STUDENTJAMA. The Flexner report and the standardization of American medical education.

1MEDICAL EDUCATION IN THE UNITED STATES TODAY IS STRIKinglystandardizedanddemanding.Itwasnotalwaysso.Prior to the widespread implementation of educational reforms, medical training was highly variable and frequently inadequate. It was not until the early decades of the 20th century that a “uniformly arduous and expensive” system of medical education was instituted nationally. Inthe19thcentury,mostmedicaleducationintheUnited States was administered through 1 of 3 basic systems: an apprenticeshipsystem,inwhichstudentsreceivedhands-on instruction from a local practitioner; a proprietary school system, in which groups of students attended a course of lectures from physicians who owned the medical college; orauniversitysystem,inwhichstudentsreceivedsomecombination of didactic and clinical training at universityaffiliated lecture halls and hospitals. These medical schools taught diverse types of medicine, such as scientific, osteopathic, homeopathic, chiropractic, eclectic, physiomedical, botanical, and Thomsonian. 2 In addition, wealthy and industrious medical students supplemented their education with clinical and laboratory training in the hospitals and universities of Europe, primarily in England, Scotland, France, and Germany. Because of the heterogeneity of educational experiences and the paucity of licensing examinations, physicians in America at the turn of the 20th century variedtremendously intheir medical knowledge, therapeutic philosophies, and aptitudes for healing the sick. 3,4 Throughoutthesecondhalfofthe19thcentury,theAmerican Medical Association (AMA) lobbied for the standardization of American medical education. These efforts were largely unsuccessful, both because political traditions in America dissuaded national regulation of professions and because the American public and much of the medical professionwerenotconvincedthatanyparticularbrandofmedi