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Relevance of the Flexner Report to Contemporary Medical Education in South Asia

Amin, Zubair MD, MHPE; Burdick, William P. MD, MSEd; Supe, Avinash MS, PGDME; Singh, Tejinder MD, MHPE

doi: 10.1097/ACM.0b013e3181c874cb
Flexner Centenary: Article

A century after the publication of Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (the Flexner Report), the quality of medical education in much of Asia is threatened by weak regulation, inadequate public funding, and explosive growth of private medical schools. Competition for students' fees and an ineffectual accreditation process have resulted in questionable admission practices, stagnant curricula, antiquated learning methods, and dubious assessment practices. The authors' purpose is to explore the relevance of Flexner's observations, as detailed in his report, to contemporary medical education in South Asia, to analyze the consequences of growth, and to recommend pragmatic changes. Major drivers for growth are the supply–demand mismatch for medical school positions, weak governmental regulation, private sector participation, and corruption. The consequences are urban-centric growth, shortage of qualified faculty, commercialization of postgraduate education, untenable assessment practices, emphasis on rote learning, and inadequate clinical exposure. Recommendations include strengthening accreditation standards and processes possibly by introducing regional or national student assessment, developing defensible student assessment systems, recognizing health profession education as a field of scholarship, and creating a tiered approach to faculty development in education. The relevance of Flexner's recommendations to the current status of medical education in South Asia is striking, in terms of both the progressive nature of his thinking in 1910 and the need to improve medical education in Asia today. In a highly connected world, the improvement of Asian medical education will have a global impact.

Dr. Amin is assistant professor, Department of Pediatrics, and assistant dean, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.

Dr. Burdick is associate vice president for education, Foundation for Advancement of International Medical Education and Research (FAIMER), and clinical professor, Department of Emergency Medicine, Drexel University College of Medicine, Philadelphia, Pennsylvania.

Dr. Supe is professor and head, Department of Surgical Gastroenterology, Seth Gordhandas Dunderdas Medical College (GSMC) and King Edward Memorial Hospital, Mumbai, India, and director, GSMC-FAIMER Regional Institute, Mumbai, India.

Dr. Singh is professor, Department of Pediatrics, and vice principal, Christian Medical College Ludhiana (CMCL), Ludhiana, India, and program director, CMCL-FAIMER Regional Institute, Ludhiana, India.

Correspondence should be addressed to Dr. Amin, Yong Loo Lin School of Medicine, 10 Medical Drive, #01-08, Singapore 117597; telephone: (65) 6872-1049; fax: (65) 6872-1454; e-mail:

One hundred years after the Flexner Report1 described the condition of medical education in the United States, medical education in a large part of Asia is in a similar predicament, with an explosion of private medical schools and questions about the quality of education. Weakly regulated growth of medical schools now threatens the quality and standards of South Asian medical education. As in Flexner's United States, competition in South Asia for students' fees and an ineffectual accreditation process have resulted in questionable admission practices,2 stagnant curricula,2,3 antiquated learning methods,2,3 and dubious assessment practices.2,4 Accreditation systems, which were weak in 19th-century America, are constrained in much of Asia by a combination of inadequate authority, insufficient resources, uneven enforcement, and occasional corruption.2,3,5,6 Dissatisfaction with the current accreditation system in India has led to a national commission's proposal for major reorganization of the Medical Council of India, the regulatory body for medical schools.7

The purpose of this article is to examine the relevance of Flexner's observations to contemporary medical education in South Asia. We review the contexts of Flexner Report, present the commonality of key factors in the recent and prolific growth of medical education across South Asia, and analyze the consequences of these factors. Our overarching aim is to bring the attention of the global audience to a developing issue that could potentially affect countries beyond the borders of South Asia.8,9

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Geographic Area and Clarification of Terminology

The primary focus of this article is South Asia, one of the five regions in Asia recognized by the United Nations. The countries in this region are India, Pakistan, Bangladesh, Sri Lanka, Nepal, the Maldives, and Bhutan. Together they are home to one-fifth of the world's population.10 The reasons for our deliberate choice are several. First, South Asian countries are more likely to be affected by problems resulting from rapid growth of private medical education than are more developed countries.11 Second, India and several other South Asian countries are the major suppliers of international physicians to the developed world.12,13 Third, these countries are transitional economies,11 and they face common challenges related to higher education.14,15

