Gunderman, Richard B. MD, PhD; Gascoine, Kelly MA; Hafferty, Frederic W. PhD; Kanter, Steven L. MD
Despite the fact that Abraham Flexner never enrolled in medical school or practiced as a physician, he is widely regarded as one of the most important figures in the history of American medicine. His eponymous report of 1910 (Bulletin No. 4 of the Carnegie Foundation for the Advancement of Teaching) is often singled out as the 20th century's single most influential document on medical education. Within years of its release, this report helped to precipitate major changes in the number, size, university affiliation, and curricula of U.S. medical schools. The enduring stature of the “Flexner Report,” as it came to be known, is reflected in the fact that Academic Medicine devoted its entire February 2010 issue to honoring its centenary.
What has received less attention is the fact that Flexner lived another 49 years after his report's publication and made major contributions to American education during this time. One of Flexner's greatest subsequent achievements was the founding of the Institute for Advanced Study (IAS) in Princeton, New Jersey. Though medicine was not part of the IAS's mission, the story of Flexner's role in its founding offers important insights into the man and important lessons for contemporary leaders in academic medicine. This article briefly reviews Flexner's career after the report and then focuses on the most salient of these lessons.
Flexner After the Report
After the publication of the Flexner Report in 1910, Flexner traveled extensively in Europe, surveying medical education there, and publishing his findings in Bulletin No. 6 for the Carnegie Foundation.1 In 1913, he joined the General Education Board of the Rockefeller Foundation, which at the time focused primarily on elementary and secondary education, the promotion of the education of blacks in the South, and the creation of endowments for universities. Flexner was a forceful advocate for medical education at the Rockefeller Foundation, and during his first six years there, he sought to leverage its resources to promote the establishment of full-time medical school teaching faculties. To do so, he allocated foundation funding to both leading and promising medical schools, including Johns Hopkins, Yale, Washington University, University of Chicago, and Columbia.2
In 1919, Flexner arranged for John Rockefeller, Sr, to donate $20 million, later increased to $50 million, to the foundation to be used for the reform of medical education. Matching these funds with monies from medical schools, other philanthropists and foundations, and the General Education Board, by 1929 Flexner had helped to inject $600 million into U.S. medical education. The equivalent purchasing power in today's dollars would be a staggering $7.5 billion. Between 1919 and 1928, Flexner sought to create and sustain centers of excellence in medical education in various parts of the country while at the same time inducing hopeless schools to go out of business. Flexner's authority in medical education was unquestioned, and he was known as both American medicine's best friend and its severest critic.2,3
By 1928, Flexner had ruffled feathers both outside and inside the Rockefeller Foundation to such a degree that he was encouraged to resign.2 He traveled to Oxford University, where he delivered the Rhodes lectures and Taylorian lecture. In 1930, he reworked these lectures into a book examining American, English, and German universities.4 Flexner opposed the view that a university education should focus purely on culture and the building of character, instead arguing for the importance of research and the discovery of new knowledge. In his view, university teaching was important primarily insofar as it contributed to the advancement of knowledge, not merely its transmission.5
As Flexner was finishing his book in 1930, he was approached by representatives of a New Jersey department store magnate, Louis Bamberger, who had sold his retail business to Macy's just prior to the 1929 stock market crash. Bamberger was childless, and he and his sister Caroline wished to use their fortune to found a medical school in Newark. As they saw it, the new school would provide medical training for Jewish students whose prospects for admission to other U.S. schools were dim.3,6
Flexner agreed to help the Bambergers with the philanthropic disposition of their fortune, though, in true Flexnerian fashion, he had his own ideas about how this might best be accomplished. Flexner doubted that Newark would be an appropriate site for a medical school. He believed that it would be too close to the existing medical schools in New York City, and he cited the fact that Newark lacked a university that could serve as host to a great medical school. Moreover, Flexner felt that if the Bambergers wanted to devote their fortune to New Jersey, the funds should be used for something other than a medical school.6
