university continues to think of and advertise itself as Hutchins defined the institution, as a place “dedicated to the primacy of research, the intimate relationship of research to teaching, and the amelioration of the condition of humankind—one of the world's great universities.”10 In general, it is clear that both Flexner and Hutchins believed that universities exist for the purposes of discovering new knowledge, transmitting knowledge to the next generation, and, ultimately, benefiting mankind.
The University of Chicago serves as an example of the way in which medical schools responded contemporaneously to the publication of the Flexner Report in the early 20th century. However, in the opening decade of the 21st century, American medical schools are expanding in size, and new schools are being planned. These situations offer a rich opportunity to consider Flexner's recommendations from a contemporary perspective as new schools evolve in their structure and practices. One such school, the Hofstra University School of Medicine, which will serve as an example for this article, was first envisioned by both the nonmedical faculty of the university and the physician leaders of the North Shore–Long Island Jewish Health system as a university-based school. When considering where to build their school, both groups insisted that it be built on the campus of Hofstra University. In addition, the school was founded as a full partnership between the university and the health system. Hofstra University has a strong tradition in liberal arts and law, and the health system made a major commitment to educating its own future physicians—a core mission that serves as a key benchmark of the success of academic medical centers (AMCs).11 The embedding of the Hofstra University School of Medicine within the partnership of university and health system was intended to ensure that the school would be enriched by both cultures, including participation in research and scholarship, as well as by community outreach and clinical care.
What Did Flexner Say?
[F]aculty members would become true university teachers, barred from all but charity practice, in the interest of teaching.
To consider the extent to which the University of Chicago and Hofstra University medical schools reflect Flexner's recommendations, and to identify the lessons that might be learned for all schools, a more thorough exploration of Flexner's theories regarding higher learning is necessary.
Flexner had a great deal to say about the structure and function of American medical schools, and those ideas persist in many (although not all) aspects of present-day medical education. What Flexner said about universities is perhaps equally important, because one of the primary theses of his report was his absolute belief that medical schools should be closely attached to universities. To fully comprehend what he hoped American medical schools might gain by being so closely allied with universities, it is necessary to consider his perspective on universities.
Flexner's thinking on universities centered on the idea that they should be committed to advanced study and research and should serve as centers for the creation of knowledge. By definition, a university that is to be a true seat of learning should possess specific characteristics.12 It must be small and flexible and must provide “comfortable places for the queer and unusual.” It must avoid standards that are relevant to business. It must rally against activities that make a mockery of student learning, such as student government or athletics (harkening yet again to Hutchins, who disbanded the University of Chicago's vaunted varsity football program). Flexner wrote that at the heart of every great university, one would find the advanced study of liberal arts and science, a robust graduate program, and professional schools whose education was based not on technical learning or service but on science and scholarship.12
Thus, Flexner's own opinion was that a medical school is, properly, a university department.1 Like Hutchins, who railed against technical learning and overspecialization, Flexner believed that the close alliance between a medical school and a university—and, indeed, the physical presence of a medical school on a university campus—would help keep the field of medicine closely allied with its scientific and intellectual content and also in touch with other disciplines, a situation that would inform and affect medicine as a discipline and in which service and practice would be a by-product of learning, not the central feature.
About medical schools
As stated in Flexner's autobiography, I Remember,12 the quality and value of a medical school rest on several decisive points, including the following:
* The entrance requirements—What are they and how are they enforced?
* The size and training of the faculty.
* The sum available from the endowment and fees for support of the institution.
* The quality and adequacy of the laboratories providing instruction of the first two years.
* The relations between medical schools and hospitals, including freedom of access to beds and freedom in the appointment of the physicians and surgeons who are the school's clinical teachers.
