One Report Closed Over a Hundred Medical Schools, and Black Doctors Disappeared With Them
The Flexner Report is often written up as the starting point of modern medical education, but it also shut down five of the seven Black medical schools, and for nearly forty years afterward no new Black medical school appeared.
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The report's author was not a doctor but an education reformer
Abraham Flexner was not a member of the medical profession. In 1890 he ran an experimental school with no fixed curriculum, no exams and no grades, and its students still got into good schools; in 1908 he wrote The American College, A Criticism, attacking American higher education, which is why Henry Smith Pritchett of the Carnegie Foundation came to him and asked him to turn the same critical eye on the medical schools of the United States and Canada. He spent two years travelling to 155 medical schools, recording each one's admission requirements, faculty, finances, laboratories and hospital affiliations, and in 1910 delivered Medical Education in the United States and Canada. It was precisely because he was an outsider rather than a member of the medical community that the assessment dared to be so unsparing.
— Tracy V. WilsonMedical schools were still teaching out-of-date knowledge
In the fifty years before the report, bacteriology, diagnostic techniques and surgery were all changing fast, but medical schools had no uniform standards. At many schools the faculty were practising physicians who taught the way they themselves had been taught and did not update the content. The result was that the care the doctors they produced gave their patients was, at best, antiquated and, at worst, life-threatening. Admission standards were just as chaotic: when the report was published, 74% of medical schools required only a high school diploma, some accepted even a high school equivalency certificate, only one in five required more than two years of college coursework, and many schools were essentially for-profit businesses.
— Tracy V. WilsonHe recommended closing 120 of the 155 schools
Flexner set standards first and then graded school by school: admission should require college-level biology, chemistry and physics; the curriculum should include classroom and laboratory work in anatomy, pathology, bacteriology and pharmacology; there should be a teaching hospital for hands-on practice; and teachers should be salaried, full-time teaching and research staff rather than physicians practising on the side. He published the results by state and by school, naming dirty laboratories and lax standards, and criticising course schedules that left students sitting for hours, exhausted, listening to dull lectures by part-time instructors. In the end he recommended closing 120 of the 155 schools. Within a decade the number of American medical schools was down to half, the surviving schools reformed their standards and curricula, and laboratory and clinical teaching were modernised on a large scale. In Canada only one school made the closure recommendation list, and in the end it did not close.
— Tracy V. WilsonHe never did the arithmetic on Black medical schools' books
The report was equally unsparing toward Black medical schools, stating that five of the seven "can make no valuable contribution at this moment", and affirming only Howard and Meharry as worth developing. But the assessment did not take into account that Black medical schools charged far lower tuition than white schools, had smaller endowments, and were already running on extremely thin margins. He wrote that "the Negro needs good schools rather than many schools", and said that one of the most important duties of Black people and Black nurses was to teach hygiene rather than life-saving skills — a statement that is itself racist. Every Black medical school he named as inadequate closed: the first four closed before 1914, the fifth in 1915, and the last held on until 1923.
— Tracy V. WilsonThe next Black medical school would not come until 1966
Howard and Meharry survived and are still there today. But the next medical school primarily serving Black students was Charles R. Drew Medical School in Los Angeles, which did not open until 1966, and then in response to the Black community's need for access to care; the one after that was Morehouse School of Medicine in Atlanta in 1975. The direct consequence of narrowing the options was a huge care gap: many potential doctors were excluded from educational opportunity by geography, and Black patients were often cared for by white doctors who, even at best, carried inherent racial bias. An expert panel convened by the AMA's Institute for Ethics in 2005 concluded that Flexner's line about "good schools rather than many schools" ensured that medicine remained segregated, and that the communities that most needed doctors were the ones left without them.
— Tracy V. WilsonThe AMA was paying for the Carnegie project
One fact not disclosed at the time: the Carnegie Foundation hired Flexner for this project, and the AMA was also a sponsor. There is also an unresolved question — whether someone connected to the AMA accompanied him on some of the school visits. His accounts differed at different times: sometimes he said the man went with him, later he changed his story to say they merely met there, so whether the report was subject to more direct directional influence cannot be determined to this day.
