Competencies in premedical and medical education: the AAMC-HHMI report

One hundred years ago, Flexner emphasized the importance of science in medicine and medical education. Over the subsequent years, science education in the premedical and medical curricula has changed little, in spite of the vast changes in the biomedical sciences. The National Research Council, in their report Bio 2010, noted that the premedical curriculum caused many students to lose interest in medicine and in the biological sciences in general. Many medical students and physicians have come to view the premedical curriculum as of limited relevance to medicine and designed more as a screening mechanism for medical school admission. To address this, the Association of American Medical Colleges and the Howard Hughes Medical Institute formed a committee to evaluate the premedical and medical school science curricula. The committee made a number of recommendations that are summarized in this essay. Most important were that competencies replace course requirements and that the physical sciences and mathematics be better integrated with the biological sciences and medicine. The goal is that all physicians possess a strong scientific knowledge base and come to appreciate the importance of this to the practice of medicine. While science education needs to evolve, Flexner's vision is as relevant today as it was 100 years ago.     

Evolutionary biology: a basic science for medicine in the 21st century

Evolutionary biology was a poorly developed discipline at the time of the Flexner Report and was not included in Flexner's recommendations for premedical or medical education. Since that time, however, the value of an evolutionary approach to medicine has become increasingly recognized. There are several ways in which an evolutionary perspective can enrich medical education and improve medical practice. Evolutionary considerations rationalize our continued susceptibility or vulnerability to disease; they call attention to the idea that the signs and symptoms of disease may be adaptations that prevent or limit the severity of disease; they help us understand the ways in which our interventions may affect the evolution of microbial pathogens and of cancer cells; and they provide a framework for thinking about population variation and risk factors for disease. Evolutionary biology should become a foundational science for the medical education of the future.     

Abraham Flexner and medical education

The Flexner Report had its roots in the recognition in the mid-19th century that medical knowledge is not something fixed but something that grows and evolves. This new view of medical knowledge led to a recasting of the goal of medical education as that of instilling the proper techniques of acquiring and evaluating information rather than merely inculcating facts through rote memorization. Abraham Flexner, a brilliant educator, had the background to understand and popularize the meaning of this new view of education, and he took the unprecedented step of relating the developments in medical education to the ideas of John Dewey and the progressive education movement. Although the Flexner Report is typically viewed as a historical document--due to an understandable tendency to refer only to the second half of the report, where Flexner provides his famous critiques of the medical schools that existed at the time--this article argues that the Flexner Report is actually a living educational document of as much significance to medical educators today as in Flexner's time. The article analyzes Flexner's discussion of medical education and shows that his message--the importance of academic excellence, professional leadership, proper financial support, and service and altruism--is timeless, as applicable to the proper education of physicians today and tomorrow as in the past.     

Abraham Flexner and the development of the Yale School of Medicine

Abraham Flexner first toured the Yale University School of Medicine in preparation for his report of 1910, but it was just the beginning of his relationship with the school. While his review of Yale in his report was generally favorable, he mentioned several shortfalls that needed to be improved to make the school acceptable. Throughout the next twenty-five years, Flexner worked with Deans George Blumer and Milton C. Winternitz to improve the school's finances, infrastructure, and quality of education through his work with the Carnegie Foundation and General Education Board Flexner has been given great accolades for his work on medical education for the country, but little mention is made of him at Yale, even though he was one of the most influential figures in the development of Yale in the last century.     

Abraham Flexner and the development of the Yale School of Medicine. 1999

Abraham Flexner first toured the Yale University School of Medicine in preparation for his report of 1910, but it was just the beginning of his relationship with the school. While his review of Yale in his report was generally favorable, he mentioned several shortfalls that needed to be improved to make the school acceptable. Throughout the next twenty-five years, Flexner worked with Deans George Blumer and Milton C. Winternitz to improve the school's finances, infrastructure, and quality of education through his work with the Carnegie Foundation and General Education Board. Flexner has been given great accolades for his work on medical education for the country, but little mention is made of him at Yale, even though he was one of the most influential figures in the development of Yale in the last century.     

