Flexner to Eisenburg: The Turning of a Nation

Medical Economics and Politics of Evidence

Let’s look at the problem of medical values in higher education, as they are essential to the current forms of care that are generally available and the consequent privileges available to a medical elite who are controlled by standards of care, whether those standards are in the best interest of a patient or not. because it is a post 1900 robber baron driven phenomena, and most people drank the Kool-Aid they were selling.

Essentially, there was a conspiracy between the AMA, Carnegie and the Rockefellers. AMA sought a monopoly on medical care and its education, and successfully gained it. Rockefellers sought 3 items, 1) a monopoly upon philanthropy as a business model 2) wash clean their sullied name and 3) control over oil based and chemically driven medicine. The Carnegies had similar motives to the Rockefellers.

Using the German medical education model as institutionalized at John’s Hopkins University, the AMA-Rockefeller-Carnegie patsy, Abraham Flexner, went on a series of site visits to medical schools. Five criteria were used by Flexner to develop his work. Here they are: a) entrance requirements and adherence to them (good!), b) the size and training of the faculty (biased) c) the sum and allocation of endowment and fees to support the institution (this criteria places power and control into the hands of the ‘philantrhopists’) d) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, (only chemically based medicines that are patentable are supported in this model) and e) the relationships between the school and its associated hospitals (another economic bias towards those institutions with philanthropic funding).

Abraham Flexner was a reformer of education, particularly in the area of medicine. His was a life devoted to education and the elevation of its place in society (“Abraham Flexner,”). It could be said that he changed the face of medical education in America with his 1910 report Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (Flexner, 1910). This article explores results on both sides regarding Flexner’s impact on medical policy and as a result, medical care. What is fascinating is that acupuncture and East Asian medical practices rose with the tide of the return beginning in the early 1970s.

The Background

Flexner ‘s report was likely part of the reduction of natural products in the US healthcare environment between 1910 and the 1960s. This is important because there is a difference between health and the need for chemical or surgical interventions.

The conditions after Flexner led to a gap between perceived and real use of natural products for health care purposes. It became obvious to policy makers when David Eisenberg’s study, Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use, demonstrated the billions of dollars that Americans spent out of pocket on ‘complimentary and alternative healthcare’. We will explore this after considering Flexner’s work in more detail.

If one considers the centennial commemorative of Flexner’s work in a 2010 special edition of Academic Medicine, medical education improved. In it, Dr. Steven Kanter, the editor-in-chief, gave summary of the essays reflecting upon the past 100 years of a post Flexnerian world (Kanter, 2010). Kanter’s summary focused upon balance as a common feature among the essays. Dialectics ranged from curricular content and the length of medical training, to the contrast between a ‘disease management’ and an ‘population-based health improvement’ (Prislin, Saultz, & Geyman, 2010). Other areas of balance included professional or scientism and humanism, rural and urban care, lab time and patient time, and “the integration of formal knowledge of the basic, clinical, and social sciences with clinical experience (Irby, Cooke, & O’Brien, 2010).” Refreshingly, Lambert et al. argued for a balance between ‘standardized’ and ‘personalized’ scientific knowledge (Irby et al., 2010). The fundamental message was that Flexner was focused upon balance. We still find today, in acupuncture schools. A debate continues between liberal arts and the sciences as appropriate preparation for the acupuncturist as an independent medical provider in society.

Flexner also took strong positions. Consider this section of his report, this one justifiably addressing the Georgia College of Eclectic Medicine and Surgery of Atlanta:

The school occupies a building in which, in respect to filthy conditions, has few equals, but no superiors, among medical schools. Its anatomy room, containing a single cadaver, is indescribably foul. The pathological and histological “laboratory” contains a few dirty slides and ordinary microscopes . . . nothing more disgraceful calling itself a medical school can be found anywhere (Flexner, 1910).

Fortunately, the advent of acupuncture and East Asian medicine arose in an environment of accreditation and licensure that ensured certain levels of quality beyond the kind of schools that were removed from the terrain after Flexner’s report.

The Turn

Carnegie Foundation published and funded the 1910 Flexnor Report, which carved out and cleaned up national healthcare policy with respect to education and the medical profession, but at what cost? It was devastating for some. Medical care in the US was altered in such a way that indigenous knowledges as employed by eclectic physicians who used Native American traditional medicine were deleted.

Five criteria for evaluating schools were used by Flexner in order to develop his work. Here they are: a) entrance requirements and adherence to them, b) the size and training of the faculty c) the sum and allocation of endowment and fees to support the institution d) the adequacy and quality of the laboratories as well as the training and qualifications of the laboratory instructors, and e) the relationships between the school and its associated hospitals. There were other criteria used to develop the Flexner Report such as full-time teaching faculty, pathological analysis of the human body and a physiochemical analysis of the human body (Flexner, 1910). There are no records of who was involved with the process for developing these criteria. A model focused upon endowment favors institutions that reside within the good graces of philanthropists, creating control by certain economic interests.

As an educator, Flexner had no background in medicine and he investigated 69 medical schools in 90 days. Here are the results of his work. Within three years of the release of his Report, 25 medical schools closed. The total number of medical schools dropped from 650 to 50. Private hospitals declined in number from an estimated 2441 in 1910 to 1076 in 1946 (Mark D. Hiatt, 2003). The 22 homeopathic medical schools that flourished in 1900 dwindled to just 2 in 1923. By 1950 all schools teaching homeopathy were closed. If a physician did not graduate from a Flexner approved medical school, no job was to be had. New licensing laws required that medical schools be certified. Further:

Schools that admitted Afro-Americans did not pass (except for two that admitted only Afro-Americans). Schools admitting Jews got lower than average grades (resulting in a 30% reduction in Jews graduating). Schools that admitted women got lower than average grades resulting in a 33% reduction in women graduating [(Starr, 1982).]

