The “Flexner Century” is over…

Feb 1, 2010

…what’s next for Complementary and Alternative Medicine?

I read an interesting article today that I thought you’d appreciate. The author, Emily Walker, a Washington Correspondent for Medpage Today wrote:

A century ago, Abraham Flexner’s pivotal report redefined medical education and laid the groundwork for the growth of academic medical centers, but increasing medical specialization was an unintended consequence and threatens patient care, according to a paper published in an anniversary issue of Academic Medicine.

The growing importance of academic medical centers during the last century has caused medicine’s “social contract” to “erode,” to be replaced by “a money culture that dominates the academic health system and has led to distortions in medical education and to our present maldistribution of physicians by specialty.”

So wrote Michael Prislin, MD, professor of family medicine at the University of California, and colleagues who authored the paper, one of a special series of articles commemorating the 100th anniversary of the Flexner Report.

In his 1910 report, Flexner, an educator on the staff of the Carnegie Foundation, criticized the quality of the 160 U.S. medical schools, noting that many of the smaller, proprietary schools taught a curriculum not based in science. He advocated that medical schools be university-based, have stringent entry and graduation standards, provide a clinical setting as well as an academic one in which students would learn, and encourage faculty research.

By 1920, nearly half the medical schools had closed and the remaining 85 were university-based and under tight regulatory oversight by the American Medical Association’s Committee on Medical Education.

Although the Flexner report is universally acknowledged as having an overall positive impact on medicine, it has also been blamed for eliminating diversity in the profession — forcing closure of smaller schools that admitted minorities, women, and low-income students.

Even today, Prislin and colleagues wrote, 75% of U.S. medical students come from families whose income classifies them as upper- or upper-middle-class.

The growth of academic medical centers and a less diverse physician population created a climate that allowed other societal changes “resulting in the proliferation of specialties,” the authors wrote.

“In the contemporary educational and practice environments, the generalist disciplines seem to be at grave risk,” they wrote, arguing that the current faculty clinical practice model would “likely be abhorrent to Flexner,” who said that “university hospitals, academic salaries, etc.” can create good conditions for learning medicine, but they cannot create the “ideals” necessary for compassionate medicine…1

This last phrase, “the ‘ideals’ necessary for compassionate medicine” caught my eye and interest.  Please allow me to explain.  One of the other side effects in the reorganization of medical education in the United states was that virtually all of the educational institutions that taught what we now know as the emerging field of “Complementary and Alternative Medicine” or (“CAM”), were wiped out.

The osteopathic and homeopathic departments and hospitals in large institutions like Boston University, The University of Michigan and numerous homeopathic colleges sponsored by Hahnemann and others were swept away as they did not fit the new “scientific” model that Flexner based largely on his observations of the medical program at Johns Hopkins University.

At that point, the modalities that we now know as CAM modalities, such as homeopathy, were cast aside without consideration of their value as a system of medicine.  The baby was unfortunately thrown out with the bath water.

Well, here we are.  100 years later and in a pickle of national proportions.  Our health care system, while very effective at treating acute issues and trauma, is largely impotent in the face of the epidemic of chronic disease.  We’re living longer, but not healthier and even that has come at an enormous price.  Literally.

The lack of effectiveness and the unsustainable economics of health care are disconcerting, to say the least.  Well, as with so many seemingly intractable issues, this Gordian Knot has a simple solution, albeit one that will require extensive renovation and implementation.  We need to reinvent primary health care!  We need to reestablish “the ‘ideals’ necessary for compassionate medicine.”

Enter CAM.  Where CAM modalities tend to shine is in the prevention and care of chronic disease.  There is a reason that CAM has enjoyed such a resurgence in our era, as the system we developed 100 years ago was necessary and helpful at the time, but its useful life is quickly waning.

Traditional Chinese Medcine, homeopathy, and many other modalities are finding open arms from proponents of “integrative medicine,” a new system of medicine that combines the best of the old with the best of the new.  We have made progress, after all, and there is no sense in simply reverting to the old system of care that predates Mr. Flexner and his sponsor, the Carnegie Institute.  In fact, researchers, doctors, administrators at the forefront of the development of this new system of medicine are finding incredible results are possible in dealing with both acute and chronic conditions.

I would encourage you to look into innovative programs and the fascinating work being done by such venerable insitutions as Duke University’s “Duke Integrative Medicine,” the Integrative Medicine Service at Memorial Sloan-Kettering, UCSF’s Osher Center for Integrative Medicine or the Bravewell Collaborative.  They and others are heralds of a new era in medicine, one in which the “ideals” can be safely and firmly established.

1 http://www.medpagetoday.com/PublicHealthPolicy/MedicalEducation/18222