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Flexner's Master Plan for American Medical Education

Based on studies of the physician/population ratio in Germany, to which we have previously referred, Flexner estimated that one doctor for every 1500 persons was an appropriate ratio to be used in determining the number of physicians actually required to provide medical care for the population of the United States. (This would be equivalent to a ratio of 67 physicians to every 100,000 population,)

He further decided that "we may in general figure on one more physician for every gain of 1500 in total population. We are not arguing that a ratio of 1:1500 is correct; we are under no necessity of proving that. Our contention is simply that, starting with our present overcrowded condition, production henceforth at the ratio of one physician to every increase of 1500 in population will prevent a shortage for the next generation at least." [37]

Having adopted the above premise, Flexner's analysis of the information acquired by his survey of American medical schools, and by his study of population density and trends in the various regions of the country, led him to the following conclusion: [38]

(The 155 American medical schools now existing should be reduced to) 31 medical schools with a present annual output of about 2000 physicians, i.e., an average class of about 70 each. (The 31 schools being recommended for retention are capable of producing 3500 graduates annually should that become necessary.). All schools to be retained are university departments, busy in advancing knowledge as well as in training doctors. Nineteen are situated in large cities with the universities of which they are organic parts; four are in small towns with their universities; eight are located in large towns always close by the partner institution. Divided and far distant departments are altogether avoided. . . .

Reduction of our 155 medical schools to 31 (with the elimination of 124 schools) would deprive of a medical school no section of the country that is now capable of maintaining one. It would threaten no scarcity of physicians until the country's development actually required more that 3500 physicians annually, that is to say, for a generation or two, at least. Meanwhile , the outline proposed involves no artificial standardization; it concedes a different standard to the south as long as local needs require; it concedes the small town university type where it is clearly of advantage to adhere to it; it varies the general ratio in thinly settled regions; and, finally, it provides a system capable without overstraining of producing twice as many doctors as we suppose the country now to need. In other words, we may be wholly mistaken in our figures without in the least impairing the feasibility of the kind of renovation that has been outlined; and every institution arranged for can be expected to make some useful contribution to knowledge and progress.

The Flexner Report includes two maps of the United States on one of which is shown the location of each of the 155 existing American medical schools. On the other map the site of each of the 31 medical schools to be preserved or established is indicated. [39]


The Western Medical Schools

The following Table lists the 8 Mountain and 3 Pacific States that constitute the Western Region of the country in which we are primarily interested.

The Table also gives the location of each of the 15 medical schools then existing in the Region, and each of the 4 1/2 schools to be retained or established there under the terms of the Flexner plan. To be specific, Flexner recommended that the number of medical schools in the Western Region be reduced from 15 to the following 4 1/2: 1 in Colorado; 1 in Utah; 1 in Washington; and 1 1/2 in San Francisco. In his Report, Flexner has few kind words and many severe criticisms for the Region's 15 medical schools. He found not one of them to be up to modern standards, Johns Hopkins being the model of a modern school.

The physician/population ratios in the Western Region, calculated for each of the eleven States in the Region and included in the Table, show there to be two to six times as many physicians per State as required under the Flexner plan which called for only one physician for every 1500 population. The Region as a whole, with a population of 4.2 million, had 10, 210 doctors (407 persons per physician), approximately 4 times as many physicians as required by the Flexnerian norm of 1500 persons per physician.

These data support Flexner's conclusion that there were too many doctors in the Western Region in 1909, and that the plethora of physicians justified his plan for allocating only 4 1/2 medical schools to the entire Region. .In brief, the issues facing medical education in the West were the same as those affecting the nation at large - too many inferior medical schools and a gross oversupply of poorly trained physicians - with the sovereign remedy being elimination of surplus schools.

