Study Backs Flexner Report's Negative Impact on Black Physicians

An early 20th century report that equipped medical schools with a framework to teach the next generations of physicians also debilitated the Black physician workforce, suggested a modeling study.

In 1910, the Carnegie Foundation and the American Medical Association jointly commissioned William Flexner to visit all 155 medical schools in the U.S. and Canada to set new standards for training future physicians. The resulting Flexner Report of 1910 refocused medical education around the scientific method, encouraged education at academic institutions, and discouraged training through for-profit proprietary schools.

Subsequently, all but 66 schools shut down, including five of seven then-extant Black medical schools. Flexner wrote they were "in no position to make any contribution of value."

Had those five schools remained open, tens of thousands of additional Black students could have become physicians.

Specifically, 27,773 Black graduates could have entered the workforce between the time the schools closed and 2019, reported Kendall M. Campbell, MD, of East Carolina University in Greenville, North Carolina, and colleagues, if the five produced physicians at the same rate as the two that did remain open, Howard University in Washington, D.C., and Meharry Medical College in Nashville.

In another model extrapolating admissions records from the Morehouse School of Medicine in Atlanta, which was founded in 1981, the number of graduates would have been even higher, at 35,315, they wrote in JAMA Network Open.

And had just Leonard Medical School and the University of West Tennessee -- which survived the immediate repercussions of the Flexner Report but later closed -- remained open, researchers estimated at least 10,587 Black graduates could have entered the workforce.

For comparison, about 22,000 Black students have graduated from medical school since 2000.

"[T]hese results suggest that investing in the creation of additional medical schools at historically Black colleges and universities may have long-lasting implications for the size and diversity of the physician workforce in the U.S.," Campbell and co-authors wrote.

Four medical schools at historically black colleges and universities (HBCUs) are now operating, though with fewer faculty members, limited funding, and poorer facilities compared to predominantly white medical schools, Campbell and co-authors noted.

To some degree, the same issues led to Flexner's dim view of the Black schools' quality. Students often came from rural, low-income communities and the schools lacked the philanthropic support of predominantly white institutions such as Johns Hopkins University, which was lauded as the model of medical education.

But Flexner also bought into racist stereotypes of Black people, writing 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.

Racial biases have continued to permeate the medical community more than a century later. In one recent study, half of white medical students reported thinking Black patients had a higher pain tolerance. Black physicians again and again report being mistaken for janitorial staff in hospitals. And hostile work environments in academic settings have pushed out other Black doctors.

In 1968, the Association of American Medical Colleges (AAMC) recommended medical schools increase admissions from underrepresented racial and ethnic groups after data showed Black individuals comprised just 2% of students. By 1997, that number had climbed to 7%, but stalled at 8% in 2019, despite African Americans making up 13% of the population, Campbell reported.

Black representation at predominantly white medical schools has increased over the years, but HBCUs are still needed because they graduate a far greater number of African-American physicians, despite having fewer resources and financial support, Campbell noted. In the past two decades, HBCUs have graduated up to a quarter of all Black graduates, per the AAMC.

Increasing the number of Black physicians in the workforce improves the medical community's ability to provide culturally competent care. Black medical school graduates are more likely to go on to pursue clinical practice, research, and advocacy that targets underserved communities, Campbell and co-authors noted. Having more Black physicians in leadership roles can also increase the number of Black students pursuing medicine.

Together, the data suggests, "the continued operation of additional historically Black medical schools might have produced substantial increases in the medical profession's capacity to address health disparities," Campbell and co-authors wrote.

This study quantifies the effects of structural racism on the physician workforce, commented Gbenga Ogedegbe, MD, MPH, of New York University School of Medicine, in an accompanying editorial.

Publishing additional research that addresses racism in healthcare is one way medical journals can contribute to breaking down inequitable structures in place, Ogedegbe said. Journals can also elucidate uncomfortable issues that people of color experience in academic medical centers, hire more people of color to their editorial teams, and publish studies that look at the role structural racism plays in health disparities, he said.

As demonstrated with COVID-19 research, journals have the power to influence policy and practice, he continued.

Thus, "medical journals must begin shaping the contours of the discourse on racism and health in the medical community," Ogedegbe said.

In response, JAMA Network Open Editor Frederick P. Rivara, MD, MPH, and Deputy Editor Stephan D. Fihn, MD, MPH, issued a call for papers on the effects of systemic racism on health and healthcare, writing that the pervasiveness of systemic racism has been "starkly highlighted" by the COVID-19 pandemic.

"Addressing these long-standing inequities requires action in many elements of society including the entire health care system encompassing the financing and delivery of health care services, recruitment and training of health professionals, and medical research," Rivara and Fihn wrote.

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