Today’s educators would do well to learn from Abraham Flexner. The man who has had the single greatest influence on modern medical education was not a physician, nor did he have a background in the sciences. Abraham Flexner was an education theorist whose model remains the foremost in the world
Abraham Flexner was born in 1866, as the third of nine children to Moritz and Esther Flexner, struggling German-Jewish immigrants in the politically torn Louisville, Kentucky. Both parents placed great emphasis on education and although maintaining Orthodox practices, they interposed no resistance to liberal teachings. Charles Darwin, Herbert Spencer, and Thomas H. Huxley took the place of prayer books for Abraham and his siblings. The Flexner brothers, although they did not know it, were members of a rising generation of secular Jews who would make a special mark on American intellectual life.
In 1884, Flexner chose to study Classics at the Johns Hopkins University in Baltimore. For Flexner there seems to have been no life outside the classroom except penning the daily postcard to “Mutti” in German – a habit he continued as long as his mamme lived. Because his family was only able to provide funding for two years, Flexner was determined to finish before the money ran out. At 19 he received a degree in Greek and Latin yet had no immediate plans.
An experimental approach
Flexner returned home and took a position at his former high school. His alma mater was plagued by rampant problems of poor discipline, deteriorating morale, and declining faculty standards. He worked there tirelessly for six years and helped turn the school around.
In 1892, he was given the opportunity to run a school of his own. “Mr. Flexner’s” school quickly became a resounding success. Of the first hundred graduates who applied to college, all were admitted. The phenomenon caught the attention of President Charles W. Eliot at Harvard, who wrote to Flexner asking him to explain the school’s approach.
The Flexner school taught an alternative curriculum – there were no exams or grades. It was an attempt at a new kind of education in America’s fin-de-sciècle years. Flexner thought that the average high school curriculum was rigidly tailored to fit
college entrance requirements which in turn made real learning impossible. He ardently believed that education should be an enjoyable, lifelong affair.
By 1905, Flexner had married and had a child but was restless. His school was sold on favorable terms and he moved his family to Boston where he took a Master’s degree in philosophy at Harvard. They then moved to London, then on to Berlin. He even mastered the “awful German language” and studied at the University of Berlin.
Finding Berlin “queer … with its incongruous combination of intellectual preferences in music and drama with a grotesque lack of taste in so many other directions,” the family returned to the U.S. in 1907 settling in New York. Now home and his wanderlust sated, Flexner returned to his true vocation – pedagogy. He was highly concerned about the state of American higher education and became known for his criticism of hierarchies, inflexibility, and risk aversion.
Critical of U.S. medical schools
The following year he published his first book, The American College, in which he was particularly critical of the university lecture as an instruction tool. Flexner believed that lectures allowed colleges to “handle cheaply by wholesale a large body of students that would be otherwise unmanageable and thus give the lecturer time for research.” Flexner’s book greatly interested Henry Pritchett, president of the Carnegie Foundation. Despite Flexner’s lack of medical experience, he was appointed to the Foundation’s research staff in 1908 to lead a study on medical education.
At the turn of the last century, American medical schools were not the state-of-the-art facilities with highly competitive admissions requirements they are today. At the time there were about 150 medical schools with approximately 25,000 students.
These schools were often housed within a single dilapidated building. Classrooms were bare with the permeating smell of decaying cadavers and formaldehyde. Clinical training was either abominable or non-existent. Schools lacked common practice and many students had less than a high school education. The curriculum consisted of interminable lectures and endless recitations. Most graduates began medical practice with fear and trepidation.
Flexner’s assignment was to visit and assess these schools. He judged two-thirds as “utterly hopeless.” His report, Medical Education in the United States and Canada, was a bombshell. He concluded that the U.S. needed fewer, better schools which should be located in cities and attached to universities and teaching hospitals. Flexner demanded a two to four year college curriculum before medical school, based on science.
Flexner’s most contentious suggestion was demanding “full-time” faculty staff (basic salary and no more), as opposed to “part-time” which usually entailed generous remuneration from private practice (The latter was generally far greater than the former – a problem which persists to this day). He also suggested that all staff activities should be subject to “peer review” and for all “for profit” medical schools to be closed immediately.
On the basis of Flexner’s report, half of American medical schools were indeed closed – including one in his hometown, Louisville National Medical College. In the drive to reform, many senior faculty members were also fired.
Backed by $ 600 million in support from the Rockefeller Foundation, Flexner was able to implement his improvements on U.S. medical education.
Flexner would have had harsh words about the current state of affairs in medical education. He did not believe in large schools like the Charité in Berlin. And he thought that universities should avoid commercialization “like the plague.” He would not have known what to make of the modern fashion of “outsourcing” and “technology transfer”. He is quoted as saying: “Nations have recently been led to borrow billions for war; no nation has ever borrowed largely for education… no nation is rich enough to pay for both war and civilization. We must make our choice; we cannot have both.” Although he said this in 1930, the same could be applied to today.
The U.S.’s first ‘think tank’
In his later years, Flexner convinced Louis Bamberger, the businessman and philanthropist, to co-found the U.S.’s first think tank archetype – the Institute for Advanced Study. From his time spent studying European medical education, from observing medical training at Oxford and the Collège de France, to analyzing curricula at institutions in Germany and Austria, he identified the need for an establishment for research in the U.S. Staying true
to his experimental approach to education, “free thinkers”, “idealists” and “Querdenker” (unconventional thinkers) were actively recruited. He believed that such intellectuals were the “spearhead of progress.” Albert Einstein and John von Neumann numbered among the many distinguished teachers there.
Abraham Flexner pioneered medical education in the 20th century and his influence still resonates. His lessons are very well worth studying today.
Prof. Dr. Fred Luft is a distinguished American physician teaching in Germany. He knows Louisville and knows what Abraham Flexner has meant to his profession