The Western Medical Schools 1909 [40]
Census Division Number of Physicians Population Per Physician Total Population Medical Current Schools Plan
Mountain States
Montana 417 584 243,528 - -
Idaho 343 472 161,896 - -
Wyoming 202 458 92,516 - -
Colorado 1,600 319 510,400 3 1
New Mexico 367 532 195,244 - -
Arizona 246 500 123,000 - -
Utah 359 771 276,789 ½ 1
Nevada 177 239 136,467 - -
Pacific States
Washington 1,404 369 518,076 - 1
Oregon 782 529 413,678 2 -
California 4,313 344 1,483,672 9 1/2 1 1/2
Regional Total 10,210 407 4,155,266 15 4 1/2
MD's Required @ 1: 1500 Population 2,770 1,500 4,155,266
National Total 133,487 569* 75,954,103

*176 MD/100,000 population.

The Flexner master plan envisaged a total of 2 1/2 medical schools for the entire Pacific tier of Western States - Washington, Oregon and California - one school to be developed by the University of Washington and 1 1/2 medical schools to be maintained in the San Francisco area as follows:

  • One full four-year medical program conducted by the Medical Department of the University of California in San Francisco.

  • A "1/2 program" conducted by Stanford consisting of two preclinical years at the University in Palo Alto.

  • Upon completion of the two preclinical years, the Stanford students would transfer to the Medical Department of the University of California in San Francisco for completion of two clinical years and receipt of the M. D. degree from the University of California.

Both Pritchett and Flexner insisted upon this arrangement on the grounds that conduct of clinical teaching programs by two medical schools in San Francisco would have dire consequences for medical education in California. In vigorous support of this idea, Pritchett lobbied the administration of both universities with near success, advancing the dubious concept of hegemony over medical education in California by the State University as a desirable goal.

It goes without saying that the Flexner proposal was entirely unacceptable to Stanford which had just completed a consolidation agreement with Cooper Medical College based on the commitment by Stanford to conduct a full four-year medical program leading to the granting of the M. D. degree.

There is no indication that either Pritchett or Flexner gave serious consideration to the historic implications for medical education and science of a commitment to these fields by Stanford, the leading private University in the West. Their vision was clouded by devotion to their mission. They were on a crusade to extinguish the nations' weaker and superfluous medical schools. Their error was to overlook the potential of a Department of Medicine at Stanford University and to reckon such a Department as inevitably weak and superfluous. Now, in the mid 90's of the twentieth century, with the perspective of eighty years, we can see what an incalculable loss it would have been had their views prevailed.

We recognize the general validity of Flexner's reservations about "divided and far distant departments" Stanford was establishing a "divided department" and therefore did not meet the strict Flexnerian standard. Over the next fifty years the inexorable logic of the Flexner position had its effect. In 1959 the clinical branch of Stanford Medical School, located in San Francisco, was united with the basic science departments in a new Academic Medical Center on the campus of the University. No longer "divided," the school entered a new era of growth and creativity.

On the whole, the Flexner Report of 1910 was of immense benefit. It provided the most thorough documentation and analysis of the malaise of American medical education yet available. It laid out and effectively advocated a rigorous national plan for its reconstruction by extinction of weak and superfluous schools, and establishment in the remaining schools of academic programs in accordance with high standards such as those prevailing at Johns Hopkins. In effect, the Flexner Report served as an aggressive adjunct to the continuing work of the AMA's Council on Medical Education, the Association of American Medical Colleges, and the various state medical examining boards. The standards of these agencies lagged behind those considered optimal by Flexner and the Carnegie Foundation because of resistance by inferior schools.

