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The Flexner Report: Standardizing Medical Students Through Region-, Gender-, and Race-Based Hierarchies

Published online by Cambridge University Press:  06 January 2021

Abstract

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Copyright © American Society of Law, Medicine and Ethics and Boston University 2017

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References

1 See Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (1910).

2 See Duffy, Thomas P., The Flexner Report–100 Years Later, 84 Yale J. Biology & Med. 269, 269 (2011)Google ScholarPubMed, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3178858/pdf/yjbm_84_3_269.pdf [https://perma.cc/Z5E5-3XA3].

3 See Flexner, supra note 1, at 17 (“It appears, then, that the country needs fewer and better doctors; and that the way to get them better is to produce fewer.”).

4 See Henry S. Pritchett, Introduction to Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching, at viii (1910).

5 See id. at x–xi.

6 See id.

7 See Flexner, supra note 1, at 185-326; Martin Kaufman, American Medical Education: The Formative Years, 1765–1910 169 (1976).

8 Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life in Learning 1–2 (2002).

9 See Neil A Grauer, Leading the Way: A History of Johns Hopkins Medicine 41 (2012). Abraham Flexner was a protégé of Daniel Coit Gilman, one of the founders of John Hopkins Hospital. Id. Flexner’s older brother Simon was a medical doctor trained at Hopkins with some financial help from Abraham. Id.

10 Michael Spangler, Abraham Flexner Papers, Manuscript Division, Library of Congress, http://lcweb2.loc.gov/service/mss/eadxmlmss/eadpdfmss/2003/ms003042.pdf [https://perma.cc/RUS2-6LS9].

11 See Abraham Flexner, The American College: A Criticism (1908); Paul Starr, The Social Transformation of American Medicine 118 (1982).

12 See William G. Rothstein, American Medical Schools and the Practice of Medicine: A History 144 (1987).

13 See id. at 143.

14 See id. at 144.

15 John Duffy, From Humors to Medical Science: A History of American Medicine 137 (1993).

16 Flexner, supra note 1, at 15–16.

17 See Kaufman, supra note 7, at 109–24.

18 See id.

19 See id.

20 See id.

21 Flexner, supra note 1; see also Kaufman, supra note 7, at 171–79; William G. Rothstein, supra note 12, at 119–20 (1987).

22 George Rosen, The Structure of American Medical Practice, 1875–1941 50–51 (1983).

23 Id. at 59–61.

24 Id. at 64.

25 Charles E Rosenberg, The Care of Strangers: The Rise of Americas Hospital System 9 (1987).

26 Robert P. Hudson, Abraham Flexner in Historical Perspective, in Beyond Flexner: Medical Education in the Twentieth Century 15 (Norman Gevitz & Barbara Barzansky eds., 1992).

27 See Kaufman, supra note 7, at 173.

28 See John Daniel Martin & Garland D. Perdue, The History of Surgery at Emory University School of Medicine 15 (1979).

29 See id. at 4.

30 See id. at 11–12.

31 See id. at 2–22.

32 See Lloyd C. Taylor, The Medical Profession and Social Reform, 1885–1945 45–46 (1974).

33 Flexner, supra note 1, at 3–6; see also Martin Kaufman, American Medical Education, in The Education of American Physicians: Historical Essays 7–8 (Ronald L. Numbers ed., 1980).

34 Flexner, supra note 1, at 6.

35 Flexner, supra note 1, at 11.

36 See Kaufman, supra note 33, at 20–21; Rosen, supra note 22, at 63–66; Starr, supra note 11, at 119.

37 See Flexner, supra note 1, at 13.

38 See id. at 14.

39 See id.

40 See id. at 16–17.

41 Id. at 17.

42 Id.

43 Id. at 22.

44 See id.

45 See Kaufman, supra note 33, at 21; Rothstein, supra note 12, at 144.

46 Flexner, supra note 1, at 17.

47 Id. at 40.

48 See id. at 148.

49 See id. at 148 n.2.

50 See id. at 42–43.

51 See id. at 24–26.

52 See Edward C. Atwater, Clinical Education Since Flexner or Whatever Became of William Osler?, in Beyond Flexner: Medical Education in the Twentieth Century, supra note 26, at 43.

