Abraham Flexner's report, commissioned by the Carnegie Foundation, was a remarkable attempt to improve the quality of medical education in North America (1). It was based on sound principles, which may appear trivial today: medical schools should be university based and their educational programmes should have a solid scientific basis. Almost a century later, its influence on medical schools is still felt worldwide.
In his report, Flexner demonstrated both vision and courage. He was a strong advocate for the adoption of high standards in the preparation of future physicians. In suggesting that physicians should practise medicine with a critical mind, always searching for evidence for the appropriateness of their decisions, he broke away from the then-current approach of physicians, who displayed arrogance and ignorance. He had great hopes for physicians, expecting their function to become "social and preventive, rather than individual and curative".
In keeping with his principles, he suggested a drastic reduction in the number of medical schools in the USA from 155 to 31, arguing that those not meeting the proposed standards and not offering society the high-quality doctors it deserves should close down. He condemned "commercial" schools, which produced lots of ill-trained doctors and introduced the concept of social need, with the corollary that a school should be "a public service corporation".
Such observations and his suggested remedial actions were certainly relevant but were ahead of the current thinking. Nevertheless, his recommendations for the "reconstruction" of medical education have been generally applied to medical schools in North America and subsequently across the globe. Strict policies on student admission into medical school, a strong emphasis on basic sciences in the educational programme, the use of a university hospital for ample clinical exposure, and the availability of "laboratories" and appropriate facilities are some of Flexner's criteria which have been widely used to assess the quality of medical education. The essence of his recommendations is clearly perceptible in most of the evaluation and accreditation systems now in use throughout the world.
The value of the Flexnerian paradigm
Almost a century after the report, we may question whether the Flexnerian paradigm is still relevant to meet the challenges of today. Does it sufficiently prepare medical schools to respond optimally to society's needs and the requirements of health systems? Clearly, the report has stimulated generations of medical educators to design medical curricula based on a better understanding of the scientific foundations of life and disease. However, we need to acknowledge that its scope needs to be considerably widened if we are to understand better the basic determinants of health and expect medical schools and medical education in general to play a more proactive role in health development.
The emphasis on the biomedical and hospital-centred model of the Flexner report has contributed to shaping many medical educational programmes in a reductionist fashion. As a result, there is little room for the social, psychological, and economic dimensions of health and the better use of the wide spectrum of health resources beyond medicine and its physicians. Too many Flexnet followers have regarded his thinking as exhaustive and have not questioned his recommendations. They should, however, have applied Flexner's own critical approach and considered a wider core of principles and approaches which could enable medical schools to fulfil their mission better in meeting people's health needs.
Although the recommendations in the report had the great merit of focusing on the search for excellence in the preparation of future physicians, they may have also diverted attention away from other aspects affecting the impact of educational strategies on the way physicians practise and health services are organized and delivered--the very things a reformed medical education system was supposed to improve. …