Flexner Report Linked to Growth of Specialty Medicine

WASHINGTON -- A century ago, Abraham Flexner's pivotal report redefined medical education and laid the groundwork for the growth of academic medical centers, but increasing medical specialization was an unintended consequence and threatens patient care, according to a paper published in an anniversary issue of Academic Medicine

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."

So wrote Michael Prislin, MD, professor of family medicine at the University of California, and colleagues who authored the paper, one of a special series of articles commemorating the 100th anniversary of the Flexner Report.

In his 1910 report, Flexner, an educator on the staff of the Carnegie Foundation, criticized the quality of the 160 U.S. medical schools, noting that many of the smaller, proprietary schools taught a curriculum not based in science. He advocated that medical schools be university-based, have stringent entry and graduation standards, provide a clinical setting as well as an academic one in which students would learn, and encourage faculty research.

By 1920, nearly half the medical schools had closed and the remaining 85 were university-based and under tight regulatory oversight by the American Medical Association's Committee on Medical Education.

Although the Flexner report is universally acknowledged as having an overall positive impact on medicine, it has also been blamed for eliminating diversity in the profession -- forcing closure of smaller schools that admitted minorities, women, and low-income students.

Even today, Prislin and colleagues wrote, 75% of U.S. medical students come from families whose income classifies them as upper- or upper-middle-class.

The growth of academic medical centers and a less diverse physician population created a climate that allowed other societal changes "resulting in the proliferation of specialties," the authors wrote.

"In the contemporary educational and practice environments, the generalist disciplines seem to be at grave risk," they wrote, arguing that the current faculty clinical practice model would "likely be abhorrent to Flexner," who said that "university hospitals, academic salaries, etc." can create good conditions for learning medicine, but they cannot create the "ideals" necessary for compassionate medicine.

Prislin and colleagues also sited the role the founding of the National Institutes of Health in the 1930s and the enactment of Medicare and Medicaid in the '60s played in advancing Flexner's goals and encouraging specialization.

The NIH provided -- and still provides -- funding for the research Flexner had urged medical school faculty to engage in. That funding focuses researchers on narrow subject areas.

Medicare and Medicaid brought dollars into the academic medical centers, paying for what had previously been charity care, the number of clinical faculty increased, and the fellows and residents they taught became revenue generators.

In 1965, the authors noted, federally funded research brought $350 million to medical schools, and patient care revenue totaled about $49 million ( just 6% of their revenue). In 2007, patient care income, at $36 billion accounted for half of overall medical school revenue.

Over the years, insurers, including Medicare and Medicaid, have also developed reimbursement mechanisms that reward physicians who practice in procedure-based specialties at much higher levels than those who practice general medicine.

Even the managed care era of the 1980s and '90s, meant to emphasize primary, preventive care, backfired. As the nation's view of managed care soured, primary care doctors were "vilified by patients and their specialty colleagues alike as 'gatekeepers,'" Prislin and colleagues wrote.

By 2002, just 21% of graduating medical school students expressed an interest in pursuing a career in primary care, and a 2007 survey found just 2% of graduates had an interest in a career in internal medicine, they noted.

The authors suggested several ideas for post-Flexnerian medical education reform including:

• Refocusing the medical school admissions process to move beyond aptitude in science courses and standardized texts
• Encouraging medical schools to adopt new initiatives to increase diversity among student populations
• Providing public funding to support a larger number of medical students
• Creating effective strategies in medical schools to shift the emphasis from subspecialties to primary care
• Placing a greater emphasis on social science such as sociology, behavioral psychology, and economics to correct the "excessive focus on disease management"

Prislin and colleagues also strongly supported passage of healthcare reform legislation that would provide coverage to every American. (One of the authors is a past president of Physicians for a National Health Plan, which advocates a single-payer system.)

"The public has lost faith in organized medicine as an answer to this crisis and tends to see physicians as part of the problem -- not part of the solution," the authors wrote. "If the medical profession can put its own interests aside and strongly advocate universal coverage for all Americans, it can reclaim much of its traditional legacy of service."

They further urged that the academic medicine community "decide how active it wishes to be in this dialogue, and it must also confront important existential questions regarding the continuing contribution of the generalist disciplines to the physician workforce."

Prislin and colleagues noted the increase in nonphysician providers and arguments that they can handle much of what primary care physicians do. "Ideally, evolving practice models will allow collaborative primary care practices to develop," they wrote.

But, they warned, "if instead the result is the loss of the generalist-physician primary care disciplines, the nature of the unique bond between patient and physician epitomized by the Hippocratic tradition will likely also be lost as physicians will increasingly provide only fragmented and episodic technical services to patients."

Comment