Flexner urged medicine to become social and preventive rather than individual and curative.
The Eugenics Congress welcomed the same message 2 years later.
In 2021 the AAMC and the AMA followed suit.
As in the eugenics movement, an elite group wants to correct all the ills of society while seizing ever-greater control of public discourse and institutional power.
This medical mission-creep has not escaped the notice of academics. Norwegian ethicist Bjorn Hofmann warned of this last year.
1. from targeting experienced phenomena, such as angina, to controlling non-experienced phenomena, such as elevated cholesterol
2. from addressing present pain and suffering to preventing potential future suffering, as with screening for cancer and heart disease
3. from reducing negative wellbeing to promoting positive wellbeing. I quote the preamble to the Constitution of the World Health Organization (Yes, they really do have a Constitution… I think they hold these truths to be self-evident.) "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Hofmann’s warning:
These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship.
"Social and preventative" medicine? In other words, this was public health medicine. Because of the severity and prevalence of communicable disease at that time. Cholera, typhoid, small pox, TB, etc., were big killers. The two Black medical schools that Flexner helped for 40 years to survive (Meharry and Howard) also emphasized research and education in public health for their medical students at the time Flexner was writing his report.
That is true, but the Flexner Report can be read as saying, "That's all you should do." That Daniel Hale Williams III shouldn't do open-heart surgery, Samuel Lee Kountz, Jr. shouldn't do kidney transplants, and Ben Carson shouldn't do brain surgery. Thanks to authors like you, I've come to doubt that that was Flexner's inner wish, but read in isolation, the Flexner Report sounds as if that's the goal. And, while public health is vitally important, Flexner, his contemporary eugenicists, and today's AAMC sail us all into dangerous waters with their metastatic definitions and missions of public health.
Meharry and Howard did emphasized public health, because of the overriding need by the Black communities. But their graduates received the broad education necessary to pass the board exams that all physicians were required to pass for licensure. And if a school couldn't produced licensed graduates, it was in a world of hurt.
Agreed. I am only referring to the specific wording of the Flexner Report, which one can read as relegating Black doctors to public health work. And again, I think it’s likely—though not certain—that that wording reflected not Flexner’s inner views, but rather what he had to say to stay within the AMA’s and AAMC’s 1910 Overton Window. Not unlike his fellow Kentuckian, Abraham Lincoln, 50 years earlier, speaking as if slavery were secondary to his intentions—when I suspect abolition was absolutely central to his every thought. With Flexner, as with Lincoln, those questions will never be fully answered.
"Relegating Black doctors to public health work." Perhaps you aren't aware that public health physicians were held in the highest esteem because of the prevalence of communicable diseases and their research which helped to control disease.
While AMA and AAMC appear to have been racist organizations, Flexner answered to the Carnegie and Rockefeller foundations, and I think history answers where Flexner stood. He readily admits to a learning curve – as in not understanding how poorly Black children were education in the South – but would a racist establish post-grad education for Black physicians? Would he work for public K-12 education for Black children in the South? Would he be on the board of a Black medical school and raise $8M for the education of Black physicians over his lifetime?
Flexner's reputation, more than anything else, suffers from modern-day presentism. I have fallen prey to the malady myself with him: I was struck by his one-sided advocacy of philanthropic financing of medical schools, dooming one of the Black medical schools (Leonard) simply because it was entrepeneurial. But at the time, the best of the best schools were all philanthropically endowed, while the worst of the worst were invariably opportunistic endeavors by solo practitioners. He and his Report were both of their time and revolutionary. It's all too easy to judge historical characters using expectations and knowledge not available in their time. Flexner wasn't a demigod, but neither was he a bigot. For what he achieved in helping to establish the primacy of science in American medicine and medical education at a crucial time in their development, historical investigation shows he earned the pedestal upon which he was placed, and it outweighs any presentistic caveats. I doubt that any modern-day problems or failings in public health & academic medicine can be reliably traced back to anything Abraham Flexner did or said a century ago.
