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[Chiropractic] is grounded upon the doctrine that all human ills are caused by pressure of misplaced vertebrae upon the nerves which come out of the spinal cord—in other words, that every disease is the result of a pinch. This, plainly enough, is buncombe. The chiropractic therapeutics rest upon the doctrine that the way to get rid of such pinches is to climb upon a table and submit to a heroic pummeling by a retired piano-mover (1).
H. L. Mencken, 1924
First, every student of medicine must have three years’ preliminary study in a university. Second, he must study medicine for four years, and then practice under the direction of a physician for a full year before beginning to practice himself ... [nor] dare to treat the ailing, except such as have beforehand in our University of Salerno passed a public examination under a regular teacher of medicine and been given a certificate not only by our professors of medicine but by one of our civil officials...(2)
Decree of Frederick II, King of the Two Sicilies, 1240 AD
A CENTENARY FOR SCIENCE
A century ago, a report by Abraham Flexner to the Carnegie Foundation for the Advancement of Teaching changed the way that medicine was taught in America (3)
. Concerned that a surplus of ill-trained practitioners was diluting the profession, the American Medical Association had asked the Carnegie Foundation to commission a survey of US and Canadian medical schools (4)
. For the next 18 months, Flexner, a pioneer of educational sociology, visited each of the 155 extant medical schools personally and in 1910 published Medical Education in the United States and Canada, now commonly recognized as "The Flexner Report (3)
."
Before Flexner, the best and brightest of American medics flocked to the universities of Paris, Berlin, or Vienna to learn physiology and pharmacology grounded in chemistry and physics, rather than from the case-books of empirical practice. Most students entered American medical schools with little more than a high school diploma and, once admitted, were provided with little direct laboratory experience. There were few full-time teachers of clinical medicine and fewer still of basic medical science. Students were taught anatomy, physiology, and pharmacology by local practitioners for whom the medical schools were profit-making enterprises.
By 1909, the medical schools had not entered the Era of Reform. The dean of Fordham University’s Medical School confessed to The New York Times, "We have not reached quite the standard of professional education which was required by law in the early part of the thirteenth century in ... Salerno (5)
." Quite so: Salerno in 1240, unlike Fordham and most other American medical schools, was hospitable to women, both as students and teachers. Salerno also had higher standards for admission. In his visitor’s note of October 1909, Flexner noted that Fordham students had little more "than a four-year high school education (6)
."
Even before the report was issued, twelve of the lowest-quality medical schools closed for fear that a description of their actual practices would be publicized. Within the next decade, scores of weaker school closed (Fordham went belly-up in 1919). While some medical colleges unconnected to universities sought affiliation, many of these shotgun marriages failed. In the surviving schools, full-time teachers became the rule rather than the exception, science set the standard of clinical teaching, and hands-on lab work became the norm.
Flexner insisted that basic research was indispensable for a medical faculty:
The functional activities of the body ... what are these but chemical problems within the realm of biology? The mechanism of circulation, of seeing, or hearing—what are these but physical problems under the same qualifications? The normal rhythm of physiological function must then remain a riddle to students who cannot think and speak in biological, chemical or physical language (7)
After the Flexner report, no medical school worthy of its name failed to establish research departments in the basic medical sciences. In was in that climate of reform and expansion that FASEB itself was founded in 1912 by men who had shared Flexner’s conviction that human ills were but chemical problems within the realm of biology (7
, 8)
.
NOTHING WAS REALLY ESSENTIAL BUT PROFESSORS...
Abraham Flexner, a native of Louisville, received his A.B. degree at Johns Hopkins in 1886, added an M.A. from Harvard, and devoted himself to a career in educational sociology. But medical education captured his primary interest, stimulated no doubt by his brother Simon, who received his graduate training in pathology under William Henry Welch at Johns Hopkins. Simon became the first president of the Rockefeller Institute for Medical Research, complementing the career of Abraham, who was later to emerge as the first director of the Institute for Advanced Study (8)
.
Abraham Flexner prepared several analyses of higher education, both in the United States and Europe, culminating in 1928, when, as the Rhodes lecturer at Oxford, he delivered the most eloquent defense of the academic spirit since Cardinal Newman’s (9)
. But it was during the early years of the "Hopkins endeavor" that Flexner gained insight into the special problems inherent to medical education. Having caught a whiff of excellence at Hopkins in the 1890s, he never quite forgot it, and tried to recreate visions of that happy time on the banks of the Charles, the Hudson, and the Isis.
