The German Model for American Medical Reform
By Charles E. McClelland
The “Flexner Report” (originally published in 1910) recently passed its hundredth anniversary. It was the culmination of a study commissioned by the new Carnegie Foundation and carried out by a German-American educational reformer (and former student at Johns Hopkins, Harvard and Berlin Universities), Abraham Flexner. Not only did it ring the death knell of apprentice-like, unscientific and private medical education in the USA; Flexner’s fame led him into a position with the Rockefeller Foundation to channel funding into the reforms he advocated and ultimately to found the Princeton Institute for Advanced Study, thanking German-speaking scholars who inspired him – such as Einstein – by recruiting them and saving them from Nazi persecution. His report may be regarded partly as a cultural manifesto, since it proposed to revolutionize higher education and the ancient “art” of healing. It still makes compelling reading and retains a number of unique features.
First, few such public documents have had such a deep impact on any cultural activity anywhere in the twentieth century, and certainly on the structure of medical education and practice in the USA and ultimately, through imitation, around the world.
Second, although this “cultural document” is much better known in North America than Europe, its background and principal ideas are distinctly European in origin and represent a successful massive cultural transfer. Effectively, this transfer meant the adoption of an organically-developed system of medical education – including an emphasis on scientific research, the integration of patient treatment and teaching, national normatization of the medical arts and professional standards previously lacking in the disparate and vast territory of the USA.
Third, although much of the lengthy analysis and even longer presentation of data concentrate on the details of each step in recruitment and rigorous scientific training of future physicians as well as how medical faculties should be reorganized to accomplish those tasks, the “unspoken assumptions” behind the detailed analysis derived largely from a European – and specifically German – model as understood by the author, himself the child of a German-Jewish émigré family.
Fourth, this blueprint for standardized and demanding professionalization carried implications of wider educational and cultural mobilization, since it presupposed a radical restructuring and upgrading of the secondary and university system in both humanistic and science fields to prepare not only future physicians for medical study but also the broader educated elite in other professions. What began as an attempt to bring some order and transparency into the extremely variegated congeries of “tertiary education”, led to the realization, in the words of the report, “that the time had come when the relation of professional education in medicine to the general system of education should be clearly defined”. Along with comparable (if less stringent) reforms in the legal profession, the tightening of standards and certification for two of the leading academic professions (medicine and law) effectively placed the USA on a century-long path to a highly stratified and elite-dominated professional culture.
Finally, the full title of the document reveals a major reason for the successful implementation of the report, the fact that it was backed with the inducement of massive financial incentives provided by the Carnegie and Rockefeller Foundations (and later other philanthropic beneficiaries of the massive untaxed wealth accumulated by the industrial oligarchs of America’s Gilded Age, then often called “robber barons”). Indeed, the way in which the wealth of two of these philanthropists, in particular Carnegie (the steel magnate) and Rockefeller (the oil czar), was funneled from the first great philanthropic foundations under the guidance of a handful of ordinary bourgeois professional advisers in order to decisively reshape cultural and educational institutions has deserved a study of its own. In today’s era of comparable unequal distributions of wealth and enfeebled state support for cultural institutions, the capacity for radical interventions in modes of cultural transmission by small and well-financed elites – for good or ill – is instructive.
The Flexner Report furthermore reflected rapid changes in the economy, demographics, and cultural needs of many parts of North America by the beginning of the twentieth century. Instead of a primarily agricultural economy based on the free or cheap lands of expanding frontiers, the USA especially had become primarily an industrial, urban, and advanced capitalist land. Waves of immigrants to burgeoning cities provoked crises in delivery of such services as health care and education. American education, like professional and cultural organization, had been at least since the Jacksonian Era (1830s) a variegated, mostly local and often entrepreneurial affair with little or no public regulation. “Free enterprise” meant almost literally that virtually anybody (except of course women and to some extent the racially discriminated) could claim to be a physician, attorney, clergyman, professor or artist, and if one of them wanted the “competitive edge” of some certificates (e.g. a medical degree), established practitioners were happy to take on “apprentices” or even set up proprietary “schools” to provide small groups – by lecture and rote learning – a few weeks of instruction in return for the fees that were the only serious requirement for admission.
