From Flexner to Worcester: Medicine’s Next Century Dawns

February 14, 2013

Remarks given by Chancellor Michael F. Collins at the Worcester District Medical Society’s 217th Annual Oration on Wednesday, Feb. 13, 2013

I want to thank the members of the Worcester District Medical Society for the invitation to present this year’s Oration. I have great respect for my colleagues in our district.

In preparation for this evening’s presentation, I read many outstanding works including each of the orations presented in the last decade. Inaugurated by Dr. Babbitt in 1795, the District has heard from Drs. Homans, Hitchcock, Brigham, Peabody, Shattuck, Fallon, Morse, Hanshaw, Wheeler, Lazare, Levine, Pappas, Young, Pugnaire, Hirsh, Aghababian, Spanknebel, Esposito and Birbara; an outstanding legacy of thought, indeed. Reviewing this long lineage of ideas provided me with a wonderful opportunity to benefit from the insights of colleagues and friends for whom I have the utmost respect. Only in childhood dreams could I have imagined to be among such a list of committed and dedicated physicians. I come cloaked in humility as it is indeed a privilege to be with you this evening.

It is a most exciting time to be in the medical profession. Over the past four decades, I have had the great good fortune to witness an explosion of medical knowledge. While I do not feel that advanced in age, when I attended medical school HIV was an unknown pathogen; elucidation of the genome was a concept; and DNA’s influence masked the power of RNA. In fact, it was on a ride to Washington D.C. with my family around the time of my medical school commencement that I read a description of an aggressive pneumonia afflicting immunocompromised men in San Francisco. The allure of medicine to this day involves unlocking knowledge unknown to benefit patients in the most vulnerable moments of their lives.

A hallmark of our profession is that a commitment to medicine requires the welcome embrace of life-long learning. As we take our oath at commencement, we commit to do what is in the best interests of our patients. Respect suffuses our commitments “to reckon him who taught me this Art equally dear to me as my parents . . . and that by precept, lecture, and every other mode of instruction, I will impart a knowledge of the art to my own sons, and those of my teachers, and to disciples bound by a stipulation and oath according to the law of medicine, but to none others.”1 [Please pardon the unenlightened gender references!] Forgoing our personal needs and conflicts, we obligate ourselves to constant and consistent learning and we accept the responsibility to provide the education of those who follow us in our profession. The defining hallmark of our profession is the oath we profess. Ours is a high calling!

When in 1911 Abraham Flexner crafted a report entitled “Medical Education in the United States and Canada” for The Carnegie Foundation for the Advancement of Teaching, he reflected on “an agitation set up by Nathan Smith Davis [that] resulted in the formation of the American Medical Association, committed to two propositions, that it is desirable “that young men received as students of medicine should have acquired a suitable preliminary education,” and “that a uniform elevated standard of requirements for the degree of MD should be adopted by all the medical schools in the United States.”2 That these truths were not self-evident is remarkable.

When discussing “over-production”2 of physicians, he used as an example the presence of two physicians to serve the 80 people in Colerain and the 100 people in Harding, Massachusetts.2 He observed, “for a region in which holds out hope, there is no need to make poor doctors, still less to make too many of them!”2 In calling for a commitment to higher quality in medical education, Flexner observed, “We may safely conclude that our methods of carrying on medical education have resulted in enormous over-production at a low level, and that, whatever the justification in the past, the present situation in town and country alike can be more effectively met by a reduced output of well trained men than by further inflation with an inferior product.”2 In calling for fewer and better trained physicians he criticized the advertising that was used to bring doctors to poor medical schools. “The deans of these institutions occasionally know more about modern advertising than about modern medical teaching!”2 He proclaimed, “Schools can no longer be open to casual strollers from the highway.”3

As he insisted that the standards of medical education be improved and impervious, he concluded, “The physician’s concern with normal process is not disinterested curiosity; it is the starting-point of his effort to comprehend and to master the abnormal.”3

