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Tuesday, April 28, 2009

Safety and Normal Birth: Turning A Bitter Historical Truth into a Bright Future

For three decades, birth activists and the obstetrical profession have hotly debated whether ‘normal’ birth is a functional and dependable aspect of our biology or a dysfunctional and harmful ‘patho-physiology’. Both sides agree that life-threatening complications do occur during pregnancy and childbirth but that is where the commonality stops. They are sharply and bitterly divided on the frequency and circumstances surrounding these serious problems and how best to prevent them. Each side is utterly convinced that the other side is utterly wrong.

As a diligent student of the science underpinning this issue, I say that both are off the mark in different ways. Many prospective parents, birth activists and a fair number of midwives do not appreciate the potential for unexpected but nonetheless life-threatening complications to occur, while the obstetrical profession believes that pregnancy and childbirth are nothing less than one disaster after another and anyone (mother or midwife) that even consider laboring and giving birth outside of a well-equipped hospital must be criminally insane.

The connection between Black Swans and Complications -- the high impact of highly improbable events

Before I identify the facts that will allow us to arrive at a reasoned conclusion about the safest, most appropriate and cost-effective model of maternity care, I’m going take a small detour into the general topic of risk – the chance that something serious will go wrong while we are traveling, pregnant, giving birth, serving in the military, etc. Two elements are necessary before we can judge the risky-ness of any event or circumstance: information on what could go wrong in severity and in frequency: how likely we personally are to suffer the impact of an improbable but difficult, painful or life-altering event – illness, injury, crime, bankruptcy, get sued, die, etc?

A lot of research has been done on the psychology of how humans relate to risks and risk-taking and many authors have published excellent articles on the subject. However, the one most useful for our purposes is a book called “Black Swans – The Impact of Highly Improbable Events” by Nassim Nicholas Taleb. It’s s long book, with many important and fascinating ideas, but I will stick to a small handful that help us to understand why humans generally have trouble accurately determining risk and why realistic assessment of risk in pregnancy and childbirth is distorted by both sides. In 20th century America, the nature of childbirth and the ‘proper’ form of care during pregnancy and childbirth has rising to the level of a bitter political controversy, one not much different than unlike partisan politics or opposing religious beliefs. The observations on human behavior described by Nassim Taleb give us some tools to help sort these things out and come to some intelligent conclusions.

Pattern recognition vs. computation: People prefer to get information through patterns (a quick mental picture), rather than arithmetic – always have, always will.

Narrative -- i.e., story form – is a patterned form of communication. Information provided as a narrative helps people simplify and organize lengthy or complex sets of data into story form, which makes it easier to ‘understand’, remember and recount to others.

Narratives always leave out more than they put in and are heavily influenced by the person creating the narrative. The temperament, emotions, style and goals of the individual who constructs a narrative decides which of the raw bits of data to emphasis and which to gloss over or leave out.

Considering the selectivity of the narrative form – what is left out and what is included as a series of personal choices of the story teller -- social scientists question whether distilling information into patterns actually represents a true understanding of the concept or if simplification leaves us with an incomplete or biased idea.

The nature and complexity associated with highly improbable but high impact events can lead even the most well-meaning people into one or more traps – that is, an illogical conclusion fiercely believed to be demonstrable ‘truth’. In regard to most topics, this falls into one of the two extremes: (1) the believe that because you have never encountered a ‘bad’ outcome, that such things are really not a significant issue (2) Because you had a direct or indirectly experience of a bad outcome, that such things are so frequent and so catastrophic, that it is worth ANYTHING – any money, any effort -- to prevent.

For our purposes, it must be noted that birth activist and obstetricians have rather naturally opposite conclusions about the risks of spontaneous birth and the rewards of obstetrical interventions.

Lets return to our topic – childbirth – and look closer at the story that each side tells itself and promotes in the public arena:

Those who believe that childbirth is a safe aspect of our reproductive biology are convinced that complications are the result of poverty, poor healthy and economic deprivation in third world countries. For healthy women with normal pregnancies in wealthy countries such as the US, the problems of pregnancy and childbirth are assumed to be (1) exceedingly so rare or (2) the result of unnecessary, unwanted and unwise obstetrical interventions. This conclusion is that birth would turn out perfectly well, if only those meddlesome doctors would leave things alone and let Mother Nature do her thing unimpeded.

The obstetrical profession is diametrically opposed to this thinking. They are convinced that childbearing is an inherently destructive biological process and that life-threatening problems are a basic, count-on-able characteristic of childbearing. Once the genes are passed on to the next generation, the vessel – the female of the species -- becomes expendable, so Mother Nature casually sacrifices women in childbirth with the same disregard for individual wellbeing as She displays towards salmon that die after spawning.

