Reforming Medical Education in Ethics and Humanities by Finding Common Ground With Abraham Flexner

Abstract

Abraham Flexner was commissioned by the Carnegie Foundation for the Advancement of Teaching to conduct the 1910 survey of all U.S. and Canadian medical schools because medical education was perceived to lack rigor and strong learning environments. Existing proprietary schools were shown to have inadequate student scholarship and substandard faculty and teaching venues. Flexner's efforts and those of the American Medical Association resulted in scores of inadequate medical schools being closed and the curricula of the survivors being radically changed.

Flexner presumed that medical students would already be schooled in the humanities in college. He viewed the humanities as essential to physician development but did not explicitly incorporate this position into his 1910 report, although he emphasized this point in later writings. Medical ethics and humanities education since 1970 has sought integration with the sciences in medical school. Most programs, however, are not well integrated with the scientific/clinical curriculum, comprehensive across four years of training, or cohesive with nationally formulated goals and objectives.

The authors propose a reformation of medical humanities teaching in medical schools inspired by Flexner's writings on premedical education in the context of contemporary educational requirements. College and university education in the humanities is committed to a broad education, consistent with long-standing tenets of liberal arts education. As a consequence, premedical students do not study clinically oriented science or humanities. The medical school curriculum already provides teaching of clinically relevant sciences. The proposed four-year curriculum should likewise provide clinically relevant humanities teaching to train medical students and residents comprehensively in humane, professional patient care.

The 1910 Flexner Report¹ (also known as Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, and Bulletin Number 4) proposed raising standards for the scientific basis of teaching in medical schools and systematically reviewed all schools in the United States and Canada in the early 20th century. This report guided the scientific method of teaching for all U.S. and Canadian medical students for years to come.

A committed educator, Flexner identified serious deficiencies in the physical plants, capabilities of the schools' faculty members, the scientific underpinnings of education, and the financial viability of medical schools in the United States and Canada. These deficiencies predominated in proprietary medical schools, which admitted students who were recognizably deficient in their preparatory scientific education.² Flexner's response was to establish standards for what a medical school ought to be, how it should be run, and how many U.S. and Canadian medical schools should exist.

The Flexner Report's emphasis on improving the quality of scientific medical education makes little note of humanistic training in the development of physicians.³ We wrote this article to better understand medical ethics and humanities education in the context of the Flexner Report and Flexner's later writings on educational reform and to propose a reform of medical humanities education inspired by our interpretation of Flexner's original vision.

The Flexner Report

Abraham Flexner was commissioned to conduct a survey to assess medical schools in the United States and Canada because there was a perception in the medical education community that medical education lacked rigor, had inadequate admission criteria, and offered a woefully inadequate learning experience. Before 1910, there had been approximately 400 medical schools founded in the United States, many of which had never survived past their first year. By 1904, there were 166 U.S. medical schools.⁴ Between 1906 and 1910, 29 medical schools closed, in part because of the impact of the new Council on Medical Education of the American Medical Association, which implemented “grading” of medical school adequacy to encourage excellence.⁴ Flexner felt that there were still far too many medical schools and that they were disproportionately placed in major cities (sometimes with many schools in one city), creating an oversupply of physicians in urban areas.

The Flexner Report proposed a dramatic reduction of U.S. and Canadian medical schools to 37, based on geographic density and population need.¹ After the Council on Medical Education's efforts and the Flexner Report, scores of U.S. schools closed, with 66 remaining open in 1933. Flexner also warned that if there was not a substantial increase in the quality of education in medical schools by way of self-regulation, federal and state regulation of medical schools would be the likely next step.