Although China is a major country in Asia, we excluded it from our analysis. We took this step because Chinese regulations prohibiting private, for-profit medical schools have kept China from experiencing the growth of private medical schools that has been seen elsewhere in Asia.16,17

Government-run, or public, medical schools are those that receive substantial funding from governmental sources, including state funds. Private medical schools are funded primarily from nongovernmental sources, including direct tuition, patient fees, alumni donations, and obligatory surcharges such as the development fund imposed on a school's students. Many private medical schools are profit-driven, but not all. Some are profit-neutral or not-for-profit, and a few others are mission-oriented. Medical schools established by charitable or nonprofit organizations prefer the term “nongovernmental,” rather than “private,” to emphasize their nonprofit nature. However, for the vast majority of private medical schools, profit is an explicit or implicit goal, and these schools are very similar to the “commercial” medical schools described by Flexner.11,18

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The Context for the Flexner Report

In 19th-century America, medical education was undergoing a transition from an apprenticeship model to a group-teaching model. Severe inadequacies in physician training and quality were exposed by Civil War medical practice, and, during that war, the military rejected one quarter of the physicians who applied to serve.19 U.S. physicians who were trained in the French observational system or the German experimental system were, on their return to the United States, disillusioned by the lack of systematic and scientific rigor in medical education.19,20 Most teachers were practitioners, and a small number of academic faculty members were concentrated at a few university-affiliated medical schools. Prolific growth of commercial medical schools, which usually were associated with universities in name only, overshadowed the few high-quality medical schools.1,19

Lax regulation, coupled with a growing market of prospective students who had the means to pay for an education and who were looking for a career opportunity, created the conditions for explosive growth of medical schools.1,19 State licensing boards existed, but, in general, they were weak and ineffective; in some cases, they were outright corrupt.20 Medical schools and doctors were largely concentrated in wealthier regions, drawn there by financial opportunity.1

In the pre-Flexner United States, there was no shortage of doctors; in fact, Flexner was more concerned about an oversupply. He reported a density of one doctor for every 568 people, which was significantly higher than the density in Europe at the time (about one doctor for every 2,000 people). His recommendation to close schools was consistent with his assertion that “the country needs fewer and better doctors.”1

At the end of the 19th century, enhanced communication was a catalyst for change. The world was becoming smaller in the 1880s, thanks to the introduction of the steam engine during the Industrial Revolution. Transatlantic transit time was reduced from five weeks in 1840 to 12 days in 1860 and then further shortened to 9 days by around 1910, as steamships replaced clipper ships. Ships also became much safer because of the shorter transit time and the use of metal hulls; passenger mortality declined by 90% little more than a decade after the introduction of faster steamships,21 which further facilitated the flow of ideas from Europe to America.

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Commonality in Diversity

Asia is an immensely diverse continent in terms of factors that affect the development of higher education, such as the sociopolitical structure of each country and its access to health care, economic advancement, and health and education needs.5,14,18 In addition, the development of medical education has been greatly influenced by each country's historical past, nation-building efforts, and current global trends.14,18 However, nearly all Asian countries face common challenges due to the rapid expansion of private education.5,14

Transitional economies, such as those found in South Asian countries, are characterized by an abrupt move from a centralized system of governance to a more liberal, market-driven system. In centralized systems, a high degree of control is maintained over various facets of education, such as admission criteria, faculty recruitment and retention, and curriculum structure.11 Although there is a public interest in maintaining equity between different geographic regions according to population density and income,11 as economies and regulation are liberalized in many transitional economies, “there is no talk about equality of opportunity; differentiation is not only admitted but encouraged.”22

Another common element has been a decrease in public spending on higher education. From 1985 to 1997, the era that heralds the most rapid growth of private medical schools, government spending on education as a percentage of gross domestic product (GDP) declined in many transitional Asian economies.11 For example, during this period, government spending as a proportion of GDP declined in China from 2.5% to 2.3%, and in South Asia it declined from 3.4% to 3.3%. By contrast, in high-resource economies, such as North America and Europe, the corresponding percentage in 1985 was almost twice as high as that in Asia, and it has actually increased since that time.11 Public funding for education diminished, despite the fact that most Asian countries have concurrently faced a serious shortage of physicians. For example, in China, Pakistan, India, Bangladesh, and Indonesia, there is, today, one doctor for every 943, 1,351, 1,667, 3,846, and 7,692 people, respectively,23 a density considerably lower than that in pre-Flexner America.

