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Abraham Flexner: Academic Medicine's Favorite Scapegoat


EDITOR'S NOTE: Dr. Sondra Zabar made history in 2020 by becoming the last person in the 62-year history of the AAMC to receive an award with Abraham Flexner's name on it. The AAMC renamed the Flexner Award for Distinguished Service in Medical Education as a demonstration of its commitment to becoming an anti-racist organization. Flexner had always been highly regarded as the “father of modern medical education" but his legacy has been reduced to becoming the "fall guy" because of his purported "racist and sexist" views. It is true that the 1910 Flexner Report was influential in the closing of half of the nation's substandard medical schools, which unfortunately included some of the schools that accepted blacks and women. He called for higher admission standards for ALL medical schools, adherence to the scientific method in research and practice, and oversight by state licensure boards. "Flexner: Academic Medicine's Favorite Scapegoat," authored by Linda Rosa, RN (a lifelong staunch opponent of pseudoscience in healthcare) offers a much different perspective for readers about the AAMC's decision to denounce Flexner. Oppressive Jim Crow laws and segregation were a tragically ugly part of our nation's landscape at the time that the Carnegie Institute commissioned Flexner to study and make recommendations about how to fix healthcare. By removing Flexner's name from their prestigious award the AAMC does NOTHING to reverse persistent racial and gender inequalities. The 2021 AAMC recipient was Dr. Thomas Viggiano, a physician who joins the ranks of the other 58 white males who have been past recipients. The first woman to receive the award was Dr. Ruth Fincher in 2012. By erasing Abraham Flexner's name from the history books, AAMC is joining the ranks of others who take down statues, rename buildings but do very little to actually fix persistent problems. Rosa cites examples demonstrating that Flexner was ACTUALLY passionately committed to promoting racial and sexual equality while insisting on excellence in education. Without Flexner's influence and persistence, it is likely the two oldest, historically black medical colleges (Howard University and Meharry) would not have survived and become the outstanding institutions that they still are today.

It’s not surprising that quack practitioners have long blamed Abraham Flexner for closing “alternative medicine” schools in the early 20th century because of “prejudice” against non-science-based health care.  But it came as something of a shock to hear that no less than the Association of American Medical Colleges (AAMC) decided to scrub his name from their most prestigious award for “Distinguished Service to Medical Education” for having “racist and sexist views.” (Redford)

While not denying Flexner’s positive impact on modern medical education, this demotion was done in service to AAMC’s commitment to “becoming anti-racist, diverse, equitable, and inclusive.”  AAMC also sees Flexner’s celebrated 1910 Report ("Medical Education in the United States and Canada"), based on first-hand inspections of all 155 US and Canadian medical schools, as “contributing” to the closure of five of seven Black medical schools existing at that time.

Because AAMC gives scant evidence for its accusations, skepticism is warranted.

RACIST?

AAMC gives two examples of Flexner’s allegedly “racist” and “pejorative language” in its Report.  First, it charges:

 “…Flexner asserted that African American/Black individuals were better suited to serve as sanitarians rather than surgeons…” [emphasis added]

But Flexner’s actual statement in context was:

A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous….The negro needs good schools rather than many schools — schools to which the more promising of the race can be sent to receive a substantial education in which hygiene rather than surgery, for example, is strongly accentuated.” [emphasis added; Report, p.180]

What AAMC failed to acknowledge was that ‘sanitarians’ in the 19th and early 20th Centuries were medical doctors and researchers specializing in public health (Freedman), not ‘sanitation workers’ or ‘health inspectors’ – not what The Washington Post (and others) would interpret as a “menial role” when editorializing on the defenestration of Flexner (Cohen, 2021). At the time of Flexner’s Report, sanitarian physicians were afforded considerable status for researching and combatting the spread of dread diseases, such as cholera, typhoid, smallpox, and tuberculosis which were leading causes of death.  Because of poor nutrition and hardships, Blacks were dying at a higher rate. Moreover, specializing in public health didn’t exempt Black schools from the high standards expected of all medical schools.

Note AAMC’s straw man: Flexner’s Report nowhere claims Blacks to be “better suited” as sanitarians, but rather as such would be “immensely useful.” Flexner actually was restating the primary mission of the two surviving Black medical schools that he worked to save – Meharry (Tennessee) and Howard (Washington, DC).  Both schools had emphasized public health as offering the greatest need of Black communities.

