I saw a marvelous and disturbing presentation recently about the stunning, yet in the end unsurprising, roots of racism in medicine. The founding of our profession was not pretty in that regard but it is something that all nurse practitioners (NPs) and PAs need to look at. It happened and has had an impact on practice today, both individually and systematically.
After the presentation I was thinking back about what I have heard about Abraham Flexner, often referred to as “the father of modern medical education.” He was not a physician but gained acclaim as a medical reformer and researcher. He is best known for his 1910 Flexner Report, which reviewed medical education and made recommendations for sweeping changes after visiting all 155 medical schools in operation at the time. According to a 2020 post from the Association of American Medical Colleges (AAMC), the Flexner Report “called for major reforms to medical education including higher admissions standards for students, adherence to the scientific method in research and practice, and oversight by state licensure boards.”
Flexner has been viewed favorably within the medical community since then. This, however, began to change in the 2010s and early 2020s when his work was revisited by many in medicine. One result was the renaming of the Abraham Flexner Award for Distinguished Service to Medical Education in 2021 to the AAMC Award for Excellence in Medical Education.
Many factors contributed to this change in attitude and even remorse about some of the impact of Flexnor’s well-known 1910 report. The report recommended new and more rigorous standards for medical training centers, many of which are still in use today in medical education, including the model of medical education including 2 years of basic sciences followed by 2 years of clinical training. At the time, many medical training facilities lacked the needed resources to adopt the curriculum and training changes, resulting in the closure of 89 of 155 medical schools. This included 5 of 7 schools that were focused on training Black physicians.
The AAMC report described the influence of that development on the current status of Black physicians, citing that only 5% of American physicians are Black, while Black Americans make up 13.4 % of the American population. If all 7 Black-focused medical training institutions had remained open there would have been an additional 35,315 Black physicians as of 2020, according to the AAMC report.
His comments about Black medical students were no less disturbing: “Black students should be trained as ‘sanitarians’ rather than surgeons and their primary role should be to protect White people from disease. A well-taught negro sanitarian will be immensely useful; an essentially untrained Negro wearing an MD degree is dangerous,” Flexner wrote.
Like Black physicians, women were also impacted by the Flexner report. Sexist writing included this description: “While women were not barred from applying to medical school, they ‘show a decreasing inclination to enter it — and that those who did have ‘obvious limitations.’”
In 1900, “women accounted for 6% of practicing physicians nationwide, and in 1909, they were accepted at 91 of the 155 medical schools — including 3 schools dedicated exclusively to educating women. However, by 1940, just 4% of physicians were women, in part due to the closure of many schools that had accepted higher numbers of women but also due to a societal backlash against the role of women in the medical profession,” noted the AAMC report. Women did not begin to catch up to men until the 1960s, and “they still lag behind their male peers in compensation, leadership positions, and research publications.”
Many people will undoubtedly say “that was over 110 years ago!” But that’s the actual point and the uncomfortable truth: the 1910 Flexner Report not only reflects the racist and sexist heritage of medical school origins but also clearly had a direct racist and sexist impact on the ongoing disparities in both the health of patients and the beliefs of clinicians.
Such reflection by practicing clinicians today is undeniably painful but also undoubtedly essential to continue to grow out of the racist and sexist roots of our profession.