Reconstruction to WWI: Rebuilding the nation,

reforming the profession

HI31LWeek 8

Rebuilding the nation, reforming the profession

I. BackgroundII. The Flexner Report

“Progress for the future would seem to require”: Flexner’s critiques:

“A poor medical school is justified in the interests of the poor boy”: Critiques of Flexner

III. Impact and after-effects

The business of medical education

• Diploma allowed as equivalent of med exam pass for licensing

• ‘proprietary medical schools’• ‘Quiz-compends’ and teaching to

the exam…• The stigma of ‘commercialism’

‘Regular’ medicine fights back

• Foundation of the AMA• ‘Old code’ and anti

association/consultation clause• Efforts to reform from within, to

fight medicine as a ‘trade’, and to raise status (and pay) of physicians

• Efforts to limit production of new MDs

Changing aspects of medical

education

Instruction in Physical Diagnosis 1903-4

Teaching Rounds, c. 1944

Elite Medical Education, pre-Flexner

• “During the last two years [of medical school] we had a few clinical lectures in the Vanderbilt clinic, but we never came within a mile of touching the patient.”

Abraham Flexner• 1866-1959• BA Johns Hopkins,

1886• NOT a physician, but

an educator• Worked under

auspices of and alongside AMA

• Adopted Johns Hopkins Medical School (itself modelled on German medicine) as ideal

Necessary conditions for Flexner’s revolution

• increased population of consumers• reduced competition among doctors• acceptance of physical observation in diagnosis• acceptance of need for clinical training (in

physical observation etc.)• popular acceptance of the hospital• acceptance that medicine had something of

unique value to offer:• acceptance of the idea of exclusive knowledge

and expertise about the body -- in essence, acceptance of elites

• State licensing boards able to require certain standards of medical education, plus examination

Impact and After Effects

• 1920 85 med schools; total number of physicians in US drops like a stone for first time ever.

• 1930, surviving medical schools require BA for admission; total number of physicians stabilizes (but 25% of American healers are either osteopaths, Christian Scientists, or chiropractors)

• By 1950s, doctors are highest paid professionals in the country

Conceptual Questions

• How and when did the medical school begin to take its modern shape, and what roles did science, competition, and the search for authority and control each play in the process? Who benefited and who lost out in the modernization of this vital institution – and why?

Reading: Terms and Concepts

• AMA code of ethics• ‘regular physicians’• “fewer and better

doctors”• Hospital Dispensary• Progressive Era• ‘sundown institutions’• Diploma mills• AAMC• “the standardizing

influence of the university”

• “teaching hospital” • “sectarian medicine”• “medical sciences”

• Morrill Act• Case records/efficiency

test• Rockefeller Institute• Carnegie Foundation• Johns Hopkins Medical

School• Temple University of

School of Medicine• Medical Education in the

United States and Canada

• doctor shortages• ‘clinical material’• ‘scientific management’

Reading Questions

• Why was the Flexner Report so influential? What factors played a role in its acceptance and implementation? How did this report fit in with and draw upon wider social trends and developments of the immediately preceding period? And how did it affect the medical profession (and patients) in the 20th century?