Book Review

Beyond Flexner: Medical Education in the Twentieth Century

N Engl J Med 1993; 328:362February 4, 1993

Article

Beyond Flexner: Medical Education in the Twentieth Century
Edited by Barbara Barzansky and Norman Gevitz. 246 pp. New York, Greenwood Press, 1992. $49.95. ISBN: 0-313-25984-4

Controversy persists about the importance of the Flexner report of 1910 in the reform of our medical-education system. Was it a revolutionary force or merely a catalyst for changes already in progress? Some undesirable changes in medical education, such as an overemphasis on science and research at the expense of the art of practice, have also been attributed to Abraham Flexner's recommendations. Nevertheless, more than 80 years after its appearance, the report continues to be one of the most frequently cited works on American medical education.

Beyond Flexner is an outgrowth of a conference held at the University of Illinois College of Medicine in June 1986 to commemorate (apparently a year late) the 75th anniversary of the publication of Flexner's Medical Education in the United States and Canada. The stated goal of the authors is “to trace a number of elements articulated in the `Flexner Report' as they evolved during the twentieth century.”

The book consists of an introduction and 12 chapters by 11 contributors. Beginning with an interesting and well-written essay on the role of the Flexner report in shaping American undergraduate medical education within the context of changes that were already under way and of other influences on its development, the book concludes with a chapter describing changes in medical education proposed in four reports that appeared in the 1980s: Future Directions for Medical Education (Chicago: Council on Medical Education of the American Medical Association, 1979), Physicians for the Twenty-First Century (Washington, D.C.: Association of American Medical Colleges, 1984), “The Reform of Medical Education” by Robert Ebert and Eli Ginzberg (Health Affairs 1988;7(Suppl):5-38), and Clinical Education and the Doctor of Tomorrow, edited by Barbara Gastel and David E. Rogers (New York: New York Academy of Sciences, 1989), sponsored by the Josiah Macy, Jr., Foundation. In between are 10 chapters that cover the teaching of basic science to medical students, clinical education, teaching in the outpatient setting, current trends in the medical curriculum, black and sectarian medical schools, health services in America, the financing of undergraduate medical education, women in medicine, and the prediction of physician-staffing requirements.

A number of the essays provide a view of the subject through the eyes of a medical historian or sociologist. Several of the authors have traced the changes in various aspects of medical education from the early 20th century to the 1980s and have identified major dilemmas or areas of controversy. The chapter on basic-science education is an especially good example of this type of presentation. The chapter on the medical curriculum includes helpful discussions of forces impinging on medical education, current issues, and some more recently introduced innovations. The concluding chapter is a useful source of summaries of the recommendations for change that were contained in the four reports.

The material concerning Flexner's influence on medical education is fascinating, but I found the major value of the book to be its presentation of a historical view of developments in American medical education and related areas from the beginning of the 20th century or earlier to the 1980s.

Although this book is an outgrowth of a 1986 conference, bibliographic references as recent as 1990 and 1991 accompany some of the essays. On the other hand, some recent developments, such as the new testing format of the National Board of Medical Examiners, are not mentioned. The tables and figures are adequate, although one of the figures is reproduced poorly and the type in some of the tables is rather small.

Beyond Flexner will be of interest to medical historians and sociologists as well as to medical educators and medical school administrators. Even veterans in the field can profit from its perspectives, since several of the presentations cover a longer period of time than is encompassed by the personal experience of any individual medical teacher or curriculum planner.

James W. Craig, M.D.
University of Virginia School of Medicine, Charlottesville, VA 22908