Abraham Flexner’s legacy---NEJM authors miss the point

The New England Journal of Medicine (NEJM) launched a series of articles on medical education with this piece on the legacy of Abraham Flexner. The 1910 Flexner Report, a comprehensive and highly critical evaluation of medical schools in the United States and Canada, helped spur a revolution in medical education, setting a blueprint for the twentieth century.

The authors, discussing how medical schools today might measure up in Flexner’s view, cite poor training in procedural skills, compromised teaching due to competing research and economic agendas and a lack of attention to professionalism and ethics. These are valid concerns. But conspicuously absent form the discussion was mention of a major problem plaguing medical training today about which we were warned in the Flexner Report: the rampant teaching and promotion of quackery and pseudoscience in medical school. Almost a year ago I pointed out that medical schools had backslidden from the recommendations of the Flexner Report as evidenced by their promotion of homeopathy, Reiki, Ayurvedic medicine and innumerable other unscientific claims.

As I reviewed the Flexner Report in its entirety this weekend I caught myself wondering whether the NEJM authors even read it at all. Flexner’s concern for the sanctity of science, practically an obsession, is evident throughout. If the authors read the report they must have skipped chapter 10 which warns strongly against what medical educators today call “integrative medicine.” The chapter is titled “The Medical Sects”, in reference to groups of teachers and practitioners who advocated for various non-scientific claims, referred to by Flexner as “dogmas.” Chapter 10 opens questioning the integration of dogma with science thusly: “Is it essential that we should now conclude a treaty of peace, by which the reduced number of medical schools should be pro-rated as to recognize dissenters on an equitable basis? The proposition raises at once as to whether in this era of scientific medicine, sectarian medicine is logically defensible; as to whether, while it exists, separate standards, fixed by the conditions under which it can survive, are justifiable.” Flexner’s emphatic answer, bolstered by eloquent arguments in the succeeding pages, is no.

Medical schools are showing increasing disregard for the principles of science. If the NEJM in its forthcoming series of reviews on medical education ignores this pernicious trend it will have done the profession a great disservice.