The health care mess: Flexner validity & aftermath

Published 12 years ago -  - 12y ago 37

It’s impossible to overstate the disaster that Abraham Flexner represented for the American health care system. All three medical schools for women closed. The last eclectic school closed in 1939 after having numbered 8 in 1915. By 1935, the number of black schools was reduced from seven to two, nine homeopathic schools to two. Every free standing medical school in the country closed.

The osteopathic and chiropractic professions were nearly destroyed. Concomitantly, M.D. incomes skyrocketed as the ratio of patients to physicians climbed. Flexner had an axe to grind and grind it he did. Then he buried it in the body of the cost of health care for the American people.

(An irony is that much of the financial support for Flexner’s project came from the Rockefeller Foundation. Yet, the John D. Rockefeller and much of his family since have been a homeopathic, osteopathic and chiropractic patients. In fact, it was through the efforts of Governor Nelson Rockefeller that the New York College of Osteopathic Medicine was founded.)

First, it’s important to realize that Abraham Flexner was not a physician but an educator. While that should not disqualify him from contributing to a debate on medical education, it was absurd to rely solely on his observations.

Another question of the validity of Flexner’s recommendations is that a representative of the AMA accompanied him on many of his evaluations. Flexner and the AMA never publicized their connection, a fact which would have likely resulted in a far different evaluation of his motives and his report.

He sought no representatives from the schools he inspected nor from any of the alternative professions. One report had his visit to an osteopathic college as lasting two hours. Their protestations fell on completely deaf ears. There was no room for argument with this autocratic hired gun.

The Report fit in with the tenor of the times. Excerpts that I have read are dipped in contempt. Many of his descriptions are graphic and important steps removed from reality. Upton Sinclair, a socialist and a founder of the American Civil Liberties Union, wrote a sensationalistic novel, ‘The Jungle’, about the meatpacking industry, that resulted in the Meat Inspection Act. Lincoln Steffens, the original muckraking journalist from the turn of the twentieth century, wallowed in the same type of exposes. He later traveled to Moscow after the communist takeover and announced, ‘I have seen the future and it works.’ True to form, Flexner’s Report caused increasing clamor for government regulation of health care and, also true to form, government didn’t shrink from the challenge.

But the worst effect was hardly economic. Hospital and medical centers became the setting for the training of physicians rather than offices. Trainees became completely oriented away from hospital and medical center care, the most inefficient and expensive venue.

Science rather than the humanities became the pathway for pre-medical study, precluding a varied background among physicians, not to mention a human factor often missing in the scientifically trained. Specialization dominated medical care at schools and large metropolitan medical centers.

Enamored of research, Flexner (remember his brother, Simon, at Rockefeller) almost automatically conferred an imprimatur of approval on schools with extensive research facilities, the more extensive the better. Research facilities in hospitals and medical schools became a gauge of quality medical education, an entity that does little, if anything, for quality of training or care administered.

With the emphasis on specialization, there was a de-emphasis on primary care. This imbalance continues today and will not be changed, under the current system, in spite of the efforts of insurers and government. Specialists dominate hospitals, medical school staffs and insurers fall in line with generous reimbursements for procedures, ‘doing something’, rather than the simple matter of talking with patients.

Which brings us to today.
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