Keen to give practical expression to the ideas that he had developed in his Oxford lectures, Flexner proposed to found a graduate university devoid of undergraduates, where the faculty would focus their time and energy on research and the advancement of knowledge. He envisioned a “free society of scholars and [graduate] students devoted to the higher training of men and to the advancement of knowledge.”3 The world-class, well-compensated faculty would be free from the typical academic pressures concerning career advancement, administration, and publishing, allowing them to devote their energies to the problems that interested them. Flexner argued that the most natural site for such an institute in the state of New Jersey would be Princeton, home of Princeton University.3,5
Eventually, the Bambergers came to see the wisdom of Flexner's vision and offered him $5 million to found the IAS.3 Flexner was appointed director of the institute in 1930. Determined to create an outstanding organization, Flexner consulted a number of scholars and educational experts in both America and Europe, including legal scholar Louis Brandeis, historian Charles Beard, financier Paul Warburg, and mathematicians Solomon Lefschtz and Oswald Veblen.6,7 Fortuitously, the most famous physicist in the world at the time, Albert Einstein, had become disenchanted with German militarism and anti-Semitism and was looking for a new home. The president of the California Institute of Technology, Robert Millikan, had been courting Einstein, but when Flexner found out that Einstein was contemplating a move to the United States, he quietly went to work luring Einstein to his new institute.3
Einstein was amenable. At one point in the negotiations, Flexner asked Einstein what he would expect in the way of salary. Einstein replied that he thought $3,000 appropriate. Determined to elevate the status of faculty in American higher education, Flexner had already determined to pay senior faculty a salary of at least $10,000 (approximately $125,000 in today's dollars), and Einstein and Veblen, the first two recruits, were each hired at a salary of $15,000, the same as Princeton's president. Though Einstein eventually accepted what he regarded as this excessive sum, he considered his pension of $7,500 simply out of bounds, and had it reduced to $6,000. With the recruitment of Einstein, Flexner's institute achieved instant acclaim and legitimacy.6
Flexner sought to establish schools within the IAS, building each one on a core of world-class faculty. The first was the School of Mathematics in 1933. Within several years it shifted the world's greatest concentration of mathematicians from Goettingen in Germany to Princeton.7 The announcement of Einstein and Veblen as the institute's first recruits was front-page news in the New York Times.5 Subsequent recruits included James Alexander, John von Neumann, and Herman Wyle.7 The School of Mathematics also attracted the IAS's first visiting professor, Paul Dirac. In 1935 came the School of Economics and Politics, which recruited David Mitrany, Winfield Riefler, and Edward Meade Earle.3
Also in 1935 came the School of Humanistic Studies, whose scholars included Benjamin Meritt, Erwin Panofsky, Elisa Lowe, Ernst Herzfeld, W.A. Campbell, and Hetty Goldman (the first woman to be hired at the IAS), many of whom were archaeologists.3 However, Flexner's aggressive plans to expand the IAS began to encounter obstacles stemming from the Great Depression. He needed more funds for expansion of facilities and faculty, but money was becoming harder to obtain. Flexner pressured Bamberger to provide more funding, but the IAS's original benefactor became increasingly resistant. For a number of reasons, including his contentious relationships with some members of the faculty, by 1939 Flexner was forced out of the IAS directorship.6
Flexner remained productive in the 20 years he lived after leaving the institute. He went on to write biographies of Henry Pritchett, the former president of the Massachusetts Institute of Technology who had hired him to produce the Flexner Report, as well as of Daniel Coit Gilman, the first president of Johns Hopkins University, Flexner's alma mater. He also authored a book on foundations as well as his own autobiography, I Remember. Educational leaders continued to consult Flexner on matters pertaining to education for the remainder of his life. His death, in Falls Church, Virginia in 1959, was front-page news in the New York Times.3
Lessons From Flexner
Flexner understood the importance of philanthropy for medical education specifically and higher education generally. As a cultivator of philanthropy, Flexner dreamed no small dreams, and in fact demonstrated a great ability to inspire donors with grand visions of the differences their gifts could make. In addition, he was not bashful about attempting to advise donors on the best use of their money.