As Flexner reviewed the stages of medical education throughout history he reflected upon three “stages” of medical education.4 “The first and longest was the era of dogma. Its landmarks are Hippocrates and Galen, whose writings were for centuries transmitted as an authoritative canon.”4 “The second era is that of the empiric. It began with the introduction of anatomy in the sixteenth century, but did not reach its zenith until some two hundred years later . . . The art of differentiation through controlled experimentation was as yet in its infancy.”4 “The third era is dominated by the knowledge that medicine is part and parcel of modern science.”4

In his introduction to Flexner’s report, Henry S. Pritchett, president of the Carnegie Foundation at the time of the report’s writing called “for an educational patriotism on the part of institutions of learning and medical patriotism on the part of the physician.”5 “By educational patriotism [he meant] this: a university has a mission greater than the formation of a large student body or the attainment of institutional completeness, namely, the duty of loyalty to the standards of common honesty, of intellectual sincerity, of scientific accuracy.”5 “By professional patriotism amongst medical men [he meant] that sort of regard for the honor of the profession and that sense of responsibility for its efficiency which will enable a member of that profession to rise above the consideration of personal or of professional gain.”5

As Flexner spent three years studying and opining on the standards for medical education, I was struck by the use of patriotism as the hallmark standard for the profession. This claim was in stark contrast to the writing of his last two chapters on The Medical Education of Women and the Negro. More charitable toward the women of the day, Flexner observed, “Woman has so apparent a function in certain medical specialties and seemingly so assured a place in general medicine under some obvious limitations [though he never comments of what these limitations might be] that the struggle for wider educational opportunities for the sex was predestined to an early success in medicine.”6 In less patriotic comments Flexner stated, “The medical care of the negro race will never be wholly left to negro physicians . . . If at the same time these men can be imbued with the missionary spirit so that they will look upon the diploma as a commission to serve their people humbly and devotedly, they may play an important part in the sanitation and civilization of the whole nation. Their duty calls them away from large cities to the village and the plantation, upon which light has hardly as yet begun to break.”7

As Dr. Leonard Morse pointed out in his most eloquent oration,8 Flexner held the Johns Hopkins University as the standard upon which all medical schools should be measured. Pritchett concluded, “Let us address ourselves resolutely to the task of reconstructing the American medical school on the lines of the highest modern ideals of efficiency and in accordance with the finest conceptions of public service.”5

I must admit that though I had heard of the Flexner Report since the early days of my medical education, I had never read the report in its entirety. For over a century, this call for quality and standards in medical education was the guidepost for schools of medicine. It was a shock to learn of the commercialism in medical education at the time of the report and the callous observations of the commitment to the education of women and persons of color. That said, the report was comprehensive and had a sentinel effect on medical education throughout the next century. It is these commitments to “the highest modern ideas of efficiency”5 and “the finest conceptions of public service”5 that formed the foundation for the founding of the University of Massachusetts Medical School in 1962.

Ellen More, a historian of our medical school, has compiled a wonderful history of our school. Entitled A History of the University of Massachusetts Medical School: Integrating Primary Care and Biomedical Research, this work recounts the founding and development of the treasure that UMass Medical School has become.

The desire to create a public medical school, to respond to the need to increase the number of practitioners in Massachusetts, to provide a university-based education for those students from working class families and to assure a “first class” education for those who matriculated to the school were the founding hallmarks of the University of Massachusetts Medical School. As has been the case over history, politics, individual perspective and perceived parochial benefit characterized the colloquy over where the school would be located and what would be its legacy.

Many within the University, particularly the university president and dean of the medical school, believed that the school should be located on the university’s Amherst campus. This was particularly pleasing to the three Boston institutions that were not interested in there being further competition for students or clinical rotation slots. Flexner’s premise that medical education should have a university base advanced the position of those who thought that the medical school campus should be located in Amherst. The actual term of the education to be provided at the school, be it two years or four, also became a serious issue of contention.

Given the Flexnerian ideals of a university-based education grounded in a foundation of learning in the sciences with the quality of education as an imperative, the University of Massachusetts first studied the prospect of establishing a medical school as World War II concluded and veterans in search of medical education returned in search of schools. It was not until the early 1960s that enough momentum could be gained to actually pass, through the legislature, an initiative to establish a medical school.