He clearly also believed that the faculty of a school must be full-time and that the quality of a school rested on its ability to hold a sufficiently large endowment to support such a faculty. A full-time faculty would, according to Flexner, prioritize scholarship and science over income and thus focus on activities that are not “trivial.” Part-time teachers, in contrast, are more likely to focus on earning large sums as practitioners and thus do not have the time for participation in teaching and research and/or for the private reflection that must underlie true scholarship.12 Seeing the goal of increasing income as entirely incompatible with scholarship and science, Flexner nevertheless does not see scholarship and experience as incompatible. Physicians should continue to engage in clinical practice, but they should avoid the trivial—thus, in Flexner's words, “pitching [the] plane of living on an academic scale.”12
Such vital teaching requires the proximity of research. Flexner writes that medicine is, in a strict sense, a profession—“a profession being definable as an activity in which practice and progress are closely interwoven and constantly reacting on each other.” Therefore, it is important that each physician obtain a medical training that “thoroughly rouses his intelligence” and that sends him or her forth “with a momentum that may carry him further every day of his life.”12
In Table 1, the multiple domains of medical education that Flexner wrote about are compared in two time periods, the beginning of the 20th century and the beginning of the 21st century. The elements in the table provide a sense of the significant evolution during the past 100 years in each domain represented. The changes in admissions standards, assessment, and finance are dramatic. Likewise, the growth of full-scale programs in graduate medical education represents a change of seismic proportion. These developments reflect the changes that have been wrought during the past 100 years in the structure and functioning of the U.S. health care system in general, in society's expectations of physicians, in technologies associated with education as well as with health care, and in the medical profession itself. In the context of so much change, why should the location of a medical school continue to matter?
Advantages of the Close Linkage Between Universities and Medical Schools: The Spirit of Inquiry and the Fostering of Learning
An education in medicine involves both learning and learning how; the student cannot effectively know, unless he knows how.
The spirit of inquiry
The writings of Hutchins and Flexner identify the university as an institution that creates knowledge, cultivates a spirit of inquiry, and fosters the creativity and curiosity that fuel the learning process. It is in this atmosphere that new knowledge is uncovered and that lifelong learning habits are developed and take hold.
The fundamental reason for (and advantage of) the close linkage of a medical school and a university is the atmosphere created by a scholarly approach to questions and to problem solving in an environment endowed with full-time faculty and facilities for research. The process of learning medicine lays a foundation for lifelong learning, which is accomplished by gaining a vocabulary, a body of knowledge, and a set of skills as well as by acquiring attitudes and behaviors. Sustaining learning over the course of an entire career is rooted in fundamental habits, practice, and thinking that are most powerfully taught in the university setting amid a culture of the discovery of new knowledge and a devotion to intellectual matters.
When a medical school is physically located on a university campus, this spirit of inquiry and the value placed on the generation of new knowledge permeate the environment and the culture, as evidenced by lectures given by invited speakers; discussions regularly occurring in classrooms and laboratories; formal, sponsored debates on campus; and the banter in coffee shops and bookstores. The university gathers together students from multiple disciplines to learn and to study side-by-side, and it holistically creates an environment that fosters a rigorous and scholarly approach to problems. Although this process of debate often slows down the ability of universities to respond flexibly and quickly to changing conditions, ultimately it yields the most creative and forward-thinking solutions to complex and intransigent problems in science, society, and human endeavor.
