Some Med Ed Traditions Showing Their Age

One hundred years ago Abraham Flexner wrote a book-length study of American medical education that dramatically transformed the education of doctors.

The influence of the 1910 Flexner report, “Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching,” was profound, so much so that the American medical education system is described still by an adjective—“Flexnerian.”

In his report, Flexner established the foundations for an educational system whose predominant features are still in existence (see What Flexner Wrought).

In the February Academic Medicine, leaders in medical education looked back on what Flexner accomplished. Nine commentaries from educational leaders consider the historical context in which Flexner made his observations and recommendations, as well as their impact today on the culture of medicine, the structure and financing of medical education, and physician training.

Several commentaries focus on how Flexner has impacted such contemporary issues as training of minority clinicians, the distribution of generalists versus specialists, and training in public health.

A common thread throughout is that the Flexnerian model of medical education may now be in for changes nearly as profound as those Flexner proposed 100 years ago.

Psychiatrist Darrell Kirch, M.D., president and CEO of the Association of American Medical Colleges, addressed changes under way in the culture of medicine and in the way health care is organized and financed that make the Flexnerian model of training obsolete.

In his essay, “The Flexnerian Legacy in the 21st Century,” Kirch argued that current realities call for a collaborative culture for which physicians are not prepared by traditional medical training, which has emphasized, since Flexner's time, individual excellence and achievement.

“[A]n underlying theme of many articles in this issue is that the medical education community's response to the Flexner report—and the individualistic, expert-centric culture to which it gave rise—may now work against the collaboration needed for greater integration across the medical education continuum, highly networked teams in discovery research, and inter-professionalism in clinical care,” Kirch wrote. “The question, as many authors suggest, is not whether medical education is being true to Flexner, but whether academic medicine is responding to the implications of post-Flexnerian education and whether it is able to embrace the cultural change needed to address 21st-century health care needs.”

Kirch noted that Flexner's model of the European university, focusing on individual professional achievement and individual acquisition of factual knowledge, has led over time to faculty members' becoming essentially “free agents” in each of academic medicine's mission areas, with corresponding proprietary references to “my lecture,” “my grants,” and “my clinic.”

“However, a different reality faces us now,” Kirch wrote. “For example, with scientific knowledge growing exponentially, an individualistic culture works against the integration and sharing of new knowledge needed in each mission area, particularly medical education.

“Moreover, as medical education moves toward outcome-based assessment, having knowledge is no longer sufficient. Students and physicians must also be able to apply that knowledge to everyday clinical situations. Just as important, young physicians must be able to effectively interact with patients, patients' families, and other health care professionals, as well as respond to the complex organizational demands of the health care system. Further, they must commit to lifelong learning that includes the ability to self-reflect and assess their own performance.”