Educational and Institutional Reform

Abraham Flexner

Honest Abraham


Monday, November 8, 1909

“The faculty” of the University of Kansas School of Medicine, opined the critic with the notepad, “is not composed of men whose training has been modern.” The School’s North End Dispensary in Kansas City, Missouri, he added, was being operated “in an incredibly slipshod manner.” And the resident pathologist was “expected to eke out his income by outside work.”

Even worse, according to this evaluator, was the arrangement that situated the Scientific Department in Lawrence and the Clinical Department in Rosedale. This bifurcation, he contended, meant the University of Kansas and its School of Medicine were really conducting “two half-schools,” both underfunded and neither entirely “creditable.”

The maker of these decidedly disapproving observations was Abraham Flexner, a researcher from the Carnegie Foundation for the Advancement of Teaching. On November 8, 1909, he visited the KU School of Medicine’s facilities in Lawrence and Rosedale, collecting data for an upcoming book. Titled Medical Education in the United States and Canada – though known popularly as the Flexner Report – it would appear the following year and have a profound and much-needed reformative impact, not only at KU, but also at scores of medical teaching institutions throughout North America.

Comprehensive and frankly written, Flexner’s “pitiless exposure” slammed the door on many fly-by-night medical diploma-mills. Just as important, it also induced many more legitimate medical schools to raise their academic standards, devise more rigorous curricula, and eventually embrace the “Flexnerian Model” of systematized, modern-science-based education, with its strong emphasis on practical laboratory work and patient care.

Ultimately, the KU School of Medicine would chart this reformative course. And while KU did come under a good deal of censure in the Flexner Report, it was mostly constructive in nature and surely could have been worse. Touring Washburn College’s medical department, for example, Flexner revealed such disgraces as its “indescribably filthy” dissecting room (containing a “single, badly hacked cadaver”) that was “simultaneously used as a chicken yard.”

The movement to reform such affronts to sound medical training was launched in the mid-nineteenth century with the establishment of the American Medical Association (AMA). Founded in 1847 as a professional physicians’ organization, the AMA looked out upon the national landscape and blanched. Members saw rampant quackery; uneven, often nonexistent, state licensing requirements for doctors; wildly divergent educational standards; and a populace generally willing to put phrenologists, spiritualists and mesmerists on equal par with practitioners of scientific medicine.

Compounding this sorry state of affairs was a widespread “buyer beware” mentality that implicitly governed doctor-patient relationships in the United States. As late as the 1890s, one critic lamented, “The popular feeling [was] that in a free country every one should have the right to follow any occupation he likes, and employ for any purpose any one whom he selects, and that each party must take the consequences.” Adding to this supply of dubious doctors was the growth of for-profit (or “proprietary”) medical colleges, where students could often obtain MD degrees after an appallingly short and unspecialized course of study.

By the early 1900s, however, times and public attitudes appeared to be changing, pushed forward by a number of important and demonstrably beneficial medical discoveries and techniques. From the germ theory of disease and the life-saving power of vaccinations to antiseptic surgery and the linking of cholera to contaminated water, these advances combined to raise, in people’s minds, the esteem for scientifically based medical treatments. Armed with this public knowledge and acceptance, the AMA redoubled its efforts to expose, shame and, if possible, close down inferior medical schools, as well as encourage those that remained to adopt uniformly high standards of admission, instruction and graduation.

To this end, in 1908, the AMA’s Council on Medical Education announced an ambitious project: to conduct an extensive review of every medical school in the United States and Canada, with an eye toward advancing two principal reforms. First, “standardization of preliminary education requirements for entry into medical school”; and second, “national implementation of an ‘ideal’ medical curriculum, consisting of two years of clinical training in laboratory sciences followed by two years of clinical rotations in a teaching hospital.”

