Medical education reform efforts and failures of U.S. medical schools, 1870-1930

Journal of the History of Medicine and Allied Sciences

Volumn 63, Issue 3, 2008, Pages 348-387

  Miller, Lynn E ^a   Weiss, Richard M ^b  

^a LA SALLE UNIVERSITY   (United States)

^b UNIVERSITY OF DELAWARE   (United States)

Author keywords

Abraham Flexner; American Medical Association; Association of American Medical Colleges; Medical education; Medical licensing

Indexed keywords

ARTICLE; EDUCATIONAL MODEL; EDUCATIONAL STATUS; HISTORY; HUMAN; LICENSING; MEDICAL EDUCATION; MEDICAL SCHOOL; MEDICAL SOCIETY; UNITED STATES;

AMERICAN MEDICAL ASSOCIATION; EDUCATION, MEDICAL; EDUCATIONAL STATUS; HISTORY, 19TH CENTURY; HISTORY, 20TH CENTURY; HUMANS; LICENSURE, MEDICAL; MODELS, EDUCATIONAL; SCHOOLS, MEDICAL; UNITED STATES;

EID: 46749116464     PISSN: 00225045     EISSN: 14684373     Source Type: Journal    
DOI: 10.1093/jhmas/jrn002     Document Type: Article

References (185)