Medical education in an era of health-care reform

Medical educators are facing a challenge today that is quite analogous to that addressed by Abraham Flexner, namely how to transform a legacy system of education that is no longer preparing future physicians adequately to meet contemporary expectations and responsibilities. In facing up this challenge, however, today's educators not only must equip students to deal effectively with the rapidly changing paradigms in health care and medical practice, they also must adapt their curricula and pedagogical methods to the demanding new paradigms of medical education. Their success in addressing these dual imperatives will determine whether the educational transformations currently underway will have as momentous an effect on the public's health as did those stimulated by Flexner a century ago.     

Flexner redux

Medical education in the 20th century has been vastly influenced by the Carnegie Foundation Flexner Report. The basic tenets of the modern four-year medical curriculum and the dominant role of the associated university teaching hospital were cemented into place and have remained the paradigm of the present-day medical educational process. The Flexner Report contributed importantly to the development of the modern health-care system. Despite enormous success, a number of current problems have been identified in today's medical educational curricula and have catalyzed the generation of a new Carnegie Foundation report that emphasizes the building of strong bridges across the artificial divide that separates the basic science and clinical years and lays the foundation for the growth and development of translational medicine. In addition, the report raises crucial issues regarding a national medical workforce policy.     

Science in the Service of Patients: Lessons from the Past in the Moral Battle for the Future of Medical Education

Medical schools instill a classic moral standoff in which the responsibility for the betterment of the patient stands at odds with the responsibility for the betterment of society. In critical ways, the latter, in the form of a robust research and technology-driven enterprise, has taken precedence over the former, resulting in harm to patients and individual dignity. This tradeoff can be traced to Abraham Flexner, the father of American medical education. In the wake of the Flexner report, American medicine set out on a course of exponential scientific advancement, but the mistreatment of research subjects and the erosion of the doctor-patient relationship in a health care system that is increasingly unaffordable, complex, and impersonal suggest that such progress has come at a price. Recent efforts by medical schools to emphasize humanism in their curricula and admissions processes have shown promise in orienting the values of academic medicine toward the individual patient’s well-being.     

Physicianship: Educating for professionalism in the post-Flexnarian era

Although he did not write extensively about professionalism, Abraham Flexner clearly understood its critical role in medical practice. In discerning the basics of medical education he characterized scientific methodology as the instrumental minimum. He left open to future generations the task of defining its necessary complement, the "noble behaviors and fine feelings" required of the medical practitioner. Situated within the current professionalism movement, and informed by previous commentary on the enduring attributes of medicine, a curriculum based on "Physicianship"--the physician as healer and professional--can serve as a logical post-Flexnerian curriculum. The conceptual armature of Physicianship and the attributes necessary for the fulfillment of both the professional and healer role can assist in the selection of students and constitute the educational blueprint for medical teaching. The critically important concepts of identity formation and the requirements for the valid and reliable assessment of professional behaviors of students and faculty are essential components. A Physicianship curriculum, as conceived and deployed at the McGill University Faculty of Medicine, might resonate with Flexner.     

Medical School Graduates Who Leave California: A Study at the University of California,San Francisco

A follow-up survey of 1,087 physicians who had graduated from the University of California, San Francisco, School of Medicine from 1951 through 1971 was completed in 1977. A total of 307 (28.2 percent) of these persons were found to have left California. Comparison of the 307 who left with the 780 who remained showed only slight and statistically insignificant differences on most variables, such as sex, academic performance in premedical and medical education, educational level and social class of parents, age at entry into medical school, ratings by admissions interviewers, choice of specialty and a wide variety of personality inventory measures. Among the variables that did differentiate were place of birth, location and prestige of premedical college, preferences for subjects in the sciences and the humanities, and the Medical College Admission Test (MCAT) scores for quantitative ability and general information. However, attempts to combine these individual differentiators into clusters or equations from which to forecast emigration from California were unsuccessful.     