As for writing, “an essentially untrained negro wearing an M.D. degree is dangerous,” Flexner was not saying anything about Blacks having inferior intellectual abilities.  He believed the public had much to fear from all untrained physicians:

…a nostrum containing dangerous drugs is doubly dangerous if introduced into the household by the prescription of a physician who knows nothing of its composition and is misled as to its effect.” (Report, p. 65)

Flexner regarded osteopaths so poorly trained that he opposed legislation that would give them the privilege to sign death certificates. (Flexner, 1960, p.86)

Second, AAMC charges Flexner with believing the primary role of Black physicians “should be to protect White people from disease.”  Again, in actual context, he wrote:

Not only does the negro himself suffer from hookworm and tuberculosis; he communicates them to his white neighbors, precisely as the ignorant and unfortunate white contaminates him.”  [emphasis added; Report p.180]

Whenever Flexner is accused of racism – even in the AMA Journal of Ethics – this same quote appears, but invariably it ends with the word “neighbors.” (Laws) A fair-minded interpretation of Flexner’s position might well be, we’re all in this together when it comes to terrible diseases.

The Report expressed Flexner’s personal respect for Blacks, as with, “He has his rights and due and value as an individual.” (Report, p.180)  Medical historian Thomas Neville Bonner cites other instances, such as:

“In the history of the world, he wondered, had any race done “what the Negroes were doing with their meager resources.” He deplored the distortions of the black role in the post-Civil War South in the pioneering film The Birth of a Nation…he said, historically it was “utterly worthless trash.” (Bonner, 2002)

SEXIST?

AAMC’s charge that Flexner was “sexist” is likewise utterly unsupportable:

[T]he Flexner report also contained gender-oppressive … ideas. … In his report, Flexner wrote that while women were not barred from applying to medical school, they ‘show a decreasing inclination to enter it’ — and that those who did had ‘obvious limitations.’ (emphasis added; AAMC FAQ, 2020)

Yet again, in actual context:

[Women are] so assured a place in general medicine under some obvious limitations that the struggle for wider educational opportunities for the sex was predestined to an early success in medicine.  It is singular to observe the use to which the victory has been put….interne [sic] privileges must be granted to women graduates on the same terms as to men.”  [Report, p. 178]

Regarding the assertion about the “decreasing inclination” of women entering medicine:  Flexner cited the number of female medical students and graduates for the years 1904 to 1909 (in both co-ed and women’s medical schools).  The total number of schools matriculating women had indeed decreased from 100 to 94, and the total number of women students had steadily decreased from 1,129 to 921.  The drop in enrollments seemed genuinely to concern and perplex him: “their enrolment [sic] should have augmented.”  (Report, p. 179)

Scholars have since suggested the drop in enrollment may have resulted from stiffer enrollment requirements, the closure of some co-ed medical schools, increased competition from men for fewer openings, and states enacting laws restricting women from doing internships. (Moehling)

As for his remark about “obvious limitations,” what those were to a reader of that age are not so obvious today. The context, however, does not disclose any prejudicial attitude, nor does AAMC offer any clarity.

Flexner’s biographers have related how ahead of their time his whole family had been in championing women’s rights and education.  Flexner put his sister through college, and later, with his wife, Anne Crawford Flexner, financed the higher education of their two daughters:  Jean would help set up the US Division of Labor Standards; and Eleanor, educated at Oxford, became a “pioneer of women’s studies,” focusing on the struggles of Black and working women.  Eleanor spoke often with her father about her book, an enduring classic entitled, Century of Struggle: The Woman’s Rights Movement in the United States.

From his position on the Rockefeller Institute’s General Education Board, Flexner worked for equal rights and educational opportunities for women, as well as for Blacks.  He pressed schools like Harvard to admit women to their medical schools.  (Bonner, 2002)

Both Abraham and his wife have been described as “feminists,” walking along with 25,000 women down 5th Avenue in New York City during the historic 1915 parade for women’s suffrage. (SNAC Obituary, Eleanor Flexner)

MEDICAL SCHOOL CLOSURES, GENERALLY

While many credit Flexner with spearheading modernization of medical education, he played a part in a process that began years before his Report. With revolutionary scientific progress, eminent physicians had convinced both the American Medical Association (AMA) and AAMC of the need for reforms in medical education, in face of a multitude of schools turning out poorly trained doctors.