To carry out this survey of 156 graduate and 12 postgraduate institutions, the AMA partnered with the Carnegie Foundation for the Advancement of Teaching. Established three years earlier by former steel baron, now full-time philanthropist Andrew Carnegie, its charge was “to do and perform all things necessary to encourage, uphold, and dignify the profession of the teacher and the cause of higher education.” The Foundation saw great merit in the AMA’s proposal, and agreed both to fund it and provide the surveyor. His name was Abraham Flexner.

On its face, the choice of Flexner seemed a rather curious one. Although an alumnus of Johns Hopkins University, this man who would undertake a detailed, 15-month survey of 168 North American medical institutions was not a trained physician, but rather held an undergraduate business degree. In fact, as he himself admitted at the time, he possessed only a “very sketchy notion of the main functions of the various [medical] departments” and had “never [stepped] foot inside a medical school.”

That said, Flexner was by all accounts remarkably intelligent. He had earned an MA from Harvard University’s Graduate School of Education; did additional graduate work in psychology at the University of Berlin; and had almost 20 years of teaching experience in his native Louisville, Kentucky, much of that heading his own private academy called Mr. Flexner’s School. In 1908, he published The American College, a critical methodological study of higher education in the US. The work was well-received and earned Flexner a wave of scholarly renown. The Carnegie Foundation was impressed enough that it invited him to join its research department that same year.

As it turned out, Flexner’s first assignment was the AMA medical school review project. And though he harbored some initial doubts about his qualifications for the task, Carnegie Foundation president Dr. Henry Pritchett quickly reassured him.

“I think these professional schools should be studied not from the point of view of the practitioner,” said Pritchett, “but from the standpoint of the educator…. This is a layman’s job, not a job for a medical man.” (Ultimately, Flexner would agree with this assessment. In his autobiography, he wrote that “Time and again it has been shown that an unfettered lay mind, if courageous, imaginative, and determined to master relationships, is, in the very nature of things, best suited to undertake a general survey.”)

Fond of the Latin phrase Ambulando discimus (“We learn by going about”), in January 1909, the 43-year-old researcher did just that, beginning his whirlwind, crisscrossing tour of 168 North American medical schools. At each, he sought to address five central questions and answer them based upon hard data and his own observations.

First, Flexner inquired about the school’s entry requirements. Second, he wanted to know “the size and training of the faculty.” Third, he asked about the institution’s budget and how its funds were allocated. Fourth, he investigated “the quality and adequacy of the laboratories.” Finally, he examined “the relations between [the] medical school and [local] hospitals,” particularly regarding access to patients. Because Flexner often spent less than a day – and sometimes less than half a day – at an individual site in pursuit of this information, certain analysts have since called into question his methodology and thoroughness. Yet as Flexner was also fond of saying, “You don’t need to eat a whole sheep to know it’s tainted.”

By the time Flexner turned his eye toward the University of Kansas School of Medicine on November 8, 1909, he had already inspected more than 100 other institutions. At KU, he found a split Medical School located on two campuses.

The two-year Scientific Department – based in Lawrence, with an annual budget of $17,000 – had been in operation since 1899 and offered the first two years of KU medical education. The two-year Clinical Department – based in Rosedale, and funded to the tune of $23,000 a year – had been established in 1905. Between the two departments, there were a total of 89 students. And each department was presided over by its own dean, the former by Dr. Mervin T. Sudler; the latter by Dr. George H. Hoxie, both of whom were physicians. Additionally, KU required students to have completed at least two years of college work before being admitted to its four-year medical school.

Flexner had almost nothing explicitly negative to say about the first two years of the program on Mount Oread – which, given his style, was almost tantamount to praise. Aside from some chiding over the fact that the pathologist needed to supplement his income by taking on additional outside work, Flexner kept his critical remarks to a minimum. He thought the laboratory facilities for anatomy, chemistry and physiology were “good and in active operation,” though pathology and bacteriology were “less highly developed.” Moreover, he added rather blandly, “Books and current scientific periodicals are accessible.”

