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Flexner Centenary: Commentary

Commentary: A Century of Progress in Medical Education: What About the Next 10 Years?

Skochelak, Susan E. MD, MPH

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doi: 10.1097/ACM.0b013e3181c8f277
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Abstract

Change was already in the air for academic medicine at the time Abraham Flexner published his report Medical Education in the United States and Canada in 1910. At the centennial of this seminal report, I examine the progress already under way at the time it was published, make the case for 21st-century changes in medical education, and underscore the importance of the next 10 years for the future of U.S. medical education.

A Climate of Change

The American Medical Association (AMA) had formed a Committee on Medical Education (CME) as one of its first actions at the organizing meeting in Philadelphia in 1847. For the next 60 years the AMA, along with sister organizations such as the Association of American Medical Colleges (AAMC) and the American Academy of Medicine, had worked to establish standards for physician education. The quality of the physician graduates of the 155 U.S. medical colleges included in the Flexner Report varied greatly at this time. Leaders in medicine advocated for medical education standards that more closely reproduced the rigor of the study of medicine at the major European universities. By the turn of the century those standards established in the United States typically included entry criteria of a high school diploma followed by training at a medical college that lasted for four years and included a minimum of six months of structured study in addition to apprentice experiences.1

Coincident with a significant organizational restructuring, the AMA formed the CME in 1904. Dr. Arthur Dean Bevan, Professor of Surgery at Rush Medical College, was appointed as CME chairman, and Dr. Nathan Colwell became the first CME secretary in 1905. One of the CME's first tasks was to rate medical schools according to the performance of their graduates on state licensure examinations and to publish these results in the Journal of the American Medical Association.1 In 1906, the CME conducted a survey of 160 medical schools operating in the United States at that time and categorized schools as “acceptable,” “doubtful,” or “non acceptable” based on a rating of 10 defined qualifications. Only 82 schools, barely half, received a rating of acceptable by the CME. These results were presented to the 1907 AMA congress by the chairman of the CME, and each school received notification of the school's rating based on the 10 criteria.1,2

In 1905, the AMA CME recommended new standards for medical education in the United States. Prospective applicants to medical colleges needed to meet admissions criteria that included acceptance into a qualified university for preliminary studies, including a minimum of one year of study in the disciplines of physics, chemistry, and biology and one year's study of a modern language. Medical colleges should follow a four-year curriculum that included two years of laboratory sciences in anatomy, physiology, pathology, and pharmacology and two years of clinical experiences with patients in both dispensary and hospital.2 The CME also advocated that future physicians spend an additional year training as an intern in the hospital. Today, over 100 years later, the requirements for physician training are strikingly similar. Along with the recent addition of passing the United States Medical Licensing Examination, completion of the same curricular requirements at an accredited U.S. medical school and one year of graduate medical education are sufficient to obtain a medical license in most states.

Changes in medical education occurred rapidly in the 10-year window that succeeded the work of the AMA CME and Flexner. Between 1905 and 1915, 65 medical schools closed, decreasing in number from 160 to 95. In fact, 30 schools—almost half of the first 65—closed before the publication of the Flexner Report in 1910.1 Fifteen more schools closed in the next decade, and the number of medical schools (80) remained constant into the 1960s. Over time, many medical schools became housed within or affiliated with universities, better enabling them to provide the rigorous scientific studies that became the standard for physician education.

Flexner's Contribution

So, given the already changing climate of medical education at the turn of the 20th century, what did Flexner do? Some say he said publicly what the AMA didn't want to say first.3,4 Drs. Bevan and Colwell were closely involved with Abraham Flexner and his work for the Carnegie Foundation, although this relationship was kept quiet at the time. Correspondence and meeting records indicate that weaker medical colleges were not happy with the publication of the CME ratings of medical schools.3 The CME sought the imprimatur of the Carnegie Foundation for the Advancement of Teaching as an independent entity that could call for the reforms advocated by the AMA. It is reported that Dr. Colwell attended every medical school visit with Flexner.1 Some have questioned whether Flexner actually visited every medical college or rather relied to some degree on the work of Nathan Colwell, who had begun inspecting medical colleges for the CME in 1906.5

Flexner made a very important contribution to medical education by highlighting the challenges of funding medical colleges, indicating that the cost of medical education could not be supported by student tuition alone. He joined Dr. Bevans and the AMA2 in their call for new methods to fund U.S. medical education, including government resources or endowment support. In the decades following the publication of the Carnegie report, Flexner became a procurer of extramural funding for medical education. Through his position on the General Education Board of the Rockefeller Foundation he helped to bestow millions of dollars in endowment money to medical schools. He remained active in working to improve medical education for generations beyond.

