The Carnegie Bulletins
In 1910, while the issue of full-time appointment of clinical faculty continued to be of theoretical interest but impractical of adoption at Johns Hopkins, the Carnegie Foundation published its Bulletin Number Four, Medical Education in the United Sates and Canada, better known as the Flexner Report. This report was based on visits to American and Canadian schools by Abraham Flexner and associates during 1909 and the winter of 1909-10. As we previously pointed out (in Chapter 31), the picture Flexner drew of these schools was dismal indeed except for a few institutions, chief among them being Johns Hopkins, Flexner's shining model, "the one bright spot, despite meager endowment and missing clinics." Bulletin Number Four caused a profound sensation nationally by its pitiless exposures. Many of the medical schools which Flexner had so unsparingly condemned collapsed and by 1927 only eighty of the former 155 schools were operating. The following is a brief resumé. 
Abraham Flexner (1866-1959), a younger brother of Simon Flexner, was the sixth of nine children, seven boys and two girls. He was born in Louisville, Kentucky. A graduate of Johns Hopkins University, he taught Latin and Greek in the high school at Louisville, for four years; and for fifteen years in the same city he ran a highly successful preparatory school of his own. Thereafter he studied at Harvard and Berlin.
He then completed the following two medical surveys for the Carnegie Foundation which established his reputation as the foremost American authority on medical education: 
- 1910, "Medical Education in the United States and Canada." Carnegie Foundation Bulletin No. 4 ("The Flexner Report") 
- 1912, "Medical Education in Europe." Carnegie Foundation Bulletin No. 6 
Mr. Gates Consults Abraham Flexner
When Mr. Gates read Bulletin Number Four, he was greatly impressed by Flexner's findings and recommendations and was eager to consult him on matters of immediate concern to the GEB. As a result he was looking forward with some anticipation to Flexner's return late in 1910 from his survey of Medical Education in Europe. We turn now to Flexner's autobiography for his account of the consultation with Mr. Gates. Flexner wrote:   
Early in 1911, while I was writing Bulletin Number Six in a rear office of the Carnegie Foundation, Frederick T. Gates, who had been for many years confidentially associated with John D. Rockefeller, invited me to lunch. I recall the occasion with great distinctness. Mr. Gates was a positive and incisive thinker and speaker. He was perhaps the greatest of American philanthropists, for he had imagination, daring, and an intuitive sense of educational strategy. He had no patience with small things. Unless he could foresee an important and large outcome he would dismiss them with the words "retail business." On the other hand, he was never deterred by the magnitude of an enterprise provided he was convinced that it was good in itself and was likely to be productive of good throughout the country. . . .
The luncheon was simple and soon finished. Mr. Gates wasted no time on preliminaries. He said:
"I have read your Bulletin Number Four from beginning to end. It is not only a criticism but a program"
I replied, "it was intended, Mr. Gates, to be both, for you will remember that it contains two maps, one showing the location and number of medical schools in America today; the other showing what, in my judgment, would suffice if medical schools were properly endowed and conducted by a well-trained personnel."
"What would you do," asked Mr. Gates, "if you had a million dollars with which to make a start in the work of reorganizing medical education?"
Without a moment's hesitation, I replied, "I should give it to Dr. Welch."
"With an endowment of four hundred thousand dollars," I answered, "Dr. Welch has created, in so far as it goes, the one ideal medical school in America. Think what he might do if he had a million more. Already the work Dr. Welch and his associates have done in Baltimore is having its effect in reorganizing the personnel of medical schools elsewhere, and we must not forget that but for the Johns Hopkins Medical School there would probably be no Rockefeller Institute for Medical Research in New York today."
"Would President Pritchett of the Carnegie Foundation release you long enough to go to Baltimore to make a detailed study of the situation and report to me?"
"I think he would," I replied.
"Ask him, and if he agrees, go."
Thereupon the luncheon terminated, Dr. Pritchett was extremely happy to realize that Bulletin Number Four might have some practical consequences of importance, and he made it possible for me to spend a period of about three weeks in Baltimore.