By 1904, the AMA had set up a Council of Medical Education (CME).  Four years later, CME reported on their two-year inspection of all the country’s medical schools, then numbering 162, finding half to be inadequate.  The AMA began rating medical schools accordingly, and state medical boards beefed up licensure requirements, in part by using these ratings.

Notably, CME didn’t publish its findings.  With aggressive competition between many medical schools – and this being the era of “trust-busting” AMA contracted with the Carnegie Foundation for the Advancement of Teaching to take the expected heat for telling the country’s medical schools to sink-or-swim.

Enter then Abraham Flexner who recently had impressed Carnegie’s director with a critique of America’s colleges.  Flexner proved a quick study on best medical education practices from Johns Hopkins and went out on an 18-month investigative trek around the continent.  At the time, medical schools were already feeling the pinch to modernize for several years. Some were already preparing to close, some were merging or becoming a university department, and many were scrambling for scarce funds.

Flexner found two-thirds of 155 medical schools to be “utterly hopeless,” including all three women’s schools and five of the seven Black schools.  Many medical schools were small, private, cash cows for lecturers who rented rooms and offered little in the way of laboratory facilities, library, or experience with actual patients.  Some were outright diploma mills. Flexner saw ‘sectarian’ schools as particularly disturbing, where homeopathy, osteopathy, allopathy (still using four humors), and spiritualism were the focus. His opinion of chiropractors was so low, he didn’t consider their schools “medical’:

 “…unconscionable quacks, whose printed advertisements are tissues of exaggeration, pretense, and misrepresentation of the most unqualifiedly mercenary character. The public prosecutor and the grand jury are the proper agencies for dealing with them.”  [Report, p.158]

Flexner’s published Report had exposed the reality, in bleak terms, that the vast majority of medical schools were turning loose hordes of poorly prepared practitioners onto an unsuspecting public.  His Report informed state licensing boards which medical schools were outright fibbing about their facilities.

In another decade, half as many physicians would be graduating from half as many medical schools, with health care improving, as Flexner hoped.  It was a true revolution in medicine – coming like the showdown at the OK Corral.  Science rode into town with more effective, reliable medicine, demanding high training standards and adequate funding.

CLOSURES OF WOMENS SCHOOLS

After the Civil War, 14 medical schools for women had been created, but there were only three left by the time Flexner made his rounds, and oddly enough, only the more homeopathic of the three survived after that.

Flexner predicted that none of the three women’s schools could make significant improvements “without an enormous outlay” of funds.  Noting that 80% of female students already attended co-ed medical schools, he recommended that “large sums” would “accomplish the most if used to develop coeducation institutions.” (Report, p.179)  As with Black schools, he recommended leniency towards co-ed schools willing to modernize.

CLOSURES OF BLACK SCHOOLS

Neglecting the realities of medical education and regulation over a century ago, the 21st Century AAMC has pronounced:

“[Flexner’s] work contributed to the closure of five out of seven historically Black medical schools. Our action today recognizes the long-standing negative impact of the Flexner report on the training of Black physicians and the health of the Black community in the United States.” (Redford)

Several biographers see Flexner not as the person who closed five Black medical schools but rather as the person who saved two.

His support for Howard and Meharry—despite their having funding levels and licensing exam pass rates that were far below those of the predominantly white schools he endorsed—likely helped ensure their survival against the forces that pressured comparable white schools to close. His support extended beyond his report’s endorsement…" (Miller and Weiss, p.240)

In the decades before Flexner’s Report, seven Black medical schools had closed.  Flexner visited the remaining seven. Out of those, he pronounced only Meharry and Howard “deserve liberal support,” despite their students’ low scores on licensing exams.  Further, he wrote that the other five schools were “in no position to make any contribution of value” and would require immense infusions of resources to survive.  Much better, he thought, to concentrate scarce resources on Meharry and Howard.

The five schools that would close together produced less than 20% of Black medical graduates, and only about half of those passed their licensing exam.  Enrollment in three of these schools (Flint, Louisville National, and Knoxville) plummeted starting in 1906, suggesting their focus switched to graduating the remaining students.  (Miller and Weiss)

In 2005, AMA would denounce Flexner for not supporting more Black schools, though medical historians claim his Report had little impact compared to AMA’s rating system.  Flexner encouraged leniency towards Black schools – certainly more than shown by the segregationist AMA, which admitted no Black physicians to its ranks and gave “A” ratings to 38 white medical schools that Flexner recommended for closure. (Miller and Weiss)

Arguably more serious obstacles for Black medical schools were poverty and poor secondary education.  In 1900, AAMC required a minimum four-year high school education for enrollment in medical schools, but in the South at that time, as few as 3% of Black children had access to a high school.