The Flexner Report begins with an introduction by Henry Pritchett, who at that time led the Carnegie Foundation.¹ Pritchett emphasized that there must be a connection between premedical and medical education. The university has an obligation to train students to be prepared for entry with “common honesty... intellectual sincerity, and scientific accuracy.”¹ Flexner began by reflecting on the conditions that had produced medical education's lamentable state in 1910. Young, “rough” men, barely up to high school standards of education, were routinely admitted to medical schools. He insisted that medical schools should instead recruit students with training in “Latin, mathematics, natural and experimental philosophy, and [that they should] serve a sufficient apprenticeship to some reputable practitioner.”¹ College education in both science and humanities would serve as the foundation for the “secondary stage” of medical training¹ (we discuss Flexner's concept of humanities in the following section). Flexner expounded a comprehensive view of medical education, building on and integrating all of one's studies prior to medical school.

The preceptorial system (also called the apprentice system), based on studying by the coattails of a physician to learn the profession of medicine, passed by the wayside in the 1800s.³ Flexner reflected favorably on the (by then) abandoned preceptorial system by quoting William Welch: “Our teachers were men of fine character, devoted to the duties of their chairs; they inspired us with enthusiasm, interest in our studies and hard work, and they imparted to us sound traditions of our profession.”¹ Flexner approved of the apprenticeship system within its historical context. Its strength had been based on the physician's close observation of his student, watching his intellectual and emotional maturation. Flexner emphasized the individual tailoring of the experience that was possible: “The preceptor could wait upon [the student's] development, initiating him in simple matters as they arose, postponing more difficult ones to a more propitious season.”¹ The great flaw was that 19th-century physicians, while good observers, were not disciplined as scientists, and as a consequence, the student mirrored knowledge, attitudes, and behavior that had little scientific basis.

In Flexner's view, medical schools once served as places where didactic lectures provided medical knowledge that supported and enhanced the preceptor system. However, the latter didactic function came to overwhelm the former: “The school was no longer a supplement (to apprenticeship); it was everything.”¹ Worse, didactic medical school teaching made rote memorization the standard in education: “The student's part was, parrot-like, to absorb.”¹ Physicians need more than just rote memorization but also “insight and sympathy on a varied and enlarging cultural experience... for scientific progress has greatly modified his ethical responsibility.”¹

Flexner conceded that gradual improvement of admission criteria to medical school had occurred by 1910. However, many of the young men were still being admitted with less than a high school diploma, while some had two years or, rarer still, four years, of college education.¹ Flexner advocated a paradigm shift to that of the physician as a scientist.¹ Physicians would be trained in bench sciences and clinical sciences and apply these to patient care, thereby transcending earlier versions of medical knowledge and education.¹ The focus was aimed at the scientific method, in which the physician is “concerned chiefly with his acquisition of the proper knowledge, attitude, and technique.”¹

Flexner asserted that the student must master inductive reasoning, courtesy, and comity.¹ Flexner also underscored that the physician serves society as an instrument of social good and that medical schools themselves are to be viewed as corporations united for the public good. “The medical profession is supported for a benign, not a selfish, for a protective, not exploiting, purpose”¹—a theme mirroring Thomas Percival's concept of the medical profession as a public trust.^1,5 Flexner's view of the physician has humanism inform the scientist: “One must rely for the requisite insight and sympathy [to complement the sciences] on a varied and enlarging cultural experience.”¹ Flexner's view of the clinically competent physician is a broad vision of the physician as a scientist, who is “culturally experienced”¹ (which means that the physician has humanistic skills). Hence, “[the] physician should understand the conditions in which diseases arise, and this required liberal educational experiences,” requiring “ethical valuation in the social context” with a “broader more liberal arts education” as its basis.⁶ In the report, only one university (Western Reserve in Cleveland, Ohio) was noted to have one hour devoted to “medical ethics, economics, and Roentgenology.”¹ The teaching of ethics and humanities was almost completely absent, but one must recall that medical ethics and humanities education were not integrated into medical education until the 1970s. As Zelenka⁶ observes, Flexner's concept of the professional physician required “an educated man, treating not just the illness, but caring for the whole human being.... The value of a humanistic liberal education is implicit in Flexner's recommendations for medical education.” The physician must be trained as a scientist who also masters humanistic skills essential to being a professional physician.

