Abraham Flexner: The Value of Medical Microbiology and Immunology as Foundation Sciences in Medical Education

The stage was set for change in medical education near the end of the 19th century. Medicine was undergoing a transformation as scientific understanding grew and the irrationality of some common techniques of the time led to their being discredited in the eyes of the public (e.g., bleeding and purging). The American Medical Association Council on Medical Education had recently completed a survey of US Medical Schools and was interested in reforming the teaching of medicine and standardizing the curriculum. In 1905 Andrew Carnegie, a self-educated man and firm believer in popular education, had founded The Carnegie Foundation for the Advancement of Teaching. One of the Foundation’s goals was to provide support for change in American education policy by bridging the gap between teaching practice, evidence of student learning, the communications and use of this evidence, and structured opportunities to build knowledge.

Shortly after The Carnegie Foundation for the Advancement of Teaching was created, Abraham Flexner (1866-1959), a secondary school teacher and principal for nineteen years in Louisville, Kentucky, joined its research staff. Based on a recommendation from the Foundation president, Henry S. Pritchett, and the executive committee, the trustees of the Carnegie Foundation commissioned Flexner in November of 1908 to study and report on the schools of medicine in the United States and Canada. In 1910, after having visited all 155 schools, he presented a comprehensive and written report entitled “Medical Education in the United States and Canada” to The Foundation.¹ The Flexner Report remains the single most critical event in the history of medical education in North America. It provided keen insights into the condition of medical education in the early 1900’s while emphasizing the need for a scientific basis in medical education. It criticized the existing financial incentives that motivated faculty actions and medical school policies, and it prompted the American public to demand changes in the study and practice of medicine. It exposed the overall nonscientific approach found in medicine and the lack of standardization and inadequacies in medical education. Flexner was a firm proponent of students learning by observation and by doing. He believed that these experiences should help students develop the ability to reason and hopefully understand the background and significance of what they observed. To this end, Flexner proposed that US and Canadian medical schools adhere to the German university tradition of combining strong biomedical sciences with hands-on clinical training.

The medical school curriculum should, in Flexner’s view, relate directly to several foundational subjects including anatomy, physiology, pharmacology, bacteriology and physical diagnosis. He felt that these subjects should occupy the first and second years of medical school and relate to the clinical work that occupied the third and fourth years of medical school. Without the scientific basis of medical education inherent in foundation courses, it would be difficult to educate the practitioner to any reasonable level of medicine.

Over the last century, medical education evolved under the framework of the Flexner Report. Modifications over the last twenty-five years have included significant efforts to overcome persistent factual minutiae, archaic assessment practices and regulator constraints. Nearly all medical schools have gone through a period of change by reconstruction of the “standard” curricula and programs. In many cases, curricular changes occurred hand-in-hand with changes in evaluative tools. Examination questions from the National Board of Medical Examiners have evolved from regurgitation of isolated minutiae to now requiring the integration of multiple basic and clinical science disciplines in the context of larger clinical scenarios. Proposed changes to these exams are likely to stress the integration and importance of basic sciences in the practice of clinical medicine.

It has been universally accepted that understanding the normal is the starting point for a comprehension and mastery of the abnormal and that understanding the normal requires a strong background in foundational sciences. The underpinnings of medicine, therefore, depend on the fundamental sciences that furnish “the essential basis of medical education” and provide the student physician with an understanding of the practical importance of the scientific method.¹ This information needs to be combined with a strong foundation in various non-science course work, behaviors, attitudes and skills. There continues to be considerable debate concerning the best way to restructure medical education in light of the exponential increase in scientific knowledge.

Medical education has been and continues to be complicated by turbulence in the healthcare industry. This instability has been linked to intense managed care pressures that force clinical faculty to bring in more income from patient care. In addition, basic science faculty members continue to feel increasing pressure to procure extramural grant support. These pressures impact and modify clinical and research endeavors and have often resulted in faculty having less time for teaching and ultimately negative changes in the curriculum. In some cases, schools have attempted to allow their faculty to specialize by developing predominantly educational positions for a handful of faculty. These medical educators facilitate the delivery of the curriculum along with traditional clinical and basic science faculty members. In other cases, schools have responded by merging classes between different health professions. Classes that combine medical students with physician assistants, dental students or students of other allied health professions attempt to address the disparate needs of the students. These changes, however, have lead to frustration on the part of faculty and stress on the curriculum.