1. Our counts include all schools that were in operation for at least a year and that offered a complete program of medical education leading to the M.D. degree; "half schools" (e.g., those offering only preclinical training) and osteopathic schools are excluded.
2. See Howard S. Berliner, "A Larger Perspective on the Flexner Report," Int. J. Health Serv., 1975, 5, 573-92;
3. Howard S. Berliner, "New Light on the Flexner Report: Notes on the AMA-Carnegie Foundation Background," Bull. Hist. Med., 1977, 51, 603-9;
4. Martin Kaufman, "American Medical Education," in The Education of American Physicians, ed. Ronald L. Numbers (Berkeley: University of California Press, 1980), 7-26;
5. Gerald E. Markowitz and David Karl Rosner, "Doctors in Crisis: A Study of the Use of Medical Education Reform to Establish Modern Professional Elitism in Medicine," Am. Quarterly, 1973, 25, 83-107.
6. John Duffy, The Healers (New York: McGraw-Hill, 1976), 291;
7. Kenneth M. Ludmerer, Learning to Heal: The Development of American Medical Education (New York: Basic Books, 1985), 47-71;
8. Paul Starr, The Social Transformation of Medicine (New York: Basic Books, 1982), 112.
9. William G. Rothstein, American Medical Schools and the Practice of Medicine: A History (New York: Oxford University Press, 1987), 143.
10. Richard A. Cooper noted that the number of schools did not begin to increase appreciably again until the 1960s, in "Medical Schools and Their Applicants: An Analysis," Health Aff. (Millwood), 2003, 22, 71-84.
11. Dean F. Smiley, "History of the Association of American Medical Colleges," J. Med. Educ., 1957, 32, 512-35.
12. Abraham Flexner, Medical Education in the United States and Canada (New York: Carnegie Foundation for the Advancement of Teaching, 1910).
13. Joseph F. Kett, The Formation of the American Medical Profession (New Haven, CT: Yale University Press, 1968), 181-84;
14. Richard Harrison Shryock, Medical Licensing in America, 1650-1965 (Baltimore, MD: Johns Hopkins University Press, 1967), 25-27.
15. Shryock, Medical Licensing, 28;
16. Duffy, The Healers, 176.
17. Thomas Neville Bonner, Becoming a Physician: Medical Education in Britain, France, Germany, and the United States, 1750-1945 (New York: Oxford University Press, 1995), 175-76;
18. N. S. Davis, Contributions to the History of Medical Education and Medical Institutions in the United States of America, 1776-1876 (Washington, DC: GPO, 1877), 43.
19. Martin Kaufman, American Medical Education: The Formative Years, 1765-1910 (Westport, CT: Greenwood Press, 1976), 42.
20. See also James G. Burrow, Organized Medicine in the Progressive Era: The Move Toward Monopoly (Baltimore, MD: Johns Hopkins University Press, 1977), 31-32.
21. Kaufman, American Medical Education, 68.
22. John S. Haller, American Medicine in Transition, 1840-1910 (Urbana: University of Illinois Press, 1981), 199-203;
23. Shryock, Medical Licensing, 27-32.
24. Bonner, Becoming a Physician, 198-99, 218-21;
25. Ludmerer, Learning to Heal, 15-18;
26. Rothstein, American Medical Schools, 56-61, 99.
27. Bonner, Becoming a Physician, 191;
28. Thomas N. Bonner, American Doctors and German Universities: A Chapter in International Relations, 1870-1914 (Lincoln: University of Nebraska Press, 1987).
29. James Bordley and A. McGehee Harvey, Two Centuries of American Medicine, 1776-1976 (Philadelphia: W. B. Saunders, 1976), 20;
30. Kaufman, American Medical Education, 102;
31. Norwood, Medical Education, 422-28.
32. N. S. Davis and F. H. Davis, "Medical Teaching - Credit to Whom Credit is Due," Med. Examiner, 15 April 1873, 14, 95.
33. Henry K. Beecher and Mark D. Altschule, Medicine at Harvard: The First Three Hundred Years (Hanover, NH: University Press of New England, 1977);
34. Kenneth M. Ludmerer, "Reform at Harvard Medical School, 1869-1909," Bull. Hist. Med., 1981, 55, 343-370.
35. Anon., "Medical Education," New York Times, 21 May 1876, 6.
36. Bordley and Harvey, Two Centuries, 131.
37. Ludmerer, Learning to Heal, 53-57;
38. Frederick C. Waite, "Advent of the Graded Curriculum in American Medical Colleges," J. Assoc. Am. Med. Coll., 1950, 25, 315-22.
39. Ludmerer, Learning to Heal, 84.
40. Starr, Social Transformation, 119.
41. From the letter inviting medical schools to send representatives to the Philadelphia meeting, quoted in Smiley, "History," 512.
42. Proceedings of the Third Annual Meeting of the American Medical College Association, 1879, 6;