Your article is, indeed, excellent. I read it shortly after it was published, and it was one of the pieces that influenced me to rethink Flexner. In fact, it's such a good piece that I regret not linking to it in my article. (I'll try to correct that in a future piece.) I agree with most of what you say, but I think it supports my two-part thesis: (1) the AAMC (along with the AMA) scapegoats Flexner for its own long-term shortcomings, and ignores the great positives he brought to medical education and the practice of medicine, and (2) Flexner is legitimately problematic, but primarily because his views were so SIMILAR to the dangerous agendas of today's AAMC and AMA--excessive faith in credentialed experts, suppression of scientific dissent, ideological litmus tests, and social engineering in lieu of individual care. To paraphrase Shakespeare, the AAMC doth protest too much, methinks.
Since Flexner's leading biographer – Thomas Neville Bonner ("Iconoclast") – is no longer with us, I thought someone needed to react to AAMC's rude dismissal of Flexner.
I'm not seeing anything seriously problematic about Flexner's character. But I allow that I may be missing something.
Are Flexner's values "similar to the dangerous agendas of today's AAMC and AMA." I think Flexner would be appalled at the "woke" AAMC and AMA, the significant lowering standards and rigor; and the emphasis on creating "social warrior" physicians instead of attentive clinicians.
If he had faith in licensed physicians, it was for their acquisition of science-based knowledge and clinical skills which he saw as a plus for society. But he could be critical of some medical schools, licensing boards, and the AMA's biased rating system that allowed less than competent physicians to practice, while competent Black physicians were locked out.
You might be referring to something else here, but the fact that Flexner "suppressed scientific dissent" is something I have long heard from "alternative medicine" practitioners – mostly naturopaths and homeopaths. Oh, how they despise Flexner. But for my tastes, mainstream medicine today does little to protect the public from scientifically invalidated practices. Numerous medical schools even have their own "alternative medicine" department.
As for an emphasis on "social engineering," from what I know of Flexner, I've seen nothing about him having an interest in eugenics. And as an educator, he thought individualize instruction best; that approach seems to have carried over into promoting clinical, bedside skills in a day when many physicians were trained exclusively in the lecture hall.
"Ideological litmus tests"? You have me at a disadvantage here. I don't know what you are referring to or how Flexner may have indulged in it.
Thank you for your comments. I have enjoyed your comments and the discussion.
You did a great service in taking Bonner’s place. It needed saying. I, too, suspect that Flexner would be appalled by the state of medical education and medical discourse c.2023. I agree that there’s no evidence that he was himself a eugenicist, that he wanted ideological litmus tests, or that he suppressed dissent. My point is that his Progressive Era idealism—enlightened educators and licensure boards, deference to credentialed experts, rigid standardization of curriculum and pedagogy—were premised on the assumption that future educators and regulators would be fair, disinterested, benevolent, and open-minded. He, in other words, put all of medicine’s eggs in one giant basket of interwoven institutions. That institutional structure meant that, for example, when the AAMC in 2023 demands ideological fealty of med school applicants and students, that there is no safety valve by which applicants, students, educators, and licensers can reject such demands. There is only one AAMC, and it holds the keys to every medical school which, in turn, hold the keys to every med student. When the AAMC decides that DEI supersedes science, Flexner’s idealistic vision of centralized governance has disarmed any who dare to dissent. For me, the problem is his naïveté—not ill intentions.
I grant you that things look very grim today for American medical education, as in much of higher education. Who anticipated wokeism taking over medical education even 20 years ago, much less 120 years ago? My hope is that it's too extreme to survive.
Something the AAMC is obviously ignoring:
In 2010, on the 100th anniversary of the Flexner Report, the Carnegie Foundation asked educator David Irby to conduct another review of medical education in the USA. Irby's report urges for improvements that Flexner would approve: e.g. emphasizing qualified instructors, more patient contact, and scientific rigor.