53 See Flexner, supra note 1, at 36.

54 See id.

55 See id. at 40–41.

56 See id. at 6, 9, 41.

57 See id. at 24–26.

58 See generally Atwater, supra note 52, at 45–47 (discussing different forms of undergraduate clinical education before medical school).

59 See Flexner, supra note 1, at 28.

60 Id. at 36.

61 See id.

62 See id.

63 See id. at 37.

64 Id. at 36–37.

65 Id. at 41.

66 Id.

67 See id. at 42–44.

68 See id. Flexner applies a logic similar to opponents of affirmative action, stating that efforts to level the playing field in regards to equal access to education is premised on lowering the bar for some at the expense of others. See id.

69 See id. at 45.

70 See Rosen, supra note 22, at 66–67. But see Flexner, supra note 1, at 43 (“Doubtless in the near future, the problem will be still further simplified in the interest of the better training by increased scholarship and other endowments ….”)

71 Flexner, supra note 1, at 30 (“To get at the real admission standard, then, of these medical schools, one must make straight for the ‘equivalent.’”).

72 See id. at 85–89.

73 See id. at 57.

74 See id.

75 See id. at 137–38; see also Rothstein, supra note 12, at 167–68.

76 See Flexner, supra note 1, at 57–69.

77 See id. at 45 (“Of course there are compensations. But the point is that a large financial inducement is not indispensable, provided a man is doing what he likes. In most sections the country doctor has better worldly prospects. The fact stands out that it is not income but taste that primarily attracts men into scholarly or professional life.”).

78 See id. at 71–125.

79 See id.

80 See id. at 76–77.

81 Id. at 85–86.

82 See id. at 88.

83 See id. (“Post mortems are practically nil. None are claimed at … Atlanta ….”).

84 See id. at 93–94 (discussing the importance of “a good clinic in internal medicine”).

85 See Rothstein, supra note 12, at 174–75.

86 Flexner, supra note 1, at 91.

87 See id. at 61.

88 See id.

89 Id. at 65.

90 See generally John S. Haller, American Medicine in Transition: 1840–1910, at 150–91 (1981).

91 Abby L. Wilkerson, Diagnosis: Difference : The Moral Authority of Medicine 18 (1998) (“Abraham Flexner understood Medicine as based strictly in physics, chemistry, biology, and related subdisciplines.”).

92 Flexner, supra note 1, at 62.

93 See generally Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education 175 (1988) (“[Flexner] admired the ‘scientific’ practitioner–the one who evaluated patients carefully, who performed tests only when they were dictated by a patient's particular circumstances, who modified his preliminary impressions on the basis of test results or the response to therapy ….”).

94 Abraham Flexner, Medical Education: A Comparative Study 177 (1925).

95 See DeWitt C. Baldwin, Jr., The Medical Curriculum: Developments and Directions, in Beyond Flexner: Medical Education in the Twentieth Century, supra note 26, at 146–47.

96 See Flexner, supra note 1, at 302–03.

97 See id. at 91–92.

98 This section title draws on the book title But Some Of Us Are Brave: All the Women Are White, All the Blacks Are Men: Black Womens Studies (Gloria T. Hull et al. eds., 2d ed. 2015).

99 Flexner, supra note 1, at 178–81.

100 See Flexner, supra note 1, at 178–81.

101 See Flexner, supra note 1, at 178–79; see also Darlene Clark Hine, Black Women in White: Racial Conflict and Cooperation in the Nursing Profession, 1890–1950 70 (1989).

102 Flexner, supra note 1, at 180.

103 Axelsen, Diana E., Women as Victims of Medical Experimentation: J. Marion Sims’ Surgery on Slave Women, 1845-1850, 2 Sage 10, 1011 (1985).Google Scholar

104 Id. at 10.

105 Id. at 10–13.

106 Id. at 11.

107 Id.

108 See, e.g., Dr. J. Marion Sims, Central Park Conservancy, http://www.centralparknyc.org/things-to-see-and-do/attractions/dr-j-marion-sims.html (2017) (describing J. Marion Sims statue erected in Central Park in New York City, New York); Apply for a Grant, J. Marion Sims Found., http://jmsims.org/home/apply-for-a-grant/ [https://perma.cc/VMK4-34RE] (describing grants issued by the J. Marion Sims Foundation in Sims’ honor).