In an environment of weak regulation, increased demand, and diminishing central funding and control, corruption may be another common factor leading to inappropriate growth and poor quality.24 In its 2008 report on the Corruption Perception Index, Transparency International25 identified Bangladesh, India, Indonesia, Nepal, Pakistan, and the Philippines as having among the worst scores in the world. These countries also demonstrated the most prolific growth of private medical schools, which highlights the potential relationship between corruption, political influences, and commercialization of education.

Commonality of ideas and issues has also been accentuated by advances in communication. Internet access26 and mobile phone use27 have accelerated the diffusion of ideas within South Asia and between South Asia and the rest of the world. This effect is similar to that of faster transatlantic movement and other innovations that preceded the publication of the Flexner Report.

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Rapid Growth and Its Consequences

The prolific growth of private medical schools, driven by economic development,28 the expansion of the middle class,29 and the attractiveness of medicine as a career,2 mirrors that in the United States in the early 19th century, as highlighted eloquently by Flexner1: “Since that day medical colleges have multiplied without restraint, now by fission, now by sheer spontaneous generation.”

Private medical education is burgeoning throughout South Asia. India, whose private medical education system is one of the most rapidly expanding such systems in the world, is a prototypical example of market-driven growth. Between 1970 and 2005, the number of private schools multiplied by a staggering 1,120%. Private medical schools now account for half of all available admission seats30; in 1970, they accounted for only 11%. India has 289 medical schools with 31,698 seats; 205 of these 289 schools were fully recognized by May 2009.31 Similar trends have emerged in other countries. In Bangladesh, 32 new private medical schools have been established in the past 10 years, and the combined student enrollment in private medical schools now exceeds that in governmental medical schools.32 In 1981 in Pakistan, there were 16 medical schools, all of which were public. The first private medical school in Pakistan opened in 1983. Between 1997 and 2005, the total number of medical schools in that country doubled—there are currently 57 approved medical schools, 32 of which are private.33,34

However, the growth has been lopsided. Most private medical schools are concentrated in the urban areas of wealthier states in India, where there is a better market for costly private education.2,30 In Bihar, one of the poorest states in India, the six medical schools in existence in 1990 increased to eight schools by 2006, with the addition of two private schools. By comparison, the state of Maharastra, with about the same population as Bihar, had 12 medical schools in 1990 and 39 in 2006, 20 of which were private.35 Eighty-eight of the 100 private medical schools in India are located in states whose average per capita income is above the median for India; 60% of the public schools (74 of 121 medical schools) are also located in those states. Seventy-five percent of new doctor registrations at state medical councils, a marker of a graduate's intention to practice in a specific area, also are recorded in the wealthier states.30 This difference further exacerbates the urban–rural divide in higher education and in medical education in particular.36 There is little incentive for private medical schools to operate in areas of the greatest need.2,30

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Shortage of faculty

Predictably, rapid growth has created an acute shortage of faculty. For example, in India, for medical school programs alone, there currently is an estimated need for an additional 26,000 full-time faculty, a gap that will be very difficult to close in the near future.37 This shortage has been compounded by other factors, such as the migration of faculty to higher-paying schools and countries12,33,38 and the loss of teaching faculty to dental schools.37,39 Moreover, as in Flexner's time and much as in U.S. medical schools today,40 it is common for “full-time” teaching faculty also to engage in private clinical practice, which potentially diminishes their availability to the school for teaching. In addition, some “full-time” faculty are simultaneously employed as part-time faculty at private schools—an arrangement that not only supplements their income but also helps the private school present the appearance of a full roster of faculty.41,42

The need for additional faculty is more pronounced in preclinical departments and at senior levels.37 For example, in India, the number of anatomy teachers required for undergraduate and postgraduate courses, according to Medical Council of India-mandated ratios, is 1,888. With an estimated attrition rate of 25% per year, 470 new anatomy faculty members are needed annually, yet only 170 new anatomy faculty join the existing pool each year, which contributes to an ever-increasing deficit.37 Fraudulent faculty rosters are common enough in some countries that regulatory inspectors usually demand that faculty be present in a room to be physically counted,42 even though this process frequently disrupts teaching, research, or faculty development activities.