As a result of the work of Flexner and the AMA CME, the standards for medical education advocated by the CME were largely adopted by all medical colleges by 1915.4 Most authors have applauded the standardization that resulted from Flexner's work.6 At the same time, others have characterized the Flexnerian movement as one motivated, in part, by entrenching professional protectionism.5,7 The improved standards for American medical education, although markedly beneficial to patients and the public, also resulted in a number of unintended consequences. Because of these standards, training opportunities for women and minority physicians were narrowed,8 emphasis on public health and social sciences in medical education were decreased,7 and a shortage of physicians in rural areas of critical concern had developed by the 1920s.7 Soon after the Flexner Report was published, five of the seven medical colleges established to educate black physicians closed, leaving only Howard University School of Medicine and Meharry Medical College to carry on this important educational function.9

100 Years Later: Still Pursuing Change

Just as the arrival of the 20th century spurred a decade of intense change in the education of physicians, national medical organizations have called for medical education innovation with the arrival of the 21st century. The AAMC Council of Deans, the Institute of Medicine, the Macy Foundation, the Carnegie Foundation, and the AMA, among others, have all recently produced reports with recommendations for changing medical education. In 2005, the AMA CME began a five-year project, The Initiative to Transform Medical Education, bringing a diverse group of leaders in medical and health professions education together to promote excellence in patient care by implementing reform in the medical education and training systems through the implementation of 10 major recommendations.10

Unfortunately, reports alone, even the most prescient, will not result in significant change. Who will do the work, have the courage, and provide the resources to support fundamental change in the way our future physicians are educated? It is worth noting that the majority of the structural changes in American undergraduate medical education implemented at the turn of the last century occurred within a 10-year time span. In the subsequent decades a whole new system developed in support of graduate medical education and specialized training. Yet the same structural format outlined by the CME 100 years ago (college-level education with foundations in science required for entry, followed by two years of basic science education and two years of clinical education, culminating with postgraduate education in teaching hospitals) remains the dominant pedagogic and structural design used by American medical schools today. Whereas some experiments in content and format have occurred, most of the evolutionary development of new curricula and assessment methods in medical schools has taken place within a system that is basically rearranging the deck chairs on a soon-to-be-sinking ship.

Flexner's model of medical education financing—to supplement tuition with government support and foundation funding—is no longer viable. The central challenge of funding medical education is as critical today as it was a century ago, but new solutions are needed. Many strategies for addressing the rising cost of medical education have been proposed, from finding new sources of funding to shortening training time. Yet significant barriers still limit major structural change in medical education.

As more and more medical students continue to accumulate an average debt of more than $200,000 during their training, medical education is in danger of becoming too expensive for all but the most affluent. The span between the highest and lowest physician incomes has grown, mirroring the country's increased gap between salaries of highly compensated CEOs and the average U.S. worker. Data from recent years have reversed the commonly held opinion that medical students don't select specialty choices on the basis of future income,11 perhaps not surprising given pressures to pay back student loans.

Graduate medical education, as currently financed with caps on the numbers of training positions, will reach its limit for capacity to train graduates of U.S. medical schools in less than 10 years—likely sooner with the rapid expansion of allopathic and osteopathic medical schools. Accreditation, certification, and licensing requirements for U.S. undergraduate, graduate, and continuing physician education are all monitored by separate entities, placing boundaries around the ability to promote holistic change in the structure for physician education. Perhaps even more challenging is the disparate funding for undergraduate and graduate education, funding that is received from and administered by completely separate entities.

