When Flexner Saw the Future
100 YEARS AGO, administrators were advised to
Fortunately, they did, and so a faltering medical college exchanged certain mediocrity for potential excellence.
Flexner's 1910 publication, critical of medical schools, became a turning point that informed the betterment of American medical education.
In April 1909, a wiry, intense man jumped off the train in St. Louis, bound for Washington University's Medical Department. Abraham Flexner had been traveling the country on behalf of the Carnegie Foundation, studying the quality of American medical schools — and so far it had been a dismal journey. Nearly everywhere, he had found shoddy facilities and inadequate curricula. Within a year, he would publish his findings in a watershed book, Medical Education in the United States and Canada, that led more than 100 schools to close and others to undertake sweeping reforms.
"One hundred years ago, the Flexner report catalyzed a major transformation of medical education," says Larry J. Shapiro, MD, executive vice chancellor for medical affairs and dean of the School of Medicine. Adds Thomas N. Bonner in his book, Iconoclast: Abraham Flexner and Life in Learning: "America owes to Flexner, more than any other person, the rapid implementation of the full-time medical school, allied to a teaching hospital, and integrated into a university."
But on the St. Louis leg of his trip, Flexner must have felt a glowing sense of anticipation. The man who had hired him, Henry Pritchett, had once been a mathematics and astronomy professor at Washington University, where he had forged a lasting friendship with its board chairman and benefactor, Robert Brookings. Now Pritchett assured Flexner that he would finally strike gold. "You are going to see something better," he said proudly, "for my friend Brookings has taken particular interest in developing the medical school."
Pritchett was dead wrong. During his two-day study of the medical school, Flexner was horrified to find "the school a little better than the worst I had seen elsewhere, but absolutely inadequate in every essential respect." Disappointed but staunchly supportive, Pritchett sent the report off to Robert Brookings, who had not even known that Flexner was in town. "I was so indignant on receipt of this report that I protested to Dr. Pritchett," wrote Brookings, a man with a big temper.
Still, Brookings must have suspected, deep down, that Flexner was right. For one thing, Flexner — formerly an educator himself, who had already written a critique of American higher education — had a solid context for his criticism. He had begun his work in December 1908, charged with visiting 155 medical schools across the United States and Canada.
And his employer, the Carnegie Foundation, was an independent agent, seeking only to discover the truth. Founded in 1905 by industrialist-turned-philanthropist Andrew Carnegie, it was dedicated to advancing the profession of teaching. At its head was Pritchett — the soul of rectitude — who had begun life as the son of a teacher in tiny Glasgow, Missouri, and whose talent had propelled him from Washington University to the presidency of Massachusetts Institute of Technology before Carnegie hired him away.
Further, Brookings had recently met with Daniel C. Gilman, the president of Johns Hopkins University, which had the nation's most progressive medical school and hospital, so he was uncomfortably aware that his medical school was not in the same league. At a speech before the Commercial Club that October, Brookings had bragged about Washington University, yet he couldn't muster his usual enthusiasm in promoting the Medical Department.
At one point he asked the crowd, rather wistfully: "How long will it be before some wise philanthropist gives to St. Louis ... a hospital to be affiliated with our Medical School?"
So when he and David Houston, the university's new chancellor, received Flexner's report, they soon regrouped. Late in May 1909, Houston called a meeting of medical faculty to talk about reform. To their great credit, these physicians declared that they supported substantial overhaul. It would be impossible, said pathologist and one-time dean Gustav Baumgarten, MD, "to improve the old system with minor changes" — whatever the consequences to their own positions.
Actually, this group of physicians had long hoped for change. The Medical Department where they taught was formerly the St. Louis Medical College, acquired by the university in 1891; it had expanded in 1899, when it merged with the Missouri Medical College. This combined school was located at 1806 Locust, part of the university's dingy, downtown campus, while the 125-bed Washington University Hospital was in the lightly revamped Missouri Medical College building at Jefferson and Lucas.
Neither building was adequate to its purpose. As one student said of the medical school: "The floors are dirty; tables, chairs, everything covered with the grime and soot of years. This in a school whose professors are trying to teach methods of cleanliness." And a poorly defined set of courses was taught by a large, part-time staff, all of whom had busy clinical practices. One dean, William H. Warren, complained openly of "lectures extemporized in the automobile."
With the blessing of the board, Brookings and Houston jumped into action, establishing a reorganization committee composed of Brookings' three closest friends: William Bixby, Robert McKittrick Jones and Edward Mallinckrodt. Now Flexner made plans to return to St. Louis, with firm instructions from Pritchett to meet with Brookings and show him exactly what was wrong.
As he later wrote, Flexner took Brookings on a revealing tour. "We went to the dean's office, and I asked to see the credentials of the students of the school, for the school pretended to require a flat four-year high-school education of all entering students. It was quickly apparent to Mr. Brookings that no such requirement was being enforced. We went through other departments, not one of which was found to be what the catalogue represented. Within less than two hours, Mr. Brookings was completely satisfied."
To the reorganization committee, Flexner offered further advice: "Abolish the school. ... Form a new faculty, reorganize your clinical facilities from top to bottom, and raise an endowment which will enable you to repeat in St. Louis what President Gilman [of Johns Hopkins] accomplished in Baltimore." Though it was not yet clear where the funding would come from, the committee voted to proceed with this plan.
In consultation with William H. Welch, dean of the Johns Hopkins School of Medicine, Flexner suggested that the university invite brilliant young David L. Edsall, MD, from the University of Pennsylvania, to guide the reform process. Edsall came and spun exciting images of a new hospital, laboratory space, and a full-time faculty of stars — in short, "an ideal medical school." A born dreamer, Brookings was hooked and promptly donated $500,000 of his own money to the project. A brand new Washington University School of Medicine was on its way.
"Robert Brookings seized the opportunity to reshape the Washington University School of Medicine around an enduring commitment to excellence in all that we do," says Shapiro. "Now, a century later, it is time to reaffirm our commitment and our resolve to continue to lead the way in medical and scientific education, in fundamental and applied research, and in the highest quality of compassionate service to our patients."