Reaching Baltimore, I sought out Dr. Welch and explained to him that there was a possibility of obtaining a million dollars which might go in a lump to the John Hopkins Medical School for additional endowment, and that I wished therefore to make a careful survey of the school and hospital and to get the judgment of the faculty as to the uses to which the income on this sum could be put. Dr. Welch was not excited at the prospect. He never became excited over possibilities, but he had been thinking, though without any hope or expectation, that this particular day might dawn. He said, "I should like to talk with you and Mall and Halsted at dinner tonight. Can you come to the Maryland Club?" After dinner - an excellent dinner, for Dr. Welch knew as much about food as he did about pathology - he explained to his associates the hypothetical question which I had put to him. There was silence for a little while, then Dr. Mall spoke out:
"If," he said, "the school could get a sum of approximately a million dollars, in my judgment, there is only one thing that we ought to do with it - use every penny of its income for the purpose of placing upon a salary basis the heads and assistants in the leading clinical departments, doing for them what the school did for the underlying medical sciences when it was started. That is the great reform which needs now to be carried through."
It must be remembered that at that time prominent men like Osler, Halsted, and Kelly received nominal salaries - a few thousand dollars annually - from the university. They had to make their living by practice. From the demands of practice they snatched what time they could to devote to clinical research and teaching - and they snatched much time, for they all cherished ideals "made in Germany." Despite the handicap under which they worked, they had started a brilliant development in scientific clinical medicine in the United States, but their success was menacing. The Johns Hopkins Hospital was a Mecca to the sick in all sections of the country. Persons who came there had to be looked after, and they sought and expected the services of the heads. The strain upon these men was therefore terrific. Nevertheless, "Halsted had established himself as the greatest surgical thinker America had yet produced," to quote the words of Dr. Carrel. Dr. Osler, by this time Regius Professor at Oxford, had greatly simplified the practice of clinical medicine by showing the uselessness of most drugs and the importance of rest, fresh air, and diet; and Dr. Kelly had, by his skill and knowledge, introduced a new era in the practice of gynecology.
"If," argued Mall, "these men have such achievements to their credit and at the same time teach and practice, what might not ultimately be expected if they could devote themselves to their hospital wards precisely as the physiologist and anatomist devote themselves to the laboratory?"
Mall's suggestion was not new to Dr. Welch and Dr. Halsted. It had first been made some years earlier in a speech, entitled "Medicine and the Universities," by Dr. Lewellys F. Barker. . . Mall had convinced Dr. Barker of the importance of academic medicine and, in (his) quiet way, (Barker) had continued his campaign of education during the years which had passed since he came to Baltimore in 1905 (as the replacement for Dr. Osler). The ground was therefore quite ready. (Welch) found that all those engaged in teaching the underlying medical sciences wished to devote every penny of additional income that could be procured to the installation of full-time academic teaching and research in the main clinical branches. Dr. Halsted and some of the younger clinicians were of the same mind. There was a good deal of hesitation among the others, partly because they feared a loss of experience; partly, I suspect, because through the prosperous practice of medicine they had adjusted their lives to a standard which would have to be greatly changed in the event of a thoroughgoing reform.
I have myself often been credited with the authorship of what is called the "full-time scheme," but I am entitled to no credit whatsoever. It did not originate with me and it is not mentioned in either Bulletin Number Four or Number Six. It did not even originate with Mall, but was attributed by him to his old teacher, the great Leipzig physiologist, Ludwig, who one day, so Mall said, remarked to him that sooner or later teaching and research in clinical medicine and surgery would have to be organized on the same basis as teaching and research in anatomy and pathology; both of these had once been in the hands of practicing physicians, and neither had prospered as they should until they commanded the full time and strength of the men engaged in their teaching and cultivation.
I spent three weeks in Baltimore and finally wrote for Mr. Gates a confidential report, in which I pointed out, first, that a thoroughgoing reform could not be accomplished even in one medical school with $1,000,000. The sum required would be hardly less than $1,500,000. I contrasted the conditions that had come about in the laboratories under full-time men and the conditions that existed in the clinics, where part-time men were driven in various directions. I pointed out further that as a matter of fact it was more important for a clinician to enjoy a full-time opportunity to carry on teaching and research, because, simplify his situation as one would, his task was infinitely harder than that of a laboratory man, for the laboratory man could concentrate upon his research and his teaching and command his entire time, dividing it as he pleased. The clinician had to organize a clinic, had to teach students, had often for his research to attend patients, and had in addition to carry on laboratory investigations aiming at the solution of the problems that arose in the clinic. I urged therefore that a sum of approximately $1,500,000 should be given to the Johns Hopkins Medical School for the purpose of reorganizing upon the full-time basis, or, as Dr. Welch preferred to call it "the university basis," the medical, surgical, obstetrical, and pediatric clinics.