According to the obstetric perspective, complications are more frequent in high-risk pregnancies, but no matter how healthy the mother, how normal her pregnancy, or how spontaneously progressing the labor, distrust of childbirth is justified. This is expressed in the obstetrical truism “Mother Nature is a bad obstetrician”, indicating that depending on normal biology is at one’s own peril. The only defense is to ‘head-em-off-at-the-pass”, via the preemptive use of interventions as a strategy of prevention.

The relative safety of PHB, compared to hospital-based obstetrical care, cannot be meaningful evaluated without addressing the bias on both sides. Such extreme and mutually exclusive views cannot both be true. In all probability, both sides are likely to be wrong in some ways and right in others. This means that so far, neither side has identified the actual dangers associated with childbearing, so that parents, professionals and policy makers could design the best system for maternity care for healthy women, one that is both safe and cost-effective AND meets the practical needs of childbearing families. An undertaking of this magnitude requires is impossible without first developing a deep understanding of the topic.

Irreducible risks and dangers of childbirth in a healthy population

Rule #1: Evaluating the irreducible risks and dangers of childbirth in a healthy population must occur in the context of time and place. Women do not give birth in isolation from their culture, as if they were spinning around in outer space tethered to an oxygen mask. It is no more appropriate to judge the ‘safety’ of childbearing in isolation from modern biological science than any other aspect of our physical wellbeing. Health and longevity for infancy, childhood disease, accidents and injuries, as reflected in morbidity and mortality statistics

In particular, we need to know what happens (how bad and how often) in the absence of all health care services -- when access to science-based maternity care and comprehensive obstetric services are totally absent or they are culturally unacceptable and therefore not used even when obviously needs. Both of these situation frequently occur in third world countries. The same question applies to First World countries with a childbearing population that is generally healthy (over 70% of all births), economically advantaged and has ample access to medical and maternity care and comprehensive obstetrical services.

Extreme Dangers, Dangerous Extremes and the Middle Way:

According to studies and statistical records, the majority of bad outcomes are associated with the two opposites ends of the maternity care spectrum. The greatest risk is associated with under use of medical services – especially the absence of care. The other areas of increased risk is associated with over medicalization, which introduces different hazards and iatrogenic and nosocomial complications and the considerable added expense accompanying this problems. It is the middle of the maternity care spectrum that has the fewest adverse events and best outcomes. This is an articulated model that integrates the classic principles of physiologically-based care, with the best advances in obstetrical medicine to create a single, evidence-based standard for all healthy women.

Here are the principles underlying those observations.

(1) Lack of access to (or ideological rejection of) maternity care and medical services during pregnancy and childbirth accounts for the great majority of maternal-infant mortality and morbidity. Horrific suffering, permanent disability and lost of life is the background risk of childbirth in a pre-scientific world that lacks any capacity to detect or treat obstetrical complications. This is often the case in developing countries, especially sub-Sahara Africia, where maternal mortality ranges from 800 to 1,100 per 100,000 pregnancies. On average, one mother dies for every 90 births.

However, this also applies to the developed world when prenatal care and obstetrical services are unaffordable, unavailable (lack of transportation, etc) or prohibited by cultural beliefs. This latter category includes childbearing women, husbands or other close relatives that reject the use of obstetrical services when a complication has developed. It also applies to labor and birth attendants that have a prejudice against the use of medical services, discourage or deny the applicability of it to a particular situation or fail to recognize an emergent need for medical or surgical intervention.

(2) When compared to evidence-based physiological management, medicalized pregnancy and childbirth services in a healthy childbearing population, which includes the preemptive use of obstetrical interventions, increases maternal mortality and morbidity by statistically significant rates and in some studies, a slight increases infant mortality and morbidity.

Two compelling situations made interventionist obstetric the standard of care in the US. The first is a century-long tradition of obstetrics as a surgical specialty.

As a surgical specialty, childbirth is a professional service for which the obstetrician is totally responsible. A physician-surgeon is legally defined as the “captain of the ship”, making him or her liability for everything that happens to the patient while under his/her care. Under these rules, the birth or ‘delivery’ becomes a surgical procedure performed by the birth attendant.

The second situation is blowback for the high malpractice litigation rate for obstetrics as a specialty. This continues to fuel intensive efforts to reduce the litigious risk to obstetricians and hospitals.

There are two major contributors to a small but statistically significant increase in mortality and morbidity in highly medicalized maternity patients.

The first category is systemic problems: lack of continuity of care, an inattentive staff that fail to recognize or respond to a complication and a busy or short-handed staff overwhelmed by the number of patients or deficiencies in the institutional system.

