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 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 afterward. 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?
Note: The
views expressed on Mises.org are
not necessarily those of the Mises Institute.
Michel
Accad, MD, practices cardiology and internal medicine in San
Francisco, offering individualized care in a free-market setting. His blog
about health care and medicine is AlertandOriented.com. Contact: twitter, facebook.
