Racial Bias in Flexner Report Permeates Medical Education Today

The early 20th century report that laid the framework for the modern North American medical school is also partially responsible for the disproportionately low number of Black physicians in the workforce today, historians and education specialists say.

In the early 1900s, the Carnegie Foundation and the American Medical Association tasked Abraham Flexner, an education specialist, with traveling to all 155 medical schools in the U.S. and Canada to assess the state of medical education. His findings, published in 1910 in what is now known as the Flexner Report, provided criteria to standardize and improve medical schools, forcing closed many institutions that didn't have the resources to implement more rigorous instruction.

By 1923, only 66 medical schools remained, and five of seven existing Black medical schools were closed. In 1910, African Americans comprised 2.5% of U.S. physicians, which would actually decrease to 2.2% in 2008 before rising to about 5% of the workforce today; African Americans account for about 13% of the general U.S. population.

"The Flexner Report was a catalyst," said Wayne A.I. Frederick, MD, president of Howard University in Washington, D.C., one Black medical school that remained along with Meharry Medical College in Nashville. "It started us down a road that is hard to undo."

The Flexner Report centralized the scientific method, increased the number of academic institutions, and reduced the number of for-profit, proprietary schools. Johns Hopkins Medical School, where the medical school curriculum consisted of 2 years of basic science followed by 2 years of clinical science, was held up as a reference standard.

In his report, Flexner wrote that African-American physicians should be trained in "hygiene rather than surgery" and should primarily serve as "sanitarians," whose purpose was "protecting whites" from common diseases like tuberculosis.

The schools that closed, including Flint in New Orleans, Leonard in Raleigh, and Knoxville in Memphis, were "wasting small sums annually and sending out undisciplined men, whose lack of real training is covered up by the imposing MD degree," Flexner wrote.

Although some standardization of medical education was necessary, Flexner's report gravely diminished the number of African Americans who could have become physicians, said Earl H. Harley, MD, of Georgetown University, who has written about the forgotten history of defunct Black medical schools.

"The opportunity to train to be a physician is still not where it should be," Harley told MedPage Today. "More than 100 years later, we are still trying to make up for the deficit."

HBCUs Help Close Gaps

Most Black medical schools in the early 20th century educated students from rural, low-income communities, and they did not have the resources or philanthropic backing necessary to implement the rigorous standards Flexner called for in his report, said Marybeth Gasman, PhD, of the Rutgers University Center for Minority Serving Institutions, whose research focuses on historically Black colleges and universities (HBCUs).

"A lot of these places that were shut down were producing doctors for Black communities and rural white communities, and were doing so on a shoestring budget, so they were not going to be prioritized," Gasman told MedPage Today. "We don't prioritize these things now."

HBCUs and Black medical schools help close gaps in the workforce by increasing the number of Black undergraduates with science degrees, as well as Black medical students. Four of the top 10 colleges sending African Americans to medical school are HBCUs, and Howard University has graduated more African-American physicians than any other institution, Frederick said.

"The role that HBCUs play both as a pipeline and as a training opportunity for physicians in this country is absolutely critical," Frederick told MedPage Today. "Unfortunately, we have an outsized impact today despite the fact we don't have the resources of predominantly white institutions and the students we train are coming from circumstances where they have less financial fortitude."

African Americans are overrepresented in low-income communities and have reduced access to educational opportunities compared to white Americans. With physicians graduating medical school hundreds of thousands of dollars in debt, low-income students are also underrepresented in medical schools, said Louis W. Sullivan, MD, president emeritus of the Morehouse College of Medicine and former secretary of the U.S. Department of Health and Human Services.

"We've set up a system whereby the cost of becoming a doctor is so great that the percentage of students from low-income families going to medical school has decreased over the past two to three decades," Sullivan told MedPage Today.

The free tuition program at the New York University School of Medicine is one example of a way to circumvent these financial barriers, Sullivan said.

"The program at NYU got a lot of attention and I'm hoping we see much more responses like that so that students who come from low-income backgrounds can see it's not unrealistic for them to want to become a doctor," Sullivan said.

Racial Bias and Health Outcomes

Black medical schools train a higher proportion of primary care physicians who care for underserved populations, not only increasing representation in the field, but also providing culturally sensitive care to African-American patients.

Racial bias in medicine contributes to disparate health outcomes faced by African Americans, with half of white medical students believing Black patients have a higher pain tolerance than white patients, for example. Racial bias can also permeate things like Crisis of Care Standards guidelines or algorithms commonly used to guide care decisions, including which patients will receive transplants. In the COVID-19 pandemic, all of these disparities in health have been exposed -- mortality in majority-Black counties is six-fold higher compared to predominantly white counties.

Increasing the number of Black doctors in the workforce could help reduce disparate health outcomes affecting Black patients, including disproportionately high infant and maternal mortality rates.

"An effective health encounter involves sharing sensitive, private information, but if a patient is going to share that information with a healthcare professional, they have to believe that a healthcare professional has their own interest at heart," Sullivan said. "That is why having diversity in the healthcare profession helps because in our current society, the individual from that same group has a greater understanding of the historical and cultural set of beliefs that the patient has."

Flexner acknowledged Black students' rights to education, but thought Black patients could only be seen by Black doctors. However, he also stated that there would not be enough Black physicians to care for all of the Black Americans at the time.

From 1910 to 1930, there was one Black doctor for every 3,000 African Americans, but this varied widely among states. In Mississippi, for example, a state in which far more of the population was Black than in northern states, there was one doctor for every 14,000 Black people, Gasman said.

Howard University and Meharry University, the two schools that survived the post-Flexner reforms, were then left to produce enough doctors to serve around 10 million African Americans living in the country at the time. The ripple effect of this disparity is evident today, Gasman said.

"I'm not saying the Black medical schools that closed were doing everything right because they didn't have good resources, but they were doing the best they could," Gasman said. "It would have been interesting if the Carnegie Foundation and other foundations had invested money in them instead of closing them, and really grown them to serve African-American populations."

Dismantling Racism in Medicine

Today, predominantly white medical schools also have a role to play in increasing representation overall and in leadership. The systems that have developed in the past century since Flexner's report cannot be ignored, said Katharine Lawrence, MD, an internal medicine resident at the NYU School of Medicine.

"In the 100 years since the Flexner Report, there were all sorts of stakeholders in place to suppress the reinvigoration of Black medical education," Lawrence told MedPage Today. "We have to do an evaluation of what the medical community has been doing in the past 100 years that allowed that to happen."

In 2012, the Beyond Flexner Alliance was created to address some of the disparities established in 1910 that still exist today. As part of George Washington University, it collaborates with other professional organizations and hosts annual conferences at which physicians can develop tools for dismantling racism or other structural issues in health systems.

"At the core of Beyond Flexner is that as healthcare professionals and physicians, we have made a commitment to the health of patients and the public," said Candice Chen, MD, MPH, chair of the Beyond Flexner Alliance. "We have a responsibility to do this."

Harley sees the current coronavirus pandemic as an inflection point.

"With COVID-19, things have turned completely upside down, and this is the chance for us to look at the whole system of medical education and make changes and correct some of the things that were affected by Flexner," Harley said. "We can make great strides right now."

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