Habits of mind and the learning environment
At a time when medical schools are expanding in both students and campuses, cultivating habits of mind is essential, not only for the future of the profession but also for the future outcomes of patients.14 Medical schools linked to universities adhere to the ideal of interdisciplinary collaboration inherent in multiple, diverse groups living and working together. Basing the learning and practice of medicine in the context of the other pursuits inherent to university campuses ensures that the context of such learning cannot help being influenced by disciplinary advances in other fields that affect medicine and health care, as well as by the larger issues and philosophical debates and controversy that are part of the “university of utopia.” That the learning environment has an impact on medical students is well understood and has, in fact, been recently incorporated by the LCME as a standard for accreditation and as a key aspect of promoting “the development of explicit and appropriate professional attributes (attitudes, behaviors, and identity) in … medical students.”15
Innovation and the “new” basic sciences
Further, whereas Flexner called for a curricular model for medical education that broke preclinical and clinical education into two blocks of two years each, more recent curricular innovations for medical schools have supported the integration of the basic and the clinical sciences throughout the four years of medical school. By breaking down the barrier between science-based research education and clinical education, recent curriculum reforms support the close linkage between universities and medical schools and also support Flexner's belief that innovation in education needs to happen in the centers of innovation that are research universities. One of Flexner's great achievements was the fostering and promoting of education in the basic sciences through his focus on ensuring adequate resources, such as laboratories and facilities, for all medical students to acquire a thorough background in anatomy and physiology. In today's medical schools, students continue to need access to adequate resources for the historical as well as the new “basic” sciences—communication, public health, health outcomes and comparative effectiveness, health systems, patient safety and quality, ethics, and law—that reflect the interdisciplinary focus and the necessary new frontiers of the practice of medicine.
Looking ahead, it is fully possible that medical education will encompass cognitive science, social networking theory (how we influence each other's behavior), and the genetic and molecular sciences, all of which underlie personalized medical practice. Although medical schools may address these new areas of learning on their own, these disciplines are encompassed within already-existing university departments such as communication, drama, law, philosophy, religion, psychology, education, systems engineering, and public policy. These disciplines have long records of scholarship of an extraordinary depth and of widespread application. Their views of the same issues that medicine also addresses often are very different from traditional “medical” thinking, and, thus, they enrich and inform discussion. Physically locating a medical school in such a milieu may not be necessary, but it is strongly in the Flexnerian tradition.
In the case of Hofstra University's new medical school, the new synergies with nonscience programs such as law, ethics, drama, communications, religion, and public policy may create new value and engender vibrant intellectual opportunities. Because the creation of knowledge is highly fluid, embedding the medical school within the university ensures that as new knowledge is developed in one arena, it can be quickly assimilated and integrated into other disciplines, which will foster creativity within each field of study and across many fields of study.
Faculty teachers and supervisors
While the importance of the connection between universities and medical schools can be clearly seen in the preclinical education of medical students, clinical education also derives enormous benefits from the full-time faculty model found in such medical schools. The development of habits of mind that sustain thinking and problem solving over the course of a physician's career derive from the foundation of thinking learned during the years of medical education. Refining diagnostic hypotheses and generating illness scripts are part of such an education, and guidance from a full-time guide who can correct and deepen hypotheses and illness scripts is crucial.16,17 The feedback and supervision that students receive as they develop and refine illness scripts lead to the progressive problem-solving and reflective practice that are the foundation for diagnostic accuracy, practice, and lifelong learning. These habits of mind ultimately ensure the momentum necessary to carry a physician through a career, which is even more crucial than ever as the pace of new medical knowledge and its translation to the bedside accelerate.
The continuum of medical education
Finally, placing medical schools and their closely linked teaching hospitals within the university confines creates a symbiotic opportunity to affect the continuum of medical education from premedical education to medical school and residency programs. This full range of medical education enhances opportunities for the spirit of inquiry and the culture of discovery to exist at every stage.
It is interesting that the interaction between medical schools and the world of graduate medical education is an entirely different world than that described by Flexner. For the most part, graduate medical education did not exist in his day, and certainly not in the large-scale programmatic way in which it currently exists. Today, the largest numbers of graduate medical education positions exist in America's non-university-affiliated teaching hospitals. Not uncommonly, however, the university sponsors those graduate medical education programs, and the university's medical students may be instructed by and may learn from the residents who are working at those affiliated hospital sites.