Of course in the more settled parts of North America (e.g. the large cities of the Northeast and a few other places), many old “colleges” had transformed themselves into something a visiting Berlin professor could recognize as a modern “university” by 1900 and several (e.g. Harvard, Yale, Columbia, the University of Pennsylvania – all in urban areas) had taken steps emulating the example of the newly founded Johns Hopkins University (Baltimore) – itself clearly modelled on German examples – by grafting a full-time medical faculty and urban teaching hospital onto the previous “college.” Until the last third of the nineteenth century, American institutions of higher education had normally embraced what in Germany would be called the philosophical and theological faculties. Even these resembled more the classical and humanistic traditions of their old English models, with considerably less rigor than even lethargic Oxford and Cambridge. Few such institutions awarded MD degrees or doctorates in law; the first PhD has been awarded (by Yale) as late as 1867. The transformation of old-line “colleges” and recently-founded (many of them “land-grant”) state universities was loosely based on the German model and notably included the addition of medical and legal faculties. Furthermore, the faculties strove toward a fully “professional” professoriate, implying as in Germany full-time salaried professors rather than “moonlighting” (part-time) local physicians and attorneys, as well as investment in laboratory sciences and other costly resources. These innovations also distinguished many brand-new foundings in the American Midwest and along the Pacific and Gulf Coasts.
The process of cultural transfer was thus already underway by 1900, even without Flexner. Stimulated by his Harvard postgraduate work, especially with the transplanted German psychology experimenter Professor Hugo Münsterberg, who urged Flexner to take a year of further study in Berlin, which would become one of “the defining experiences of his life”. His subsequent book criticizing American education led to the offer of a unique job by the Carnegie Foundation, seeking to distribute some of the massive wealth of its founder by improving education, including the support for and establishment of hundreds of public libraries. Flexner’s personal training and his connections through his physician brother to the medical profession in general as well as the Johns Hopkins University in particular led to his being chosen to prepare a survey on the effectiveness of medical education in the USA. But the majority of the 155 self-styled “medical schools” visited by Flexner before issuing his report continued as free-standing proprietary institutions or, even if they were nominally linked up with a private or even public institution of higher learning, they often disposed over inadequate or non-existent laboratories, equipment, hospitals or the funds to acquire them. Their educational requirements for admission were often abysmally low, the course of study short and superficial, based chiefly on lectures and textbooks. In an era when Nobel Prizes were regularly being awarded to German medical researchers for life-saving scientific discoveries, many American physicians probably did not know how to use a microscope or read an x-ray properly. Flexner demanded a minimum standard of prior education (high school diploma and at least two years of college with basic science), four full years of medical study, exposure to laboratory science, the predominance of full-time faculty rather than part-time local MDs as instructors, and active clinical experience in a hospital. This represented something approaching the minimum standards of universities he knew in Germany, such as Berlin.The rigorous, university-based, clinic-linked education of many Central European physicians (supplemented by continuing education after licensing), strict licensing requirements, and the incidental vast increase in public medicalization as a result of state-sponsored health insurance schemes contrasted sharply with the haphazard, still loosely-controlled formal education, clinical experience, licensing and professional sanctions typical of the USA as late as 1900.
Flexner’s report received widespread public discussion that generated political pressure in the Progressive Era. For example, whereas only 16 out of 155 medical schools had required two years of prior undergraduate college education for admission in 1910, over 90 per cent of the surviving ones did by 1920. Up to 40 per cent of proprietary medical schools closed, merged, or linked up with universities and upgraded, many as a result of Flexner’s harsh criticisms.
Flexner’s report mentions Germany only once (and indeed the other European models he had in mind never). The American Progressive Era in which his report is imbedded eschewed references to Europe’s superiority in matters of culture and science. It was the beginning of American world empire and self-confidence. Nevertheless, the handful of exemplary American medical faculties cited in Flexner’s long report were all based on the reforms introduced in a few elite private and ambitious public universities scant decades before, themselves the result of a cultural transfer carried personally by tens of thousands of American students who had studied in Central Europe. Indeed, the Flexner Report may be seen not so much as a completely novel initiative as the culmination of this longer transfer, even as a cultural “declaration of independence” from the long-standing need of Americans to spend years during the nineteenth century – first in Britain, then Paris, latterly in Germany, Austria-Hungary or Switzerland – to obtain cutting-edge higher education. It was only fitting that Flexner, one of the first great administrators of vast private cultural patronage in the USA, was able to repay America’s debt to Europe by raising funds for and organizing the Princeton Institute for Advanced Study as the clouds of fascist anti-intellectualism gathered in 1930s Europe. He could offer a refuge to Albert Einstein and others there, promoting another kind of cultural interchange and transfer of world-historical significance.
