100 Years Later, the Flexner Report Is Still Relevant

The centenary celebrations of the Johnson-Jeffries "fight of the century," which took place on July 4th, 1910, overshadowed another event that is arguably more important and relevant to Americans living today—the publication of "the Flexner Report" on the state and reform of American medical education.

Abraham Flexner, working for the Carnegie Foundation at the behest of the American Medical Association, issued Bulletin No. 4 in June 1910. Flexner had traveled across the country visiting every school that purported to offer a medical education, and his report was a ringing condemnation of most of them. In the late nineteenth and early twentieth century, you could essentially buy a medical degree in America. You did not even need a high school diploma to enter a medical college, and the coursework often consisted of listening to practitioners talk about their medical experiences. No laboratories, anatomy classes, or basic science were mandatory.

Flexner insisted that American medical schools follow Johns Hopkins and Harvard in establishing programs that were much closer to the leading German medical schools of the day. Ultimately, an undergraduate bachelor's degree plus four years of medical school (two in basic science and two in supervised clinical practice) were required in order to obtain a state license. Medical schools that could not offer such training ultimately either merged with schools that could or went out of business.

The increasing professionalism of medicine in the first two decades of the past century put doctors in charge of the medications they prescribed. Drug companies quickly succumbed to rules set by doctors that prohibited direct advertisements and required companies to submit their products to more rigorous testing of effectiveness and safety.

The professionalism of medicine is again in question. Over the last two decades, changes to the rules and funding for medical research have pushed doctors (especially university scientists) and the drug industry together, with the hope that the relationship would lead to new and more beneficial products. Instead, the creativity of the drug industry has stagnated (though not in terms of making profits), and doctors' credibility has been deeply damaged. From the highest levels of medical academia to front-line practicing specialists (especially in psychiatry, orthopedics, and cardiovascular medicine), there is proof of industry influence on doctors' opinions and decision-making. According to the Prescription Project, over fifty percent of Americans now think that drug companies exert a "large influence" over doctors' choice to use a specific drug.

The medical profession desperately needs a Flexner Report for the twenty-first century. The Physician Sunshine Payment Act, signed into law on March 23, is a step in the right direction: it requires that by 2013, drug companies post any gift or payment to doctors and hospitals. This will help inform the public about doctors' potential conflicts of interest. But it's not enough to have doctors' payments from drug companies listed on a Web site somewhere. Every waiting room should have information about the payments doctors have received from companies and the drugs and products involved. Additionally, medical research and academia must find a better way to separate their work from their sponsors' money. A general research fund of drug company money directed by an independent board has been suggested.

There are also signs of continued resistance from the elites in the medical profession. Just last month, the assembly of the American Psychiatric Association rejected a strict code of ethics on drug industry monies and conflict of interest, citing infringements of personal rights. Circulating just beneath the official explanation is a less ennobling explanation of infringement on personal income. Another example is Harvard University's foot-dragging in resolving the status of Joseph Biederman, a leading academic child psychiatrist accused of receiving $1.6 million of undeclared income from drug companies.

The hundred-year anniversary of the Flexner Report should remind physicians and the public alike that physicians do not become "professionals" merely by obtaining a medical degree. The field must collectively maintain worthy standards for itself that warrant the label.