One Report Closed Half of All Medical Schools, and Black Doctors Were Scarce 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 elimination 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, which led Carnegie Foundation president Henry Smith Pritchett to ask him to turn the same critical eye on medical schools. He spent two years visiting 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 bias and no mercy — he would name dirty laboratories and lax standards outright, and criticize students packed into all-day dull lectures.
— Holly Frey / Tracy V. WilsonAt the time, over 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, some even accepting 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 faculty were mostly part-time practicing doctors teaching the old material they had learned, without updating. Flexner argued this directly threatened public health: the doctors produced would at best give patients outdated care, and at worst endanger their lives.
— 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; courses with both lectures and labs in anatomy, pathology, bacteriology and pharmacology; access to a teaching hospital for hands-on practice; and faculty who were salaried and full-time at teaching and research rather than part-time practicing doctors. He argued 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 U.S. medical schools was half what it had been at the report's publication, and the surviving schools generally reformed their standards and curricula. Only one Canadian school appeared on 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 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 widened the health care gap in Black communities
With Black medical schools squeezed out, aspiring Black 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 bias. In 2005 the AMA's Institute for Ethics convened an expert panel to review medicine's history of racism, and one finding was that the Carnegie Foundation hired Flexner for the project and the AMA was also a sponsor, which was not disclosed at the time. Flexner's phrase "good schools rather than many schools" ensured medicine remained racially segregated, and the communities that most needed 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: "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 hiring 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 thoroughgoing racist, the latter based mainly on his describing hygiene as the most important duty of Black doctors rather than life-saving skills. Some scholars also point out that the leaders of Meharry and Howard had used similar language two years before the report.
— Holly Frey / Tracy V. WilsonHis view of equality came from a Louisville childhood
Biographer Thomas Neville Bonner argued that Flexner's progressive views came from growing up in Louisville, Kentucky, where services and opportunities for the Black community were greater than in many places: there were more than a dozen Black schools and 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 he and his siblings often played with Black children in the community. This may have made him overly idealize the reality of Black family life — to him, the children he played with would naturally grow up to do the same work he did, but he did not realize others did not see it that way. He admitted in his lifetime that only later, when he studied educational institutions, did he understand how disadvantaged the Black students he knew as a child had been.
— 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 — both Black and white — were already in financial trouble, partly because they had been struggling to meet standards issued by the AMA, 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 number of U.S. medical schools a decade after the report | only half remained | 19:33 |
| Bambergers' donation to the Flexner Institute | $5 million | 10:16 |
| Nobel, Fields and Abel laureates at the Institute for Advanced Study | 34 Nobel Prizes, 42 Fields Medals, 18 Abel Prizes | 11:16 |
| Year the next predominantly 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 report "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 for the report itself.