Many black medical students needed a job and preferred night classes, but schools offering night classes could be denied an “A” rating.

Post-Report, Flexner went to bat for both Meharry and Howard, requesting that licensing boards give these schools time to make improvements.   While Howard would continue to get federal funding, Flexner worked the next 30 years to secure large private grants for both schools.  He would be elected to Howard’s board of trustees, and eventually became chair.

Flexner also nagged the AMA to upgrade Meharry’s rating from “B" to “A,” which was necessary for its graduates to be licensed.  He pointed out less deserving white schools that had been given “A” ratings.   (Bonner, 2002)

Some commentators have suggested Flexner could have consider saving Leonard Medical School (Raleigh, NC), the nation’s first 4-year medical school.  In 1910, Leonard had an AMA rating of “B,” and its graduates had higher exam scores than Meharry.  But with few resources – and membership in the AAMC rejected – Leonard became a 2-year medical school in 1914, with students finishing their training at either Meharry or Howard.   It closed in 1919. (Murray, 2006)  It is likely there were not enough Blacks with a high school education to support another medical school at this time. (Miller and Weiss, p.241)

One can only speculate what Flexner, a man with progressive and outspoken views, thought in passing up the opportunity to recommend desegregated medical schools while his Report held the industry’s attention.

QUANTIFYING RACISM IN MEDICAL EDUCATION

AAMC blames Flexner’s Report for “exacerbated systemic racism in medicine,” relying, in part, on a paper appearing in JAMA Network Open which dubiously extrapolates that had not five of the seven Black medical schools that closed in the Flexner era (Flint, Leonard, Louisville National, Knoxville, and the University of West Tennessee), an additional 35,315 Black physicians would have entered the workforce between 1911 and 2018. (Campbell, 2020)

Statistical models, as reported by this paper, need to be meticulous in their methods and assumptions to avoid “garbage-in/garbage-out” pitfalls. It was good that the authors honestly admitted that their use of linear regression was sub-optimal because “variable and incomplete data on year-specific enrollment and graduation rates” for three of the five closed schools.  (That alleged “missing data,” is readily available in JAMA’s archived“Medical Colleges of the United States” annual reports.  Researchers such as Miller and Weiss have used this data in their analyses.)

 

If there had been peer reviewers, they probably would have taken note of the authors apparently turning one school (University of West Tennessee) into two schools (Table 1).  And they surely would have questioned the “conservative assumptions” underlying the modeling in the Campbell study – not all that conservative, as it turns out, because the authors put a “cap” on the annual output of graduates, suggesting the modeling results beggared belief.

This sort of “modeling” seems little better than picking numbers out of a hat. Moreover, as an “economic” study, it failed to consider the stress on these five medical schools had they survived, such as discrimination in scoring licensing exams, poor secondary schooling for Blacks, the Great Depression, two world wars, inflation, the Black migration to the North and competing desegregated medical schools.

Referring to the Campbell study – lauded as “innovative” (Laraque-Arena) – JAMA editors later indulged in some historic revisionism that ignored the contributions of the two surviving Black medical schools, Meharry and Howard:

“Black men and women were nearly completely expunged from medicine. The consequence of those closures substantially reduced any meaningful capacity to educate Black men and women as physicians…” (Yancy & Bauchner)

But according to Miller and Weiss the Black medical schools that closed were not the whole story:

“With the exception of Leonard … the schools that closed between 1910 and 1923 were small operations that together produced fewer than a fifth of the black doctors who graduated in any given year.”  (pp.240-241)

CONCLUSION

What can be done to counter the actual legacy of racism in medical education?

Perhaps honesty about its history would be a good start. It was certainly tragic that there were not more medical schools and hospitals with adequate resources serving Blacks.  There is no denial of the injustice of Jim Crow and so many segregated medical schools.

AAMC would have done better recognizing Flexner’s example of promoting medical education for Blacks and women, and owning up to its organizational failure to follow that example.  Just as the AMA needed a fall guy back in 1910, today’s AAMC has found it most convenient to slander the stellar legacy of a man who did much to promote racial and sexual equality while hewing to excellence in education.