Mar 27, 2023·edited Mar 27, 2023Liked by Robert F. Graboyes
The article's mention of allopathy as a label for the scientific practice of medicine is misguided. "Allopathy" is the label invented in the 19th Century by Samuel Hahnemann, creator of the homeopathy quackery, applying it to the practice of medicine contravening his own. It has nothing to do with today's medicine. Use of the label today is a false flag raised by practitioners of 'alternative medicine' or 'natural medicine', and is also a thinly disguised insult. Part of the irony of some true medical practitioners adopting the term is that by using it themselves, they are contradicting of the very point which Flexner explicitly made in his Report: that a scientific outlook in medical education & practice was antithetical to *both* homeopathy and allopathy.
Allopathy, at the time of Flexner's review of medical schools, was based on the notion of four "humors" (blood, phlegm, yellow bile, and black bile) and all the miserable practices to "bring them into balance." Flexner reported (p.162) the famous Dr. Osler's opinion of allopaths: "A new school of [science-based medical] practitioners has arisen which cares nothing for homeopathy and less for so-called allopathy."
Note my comments above to Larry Sarner. Very informative. I’ve clearly been using “allopathy” in its modern sense, and not in the sense extant in Flexner’s time. And I do plan to add an addendum to my article to recognize what you’ve both said. Thanks so much.
Interesting! I didn’t know the origins of the word. I suspect that what we have here is similar to the etymological life-cycle of “capitalism.” The word was popularized by mid-19th century socialists as a pejorative. Eventually, the objects of their scorn accepted the term and wore it with pride. Some quick reading this morning makes clear that you are correct—that Hahneman created the word as a pejorative. Somewhere along the line, the word’s vibe changed. The second paragraph of the Wikipedia entry on allopathic medicine describes Hahneman’s coinage. The third paragraph says that in 2001, the WHO defined allopathic medicine as “the broad category of medical practice that is sometimes called Western medicine, biomedicine, evidence-based medicine, or modern medicine.” The Wiki article says the WHO uses “allopathic medicine” to differentiate its practitioners from traditional and alternative medicine. I’ll add an addendum to my article to recognize what you’ve said here. And when I have time, I’ll re-read the Flexner Report with your comments in mind. Thanks so much for the thoughtful comments.
I was unaware of the WHO "definition", probably because I don't regard it (WHO) as having any authority—definitionally, etymologically or otherwise. I'm not surprised, though, to learn it goes on to say the term denotes what is "sometimes called Western medicine, biomedicine, evidence-based medicine, or modern medicine." Proponents of "other ways of knowing," had been desperately seeking some way of collectively distinguishing their beliefs & practices from that which accounts for the model practiced by successful medical practitioners. They finally found it, not for their collective selves (eclectics, Flexner called them), but for their competition. They realized the marketing disadvantage they would have in calling what real physicians do with the correct modifier: *scientific* medicine.
Myself, I don't believe any modifier is necessary, much less desirable. WHO notwithstanding, there is no "category of medical practice" other than scientific. There is only *medicine*. There is no other way of knowing what it really is than by science.
I didn’t know the WHO quote till today. But I’ve long heard “allopathic medicine” used in ways consistent with the WHO description. “eclectic” medicine long predated Flexner, and its practitioners used the term themselves. There were medical schools whose official name included the word “eclectic” as early as the 1830s. The multicultural and regional aspects were considered a plus.
Mar 28, 2023·edited Mar 28, 2023Liked by Robert F. Graboyes
Exactly. And it resulted in the hodge-podge of "medical schools" that existed in the early 20th Century. Flexner's Report was consistent in calling for their dissolution as paradigmatic of the non-scientific approach to medicine; a few must have been described as "allopathic." Anyway, it's clear that the term "allopathic" has been resurrected and repurposed to avoid having "scientific" being applied to real medicine.
Enjoyed your post.
Loved the video.
Now attempting to stop myself from buying a Justin Johnson Signature 3-string Shovel guitar.
https://justinjohnsonstore.com/collections/guitars/products/signature-3-string-shovel-guitar
Thanks! Go buy the guitar. If you don't, you'll regret it for the rest of your life. :)
Flexner urged medicine to become social and preventive rather than individual and curative.
The Eugenics Congress welcomed the same message 2 years later.
In 2021 the AAMC and the AMA followed suit.
As in the eugenics movement, an elite group wants to correct all the ills of society while seizing ever-greater control of public discourse and institutional power.