When it came to the campus at Rosedale, where the final two years of clinical medical study took place, Flexner was slightly more animated. Upon touring the recently completed Eleanor Taylor Bell Memorial Hospital, he wrote: “The Clinical Department has a small hospital of 35 beds, not used, however, to the best advantage, partly because the faculty is not composed of men whose training has been modern, partly because, being [private] practitioners, they cannot devote enough time to teaching.”

Indeed, of the 24 Medical School professors at Rosedale, only a few were full-time – and one of those was Dean Hoxie, who focused much of his energies on administrative tasks. Bemoaning students’ lack of adequate patient-care experience and charging that the School’s “so-called North End Dispensary” in Kansas, City, Missouri, was being “handled in an incredibly slipshod manner,” Flexner concluded that, “On the whole, far too little clinical material under proper control is offered.”

In summarizing his impressions of this “divided school” composed of two “severed halves,” Flexner did allow that KU “has shown the desire to provide instruction of high grade.” This was evidenced by its entrance requirement of two years college work, raised from the original mandate of only a high school diploma. (Unmentioned, however, was that this admissions change was not made until September 1909, just two months before Flexner arrived.)

Although Flexner lauded these standards, in his opinion the University “did not realize that it was incumbent upon it to improve facilities and instruction at the same time.” As things stood now, both departments (but Rosedale especially) were starved for funding support, largely isolated from each other, and unable to effectively cooperate.

It is unclear exactly how much time Flexner spent touring the KU campuses and formulating these conclusions. However, it seems certain it was not more than two days, during which time he also visited the Kansas Medical College in Topeka (which doubled as Washburn College’s medical department) and the Western Eclectic College of Medicine and Surgery in Kansas City, Kansas.

Of all the schools Flexner visited in Kansas, Western Eclectic ranked highest on the squalor scale. Noting the alleged college’s “indescribably dirty and disorderly” facilities, its “filthy specimens” and “wretched rooms” with “no running water,” Flexner appeared not to hesitate in declaring that “the future of medical education [in Kansas] very properly lies with the state university,” i.e. KU.

Without some significant statewide reforms, however, the future, in Flexner’s estimation, would be a bleak one. As he saw it, Kansas had yet to work out a “comprehensive and well coordinated scheme of state educational development.”

The most obvious problem was that while the KU School of Medicine (really “two half-schools,” as Flexner put it) was languishing due to insufficient funds, engineering and education departments existed at several publicly supported institutions. This needless overlap, if corrected, Flexner contended, would naturally result in a more equitable and efficient use of state monies.

Even then, the cost of building a truly “creditable” medical program was such that, in the meantime, KU may have “to refrain from many other projects.” Only by a deliberate, steady and well-thought-out plan – “realized unit by unit, year by year,” as Flexner put it – could the University and the state create a first-class medical institution.

It is perhaps some testament to Flexner’s belief that such an outcome was in fact possible that he took time to offer this sound advice. Other schools nationwide were not so fortunate. Indeed, when the fruit of his labors – the 1910 tome titled Medical Education in the United States and Canada – was published, many medical colleges were profoundly embarrassed and drummed out of business, if not run out of town.

Some of the most egregious examples included the California Medical College, derided by Flexner as “a disgrace to the state whose laws permit its existence.” Tufts College Medical School in Massachusetts had entry requirements “below [that of] an actual high school,” while the Memphis College of Physicians and Surgeons’ policy was simply to accept any student and “try them out.”

Additionally, the University of Buffalo Medical Department in New York was “a fiction” and the Washington University Medical School in St. Louis “must be either abolished or reorganized.” Topping this list of the damned, however, was the Georgia College of Eclectic Medicine and Surgery, which Flexner deemed beneath contempt. “Nothing more disgraceful calling itself a medical school,” he wrote, “can be found anywhere.”