43. Smiley, "History."
44. Smiley, "History"; Anon., "Editorial," Gaillard's Med. J., 1882, 33, 590-91. The Gaillard's editorial poked fun at the AMCA for passing a convoluted amendment to its Articles of Confederation declaring that two five-month sessions would be regarded as three sessions, as well as at various members for blustering about the need for a three-session curriculum, only to desert the association when it became apparent that the lengthened curriculum would be compulsory.
45. Waite, "Advent."
46. Anon., "Medical Education in the United States," J. Am. Med. Assoc., 1894, 22, 393-94.
47. Samuel L. Baker, "Physician Licensure Laws in the United States, 1865-1915," J. Hist. Med. Allied Sci., 1984, 39, 173-97;
48. Waite, "Advent."
49. Mark D. Bowles and Virgina P. Dawson, With One Voice: The Association of American Medical Colleges, 1876-2002 (Washington, DC: Association of American Medical Colleges, 2003), 32.
50. Ibid., 31.
51. Letter from E. Fletcher Ingals to W. H. Howell, 18 December, 1899, Governance Records Inventories, Box 1: Misc. Historical Documents, AAMC Collection, Mary H. Littlemeyer Archives, Association of American Medical Colleges, Washington, DC.
52. Albert R. Baker, "Evolution of the American Medical College," Bull. Am. Acad. Med., 1901, 5, 489-502, 495.
53. George M. Kober, "The Past and Present Status of Medical Education in This Country," AAMC Proceedings, 1907, 26-36, 31 [emphasis added].
54. Fred C. Zapffe, "The Present Status of Medical Education," AAMC Proceedings, 1909, 41-51, 41-42.
55. Ludmerer, Learning to Heal, 96-99.
56. Anon., "Attacks Medical Colleges," New York Times, 23 March 1910, 20.
57. Bowles and Dawson, One Voice, 40;
58. Smiley, "History."
59. Ludmerer, Learning to Heal, 129.
60. In 1918, more than 80 percent of the schools that were A-rated by the AMA had joined the AAMC; most nonmembers were B- or C-rated.
61. Baker, "Licensure Laws"; Ronald Hamowy, "The Early Development of Medical Licensing Laws in the United States, 1875-1900," J. Libertarian Studies, 1979, 3, 73-119.
62. Baker, "Licensure Laws"; Berliner, "Larger Perspective"; Markowitz and Rosner, "Doctors in Crisis."
63. Shryock, Medical Licensing, 42-49.
64. Samuel L. Baker, "A Strange Case: The Physician Licensure Campaign in Massachusetts in 1880," J. Hist. Med. Allied Sci., 1985, 40, 286-308.
65. Shryock, Medical Licensing, 54-55;
66. Rosemary Stevens, American Medicine and the Public Interest (New Haven, CT: Yale University Press, 1971), 59-62.
67. Baker, "Licensure Laws."
68. Ibid.;
69. Annual Report of the State Board of Health of Illinois, 1891, 129. Hamowy, in "Early Development," noted that in some cases, merely claiming to hold a degree was sufficient grounds for licensure, as the person was assumed to hold a degree from a legitimate school unless it could be proven otherwise.
70. Thomas Goebel, "Professionalization and State Building: The State and the Professions in Illinois, 1870-1920," Soc. Sci. Hist., 1994, 18, 309-37;
71. Kenneth H. Schnepp, "Medical Licensure in Illinois: An Historical Review," Ill. Med. J., 1976, 150, 229-34.
72. Anon., The Standard Medical Directory of North America (Chicago: G. P. Engelhard, 1902).
73. "State Ex Rel. Johnson v. Lutz et al.," Supreme Court of Missouri, 23 December 1896, cited in Annual Report of the State Board of Health of Illinois, 1898, p. CXVI.
74. Anon., "Medical Education in the United States," J. Am. Med. Assoc., 1894, 22, 393-94.
75. Victor Clarence Vaughan, A Doctor's Memories (Indianapolis: Bobbs-Merrill, 1926), 439.
76. Shryock, Medical Licensing, 54.
77. Ludmerer, Learning to Heal, 326-27, n. 6.
78. Baker, "Licensure Laws"; Hamowy, "Early Development."
79. Baker, "Licensure Laws."
80. Anon., "The Education of the Interne," J. Am. Med. Assoc., 1904, 43, 469-70.
81. Willard C. Rappleye, Final Report of the Commission on Medical Education (New York: Office of the Director of Study, 1932), 141.
82. Burrow, Organized Medicine; Ludmerer, Learning to Heal, 116-17.
83. Lester S. King, American Medicine Comes of Age, 1840-1920 (Chicago: American Medical Association, 1984), 16;
84. Lester S. King, Transformations in American Medicine (Baltimore, MD: Johns Hopkins University Press, 1991), 210.
85. Rothstein, American Medical Schools, 63.
86. Haller, American Medicine, 214;
87. Stevens, American Medicine, 37.
88. Hamowy, "Early Development."
89. Ibid.
