Flexner versus Osler

In the introduction to a talk I gave at the Mises Institute this year, I noted how, in the early part of the twentieth century, a convergence of interests between social progressivists and ideological empiricists led to the publication of the Flexner report and the subsequent enactment of licensing laws.

That historical context is further treated in an outstanding article by Alfred Tauber, who was professor of medicine and philosophy at Boston University School of Medicine.

In “The two faces of medical education: Flexner and Osler revisited,” Tauber contrasts the radically different views these two men held about the ethos of medicine and the proper approach to medical education.  It is ironic that the victorious position would be the one pushed by Flexner who, as Murray Rothbard put it, was “an unemployed former owner of a prep school in Kentucky…sporting neither a medical degree nor any other advanced degree.”

Tauber perfectly captures the aim of Flexner:

‘Flexner had another agenda than simply eliminating substandard institutions. The registration of medical schools with the Association of American Medical Colleges, the imposition of state licensing linked to such accreditation, the development of a model medical school at Johns Hopkins, and finally the effective use of philanthropic foundation support (e.g., Rockefeller, Carnegie) helped mould American medical standards closely to those advocated by Flexner. The 20th century doctor was to be an active and skeptical medical scientist.

He offers the following quotes from the report, documenting the conflation of medicine and science: “medicine is part and parcel of modern science.  The human body belongs to the animal world. (p.53)” “Is there any logical incompatibility between the science and the practice of medicine? (p. 54) “Investigation and practice are thus one in spirit, method, and object. (p.56)”   Flexner, vaunting the effect of a strictly scientific education, also remarked that:

The student who has been successfully trained to regard the body as an infinitely complex  machine learns to doubt his capacity to mend it summarily.

Despite having no medical degree, Flexner was not completely disconnected from the medical world.  In fact, his brother was Simon Flexner, a microbiologist (of Shigella Flexneri fame), who was then director of the Rockefeller Institute for Medical Research.  Simon Flexner had co-authored a book with William Welch, the founder of the Johns Hopkins medical school, and Welch had built the Johns Hopkins curriculum on a German model of medical education that was strongly reductionist in emphasis (in reaction to a then-prevalent current of German medical idealism).  Abraham Flexner himself had been a student at Johns Hopkins University and, in his report, proposed a model for medical education based on the one instituted by Welch.

Of course, we should not neglect the role and interests of the AMA which had been pining for fifty years to get licensing laws passed and impose trade restrictions favorable to its members.  Ronald Hamowy has well documented that, in its early history, the AMA had little concern for scientific medicine: “Blood letting and blistering, and the administration of massive doses of compounds of mercury, antimony, and other mineral poisons as purgatives and emetics, followed by arsenical compounds thought to act as tonics,” were standard of care for the allopaths.

By the turn of the twentieth century, however, the organization saw the political advantage of touting itself as a promoter of a scientific education.  It provided much of the background material upon which Flexner built his report and, of course, became one of the biggest benefactors of the licensing laws that were passed soon afterwards.  From then on, the AMA would largely control medical school accreditation, which would become bureaucratized and sclerotic.  It also became the officially recognized entity authorized to speak on behalf of all physicians.

In contrast,  “Welch’s position was rigorously opposed in his very institution by William Osler, who idealized the opposite pole of medicine’s foundation: the crucial vector was from bedside to the laboratory.”  Likewise, “Francis Peabody, Chairman of the Harvard Medical Service at the Boston City Hospital, warned ‘the laboratory never can become and never should become the predominating factor in the practice of medicine.'”

Tauber continues: “The Flexner report, with its sole reliance on a reductionist science to serve as an ideal for medicine, essentially omits the dynamic, or sociological encounter between patient and physician.”

But, ultimately, the AMA-Welch-Flexner-Carnegie model prevailed over the Osler-Peabody view.  And the ensuing bureaucratic machinery wouldn’t cope with the massive increase in scientific knowledge that has occurred since the Flexner reforms fossilized medical education into following a standardized format.

Isn’t it astonishing that the medical school curriculum structure has remain unchanged for more than a hundred years?  And, if we omit “the dynamic, sociological encounter between patient and physician,” is it any wonder a healthcare crisis would emerge?

[Related post: An economic history of the American healthcare system – part 1]

[Related post: Is medicine a scientific enterprise?]