The combined effect of these agencies and the Flexner Report is registered on the accompanying chart which shows the number of medical graduates each year during the fifty-year period from 1880 to 1930. The peak output of physicians from American medical schools during that period was in 1904 when there were 5750 graduates from some 155 medical schools. As the graph shows, there was a 50 % drop in the annual number of medical graduates between 1904 and 1922 when there were 2500 graduates from 81 medical schools. The rate of physicians per 100,000 population nationally fell to about 130 - equivalent to 769 persons per physician. [41] [42]

Flexner's goal of only 31 medical schools nationwide was never achieved and he doubtless did not expected such an outcome. Nevertheless, reduction of American medical schools and medical graduates annually by about one half over the 18 year period from 1904 to 1922 was a remarkable achievement. Thereafter, the number of American medical schools reached the low point of 76 in 1929. The number of schools then lingered around 77 until 1950 when it began a steady climb to a peak of 124 in 1990. At that point, annual physician output leveled off at around 15,000. [43] [44] [45]

After the Flexner Report in 1910, oversupply of physicians in the United States did not threaten again until the 1970's when data began to indicate that the supply of doctors was outpacing the growth of the population. Barring drastic changes this trend is expected to continue for another 20 years (that is, into the second decade of the 21st century).

In 1992 there were 15, 243 graduates from 120 medical schools. At that time the supply of physicians (about 200 physicians per 100,000 population , or 1 for every 500 persons) was generally agreed to be excessive.

Coincident with the progressive increase in the supply of physicians since the 1970's there has been a significant change in medical practice from mainly fee-for-service medical care to systems increasingly dominated by managed care and HMO's (Health Maintenance Organizations). Under these types of practice, staffing requirements are only about 150 physicians per 100,000 population (667 persons per M. D.). There is also a reduced requirement for specialists who in 1992 represented 65% of practicing physicians whereas the need is probably best met by a combination of 50 % generalists and 50% specialists. In view of these developments, most analysts of the medical work force believe that "the underemployment or unemployment of specialist physicians in the early 21st century is a distinct possibility in the United States, as is already the case in several European countries." [46]

Thus, for American medical education, the twentieth century will close as it began - face to face with the complex problem of too many medical schools and too many doctors.


Henry Gibbons, Jr. (1840-1911)

Dr. Gibbons, Jr., was confined to his bed with "rapidly advancing arteriosclerosis" in the late summer of 1911, and died on 27 September. He had continued his active work in teaching and practice until a few weeks before he passed away. At the time of his death he held the academic titles of Professor of Obstetrics and Diseases of Women and Children and Dean in Cooper Medical College. He had also been appointed Professor of Obstetrics Emeritus in the Medical Department of Stanford University.

Dr. Gibbons was born in Wilmington, Delaware, on 24 December 1840. He came to California in 1851 when his father, Dr. Henry Gibbons, Sr., brought the family to San Francisco. He graduated from San Francisco High School in 1856 at the age of sixteen years. He then taught school for a time before entering the Medical Department of the University of the Pacific where he graduated on 12 March 1863. While a medical student he was closely associated with Dr. E. S. Cooper, receiving in consequence an exceptional training in surgery. This training stood him in good stead when, immediately upon graduation, he went east to join the United States Army in Washington D. C. as an assistant surgeon. This was followed by the Civil War experience to which we have previously referred.

When he returned to San Francisco he was associated with his father in medical practice, in the editorship of the Pacific Medical Journal, and in the revival of the Medical Department of the University of the Pacific of which he was named the Dean in 1871 - a position he held continuously in the successor schools for the next forty years. [47]

It was to celebrate these forty years of devoted service, which we have amply described in the foregoing chapters, that special exercises were held at Lane Hall of Cooper Medical College on the eighth day of December, 1911. A large assemblage of persons gathered in the Hall for doing honor to his memory, Dr. Edward R. Taylor, President of the College, presiding.

Doctor William Fitch Cheney, Secretary of the Faculty, spoke of Dean Gibbons' compassionate character: [48]

He was loved by all this Faculty as one of its officers; he was loved by all the young students who had known him as their teacher; he was loved by thousands of people whom he served as their physician, and by all into whose lives he came he was loved as a man. . . His attitude was ever that of trustfulness, and he gave every man credit for the same high sense of honor as his own. Therefore one of the greatest sorrows that ever came into his life was the discovery some few years ago that a man (C. N. Ellinwood), given every confidence by him and by others in authority, could be guilty of what seemed to him a deliberate violation of a moral trust. To Dr. Gibbons honesty was all his life a sacred thing, and in all the years of his stewardship not one word or question ever arose about the moneys entrusted to his care, any more than about the performance of any other duty he had assumed, either inside or outside the college.