For an accurate history of Flexner, AAMC needed only to look under its own nose – at its own journal.  In 1998, Thomas Neville Bonner, PhD, published “Searching for Abraham Flexner” in Academic Medicine.  The journal’s editor referred to Bonner as a “distinguished historian of medicine,” and indeed, he soon published the definitive biography of Flexner (Iconoclast:  Abraham Flexner and a Life in Learning).  Bonner surely would have challenged AAMC’s indefensible historical revisionism had he not died in 2003, perhaps even by repeating this as a poignant retort:

“In December 1940, Flexner made ‘a hemispheric broadcast’ by radio on the American way of life, in which he expressed regret ‘that Democracy [had] not come to prevail in the relations between the colored man and the white man [nor] in the relations between men and women.’  He called for a ‘militant’ extension of freedom.”  (Bonner, 2002)

For a man with his achievements, who said that at the height of Jim Crow, and now be called a racist and sexist by an institution which owes him much – and should know better – reflects more on AAMC than on Flexner.  It actually may be a good thing that AAMC has dissociated itself from Abraham Flexner, particularly with its award, previously ‘distinguished’ by using his name. With its action, AAMC has presently shown itself less worthy of a connection to him than he to it.

 

             Abraham Flexner, circa 1910 (Photo credits: By W. M. Hollinger - The World's Work, 1910: https://archive.org/stream/worldswork20gard#page/13100/mode/2up, Public Domain, https://commons.wikimedia.org/w/index.php?curid=26650987)                                      

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Acknowledgement:  The author’s gratitude to Larry Sarner for his editorial assistance and review of the Campbell study mentioned in this paper.

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Bibliography:

Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life in Learning, (Johns Hopkins University Press, 2002)

Thomas Neville Bonner, “Searching for Abraham Flexner,” Academic Medicine, Feb 1998, 73(2):160-166.

Kendall M. Campbell, et al, “Projected Estimates of African American Medical Graduates of Closed Historically Black Medical Schools,” JAMA Network Open, 20 Aug 2020. 

 

Noam Cohen, “Sure, erase the names of historys racists. That wont undo their messes,” The Washington Post, 26 Mar 2021.

Abraham Flexner, Abraham FlexnerAn Autobiography, Simon & Schuster, NY, 1960) p. 86

 

Abraham Flexner, "Medical Education in the United States and Canada," Report to the Carnegie Foundation for the Advancement of Teaching, 1910.

Eleanor Flexner, Century of Struggle: The Womans Rights Movement in the United States, Harvard University Press, 1959.

Eleanor Flexner, 1908-1995. Social Networks and Archival Context (SNAC).

Ben Freedman, “The History of the Sanitarian,” The Sanitarian, Sep-Oct 1954; 17(2):67-79

E Hoover, “Did Flexner's Report condemn black medical schools? Not so, in my opinion,” J of the National Medical Association, Sep 2006; 98(9):1432-1434.

JAMA, “Medical Colleges of the United States:  Annual Presentation of Educational Data by the Council on Medical Education,” 1910, 1911, 1912, 1913, 1914.

Danielle Laraque-Arena, “Historically Black Universities and Medical CollegesResponding to the Call for Justice,” JAMA Network Open, 20 Aug 2020.

Terri Laws, “How Should We Respond to Racist Legacies in Health Professions Education Originating in the Flexner Report?” AMA J of Ethics, Mar 2021.

Lynn E Miller, Richard M Weiss, Revisiting Black Medical School Extinctions in the Flexner Era,” Invited Commentary, J of the History of Medicine and Allied Sciences, 2 Feb 2011; 67(2):217-243.

Carolyn M Moehling, et al, “Shut Down and Shut Out: Women Physicians in the Era of Medical Education Reform,” Social Science History Association presentation, Apr 2019.

Elizabeth Reid Murray, “Leonard Medical School,” 2006, NCPEDIA.

Gabrielle Redford, AAMC Managing Editor, “AAMC renames prestigious Abraham Flexner award in light of racist and sexist writings,” 17 Nov 2020.

AAMC, “Frequently Asked Questions: AAMC Award for Excellence in Medical Education, formerly the Abraham Flexner Award for Distinguished Service to Medical Education,” (date presumed Nov 2020)

Todd Savitt, “Abraham Flexner and the Black Medical Schools,” J of the National Medical Association, Sep 2006, 98(9): 1415-1424.

Clyde W. Yancy and Howard Bauchner, “Diversity in Medical SchoolsNeed for a New Bold Approach,” Editorial, JAMA Network, 2 Jan 2021; 325(1):31-32.

 

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