San José State University
Department of Economics
Thayer Watkins
Silicon Valley
& Tornado Alley

The AMA and Medical Education

The American Medical Association (AMA) acquired around 1910 the power to accredit or not accredit medical schools in the U.S. It used this power to close down half of the medical schools and forced the remaining ones to reduce their admissions. This was supposedly to improve the quality of trained physicians but, as Reuben Kessel demonstrated, it was largely a strategy to artificially restrict the supply of physicians and thereby to raise their pay.

Through the accreditation power the detailed character of the training was imposed upon medical schools reducing the opportunities for innovation. The power to accredit medical schools was acquired as a result of a study sponsored by the Carnegie Foundation. The AMA needed the public interest credibility of the Carnegie Foundation to achieve its goals. A survey of medical schools previously carried out by the AMA itself had not received the political support it desired. It therefore encouraged and supported the Carnegie Study. And, ultimately to a high degree, the AMA controlled the study.

The Carnegie Foundation commissioned Abraham Flexner to carry out the study. As Reuben Kessel states

Flexner's work consisted of a grand inspection tout of the medical schools of the time-- , some were evaluated in an afternoon—-to determine how they produced their outputs. His model of how doctors should he produced was the medical school of Johns Hopkins University. There was no attempt to evaluate the output of medical schools; there was no investigation of what their graduates could or could not do. Nor was there any discussion of what a graduate of a medical school should be able to do, or of the possibility of raising standards of medical education through stiff licensure examinations. The entire burden of improving standards was to be burnt by changes in how doctors should be produced--that is, how students, facilities, and faculty ought to be combined to generate physicians. He implicitly ruled out all production functions other than the one he observed at Johns Hopkins.

It is a paradox that a group ostensibly so concerned as the AMA with the qualifications of doctors for the practice of medicine failed to be disturbed by Flexner's lack of qualifications for the task he undertook. Flexner was neither a phvsician nor a scientist, and had no qualifications as a medical educator. He had an undergraduate degree in arts from Johns Hopkins and had operated a small, private, and apparently profitable preparatory school in Louisville for fifteen years. It is unlikely, if not inconceivable, that he would have been accepted in a court of law as an expert witness in the field of medical education before he undertook his studv.7

Virtually all the work Flexner undertook had already been done by the AMA, and N. P. Colwell, the secretary of the AMA's Council on Medical Education at the time, accompanied Flexner in some of his inspections and provided him with the results of the AMA's previous labors.` Indeed Flexner spent many hours at the Chicago headquarters of the AMA. It was clearly recognized that Flexner, or more properly the Carnegie Foundation, had a comparative advantage over the AMA in publishinp an attack on the medical schools of the time. The Carnegie Foundation was comparatively invulnerable to a self-interest charge.

Kessel quotes from an article by Bevan entitled "Cooperation in Medical Education and Medical Service" from the Journal of the American Medical Association, 1173.

[I]f we could obtain the publication and approval of our work by the Carnegie Foundation for the Advance- ment of Teaching, it would assist materially in securing the results we were attempting to bring about.

Reuben Kessel goes on to say,

As a result of the implementation of the Flexner report, medical education became considerably more expensive and exhibited relatively little variation from school to school. To this day, there probably is less variation in medical training than in almost any other field. The implementation of Fiexner's recommendations made medical schools as alike as peas in a pod. In their first year medical students almost invariably took anatomy, biochemistry, and physiology; in the second, microbiology, pathology, and pharmacology. The next two years consisted of supervised contacts with patients in the major clinical specialties of a teaching hospital. Often this training pattern was written into state laws.

Kessel notes that Flexner was even more severe than the AMA is downrating medical schools. In 1906 the AMA's Council on Medical Education rated 82 schools Class A; Flexner in 1910 rated only 72 as Class A. One of the schools put out of business by the Flexner report was one that his brother, a distinguished physician, had graduated from.

The implementation of the Flexner report has, until relatively recently, sharply reduced experimentation in the training of physicians. As a result, there was a hiatus of over forty years in the search for better curricula and teaching methods, and in the utilization of the talents of scientists outside of medical schools for the training of physicians. It is only in recent years, in the decade of the 1960s, that the fetters imposed by the Flexner report have been loosened. As a consequence, medical education is currently in a state of flux, and the number of electives open to medical students has increased enormously. In addition, the economic cost of acquiring the MD degree has started to decrease, because some medical schools have relaxed their requirements for a bachelor's degree as a condition for admission. Moreover, as a result of student pressure, medical schools have increased their willingness to substitute undergraduate courses for preclinical courses.

One consequence of Flexner's use of the Johns Hopkins medical school as the ideal is that the practice of working resident physicians unreasonably long hours was also copied from Johns Hopkins. Charles A. Czeisler of the Harvard Medical School says in the October 24th, 2009 issue of Science New, that the tradition of working resident physicians in shifts as long as 24 hours was established in the 1890's at Johns Hopkins by William Halsted. It seems that Halsted had a cocained addiction that may have influenced his judgment as to how long a physician-in-training can safely work. Czeiler notes that after working 24 hours straight resident physicians are 168 percent more likely to be involved in a car crash driving home. A 2006 Harvard Work-Hours Health and Safety Group reported that 20 percent of resident-physicians admitted to having made a fatigue-related mistake that injured a patient. Five percent of the resident physicians confessed to having made a fatigue-related mistake that resulted in a patient's death. With there being about one hundred thousand physicians in training in the U.S. that is quite a death toll.

(To be continued.)

HOME PAGE OF applet-magic
HOME PAGE OF Thayer Watkins