This medical mission-creep has not escaped the notice of academics. Norwegian ethicist Bjorn Hofmann warned of this last year.
(Managing the Moral Expansion of Medicine, BMC Medical Ethics, September 2022 — https://pubmed.ncbi.nlm.nih.gov/36138414/.)
Hofmann identifies 3 patterns of expansion
1. from targeting experienced phenomena, such as angina, to controlling non-experienced phenomena, such as elevated cholesterol
2. from addressing present pain and suffering to preventing potential future suffering, as with screening for cancer and heart disease
3. from reducing negative wellbeing to promoting positive wellbeing. I quote the preamble to the Constitution of the World Health Organization (Yes, they really do have a Constitution… I think they hold these truths to be self-evident.) "Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity."
Hofmann’s warning:
These expansions create and aggravate problems in medicine: medicalization, overdiagnosis, overtreatment, risk aversion, stigmatization, and healthism. Moreover, they threaten to infringe ethical principles, to distract attention and responsibility from other competent agents and institutions, to enhance the power and responsibility of professionals, and to change the professional-beneficiary relationship.
Fantastic observations. Something akin to “Minority Report”—the Precrime Unit. I’ll probably steal this from you (giving you credit, of of course).
"Social and preventative" medicine? In other words, this was public health medicine. Because of the severity and prevalence of communicable disease at that time. Cholera, typhoid, small pox, TB, etc., were big killers. The two Black medical schools that Flexner helped for 40 years to survive (Meharry and Howard) also emphasized research and education in public health for their medical students at the time Flexner was writing his report.
That is true, but the Flexner Report can be read as saying, "That's all you should do." That Daniel Hale Williams III shouldn't do open-heart surgery, Samuel Lee Kountz, Jr. shouldn't do kidney transplants, and Ben Carson shouldn't do brain surgery. Thanks to authors like you, I've come to doubt that that was Flexner's inner wish, but read in isolation, the Flexner Report sounds as if that's the goal. And, while public health is vitally important, Flexner, his contemporary eugenicists, and today's AAMC sail us all into dangerous waters with their metastatic definitions and missions of public health.
Meharry and Howard did emphasized public health, because of the overriding need by the Black communities. But their graduates received the broad education necessary to pass the board exams that all physicians were required to pass for licensure. And if a school couldn't produced licensed graduates, it was in a world of hurt.
Agreed. I am only referring to the specific wording of the Flexner Report, which one can read as relegating Black doctors to public health work. And again, I think it’s likely—though not certain—that that wording reflected not Flexner’s inner views, but rather what he had to say to stay within the AMA’s and AAMC’s 1910 Overton Window. Not unlike his fellow Kentuckian, Abraham Lincoln, 50 years earlier, speaking as if slavery were secondary to his intentions—when I suspect abolition was absolutely central to his every thought. With Flexner, as with Lincoln, those questions will never be fully answered.
"Relegating Black doctors to public health work." Perhaps you aren't aware that public health physicians were held in the highest esteem because of the prevalence of communicable diseases and their research which helped to control disease.
While AMA and AAMC appear to have been racist organizations, Flexner answered to the Carnegie and Rockefeller foundations, and I think history answers where Flexner stood. He readily admits to a learning curve – as in not understanding how poorly Black children were education in the South – but would a racist establish post-grad education for Black physicians? Would he work for public K-12 education for Black children in the South? Would he be on the board of a Black medical school and raise $8M for the education of Black physicians over his lifetime?
Flexner's reputation, more than anything else, suffers from modern-day presentism. I have fallen prey to the malady myself with him: I was struck by his one-sided advocacy of philanthropic financing of medical schools, dooming one of the Black medical schools (Leonard) simply because it was entrepeneurial. But at the time, the best of the best schools were all philanthropically endowed, while the worst of the worst were invariably opportunistic endeavors by solo practitioners. He and his Report were both of their time and revolutionary. It's all too easy to judge historical characters using expectations and knowledge not available in their time. Flexner wasn't a demigod, but neither was he a bigot. For what he achieved in helping to establish the primacy of science in American medicine and medical education at a crucial time in their development, historical investigation shows he earned the pedestal upon which he was placed, and it outweighs any presentistic caveats. I doubt that any modern-day problems or failings in public health & academic medicine can be reliably traced back to anything Abraham Flexner did or said a century ago.
