One Report Closed Half of America's Medical Schools, and Black Doctors Disappeared for Sixty Years
The Flexner Report cut U.S. medical schools from 155 to fewer than half, and the price of standardization was the near-total destruction of Black medical schools — the next Black medical school would not appear until 1966.
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The report's author was not a doctor but an education reformer
Abraham Flexner never attended medical school. He first wrote a book criticizing American higher education, The American College, A Criticism, and Carnegie Foundation president Henry Smith Pritchett then asked him to turn the same critical eye on medical schools. He spent two years traveling to 155 medical schools, recording each one's admission requirements, faculty, funding, laboratories and hospital affiliations. Precisely because he was an outsider to medicine, his assessments carried no professional preconceptions and no mercy — he would name dirty laboratories and lax standards outright, and criticize students packed into all-day stretches of dull lectures.
— Holly Frey / Tracy V. WilsonAt the time, more than seventy percent of medical schools required only a high school diploma
When the report was published, 74% of medical schools required only a high school education for admission, and some even accepted a high school equivalency certificate; only one in five required more than two years of college before entry. Many medical schools were essentially for-profit businesses. Meanwhile bacteriology, diagnostic techniques and surgery were all advancing rapidly, but the faculty were mostly part-time practicing physicians teaching the old material they had learned years earlier, without updating it. Flexner argued this directly threatened public health: the doctors being produced gave patients outdated care at best and endangered their lives at worst.
— Holly Frey / Tracy V. WilsonHe recommended closing 120 of the 155 schools
Flexner's model of an acceptable school included: college-level biology, chemistry and physics before admission; coursework with both lectures and laboratories in anatomy, pathology, bacteriology and pharmacology; hands-on practice in a teaching hospital; and faculty who were salaried and worked full-time on teaching and research rather than practicing on the side. He argued that state licensing boards should refuse licenses to graduates of substandard schools. In the end he recommended closing 120 of the 155. Within a decade, the number of American medical schools was half what it had been at the report's publication, and the surviving schools generally reformed their standards and curricula. In Canada only one school made the closure list, and it ultimately did not close.
— Holly Frey / Tracy V. WilsonBlack medical schools were almost all shut down, leaving only two
The report said: "of the seven medical schools for Negroes in the United States, five are at this moment in no position to make any contribution of value." He praised Howard and Meharry as worth developing; the rest he judged essentially useless. But that assessment did not account for the fact that Black medical schools charged far less tuition than white schools, had smaller endowments, and were already running on razor-thin margins. Every Black medical school he named closed: the first four by 1914, the fifth in 1915, and the last held on until 1923. Howard and Meharry survived. The next medical school primarily serving Black students, Charles R. Drew Medical School, did not open in Los Angeles until 1966, and the one after that was Morehouse School of Medicine in Atlanta in 1975.
— Holly Frey / Tracy V. WilsonFewer medical schools meant a widening care gap in Black communities
With Black medical schools squeezed out, Black students who wanted to become doctors were excluded from medical education by geography and lack of opportunity, and care for Black patients often fell to white doctors who, even at best, carried entrenched racial prejudice. In 2005 the AMA's Institute for Ethics convened an expert panel to review medicine's history of racism, and one of its findings was that the Carnegie Foundation hired Flexner for the project and the AMA was also a sponsor, something not disclosed at the time. Flexner's line about wanting good schools rather than many schools ensured that medicine remained racially segregated, and that the communities most in need of doctors had none.
— Holly Frey / Tracy V. WilsonDid he know he was constraining Black medicine?
Flexner knew he was limiting the scale of Black medicine. He wrote in the report that "the upbuilding of Howard and Meharry will profit the nation much more than the inadequate maintenance of a larger number of schools." In 1933 he wrote to his own institute's board opposing discrimination, saying that in appointments and admissions "no account shall be taken of directly or indirectly, of race, religion, or sex." But medical historians have no consensus on his motives: some see him as a benevolent paternalist, others as a racist to the core, the latter mainly on the basis that he described hygiene as the most important duty of Black doctors rather than life-saving skills. Other scholars point out that the leaders of Meharry and Howard had used similar language two years before the report.
