A century ago this year, a Kentucky high school teacher wrote a report that had a dynamic effect on the shape and quality of American medical schools. His name was Abraham Flexner. By the time he undertook a study of medical schools in the United States and Canada, he had given up teaching and was a research associate at the Carnegie Foundation for the Advancement of Teaching. His brother, Simon Flexner, was the scientific director of the Rockefeller Institute, a philanthropic structure funded by the oil tycoon John D. Rockefeller.
The first American medical school was started in 1765 at the University of Pennsylvania in Philadelphia. A few schools had academic sponsorship. But most were proprietary ventures created by a few doctors and supported entirely by fees charged to students. Some had no hospital connections or laboratories, and the students got no experience with patients. Others lacked any faculty members who taught basic biology courses. Some gave no tests to students, but their diplomas were accepted by the states of residence as qualification for a medical license. When the American Medical Association was founded in 1847, its stated objective was to standardize and improve medical training. It made some progress, but not enough to create national standards for all of the 155 schools in the United States and Canada at the turn of the 19th century.
Shortly after the beginning of the 20th century, Abraham Flexner began boarding trains in New York City to visit every one of the functioning medical schools. The project was sponsored by the American Medical Association and the Association of American Medical Colleges and funded by the Carnegie Foundation. He was able to persuade all of the medical schools to let him visit and observe how they were structured and how they operated. Many of them must have wished that they had refused. His analysis of their operations was critical and, for many schools, a basis for their destruction.
Flexner praised only five schools. The one he cited as best of the lot was Johns Hopkins University in Baltimore, Maryland. The Johns Hopkins Hospital opened in 1889, and the medical school began four years later. Flexner had been an undergraduate student at Johns Hopkins, graduating at the age of 19 in 1885. Some of his critics charged that he was biased in favor of his alma mater. He spent one year in graduate school at Harvard University and two years studying educational patterns in Germany before returning to his hometown of Louisville, Kentucky, to become a high school teacher. He had no training or degree in medicine, but he was an insightful critic.
Some years later, when his older brother, also a Hopkins alumnus, had gotten involved with the Rockefeller Institute, he followed him to New York and got his job with the Carnegie Foundation.
Abraham Flexner’s viewpoint of a medical school was what became the prevailing pattern. It should have a full-time faculty of biologic scientists and qualified practicing physicians with special competence in surgery, obstetrics, pathology, and internal medicine. It should accept only students with academic qualifications, including what later became regarded as premedical training. It should have laboratories for its students and the research of its faculty. The school should have an affiliation with a hospital and preferably own and control the hospital. And the school should have funding sources well beyond the tuition charges to its students. After a decade of operation, Johns Hopkins came closest to meeting Flexner’s criteria. Besides the basic endowment of its namesake, the Hopkins medical school had begun to get support from the Rockefeller organizations and from other philanthropic foundations.