More reading on Flexner reveals a different characterization:
https://www.physicianoutlook.com/articles/abraham-flexner-academic-medicines-favorite-scapeg
Your article is, indeed, excellent. I read it shortly after it was published, and it was one of the pieces that influenced me to rethink Flexner. In fact, it's such a good piece that I regret not linking to it in my article. (I'll try to correct that in a future piece.) I agree with most of what you say, but I think it supports my two-part thesis: (1) the AAMC (along with the AMA) scapegoats Flexner for its own long-term shortcomings, and ignores the great positives he brought to medical education and the practice of medicine, and (2) Flexner is legitimately problematic, but primarily because his views were so SIMILAR to the dangerous agendas of today's AAMC and AMA--excessive faith in credentialed experts, suppression of scientific dissent, ideological litmus tests, and social engineering in lieu of individual care. To paraphrase Shakespeare, the AAMC doth protest too much, methinks.
Thank you for the kind words about my article.
Since Flexner's leading biographer – Thomas Neville Bonner ("Iconoclast") – is no longer with us, I thought someone needed to react to AAMC's rude dismissal of Flexner.
I'm not seeing anything seriously problematic about Flexner's character. But I allow that I may be missing something.
Are Flexner's values "similar to the dangerous agendas of today's AAMC and AMA." I think Flexner would be appalled at the "woke" AAMC and AMA, the significant lowering standards and rigor; and the emphasis on creating "social warrior" physicians instead of attentive clinicians.
If he had faith in licensed physicians, it was for their acquisition of science-based knowledge and clinical skills which he saw as a plus for society. But he could be critical of some medical schools, licensing boards, and the AMA's biased rating system that allowed less than competent physicians to practice, while competent Black physicians were locked out.
You might be referring to something else here, but the fact that Flexner "suppressed scientific dissent" is something I have long heard from "alternative medicine" practitioners – mostly naturopaths and homeopaths. Oh, how they despise Flexner. But for my tastes, mainstream medicine today does little to protect the public from scientifically invalidated practices. Numerous medical schools even have their own "alternative medicine" department.
As for an emphasis on "social engineering," from what I know of Flexner, I've seen nothing about him having an interest in eugenics. And as an educator, he thought individualize instruction best; that approach seems to have carried over into promoting clinical, bedside skills in a day when many physicians were trained exclusively in the lecture hall.
"Ideological litmus tests"? You have me at a disadvantage here. I don't know what you are referring to or how Flexner may have indulged in it.
Thank you for your comments. I have enjoyed your comments and the discussion.
You did a great service in taking Bonner’s place. It needed saying. I, too, suspect that Flexner would be appalled by the state of medical education and medical discourse c.2023. I agree that there’s no evidence that he was himself a eugenicist, that he wanted ideological litmus tests, or that he suppressed dissent. My point is that his Progressive Era idealism—enlightened educators and licensure boards, deference to credentialed experts, rigid standardization of curriculum and pedagogy—were premised on the assumption that future educators and regulators would be fair, disinterested, benevolent, and open-minded. He, in other words, put all of medicine’s eggs in one giant basket of interwoven institutions. That institutional structure meant that, for example, when the AAMC in 2023 demands ideological fealty of med school applicants and students, that there is no safety valve by which applicants, students, educators, and licensers can reject such demands. There is only one AAMC, and it holds the keys to every medical school which, in turn, hold the keys to every med student. When the AAMC decides that DEI supersedes science, Flexner’s idealistic vision of centralized governance has disarmed any who dare to dissent. For me, the problem is his naïveté—not ill intentions.
I grant you that things look very grim today for American medical education, as in much of higher education. Who anticipated wokeism taking over medical education even 20 years ago, much less 120 years ago? My hope is that it's too extreme to survive.