Schools that were “commercial institutions” (able to function entirely by student fees) did not pass.By 1925 10,000 herbalists were out of business.

While Flexners ideals are espoused in reflection pieces upon him, it is also clear from the reults how the document was used. Conventional medical systems in America effectively excluded indigenous forms of medical knowledge from 1910 until the 1960s.

The Return

Acupuncture was part of the theme as the return of patient choice, or patient centered care became apparent. The patient’s view was made apparent to policy makers by Eisenberg’s study, Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use (Eisenberg et al., 1993), showed that the US had began to recover from the losses created by the Flexner report. In 1990, there was an estimated 425 million visits to providers of unconventional therapy exceeding the 388 million visits to primary care physicians. Moneys spent were approximately $13.7 billion, three quarters of which ($10.3 billion) was paid out of pocket. $12.8 billion was spent out of pocket annually for all hospitalizations in the United States (Eisenberg et al., 1993).

Not long after Eisenberg published his landmark study, on Friday, December 6, 1996 the FDA announced the reclassification of acupuncture needles from class III (premarket approval) to class II (special controls). They identified the acupuncture needle as “a device intended to pierce the skin in the practice of acupuncture. The device consists of a solid, stainless steel needle. The device may have a handle attached to the needle to facilitate the delivery of acupuncture treatment (FDA, 1996).” Thus, the experimental status was removed from acupuncture needles.

Growth and change continued. On March 7, 2000, President William Jefferson Clinton gave executive order 13147, forming the White House Commission on Complimentary and Alternative Medicine Policy (CAM, 2002). Medical schools began including a consideration for nutrition and natural products. Further, in 2010, Rick Marinelli, ND, LAc, was appointed to the Institute of Medicine’s (IOM) Committee on Advancing Pain Research, Care, and Education. It is necessary for practitioners who are fully educated in CAM medicine practices such as acupuncture and naturopathy to be involved in the national policy dialogs for there to be any true integration of care in society.

The Summary

Carnegie Foundation published and funded the 1910 Flexnor Report (Flexner, 1910). Minutes from AMA meetings at that time express the need to have the report separate from the AMA in order to give an impression of neutrality and authority (Kirch, 2010) (can we say objective proofs?).

The Carnegie-Rockefeller-AMA conspirators effectively crushed an American free market in medicine and its education. Non-profit values serve as a cloak for this form of evil.

Flexner is arguably the grandfather of the “site visit” in medical education and higher education. The benefits of his work are clear, the US has one of the strongest medical education systems in the world. The American public was divested of a more rich a plural form of medical care. Powers that be noticed in 1990 after Eisenberg’s study that people have mode complex needs than the corporate-technological forms of medicine. That trend was present all along and gained momentum during the sixties. Later studies that Eisenberg conducted have demonstrated that the growth of a plural medical system continues. Lastly, We need to nurture and espouse patient centered care, which if pursued, clearly supports the use ‘alternative medical approaches’, “integrative medicine’ or in the case of this field, acupuncture and East Asian medicine.

Notes

Abraham Flexner. http://www.ias.edu/people/flexner

CAM, W. H. C. o. (2002). White House Commission on Complementary and Alternative Medicine Policy http://www.whccamp.hhs.gov/finalreport.html

Eisenberg, D. M., Kessler, R. C., Foster, C., Norlock, F. E., Calkins, D. R., & Delbanco, T. L. (1993). Unconventional Medicine in the United States — Prevalence, Costs, and Patterns of Use. N Engl J Med, 328(4), 246-252. doi: 10.1056/nejm199301283280406

FDA. (1996). Medical Devices; Reclassification of Acupuncture Needles for the Practice of Acupuncture. Federal Register 61(236). http://www.gpo.gov/fdsys/pkg/FR-1996-12-06/html/96-31047.htm

Flexner, A. (1910). Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. . In Updyke (Ed.). Boston, MA.

Irby, D. M., Cooke, M., & O’Brien, B. C. (2010). Calls for Reform of Medical Education by the Carnegie Foundation for the Advancement of Teaching: 1910 and 2010. Academic Medicine, 85(2), 220-227 210.1097/ACM.1090b1013e3181c88449.

Kanter, S. L. (2010). A Letter to Those Who Read This Issue in 2110. Academic Medicine, 85(2), 181-182 110.1097/ACM.1090b1013e3181cfbf1096f.

Kirch, D. G. (2010). Commentary: The Flexnerian Legacy in the 21st Century. Academic Medicine, 85(2), 190-192 110.1097/ACM.1090b1013e3181c1099a1095d1091.

Mark D. Hiatt, M. D., M.S., M.B.A. and Christopher G. Stockton, M.S.M. (2003). The Impact of the Flexner Report on the Fate of Medical Schools in North America After 1909. Journal of American Physicians and Surgeons, 8(2).

Prislin, M. D., Saultz, J. W., & Geyman, J. P. (2010). The Generalist Disciplines in American Medicine One Hundred Years Following the Flexner Report: A Case Study of Unintended Consequences and Some Proposals for Post-Flexnerian Reform. Academic Medicine, 85(2), 228-235 210.1097/ACM.1090b1013e3181c1877bf.

Starr, P. (1982). The social transformation of American medicine. New York: Basic Books.