Flexner's report to Mr. Gates concerning the visit to Baltimore was enthusiastically received and approved in principle by Mr. Gates and the General Education Board. As the next step in deciding on a joint course of action to be taken by the GEB and Hopkins University, Flexner was requested to return to Baltimore for the purpose of submitting the report to Dr. Welch and his associates. He was authorized to convey to them the "intimation" that money would be available provided that, after due reflection and discussion, the Hopkins faculty and trustees actually wished to undertake the experiment of establishing full-time clinical appointments.
Late in March 1911 Flexner returned to Baltimore and met with Dr. Welch and the University trustees on the evening of his arrival in the city. After a detailed discussion of the issues, Flexner received from them an assurance of their solid support for the reorganization of the clinical faculty on a full-time basis. In the course of the conversation Flexner urged that, if a change to full-time teaching were made, the attendance of the school should be cut down to two hundred fifty students.
Flexner returned to New York by train that night and on the following day prepared a report of the meeting for Mr. Gates. On 2 April 1911 Mr. Gates called Flexner to say: "I have just finished reading your report. I can hardly find words to express my satisfaction and delight. I am more than satisfied. It is a model. I have occasion to read many reports, but when I have read anything like that I cannot recall."
On the basis of Flexner's report, Mr. Gates and the GEB were under the impression as early as April 1911 that Welch and the Hopkins trustees supported the plan to appoint the heads of certain clinical departments on a full-time basis. They further assumed that a request for a grant to fund the experiment would be soon forthcoming from Dr. Welch. Such was not to be the case. Since adoption of the plan was subject to ratification by the faculty, more than a year and a half dragged by before a consensus was reached.
Within the medical faculty the laboratory men unanimously endorsed the plan, but there was a rift among the clinicians over the assignment of income from private practice to the school rather than to the physician. Welch made no effort whatever to push the idea. He saw that every member of the faculty had a copy of the report, and bided his time. He was determined not to alienate those members of the faculty who remained unconverted. As a result, Welch deferred submitting a grant application to the GEB until, as we shall later recount, Flexner prodded him to do so in October of 1913.
Flexner Joins the General Education Board
As to the fortunes of Abraham Flexner, he had by the fall of 1911 completed his commission to evaluate European medical education for the Carnegie Foundation and had prepared a report on the subject. (His report was published by the Foundation in 1912 as Bulletin Number Six.) Also, by this time, his services were no longer needed by the General Education Board as an emissary to Hopkins. He was thus free of commitments (that is, he was unemployed) when, late in 1911, he was approached urgently by John D. Rockefeller, Jr., to undertake an investigation of prostitution in Europe on behalf of the New York Bureau of Social Hygiene.
During Flexner's temporary association with the General Education Board in connection with the Hopkins negotiations he had enjoyed a cordial relationship of mutual respect with the junior Rockefeller who was an important member of the Board. Under the circumstances Flexner felt obliged to accept the difficult assignment that Rockefeller pressed upon him. Early in 1912 he went to Europe and began the study of prostitution in major cities.
In March of 1913, near the completion of the study, Flexner received word in London that Mr. Rockefeller had arranged for him to become a member of the General Education Board.
The news of an invitation to join the GEB was a godsend to Flexner who had been in grave doubt as to what his future employment might be upon completion of the European assignment. Now, upon his return to New York in the spring of 1913, Abraham Flexner embarked upon a new career as a member of the GEB where he served as Assistant Secretary of the Board from 1913 to 1917, as Secretary from 1917 to 1925, and as a Trustee of the Board from 1914 to 1928.  
Harvard and Hopkins Apply to the GEB
Upon joining the GEB Flexner renewed his special interest in the Hopkins experiment with the clinical full-time system. In early October 1913 he learned that the Board would take final action later that month on the grant applications it had received thus far.