— Holly Frey / Tracy V. WilsonHis idea of equality came from a Louisville childhood
Biographer Thomas Neville Bonner argues that Flexner's progressive views came from growing up in Louisville, Kentucky, where the services and opportunities offered to the Black community were greater than in many places: more than a dozen Black schools, plus vocational training schools for Black teachers, medicine and law. The Flexner family was not wealthy and lived in a neighborhood with Black neighbors, and Abraham later said that he and his siblings often played with the Black children in the community. This may have made him overly idealistic about the reality of Black family life — to him, the children he played with would naturally grow up to do the same work he did, and he did not realize that others did not see it that way. In his lifetime he admitted that only later, when he studied educational institutions, did he understand how disadvantaged the Black students he had known as a child really were.
— Holly Frey / Tracy V. WilsonThe AMA did not apologize publicly until 2008
Following the ethics committee's findings, the AMA issued a public apology in 2008 for "its past history of racial inequality toward African-American physicians" and announced a series of programs to encourage minorities to enter medicine. The hosts also note that there are signs that before the Flexner Report was published, many medical schools — Black and white alike — were already in financial trouble, partly because they had been struggling to meet standards the AMA had issued, and the financial burden of meeting those standards was itself unsustainable.
— Holly Frey / Tracy V. WilsonIn their own words · checked verbatim
of the seven medical schools for Negroes in the United States, five are at this moment in no position to make any contribution of value.
Holly Frey23:43
The Negro needs good schools rather than many schools.
Holly Frey23:43
Flexner's line of good schools rather than many schools had ensured that medicine stayed segregated and that communities who needed doctors the most were just left without them.
Tracy V. Wilson26:51
his own idealism put him in this situation not dissimilar to the scientists that he once wrote about who accidentally advanced the technologies of warfare.
Tracy V. Wilson33:59
for its past history of racial inequality toward African-American physicians.
Holly Frey36:01
if he was operating from his best intentions, like, still racist, though.
Tracy V. Wilson38:06
Figures
| Number of medical schools Flexner surveyed | 155 | 6:09 |
| Number of medical schools Flexner recommended closing | 120 of the 155 | 18:31 |
| Share of medical schools requiring only a high school diploma at the report's publication | 74% | 15:24 |
| Share of medical schools requiring more than two years of college before admission | one in five | 15:24 |
| Change in the number of U.S. medical schools a decade after the report | only half remained | 19:33 |
| The Bambergers' donation to the Flexner institute | $5 million | 10:16 |
| Nobel, Fields and Abel Prize winners at the Institute for Advanced Study | 34 Nobel Prizes, 42 Fields Medals, 18 Abel Prizes | 11:16 |
| Year the next primarily Black medical school opened | 1966 (Charles R. Drew Medical School) | 24:44 |
| Year of the AMA's public apology | 2008 | 36:01 |
Glossary
- Flexner Report
- The 1910 publication "Medical Education in the United States and Canada," which reshaped American medical education standards.
- AAMC
- Association of American Medical Colleges, founded in 1876, which had set its own uniform standards for medical curricula.
- AMA
- American Medical Association, founded in 1847, which long refused to admit Black doctors and apologized in 2008 for its history of racial inequality.
- hygiene
- The subject the Flexner Report recommended Black doctors focus on teaching, criticized as confining Black doctors to public health roles rather than life-saving skills.
How to listen
Listeners interested in the history of medical education, how racial inequality gets locked in by institutions, and the mechanics of well-intentioned reform that causes harm.
The opening on Flexner's personal life (marriage, later years, the death of his wife) can be fast-forwarded; jump straight to 14:23 and the report itself.