In the wake of Bulletin Number 4, dramatic changes occurred in the scientific training of physicians, especially the realignment of the curriculum emphasizing laboratory-based education in the first two years and hospital-based education in the last two years. Admission criteria were strengthened, scores of medical schools closed, and ultimately a four-year premedical college requirement was established. Yet, 15 years after Bulletin Number 4, Flexner, in a letter to his brother Simon Flexner (the eminent pathologist), bemoaned that the efforts toward medical school reform had concentrated only on science while entirely leaving out the humanities.^7,8 That same year, Flexner lamented in his 1925 book Medical Education,⁹“Medicine... is today sadly deficient in cultural and philosophic background” (italics ours). What did Flexner mean by this?

Flexner's View of Premedical Education and Humanities

In considering Flexner's 1925 statement quoted above, we take as our point of departure Flexner's insufficiently appreciated understanding that the humanities are essential to physician education and are therefore pivotal components in the training of medical students for them to become professional physicians. Flexner began his educational career in Louisville, Kentucky as an educator in a private high school that he established, and he became nationally prominent for his efforts. Before and after Bulletin Number 4, Flexner wrote multiple articles and books on education in primary schools, secondary schools, and colleges.^10–15 He was greatly distressed about the quality of American education, especially when compared with European education.

Although his vision of reform can be interpreted as dynamic over his lifetime, Flexner was consistently devoted to humanities education, particularly in the years following the Flexner Report.⁶ College education at that time did not take seriously the future professional considerations of the student.¹¹ In his article “Purpose in the American college,” Flexner¹⁰ described a thematic continuity of education for both high school and liberal arts collegiate education in America leading to “intellectual purpose.” Aesthetics was highlighted, as college students “should enjoy music, art, poetry.”¹⁰ Flexner also noted the necessity of students developing a sense of “character, strength of intellect, and breadth of culture” through their experiences in collegiate life.¹⁰ The relationship of science to the humanities was essential in the American university, since “philosophers... gain in importance as science makes life more complex: more rational in some ways, more irrational in others. But there are other senses in which modern universities must promote humanism. For humanism is not merely a thing of values—it has, like science, consequences.”¹⁵ In preprofessional training, Flexner noted that in preparatory school, mental discipline and the faculties of “observation and concrete reasoning” would be honed while learning topics in “science, literature, history, modern languages, and industrial processes.”¹⁴

Flexner envisioned college education that would bring specific skills to the premedical student's development. Flexner clearly valued the humanities and how humanism is applied to clinical care.⁶ Flexner's educational vision in Bulletin Number 4 was based on his assumption of an integrative science and humanities liberal arts collegiate curriculum that would serve as the basis for the scientific medical education that followed. Flexner's educational vision, read in the context of his other works that discuss higher education, thus presumes that liberal arts education would provide the humanities-based education of all future physicians. This is one of the reasons he pilloried medical schools that allowed high school student dropouts and graduates to enter medical school directly.

Flexner detailed how education at all levels could be reformed, enhanced, and integrated, to allow students to have an appreciation of how humanities inform the medical sciences, and to think critically.¹³ Flexner expected students to come to medical school having already mastered critical thinking in the full range of subject matters with knowledge in aesthetics, civics, and cross-disciplinary studies, based on curiosity and experience.¹³ One may infer that the deficiency of a “cultural and philosophic background” (italics ours) that Flexner refers to is a reference to humanities education that should have been imparted during a medical student's undergraduate education.

Although Flexner did not explicitly detail what was needed before medical school, he revealed an evident intellectual premise concerning professional education: College education should focus on both science and humanities, integrating and amplifying skills necessary to become a physician.⁶ As noted by Zelenka,⁶ “[the] value of humanistic liberal education is apparent in Flexner's recommendations for medical education.” Flexner's educational goal of the humane scientist was grounded in the humanities-based preparation of the medical student accomplished at the college level.¹¹ When Flexner later writes on medical education, he argues for both “humanity and empiricism” and that being “humane” is “equally important” with employing “the severest intellectual effort.”⁹ Turning to Flexner's medical education writings after Bulletin Number 4 sheds more light on this relationship.