While Flexner was with the Rockefeller Foundation's General Education Board, he advised Albert Lasker, often considered the founder of modern advertising, to avoid making a $1 million donation to the University of Chicago. Flexner did so not because he felt the university did not deserve the money but because Lasker intended to specify that the funds should be used to support investigations that might lead to the cure for cancer. Flexner urged Lasker to make his donation in a less restricted way, by establishing a general research fund. Such a fund could then be put to whatever purposes its directors regarded as most promising at the time. Lasker, who wanted to make sure that the university made the most of his money, was happy to do so, and wished that university administrators would have suggested as much in the first place.2
As we have seen, Flexner influenced the Bambergers in much the same way. Donors generally appreciated this approach because it demonstrated to them that Flexner intended to help them make the greatest possible impact with their gift. He was less interested in the number of dollars he could collect than in making sure that the money was used in the best possible way.
Today, philanthropy seems to play a much smaller role in medical education. In stark contrast to the huge sums of money raised by Flexner for medical education in the second and third decades of the 20th century, only 2.7% of U.S. medical school revenue in 2008 came from philanthropy.8 Compounding this problem, some academic medical centers today have allowed their teaching missions to be subordinated to the financial ambitions of their health systems and the pursuit of extramural research funding, to the detriment of education. If the priority of the educational mission is to rise, academic medicine needs to develop new funding sources, and the time is ripe for a resurgence of philanthropy. This will require the development of a new breed of leaders as influential as Flexner—people committed to excellence in education and capable of presenting a compelling educational vision to potential donors.
Flexner devoted a great deal of time and thought to his projects, and he pursued them with great determination. For example, while at the General Education Board, he considered the development of full-time clinical faculty at U.S. medical schools such a high priority that he argued for the withholding of funds from any school that chose to pursue an alternative path. This caused some to regard him as inflexible, but Flexner believed strongly in his vision and felt that he needed to adhere to it, even when it was inexpedient or unpopular to do so.
Another example of Flexner's determination concerned American innovator and philanthropist George Eastman, who invented roll film and founded the Eastman Kodak Company, headquartered in Rochester, New York. In 1920, Flexner wanted Eastman to make a gift to the University of Rochester to found a medical school. Flexner estimated the total cost at $10 million. Eastman offered $2.5 million. Flexner regarded this as insufficient and told Eastman that he would wait “until you sell more Kodaks.” Days later, Eastman offered $3.5 million. Flexner again declined. A few weeks later, Eastman offered a contribution of over $5 million. Flexner accepted this offer, agreeing to match it with funds from the General Education Board, although at the time he had no commitment from the board to do so. Several months later, Flexner would celebrate the founding of the school and Rochester's decision to adopt his model of full-time clinical teaching. Flexner was willing to risk losing a multi-million-dollar donation in hopes of securing a larger gift that would allow him to fund and conduct his project as he thought appropriate.2
Of course, Flexner's determination at times proved problematic as well, and U.S. medical education is still coping with one of its downsides. Flexner felt very strongly that medical schools needed to be affiliated with universities and that academic medicine should be characterized by a strong commitment to research. This vision has rendered American medicine second to none in terms of scientific achievement and technical capability. However, it has also spawned a high level of specialization, to the neglect of other possible foci such as primary care and public health. In his zeal to weed out inadequate schools, Flexner promoted a monolithic view of what medical education should look like. Had he sought to promote more diversity in medical education, the United States might have a more varied population of schools, some focused on bench or clinical science, others focused on producing primary care physicians, and still others focused on public health or leadership and administration.
In the end, Flexner's single-mindedness had its pros and cons. Overall, his determination and dedication to medical education served the field well and played an important role in making American medical education as strong as it is today. But a combination of determination and flexibility might have carried Flexner's work even further and produced an even more robust medical education system in the long run.
Flexner cultivated personal contacts in many fields, including medicine, education, business, government, and the philanthropic community. While he was touring Europe working on his book on universities, he met with as many as 20 people each day, gaining insights from their distinctive perspectives while simultaneously “comparing, thinking up new relationships, thinking out suggestions, problems, possibilities.”3 These contacts opened doors for him and enabled him to open doors for others.
