The AMA, NMA, and the Flexner Report of 1910

Prepared by Ololade Olakanmi

For the Writing Group on the History of African Americans and the Medical Profession

Summary

There are several direct links between Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (1910), commonly known as “The Flexner Report,” and the American Medical Association’s Council on Medical Education (Council). The Council requested that the Carnegie Foundation carry out the report; the Secretary of the Council accompanied Flexner on many, and perhaps all, of his visits to medical schools; and the Council reinforced Flexner’s work by continuing to rank medical schools along the lines Flexner recommended, which maintained pressure to close certain schools. This report provides a summary of these links—wherever possible focusing on primary documentation.

Initiation of the Flexner report

In 1907, in an effort to raise educational standards and put pressure on poor quality schools to improve or close, the AMA Council on Medical Education (Council) carried out inspections of American medical schools and created a classification system (i.e., rankings) for these schools. Following this, the Council decided in 1908 that it would be advantageous to solicit the Carnegie Foundation for the Advancement of Teaching to work on this issue (Medicine Pays Tribute to Dr. Flexner. American Medical Association News, October 5, 1959). This was because many physicians and medical schools were bitter that their institutions were under pressure or had already closed as a result of the Council’s efforts. A 1982 Council report to The House of Delegates summarized the situation:

“The classification of schools [in 1907], even though the individual ratings were not published, generated a considerable amount of resentment toward this activity of the AMA, and stimulated the Council to seek the assistance of the Carnegie Foundation for the Advancement of Teaching in further efforts to improve the quality of medical education.” (Future Directions for Medical Education, A Report of The Council on Medical Education, Adopted June 15, 1982, by The House of Delegates of the American Medical Association, pg. 58.)

At the Annual Congress on Medical Education, Medical Licensure and Hospitals (Chicago, February 6, 1928), Dr. Arthur Dean Bevan—who was chairman of the Council from 1904 to 1928—wrote the following in JAMA:

“As the work of the Council developed, it occurred to some of the members of the Council that, if we could obtain the publication and approval of our work by the Carnegie Foundation for the Advancement of Teaching, it would assist materially in securing the results we were attempting to bring about. With this in mind we approached President Henry S. Pritchett of the Carnegie Foundation, presented to him the evidence we had accumulated and asked him to make it the subject of a special report on medical education to be published by the Carnegie Foundation. He enthusiastically agreed to this proposition.” (Bevan, Arthur Dean. Cooperation in Medical Education and Medical Service: Functions of the Medical Profession, of the University and of the Public. The Journal of the American Medical Association 90(15) (April 14, 1928): 1175.)

Dr. Carlos J. M. Martini, President of the AMA’s Medical Education Group, wrote in 1990:

“Recognizing the need for overall public support of its efforts, the Council approached the Carnegie Foundation for the Advancement of Teaching to enlist its aid as a neutral party.” (Martini, Carlos J. M. An Estimable Legacy. The Journal of the American Medical Association 264(7) (August 15, 1990): 796.)

In sum, the Council spearheaded the effort to create The Flexner Report as a follow up to its own efforts to rank medical schools and thereby raise educational standards in the United States.

Concerns about independence

The Council provided the Foundation with data that had been collected during the course of its work, to provide a baseline and framework for the new report. However, the Council and the Carnegie Foundation agreed that it would be best if the Council was not directly recognized as spearheading the new report. The Council and the Carnegie Foundation believed that the observations and recommendations in the report would be more widely accepted if they came “from a neutral educational foundation of high standing” (A History of the Council on Medical Education and Hospitals of the American Medical Association, 1904- 1959, pg. 10.). Consequently, the Carnegie Foundation appointed their own investigator, Mr. Abraham Flexner, to lead the investigation of medical schools in the United States and Canada. According to Dr. Bevan:

“He [President Henry S. Pritchett] was fortunate in the selection of the man to make this report, Abraham Flexner, who had a wide knowledge of general education and a genius for this sort of work.” (Bevan, Arthur Dean. Cooperation in Medical Education and Medical Service: Functions of the Medical Profession, of the University and of the Public. The Journal of the American Medical Association 90(15) (April 14, 1928): 1175.)

An excerpt from the minutes of the December 1908 meeting of the Council (New York) states:

“At one o’clock an informal conference was held with President Pritchett and Mr. Abraham Flexner of the Carnegie Foundation. Mr. Pritchett had already expressed, by correspondence, the willingness of the Foundation to cooperate with the Council in investigating the medical schools. He now explained that the Foundation was to investigate all the professions, law, medicine and theology. He had found no efforts being made by law to better the conditions in legal education and had met with some slight opposition in the efforts he was making. He had then received the letters from the Council on Medical Education and expressed himself as most agreeably surprised not only at the efforts being made to correct conditions surrounding medical education but at the enormous amount of important data collected.