Flexner's Writings on Humanities Education After Bulletin Number 4

After 1910, Flexner evaluated medical schools in Europe, where he noted that “the [educational] center of gravity must lie within the one or the other—humanities or science; it cannot lie in both.”¹⁶ Flexner viewed medicalschool as a means to inculcate the skills and knowledge of the physician as scientist. Yet medical education also is to be influenced by those aspects of humanities that promote sound patient care. Flexner's efforts to promote humanities for medical and premedical education during this phase of his life were noted to be tireless.^6,8 Possible evidence of his influence on institutions are noted in articles by other contemporary educators regarding courses incorporating illustrative art and the history of medicine in the Bulletin of Johns Hopkins Hospital (Johns Hopkins was Flexner's beloved alma mater) and Flexner's own encouragement in creating an endowed chair in medical history there.^8,17,18 Flexner “suggested that until the problem was addressed by future medical education studies and development, the colleges need to set” premedical requirements for “sound liberal humanistic education”—a mandate for change first by colleges, then by the medical schools themselves.⁶

His seminal 1925 book, Medical Education: A Comparative Study,⁹ looked back at the strengths and weaknesses of medical education in the United States, Canada, the United Kingdom, Germany, and France. Flexner made pointed references to those topics that Bulletin Number 4 did not include. He noted that engagement in empirical, scientific method could be perceived as a lack of humanity, but he cautioned that there is no contradiction between the two: “In the long run, precisely the opposite is the case!... The art of noble behavior is thus not inconsistent with the practice of scientific method.”⁹ The physician–scientist was also to be skilled in those humanistic qualities that promote patient care. Flexner opined that premedical education was “inadequate and based on false assumptions with regards to scope and quality.”⁶ Indeed, Flexner considered physicians ill prepared in “liberal education,” thereby leading to inferior training for the resulting physician.⁶ Flexner argues also for scientific thinking, stressing that the physician must learn to observe and reflect on what he or she sees, analyze its importance, and use these observations to enhance future reasoning and abstraction.⁹

Flexner compared education in Europe and the United States, finding the United States lacking in both philosophy and culture.⁹ Flexner applauded how Europeans teach the history of medicine, thereby cultivating “philosophical points of view,” and teach legal medicine, which at that time was “practically ignored in the United States.”⁹ Flexner pointed out that Europe's secondary education was superior in selecting and training students for a pathway to medicine. The United States, unfortunately, was much less rigorous in this task, such that “American high schools and colleges are nonselective and too often postpone severe training until the student reaches the professional school itself.”⁹ He noted with great concern the deficiencies of both high school education and the end points of education from the American college, such that those entering U.S. medical schools were markedly behind their peers in Europe.⁹

A Proposal to Enhance Medical Ethics and Humanities Education

Although U.S. medical education has come a long way in the last century by improving the teaching of basic and clinical sciences, the U.S. premedical educational system never required the humanities in the way Flexner envisioned, despite his long-standing attempts to bolster humanities education.⁶ College graduates currently do not uniformly bring to medical school the same strong foundation in the humanities that they do in the sciences. This is because humanities courses for premedical students are shaped by, and oriented to, the liberal arts goal of a broad education rather than the goal of preparing for the professions. In the case of the profession of medicine, the latter goal is understood to be the responsibility of medical faculties, not undergraduate humanities faculties. To preserve and enhance Flexner's understanding of the physician–scientist with a humanities liberal arts background, we medical educators can either alter whom we accept into medical school or alter how we train medical students. We emphasize the latter, as we will explain.

Medical schools could require all premedical students to take courses that are designed and documented to teach critical thinking in the sciences, humanities, arts, and social sciences. This would entail a radical shift in admission prerequisites because, regrettably, many premedical students have historically taken only prerequisites in basic sciences and mathematics. Because most medical schools currently cling to the science and math prerequisites, a mandated premedical requirement of humanities would most likely be needed to change what undergraduate courses students take.