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Inadequate clinical exposure

Adequate patient contact was a problem in the United States in Flexner's time and is a problem in South Asia today. Flexner described a limited relationship between medical schools and hospitals, which did not see their mission as including education or research. With the notable exception of Johns Hopkins, most schools, including very prestigious ones, could not get hospitals to agree to allow medical students to have access to patients. As a consequence, most students had little or no contact with patients before graduation.1,19 Students at private medical schools in South Asian countries also suffer from limited clinical experience, but for different reasons than pertained in the United States in Flexner's time.2 Although many of these schools may be better funded than government schools because of higher tuition receipts, and, thus, their faculty are better-paid, they often lack access to patients, because most of the population cannot afford the nonsubsidized prices for health care.43 An exception can be found in the charitable private institutions or mission-based medical schools that offer subsidized care. The result, as in the pre-Flexnerian era, is limited exposure to patients.

In an attempt to fraudulently misrepresent the opportunities for clinical experience by their students, schools have been reported as placing healthy people in hospital beds to give the appearance of adequate clinical access when government accreditors count “patients” during their site visits.44

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Commercialization of postgraduate (residency) education

Growth in private medical education, which so far is largely concentrated at the undergraduate, or medical school, level, is now starting to occur in postgraduate education. In South Asian countries, there is a significant mismatch between the number of students completing the MBBS (MD) course and the number of postgraduate seats: in 2006, residency positions in India were available to only 29% of the graduating medical school class.35 The Jawaharlal Institute of Postgraduate Medical Education and Research recently had 400 applications for two postgraduate positions in cardiology.45 Nepal, with a population of 28.6 million,10 graduated only 208 physicians from postgraduate programs in the 10 years from their inception in 1994 to 2004.46 With this level of unmet demand, postgraduate education, which traditionally provides on-the-job training experience, has become a fee-paying enterprise. At one Indian university, fees range from $16,000 for a two-year “PG [postgraduate] diploma” program to $57,000 for a three-year “MD” postgraduate program.47 Fees for nonresident Indians are higher, ranging from $83,000 to $114,000 for clinical “MD” programs.48 So far, the trend of fee-paying postgraduate education is most noticeable in India. However, with similar forces in play elsewhere in Asia, this trend may spill over to other countries.

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Emphasis on rote learning

Flexner recognized the importance of active learning and inquiry by the faculty as role models and by students in preparation for their work as practitioners.1 In Asia today, static, highly proscriptive accreditation standards frequently specify infrastructure details, delineate detailed curriculum hours, or dictate assessment guidelines that lock in outdated methods and topics.49 As a result, teaching methods have become frozen in time, and that frequently results in conditions quite similar to those described by Flexner.2,39

Flexner's thinking was influenced by the work of John Dewey, a strong proponent of active inquiry. “Out-and-out didactic treatment is hopelessly antiquated,” Flexner1 wrote. “It belongs to an age of accepted dogma or supposedly complete information, when the professor ‘knew’ and the students ‘learned.’” Flexner argued that the faculty needed to embody the connection between investigation and clinical practice and, therefore, needed to embrace an open-minded, questioning spirit, in order to instill it in their students.50

Whereas Flexner's philosophy of active learning is broadly accepted in the United States today, such is not the case at most medical schools in Asia, where passive lecture-based teaching is still the norm. In parts of Asia where respect for elders is a deeply held value, medical teachers remain committed to a more authoritarian and didactic system of teaching, in which expert opinion and rote learning of facts prevail.2,3,32,35 Moreover, administrators, eager to meet requirements of the prescribed national curriculum and working on a tight budget, prefer large-group teaching rather than the more resource-intense small-group format. Many poorly run and inadequately equipped private medical schools deliver their curricula by using part-time teachers who lack necessary knowledge about the broader curricula.42

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Implications of the Flexner Report for Contemporary South Asia

Although conditions in the United States at the time of the Flexner Report and in contemporary Asia are separated by a century and a continent, many of the conditions are sufficiently similar that adaptation of some of Flexner's 1910 recommendations should be considered for South Asian medical education today. These recommendations include (1) create a stronger and more meaningful accreditation process to ensure the quality of medical schools, (2) establish health professions education as a recognized field of study, and (3) address the faculty shortage through a system of faculty development.