His 1910 report presented a state of affairs as discouraging as an auditor’s tally sheet for FEMA. To begin with, there were just too many medical schools in North America, and most of them were inadequate and unstable:
First and last, the United States and Canada have in little more than a century produced four hundred and fifty-seven medical schools, many, of course short-lived, and perhaps fifty stillborn. One hundred and fifty-five survive today. Of these, Illinois, prolific mother of thirty-nine medical colleges, still harbors in the city of Chicago fourteen; forty-two sprang from the fertile soil of Missouri, twelve of them still "going" concerns; the Empire State produced forty-three, with eleven survivors; Indiana, twenty-seven, with two survivors; Pennsylvania, twenty, with eight survivors; Tennessee, eighteen, with nine survivors. The city of Cincinnati brought forth about twenty, the city of Louisville eleven. These enterprises—for the most part they can be called schools or institutions only by courtesy—were frequently preempted. Wherever and whenever the roster of untitled practitioners rose above half a dozen, a medical school was likely at any moment to be precipitated. Nothing was really essential but professors. The laboratory movement is comparatively recent. Little or no investment was therefore involved. A hall could be cheaply rented and rude benches were inexpensive. Janitor service was unknown and is even now relatively rare. Occasional dissections in time supplied a skeleton—in whole or part—and a box of odd bones (10)
Moreover, the bulk of students were ill qualified. Only a few medical schools, classed as first-rank (e.g., Hopkins and Harvard) accepted students after completion of an undergraduate degree. Once admitted, the student encountered mainly didactic teaching, with insufficient exposure to laboratory or experimental work. The majority of medical schools possessed laboratory facilities incapable of providing students with practical instruction. Many schools lacked basic lab equipment:
It is indeed stretching terms to speak of laboratory teaching in connection with them at all ... The pathological laboratories of the Chattanooga Medical College and the College of Physicians and Surgeons, San Francisco rejoice in the possession of one microscopic apiece; Halifax Medical College provides one utterly wretched laboratory for bacteriology and pathology ... the eclectic school at Lincoln, Nebraska, pretends to give clinical instruction at Cotner University, a few miles from town. When questions are asked in Lincoln regarding physiology or pathology, the answer is made: "That is given at Cotner," when the same question is asked at Cotner, it is answered: "That is given at Lincoln." A quick transit from one to the other failed to find anything at either ... At the Eclectic Medical College of New York an inquiry was made as to the teaching of experimental physiology, no outfit for which had been noticed in the course of the inspection. A mere oversight! A messenger was dispatched to fetch it, and did—a single small black box, of about the size and appearance of a safety-razor case, containing a small sphygmograph (11)
The bulk of medical training was conducted in institutions only nominally connected with universities; in consequence, ill-trained and avaricious graduates of these shadow academies were released on the public.
The schools were essentially private ventures, moneymaking in spirit and object. A school that began in October would graduate a class the next spring; it mattered not that the course of study was two or three years; immigration recruited a senior class at the start. Income was simply divided among the lecturers, who reaped a rich harvest enriched by consultations, which the loyal former students threw into their hands (12)
.
One wonders what Flexner would have made of the latest trends in medical education:
Item: Why would a university renowned for its school of medicine ever sell its teaching hospital? In his newest book, Dr. John A. Kastor tells the story of two universities that, under financial duress for more than a decade, chose to sell their teaching hospitals. George Washington University sold to a national, for-profit corporation, Universal Health Services, Inc., and Georgetown University sold to a not-for-profit, local company, MedStar Health (13)
.
Item: Flood of new medical schools filling accreditation pipeline. In 2007, seven allopathic medical schools were in various stages of the accreditation process. Five osteopathic schools won provisional accreditation, which allows them to start admitting medical students. The rush is particularly unusual for the allopathic medical school community, which has had only one new school open in the past 20 years. The osteopathic community has added 10 schools since 1981(14)
.
Item: School of Medicine Hofstra University. Chair, Department of Basic Science Education. Must hold an M.D. or Ph.D. with significant teaching and leadership experience in the basic sciences as well as curricular design. Research experience preferred (sic!) (15)
.
SECTARIAN MEDICINE
In Flexner’s view, the situation was discouraging enough in schools which taught "allopathic" medicine—the standard of the time as set by London, Paris, or Vienna. It was however infinitely worse for students who were exposed to what Flexner called the "sectarian" practices of the New World. He had great pity for the unsuspecting youngster trapped in the intellectual boondocks of the chiropractic, osteopathic, homeopathic, and naturopathic schools. Each sect, he pointed out, held equal and mutually contradictory claims for its way of treating the sick. Each had its own medical schools and hospitals; each had its own devoted clientele of patients and practitioners. Sectarian medicine, needless to say, persists today, and its several claims remain mutually exclusive. Flexner sounded the tocsin for science and reason, then and now:
Modern medicine ... wants not dogma, but facts. It countenances no presupposition that is not common to it with all the natural sciences, with all logical thinking. To plead in advance a principle couched in pseudo-scientific language or of extra-scientific character is to violate scientific quality (16)
There is of course, no end to American credulity when it comes to extra-scientific accounts of the human condition. In our short national history we’ve spawned more than our fair share of world religions, including Mormonism, (Joseph J. Smith; Palmyra, New York, 1830), Christian Science (Mary Baker Eddy; Lynn, Massachusetts, 1866), Theosophy (Madame Blavatsky; Rochester, New York, 1874), and Dianetics (L. Ron Hubbard; Elizabeth, New Jersey, 1950).