Indeed, this traditional preadmission focus on basic science courses has been countered with a recommendation by the Liaison Committee for Medical Education (LCME): “Students preparing to study medicine should acquire a broad education, including the humanities and social sciences.”¹⁹ This recommendation encourages, but does not require, those humanities courses that could help premedical students become professional physicians. Such recommendations are helpful, but they do nothing to ensure premedical students' mastery of critical reading and thinking skills or the effective expression in written and oral forms that undergraduates acquire in upper-level humanities courses.

Additionally, implementing a mandated premedical humanities curriculum for America's thousands of undergraduate institutions would be a daunting challenge, taking many years to implement effectively. But there is a more important reason why relying solely on premedical humanities is likely insufficient—College-level humanities teaching does not have a clinical orientation, any more than the science teaching does. Even if humanities requirements for premedical students were expanded, it would not change the lack of clinical experience of the humanities in the premedical venue for the future physician. Humanities faculty in undergraduate colleges typically lack clinical experience as well as resources, and they are therefore unable to provide this relevant education. This lack of a clinical focus is entirely appropriate in the context of the college liberal arts curriculum, which aims for a broad education in sciences and the humanities, one that necessarily must be supplemented in medical schools. Students continue their studies of the sciences once they enter medical school, but with a clinical focus and relevance that college and university science teaching usually cannot provide. Medical humanities should be taught in the same way: with a clinical focus.

We maintain that the clinical relevance and applicability of humanities education to the medical student's education as a professional clinician and scientist means that such education should become an essential component of the medical school curriculum because it would equip medical students with the conceptual and clinical tools of professionalism and humane care. Reformed humanities curricula in medical schools would thus cohere and contribute directly to the development of the competencies-based curriculum now mandated by the LCME and the Accreditation Council for Graduate Medical Education (ACGME), because the student's (and resident's) education in matters of clinical relevance can best be understood in the care and context of patients, which humanities training would enhance.^19,20 We next make a specific proposal for how humanities teaching could be given a greater focus in medical schools.

Reforming medical ethics and medical humanities education should build on foundations put in place during the last four decades. Medical educators now appreciate that human values must complement science in education. Medical ethics, humanities, humanistic skills, and professional behavior in medical education have been progressively emphasized and added since 1970. The changes occurred in two time-periods—the 1970–1980 (civil rights and post-Tuskegee) period for medical schools, and the 1999–present period for both medical schools and residencies.^2,5 Our current period, influenced in large part by the requirements and recommendations of the ACGME and the LCME, focuses on competencies (i.e., outcomes) of education, in which ethics and humanism play a central role.^21–25

The teaching of medical ethics is now a common element of the U.S. medical school curriculum and, indeed, is an LCME-required preclinical educational element.²⁴ The LCME requires training in not only medical ethics but also in skills in medical humanism and professionalism that will allow for developing young doctors to be prepared to achieve the general competencies expected in their residency education. These general competencies are an essential part of the ACGME pedagogic requirements that follow.²⁴

But medical ethics teaching today is often consigned to “bull sessions”—discussion groups on topical issues, with a general sprinkling during the four-year curriculum.^25,26 Such pedagogy is not uniformly integrated into the rest of the curriculum (or across medical schools), which can make its relevance questionable to students and professors. This method of ethics teaching is not comprehensive to the educational experience, mainly attends to anecdotes rather than the underlying principles and reasoning that should guide humanistic clinical care, and enjoys no sustained monitoring by individual faculty.

We propose the development of a standardized curriculum integrating scientific reasoning with humanities-based reasoning called the Art and Culture of Medicine. The curriculum's goal should be to build on one's cultural and philosophic background to inform one's role as a physician–scientist. The emerging physician–scientist could thereby acknowledge and use humanities-based reasoning in the humane care of his or her patients. This curriculum should be distinct from any college experience of didactics that are detached from clinical relevance. Instead, this curriculum would emphasize clinical humanities linked to patient care and the professional formation of medical students, so that the student's reasoning and manner would be broadened. As stated by the LCME and the ACGME, the humane care of the patient is the ultimate mandated goal. The proposed curriculum should have four components: argument-based reasoning in medical ethics, narrative-based reasoning in literature, creative reasoning in the fine arts, and historical reasoning in learning from the past to uncover hidden assumptions and biases^23,27,28,29 (see List 1).