The Premedical Education of the First-Year Class in Canadian Medical Schools: 1965-66

The premedical academic records of the 1965-66 entering class of Canadian medical students were analysed. Ninety-six per cent of the class had taken their preparation in a Canadian institution, while 80% had taken it in the same university as the medical school in which they enrolled. Forty per cent entered without a degree, the remainder having at least a bachelor''s degree in arts or science.Thirty-six per cent of all courses taken by these students in their premedical education were in the physical sciences, 22% in the biological sciences and 41% in the social sciences and humanities. One-third of the students had taken no course in the behavioural sciences and another third had taken only one course.Analysis of the level of performance of the entering class showed that 10% had obtained an A average, 49% a B average, 41% a C average and 3% a D average. The grades of these students were higher generally in the natural sciences than in the social sciences or humanities.It was concluded that it could be questioned whether medical students received a premedical preparation which met the philosophy of a “broad, liberal education”.     

Bad chemistry

General chemistry courses haven't changed significantly in forty years. Because most basic chemistry students are premedical students, medical schools have enormous influence and could help us start all over again to create undergraduate chemistry education that works.     

The Flexner Report--100 years later

The Flexner Report of 1910 transformed the nature and process of medical education in America with a resulting elimination of proprietary schools and the establishment of the biomedical model as the gold standard of medical training. This transformation occurred in the aftermath of the report, which embraced scientific knowledge and its advancement as the defining ethos of a modern physician. Such an orientation had its origins in the enchantment with German medical education that was spurred by the exposure of American educators and physicians at the turn of the century to the university medical schools of Europe. American medicine profited immeasurably from the scientific advances that this system allowed, but the hyper-rational system of German science created an imbalance in the art and science of medicine. A catching-up is under way to realign the professional commitment of the physician with a revision of medical education to achieve that purpose.     

On the Outcome Project

Background: In 2001, graduate medical education in the United States was renovated to better complement 21st century developments in American medicine, society, and culture. As in 1910, when Abraham Flexner was charged to address a relatively non-standardized system that lacked accountability and threatened credibility of the profession, Dr. David Leach led the Accreditation Council of Graduate Medical Education (ACGME) Outcome Project in a process that has substantially changed medical pedagogy in the United States.Methods: Brief review of the Flexner Report of 1910 and 6 hours of interviews with leaders of the Outcome Project (4 hours with Dr. David Leach and 1-hour interviews with Drs. Paul Batalden and Susan Swing).Results: Medical educational leaders and the ACGME concluded in the late 1990s that medical education was not preparing clinicians sufficiently for lifelong learning in the 21st century. A confluence of medical, social, and historic factors required definitions and a common vocabulary for teaching and evaluating medical competency. After a deliberate consensus-driven process, the ACGME and its leaders produced a system requiring greater accountability of learners and teachers, in six explicitly defined domains of medical “competence.” While imperfect, this construct has started to take hold, creating a common vocabulary for longitudinal learning, from undergraduate to post-graduate (residency) education and in the assessment of performance following graduate training.     

Flexner at 100: a brief view from Oxford

Of all the principles set out by Flexner in 1910, the most fundamental, that of academic and scientific excellence, is more relevant to medical education in the United Kingdom today than ever before. To realize this, undergraduate medical education (UGME) at Oxford has evolved to incorporate the tutorial method of teaching to promote independent and critical thought. Coupled with the usual didactic experiences, each medical student is also required to complete a 26-week research experience before going on to clinical study. Outcome measures reveal that Oxford graduates have consistently achieved highest marks in the U.K. equivalent of the United States Medical Licensing Examination. In contrast to UGME in the United Kingdom, postgraduate medical education (PGME) occurs largely outside the academy and often emphasizes the practical at the expense of the underlying Flexnarian principles of academic excellence. A reassertion of Flexner's belief that universities and medical schools should be the center for all medical education would greatly benefit PGME in the United Kingdom and be a tribute to Flexner's enduring legacy.     