Flexner's relationships, however, were anything but utilitarian. They were genuine friendships that all sides generally valued for their own sake. Flexner took a sincere interest in others and sought to build deep and enduring relationships. For example, Wallace Buttrick, who served as president of the General Education Board, wrote to Flexner, “You have grown into my life as a brother beloved.”3 Flexner made sure that he helped his friends at least as much as they were helping him. Particularly during the early years of IAS, Flexner and his wife Anne operated a kind of salon, hosting frequent dinner parties that provided faculty and students the opportunity to socialize on an informal basis, thereby creating a community that fostered friendship, collaboration, and productive research.6 Flexner's efforts to foster collegiality and faculty interaction outside of work serve as reminders of an important element of professional life that, in many quarters today, is no longer in evidence.
One of Flexner's most important friendships was with Frank Aydelotte, whom he met in Louisville when both were teaching. Flexner helped Aydelotte learn Greek, provided funding for Swarthmore College when Aydelotte became president there, and secured a position for him on the board of the IAS. When Flexner left the General Education Board, it was Aydelotte who nominated him to deliver the Rhodes lectures at Oxford. Later, Flexner took steps to ensure that Aydelotte would succeed him as director of IAS.3,6 Flexner and Aydelotte were not making calculated judgments about how much career support each could extract from the other. Far from it, they enjoyed one another's company, and they frequently spent portions of their summers together at Flexner's summer camp north of Toronto. Through sincere friendship, each knew the other's talents and capabilities and offered advice or help when needed, allowing both to realize their dreams.
Flexner's efforts to build bridges were remarkably free of the ethnic, religious, and national prejudices that often characterized the affairs of his day. For example, the Bambergers originally wanted to found a medical school for Jewish students, but Flexner resisted on the grounds that it made no more sense for Jewish students to be associated solely with other Jews than for Christian students to associate solely with other Christians. In founding the IAS, Flexner felt strongly that the key consideration was to select the best minds, regardless of their background. He told the Bambergers, “There shall be no distinctions whatsoever in the student body, in the faculty, or in the board of trustees based upon race, religion, or sex.”3 He hoped that the fact that the institute was being financed by two Jews possessed of such an attitude might help encourage much-needed tolerance in the United States and elsewhere.
Downplaying gender, ethnicity, and religion, Flexner was committed to hiring the most intellectually capable personnel in each academic field, and he harbored doubts about recruiting on any basis other than academic potential. Today, the blatant discrimination that Flexner opposed has been replaced by efforts to strike a balance between demographic diversity and purely intellectual distinction.
Flexner believed that there is no real conflict between the natural sciences and humanities. In fact, he argued for synergism between the two. The fact that Flexner would follow his first school at the IAS (mathematics) with a school of humanistic studies reflected this belief. Flexner was convinced that a person who knew both the rigorous methods of science and the broad cultural values of the humanities would function as a more learned, creative, and effective force for good than someone who knew only one or the other. Regarding medical education, Flexner felt it just as important for physicians to be humanely educated as that they employ “the severest intellectual effort in their scientific study.”3 Far from abandoning the humanities, Flexner's advocacy for the highest scientific standards in medical education was balanced by a commitment to help bring historical and humanistic depth to American medical training.
This conviction was further reflected in Flexner's great admiration for the founding dean of the Johns Hopkins School of Medicine, William Welch, whom Flexner regarded as one of the most cultured and literate of American physicians. This admiration took practical form in Flexner's strong advocacy for the creation of a new medical library and a chair in the history of medicine at Hopkins, both named in Welch's honor.3 These innovations at what Flexner regarded as the premier medical school in the United States reveal the strength of his esteem for the humanities in medical education. Against the tendency to measure institutions of higher learning by their numbers of programs or students, Flexner argued that the best learning, especially in the humanities, takes place in small groups under the tutelage of a committed educator.2 Flexner believed that the study of the humanities plays a crucial role in fostering critical inquiry and creative activity throughout both medicine and higher education. Moreover, it fosters learners' abilities to address the most fundamental of all questions: namely, what problems are ultimately most worth studying and working to solve?