To enhance the development of knowledge, values and skills in contemporary medical education, modernization practices have founded a new series of principles. These principles include concepts that match the way we teach with the way we learn. Current methods include peer evaluations, written assessments, self-assessment, standardized patient examinations, sophisticated simulations and substantial formative feedback. Many, if not all, medical schools have provided small group interactive sessions, interactive laboratories, and other forms of cooperative learning environments. Advances in computer science have allowed new and innovative methods of teaching, including immediate feedback and self-directed and interactive learning experiences. In addition, instructional methods include opportunities for active learning and independent study, both of which drive the concept of lifelong learning. There is little question that the incorporation of these principles has provided a firm basis for student learning.

Flexner underscored the critical importance of devoting adequate time to the teaching of the basic principles of science when he wrote in 1910 about how difficult it was to adequately cover this material in “already crowd[ed]…two years of the curriculum…assigned to them.”¹ This observation, of course, has been confounded in 2010 by the monumental increase of information in microbial and immunological diseases and the potential impact of genomics and proteomics on infectious disease and biopharmaceuticals. By the very nature of information overload it is becoming increasingly difficult to find time for a meaningful discussion of the advances in microbiology and immunology while providing the necessary foundation for someone recently introduced to the discipline. Yet, in modern 21st century medicine there is a critical and real need for physicians to have a competent knowledge base in addition to the clinical skills and behaviors needed to competently deliver medical care. Departure from this base will unfortunately result in premature demise of the patient.

Resting on the foundation of Flexnarian principles are modern day courses, including medical microbiology and immunology. These courses use illustrations from the bacterial and immunological diseases of humans that play an important role in understanding medicine and healthcare. Under the medical microbiology and immunology umbrella there are essential requirements for advanced knowledge in the many aspects of microbes, diseases, and host defenses. For example, a change in the Earth’s climate may result in an increase in arboviruses, and indeed there is a very real requirement for knowledge related to the agents of war and global terrorism and the innate and acquired defenses that are related to infectious diseases. Unlike the approach to understanding normal structure of the body in anatomy and physiology, medical microbiology and immunology focus on the abnormal, i.e., disease and disease processes, which at the end of the day are the essence and basis of medicine. As aforementioned, these sciences have been integrated in varied forms into the first and second years of medical school and provide a firm basis for a clinical understanding of the scientific method and the etiology of diseases. In addition, the concept of modern hygiene in clinical medicine was devised through an understanding of infectious diseases and the immune response to infection. A thorough understanding of medical microbiology and immunology requires not only knowledge of disease and disease processes and the interaction of microbes and their hosts (human and zoonotic), but also an understanding of the structure, function, and physiology of organisms fundamentally different from humans. It is appropriate therefore that these areas of science be integrated into the ‘introductory’ years of medical school, providing a sound basis for clinical medicine.

The academic requirements for entry into medical school have varied. In 1910 Flexner championed a strong knowledge of chemistry, biology, and physics. These requisites were to be obtained in a university educational setting. Interestingly, a recent cooperative report from the Howard Hughes Medical Institute and the Association of American Medical Colleges (HHMI-AAMC) has addressed these requirements.² The partnership convened a group, known as the Scientific Foundations for Future Physicians (SFFP) Committee, to assess the most relevant scientific competencies for premedical students prior to medical school admission.² In short, the SFFP Committee focused on overarching competencies rather than specified prerequisite courses. Premedical students are expected to demonstrate “observational and analytical skills and the ability to apply those skills and principles to biological situations.”² With the ever increasing amount of knowledge and complexity of the concepts involved in medical microbiology and immunology, it is critical that students entering medical school have a high level of competency to “demonstrate both knowledge of and ability to use basic principles of mathematics and statistics, physics, chemistry, biochemistry, and biology needed for the application of the sciences to human health and disease.”² The Committee, therefore, shifted the emphasis from direct courses to the acquisition of competencies “that equip an individual to learn medicine.”² The SFFP Committee defined “a competency as the knowledge, skill, or attitude that enables an individual to learn and perform in medical practice and to meet or exceed the standards of the profession.”² In addition the HHMI-AAMC emphasized “a greater flexibility in the premedical curriculum that would permit undergraduate institutions to develop more interdisciplinary and integrative science courses….”²