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Strengthen accreditation

Accreditation serves as a quality assurance mechanism promoting professional and public confidence in the quality of medical education, assists medical schools in attaining desired standards, and ensures that the performance of a school's graduates complies with national norms.51,52 It should be flexible enough to accommodate innovative programs and should use research and evaluation of education methods to periodically adjust standards.53

It is important that accreditation standards include both outcome and process standards.51,52,54 Outcome standards assess the product of an education system and ask whether the graduate is capable of meeting certain uniform thresholds for knowledge, skills, and attitudes. However, education is not simply about passing a set of tests; it involves a much richer tapestry of interactions and learning that are not likely to be captured by an imperfect assessment system.55 Therefore, process standards are necessary for review of the methods of selection, education, student evaluation, and promotion used by the education institution. The setting of these standards may be aided by looking outside Asia to international standards such as the standard created by the World Federation of Medical Education.56 These standards focus on the process of medical education and can serve as a template for building national or regional standards.

Quality standards are useful only if they are meaningfully and consistently applied and regularly updated.52,57 Institutional self-assessment, site visitation with collection of triangulated data by trained reviewers, and stringent ethical standards for the accrediting body will promote confidence in the process and stimulate the development of a culture of improvement at schools.54 Accreditation standards are not static, and they should be frequently revisited and reevaluated against current education research.5,52,57

External national or regional assessment of students may be a useful tool to consider in promoting quality assurance of medical schools. A uniform examination for students at the conclusion of their undergraduate medical education has been debated in a number of settings.58–60 Standardized assessment has both the advantage of providing a benchmark for achievement of all graduates and the potential to identify schools at which students are less well prepared for the next stage of their career or education. It also has the potential to stimulate the growth of educational activities that are relevant to the examination content.50,61

Good assessment drives good education; unfortunately, the opposite is also true.62 A standardized examination has the potential to encourage memorization if recall of knowledge is the predominant cognitive task or to encourage the retention of outdated topics if they are still part of the examination content.55,63 It may also cause schools to de-emphasize student achievement goals that are harder to measure, such as self-directed learning or professionalism, because they may be overshadowed by the need for achievement on the tested domains. In general, if the test remains excessively static, it will discourage innovation.59,62

The potential impact of standardized examinations necessitates the highest psychometric standards for validity, reliability, and standard setting in the local health care context. With caveats such as those mentioned above, a uniform test has the potential to serve as one component of an external institutional quality assessment, alongside a robust accreditation system.

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Establish health professions education as a recognized field

A critical intermediate step in improving health professions education in Asian countries is its establishment as a recognized field.64 In the United States, where there is minimal public control of the disciplines of medicine, medical education developed organically as a growing body of education research, which led to an organizational structure of national and regional associations, medical journals, and medical school departments.20 This organic development gradually led to a broadening of criteria for promotion at many schools to include education achievements and publications.65 In more centrally controlled environments, where a government agency must be convinced of the validity of the field, authorities will be more likely to do this as more education research is produced.

The inverse is also true, however; more research will be generated once the field is established. In Sri Lanka,66 where the field, or specialty, of medical education was recently established, faculty will now be eligible for advancement and promotion on the basis of education research, publication, and other forms of scholarship in education. This structure is likely to draw more faculty to the field and to incentivize interested faculty to publish in the domain of education research and practice. Development of the field will also promote creation of venues for the presentation of and debate about ongoing research, thus encouraging the diffusion of ideas throughout the region.39

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Address faculty shortage through faculty development

The shortage of faculty that has resulted from a dramatic increase in the number of medical schools and that has been exacerbated by the departure of doctors and faculty members from their countries12,33,38 may be partly alleviated by increasing the attractiveness of a career in medical education.67 Faculty skills in education methods and research are weak in most regions in Asia, because many faculty members view teaching as a secondary aspect of their responsibilities, after research and clinical work.4

To address the current situation, a trilevel approach—consisting of educating all faculty in teaching methods and skills, educating a subset of the faculty in research methods to improve quality in medical education, and developing leaders in education—is recommended.68,69 This aim can be accomplished by the establishment of basic educational courses at all institutes; the creation of advanced courses at regional centers that include research, leadership, and management issues; and the initiation of programs for higher educational degrees and diplomas at national centers. Faculty development in education leadership and management is essential to promote a culture that values and generates new ideas, values teamwork, and is able to implement and sustain change.67,69 Another important goal of faculty development programs should be the creation throughout the region of a community of educators who can turn to each other for support and ideas.