90. Starr, Social Transformation, 103. The AMA's attempts to enforce its "ethical" stricture against consultation with sectarian physicians resulted in some very public embarrassments, particularly in Massachusetts and New York, where the ranks of elite physicians included a number of well-regarded homeopaths and the state medical societies were bitterly divided over whether to comply with the AMA's policy (see Baker, "Strange Case"; King, Transformations, 211-14).
91. The 1893 JAMA publication of a lengthy address "Points of Similarity between Us and Homeopathic Physicians" (John B. Roberts, J. Am. Med. Assoc., 1893, 20, 580-84) signaled a softening of the AMA's antipathy toward sectarian medicine. Perhaps this expression of comity helped attenuate resistance to licensing laws, as the number of states mandating licensing examinations increased dramatically over the next few years.
92. James G. Burrow, AMA: Voice of American Medicine (Baltimore, MD: Johns Hopkins University Press, 1963), 27-66.
93. Ibid., 52.
94. Frank Billings, "Medical Education in the United States," J. Am. Med. Assoc., 1903, 40, 1271-76;
95. George H. Simmons, "Medical Education and Preliminary Requirements," J. Am. Med. Assoc., 1904, 42, 1205-10;
96. John H. Musser, "Some Aspects of Medical Education," J. Am. Med. Assoc., 1904, 42, 1535-40;
97. Anon., "Too few physicians? Hardly!" J. Am. Med. Assoc., 1905, 44, 1689.
98. Stevens, American Medicine, 58.
99. Ibid., 65.
100. Ibid., 65;
101. Burrow, Organized Medicine, 41;
102. Robert P. Hudson, "Abraham Flexner in Historical Perspective," in Beyond Flexner: Medical Education in the Twentieth Century, ed. Barbara Barzansky and Norman Gevitz (New York: Greenwood Press, 1992), 1-18, 8;
103. Magali Sarfatti Larson, The Rise of Professionalism (Berkeley: University of California Press, 1977), 162.
104. Ludmerer, Learning to Heal, 240.
105. Ibid., 242-43.
106. Burrow, AMA, 51;
107. Starr, Social Transformation, 121.
108. Thomas Neville Bonner, Iconoclast: Abraham Flexner and a Life of Learning (Baltimore, MD: Johns Hopkins University Press, 2002), 188-89;
109. E. Richard Brown, Rockefeller Medicine Men: Medicine and Capitalism in America (Berkeley: University of California Press, 1979), 153;
110. Ludmerer, Learning to Heal, 246.
111. Smiley, "History."
112. Ibid.
113. Shryock, Medical Licensing, 86-87;
114. Stevens, American Medicine, 168-69.
115. Rothstein, American Medical Schools, 149.
116. See also Rappleye, Final Report, 166-67.
117. Ludmerer, Learning to Heal, 170;
118. Starr, Social Transformation, 118.
119. Council on Medical Education, "AMA Minutes of Meeting," 28 December 1908, in Minutes of the Business Meetings of the Council on Medical Education and Hospitals: 1907-1917 (Chicago: AMA Library, 1907-1917).
120. Bonner, Iconoclast, 63.
121. Starr, Social Transformation, 119;
122. Stevens, American Medicine, 67.
123. An editorial, "The Influence of the Carnegie Foundation on Medical Education," helped to plant this latter expectation (Anon., J. Am. Med. Assoc., 1909, 53, 559-60). It noted that many medical schools were not yet benefiting from the foundation's pension fund and stated that the foundation periodically would need to "carry out comprehensive investigations of all the medical schools in the country" (560) to ensure that "the work of the institutions that are admitted to the benefits of a pension system. . .[meet] a reasonable standard" (559).
124. Hubert Royster provided direct evidence that schools viewed pension fund benefits as linked to cooperation with Flexner's inspections, in Royster, Historical Sketch of the University of North Carolina Medical Department at Raleigh (Raleigh: University of North Carolina Alumni Association, 1941), 11. He noted that the president of the University of North Carolina pressured the medical school into compliance with Flexner's recommendation to close its clinical program in Raleigh, fearing that the university would be removed from the Carnegie pension system.
125. Gert H. Brieger, "The Flexner Report: Revised or Revisited?" Med. Heritage, 1985, 1, 25;
126. Carleton B. Chapman, "The Flexner Report by Abraham Flexner," Daedalus, 1973, 103, 105-17.
127. Flexner, Medical Education, 190.
128. Ibid., 227.
129. Ibid., 297.
130. Ibid., 257.
131. Ibid., 292.
132. Ibid., 14, 17, 49.
133. Bonner, Iconoclast, 144-73.
134. See, for example, Anon., "Medical Education Scandals Exist in America Only," New York Times, 16 June 1912, SM1.