The big picture effects of Flexner’s exposé were particularly striking. According to a 2003 article in the Journal of American Physicians and Surgeons, by 1920, the number of US medical schools had been cut in half, from 168 to 85. Similarly halved were medical student enrollments across the country, dropping from 28,142 to 13,798. Flexner himself would have actually preferred even more drastic reductions, insisting that America was still suffering from “an enormous over-production” of physicians.

But he was nonetheless pleased with the beneficent devastation he had wrought. So was the AMA, which gained immense prestige from Flexner’s exhaustive study. Moreover, in its wake, the organization began wielding substantial influence over medical education nationwide, as colleges and state licensing boards rushed to implement – sometimes forcibly – its recommended reforms.

For the KU School of Medicine, the years following the publication of Flexner’s report were ones of considerable change. The only Kansas medical educational institution to survive much beyond 1910, it did not, however, emerge unscathed. Dean Hoxie, who had been weakened by years of bad relations with his Clinical Department faculty in Rosedale, resigned his office in 1911. Replacing him – in a shrewd PR gambit by KU – was renowned Kansas public health advocate Dr. Samuel J. Crumbine, who accepted the job as a titular position while Dr. Sudler was named associate dean and ran the school on a day-to-day basis.

Yet these cosmetic changes did not address the major issues raised by Flexner. Still outstanding were the serious and unresolved problems associated with divided departments, not enough full-time physicians on staff, and a teaching hospital that was simply too small.

What’s more, during the early 1910s arguments persisted about whether to move the entire Medical School to Rosedale or, possibly, to scrap the Rosedale campus altogether and either set up the clinical program in Topeka or put everything on Mount Oread. Not surprisingly, this resulted in a stalemate between partisans of the various positions, effectively checkmating progress.

More roadblocks to reform came from the uneven financial support offered by the Kansas legislature, as well as simmering complaints among the Kansas medical community about the high number of Missouri residents working at the Rosedale campus.

In combination, these problems prevented the KU School of Medicine from acting seriously on any of Flexner’s suggestions, though a second and larger Eleanor Taylor Bell Memorial Hospital was opened on Goat Hill in 1911. For the most part, however, the Medical School languished during the 1910s and, at times, teetered precariously on the brink of losing its AMA accreditation.

By 1924, however, some much-needed steadying forces appeared to be at work. That year, KU opened a new $235,000 classroom and teaching hospital (the third to bear Eleanor Taylor Bell’s name) at 39th and Rainbow Boulevard in Kansas City, Kansas. As medical historian Thomas Neville Bonner put it, at last there was some solid “evidence that the legislature, the medical profession, and the people of Kansas were now rallying … around their state medical school.” And though some Kansans were not quite finished arguing the issue, it did seem that most were beginning to accept Rosedale (by then incorporated into KCK), as the future home of a consolidated KU School of Medicine.

Thus energized, in June 1924, the trio of Kansas Governor Jonathan Davis, KU Chancellor Ernest Lindley and Dean Mervin Sudler (now heading the School in his own right) trekked to New York City hoping to secure some additional financial support. Their destination was the Rockefeller Foundation, specifically the office of KU’s erstwhile critic – none other than Abraham Flexner himself. As director of medical philanthropy, Flexner was figuratively perched atop a mountain of oil money and had proved willing to grant sizable chunks of it to foster collegiate medical education. Between 1919 and 1925, for example, Vanderbilt University in Tennessee received more than $10 million to fund a complete reorganization of its medical school. The Kansans, however, had more modest ambitions: for them, $2.5 million would be just fine.

According to Bonner, “They told Flexner something of their [KCK consolidation] plans but indicated their willingness to give the Rockefeller Foundation a decisive voice in shaping the School’s future if substantial aid were forthcoming.” Lending his clout, Governor Davis expressed a desire to “put the medical school on the map in a way that will make it one of the greatest institutions of its kind in the West.” Apparently intrigued, Flexner agreed to personally visit Kansas for further talks in the fall of that year.

