Do we need a new Flexner report?

5 Feb
2010

Those who have read my rants for almost 8 years can guess my answer.  Either we have worshiped Flexner too reverently or we have misinterpreted his recommendations.  These primary physicians blame the Flexner report on our current imbalance between primary care and subspecialty care.

Flexner Report Linked to Growth of Specialty Medicine

This paper focuses on several issues, but I will choose one as the most disturbing.

The growing importance of academic medical centers during the last century has caused medicine's "social contract" to "erode," to be replaced by "a money culture that dominates the academic health system and has led to distortions in medical education and to our present maldistribution of physicians by specialty."

Whenever we have a problem in our society, our investigation should start by following the money.  The money in academic centers comes from grants and clinical practice.  As I often say, you look at most medical schools and the priorities are (in order):

  1. Grants
  2. Clinical income
  3. Fellowship training
  4. Residency training
  5. Medical student education

I hope that I am not being optimistic ranking medical student education so high.

Now those who are not physicians are scratching their heads.  Medical students are cheering.  Medical school higher ups should reflect carefully on how we prioritize our activities and our hierarchy.

We do need a new Flexner report.  We need a report on refocusing medical schools so that education really is the number one priority.  What could be more important that providing excellent humane training for those who will soon provide our own care?

As someone once said (would love an attribution), the only thing unique about medical schools is that they are designed to teach medical students.  You can do research at a research institute; you can provide complex care at a hospital without students; you can train fellows and residents without students.  But medical schools have their name because they are supposed to teach students (who by the way pay exorbitant tuition) both the art and the science of medicine. 

I wish our schools had mission statements that were that simple.

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5 Responses to Do we need a new Flexner report?

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PeterW

February 5th, 2010 at 7:59 pm

Good point on focusing on students, but remember that even with exhorbitant tuition, it costs still more to train students and residents.  So SOME form of revenue is still needed, even if we could prune back other activities..

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Clinton

February 6th, 2010 at 9:26 pm

Keep up the good work, DB.  I am on the verge of graduating from medical school and I have been pondering going down the academic medicine professional pathway post-residency… but only if we can stick to a mission statement of "teach students and residents."

I agree that all too often, the business philosophy dominates and the students (and patients!) suffer.

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Medical Contrarian

February 7th, 2010 at 10:05 am

I could not agree with you more. I just yesterday wrote a piece on a related aspect of this marriage of medicine and the university. 
 http://georgiacontrarian.blogspot.com/2010/02/medical-knowledge-vs-medical-know-how.html

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Jared

February 7th, 2010 at 10:38 am

DB, this line from the linked article frightens me.  "These schools' defense, that even an inadequately funded medical school served a purpose by offering an opportunity for disadvantaged individuals to attend, was soundly and correctly rejected as a bogus argument."

It is true that inadequate funding, and lack of experience or knowledge have been shown to inhibit education.  But, if that were a primary inhibitor of education, scholarship would have stagnated more than we think it has. 

Where I believe we need to focus our efforts is to define where the mission creep has occurred throughout medicine and medical education, and provide for a new Flexner-styled report to help us understand what has happened, and bring us back to our foundations.  Actually part of that has happened in an NPR program titled "This American Life". 

The two-part discussion is here http://www.thisamericanlife.org/Radio_Episode.aspx?episode=391 and here http://www.thisamericanlife.org/Radio_Episode.aspx?episode=392

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PK

February 12th, 2010 at 10:20 am

I’m afraid that in my experience “medical student education” has fallen farther down the list than #5. This varies from service to service, but in some rotations medical students are just there to do scut work and if they manage to learn something along the way it’s just bonus.

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