135. Berliner, "Larger Perspective"; Hudson, "Abraham Flexner"; Ludmerer, Learning to Heal, 181;
136. Starr, Social Transformation, 119.
137. Donald Fleming, William Welch and the Rise of Modern Medicine (Boston: Little, Brown and Company, 1954), 174.
138. George Rosen, The Structure of American Medical Practice, 1875-1941 (Philadelphia: University of Pennsylvania Press, 1983), 65.
139. Ibid., 62.
140. Ludmerer, Learning to Heal, 181.
141. Starr, Social Transformation, 118, 120.
142. Rothstein, American Medical Schools, 146.
143. Brown, Medicine Men, 154.
144. Anon., American Medical Directory (Chicago: American Medical Association, 1934), 78-88;
145. "Table 4. Existing and Extinct Medical Colleges," J. Am. Med. Assoc., 1908, 51, 597-602;
146. "Table 4. Existing and Extinct Medical Colleges," J. Am. Med. Assoc., 1919, 73, 507-12.
147. For example, Leslie B. Arey, Northwestern University Medical School, 1859-1959 (Evanston, IL: Northwestern University, 1959);.
148. Bill Carey, Chancellors, Commodores, and Coeds: A History of Vanderbilt University (Nashville, TN: Clearbrook Press, 2003);
149. Coy C. Carpenter, The Story of Medicine at Wake Forest University (Chapel Hill: University of North Carolina Press, 1970).
150. Major sources include: Harold J. Abrahams, The Extinct Medical Schools of Nineteenth-Century Philadelphia (Philadelphia: University of Pennsylvania Press, 1966);
151. Harold J. Abrahams, The Extinct Medical Schools of Baltimore, Maryland (Baltimore: Maryland Historical Society, 1969);
152. Colin B. Burke, American Collegiate Populations: A Test of the Traditional View (New York: New York University, 1982), Appendix A;
153. Samuel Wood Geiser, Medical Education in Dallas 1900-1910 (Dallas: Southern Methodist University Press, 1952);
154. John S. Haller, Medical Protestants: The Eclectics in American Medicine, 1825-1939 (Carbondale: Southern Illinois Press, 1994);
155. Burton D. Myers, The History of Medical Education in Indiana (Bloomington: Indiana University, 1956);
156. Norwood, Medical Education;
157. Francis R. Packard, History of Medicine in the United States (New York: Paul B. Hoeber, 1932);
158. Todd L. Savitt, "Four African-American Proprietary Medical Colleges: 1888-1923," J. Hist. Med. Allied Sci., 2000, 55, 203-55.
159. By tracing schools' histories from a range of archival materials and interviews with medical school archivists, we were able to distinguish between mergers and absorptions. In the case of absorptions, students at the absorbed school transferred to the absorbing school; the absorbing school continued to operate under the same name and only the absorbed school was coded as closing. The merger of two schools as equals resulted in the creation of a new school, which was added to our data set; both of the former schools were coded as failing on the assumption that neither was viable on its own. Multinomial logit analyses were conducted (using the SAS CATMOD procedure) to determine whether the predictor variables had different effects on disbandings than on mergers and absorptions. They generally did not, although, in the nineteenth century, state requirements for four-year curricula were associated with greater odds of mergers than of other forms of failure and, in the twentieth century, schools that were nonmembers of the AAMC were more likely to disband, but no more likely to merge, than member schools.
160. Following Norwood (Medical Education, 382), schools were considered to be integrally affiliated with a university when the university's trustees, rather than the medical faculty and administration, exercised control over decisions regarding the medical department. When a school's historical record indicated that trustees exerted only partial control, we considered the school to be proprietary if the university had not assumed financial responsibility for its medical department.
161. See Savitt, "Proprietary Medical Colleges."
162. Waite, "Advent."
163. The dues ledger for 1896-1903 and membership lists from annual AMCA Proceedings (1877-1882) and AAMC Proceedings (1892-1895 and 1904-1930) are from the Mary H. Littlemeyer Archives, Association of American Medical Colleges, Washington, DC.
164. Baker, "Licensure Laws";
165. Hamowy, "Early Development";
166. Anon., Medical and Surgical Directory of the United States (Detroit: R. L. Polk, 1896);
