Centenary of the Flexner report



In January 1909, Abraham Flexner started at Tulane University in New Orleans a series of visits and research to 155 medical schools in the United States and Canada. The objective was to evaluate the quality of these schools regarding: admission requirements, size and training of the teaching staff, budget and support taxes of the institution, quality and adequacy of the laboratories as well as the relationship between school and hospitals. Flexner examined all schools under the patronage of the Carnegie Foundation for Advancement of Teaching, which was attending a request of the American Medical Association, through the Council on Medical Education (CME).

Flexner was the sixth son of a nine brother Jewish immigrant family. Born in November 13th 1866 in Louisville (Kentucky), he died in September 21st 1959 in Falls Church, Virginia. He studied in Louisville and graduated in humanities from Johns Hopkins University and then returned to his hometown. In 1906, he joined Harvard University, but did not conclude his post-graduation studies, going to study in Berlin. From 1912 to 1927, Flexner worked at the General Education Board, founded in 1902 by John D. Rockfeller.

In his classic evaluation report, Flexner concluded that only 31 schools presented conditions to work, as in all others the students did not have a previous preparation; there were no laboratories nor a relationship between scientific education and clinic work; the professors did not have any control under the university hospitals, the curriculum were not standardized and the teaching was purely commercial. Johns Hopkins, described as a "medical education model" was the base to his recommendations, highlighting the following criteria: admission after secondary school diploma and at least two years of academic studies; the course should be extended for four years and its content decided by the CME. According to his recommendation, the private school should be closed or incorporated to the existent universities; clinic professors designated to full time; the teaching should be linked to research and the professional exercise controlled by the medical corporation.

The impact of the Report was evident: in the period of 1910 to 1922 the number of medical school in the USA decreased from 131 to 81; five out of seven afro-descendants schools were closed, as well as three women-only schools. From 1910 to 1920, 16 homeopathic schools were closed turning into biomedical schools.

Recent analysis reveals that, although Flexner defended "scientific rigor and the standardization of the medical education", he also highlighted that: the training, the quality and the quantity of medical education should respond to the needs of the society; doctors have a social obligation with the disease prevention and health promotion and should receive enough training to accomplish with such demands. Also the collaboration between the academic medicine and community's public health results in benefits to both sides.

More than celebrating the centenary of the document "Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching" that went through the 20th century up until us, it is important to critically reflect on its legacy and try to progress in the construction of a health sector of public and collective interest.


Everardo Duarte Nunes
Associate editor

ABRASCO - Associação Brasileira de Saúde Coletiva Rio de Janeiro - RJ - Brazil
E-mail: revscol@fiocruz.br