The mutual financial rewards of placing a medical school within the university, recognized a century ago, are still part of the picture today. Through their medical schools, universities acquire access to National Institutes of Health funding streams and to funds from other biomedical granting agencies for indirect cost recovery, to philanthropy from both alumni and grateful patients, and to the less quantifiable but very real prestige that universities hope their medical schools will confer on their reputations. The opportunities for cross-fertilization of research teams and partnerships in scholarly projects enrich everyone's work. These advantages are perhaps most clearly recognized by those seeking to establish new medical schools within their universities. For example, the president of Hofstra University recently remarked that the new medical school is “a necessary step to a full-fledged university.”18 He envisions that the medical school will help the university to expand its undergraduate and graduate science programs, to add new, cutting-edge, degree-granting programs, and to bring new sources of revenue through biomedical research grants. Within one year, serious planning to develop or expand programs in health policy, medical physics, biomedical engineering, health of the suburban population, clinical psychology, and qualitative research methods has moved forward. Furthermore, the medical school will serve as the centerpiece for a new fund-raising campaign for the university.19
Contemporary Challenges: Why the Value of Linking Medical Schools and Universities May Be Diminishing
[T]he physician is a social instrument … whose function is fast becoming social and preventive, rather than individual and curative.
When Flexner issued recommendations for the ideal organization of medical schools, he focused on admission standards, the importance of a strong foundation in basic sciences, and a commitment to full-time faculty teachers. He went on to be very clear about linking each medical school directly to a larger university as the best way to accomplish those goals. Revisiting Flexner's model as new schools are being developed invites questions regarding the location of those schools and whether the university is still the most appropriate site.
Flexner identified the forces of commercialism as a problem and railed against the ways in which financial considerations and proprietary medical schools affected medical education by treating academic standards as less important than profitability. In the 21st century, the forces of commercialism are every bit as powerful as they were in Flexner's day, but they are likely to be found in different guises. The full-time faculty model is not sufficient to ensure the protection of faculty against engagement in the “trivial” activities Flexner had disparaged. Today's clinical educators—who have traditionally done the lion's share of teaching—are under increasing pressure to see ever more patients and to generate more clinical income, whereas the expectations of the funding agencies are that research faculty will spend the great majority of their time engaged solely in research. Although many AMCs continue to be staffed primarily by full-time faculty, it is not a given that these faculty members are available for the teaching, supervision, and mentorship of their medical students.19,20 While faculty continue to report multiple demands on time and increasing pressure to generate revenue and obtain grant support, time for teaching is endangered. After the publication of his report, Flexner himself was lamenting that the university was sacrificing teaching at the altar of research.5 In the decades since Flexner first expressed such a worry, this concern has only intensified, causing many to ask, “Where are the teachers?” Thus, the physical location of a medical school on a university campus can no longer be presumed to ensure the actualization of teaching and supervision.
Furthermore, there are numerous conflicts of interest that undermine disinterested scholarship and raise concerns over who is paying the faculty and whose interests are, in fact, being served. The large endowments that both Flexner and Hutchins saw as crucial to preserving the independence of universities and medical schools are subject, as has been seen, most painfully, over the past year, to economic circumstances.
Clinical teaching continues to take place primarily in hospitals, but to remain economically viable in the 21st century, hospitals must adapt rapidly to changing expectations on the part of the public, including payers, regulatory agencies, and insurance companies, in ways that universities have never needed to do and are not well equipped to do.3 Deliberative debate and thoughtful inquiry may yield innovative theories and robust new knowledge, but they impede the ability to quickly address changing circumstances. Federal and state regulations of AMCs have turned teaching, learning, and health care delivery into cumbersome processes. It is not uncommon for the independent teaching hospital—or the osteopathic medical school, for that matter—to be able to more flexibly and quickly adapt to new expectations in the health care environment than can the entrenched systems of universities. While it is clearly a benefit to the medical school to live in the dual worlds of “the university” and “the hospital,” it is less clear that the full AMC also benefits. Certainly some of the university resources in business, public health, law, and research would add to the strength of the AMC. Yet the juxtaposition of cultures, values, and operational styles may create as much conflict as synergy. Flexner did not directly address this possibility, and certainly the megabusiness that is academic health care today was never envisioned 100 years ago. The answer to this question remains to be learned.