He also learned that Welch at Hopkins had not submitted an application, but that an application had been submitted by the following prestigious Harvard committee appointed by Harvard President Lowell: Henry Christian, former Dean and full-time Professor of Medicine located at the Peter Bent Brigham Hospital, chairman; Harvey Cushing, full-time Professor of Surgery also at the Brigham; and Dean Edsall of Harvard Medical School. The Harvard application requested a grant of $ 1. 5 million for the purpose of placing "all of its clinical departments. . .on a satisfactory university basis." The professors were to "devote the major part of their time to school and hospital work, "but they were not to be barred from receiving fees from private patients."  
In fact, Flexner had visited Harvard in June 1913 to advise Christian on the Harvard application. Harvard Medical School was no stranger to Flexner. Four years earlier, during his survey of medical education in the United States and Canada, he had measured Harvard against the standard of medical education set by Johns Hopkins and found it wanting, particularly because it had no teaching hospital of its own but relied on private hospitals such as the Peter Bent Brigham and Massachusetts General for teaching beds. He also knew that the provision in the application which allowed senior professors to conduct a limited consultative practice in the hospitals and to keep the fees, was unacceptable. It did not eliminate the profit motive in clinical teaching, an objective central to the effectiveness of the full-time system, according to the standards set by Flexner and the GEB. Instead of advising Christian specifically regarding these important items of concern, Flexner limited his comments to requests for further data about the medical faculty and student body, and promised on leaving that he would discuss matters more fully in the fall.  
Following that meeting with Christian, Flexner sent a number of suggestions to Welch and his associates at Hopkins about what they should include in the application they were preparing for submission to the Board. Furthermore, early in October, when Flexner learned that the GEB would take final action later that month on the grant applications it had received, he alerted Welch to the necessity of submitting the Hopkins proposal before that meeting. 
In contrast, at no time did Flexner, following his visit with Christian in June 1913, make an effort to communicate about the Harvard application either with Christian or any of his colleagues. It was not until Christian wrote Flexner in late September requesting an opportunity to discuss the Harvard proposal with him again that Flexner finally agreed to meet with Christian at Harvard Medical School in mid-October. 
The meeting proved a shock to Dr. Christian. Flexner told him plainly that the Harvard application was not acceptable and that it would have to be totally revised if it was to be seriously considered by the Board. But Flexner did not inform Christian that the Board would make its final decision in the next week on the applications before it, which consisted of the applications from Hopkins and Harvard. Unaware of the deadline, Christian began immediately to revise the Harvard application and was still in the process when the General Education Board met on 23 October 1913 and made its decisions. 
Approval of the Hopkins Application by the GEB
The Hopkins application received a quite different treatment from that of Harvard. Thanks to the patience of Dr. Welch and the coaching of Flexner, the entire Hopkins faculty was at last supportive of the clinical full-time plan and, on 21 October 1913, Welch submitted a formal application to the General Education Board for a grant of $1.5 million to support establishment of three clinical full-time appointments. His application included the following succinct description of the objective of the Hopkins full-time plan: 
The faculty of the Medical School are fully convinced of the wisdom and necessity of commanding the entire time and devotion of a staff of teachers in the main clinical branches precisely as the school has since its beginning commanded the entire time and devotion of the teachers of the underlying sciences; we are persuaded that the time is ripe for the step in question and we are desirous of undertaking the innovation. Should the General Education Board provide the funds, the departments of medicine, surgery, and pediatrics would be organized on the full-time basis - that is, the professor and his staff consisting of associate professors, associates, assistants, etc. - would hold their posts on the condition that while engaged in the service of the university and hospital they accept no fees for professional services. They would be free to render such service required by humanity or science, but from it they would be expected to derive no pecuniary benefit. Fees charged by the hospital for professional services to private patients, whether within or without the hospital, by members of the full-time staff, such as at present are paid directly to the physician, would be used to promote the objects for the attainment of which this request is made.
The General Education Board acted swiftly. On 23 October 1913, two days after the date of Dr. Welch's application, the Board passed the necessary resolutions making available to Hopkins the sum of $1.5 million to be used to carry out the full-time proposal as set forth in Welch's application of 21 October 1913.  
The outcome was predictable. According to the minutes of the Board, the Hopkins application met every criterion that had been set up and was unanimously approved.