Flexner viewed the liberal arts as important for another reason as well. He saw them as an important antidote to the mercenary spirit in education. Flexner was an astute judge of finances, and he handled large sums of money quite successfully over long periods of time during his life. He could display a remarkable pragmatism, as in determining which school of the IAS should be founded first. He felt that the logical place to start was mathematics, in part because mathematicians would not require a large initial investment in space, equipment, and personnel. It took, he said, just “a few men, a blackboard, and some chalk.”3 Flexner recognized that medical schools, hospitals, and universities need to operate according to sound business practices. If they did not, they would soon find themselves seeking revenues in ways that might compromise their primary responsibilities to scientific advancement and learning.
Flexner felt strongly that a medical school is not a business whose product just happens to be medical degrees, nor is a hospital a business whose product happens to be health care, nor a university a business whose product happens to be education. To the contrary, the primary missions of these institutions are to educate human beings and care for the suffering, not to generate revenue. To Flexner, revenue was not the end but, rather, a means to a larger end. When Franklin McLean, dean of medicine at the University of Chicago, was thinking of moving away from a full-time faculty for financial reasons, Flexner wrote him that the school and its hospital were in danger of abandoning their founding purpose merely “in order that they might become profit-making institutions.”3 The study of the liberal arts, Flexner believed, would help future physicians realize that there is more to life than making money.
Flexner regarded education as a lifelong process, a conviction reflected in the fact that he remained a voracious reader and active inquirer throughout his adult life. He derided passive learning and indoctrination, arguing that learners must be actively engaged in the pursuit of understanding. The fate of each person hinges in large part on what he or she knows, and the same can be said for that of nations. An ignorant nation would fare no better than an ignorant person. The fact that the United States is a democracy in no way authorizes what Flexner called “intellectual mediocrity and inferiority.”3 Instead, to realize its true promise, the United States would need to foster an open society where people were free to explore and develop their interests and abilities.
As we have seen, Flexner saw education not as a product that can be purchased and then stored on a shelf but, rather, as a continuous achievement, much more closely resembling tending a lamp flame than burnishing a sculpture. It is possible to require medical students, residents, and practicing physicians to keep learning through such mechanisms as examination scores and the documentation of hours of attendance at instructional courses. Yet Flexner believed that excellent clinicians, scientists, and educators must be inspired from within by an innate love of discovery. Educational leaders, he thought, must spend less time and energy on the size of their institution's buildings and endowments, focusing instead on the quality of education and intellectual discourse they offer. The goal is not just to qualify and credential graduates, nor even to meet health care workforce needs, but to educate human beings who will contribute as much as possible to the pursuit of knowledge.
Flexner's perspectives and approaches were not uniformly exemplary, and one area in which he suffered as an educational leader was the lack of transparency with which he acted. In founding the IAS, Flexner envisioned a faculty unencumbered by administrative duties yet possessing a strong voice in the running of the institute, with seats on the board of trustees. The latter idea was defeated by Bamberger himself, but Flexner never shared with the faculty how much he believed in and fought for this idea.3 Over time, and contrary to these earlier convictions regarding faculty participation, Flexner became increasingly confident about his own ability to assess scholarly talent and less and less solicitous of faculty input, eventually beginning to hire new faculty members in an atmosphere approaching secrecy. This progressed to the point that existing faculty, who were typically world authorities in their fields, did not even know who their new colleagues would be until the hiring process was complete.6
As a result, members of the faculty frequently complained that they felt ignored in matters vital to the institute's future. Ultimately, faculty members approached the institute's board with the request that Flexner be replaced.6 Why did he operate in this way? One possible explanation is the fact that although Flexner wielded great influence in American education, he had never experienced university life on the inside as a faculty member or administrator.