Abraham Flexner’s own biography and career arc are interesting in themselves as signs of an era in transnational cultural interchange. His father began as an itinerant Jewish peddler, an immigrant from Bohemia to Kentucky. His brother Simon became a distinguished professor of medicine and later director of the Rockefeller Institute for Medical Research in New York. From this position he could lever Abraham out of running an experimental private prep school in frontier America along the lines of Pestalozzi and Dewey (leading to a book about American school failure) and into the unprecedented job of advising billionaires about how to spend their money to improve education. Flexner’s concern, as well as that of his backers, was not merely the reform of professional higher education, but of the entire structure of American education. Here Continental school models, from Kindergarten to the German Realgymnasium, appealed as an alternative to the haphazard anarchy of a parochially-grown, decentralized American patchwork. Carnegie’s hundreds of public free libraries were as much a part of this cultural adaptation as were efforts to reform medical training. And, as in Europe, a medical or legal professional was meant to take on the attributes of a gentleman learned in the humanities and sciences, transcending the artisanal and uncultured reputation of many small-town and rural doctors emitted by the de facto businesses that proprietary short-course medical “schools” represented. One important intended result of making medical education more demanding – and expensive – was to reduce the quantity of physicians, reduce competition and “quackery” while massively enhancing the authority, incomes and social standing of this new medical elite. As Flexner stated in his report, the USA was then producing four to five times the number of physicians per capita as Germany – too many and too poorly prepared to meet the health needs of the nation. This was incidentally exactly the wish list of German physicians at the time as well, but their successes in the “professionalization project” (partly no doubts as a consequence of World War I) were not as dramatic as their American colleagues. The new American medical elite in turn, principally through the massive influence of a reinvigorated American Medical Association, was largely able for the first time to dictate the terms of medical care in the United States for a half-century or more after the Flexner Report. The relative success of the “professionalization project” among American (as contrasted to Central European) physicians should also alert us to the non-linearity of cultural transfers, as well as to the significance of widely diverging economic and political matrices after 1910. The radical tightening of standards for the production of physicians attributed to the Flexner reforms, which produced a trend toward greater social exclusivity and dominance over the market for medical services in America, contrasted strongly with the wartime loosening of educational and licensing standards followed by opening the floodgates to university study in post-1918 Germany.
Despite the many contrasts and even ironies wrapped up in the further history of this cultural transfer, the Flexner Report and its largely unspoken assumptions about contemporary Central European educational purposes and outcomes arguably deserves more attention outside the narrower history of medicine than it now receives.
 Essay on the source: Abraham Flexner: Medical Education in the United States and Canada (1910). A printed version of the essay is published in: Isabella Löhr, Matthias Middell, Hannes Siegrist (Hgg.): Kultur und Beruf in Europa, Stuttgart: Franz Steiner Verlag 2012, S. 189–194, Band 2 der Schriftenreihe Europäische Geschichte in Quellen und Essays.
 Flexner, Abraham, Medical Education in the United States and Canada. A Report to the Carnegie Foundation for the Advancement of Teaching, New York 1910, pp. vii–viii, x–xi, 14, here p. viii.
 Wheatley, Steven. C., The Politics of Philanthropy. Abraham Flexner and Medical Education, Madison 1989.
 For an example, see Münsterberg, Hugo, Amerika, in: Kirchhoff, Arthur (ed.), Die akademische Frau. Gutachten hervorragender Universitätsprofessoren, Frauenlehrer und Schriftsteller über die Befähigung der Frau zum wissenschaftlichen Studium und Berufe, Berlin 1897, pp. 343–353, and the discussion of its findings in: McClelland, Charles E., American Examples for German Universities. Admitting Women before World War I, in: Keiner, Edwin (eds.), Metamorphosen der Bildung. Historie – Empirie – Theorie, Bad Heilbrunn 2011, pp. 323–335. Münsterberg became a close advisor to Flexner a decade later when the latter did postgraduate work at Harvard.
 Bonner, Thomas Neville, Abraham Flexner and the German University. The Progressive as Traditionalist, in: Paedagogica Historica 33 (1997), p. 103.
 The best biography is Bonner, Thomas Neville, Iconoclast. Abraham Flexner and a Life in Learning, Baltimore 2002; Wheatley, The Politics of Philanthropy.
Barzansky, Barbara M.; Gevitz, Norman, Beyond Flexner. Medical Education in the Twentieth Century, New York 1992.
Bonner, Thomas Neville, Abraham Flexner and the German University. The Progressive as Traditionalist, in: Paedagogica Historica 33 (1997), pp. 100–114.
Bonner, Thomas Neville, Iconoclast. Abraham Flexner and a Life in Learning, Baltimore 2002.
Flexner, Abraham, Medical Education. A Comparative Study, New York 1925.
Wheatley, Steven. C., The Politics of Philanthropy. Abraham Flexner and Medical Education, Madison 1989.