Something the AAMC is obviously ignoring:
In 2010, on the 100th anniversary of the Flexner Report, the Carnegie Foundation asked educator David Irby to conduct another review of medical education in the USA. Irby's report urges for improvements that Flexner would approve: e.g. emphasizing qualified instructors, more patient contact, and scientific rigor.
https://www.youtube.com/watch?v=VbUfW8zrsJU
https://biostat.app.vumc.org/wiki/pub/Main/EnduringConcepts/Irby_Cooke_OBrien.pdf
Thanks! I’ll look forward to reviewing these links.
The article's mention of allopathy as a label for the scientific practice of medicine is misguided. "Allopathy" is the label invented in the 19th Century by Samuel Hahnemann, creator of the homeopathy quackery, applying it to the practice of medicine contravening his own. It has nothing to do with today's medicine. Use of the label today is a false flag raised by practitioners of 'alternative medicine' or 'natural medicine', and is also a thinly disguised insult. Part of the irony of some true medical practitioners adopting the term is that by using it themselves, they are contradicting of the very point which Flexner explicitly made in his Report: that a scientific outlook in medical education & practice was antithetical to *both* homeopathy and allopathy.
Allopathy, at the time of Flexner's review of medical schools, was based on the notion of four "humors" (blood, phlegm, yellow bile, and black bile) and all the miserable practices to "bring them into balance." Flexner reported (p.162) the famous Dr. Osler's opinion of allopaths: "A new school of [science-based medical] practitioners has arisen which cares nothing for homeopathy and less for so-called allopathy."
Note my comments above to Larry Sarner. Very informative. I’ve clearly been using “allopathy” in its modern sense, and not in the sense extant in Flexner’s time. And I do plan to add an addendum to my article to recognize what you’ve both said. Thanks so much.
Interesting! I didn’t know the origins of the word. I suspect that what we have here is similar to the etymological life-cycle of “capitalism.” The word was popularized by mid-19th century socialists as a pejorative. Eventually, the objects of their scorn accepted the term and wore it with pride. Some quick reading this morning makes clear that you are correct—that Hahneman created the word as a pejorative. Somewhere along the line, the word’s vibe changed. The second paragraph of the Wikipedia entry on allopathic medicine describes Hahneman’s coinage. The third paragraph says that in 2001, the WHO defined allopathic medicine as “the broad category of medical practice that is sometimes called Western medicine, biomedicine, evidence-based medicine, or modern medicine.” The Wiki article says the WHO uses “allopathic medicine” to differentiate its practitioners from traditional and alternative medicine. I’ll add an addendum to my article to recognize what you’ve said here. And when I have time, I’ll re-read the Flexner Report with your comments in mind. Thanks so much for the thoughtful comments.
I was unaware of the WHO "definition", probably because I don't regard it (WHO) as having any authority—definitionally, etymologically or otherwise. I'm not surprised, though, to learn it goes on to say the term denotes what is "sometimes called Western medicine, biomedicine, evidence-based medicine, or modern medicine." Proponents of "other ways of knowing," had been desperately seeking some way of collectively distinguishing their beliefs & practices from that which accounts for the model practiced by successful medical practitioners. They finally found it, not for their collective selves (eclectics, Flexner called them), but for their competition. They realized the marketing disadvantage they would have in calling what real physicians do with the correct modifier: *scientific* medicine.
Myself, I don't believe any modifier is necessary, much less desirable. WHO notwithstanding, there is no "category of medical practice" other than scientific. There is only *medicine*. There is no other way of knowing what it really is than by science.
I didn’t know the WHO quote till today. But I’ve long heard “allopathic medicine” used in ways consistent with the WHO description. “eclectic” medicine long predated Flexner, and its practitioners used the term themselves. There were medical schools whose official name included the word “eclectic” as early as the 1830s. The multicultural and regional aspects were considered a plus.
Exactly. And it resulted in the hodge-podge of "medical schools" that existed in the early 20th Century. Flexner's Report was consistent in calling for their dissolution as paradigmatic of the non-scientific approach to medicine; a few must have been described as "allopathic." Anyway, it's clear that the term "allopathic" has been resurrected and repurposed to avoid having "scientific" being applied to real medicine.