The second category is iatrogenic and nosocomial complications: hospital-acquired and drug-resistant infections, side effects and adverse reactions to drugs, procedures or treatments or synergistic interactions between by drugs and/or treatments.

In the US, an average of seven significant medical and surgical interventions are used every year on each of the 4 million women who give birth. This intervention rate is 2 to 10-fold higher than physiologically-based care. Interventionist obstetrics annually generates 28 million medical or surgical opportunities for medical errors, adverse events, anesthetic accidents, hospital-acquired infections, and unanticipated consequences such as delayed or downstream complications. This sheer volume makes increased maternal mortality inevitable.

The shadow side of medicalization rarely ever makes it into the public press, except as undifferentiated statistics for iatrogenic mortality. This is usually characterized in the media as ‘medical errors’, which account for 100,000 deaths each year. There are no figures for what percentage of that applies to obstetrical care, but 25% of all hospital care is maternity care, obstetrical care generates 8% of all malpractice suits, 50% of which involve the use of Pitocin to induce or speed up labor. Obstetrical training materials developed to teach risk-reduction strategies to nurses, midwives and other professionals recount many vivid examples of preventable ‘adverse events’ occurring during labor and hospital delivery.
The facts of each situation often show how the sheer complexity of medicalized labor triggers unexpected problems.

One recent example was a hospital in the UK that had 10 preventable maternal deaths within a few years, 3 within a few months. One maternal death occurred after bupivacaine, the local anesthetic used in epidurals, was accidentally put in the mother’s IV line in her arm instead of the epidural catheter in her back. A host of precautions and intricate protocols are suggested to prevent such ‘errors’ in the future, but many of them increase the complexity of medicalized care. This unintentionally and unavoidably creates further opportunities for iatrogenic and nosocomial complications.

According to the World Health Organization’s document “Managing Complications in Pregnancy and Childbirth” (2001), the best description of childbirth risk is as follows:

“While most pregnancies and birth are uneventful, all pregnancies are at risk. Around 15% of all pregnant women develop a potentially life-threatening complication that call for skilled care and some will require a major obstetrical intervention…”

Surprise! Both Sides Wrong, Both Sides Are Right:

Turns out birth activists and obstetricians have both gotten it wrong. Blindly ‘trusting birth” is no better than blindly trusting obstetrical medicine. One group leans hard to the starboard while the other leans to port -- together they are destined to make endless circles in the opposite direction. From that perspective, birth activists and obstetricians have a lot in common, which is to say that both gravitate towards ideological extremes.

One side insists that birth is a safe as life gets and that trust in birth makes modern maternity care all but irrelevant. They dismisses the substantial risks to childbearing women when they are isolated from the safety net of modern science -- prenatal care, risk-screening, referral to medical service as indicated, presence of a skilled birth attendant and appropriate access to comprehensive obstetrical care whenever necessary. The other has a century long tradition of defining normal birth as so dangerous that the preemptive use of obstetrical interventions is the only ethical course of action.

interventionist obstetrics as applied to healthy women ignores the unnatural and unnecessary complications associated with these medical and surgical procedures, including Iatrogenic and nosocomial complications and delayed and downstream problems inevitable associated with invasive interventions and surgical procedures.

Over-treatment is not better than under-treatment -- excesses are bad for mothers and babies, whatever their origins.

As long as this issue is seen in the extremes of black and white, right/wrong, good/bad, doctor versus midwives or hospital versus midwife, the long process of reconciliation will remain beyond our grasp. The point of balance lies in the middle of the spectrum, an articulated model of maternity care that integrates the best of physiologically-based principles of management and comprehensive obstetrics.

If a balanced model of maternity care is ever to be more than a pie-in-the-sky pipe dream, we must re-evaluate the language used by each side and consider whether either one matches with facts. The idea of childbirth as so benign that rejecting all health and maternity care made childbirth safer does not stand up to scrutiny. This is amply documented by the mortality statistics from 3rd world countries, which clearly demonstrates that childbirth in a non-scientific, non-technological society has a high potential for death and disability. It is also clearly evident in the well-researched history of the religious group in Indiana that eschewed all forms of health or maternity care, even when obvious life-threatening complications developed.

However I take equal exception to the idea so often repeated that being born is the most dangerous thing that ever happens us as human being. I don’t argue with the numbers, but the perspective is skewed. The notion of birth as unparallel danger exists in isolation from the broad experience of history and from the reality of daily life. We human beings exist within fragile biology of bodies – that has never been a ‘safe’ or stable place to be if judged by complete freedom from illness, injury or death. We reasonably rely on modern biological sciences to keep small health problems from becoming tragedies. Nonetheless, we don’t think about, or talk about, normal life as “the most dangerous thing that ever happens to us”.