“He agreed with the opinion previously expressed by the members of the Council that while the Foundation would be guided very largely by the Council’s investigation, to avoid the usual claims of partiality no more mention should be made in the report of the Council than any other source of information. The report would therefore be, and have the weight of an independent report of a disinterested body,

which would then be published far and wide. It would do much to develop public opinion.” (Reprinted in A History of the Council on Medical Education and Hospitals of the American Medical Association, 1904-1959, pg. 10.; Reprinted in Johnson, Victor. A History of the Council on Medical Education and Hospitals of the American Medical Association, pg. 11. In Fishbein, Morris. A History of the American Medical Association, 1847-1947. Philadelphia: W. B. Saunders Company, 1947.)

Dr. Martini summarized the situation this way:

“The Foundation responded enthusiastically and appointed Abraham Flexner, MA, to conduct a continuing investigation of the medical schools. Although the Foundation would be directed fundamentally by the Council’s previous investigations, it was decided that to guarantee the objectivity and partiality of the final report, the Council would be mentioned only as a source of information.” (Martini, Carlos J. M. An Estimable Legacy. The Journal of the American Medical Association 264(7) (August 15, 1990): 796.)

Implementation of the Flexner Report

Dr. Nathan P. Colwell—secretary of the Council from 1904 to 1931—accompanied Flexner on many, if not all, of the medical school site visits in preparation for The Flexner Report.

According to historical documents at the American Medical Association:

“The Carnegie study [The Flexner Report] was begun in January, 1909, by Mr. Abraham Flexner for the Carnegie Foundation and Dr. N. P. Colwell of the Council. Their results were published in 1910 in what is commonly known as ‘The Flexner Report’.” (A History of the Council on Medical Education and Hospitals of the American Medical Association, 1904-1959, pg. 10.; Johnson, Victor. A History of the Council on Medical Education and Hospitals of the American Medical Association, pg.

11. Reprinted from Fishbein, Morris. A History of the American Medical Association, 1847-1947. Philadelphia: W. B. Saunders Company, 1947.)

And:

“The Carnegie Foundation for the Advancement of Teaching was receptive to the overtures of the Council on Medical Education and beginning in 1909, a survey of all medical schools in the United States and Canada was conducted by Mr. Abraham Flexner of the Carnegie Foundation and Dr. N. P. Colwell of the Council.” (Future Directions for Medical Education, A Report of The Council on Medical Education, Adopted June 15, 1982, by The House of Delegates of the American Medical Association, pg. 58-59.)

The Council decided that The Flexner Report should be released before the Council released its 1910 publication of “satisfactory colleges,” to enhance the impact of the latter. The minutes of the December 1908 Council meeting state that:

“It was considered wise to withhold publication of the list of satisfactory colleges until the Carnegie report [The Flexner Report] comes out…(so that)…that report would make the council’s report at a later date more effective.” (Reprinted in A History of the Council on Medical Education and Hospitals of the American Medical Association, 1904-1959, pg. 10.; Reprinted in Johnson, Victor. A History of the Council on Medical

Education and Hospitals of the American Medical Association, pg. 11. In Fishbein, Morris. A History of the American Medical Association, 1847-1947. Philadelphia: W.

1. Saunders Company, 1947

Since the research for The Flexner Report and the list of “satisfactory colleges” were both gathered from 1909 to 1910 by the Council (JAMA 57(8) (1911): 659; JAMA 65(8) (1915): 717), and since Flexner and Colwell largely performed this research together, it is likely that the two reports were based on the same data.

Recommendations of the Flexner Report

Although the AMA played an instrumental role in creating The Flexner report and collaborated in data collection, the AMA did not officially endorse the recommendations within The Flexner Report. In particular, no AMA policy statements or reports of the era addressed the education of African Americans or the performance and role of African American medical colleges. In view of the Council’s decision that the AMA should maintain some distance from the public release of the report, to enhance its credibility and impact, this lack of explicit, public support for the report’s recommendations is not surprising.

However, implicit support for the basic recommendations of the report existed in the ongoing work of the Council to rate medical schools, which helped to maintain pressure on schools to close if they could not meet the standards laid out in the Flexner Report. African American schools consistently rated in the lowest tier of the Council’s rating categories.

References

1. A History of the Council on Medical Education and Hospitals of the American Medical Association, 1904-1959,
pg. 10.

2. Medicine Pays Tribute to Dr. Flexner. American Medical Association News, October 5, 1959.

3. Bevan, Arthur Dean. Cooperation in Medical Education and Medical Service: Functions of the Medical Profession, of the University and of the Public. The Journal of the American Medical Association 90(15) (April 14, 1928): 1175.

4. Future Directions for Medical Education, A Report of The Council on Medical Education, Adopted June 15, 1982, by The House of Delegates of the American Medical Association, pg. 58-59.

5. Johnson, Victor. A History of the Council on Medical Education and Hospitals of the American Medical Association, pg. 11. Reprinted from Fishbein, Morris. A History of the American Medical Association, 1847-1947. Philadelphia: W. B. Saunders Company, 1947.

6. Martini, Carlos J. M. An Estimable Legacy. The Journal of the American Medical Association 264(7) (August 15, 1990): 796.

7. Medical Education—A Review of Fifteen Years’ Progress. The Journal of the American Medical Association 65(8) (August 21, 1915): 717.

8. Seven Years’ Progress in Medical Education. The Journal of the American Medical Association 57 (8) (August 19, 1911): 659.