Custers, Eugène J. F. M. PhD
Dr. Custers is researcher in medical education, Center for Research and Development of Education, School of Medical Sciences, University Medical Center, Utrecht, Utrecht, the Netherlands.
Correspondence should be addressed to Dr. Custers, University Medical Center Utrecht, Center for Research and Development of Education, HB Building, 4.05, PO Box 85500, 3508 GA Utrecht, the Netherlands; telephone: (31) 88-75-56793; e-mail: firstname.lastname@example.org.
Abraham Flexner's 1910 report, Medical Education in the United States and Canada, was hardly noticed in the Netherlands, and though his 1925 book, Medical Education: A Comparative Study, was extensively discussed in the Dutch Medical Journal, it did not and could not affect medical education in the Netherlands. Until the 1970s, the medical curriculum in the Netherlands consisted of four phases: the propaedeutic year (premedical sciences), two preclinical years, two theoretical clinical years, and one-and-a-half to two years of clerkships. When in the 1970s interest in curriculum innovation arose in the Netherlands, it was based on developments in North America that challenged “Flexnerian” norms in medical education. As hardly anyone in the Netherlands cared to study Flexner's work closely, his name became synonymous with the conventional curriculum just as it had in North America. However, the Dutch conventional curriculum was quite different from the American conventional curriculum, so attributing its origins to Flexner's work was a serious misrepresentation. In this commentary, the author clarifies common misconceptions about the history of Dutch medical education and argues that the curriculum as Flexner saw it differed considerably from the Dutch medical curriculum a century ago.
In 1992, the Dutch anatomist and medical educator Han Moll (1921–1995) borrowed Flexner's book Medical Education: A Comparative Study (1925) from Utrecht University's medical library, only to find that the pages had not yet been cut. Apparently, the book had been on the shelves for almost 70 years without anyone even opening it. “Decades of missed reading pleasure,” Moll regretfully concluded.1 Yet, in contemporary medical education, another of Flexner's writings, the 1910 “Flexner Report,” Medical Education in the United States and Canada, is well known and often referred to in the Netherlands; it even features prominently in our medical education canon.2,3 When it comes to Dutch medical education, Flexner is often referred to, but widely unread—a recipe for misunderstanding. In this commentary, I argue that Flexner's view of the ideal medical curriculum has been largely misrepresented in contemporary Dutch medical education.
Dutch Medical Curriculum in Flexner's Days
Two factors have contributed to this misrepresentation. First, the conventional Dutch medical curriculum superficially resembles the ideal curriculum as Flexner saw it, and second, Dutch medical education has, because of its lack of its own historical perspective, vicariously adopted the history of American medical education as its own. In fact, the development in the Netherlands from the medieval university medical curriculum into a more “Flexnerian” curriculum started in the 17th century at Leiden University (with Utrecht University close behind). The major transition was the introduction of bedside teaching into the formerly purely theoretical (i.e., scholastic) curriculum. This system reached its apex under Herman Boerhaave (1668–1738), after which it gradually declined, though Boerhaave's pupils continued it in Edinburgh and Vienna.4 By the early 19th century, practical clinical training had all but disappeared from the medical program, which now fitted the traditional division of university education into three phases: a propaedeutic phase entirely dedicated to the natural sciences, a candidate phase in which the student would dissect animals and humans and study physiology and pathology, and a doctorate phase consisting of theoretical clinical lessons and patient demonstrations.5 The fourth phase, the clerkships, was formally placed under academic supervision in 1865, but in fact the medical faculties had little control over what happened to their students in the clinic. Basically, this four-phase structure remained in operation at all medical faculties until the mid-1970s, when the first medical faculty with a problem-based learning (PBL) curriculum opened its doors.
Reception of Flexner's Work in Dutch Medical Education
I could not find any evidence in the Dutch literature that publication of the Flexner Report was noticed at all at the time of its publication. For one thing, a century ago, Dutch medicine, including medical education, was grafted onto the German, rather than the American, model. Almost everyone was looking toward the East. But even if it had attracted attention, the Flexner Report could not have affected medical education, for the Academic Statute, which became effective in 1877 and had the status of a law, prescribed that the disciplines be taught in the three phases of medical education. Freedom of teaching, and hence variation, existed exclusively within courses, where professors could express their fads and fancies as they pleased.