An important first step would be to measure existing faculty development programs against this paradigm and revise them to meet the multitiered needs.70 Because capacity building works best when related to the learner's local context,71 faculty development in education should be linked to projects in participants' home institutions.67,72 Workshop leaders should also model the education principles they espouse and should encourage the active engagement of participants.70,72 Support for faculty to attend education development programs, as well as funding to support education research and capacity building in research, would bolster faculty development efforts in education. Recognition of teaching at national and regional levels through awards, fellowships, and traveling professorships is a valuable way to promote a teaching culture.

Finally, the lack of opportunity for postgraduate education must be addressed. An increase in postgraduate education will help produce more faculty to fill teaching posts and will allow more physicians to stay in their home countries to complete their medical education.13

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The contexts of medicine and medical education in the United States during the period preceding the Flexner Report and in contemporary Asia are similar in some respects and different in others. An explosion of private medical education and weak government regulation define both periods. Internationalization was a factor in both settings, but with different effects. In the United States, there was a resultant increase in the diffusion of ideas, which contributed to a recognition of the poor state of U.S. medical education and medical practice. In contemporary Asia, the result has been the emigration of health workers to countries that are perceived to offer greater economic opportunity and better and more available postgraduate medical education.13 The density of doctors in the United States was relatively high in Flexner's time; it is strikingly low in most of Asia today, partly because of migration. Although it is difficult to generalize and compare teaching practices, the two scenarios bear many similar deficiencies—emphasis on memorization, lack of integration of science with clinical knowledge, limited clinical experience, and weak student assessment systems.

The recent growth of private medical schools in Asia is both an opportunity and a threat. These schools, which carry little historical baggage, can potentially maintain a clear focus and interest in medical students' education, and they may be capable of leading and propagating innovations across private and government medical schools.32 Government (public) medical schools, once the dominant player in medical education in Asia, may face increasing competition from innovative private schools, many of which are highly regarded as world leaders in education.73 However, many accrediting agencies in Asia have not lived up to their potential to improve the quality of medical education in their countries, and that failure has resulted in concerns that unplanned and poorly regulated growth may lead to lower quality.24

It is difficult to anticipate whether stricter accreditation and quality assurance would force some South Asian medical schools to close, as happened in the United States after the publication of the Flexner Report,50 or whether schools would adjust to the more stringent standards and make improvements. The Flexner Report was commissioned by an agency outside of the government that was frustrated by inaction or inadequacies in the public sector50; whether a similar review is advisable or even possible in Asia is not clear.2

The Flexner Report was successful, in part, because it directly addressed the concerns of the public, which understood for the first time that effective medical care by competent physicians could make a difference in their lives.50 To garner support from the public and the relevant government entities in South Asia, the strategy of the Flexner Report should be followed. Recommendations for improving medical education in contemporary Asia should be made in the context of improving the health of the population.

Complexities surrounding the change process necessitate careful consideration of political, social, cultural, and administrative factors.74,75 Experience in Asia suggests76 that the success of any changes depends on collaboration with key stakeholders and constituencies and on the judicious selection of high-priority areas for improvements that are less likely to face resistance.50 Examples of such areas are creating faculty development opportunities, promoting active learning, and recognizing medical education as an established field of scholarship. High-priority but high-resistance areas of improvement might be centered on the more contentious issues, such as criteria for admission and standardized regional examinations. Diversified promotion of change at individual, institutional, and national levels may also increase the overall likelihood of success. Advocates for change in each country need to think strategically and to start with innovations that have a higher chance of success.76

The relevance of Flexner's recommendations to the current status of medical education in Asia is striking, in terms of both the progressive nature of his thinking in 1910 and the need to improve medical education in Asia today.77,78 The improvements in U.S. medical education that began before the Flexner Report's release and that followed it had a profound effect on medical education on several continents.50 Given the movement of physicians around the world, particularly the export of physicians from Asia to the West, improvement in medical education in South Asia also will have a global impact.

Funding/Support: None.

Other disclosures: None.

Ethical approval: Not applicable.

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