Reports heard ’round the world

[Fall 2013 Centennial issue]

The man whose muckraking 1910 report spurred a wholesale reform of U.S. medical education had never been a student in the system he critiqued.

A veteran schoolteacher and principal from Kentucky, Abraham Flexner had a passionate interest in pedagogical strategy, fueled by study at Harvard and visits to schools in Europe. His unlikely career as a medical reformer began after his book The American College apparently caught the attention of the head of the Carnegie Foundation for the Advancement of Teaching, leading to an invitation to survey medical schools throughout the United States and Canada and make suggestions for their improvement.

Medical Education in the United States and Canada—now known simply as the Flexner Report—was a stinging indictment of the era’s medical schools, which for the most part operated as for-profit diploma mills with notoriously lax standards. Flexner proposed that the multitude of vastly inadequate schools be replaced with far fewer but infinitely better university-based programs designed along the lines of German medical education. In particular, Flexner changed the doctor’s education from an apprenticeship model to an academic model, establishing rigorous science and other requirements. The Flexner Report gained regulatory support from the enactment of state licensing laws, leading to the closure of many schools, while others moved to align themselves with Flexner’s vision.

Two years after his report’s publication, Flexner ascended to the rank of secretary of the Rockefeller Foundation, where the reform impulse soon expanded to the newly burgeoning field of public health. In 1915, the Welch-Rose Report that evolved from Rockefeller Foundation deliberations outlined a system of public health education for the United States—essentially doing for public health what the Flexner Report had done for medicine. One notable feature of the new report was the competing visions of its two architects. While Wickliffe Rose favored an emphasis on public health practice, William Henry Welch favored an emphasis on scientific research, the approach that ultimately won Rockefeller support to create the Johns Hopkins School of Public Health in 1916 and, five years later, to establish Harvard School of Public Health independent from MIT, its partner since 1913.

In 2010—a century after the Flexner Report changed the face of medical education—a global independent commission co-chaired by HSPH Dean Julio Frenk took its place in the series of historic reports aimed at reforming health education. Like the Flexner and Welch-Rose reports before it, the commission’s report, published in full in the December 2010 issue of The Lancet, targeted the most urgent health issues of the day. Among them: nations’ glaring lack of preparedness for new health threats emerging in a time of rapid demographic and epidemiological transition, and the need for “transformative learning” geared to producing professional leaders within a framework of interdependent professions and institutions. As the commission wrote, “[W]e call for a global social movement of all stakeholders—educators, students and young health workers, professional bodies, universities, nongovernmental organizations, international agencies, donors, and foundations—that can propel action on this vision and these recommendations to promote a new century of transformative public health education.”

– Madeline Drexler