The situation in the Netherlands was quite similar to that in Germany, which Flexner extensively discussed. Flexner repeatedly expressed that there was a “Germanic bloc,” consisting of Germany, the German-speaking parts of Switzerland and Austria, the Scandinavian countries, and the Netherlands (and possibly including Belgium as well, but Flexner seems not to be entirely consistent with respect to this country), across which the educational system was largely the same. Popular view holds that Flexner was laudatory of medical education in Germany, but actually he observed quite a few defects: The premedical sciences should be taught in secondary schools, not at the medical faculties; there were too many lectures and there was too little opportunity for practical work; full professors had too much power; and there were no private funds to support medical education.6 He also described the arrangement in Germany as chaotic and wasteful, with a high dropout rate and a long average study duration being the negative counterparts of students' freedom and personal responsibility for their progress. At least in the Netherlands, from the late 1950s onward, high dropout rates and the extension of study duration (often by years) beyond what was intended became a major source of concern and eventually an important catalyst of curricular reforms. What I believe also has contributed to the popular view of Flexner's endorsing the German system is that he presented its benefits as lessons to be learned by American medical education, whereas its drawbacks are mentioned almost in passing (“I was not trying to reform Germany, but to reform America”).7
Unlike the 1910 report, Flexner's 1925 book Medical Education: A Comparative Study was extensively discussed in the Dutch Medical Journal by managing editor Gérard Van Rijnberk, who apparently experienced similar reading pleasure as Han Moll 70 years later. Van Rijnberk (1875–1953), an Amsterdam-based physiology professor and one of the few authors in the Netherlands at the time who was really interested in medical education beyond the limits of his own discipline, devoted no fewer than nine main editorials to the book, rather than a single book review.8 Because Van Rijnberk largely agreed with Flexner's view of medical education, the general drift of the editorials was that of an affirmative summary. He couldn't have agreed more with Flexner's position that the laboratory sciences (anatomy, physiology, and pathology) should be taught as pure sciences, not as medicine's “handmaids.” In fact, in a 1921 editorial, Van Rijnberk had already argued exactly the same: Anatomy should be taught as pure anatomy, not as clinical anatomy; and physiology should be taught “as if all students strived for an academic chair in physiology.”9 Of course, it did not escape Van Rijnberk that Flexner mentioned the physiology departments in Amsterdam—where Van Rijnberk himself was the director—and Bern, Switzerland as positive exceptions on the continent, where the professors managed to provide good practical courses despite limited facilities.10
According to Flexner, clinical education in the Germanic bloc was generally good, except for one aspect—too much lecturing and too few opportunities for practical training. In Germany, this was compensated to some extent by nearly every student serving a few months as a famulus (volunteer) in medicine and surgery, and as a Haus-praktikant (intern–practician) in obstetrics. Flexner was less positive about the Dutch system of clinical education, with its “total divorce of theoretical clinical instruction from practical experience of whatever kind.”10 This referred to the doctorate program (the fourth and fifth year), where students endured “two years of unrelieved demonstrative lecturing” before being extensively examined on their knowledge of clinical theory.10 There was no room for optional courses. The scientific spirit, featuring prominently in the preclinical laboratories, was completely lacking. The idea, apparently, was that students should have learned all there was to know about clinical theory before entering medical practice. The Dutch clerkships, finally, were also deficient in Flexner's eyes; though students could witness everything happening, the clinical rotations were too rapid and the hospital organization too undeveloped for proper practical training and a thorough study of diseases. Reports of physicians who studied medicine at the time when Flexner prepared his book testify to this. Clerks were often charged with menial and routine tasks, such as investigating urine or blood samples, without any opportunity to examine the patients that were the source of these specimens. Van Rijnberk did not further discuss this issue, probably because he was too unfamiliar with clinical education or did not want to offend or defend clinical teachers. “So much for our beloved doctorate- and clerkship examinations,” he shortly concluded.8
Flexner's Reappearance in the Dutch Medical Literature
Although the Dutch Journal of Medicine, including Van Rijnberk's editorials, was widely read by physicians in the 1920s, Han Moll's experience with Flexner's book may have been quite representative. Few, if any, people bothered to take Flexner's work in their hands. In fact, to the best of my knowledge, his name was not mentioned in the Dutch medical literature for several decades, except for a small obituary in 1959 (“Older readers will remember the survey of American and Canadian medical schools by this nonphysician around 1910”).11 Yet, somewhere in the late 1970s or early 1980s, the Flexner Report suddenly made a comeback. This was a consequence not of increased interest in the history of Dutch medical education but of contemporary American publications about innovations in medical education becoming popular in the Netherlands. In the 1970s, the first medical educators using PBL techniques appeared on the stage in the Netherlands, read about innovations in North America, and saw these contrasted with the Flexnerian curriculum. Subsequently, they projected this curriculum onto the history of Dutch medical education. In a certain sense, they appropriated Flexner. The effect has been surprising—not a few authors credit Flexner for introducing the preclinical sciences into the Dutch curriculum, or for splitting up the curriculum into a theoretical and a practical phase. Soon, the terms “Flexnerian curriculum” and “conventional curriculum” became synonymous. But the American conventional curriculum is not the same as the Dutch conventional curriculum. To be sure, there are similarities, most predominantly the strong emphasis on the preclinical sciences. But in all likelihood, Flexner would not have approved of his name being associated with a curriculum predominantly characterized by lectures with little room for hands-on training, by a strict separation of clinical theory and clerkships, by authoritarian professors, and by a poor organization of clerkships. The Flexner centenary might be an excellent opportunity to correct this mistaken view once and for all.
At the Conference of the Association for Medical Education in Europe in Glasgow, Scotland, United Kingdom, September 5–8, 2010, the author presented a short communication entitled “Putting Abraham Flexner's heritage into perspective.” Some of the ideas included in this paper were put forward there as well.
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10 Flexner A. Medical education: A comparative study. New York, NY: MacMillan Company; 1925.
11 Van Loghem JJ. Abraham Flexner passed away [in Dutch]. Ned Tijdschr Geneeskd. 1959;103:2215.