From infancy to old age, humans have always faced both common-place and unusual or unexpected dangers. The simplest aspects of daily life could suddenly result in a potentially fatal injury or infection – stumble or step on a sharp stick. A long list of diseases, from kidney failure to brain tumors, befell earlier generations just as much as now, only there were no effective medical treatments. Every period of history and every geographical location that lacked the ability to diagnosis and treat disease and injury meant that sudden death or slow painful demise were everyday facts of life. Turn-of-the-century cemeteries are filled with the graves of whole families who died of diphtheria, typhoid fever, or small pox. This was often the consequence of a minor illness or a transient problem that we would avoid by simply making a late-night trip to the ER for stitches, an x-ray or a prescription for antibiotics.

Until approximately 150 years ago, contagious illness and injuries with contaminated wounds was the most frequent cause of death. Until the work of Louis Pasteur was published in 1881, no one knew about the world of micro-organisms – microscopic bacteria and other germs. Personal hygiene was merely a personal preference, some held in distain by most people, including physicians. There was little in the way of public sanitation after the Roman Empire fell and along with it, societal valuing of cleanliness for its own sake . Historical records of my own ancestors ascribe the untimely death of my great-great-great grandfather (1840s) to walking barefoot to the barn, stubbing his toe on a stick that he himself had whittled earlier in the day, and developing a fatal septicemia (probably a bacterial infection from the barnyard animals). According to anthropologists, life expectancy in primitive cultures was only 35 years.

However, these same problems can easily apply to modern life when customary health care services are cut off (like the aftermath of Hurricane Katrina) or when people are forced by family or choose based on religious beliefs to turn their back on the biological sciences and the use of medical services when indicated.

Reintegrating Our Thinking about Childbirth back into the Biological Sciences

It’s not helpful to focus on childbearing as separate from the general fragility of human life by singling out pregnancy and childbirth as many times more dangerous, as if they existed in isolation from modern scientific knowledge, and the principles practice of modern medicine. We don’t apply this narrow focus to the other stages and phases of human life. Across the board, modern life – pregnancy, birth, infancy and all the subsequent stages of development are orders of magnitude safer as a result of universal education and modern biological science -- sanitation, nutrition, preventative medical care and emergency services for illness and injury.

Characterizations that portray maternity care and skilled birth attendants as unnecessary, since we need only ‘trust birth’, and those that promote childbirth as monstrously dangerous are both at crossed-purposes to the humanitarian interests of society.

Continued later in the week.....

Saturday, March 14, 2009

In the last year or so, the American Medical Association has adopted an aggressive stance that seeks to limit the provision of healthcare services by non-physician practitioners such as nurse anesthetists, nurse midwives, physician assistant and other 'alternative' healthcare provider.

The following material is commentary on what is called the Flexner Report. It reiterated the 1904 recommendations by the AMA's Council on Medical Education. The ultimate consequence of these policies, which were adopted into law by state medical boards, was to make the practice of medicine into a legal monopoly controlled by the AMA in 1910. Under the outdated "1.0 operating system" installed by the AMA's Council on Medical Education (CME) in 1910, we continue to have an expensive and a profoundly dysfunctional health care system. Its is breaking the bank at home and making it impossible to compete on a level playing field in the global economy.

For example, the manufacturing costs of a car assembled in Canada reflects only $900 of health care expense, while one built in Detroit at a GM plant is weighted down with $4,500. The US now spends 18 % of its entire GDP or $2.2 Trillion dollars a year on health care. Price-Waterhouse-Coopers' has estimated $1.2 trillion of the current $2.2 trillion spent last year is wasted (that's 55 cents of every dollar). Bad as those numbers are, some experts predict health care costs to spike to $4.4 trillion in the next decade, while we continue to waste over half of every dollar spent. If the unproductive health care expenses were eliminated, we would pay off the current federal deficit of $14 trillion with the saving of just 7 years of a cost-effective system of health care.

In spite of these trillions, a 100,000 people die every year of medical mistakes and another 20,000 die because they didn't have health insurance, while 1.3 million mothers have C-sections -- equal to the number of students that graduate from American college each year -- 40% of which are paid for by the federal Medicaid program for the medically indigent.

The AMA latest 'Scope of Practice" resolution is now trying to eliminate the few gains non-MD practitioners have made in the last 25 years. This is exactly the same issue as it was in 1910 and it is still as misunderstood by the public as the CME's Flexner Report-- the false premise of that only an MD is able to provide 'safe' health care.

Next year will be the hundred year anniversary of the Flexner Report. Lets make this centennial anniversary the kick off for the idea of NO MORE of this 100 year-old failed experiment.