Harvard Grant Applications Rejected by the GEB
At its meeting on 23 October 1913 the General Education Board rejected the Harvard application because the improvements it recommended in clinical teaching were not "sufficiently fundamental." Even more irritating to the Harvard grant committee was the added comment that "although a member of the Board had conferred with the committee at Harvard Medical School and indicated that the Board would be interested in a more comprehensive proposal for reorganization, no such proposition had been received." 
Once Flexner had embraced the vision of the full-time system as described by Mall he insisted on a literal application of the concept, with the Hopkins program being the model. This doubtless accounted for his negative reaction to Harvard's application to the General Education Board. From Flexner's viewpoint there were several major deficiencies in the Harvard application.
First, it did not convince Flexner, upon whose judgment the GEB relied implicitly, that Drs. Christian and Cushing were already functioning as "full-time clinical faculty devoted primarily to research and teaching, " which was Christian's presumption. Second, the Peter Bent Brigham Hospital was a private hospital and did not, strictly speaking, fulfill the criterion of being a "university hospital," owned and operated by the medical school.
Like Flexner, Christian's goal was to establish all clinical departments on a full-time basis, but they differed on the method to achieve this result. Flexner wished primarily to establish full-time chairs in the major clinical departments; Christian proposed that young assistants in the various clinical departments be placed on a full-time basis with an adequate yearly salary and that the salaries of the professors of pediatrics, gynecology, obstetrics, and psychiatry be increased so that they too could afford to devote themselves full-time to their academic and hospital duties. However, Christian said nothing specifically about clinical full-time appointments in the departments of medicine and surgery. He apparently believed it to be obvious that he and Cushing were already working on such a basis at the Brigham.
Finally, there was an issue that on its face disqualified the Harvard proposal. This was the continuing insistence by the Harvard committee that full-time clinical faculty be permitted, in accordance with Harvard tradition, to see patients and collect fees. Although Christian's proposal forbade members of the clinical departments (professors as well as assistants) to engage in general private practice, it did insist that senior professors have the privilege of seeing a limited number of private patients in the hospital on a consultative basis and of keeping the fees. To the uncompromising Flexner, this policy alone made the Harvard program inconsistent with his conception of the strict clinical full-time system which GEB grants were designed to install. 
Christian and the Harvard administration were incensed by the manner in which their application had been handled. They concluded that, given the prior negotiations by the GEB with Welch and the Hopkins school, this first competition sponsored by the Board to advance clinical education by installation of the clinical full-time system was little more than a charade organized by Gates and deftly carried to fruition by Abraham Flexner.  
There followed a period of soul searching and despair at Harvard. Two more grant applications were submitted to the GEB during the next two years, both unsuccessful. Finally in 1916 ex-President Eliot of Harvard, a trustee of the GEB since 1908, came forward with a third proposal that was denied on the grounds that the "proposition continues the old order. . . It is questionable whether in this form the full-time scheme could achieve its purpose." 
Internal negotiations at Harvard during the immediately ensuing years failed to result in an application acceptable to the General Education Board. The chief deterrent was insistence by Christian and Cushing on the privilege of senior full-time clinical faculty to consult and retain the fees. It was inevitable that applications from Harvard retaining that privilege would be vetoed on arrival by Flexner, who was pointedly excoriated by Dr. Cushing and others of the Harvard faculty for his bureaucratic rigidity and cavalier disregard for their sensibilities. 
For an opinion of the Flexnerian doctrine and the Hopkins model from the Harvard viewpoint, and a reminder that Harvard has also made substantial contributions to American medical education, one may consult Medicine at Harvard (1977) by Professors Beecher and Altschule. They concluded, somewhat peevishly: 
In the end, it matters very little who achieved leadership in the reform of medical education in this country - Eliot (President of Harvard University), the American Medical Association, or Flexner. The fact is that essential reform did come, and with far-ranging benefit to the medical establishment in this country and in other countries. There is honor enough for many. What is important is that the Eliot reform strengthened medicine and the Flexner reform deformed it. Today's criticism of the shortsightedness of government agencies that spend billions to support research at medical schools and zero to support clinical teaching is not warranted. The blame lies not with these agencies but with the Flexnerian educators who told them what to do. Today's medicine, which many find irrelevant to patients' needs, is the fruit of Flexner's report. This was not the first time, nor will it be the last, that medical educational policy has come under the influence of a well-informed but short-sighted reformer supported by an enthusiastic but deluded lay press.