Doctor Gibbons was also highly regarded by the officers of Stanford University. During the negotiations leading to consolidation, he dealt with them as Treasurer of Cooper Medical College as well as its Dean. Professor Orrin Elliott, Registrar of the University, recalled their relationship: [49]

During these last years, indeed, Doctor Gibbons has been a member of the Stanford Faculty, and a colleague. His work, however, remained in the city and his connection with those of us at the University was naturally slight. But though slight, it was not nominal. He made it real by his identification with us, by the pains he took to respond to those formal occasions when the Faculty stands together in its relation to the whole university and the larger community outside. His confidence in us and his fellow-feeling won recognition and respect. And in behalf of the Faculty of Stanford University I may be permitted to voice our appreciation of the perfect modesty and courtesy with which he entered into this new relation and took his place among us.

The Honorable Horace Davis, a member of the Board of Trustees of the Leland Stanford Junior University, then spoke as follows: [50]

We are gathered today to honor the memory of a man whose whole life was a benediction. Born of old-fashioned Quaker stock, he carried out in his daily life their best traditions, "Peace on earth, good will to men.". . . .He was a man of high principle, even stern in his integrity, but with a large, open heart. . .Such men are the salt of the earth. Quiet, retiring, indifferent to fame, realizing the golden rule: "Do unto others as you would they would do unto you". The world rarely appraises such a man at his true value until he is gone. Then we wonder how great a place he filled and so quietly. Thus we shall think of Dr. Gibbons as the years roll by. As for me, personally, so long as I live I shall hold him in tender, affectionate memory.

Then, Doctor Edward Robeson Taylor, President of Cooper College, rendered the final words of eulogy: [51]

A noble soul, a model of all the virtues has fallen; a friend of humanity, a helper of the suffering, a resolute, indomitable soul.. . . His was a life of service from the time of his early years when, during the Civil War, he labored day and night in the hospitals at Washington among the mangled human creatures coming in day by day, in hundreds and thousands from the awful fields of war

It is indeed a wonder that his life went beyond the psalmist's three-score and ten, his labors were so great and incessant. For consider, that in addition to his large and strenuous medical practice and his pedagogical labors, he has always been Dean of Cooper Medical College, and of late years President of its Faculty, and a member of its directorate, while he was also its treasurer, through whose hands passed all of its moneys and by whom its accounts and books were personally kept. Yet he never once complained; he never dreamed of flagging but willingly and cheerfully bore every burden put upon his shoulders. His religion was that of service - the one true religion that all can subscribe to of whatsoever creed or race.

Where he was but yesterday, as it were, there remains a great void, not to be filled in this life of ours. Yet, he is not dead, he lives. He lives to us in soul-enriching memories that time can never take away; his example blazes as an oriflamme to lead us to a life as greatly honorable as was his; he lives in his deeds that are imperishable. And so we leave him now to time and memory, with wreath of unfading laurel on his brow, and with countless affections hallowing his name..

Something further remains to be said in praise of the worthy Henry Gibbons, Jr. He was the last of the honorable triumvir - Henry Gibbons Senior and Junior and the indomitable Levi Cooper Lane - who traced their inspiration for medical education on the Pacific slope directly to Elias Samuel Cooper. The unselfish and lifelong commitment of these three was responsible for assuring the survival of Cooper's vision of a medical school until its long-range future could finally be secured through union with Stanford University. In a more fundamental sense, we can attribute the ultimately favorable outcome of Cooper's venture to the ideals of loyalty, learning and humanitarian service imparted to Cooper and his partisans by the Quaker faith during their formative years.

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