of another big event for medical schools. And that was that 100 years ago this
year, the famous Flexner Report was published.
Medical education in the United States before 1910 was, in general, a mess.
Literally you could go to cities in this country and get a medical degree delivered
with almost no teaching from a storefront medical school, many of them
for-profit enterprises simply there to generate a little income, not to really create
a doctor. The AAMC, my organization, and the AMA knew this was a disgrace,
and they partnered together with the Carnegie Foundation to do a report on
medical education, which became the famous Flexner Report. And that report
100 years ago – it was a revolution. It changed medical education totally in this
country, and it built a model that was very different from those storefront medical
schools, and that has persisted for much of the century….
Now the key tenet of the Flexner criticisms was that medical schools were out
there in these fly-by-night operations, and they belonged in the university. You
want a doctor who understands science. You want a doctor who’s a scholar. And
not only should it be in the university, it should be closely connected to the real
world of the best clinical practice you can find. That was Flexner’s concept. It was
absolutely necessary at that time. I’m not faulting what he said or what we did
with it. But like most good ideas, some things can head in directions we wouldn’t
necessarily have wanted. And that happened with Flexner….
[Y]ou know there’s a kind of culture to the university, right? Basically it’s the
culture of experts. It’s also a very hierarchical kind of culture, right? I go from
instructor to assistant professor to associate professor. It’s a very independent culture.
If any of you have ever worked with faculty members – they don’t exactly
view themselves as employees. They view themselves as autonomous experts,
with some good reason.
So Flexner did that. He said you need to get back to the scholarly roots of the
university. That’s what we did…. [T]hen something happened after World War II.
What happened was that we built what is arguably the greatest research institution
the planet has ever seen. It’s called the National Institutes of Health, and it is a wonderful
thing. I was privileged to work there. But it added its own culture to medical
schools and their world. And the way it did it was fascinating. They decided that the
way they could best support research was to go find those experts in the universities
and give them grants. Those of you who know our world know they call them even
R01s – project grants that were given to an individual, for their expertise in a particular
area of science. This also is good. We would not have the treatments we have for
a broad range of diseases if it wasn’t for that kind of investigator-initiated research.
But it also reinforced that culture of independence. If it was all about me, as an independent
scientist, and all about my grants, it didn’t exactly engender a spirit of collegiality
or teamwork. So it produced great science, without question, but it reinforced
the sense that we were just a collection of independent faculty members.
It also injected a new element in the education program. Because if I’m busy with
my next grant deadline due, I may be less inclined to want to spend time talking
with you about the pharmacology of this or that class of drugs as a medical student.
62 | Breaking the Mold