— Tracy V. WilsonDid he know he was constraining Black medicine?
He knew. The report contains a passage of idealistic colouring, saying that building up Howard and Meharry would benefit the nation far more than barely sustaining more schools. In 1933 he wrote to the board of the institute he had founded, arguing that hiring and admissions "shall not directly or indirectly take account of race, religion or sex". One explanation comes from his biographer Thomas Neville Bonner: when Flexner was growing up in Louisville, the local Black community had more services and opportunities than in many places, with a dozen or so Black schools and vocational training in medicine and law for Black students; the Flexner family was not well off, there were Black families among the neighbours, and he and his siblings often played with Black children in the community. This may have made him overly idealistic about the reality of Black family life, and he later admitted that it was not until he studied educational institutions that he realised how disadvantaged those Black classmates of his had been.
— Tracy V. WilsonThe hygiene line may not have been his own
The claim that hygiene was the main duty of Black doctors is one of the key pieces of evidence for judging Flexner a racist. But the leaders of Meharry and Howard had said similar things in 1907 and 1908 — two or three years before the report — and those leaders were also white. This suggests Flexner's formulation may have been a restatement of the schools' established mission rather than a judgement he arrived at independently. In 2011 Lynn E. Miller and Richard M. Weiss, writing in the Journal of the History of Medicine and Allied Sciences, proposed another possibility: that this language was in fact opening up a public health role for the doctors at these schools, in order to win support across the racial divide — because those statements about hygiene being the most urgent need were immediately followed by the conclusion that these institutions obviously ought to be supported. In 2008 the AMA issued a public apology for its history of racial inequality.
— Tracy V. WilsonIn their own words · checked verbatim
the doctors they trained were in danger of offering their patients poor or outdated care at best and endangering their lives at worst.
Tracy V. Wilson15:24
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.
Tracy V. Wilson23:43
The Negro needs good schools rather than many schools.
Tracy V. Wilson24:44
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
there are some indicators that a number of medical schools, black and white, were already in an economic tailspin before Flexner's report was released.
Tracy V. Wilson36:01
if he was operating from his best intentions, like, still racist, though. Like, it's impossible to grow up in a position of privilege in a racist society that is threaded all through with many layers of racist, of racism, and, like, to not be racist.
Tracy V. Wilson38:06
Figures
| Number of medical schools Flexner surveyed | 155 | 6:09 |
| Share of medical schools requiring only a high school diploma for admission | 74% | 15:24 |
| Share of medical schools requiring more than two years of college coursework | One in five | 15:24 |
| Number of medical schools Flexner recommended closing | 120 of 155 | 18:31 |
| Number of American medical schools a decade after the report | Down to half | 19:33 |
| Donation to Flexner from the Bamberger siblings | $5 million | 10:16 |
| Nobel, Fields and Abel laureates at the Institute for Advanced Study | 34 Nobel laureates, 42 Fields medalists, 18 Abel Prize laureates | 11:16 |
| First Black American to earn a medical degree | David J. Peck, graduated in 1847 from Rush Medical School in Chicago | 20:33 |
| Founding years of Howard and Meharry | Howard 1868, Meharry 1876 | 21:37 |
| Year the AMA publicly apologised for its history of racial inequality | 2008 | 36:01 |
Glossary
- Flexner Report
- The 1910 publication Medical Education in the United States and Canada, which reshaped North American medical education standards.
- AAMC
- The Association of American Medical Colleges, founded in 1876 and made up of 22 member schools, which had itself agreed on uniform standards for the medical curriculum.
- The Usefulness of Useless Knowledge
- A 1921 memorandum Flexner wrote for the board of the Rockefeller Foundation, later turned into an essay, arguing that the pursuit of pure curiosity yields unexpected uses.
How to listen
Listeners interested in the history of medical education, the history of racial inequality in the United States, and how professional associations reshape an industry through standard-setting; anyone who wants to understand why "standardisation" can take out weaker institutions along with the rest.
The first ten minutes or so of Flexner's life and family chronology, plus the sponsor break in the middle.