July 13, 2010

100 Years Later - The Flexner Report Still Relevant

The centenary celebrations of the Johnson-Jeffries “fight of the century” which took place on July 4th, 1910 understandably overshadowed another event, arguably more important and relevant to Americans living today – the publication in June, 1910 of the Flexner Report on the state and reform of American medical education.

Abraham Flexner, working for the Carnegie Foundation at the behest of the American Medical Association (at that time a relatively weak organization) issued Bulletin No. 4 a few weeks before the Johnson boxing match.  Flexner had traveled across the country visiting each and every medical college in the U.S. that purported to offer a medical education.  The Flexner Report was a ringing condemnation of the state of most of the medical schools of the time and called for them to reform or close.


Indeed, through the late 19th and early 20th century, one could essentially buy a medical degree in America.  You didn't even need a high school diploma to enter a medical college which often consisted of two years of listening to local practitioners talk of their medical experiences.  There were no mandatory laboratories, no anatomy classes, no basic science necessary at all.  Faculty was paid according to the number of students the college could get to attend.

Poorly trained doctors faced a number of successful challengers for their services.  “Patent” medicine companies in direct advertisements to the public proclaimed a doctor wasn't necessary if you just used their treatment.  A multiplicity of practitioners ranging from Christian Science to homeopathy successfully competed with the allopathic M.D.'s for patient services and dollars.

Flexner insisted that American medical schools follow Johns Hopkins and Harvard in establishing programs that were much closer to the leading German medical education of the day.  Ultimately an undergraduate bachelor's degree plus four years of medical school (two in basic science and two in supervised clinical practice) were required in order to obtain a state license.  Proprietary medical schools that could not offer such training ultimately either merged with university associated schools or went out of business.

The increasing professionalism of medicine in the first two decades of the past century allowed doctors to be in charge of the medications prescribed.  Drug companies quickly succumbed to rules set by doctors that prohibited direct advertisements and required companies to submit their products to more rigorous testing of effectiveness and safety.  Even before antibiotics, the new “scientific” medical profession impressed the public so, that M.D.'s had the authoritative knowledge and skills that could make a difference in healthy living.

However, in the last two decades the federal government in changing rules and funding for medical research pushed doctors (especially university scientists) and the drug industry together in the hope that new and more beneficial products would emerge.  Instead drug industry creativity has stagnated (not in terms of making profits) and doctors' credibility has been deeply damaged by multiple allegations of conflict of interest.

From the highest levels of medical academia to the front line practicing specialists (especially in psychiatry, orthopedics and cardiovascular medicine) there is proof of industry influence on doctors' opinions and decision-making.  According to the Prescription Project over fifty percent of Americans now think that drug companies exert a “large influence” over doctors' choice to use a specific drug.

America and the medical profession desperately need a new Flexner Report for the 21st century. The Physician Sunshine Payment Act, signed into law on March 23rd, is a step in the right direction.  It will require by 2013 that drug companies post any gift and payment to doctors and hospitals.  This measure will go a long way to informing the public as to potential professional conflict of interests of the doctors they use.

However, there are also signs of continued resistance from the elites in the medical profession.  Just last month, the assembly of the American Psychiatric Association, rejected a strict code of ethics on drug industry monies and conflict of interest citing infringements of personal rights.  Circulating just beneath the official explanation, a less ennobling explanation of infringement on “personal income” highlights the threat to doctors’ professional credibility.  Another example is Harvard’s University’s foot-dragging delay (now over fifteen months) in resolving the status of Joseph Biederman, a leading academic child psychiatrist, accused of receiving 1.6 million dollars of undeclared income from drug companies.

It's not enough to have doctors’ payments from drug companies listed on some website.  In every waiting room, patients should be able to read clear signs indicating doctors' payments received from companies and the specific drugs and products involved.  In the long term medical research and academia must find a better way to separate their work from their sponsors’ money.  A general research fund of drug company money directed by an independent board has been suggested but seems unlikely given the profit driven priorities of the drug industry.

In the long term it is in the best interests of doctors to self-reform but physicians like everyone else are influenced by short-term economic incentives. Licensure and civil law suit threats, along with continuing high negative publicity for practitioners and institutions that fail to make changes, will likely be the necessary tools to bring credibility and trust back to a damaged profession.  The hundred year anniversary of the Flexner Report should remind physicians and the public alike that, the medical profession risks losing their very “professionalism” unless similar type reforms take place again.

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