Society has historically fostered a culture of prestige and status for physicians, regardless of whether they possessed “magical” healing powers or a degree from an accredited medical university. As the saying goes, with great power comes great responsibility, but who or what dictated the breadth of this responsibility that physicians were expected to obey? To address this question, American educator Abraham Flexner produced an exhaustive critique of the American medical education system in the early 20th century. This led to the emergence of the biomedical approach to health care, which emphasized academic excellence in the fundamental sciences and practical exposure to the clinical experience. In the century following the Flexner Report, however, shortcomings of this biomedical model have grown increasingly more apparent. Did Flexner galvanize the multigenerational birth of physicians whose infatuation with scientific discovery has led to an erosion of patient care and beneficence? In other words, has the healthcare system become too focused on research and technological advancement at the expense of patients' social, emotional, and psychological needs? It is essential to ask these questions to evaluate the limitations of the Flexner model and explore alternative—and more holistic—approaches to healthcare that prioritize patient care and well-being above all else.
Flexner was a strong proponent for the fundamental sciences, asserting that the competence of physicians depends on the extent to which they “are trained in the methods and impregnated with the fundamental truths of biology” (25). He proposed a curriculum that strips humanity into nothing but tissues and organs—putting forth the image of physicians as bioscientists, disease as generic, and medicine as hyper-rational. In Dear doctor: A personal letter to a physician, C.E. Odegaard challenges this idea, arguing that in order for doctors to address the complex emotional and social needs of their patients, they must be trained to see them as social beings with “memories; hopes; fears; aspirations, sense of achievement and of failure,” etc. rather than a collection of interrelated tissues and organs (16). In other words, Odegaard’s ideal physician, in contrast to Flexner’s, is one who bears the responsibility of restoring a patient’s biological as well as social or emotional health.
Flexner and, to all practical purposes, American medical educators have traditionally viewed a physician’s involvement in the social and cultural sphere as dispensable. We see this ideology come into light when we read more modern patient narratives, such as Margaret Edson’s play W;t. This play dramatizes the effects of a healthcare system that adheres to the Flexner model of medicine. It follows an English literature professor and stage-four ovarian cancer patient Vivian Bearing on her institutionalization in a dehumanizing hospital environment that consistently neglects to respond to her emotional requests and primitive desire for social support. The medical oncology fellow, Dr. Jason Posner, has lost touch with—or perhaps has never known—what it means to actively listen and provide support to a patient having qualms about her treatment. We see this blissful ignorance appear in many instances throughout the play, such as when Dr. Posner explains to Vivian why he thinks cancer is “awesome” and why he cannot wait to “survive” his fellowship or—in Vivian’s words—“the part with the human beings” (Edson 56-7). Dr. Posner is vividly portrayed as the poster child of the Flexnerian biomedical model. His zeal for publication and its subsequent fame comes at the expense of bedside manner, a course in the modern curriculum which he unapologetically declares to be a “colossal waste of time for researchers” (Edson 55). He even goes so far as to bluntly discredit clinicians as being “troglodytes”, insinuating that the patient care aspect of medicine is an outdated, impractical, and futile concept (Edson 57).
It is significant to note Dr. Posner’s identification of himself as a researcher instead of a clinician, thereby intentionally distancing himself from any emotional attachment towards his patients. We can draw a parallel to Odegaard who noted, “Tied for obvious historic reasons to their hospital laboratories, [medical students’] clinical faculties have often been physically separated from the rest of the university” (17). Modern science, however, has called for the integration of humanities and social sciences into the orthodox biomedical curriculum. Physicians like Dr. Posner have been fed through a Flexnerian system that excludes them from the social and cultural contexts within which their patients live and function. In effect, many of the doctor-patient interactions in W;t are truncated, mechanical, apathetic, and condescending. We observe these, for example, in instances where Dr. Posner asks—or rather demands—Vivian to be “tough” for her chemotherapy treatments, with no regard for the mental and physical agony she has already incurred. Their hospital prestige comes hand-in-hand with a superiority complex that compels them to presume that Vivian lacks the proper education needed to make her own treatment decisions and comprehend the mechanisms behind her own health issues. Flexner’s model asserts that the ultimate goal of medicine in healthcare is to “fight the battle against disease most advantageously to the patient” (23). Through Vivian’s treatment in W;t, however, we can observe a clear line of distinction between treating the patient and treating the disease itself—the latter being prioritized by researchers like Dr. Posner.
Despite being a fictional dramatization of a medical narrative, W;t underscores the systemic hyper-rationalization in medicine that has resulted in an inherent imbalance between patient care and research. As Odegaard implied, the Flexner Report disproportionately endorsed the role of physicians as esteemed bioscientists above their more ethical primary role as beneficent healers. This oversight may have ultimately cost Vivian her peaceful last moments before and after death, which were turned chaotic at the hands of a medical faculty far separated from expressing compassion or respect for the critically ill. In its quest to standardize medical education, the Flexner Report has standardized the patient experience and, in effect, has disparaged the professional ethos of individualized caring. In doing so, an exclusive Flexnerian approach to healthcare does not faithfully address the holistic needs and interests of institutionalized patients. Although Flexner’s approach remains the dominant model in contemporary medicine, a revitalization is in order to re-balance biomedicine and clinical care on the grander scale of American medical education.
Take Action: Learn more about the limitations of the Flexnernian biomedical model using the resources below.
Educational Resources:
Edson, Margaret. W;t. Faber and Faber, 1999.
Flexner, Abraham. “The Proper Basis of Medical Education.” Medical Education in the United
States and Canada: A Report to the Carnegie Foundation for the Advancement of
Teaching, Bulletin Number Four, Manhattan, NY, 1910, pp. 20–27.
Odegaard, Charles E. Dear Doctor: A Personal Letter to a Physician, H.J. Kaiser Family
Foundation, Menlo Park, CA, 1986, pp. 12–20.
Comments