The high hopes that emanated from this visit with Flexner in New York were soon dashed. Despite their outward comity, back in Kansas, Davis and Lindley had already crossed swords over a variety of matters. They differed in their political party affiliations – Davis was a Democrat while Lindley was a Republican – and clashed over such issues as university governance, professorial pay scales, and the governor’s determination to place his supporters in patronage jobs at KU.

The situation became ugly when the Kansas Board of Administration – a body of political appointees that then exercised jurisdiction over the state’s four-year public colleges and universities – fired KU’s buildings and grounds superintendent on trumped-up charges after he failed to heed the Board’s blandishments to hire Davis supporters as campus workmen.

It became even more ugly in July 1924, barely a month after the meeting with Flexner, when an erroneous report circulated that the Board had fired Sudler from his position as dean of the Medical School. Sudler, who had actually been long vulnerable to dismissal, was humiliated by the brouhaha and tendered his resignation, which was accepted.

From this point on, political partisanship raged across Kansas, further fueled by the fact that 1924 was an election year and Davis was seeking to retain the governorship. The state’s Republican establishment and largely Republican-oriented press pounced on Davis, charging him with everything from rank cronyism to being a sympathizer of the Ku Klux Klan.

The Wichita Beacon declared that Davis had “wiped out the work of five administrations which had earnestly sought to build up a condition of merit in the educational personnel of state institutions.” The Kansas City Star, a Missouri paper with wide circulation in Kansas, claimed the governor had wrested control of the University “out of the hands of the chancellor and has made even the positions of the faculty mere political jobs.” Unless he was defeated, continued the Star, the University would soon become the “pawnshop of every political broker in the state.”

This situation – accusations of rampant statehouse jobbery, a hopelessly politicized Board of Administration, virtual warfare between chancellor and governor, and a medical school with no dean – was the picture of Kansas in the summer of 1924. Needless to say, Abraham Flexner and the Rockefeller Foundation were not amused.

The just-sacked Sudler was the first to find this out. He wrote a letter to Flexner, sincerely albeit perhaps naively, expressing hope that these events would not discourage him from making his planned fall visit to the Sunflower State. Flexner responded with his usual pith. “Under present circumstances,” he wrote, “I am no longer interested in the Medical School of the University of Kansas.”

John H. McCool

Department of History

University of Kansas


[Source Notes: Abraham Flexner, Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching; Bulletin No. 4, (Carnegie Foundation for the Advancement of Teaching, 1910); Abraham Flexner, An Autobiography, rev. ed., (Simon and Schuster, 1960); Andrew H. Beck, “The Flexner Report and the Standardization of American Medical Education,” Journal of the American Medical Association 291:17 (May 5, 2004); Mark D. Hiatt, M.D., and Christopher G. Stockton, “The Impact of the Flexner Report on the Fate of Medical Schools in North American After 1909,” Journal of American Physicians and Surgeons 8:2 (Summer 2003); Clifford S. Griffin, The University of Kansas: A History, (University Press of Kansas, 1974), pp. 264-273; Robert Taft, The Years on Mount Oread, (University Press of Kansas, 1955), pp. 86-89, 151-153, 201; Ralph H. Major, M.D., An Account of the University of Kansas School of Medicine, (University of Kansas Medical Alumni Association, 1900), pp. 5-100; Lawrence H. Larsen and Nancy J. Hulston, The University of Kansas Medical Center: A Pictorial History, (University Press of Kansas, 1992), pp. 3-49; Thomas Neville Bonner, The Kansas Doctor: A Century of Pioneering, (University Press of Kansas, 1959), pp.147-148, 180-183; Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life in Learning, (Johns Hopkins University Press, 2002);“Concerning the Summary Dismissal of a Member of the Faculty of the School of Medicine,” (University of Kansas, 1924).]

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