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Medical EducationThink of the amount of formal medical education required to become a medical doctor in the 21st century. Got that in your mind? Now contrast that with what was required in the middle 1800s in America. What a difference!

With the demand for doctors spurred on by the Revolutionary War, medical education in our newly established country forged ahead with the establishment of what were called proprietary medical schools. Founded by doctors and run for profit, these schools had only the bare necessities: a building, desks, maybe some charts of human anatomy, and possibly a skeleton and a few miscellaneous specimens. Students were taught primarily through lecture and memorization.

Entrance requirements for these schools were almost nonexistent. Many of the students had less than a high school education, and some were even functionally illiterate. As long as a student paid his tuition, he was almost always awarded a degree, whether he regularly attended lectures or not, for an equivalent of one year of study. Young men often enrolled without any real understanding of the profession, being attracted mainly by the promise of “an easy road to wealth.” (The irony was that the only physicians who made a decent living from medicine in the 19th century were those who were educated in medical schools attached to universities and who practiced in large cities where there were wealthy clients. See the previous post: “Who Pays the Doctor?”)

By 1840, twenty-six new proprietary medical schools appeared; thirty years later, there were forty-seven more. The American Medical Association and other professional organizations urged the establishment of uniform requirements for entrance to and graduation from medical schools, but they fought an uphill battle. Then came the Flexner Report of 1910, which sounded the death knell for proprietary medical education.

The report emerged from a grant that was given to the Carnegie Foundation in 1905 to aid teachers in colleges and universities in the U.S. and Canada. But the list of institutions calling themselves colleges and universities revealed no uniform definition. Many so-called “colleges” were no more than secondary schools. So in 1908 the Foundation hired Abraham Flexner to do a study of existing medical schools to determine which, if any, were indeed institutions of higher learning.

Flexner took on the task with vengeance, personally visiting 150 schools in two years. And what he found in most of them shocked him. As an example, the report on the Toledo Medical College, which Dr. Blaine attended and then served as a faculty member for a short time, revealed these conditions. The entrance requirements were “a four-year high school education or its equivalent.” That seemed to be on track. But as for laboratory facilities, “The school has nothing that can be fairly dignified by the name of laboratory. Separate rooms, badly kept and with meager equipment, are provided for chemistry, anatomy, pathology, and bacteriology. The class-rooms are bare: no charts, bones, skeleton, or museum are in evidence. There is a small library in the office …. There is a wretched little dispensary in the college building.”

As you can imagine, Flexner’s judgmental tone raised the ire of faculty members and other supporters. They had been trying, as had other proprietary schools, to obtain more equipment, lengthen the number of required sessions, and tighten up on the entrance requirements. But in that highly competitive environment, increasing the requirements simply drove students to the less demanding schools. Unwilling or unable to spend the money, proprietary schools just couldn’t keep up with the fast-changing climate of scientific progress in medical education. In fact, enrollment in these schools had already begun to taper off  before 1910. Flexner’s devastating report simply drove them all out of business. Only a small number re-emerged as departments of established universities.

In the introduction to the Flexner Report, Henry Pritchett wrote, “Our hope is that this report will make plain once for all that the day of the commercial medical school has passed.” Obviously, their hope became reality.


Duffy, John. From Humors to Medical Science: A History of American Medicine, 2nd Ed. Chicago: University of Illinois Press, 1993.

Flexner, Abraham. Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching. NY: The Carnegie Foundation, 1910.