Linking clinical education with university teaching hospitals, as Flexner and others recommended, is now limiting the practical education of future physicians. As medical practice has moved to provide the majority of patient care outside the teaching hospital setting during the past 30 years, the opportunities for trainees to experience the full spectrum of disease, prevention, and wellness has been significantly limited by curricular and training program requirements still tied largely to teaching hospitals. The movement of medical care delivery to the outpatient setting, in addition to increased supervision of patient care and duty hours limits for trainees, have led some to question the readiness of recently trained physicians to enter independent practice in a location not supported by an academic health center environment.

Finally, a significant gap in information management skills and use of technology in support of patient care and teaching exists between currently available technologic resources and the skills of most medical school faculty, challenging the ability to take full advantage of the age of the electronic health record. Many faculty also have limited experience with effectively implementing the current best practices supporting the highest-quality patient-care outcomes.

The Next 10 Years

Now is the time for a new “Flexnerian” revolution in medical education. As most post-Flexner changes occurred in the 10 years preceding and immediately following the publication of his report, we must focus on our own immediate future. New partnerships must be developed before 2020, echoing the forceful impetus to change that resulted from the partnerships between Abraham Flexner, the AMA, and others who held a new vision for medical education in the 20th century.

New partnerships are needed to develop medical education systems and standards that incorporate the best evidence and new modalities in support of lifelong adult professional education. These partnerships must include experts from the education academy, experienced in the knowledge and skills needed to develop asynchronous educational formats supported by education technology resources.

Meaningful educational partnerships with nursing, pharmacy, public health, and others have yet to be formed across the academy of health professions education. Our students (and their future employers) have been asking for integrated curricula and team training, but health professions educators have been slow to respond, largely because of financial and structural constraints. Yet, at most academic health centers, one can encounter medical, nursing, and pharmacy students assigned to learn from patients in the same location of the hospital, supervised by their respective professional teachers. Bringing these teams of students together in the clinical setting for meaningful interdisciplinary learning would cost comparatively little, but it requires a mutual commitment by multidisciplinary faculty for implementation.

Innovative partnerships between the accrediting, certifying, licensing, and regulatory organizations in medicine must occur to allow self-paced, competency-measured education models that could shorten the medical education timeline. Students have questioned the necessity of some curricular requirements, such as basic biochemistry and genetics, when they have already mastered these subjects in undergraduate or graduate programs. Individually tailored pathways in medical education have the ability to reduce costs to students and trainees while simultaneously reinforcing lifelong learning skills in support of the highest quality of patient care.

Funding for medical education remains one of the greatest challenges in implementing change. In addition to the obvious aberration of U.S. graduate medical education funding, medical school finances are inextricably linked across the missions of education, research, and patient care. In most cases, funding is also tied to the bottom line of parent universities and teaching hospitals. As a first step to halt the inexorable climb of medical student debt, a freeze on medical student tuition costs and fees could be negotiated at each institution.

Holding the line on medical school tuition, although important to current and future medical students, will not contribute to new strategies for medical education funding. Leadership at academic health centers must continue to work toward transparency in financing. Funding allocations for the medical school missions can be identified and redirected, as needed, to better align school resources with their intended uses.12 Cross-subsidization—from clinical income, tuition, endowment, extramural funding, and government sources—will likely still be a necessity to meet all of the missions of today's academic health center. However, no new medical education funding strategies will occur without transparent and understandable financial data, including data that can be compared across institutions.

Strategies listed above—efficient use of faculty, technology, and training time—can help the financial viability of the education mission of academic health centers. However, it is imperative to note the number of new clinical partnerships being developed to accommodate increasing numbers of medical school graduates as a result of the expansion in number of medical schools and increased class sizes. Alternate financing strategies are needed to support training in outpatient and nonteaching hospital locations to ensure our students and residents are learning in the environments where health care is currently provided occurring for more than 95% of our patients.

As in 1910, medical education funding is the major issue that must be addressed to provide the best possible education for future physicians and members of the health care team. If the medical profession and medical educators don't take action in the next 10 years to develop alternatives to today's increasingly unsustainable model for training future physicians, others will find ways to fill the gaps needed to provide patient care in our 21st century. In comparison with the Flexnerian benchmark, we're already a decade behind. Do we have the wisdom and courage to support the innovations that are needed in the next 10 years?

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

Disclaimer: This commentary represents the personal views of the author and does not reflect the official position of the American Medical Association.

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