109 See Flexner, supra note 1, at 178–79.

110 See id. at 178.

111 See id.

112 See id. at 179.

113 See id.

114 See id. at 178–79.

115 See id.

116 Jane Leserman, Men and Women in Medical School 12 (1981). Women were not admitted to the American Medical Association until 1915 and even then were not allowed to examine men’s genitals, though gynecology and obstetric specialties were practiced by men. Id. For more on women in medicine, see Mary Roth Walsh, Doctors Wanted, No Women Need Apply: Sexual Barriers in the Medical Profession 1835-1975 (1977); Women in Medical Education: An Anthology of Experience (Delese Wear ed., 1996).

117 See Flexner, supra note 1, at 180–81.

118 Id. at 180.

119 Id.

120 Id.

121 See id. Conversely, some Black doctors had trouble attracting Black clients because of internalized racism that made Black patients question the aptitude of Black practitioners. See John Dittmer, Black Georgia in the Progressive Era, 1900–1920 35 (1980).

122 See Flexner, supra note 1, at 180.

123 Todd L. Savitt, Abraham Flexner and the Black Medical Schools, in Beyond Flexner: Medical Education in the Twentieth Century, supra note 26, at 72–73.

124 Flexner, supra note 1, at 180.

125 See id. at 180–81.

126 Id. at 181.

127 Id.

128 Epps, Howard R., The Howard University Medical Department in the Flexner Era: 1910-1929, 91 J. Natl Med. Assn 885, 885-911 (1989).Google Scholar

129 Todd L. Savitt, Abraham Flexner and the Black Medical Schools, in Beyond Flexner: Medical Education in the Twentieth Century, supra note 26, at 75.

130 Id. at 76.

131 See James Summerville, Educating Black Doctors: A History of Meharry Medical College 54–55 (1983).

132 See Vernon W. Lippard, A Half-Century of American Medical Education, 1920–1970 104 (1974); Kenneth M. Ludmerer, Time to Heal: American Medical Education from the Turn of the Century to the Era of Managed Care 255 (1999); Molly Cooke et al., American Medical Education 100 Years After the Flexner Report, 355 New Eng. J. Med. 1339, 1343 (2006).

133 Summerville, supra note 131, at 54–55; see generally Todd L. Savitt, Black Doctors: A Strong Medicine to Take in the New South, Crisis, Jan./Feb. 2001, at 26–30.

134 It is important to note that the Flexner Report does not acknowledge Asian, Arab, Indigenous, Latino races or ethnicities. These identity categories were not intelligible at the time of Flexner’s report. The realities for these non-white doctors cannot be gleaned from this document, although Asian and Latino students are visible in the Emory yearbooks. See John D. Martin, Jr. & Garland D. Perdue, The History of Surgery at Emory University School of Medicine 237–46 (1979). The complete erasure of indigenous peoples in Flexner’s report is an important omission because there was a great deal of representational imagery regarding their existence in the late 19th and early 20th century. See, e.g., American Indians and Popular Culture (Elizabeth DeLaney Hoffman ed., 2012); Devon A. Mihesuah, American Indians: Stereotypes & Realities (1996); S. E. Wilmer, Native American Performance and Representation (2009). The ways in which Indigenous bodies were used in medical experimentation and indigenous youth were adopted into white families does register them in the sight of a medical education review if only in the limited scope of patients in need. See Andrea Smith, Conquest: Sexual Violence and American Indian Genocide 109–17 (2005).

135 See Flexner, supra note 1, at 180.

136 Lauran A. Kerr-Heraly, Race, Gender, and African American Women Doctors in the Twentieth Century 7 (2010).

137 See Savitt, supra note 133, at 28.

138 See id.

139 See Vanessa Siddle Walker & Ulysses Byas, Hello Professor: A Black Principal and Professional Leadership in the Segregated South 20 (2009).

140 See 1906 Ga. Laws 1105.

141 See Martin & Perdue, supra note 134, at 14–18.

142 See Crenshaw, Kimberlé Williams, Race, Reform, and Retrenchment: Transformation and Legitimation in Antidiscrimination Law, 101 Harv. L. Rev. 1331 (1988).CrossRefGoogle Scholar

143 See id. at 1362.