Similar problems arose with Flexner's desire to maintain a sanctuary for scholars free of worldly distractions, a vision that sometimes gave rise to tensions. Einstein, for example, was one of the most recognizable figures in the world, a true celebrity of his day, and his great wit and lack of pretension endeared him to the public. As Einstein left Germany, his home and property were seized, and rumors circulated that the Nazis were planning to assassinate him. Fearful of disaster, Flexner sought to protect Einstein, warning that if he continued in a position of prominence in the public eye, no nation in the world could keep him safe. At one point, Flexner even saw fit to decline on the Einsteins' behalf a dinner invitation from President Franklin D. Roosevelt. Furious, Einstein complained that Flexner was seeking to manage his private life. Over time, Flexner learned his lesson and interfered to a much lesser extent.7 Interestingly, Einstein, too, seems to have changed his perspective somewhat, and began accepting fewer invitations and honorary appointments.
Flexner's “Paradise” Today
Abraham Flexner was one of the most important figures in the history of American medical education. To understand fully who he was and what he hoped to contribute to the field, we must look beyond his strictly medical writings and survey his broader views on higher education, many of which were further honed after his period of most direct involvement in medical education. What educational purpose did he see as most essential? To what extent did he think that the fate of whole professions and societies hinges on their views on learning? For deep insights into these matters, we need look no further than Flexner's role as founder of the IAS, through which he enjoyed the best opportunity of his life to give practical expression to his educational philosophy. It is as the IAS's founder that Flexner the visionary shines forth most brightly, offering profound insights that deserve as much attention today as they did at the institute's founding 80 years ago.
In addition to these broader themes, Flexner's vision for the IAS and his tenure as its director reflect several contemporary challenges facing medical education. Flexner envisioned what he called a “paradise for scholars” that would link theory (mathematics), application (economics and politics), and heart (humanistic studies), and he was able to unfold that vision even in the face of financial constraints brought about by the Great Depression. The parallels to today's challenging economic times are striking. Economic shortfalls and dwindling resources were Flexner's constant companions. Yet he prevailed, and he did so at an age (70 years) when most leaders have retired. He recognized that the most precious resource of all is not funding but vision. Flexner remained true to his vision in the face of what others (then and now) would view as insurmountable odds, subordinating resource constraints to his dream, rather than the other way around.
Flexner understood the importance of philanthropy as an engine of creative enhancement in medical education, and he excelled as both a fundraiser and a distributor of funds. He could create in the minds of potential donors a dream about the difference their gifts could make in the lives of individual patients, communities, the profession, and the nation, a dream that inspired many wealthy individuals to give generously. In addition, he made sure that grants and endowments created from these funds were used in innovative ways that could leverage existing resources to create even larger opportunities in the future. In view of the IAS's relatively small size and budget, it has exerted a remarkable impact on human understanding the world over. What could today's leaders be doing to create a more inspiring vision of academic medicine and enabling potential donors to play a more catalytic role in bringing it to fruition?
In creating the IAS, Flexner envisioned an intellectual community where scholars and scholarship took precedence over administration and financial management. He believed that both scholarship and education should be fully funded, freeing investigators and teachers from the tyranny of generating outside revenues. He would be disturbed by the increasingly commercial nature of today's academic medical centers, especially the demands being placed on academic physicians to generate clinical income to support their academic pursuits. Likewise, he would object to the large payments from pharmaceutical and medical device manufacturers to clinicians and scientists, creating conflicts of interest that have only relatively recently begun to receive close scrutiny. Medical education has always struggled to fund itself, and we are now paying the price Flexner dreaded. Many in the present call for the “management” of such conflicts. Flexner would have demurred.
Finally, Flexner conceived of the IAS as a community of inquiry, and he would be an enthusiastic proponent of efforts to develop and enhance interdisciplinary collaboration throughout academic medical centers and universities. Flexner believed deeply in the power of social networks, in particular the ability of interdisciplinary conversation to spawn new perspectives and new ways of tackling problems. On the other hand, he would not be pleased with efforts to give research a more applied or translational character, or efforts to tie research funding to extant social problems. Flexner believed that too great a focus on the practical value of research would promote the insidious commercial corruption of academic medicine, tying inquiry too closely to the promotion of commercial interests. He held that loyalty to truth and service to mankind should always come first.
The opinions expressed in this article are solely those of the authors.