The SFFP Committee has provided and underscored eight well-defined “competencies [including learning objectives] deemed important for medical school education.”² Included under this umbrella is an array of information related to medical microbiology and immunology. For example, Competency M4, Competency M5 and Competency M6 stipulate that the graduating medical student should be able to, respectively,

“Apply the principles of the cellular and molecular basis of immune and non-immune host defense mechanisms in health and disease to determine the etiology of disease, identify preventive measures, and predict response to therapies.” [M4] “Apply the mechanisms of general and disease-specific pathological processes in health and disease to the prevention, diagnosis, management, and prognosis of critical human disorders.” [M5] “Apply principles of the biology of microorganisms in normal physiology and disease to explain the etiology of disease, identify preventive measures, and predict response to therapies.” [M6]

Inherent in the learning objectives for these competencies are the roots for understanding scientific knowledge and the means to move forward with a competency-based curriculum. The report also noted a need for renewal of the curriculum and provides a format for the competency approach to medical education. A similar movement towards a competency-based curriculum has occurred in graduate medical education. The Accreditation Council for Graduate Medical Education (ACGME) has started to include the acquisition of curricular-based competencies as part of the accreditation of post-MD medical training programs within the United States.³ At a minimum Flexner would be pleased with these changes, which in a sense provide support for modern day medical education and emphasize his focus on “competency”:

“From the foregoing discussion, these conclusions emerge: By the very nature of the case, admission to a really modern medical school must at the very least depend on a competent knowledge of chemistry, biology, and physics. Every departure from this basis is at the expense of medical training itself.”¹

In addition to scientific competency Flexner accurately reflects on the “scientific method” and the concept of life¬long learning as aspects of professional competency:

“The sick man’s progress is nature’s comment and criticism. The professional competency of the physician is in proportion to his ability to heed the response which nature thus made to his ministrations. The progress of science and the scientific or intelligent practice of medicine employ, therefore, exactly the same technique. To use it, whether in investigation or in practice, the student must be trained to the positive exercise of his faculties; and if so trained, the medical school begins rather than completes his medical education. . . A professional habit definitely formed upon scientific method will convert every detail of his practicing experience into an additional factor in his effective education.”¹

In modern day medicine student physicians are committed to life-long learning, using the scientific method to interpret and evaluate both scientific and clinical information. In addition, physicians stay informed about advances in medical knowledge and their integration into patient care by participation in continuing medical education, the technological availability of medical information and research endeavors. Flexner notes that:

“Educationally, then, research is required of the medical faculty because only research will keep the teachers in condition. A non-productive school, conceivably up to date to-day, would be out of date to-morrow; its dead atmosphere would soon breed a careless and unenlightened dogmatism.”¹

In short, the educational strategies in medical microbiology and immunology in modern medical education provide solid support for professional and personal learning goals that lead to life-long learning and support the “foundation” of clinical medicine.

REFERENCES

1. Medical Education in the United States and Canada. A Report to the Carnegie Foundation. Abraham Flexner. (1910). Retrieved January 20, 2010, from the World Wide Web: http://books.google.com/books?id=DYcaAAAAMAA J&printsec=frontcover&source=gbs_similarbooks_r& cad=2#v=onepage&q=&f=false
2. Association of American Medical Colleges. (2009). Retrieved January 20, 2010 from the World Wide Web: https://services.aamc.org/publications/index.cfm?fuse action=Product.displayForm&prd_id=262&prv_id=32 1
3. Accreditation Council for Graduate Medical Education. (2010). Retrieved January 20, 2010 from the World Wide Web: http://www.acgme.org/acWebsite/home/home.asp