Iconoclast: Abraham Flexner and a Life in Learning (review)

Just before Tom Bonner died in September 2003, at age 80, the book review editor of this journal invited me to write about Flexner's influence on medical education, using my comment on the book's dust jacket as a starting point. I had written: "Abraham Flexner was one of the great innovators in education of the twentieth century. Thomas N. Bonner, a distinguished historian as well as an educator/manager, is the biographer Flexner deserves."

The careers of Flexner and Bonner were exceptions to the increasing specialization of professional lives that began in the closing decades of the 19th century. Both Flexner and Bonner were teachers as well as managers and innovators in complex organizations. Both were disciplined researchers who also wrote persuasive plain-style prose. Moreover, both transcended humble origins as a result of intelligence, charm, and diligence, and both attracted effective mentors.

Flexner and Bonner made substantial contributions to scholarship during careers as responsible officials in significant institutions. Flexner was an executive for the Carnegie and then the Rockefeller philanthropies from 1910 through the 1920s, when leading foundations were surrogates for government in creating new health policy. He was subsequently the founding president of the Institute for Advanced Study in Princeton, New Jersey. Flexner wrote influential reports, articles, and books, not just about medical education but, in Bonner's words, as a "reformer and critic of the way Americans learn, from elementary school through postgraduate study" (ix). Bonner was president of the University of New Hampshire, Wayne State University, and Union College, provost at the University of Cincinnati, an aide to Senator George McGovern, and a candidate for Congress. He bracketed this career with seven distinguished books on the history of medicine.

Bonner's Flexner is a scholar and activist who mastered the politics of policy-making in organizations. He combined intelligence and energy with profound appreciation for contingency. By "contingency," I mean the unpredictable ways that individual and group interests, bureaucratic circumstances, and chance influence important decisions. Historians, both professionals and amateurs, too often claim that these decisions are the result of socioeconomic forces or the advance of science. Social forces and science matter, but only in the context of contingency. Continuity and change in history are neither inexorably determined nor "one damn thing after another."

Most people who have cited Flexner's report on medical education in the United States and Canada since its publication in 1910 have assumed that his strong personal opinions drove his recommendations. Bonner demonstrates that Flexner's opinions had contemporary and historical importance only because they helped make the case for what leading philanthropists and their allies in medicine believed to be practicable policy. Flexner inspected 150 medical schools and wrote forcefully about their weaknesses and, in a few instances, their strengths, at the request of powerful people who wanted to change whom, where, what, and how the schools taught. Bonner carefully writes that Flexner contributed more to the "rapid implementation" of new policy than he did to the substance of that policy (xi).

In contrast, most people who talk and write about the education of physicians have oversimplified Flexner in two ways. The oldest oversimplification is to describe Flexner as the scourge of incompetent physician-educators on behalf of the elite of biomedical science. Some commentators have praised this version of Flexner for helping to improve the quality of American medical education and research, while others have criticized him for inspiring curricular rigidity on behalf of science and specialization at the expense of primary care, women, and African Americans.

The second oversimplification is more recent: it is Flexner as a progressive educator. Bonner, following the physician-historian Kenneth Ludmerer, writes: "Flexner taught that students learn best through activities of mind and body rather than traditional bookish learning and daily recitations" (x). This Flexner was a theorist and foundation executive who brought medical educators into the mainstream of educational thinking about learning by doing and hence hastened their integration into the American...