Carnegie Foundation BULLETIN NUMBER FOUR
Excerpts from primary and secondary sources accessed thru the Internet and from Wikipedia

Abraham Flexner 1866-1959): born in Louisville, Kentucky, Flexner was a professional educator specializing in the institutions of higher learning and educational practices in graduate and professional training programs. Some but not all sources identify his brother Simon Flexner to have been trained as an MD and a practicing physician.
Flexner graduated from Johns Hopkins in 1886 and shortly afterwards, opened a preparatory school in Louisville that he owned for 15 years. In 1905 he began his post-graduate studies in education at Harvard and the University of Berlin, To research professional educational systems in other countries, he traveled extensively in England, Germany, France, and Canada. He saw universities not as popular institutions reflecting the desires and whims of society but as intellectual leaders. "Universities must at times give society not what society wants, but what it needs". Later in his life, Flexner also served as first director of the Institute for Advanced Study at Princeton.

As research fellow at the Carnegie Foundation for the Advancement of Teaching in New York City in 1908, Flexner’s first impact on American education took the form of "Germanizing" American medical education. Flexner doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of ‘chemical’ treatments such as vaccines to prevent and cure illness as tantamount to quackery. His opinions and policy recommendation as best reflected in a quote by him taken directly from his final report: “If the sick are to reap the full benefit of recent progress in medicine, a more uniformly arduous and expensive medical education is demanded.” 1

After finishing his landmark study of medical education in 1910, Flexner investigated prostitution in Europe. He was also known as an ‘able fund raiser’. Thru his personal and professional relationships with philanthropists he secured a $1.5 million gift from the Rockefeller Foundation’s General Education Board to his alma mater -- the German-oriented Johns Hopkins University.

In 1913 he left the Carnegie Foundation and joined the educational board of the Rockefeller Foundation as assistant secretary. After four years, he was promoted to principal executive officer and ran the operations of the Board for eight years in partnership with its president, Wallace Buttrick. As the resident intellectual and educator on the Board, Flexner's directed millions of dollars of medical education endowments to institution that promoted ‘chemical’ (pharmaceutical) and surgically-oriented medicine in the United States. Over the next 47 years, the Rockefeller’s GEB contributed $96 million to medical schools to Johns Hopkins and other university medical schools that disregarded naturopathy, homeopathy and all other forms of ‘alternative’ medicine (such as midwifery), favoring only those that taught its practitioners to depend exclusively on the use of prescription drugs and surgery.

Overview: Flexner and the Carnegie Foundation for the Advancement of Teaching’ report on Medical Education in the United States and Canada

In 1904 the American Medical Association created an in-house committee known as the “Council on Medical Education”. It developed higher, more restrictive standards for medical education that required additional years of schooling and called for all ‘irregular’ medical schools to be closed down. In 1908 the AMA asked the president of the Carnegie Foundation, Henry Pritchett, to underwrite a major study of medical schools in the United States and Canada. Pritchett was a staunch advocate of medical school reform and chose Flexner, a researcher at the Carnegie Foundation for the Advancement of Teaching, to conduct the survey.

From January 1909 to April 1910, Flexner visited 167 medical colleges and post-graduate programs in the U.S. and Canada seeking data on five points for each school:

(1) entrance requirements and adherence to them
(2) size and training of the faculty
(3) amount of tuition, endowments and fees to support the institution
(4) quality of the laboratories and qualifications of the laboratory instructors
(5) relationships between the school and hospitals used as sites for clinical training

He had “no fixed method or procedure” and used no standard questionnaire. As a layman, he had never by his own admission "[set] foot inside a medical school" and "knew neither anatomy, physiology, nor psychology enough to warrant embarking on a highly specialized bit of experimentation." Although this obviously conflicted with the scientific medicine Flexner claimed to promote, he himself admitted that its "inconsistency never bothered me."
The plan called for Flexner to travel to and comprehensively evaluate each campus of 167 geographically dispersed institutions scattered over the entire North American continent. The actual number of site visits was even greater (175), since some schools maintained separate campuses in different cities. According to the itinerary in his footnotes [see addendum] he would have had only a fraction of a day to travel and evaluate each of the 167 institutions. Although 16 months were allotted to the fieldwork, the majority of the visits occurred in only in eight months.

He made 157 or 90 % in approximately 240 days. His pace was even more amazing in April 1909, when he investigated 31 schools in 30 days in six western states (Colorado, Illinois, Iowa, Missouri, Nebraska, and Utah). Flexner often visited schools when they were not in session and toured some institutions unaccompanied by school officials. On one occasion bribed the janitor to open the laboratories and when he didn’t see any glass bleakers, Bunsen burners or other apparatus, he concluded that the school had no equipment. He never checked with the director or considered other possibilities.
The logistical challenge of visiting multiple schools in such a limited period of time was complicated by returning frequently to his home base in New York, where he stayed for many months at a time. Train travel was fastest but still took one to three days in each direction. Excluding weekends, the train-dependent Flexner would have had only 0.71 of a 12-hour day per school.