167. Anon., Polk's Medical and Surgical Register of the United States and Canada (Detroit: R. L. Polk, 1900);
168. Anon., Standard Medical Directory.
169. Anon., "Medical Education in the United States," J. Am. Med. Assoc., 1930, 95, 533-34.
170. Annual Report of the State Board of Health of Illinois, 1881, 1884, 1886, 1891, 1894.
171. For the 1870-1900 period, enrollment data, when available, correlated highly with the number of graduates (correlation= 0.90, n = 1861), suggesting the number of graduates is a good indicator of the relative size of schools.
172. Most of these programs and announcements were obtained from the Lisabeth M. Holloway Collection of Biographical Information on Physicians at the Historical Medical Library of the College of Physicians of Philadelphia, but were also supplemented by material from the archives of the History of Medicine Division of the National Library of Medicine, National Institutes of Health, Washington, DC.
173. Of the variables used in this study, data on the nineteenth-century graduation counts were the most difficult to obtain; they were available for 84 percent of the cases used in Table 2 analyses. For another 6 percent of the cases, we were able to estimate the number of graduates from the school's size in adjacent years. For remaining cases, we excluded the school's data for that year from analysis. This accounts for the drop in the number of cases (n) that occurred when School Size was added to analyses in Table 2, Model 3. Size data were particularly likely to be missing among schools that were sectarian, proprietary, non-AAMC members, and negatively evaluated by the Illinois state board. Nevertheless, a comparison of Models 2 and 3 in Table 2 shows that most results changed little when size was added to the analysis; the exceptions are discussed in the text.
174. Paul D. Allison, Survival Analysis Using the SAS System: A Practical Guide (Cary, NC: SAS Institute Inc., 1995), 211-31.
175. Ludmerer, Learning to Heal, 146-50.
176. The enrollment data we have indicate that these schools did lose enrollment when they began to require a third year of training, and their median number of graduates was about 25 percent lower than at other schools throughout the 1880s; yet, all but one survived into the twentieth century. Moreover, in 1895 these schools were almost three times larger than they had been a decade earlier, while other schools typically only doubled in size during that period. Thus, it appears that once the weaker schools began to require a longer training period in the 1890s, students increasingly chose the schools that had pioneered the reforms.
177. The median number of graduates at women's schools was nine per year during the period from 1870-1900. Other schools were much larger, with a median number of graduates of twenty-four.
178. Although results for the A-Rated X Post-World War I interactions are nonsignificant, they are presented in Table 4 because the variables A-Rated and B-Rated are used jointly to code A-, B-, and C-rated schools.
179. As noted, the years between the AMA's first inspection and publication of the Flexner report (1907-1909) are excluded from the analyses in Table 4 because Flexner's recommendations were not available until 1910. Additional analyses excluding Flexner's recommendations (not shown), however, indicate that the failure rates for A- and B-rated schools were about the same in the 1907-1909 time period as they were in the post-Flexner years. Almost 40 percent of the schools that received C ratings in 1907 closed by 1909, whereas only 8 percent of the A-rated schools and 17 percent of the B-rated schools did so.
180. One result that merely appears to be different is that in Table 4 the main effects for the Post-World War I time marker show that failure rates declined significantly for the post-war years 1919-1930 compared to the years 1910-1918, whereas in Table 3 the main effects for Post-World War I were nonsignificant. The results in Table 3, however, were in comparison to the pre-AMA inspection years (1901-1906), since three time markers were being used to divide the span of years into four periods for those analyses.
181. "The Education."
182. Starr, Social Transformation, 118.
183. Ludmerer, Learning to Heal, 235.
184. Hamowy, "Early Development."
185. Soma Hewa, "Rockefeller Philanthropy and the 'Flexner Report' on Medical Education in the United States," Int. J. Sociol. Soc. Policy, 2002, 22, 1-47.