Reminiscences from my medical school and residency days

A physician who was a medical student and resident in the 1930s at the Washington University School of Medicine recalls many of the remarkable professors who were recruited after Abraham Flexner had recommended a complete reorganization of the school in 1910, and who shaped the development of the school. Each of these individuals pioneered developments that shaped the research, clinical, and organizational advances of medicine in the 20th century. More than 60 years after graduation, the recollections rekindle the excitement and fun of medical education during that period.     

Medical decision making and medical education: challenges and opportunities

The Flexner Report highlighted the importance of teaching medical students to reason about uncertainty. The science of medical decision making seeks to explain how medical judgments and decisions ought ideally to be made, how they are actually made in practice, and how they can be improved, given the constraints of medical practice. The field considers both clinical decisions by or for individual patients and societal decisions designed to benefit the public. Despite the relevance of decision making to medical practice, it currently receives little formal attention in the U.S. medical school curriculum. This article suggests three roles for medical decision making in medical education. First, basic decision science would be a valuable prerequisite to medical training. Second, several decision-related competencies would be important outcomes of medical education; these include the physician's own decision skills, the ability to guide patients in shared decisions, and knowledge of health policy decisions at the societal level. Finally, decision making could serve as a unifying principle in the design of the medical curriculum, integrating other curricular content around the need to create physicians who are competent and caring decision makers.     

On bacteriophage anti-Flexner

Summary 1. The Flexner strain KB ofFlu from 1921 has given rise to two strains: the Flexner strain 38 which has grown SR and the Flexner strain 39 which has grown R. The Flexner strain 39 is at this moment a spontaneously agglutinating, lyso-sensitive strain, while the Flexner strain 38 apparently has kept up its original properties and is inagglutinable and lyso-resistant. Both strains belong to the type X ofAndrewes andInman. The Flexner strain 38, however, appears to agglutinate very specifically with an X serum. This strain can also be lysed by a special group of Flexner phage and not by others.2. The Flexner strain 38, however, is probably no variation of the strain KB ofFlu.3. The results ofBurnet andMcKie as to the correlation between antigenic structure of the Flexner strains and their sensitiveness to some groups of bacteriophage anti-Flexner could be confirmed in a high measure.     

The rising level of medical student debt: potential risk for a national default

At the turn of the 20th century, mostly as a result of the Flexner report, medical education changed dramatically by establishing a scientific basis for the study of medicine within the institutions of the major universities. There have been major and dramatic changes in medicine during the past 80 years that have improved medical education in the United States, but these changes have also placed major economic strains on students who have educational debts. If medicine is a social responsibility to the public, then the public should share the responsibility of identifying and supporting new approaches to funding and financially managing the teaching of future physicians. There is no universal solution because there are various approaches institutions may take to structure these financial responsibilities. This article describes trends in medical student educational debt, identifies the financial needs of medical students, and proposes ways of addressing those needs to avert a possible national financial crisis among medical students. We must invest in medical students because they will be the leaders we need to help care for our society and our own families in the next century.     

Canadian medical schools before ACMC.

The earliest medical schools were established to supplement apprenticeship, the only route to practice available in colonial Canada. By 1885, eight medical schools were trying to accommodate the volume of new scientific information flowing from Europe. In 1910, when Flexner evaluated the schools against the Johns Hopkins model, some were woefully deficient, but by 1928 all had achieved Class A rating. The 1921 discovery of insulin in Toronto gave impetus to scientific research and, possibly, influenced the formation and funding of the National Research Council in 1934. Clinical specialization expanded, leading in 1929 to the establishment of the Royal College of Physicians and Surgeons of Canada to accredit training and certify graduates. The Association of Canadian Medical Colleges was formed at a meeting of deans to discuss a federal offer of funding and to accelerate the graduation of physicians for the war effort.