Flexner himself admitted that his tour of medical schools was "swift," and that he finished his inspections "within less than a year." His explanation of these methods was his personal maxim of Ambulando discimus or "we learn by going about". His very negative report on American medical education was quickly picked up by the Hurst publishing empire, made into a front-page story and syndicated all across the country. As a result, about half of the medical schools in the United States were forced to close. This included all that taught non-AMA approved methods and nearly all that accepted women and minorities.
As of 2010, the recommendations in the Carnegie Foundation’s “Medical Education in the United States and Canada” will have defined both medical education and medical practice for an entire population of 300 million people for an entire century. However, the underlying research for this power-broker document was undertaken at the request of the AMA. Unfortunately for us all, its conclusions were never been questioned by the public or been reexamined by professionals or policy-makers.
The only exception to the blanket acceptance of an AMA monopoly of healthcare comes from an unlikely source -- the Catholic social theorist Ivan Illich. His 1975 book, Medical Nemesis, he subjected contemporary western medicine to a detailed scrutiny and was the first to introduce the concept of iatrogenic disease to the public. He argued against the routine medicalization of life.

In this context, medicalization is usually defined as “the process by which health or behavior conditions come to be defined and treated as medical issues. The term refers to the process by which certain events or characteristics of everyday life become medical issues, and thus come within the purview of doctors and other health professionals to engage with, study, and treat.” [Wikipedia]

Since 1910 many aspect of our biology, including normal childbirth and anticipated natural death (ex. elderly or terminally ill persons) have become intensely medicalization. Ivan Illich was convinced this caused more harm than good and had turned the entire population of the United States into lifelong patients. Mortality and morbidity statistics in his book also showed the ‘shadow side’ of medicalization, in the shocking extent of post-operative side-effects and drug-induced illness in now rampant in advanced industrial societies that depend solely on drugs and surgery for all their healthcare needs.

About the Carnegie Foundation's report written by Abraham Flexner on standardization of American medical education

From Wikipedia:

The Flexner Report is a book-length study of medical education in the United States and Canada, written by the professional educator Abraham Flexner and published in 1910 under the aegis of the Carnegie Foundation (available on the web as a Google book). Many aspects of the present-day American medical profession stem from the Flexner Report and its aftermath.

The Report (also called Carnegie Foundation Bulletin Number Four) called on American medical schools to enact higher admission and graduation standards, and to adhere strictly to the protocols of mainstream science in their teaching and research. Many American medical schools fell short of the standard advocated in the Report, and subsequent to its publication, nearly half of such schools merged or were closed outright. The Report also concluded that there were too many medical schools in the USA, and that too many doctors were being trained. A repercussion of the Flexner Report resulting from the closure or consolidation of university training, was reversion of American universities to male-only admittance programs to accommodate a smaller admission pool. This was a reversal of a trend by universities, which had begun opening and expanding female admissions as part of women's and co-educational facilities only in the mid-to-latter part of the 19th century with the founding of co-educational Oberlin College in 1833 and private colleges such as Vassar College and Pembroke College.


In the late 19th century, what came to be called modern medicine emerged after a struggle with other forms of medicine such as homeopathy. This new medicine was grounded in antiseptic surgery, the germ theory of infectious disease (which informed a large number of effective public health measures), and the scientific method, including evidence-based medicine and clinical trials. In 1904 the AMA created the Council on Medical Education (CME) whose objective was to restructure American medical education.

At its first annual meeting, the CME adopted two standards: one laid down the minimum prior education required for admission to a medical school, the other defined a medical education as consisting of two years training in human anatomy and physiology followed by two years of clinical work in a teaching hospital. In 1908, the CME asked the Carnegie Foundation for the Advancement of Teaching to survey American medical education, so as to promote the CME's reformist agenda and hasten the elimination of medical schools that failed to meet the CME's standards. The president of the Carnegie Foundation, Henry Pritchett, a staunch advocate of medical school reform, chose Flexner to conduct the survey.

At that time, the 155 medical schools in North America differed greatly in their curricula, methods of assessment, and requirements for admission and graduation. Flexner visited all 155 schools and generalized about them as follows: "Each day students were subjected to interminable lectures and recitations. After a long morning of dissection or a series of quiz sections, they might sit wearily in the afternoon through three or four or even five lectures delivered in methodical fashion by part-time teachers. Evenings were given over to reading and preparation for recitations. If fortunate enough to gain entrance to a hospital, they observed more than participated." The Report became notorious for its harsh description of certain establishments, for example describing Chicago's 14 medical schools as "a disgrace to the State whose laws permit its existence... indescribably foul... the plague spot of the nation."