What, then, is the impact on the clinical education of students of the joining of medical schools and universities? Just as Flexner avowed that medical students should have access to the best facilities and laboratories, so too did he believe that students should have access to education at the institutions that provide the best models for the delivery of effective and efficient health care. It is not a given that these institutions are AMCs.21 Creativity and diversification of the clinical education portfolio are necessary to preserve what is valuable about the AMC while supporting greater access to the models of care found in the community. Because AMCs are organized in departmentalized structures and geared toward reimbursement systems that emphasize the provision of services rather than overall health, patient care models that emphasize longitudinal, coordinated, and team-based care are more likely to be found among community practices, not in the AMC.21
Most crucially, the current health care environment, which emphasizes patient safety as the highest priority, poses a threat to the education of medical students.22,23 Robust experiential learning and a large volume of clinical experience are fundamentally valuable to students' learning and are crucial to the development of physicians.24 First espoused by Dewey in the context of the progressive education movement, and most recently proposed by Griffith and colleagues,24 direct experience with patients fosters learning in a powerful way. Neuroscientists report that the power of a memory is linked to the emotional component of that memory.25 When a medical student (or physician) directly cares for patients in emotionally charged and complex situations, the memories of that experience are most powerful, and clinical medicine is learned and remembered. Such a connection is the reason that the direct care of patients cannot be entirely replaced by “care” for mannequins, simulators, and standardized patients.
Furthermore, the close relationship between universities and AMCs is fraught with financial risks, to which universities have responded in a myriad of ways.26,27 Medical schools can be a financial giant in the university community, and that status creates not only jealousy but also true financial risk for the entire university enterprise. AMCs are frequently guided not by academic concerns but by economic ones, which results in the functioning of a business at the heart of an educational enterprise and, too often, in a tendency to have deeper concern for the bottom line than for pedagogic standards.
Universities themselves also have changed in fundamental ways during the past 100 years and have become more subject to market-driven competition. Just as Flexner accused the medical schools of his era of spending more on advertising than on laboratories or teaching,1 so too has the marketing of universities and professional schools become a more competitive and commercial process, and this change has led to market-driven behavior.28
The Challenge Ahead
The existence of many of these unnecessary and inadequate medical schools has been defended by the argument that a poor medical school is justified in the interest of the poor boy. It is clear that the poor boy has no right to go into any profession for which he is not willing to obtain adequate preparation.
Despite the challenges we have discussed, Flexner's idea about the importance of the university as a vibrant locale for the discovery of new knowledge and the interchange of new ideas that lead to innovation and advances remains constant. In his time, Flexner was motivated by improving the overall quality of medical education in order to provide the public with the best-trained physicians. Nevertheless, it is clear that the Flexner Report1 had a devastating impact on rural medical schools and minority medical schools, which led to a geographic maldistribution, as well as a lack of diversity among physicians, which persists to this day.29 See Maps 1 (http://links.lww.com/ACADMED/A7) and 2 (http://links.lww.com/ACADMED/A8) for graphic presentation of the suggested (Map 1) and actual (Map 2) number, location, and distribution of medical schools in 1910. In today's society and health care environment, many of Flexner's prescriptions sound elitist and more concerned with the prestige of the profession than with the health of the public. Today, all medical schools face an ever greater demand from the American public to serve the health care needs of the population, and, therefore, as the number of schools expands, it may be that the health of the public requires that a school be located in geographic areas of the country or in community settings where they are not attached to a university (Figure 1).30 In these cases, the schools may be regional campuses of a university. Already, it is not uncommon to find an AMC far away from the original campus. Sometimes, medical schools and their affiliated AMCs are relocated to cities where they occupy expanded campuses and are the largest employer in town, thus becoming essential to the local economy. In some cases, the university has concluded that the medical center is a corrosive problem for the university and has divested itself of that financial burden.31
As the numbers of schools and of students expand, there is a danger of returning unintentionally to a pre-Flexnerian atmosphere, in which technical training becomes more important than the culture of inquiry. The issue may not be whether all medical schools would benefit from physical proximity to a university: clearly, physical proximity can make colleagues of those who otherwise would be strangers, but such proximity is not necessary. The more important issue for medical schools rests on the values of learning, critical thinking, professionalism, inquiry, and scholarship and the culture of intellectual discourse that are nurtured in a university setting and that protect medical education and the profession from degenerating into the trade school world that Flexner so strongly reacted against.
