A herculean report

2010 marks the 100th anniversary of the publication of the Flexner report — a report that revolutionised the structure and context of medical education. It arose from widespread community concerns about the clinical competence and professionalism of medical graduates of North American medical schools.

From January 1909 to April 1910, Abraham Flexner, funded by the Carnegie Foundation for the Advancement of Teaching, criss-crossed North America visiting all 155 medical schools to assess their programs. He was accompanied by Nathan P Colwell of the American Medical Association, which had been formed in 1847, in part to improve the standard of American medical education.

The schools were mainly proprietary medical schools, where local doctors had banded together to open up a shopfront, frequently bearing their names. Once established, they accepted fee-paying students, with few formal entry requirements. They offered a year or two of lectures, some anatomy tuition and an apprenticeship. The teaching tended to be didactic, focusing on memorisation of readings and a few selected textbooks.

The resulting report entitled “Medical education in the United States and Canada” became known as the Flexner report. As far as reports go, it proved to be both ruthless and visionary, recommending that only 31 of the 155 medical schools should remain open.

It is significant that Flexner’s recommenda-tions were part of seminal reform, becoming the foundation of modern medical education, insisting that medical schools be properly equipped and linked to first-rate teaching hospitals. Second, he insisted that students have high levels of preadmission qualifications, including at least 2 years of college or university study; and finally, that medical schools should revolve around research and investigation so that these activities underpin medical scholarship.

The recommendations were widely accepted. Since the Flexner report, there have been a multitude of reports on medical education, but none have been as herculean in scope and revolutionary in impact.