Table: List 1 The Art and Culture of Medicine: Examples of Medical Humanities Elements

This longitudinal curriculum would include both the preclinical and clinical years of the student's scientific development. Students would be presented with an ascending level of complexity with each year. Preclinical efforts would incorporate didactics, seminars, and case discussions to prepare the student for the clinical activities ahead. Students would first be introduced to fundamental concepts of ethical argument and analysis, reflective narrative, fundamentals of observational skills in the fine arts, and the basis of history regarding the art of medicine.

Correlative mentored interactions with patients would commence early in the first year with observation and with integration into patient care.^23,30 The notion of this apprenticeship would allow students to learn not only fundamentals of knowledge and clinical care but also the art of medicine: humanistic attitudes, behaviors, and interpersonal skills. In the preclinical years, such observational activities could whet the appetites of students while also preparing them for the assumption of the responsibilities of the clinical clerkship.

As students progress further in their clinical activities, integration of these humanities-based skills would continue. Clinical education exposures would reinforce activities in ethics, narrative, fine arts, and medical history relevant to the various phases of outpatient medicine, inpatient clinical medicine, surgery, obstetrics–gynecology, and other venues of care. Clinical education would include rounding with educators grounded in clinical ethics and medical humanities as well as in case-based discussions, with integration and reinforcement of concepts of argument, reflection, observation, and reevaluation of medical history. In the clerkships, an apprenticeship experience would reinforce key concepts of ethics and professionalism as the student was observed in his or her clinical interactions with patients by a preceptor.

Thinking like a professional physician would need to be constantly reinforced. Therefore, the curriculum should fortify fundamental concepts with interactive experiences during the student's clinical experiences. The LCME observes that in medical pedagogy, “general education that includes the social sciences, history, arts, and languages is increasingly important for the development of physician competencies outside of the scientific knowledge domain.”²⁵ Teaching humanities-based reasoning would be offered as an essential component of the drive to create a comprehensive medical curriculum that teaches medical learners how to integrate their role of scientist with the application of medical ethics and humanities to better promote the patient's welfare.

Next Steps in Achieving a Balance

The first step toward creating this curriculum is to call on leading medical humanities and ethics scholars and educators to develop systematically the specifics of this program for proposed use by U.S. medical schools. The goal of this effort is to create an innovative, comprehensive curriculum that balances the needs and rigors of becoming a physician-scientist with the humanistic skills to better care for one's patients. Once done, much work and care will need to be taken in planning and integrating the various elements of this pervasive curriculum into the existing courses. But the results will more than repay the effort required, because the new curriculum will better prepare professional physicians for their work in this challenging century by emphasizing both the science and art of medicine, thereby fulfilling a vision of medical education first articulated by Abraham Flexner.

Acknowledgments:

The authors thank Edward C. Halperin, dean and Ford Foundation Endowed Chair of Medical Education of the University of Louisville, for his insightful comments at the Academic Medicine Flexner Colloquium on an earlier draft of this manuscript, and thank the anonymous reviewer for his or her extremely helpful and constructive comments.

Funding/Support: None.

Other disclosures: The authors serve as the investigators of a nationwide project, funded by the Patrick and Edna Romanell Fund for Bioethics, entitled PRIME, The Project to Rebalance and Integrate Medical Education, commencing in 2010 (the Flexner Centenary), which will initiate a nationwide effort toward building a comprehensive curriculum that will balance the needs and rigors of becoming a physician–scientist with the humanistic skills to better care for one's patients.

Ethical approval: Not applicable.

Previous presentations: An earlier version of this article was presented as a talk at the Annual Meeting of the American Society of Bioethics and Humanities on October 15, 2009.