As recounted in an editorial in the New England Journal of Medicine in 1965, “On June 4, 1965, eighteen months after a dean of the Medical School had been appointed, and almost four years after the Medical School had been authorized, the trustees of the University of Massachusetts voted on the location of the school. In the semifinal ballot, 11 votes were cast for a location at the University [in Amherst], and 11 votes for a location in Worcester. On the final ballot, [one] man changed his mind, and Worcester was chosen, 12 to 10.”9 As the editorial went on, criticizing the trustees who had voted, it stated that the trustees “lost their golden opportunity to avoid the handicaps that have been associated with those institutions where the medical school is separated from the university.”9 Arguing that it did not matter whether the school was located in an urban [in this case Worcester] or rural [Amherst] location, the editor claimed, “Even now the automobile carries ward patients not to the nearest hospital but to the hospital of excellence that practices personal care . . . the distinction between an urban and a rural locale is no longer valid.”9

In perhaps the most damning of claims made by the editor, he stated, “A medical school only at Worcester can neither strengthen the University nor be strengthened by it. At Worcester it may be immeasurably more difficult to recruit a clinical and preclinical faculty for a medical school away from the parent university.”9

In a letter to the editor, Hyman Heller, MD, president of the Worcester District Medical Society, took great exception to the opinions expressed in this editorial. Published one month later, he wrote, “It is evident that the writer of the editorial knows very little about the attributes of Worcester as a prime location for the Medical School other than it is not the campus at Amherst. He appears unwilling to concede that Worcester, which is highly regarded as an educational center . . . can offer an ‘intellectual ferment’ reasonably equivalent to that provided by Amherst.”10

Ellen More found an interesting letter written for the “UMass Amherst campus paper [that] minced no words: ‘Anyone of a stature suitable to be a professor of medicine or any student of a caliber suitable to attend a first-rate medical school would without hesitation prefer to do his work in the garden setting of Amherst with its higher saturation of sophistication, intelligence and the amenities of life than in or about the city of Worcester. Undoubtedly the drabbest, dullest, most mediocrity-impregnated communities in the country are its medium-sized cities. Even though Worcester is well above average in this category it cannot escape that curse.”11

As the members of the first class came to campus in 1970, the politics had receded into the past and Dean Soutter welcomed the first 16 students to a campus that would several years later, after vigorous battles with the legislature over resources, open a medical school and clinical teaching facility. Flexner would have been quite proud of what was to come.

As the University of Massachusetts Medical School approaches its 40th commencement we are proud of the many accomplishments gained over the past four decades. Contrary to viewpoints in the days during which the creation of the medical school was being considered:

• The University has attracted the finest applicants to its medical, nursing and graduate schools. Reserving most of its medical school seats for residents of Massachusetts, ranked seventh in the nation,12 the school continues to fulfill its mission to educate primary care practitioners for the commonwealth. Based on the 2012 National Residency Match Program (NRMP), 69 percent of our graduates entered primary care disciplines, which includes Ob/Gyn, emergency medicine, medicine/primary care, medicine/pediatrics, pediatrics/primary care, family medicine or any combined programs therein. The NRMP data is consistent with the results of our recent alumni survey, which reflected that 60 percent of our graduates enter primary care disciplines.

• Graduates of our nursing school are making an important impact in the care of patients in Massachusetts and beyond. Furthermore, the all-graduate school nature of our nursing school has positioned us well to educate the next generation of nursing school faculty and advanced practice nurses.

• Our Graduate School of Biomedical Sciences’ student body has contributed to the publication of more than 2,000 peer-reviewed scientific articles.

• Members of our faculty have won the Nobel and Lasker prizes; we have seven Howard Hughes Investigators; five members of the national academies; over $250 million of sponsored research this year; we rank among the top 15 universities in the amount we derive from revenues from intellectual property; our scientists are among the most quoted in the world and we believe in collaboration and the importance of clinical translation for our scientific discoveries.