It is crucial that consideration be given to the advantages and disadvantages of a medical school's being linked to a university. This analysis must be from both perspectives, that of the medical school and the university. Equally worthy of consideration are the threats to the university itself that might undermine the value such a linkage once brought.
Examples from the 20th and 21st centuries
Table 2 provides data on two medical schools—one established in the 20th century and one established in the 21st century—to allow a comparison of the ways in which the schools drew on existing models to shape their educational content and opportunities for students.
In the case of the newly formed Hofstra School of Medicine, the choice was made to locate the school on the campus of the university so that the medical school could benefit from the full-time faculty model, interdisciplinary opportunities, and the opportunity to learn from the university's administrative practices, policies, and procedures. This unusual model of the (intellectual) university and the (corporate) health system coming together to give birth to a medical school will integrate the values and cultures of the two institutions, with the hope that such integration may serve as a model for the future.
In the case of the University of Chicago, the Pritzker School of Medicine—both the school and the major teaching hospitals—continues to be embedded within the university campus itself, thereby availing itself of the interdisciplinary opportunities and culture of scholarship and discovery. At the same time, new academic affiliations are in place to provide exposure to clinical practices found in community health care settings, which enriches the educational experience of the students.
Flexner's principles regarding the shaping of American medical education continue to have profound relevance. The symbiotic relationship between medical schools and universities was a central tenet of the Flexner Report. Very quickly after its publication, the report resulted in the creation of standards and the development of more uniform admissions requirements, a decrease in the total number of schools and in the numbers of doctors graduating from those schools, and the development of a more rigorous curriculum based on solid, laboratory-based scientific work and direct experience with patients. One of Flexner's great achievements was to declare the value of the full-time faculty model, as found in the university. One way that the lessons learned from the Flexner Report are embodied in the creation of new medical schools is in a greater recognition of the value of the relationship of the medical school and the university, a value that perhaps has been overlooked by those schools whose association with universities is more long-standing. The 100th anniversary of the Flexner Report inspires us to remember the ways in which the medical profession was galvanized when medical schools and their faculties adopted university values.
In reexamining the relationship between universities and medical schools, identifying the most critical components of medical schools and universities is essential. During the period of formal medical education—both undergraduate and graduate—the seeds of future careers and lifelong learning are planted. At their core, universities are collections of teachers and students, and it is the relationship of teachers and learners in an environment of inquiry and discovery that establishes the quality of the education. Those teachers, role models, and leaders, by teaching medicine, caring for patients, and making discoveries in the laboratories and beyond, inspire generations of students. Although multiple types of environments might be capable of creating such a learning environment, universities are ideally organized and positioned to accomplish this and to withstand challenges that undermine these values.
In the activity of the current health care environment, it is easy to lose track of the value of such unremunerated activity and the inspiration wrought by great teachers. There is an urgent need for medical schools and their universities to reclaim an aspiration for excellence and to make it more possible for the faculty to be supported to inspire greatness and to invigorate the call to service among our students. This need can be met by medical schools and their leaders embracing the faculty as their teachers and scholars and providing the vision for the way forward during an era when the health care needs of the nation have never been greater.
Other disclosures: None.
Ethical approval: Not applicable.