Author Q & A: The Making of an 'Iconoclast'

Thomas Neville Bonner, Ph.D. Photo: Rick Bielaczyc

Abraham Flexner (1866-1959) was, according to historian and biographer Thomas Neville Bonner, Ph.D., the most influential person in U.S. medical education history. In Iconoclast: Abraham Flexner and a Life in Learning [Johns Hopkins University Press, 2002], Dr. Bonner - a historian and former president of three universities - outlines the career of the controversial medical school reformer and curriculum critic in great detail.

Born in Louisville, Ky. (which today has a street named after him), Flexner was the son of German Jewish immigrants who instilled in their nine children the value of education. After Flexner graduated from the new Johns Hopkins University, he began constantly questioning the status quo of the US education establishment, and railed against "rote learning" in favor of more practical, interactive education. Among the many accomplishments over his long career, Flexner was perhaps best known for his groundbreaking 1910 report that shook the medical education community and led to many subsequent reforms. He was the first to effectively champion folding medical schools and teaching hospitals into the university setting and favored the education of black physicians. He was also known as "the man who brought Albert Einstein to America."

As a tribute to his lasting influence, the AAMC since 1958 has awarded the annual Abraham Flexner Award to an individual for extraordinary contributions to the medical education community. The winner receives the Flexner Medal and $10,000. Nominations for the 2003 award are due May 9; for information, visit www.aamc.org/about/awards/flexner.htm.

Q: Is Abraham Flexner the most important figure in US medical education history?

A: No one in the 20th century left such a mark on the way doctors are educated as Flexner. I can't begin to think of anybody you could put in the same class for his influence both on the theory of medical education and on the actual structure of individual schools of medicine. At least eight or 10 schools' historians have pointed out that without Flexner they would not have developed the way they had. He had enormous influence on so many levels of education in so many ways; raised so much money; wielded so much power over individual schools. It's remarkable that apart from people in medicine, he is not very well known.

Q: What made Abraham Flexner an iconoclast?

A: Flexner had the nerve to tackle some of the strongest people in education in the period in which he lived. He stayed stubbornly with his positions and seemed to be fearless and to be very sure of himself, although he did not seek publicity. Many people thought him difficult because he challenged them, and he turned down many requests from people because they did not fit with his ideas of how a particular program ought to go. So while he was extremely respected - and feared in many ways - he was not always popular.

Q: What was groundbreaking about Flexner's famous 1910 medical education report?

A: The report was the first completely codified attempt to bring together all of the reform suggestions about medical education that had been brewing since the Civil War and the advent of the modern university in the 1870s. That included the importance of affiliating medical schools with universities; most American medical schools at that time were independent and had no relationship with a university. Second, he wanted every medical school to have control of the teaching in a hospital, so the students would get first-hand - hands-on - education, with qualified people. He said that these should not be just busy, part-time practitioners who came for an hour's lecture, but who spent all or most of their time on education. Education was the important thing, and medical schools needed full-time clinical teachers, as well as laboratory teachers working in the basic sciences.

Q: How was the report commissioned?

A: The report was backed by the Carnegie Foundation for the Advancement for Teaching. The foundation was charged with developing ways of improving American education; and the head of the foundation, Henry Pritchett, was looking for ways to influence graduate and professional education, law, medicine, engineering, and other fields. Almost by accident, he hired Flexner at the same time the AMA, for its part, was trying to get support for its program to build up medical schools to increase the amount of science and admissions standards, the level of study, and to set a minimum three years for graduation.

Q: Why did it ruffle so many feathers?

A: The report was made up of two parts. One was a generalized recitation of what a good medical school should be, how it should be made up, and what kind of standards it should have. The second, more controversial, part was made up of his comments on every medical school in the United States and Canada. There were 155 at the time, and Flexner visited every one of them. Many of his comments were devastating, outright condemnations of a kind that had never before been heard publicly. The report attracted a lot of attention, eliciting headlines such as "Schools for Ignorant Doctors" in the New York Times. It also attracted attention because medicine has to do with life and death, whereas law and engineering, while important, didn't have the personal quality to them that says, "Your doctor may be a quack."

Q: How many medical schools did Flexner affect?

A: He had some effect on all of them. Many were driven out of business in the first 10 or 15 years after the report. Flexner was a great money raiser, and was able to put money into schools that followed his model. He was very much influenced by the Johns Hopkins School of Medicine model, which was founded in 1893 and was very much in advance of other medical schools by hiring world-class faculty and requiring college graduation before medical school. When he was in a position to give out money, Hopkins became the first to get a large grant, for the purpose of beginning full-time clinical teaching. Later, the money he controlled led to full-time school teaching at such medical schools as Yale, Vanderbilt, and the University of Rochester.

Q: How would Flexner view medical education today?

A: Would he be pleased, surprised, overwhelmed? Probably. I think he would be sympathetic to many of the current reform efforts, which in many ways address what he called for in 1910. He would applaud the move toward flexibility, and be critical of the rigidity of many medical school curricula. I think he would deplore the decline of the university influence in medical schools and the tendency to separate medical centers from the universities in many cases. The basic structure of medical education today goes back to the set of ideas he put forward. One is that a medical student should be well-versed in science and should do laboratory work - he imported this idea from Germany. He also borrowed from the English tradition of clinical clerkships, where the student deals with patients under the supervision of a professor. He would undoubtedly have been strongly opposed to the impact of the bottom-line, budget-driven, HMO-sponsored developments that have increasingly limited the educational experience of today's medical students.

- Michael G. Malloy

Editor's note: Dr. Bonner can be reached at tnbonner@worldnet.att.net

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