Recommended changes

When Flexner researched his report, many American medical schools were "proprietary", namely small trade schools owned by one or more doctors, unaffiliated with a college or university, and run to make a profit. A degree was typically awarded after only two years of study. Laboratory work and dissection were not necessarily required. Many of the instructors were local doctors teaching part-time, whose own training left something to be desired. The regulation of the medical profession by state government was minimal or nonexistent. American doctors varied enormously in their scientific understanding of human physiology, and the word "quack" flourished. There is no evidence that the mass of Americans were dissatisfied with this situation.

Flexner looked this situation in the face. Using the Johns Hopkins University School of Medicine as the ideal[1], he boldly recommended that:
Admission to a medical school should require, at minimum, a high school diploma and at least two years of college or university study, primarily devoted to basic science. When Flexner researched his report, only 16 out of 155 medical schools in the United States and Canada required applicants to have completed two or more years of university education (p 28). According to Hiatt and Stockton, by 1920 92% of U.S. medical schools required this of applicants.

The length of medical education be four years, and its content should be what the CME agreed to in 1905.

Proprietary medical schools should either close or be incorporated into existing universities. Medical schools should be part of a larger university, because a proper stand-alone medical school would have to charge too much in order to break even.

Less known is Flexner's recommendation that medical schools appoint full-time clinical professors. Holders of these appointments would become "true university teachers, barred from all but charity practice, in the interest of teaching." Flexner pursued this objective for years, despite widespread opposition from existing medical faculty.
Flexner was the child of German immigrants, and had studied and traveled in Europe. He was well aware that one could not practice medicine in continental Europe without having undergone an extensive specialized university education. In effect, Flexner was demanding that American medical education conform to prevailing practice in continental Europe.
By and large, medical schools in Canada and the United States have followed Flexner's recommendations down to the present day. Recently, however, schools have increased their emphasis on public health matters.

Consequences of the report

To a remarkable extent, the following present-day aspects of the medical profession in North America are consequences of the Flexner Report:

1. A physician receives at least six, and preferably eight, years of post-secondary formal instruction, nearly always in a university setting;

2. Medical training adheres closely to the scientific method and is thoroughly grounded in human physiology and biochemistry.

3. Medical research adheres fully to the protocols of scientific research;[2]

4. Average physician quality has increased significantly;[3]

5. No medical school can be created without the permission of the state government. Likewise, the size of existing medical schools is subject to state regulation;

6. Each state branch of the American Medical Association has oversight over the conventional medical schools located within the state;

7. Medicine in the USA and Canada becomes a highly paid and well-respected profession……….

The annual number of medical school graduates sharply declined, and the resulting reduction in the supply of doctors makes the availability and affordability of medical care problematic. The Report led to the closure of the sort of medical schools that trained doctors willing to charge their patients less. Moreover, before the Report, high quality doctors varied their fees according to what they believed their patients could afford, a practice known as price discrimination. The extent of price discrimination in American medicine declined in the aftermath of the Report;

Western Medicine as a Cartel, AMA and State Medical Boards as legal enforcers

Kessel (1958) argued that the Flexner Report in effect began the cartelization of the American medical profession, a cartelization enforced by the American Medical Association and backed by the police power of each American state. This de facto cartel restricted the supply of physicians, and raised the incomes of the remaining practitioners.

The Report is now remembered because it succeeded in creating a single model of medical education, characterized by a philosophy that has largely survived to the present day. "An education in medicine," wrote Flexner, "involves both learning and learning how; the student cannot effectively know, unless he knows how." Although the report is more than 90 years old, many of its recommendations are still relevant—particularly those concerning the physician as a "social instrument... whose function is fast becoming social and preventive, rather than individual and curative."

Closure of many medical schools

According to Hiatt and Stockton (p. 8), Flexner sought to shrink the number of medical schools in the USA to 31, and to cut the annual number of medical graduates from 4,400 to 2,000. A majority of American institutions granting M.D. or D.O. degrees as of the date of the Report (1910) closed within two to three decades. (No Canadian medical school was deemed inadequate, and none closed or merged subsequent to the Report.) In 1904, there were 160 M.D. granting institutions with more than 28,000 students. By 1920, there were only 85 M.D. granting institution, educating only 13,800 students. By 1935, there were only 66 medical schools operating in the USA.