• We have saved the commonwealth billions of dollars through the initiatives of Commonwealth Medicine, our health care consulting division, where our comprehensive, innovative health care solutions draw on our team’s academic knowledge and public health service expertise.

• Through MassBiologics of the University of Massachusetts Medical School we have discovered and developed products that will significantly improve the public health and human condition. Over the years we have provided over 100 million doses of biologics in service to patients and in furtherance of the public health.

• Together with our health system partner, we are responsible for in excess of $5 billion in economic activity throughout our region.

• Over the years of growth, one thing has remained constant; as a public institution of higher education, commitment to public service remains the hallmark of our mission and our work. We are committed to our community. In the past year colleagues of the medical school have provided over 71,000 hours of community service and over 35,000 of those hours were in the greater Worcester area.

We are engaged, committed, and principled. I only wish that Abraham Flexner had a chance to visit our school!

As we look to the future I can’t help but recall Sir Luke Fildes’ painting of The Doctor, a work inspired by the devotion of a physician who sat by Fildes’ son’s side as he suffered and died of tuberculosis in 1877. This painting adorns the wall in each of my offices as a constant reminder of the covenantal relationship that exists between physician and patient.

As we educate the next generation of physicians, we accept a sacred obligation as we profess our oaths to care for our patients and to educate those who come behind us in our profession. As the doctor sat beside the patient in 1877 there were no antibiotics, no advanced radiologic techniques, no sophisticated inpatient units and no prepaid health plans. As the child suffers and the parents grieve in anticipation of their loss, the physician attends to their most intimate needs and vulnerabilities. Any notion of a commercial relationship absents itself from this moment. There is but caring and compassion.

Flexner was concerned that commerce had invaded the foundations of American medicine and its education enterprise. He proposed principles and standards that when adopted made American medical education the envy of the world. It remains so.

Yet, we are challenged this very day to educate our students to develop essential competencies, not mastery of content, as the goal of their education. Technology advances at astounding speed. Many posit that the inpatient setting of tomorrow will be limited to operating room suites and intensive care units. We are moving from a payment system that rewards volume to one that rewards value. There are so many external factors that can come between physician and patient.

Along the path from Flexner to Worcester, our medical school has risen from a field in Worcester, where dreams anticipated now capture the imagination and attention of the world. Our potential is limitless. Expectation is heightened.

Yet, each day as we shape our future and change the course of history of disease, I am still struck by the covenant we share with our patients. They extend their hands towards ours. We reach to accept and in doing so, we touch their hearts.

Whatever was expected when our medical school was placed in Worcester, as physicians we have been given an extraordinary privilege to care for others and with our actions to promote their human dignity. In the century to come, we will remain faithful to our mission and fulfilled as professionals, if the work of our minds and hearts allow our hands to become one with our patients.

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1 Adams, F. The Genuine Works of Hippocrates. Vol. I. Birmingham, AL. The Classics of Surgery Library, a division of Gryphon Editions; 1985. 779 p.

2 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Chapter I: Historical and General. 3 p.

3 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Chapter II: The proper basis of medical education. 21 p.

4 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Chapter IV: The course of study: The laboratory branches. 52 p.

5 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Introduction. xiii p.

6 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Chapter XIII: The medical education of women. 178 p.

7 Flexner, A. Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching. The Merrymount Press, 1910: Chapter XIV: The medical education of the negro. 180 p.

8 Morse, Leonard. Islands of excellence and the street physician. Worcester District Medical Society’s Annual Oration. 1974.

9 University of Massachusetts School of Medicine. N Engl J Med. 1965 July 8;273:107-108.

10 Hyman, H. University of Massachusetts School of Medicine. N Engl J Med. 1965 Aug 12;273:398.

11 More, ES. A History of the University of Massachusetts Medical School: Integrating primary care and biomedical research. 2012:88. http://escholarship.umassmed.edu/umms_history/1/

 

12 Best Medical Schools: Primary Care. U.S. News and World Report. 2012. http://grad-schools.usnews.rankingsandreviews.com/best-graduate-schools/top-medical-schools/primary-care-rankings