Between 1910 and 1935, more than half of all American medical schools merged or closed. This dramatic decline was in some part due to the implementation of the Report's recommendation that all "proprietary" schools be closed, and that medical schools should henceforth all be connected to universities. Of the 66 surviving M.D. granting institutions in 1935, 57 were part of a university. An important factor driving the mergers and closures of medical schools was that all state medical boards gradually adopted and enforced the Report's recommendations.

American medicine becomes a less diverse profession

One of the consequences of Flexner's advocacy of university-based medical education was that medical education became much more expensive, putting such education out of reach of all but upper class white males. The small "proprietary" schools Flexner condemned, which were contended to be have been based in generations-old folk traditions rather than relatively recent western science, did admit African-Americans, women, and students of limited financial means. These students usually could not afford six to eight years of university education, and were often simply denied admission to medical schools affiliated with universities.

At the same time, the Report tended to delegitimize existing women doctors and doctors of color. While many such doctors continued to practice, usually within underserviced clienteles, they did so under proscribed circumstances and for less pay. In general, the standardization of medical education advocated in the Report led to the domination of American medicine by well-off white males. It also made it more difficult for people of color, residents of rural areas, and for those of limited means generally to obtain medical care in any form. The Flexner report recommended the closure of several African American medical schools, including the Leonard Medical Center, the oldest four-year medical school in the country for African-Americans. Ironically one of the schools was located in his own hometown of Louisville, Kentucky, Louisville National Medical College.

Impact on alternative medicine

When Flexner researched his report, "modern" medicine faced vigorous competition from several quarters, including osteopathic medicine, eclectic medicine, physiomedicalism, naturopathy and homeopathy. Flexner clearly doubted the scientific validity of all forms of medicine other than biomedicine, deeming any approach to medicine that did not advocate the use of treatments such as vaccines to prevent and cure illness as tantamount to quackery and charlatanism. Medical schools that offered training in various disciplines including eclectic medicine, physiomedicalism, naturopathy, and homeopathy, were told either to drop these courses from their curriculum or lose their accreditation and underwriting support. A few schools resisted for a time, but eventually all complied with the Report or shut their doors.[citation needed]

Impact on osteopathic medicine

Although almost all the alternative medical schools listed in Flexner's report were closed, the American Osteopathic Association (AOA) were able to bring a number of osteopathic medical schools into compliance with Flexner's recommendations. As a result, American osteopathic medical schools today teach from an evidence-based, medicalised, scientific knowledge base. The curricula of DO and MD awarding medical schools differ only minimally, the chief difference being the additional instruction in osteopathic schools of manipulative medicine. This dramatic convergence of osteopathic and biomedical training demonstrates the sweeping effect the Flexner report had, not only in the closure of inadequate schools, but also in the standardization of the curricula of surviving schools.

Comments: The purposeful elimination of midwifery as an independent profession does not even get mentioned as one of the causalities of the Flexner Report – another example of the truism the “history is written by the winners”.


UNMC's Flexner's Impact on American Medicine
Beck, Andrew H. (2004), "The Flexner Report and the Standardization of American Medical Education", JAMA: the Journal of the American Medical Association 291 (17): 2139–2140, doi:10.1001/jama.291.17.2139, PMID 15126445
Barzansky, B.M.; Gevitz, N. (1992) (w),

Further reading
Beck, Andrew H., 2004, "The Flexner Report and the Standardization of American Medical Education", Student JAMA 291: 2139–40.
Bonner, Thomas Neville, 2002. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins Univ. Press. ISBN 0801871247.
Flexner, A., 1910. Medical Education in the United States and Canada. Carnegie Foundation for Higher Education.
Gevitz, Norman, and Grant, U. S., 2004. The D.O.s (2nd ed.). Baltimore: The Johns Hopkins University Press. ISBN 0-8018-7834-9.
Goodman, John C., and Gerald L. Musgrave, 1992. "How The Cost-Plus System Evolved". Patient Power. Washington, D.C.: Cato Institute,
Kessel, Reuben, 1958. "Price Discrimination in Medicine", Journal of Law and Economics 1 (Oct., 1958): 20–53.
Starr, Paul, 1982. The Social Transformation of American Medicine. Basic Books. ISBN 0465079350.
Steinreich, Dale, 10 June 2004. "100 Years of Medical Robbery".
Wheatley, S. C., 1989. The Politics of Philanthropy: Abraham Flexner and Medical Education. University of Wisconsin Press. ISBN 0299117502, ISBN 0299117545.

Link to a modern day example of the AMA-type relationship with maternity care provided to healthy women as the property of obstetricians, who misused their power to close down nurse midwifery services in hospital all across the country.

Tomorrow -- Excerpts from TWILIGHT SLEEP :
~ A Simple Account of New Discoveries in Painless Childbirth
By Henry Smith Williams, B. Sc, MD, LLD ~ 1914