We’ve followed this tradition by raising 19th century notions of vertebral pathology to the level of 21st century belief. "Subluxation" or "the pinched nerve nonsense" is alive and well:
Item: The new Rocky Vista University College of Osteopathic Medicine (RVUCOM) in Parker, Colo, ... has received pre-accreditation status by the American Osteopathic Association’s Commission on Osteopathic College Accreditation (AOA COCA), RVUCOM is on its way to becoming the first contemporary for-profit medical school—osteopathic or allopathic—in the United States in nearly 100 years ... This institution is a for-profit, limited liability corporation [while] the "chancellor" of RVUCOM is also president and chief operating officer of the for-profit American University of the Caribbean School of Medicine in Cupecoy, St. Maarten, Netherlands Antilles, though he resides in Coral Gables, Fla, where he is also a real estate investor.
Journal of the American Osteopathic Association, 2007 (17)
Item: In our opinion Council on Chiropractic Education (CCE) needs to make the admissions standards more stringent, including the requirement for a baccalaureate degree prior to admission and the use of a chiropractic college admissions test. Some believe that increasing the difficulty of entry into chiropractic college would cause a dramatic decrease in enrollment.
Chiropractic & Osteopathy, 2005 (18)
THAT "PINCHED NERVE NONSENSE"
The "pinched nerve nonsense" has been used to explain every disease from deafness to diabetes (19)
. We owe it all to Andrew T. Still, an itinerant autodidact of noble motive but questionable reason. After attending Holston College in Newmarket, Tennessee, "for nearly three years," Still learned medicine from his father, took a turn at the military, ran a farm and a partnered a lumber business. But in 1874, three of his children died of spinal meningitis, and the nostrums of the day were of little use. Convinced that the spine was the seat of all human ills, he became the world’s first osteopath and "thereafter abandoned the use of drugs in his treatment of disease (20)
." Still’s American School of Osteopathy at Kirksville, Missouri, became the mother church of the movement and retains its standing as the A. T. Still University.
Still’s major disciple in the spinal healing trade was a Canadian-born "magnetic healer," D. D. Palmer, who in 1895 cured one patient of his deafness, and another of his "heart trouble" by manually relieving the "subluxation" of a vertebral body to remove pressure on the affected nerves. "Then I began to reason that if two diseases, so dissimilar as deafness and heart trouble, came from impingement, a pressure on nerves, were not other diseases due to a similar cause (21)
?"
"Doc" Palmer and his son B. J. Palmer moved on to establish the "Science of Chiropractic," that—then and now—required even less basic science training than osteopathy (1)
. Needless to say the Palmers were men of prodigious reach. A generation before Erwin Schrödinger asked the question, D. D. Palmer had the answer: "It was I who combined the science and art, and developed the principles, thereof. I have answered the time-worn question—what is life (22)
?" And a century after Edward Jenner proved its efficacy, B. J. Palmer was certain that vaccination was inferior to chiropractic’s "relief of subluxation:"
Chiropractors have found in every disease that is supposed to be contagious, a cause in the spine. In the spinal column we will find a subluxation that corresponds to every type of disease. If we had one hundred cases of small-pox, I can prove to you where, in one, you will find a subluxation and you will find the same condition in the other ninety-nine. I adjust one and return his functions to normal and you could do the same with the other ninety-nine (23)
Many of the sectarian schools—then and now—taught didactic courses in chemistry, physiology, and pathology in the preclinical years, but lapsed into sectarian dogma once the student entered the clinic. Nowadays osteopaths are taught enough basic and clinical science to pass the same exams for licensure as graduates of Johns Hopkins, but basic science research at these schools remains woefully undeveloped. For biochemistry in 2002, the 19 schools of osteopathy received 1.8 million dollars in toto in research grants (24)
. That’s enough for a lab, but not a discipline.
Don’t worry about biochemistry, though. The American Academy of Osteopathy, members of which swell the ranks of America’s practitioners, assures its acolytes that they are in capable hands: "Osteopathic principles and practices, which emphasize the relationship between body systems, are integrated into the four-year curriculum. Students learn osteopathic manipulative treatment for prevention, diagnosis and treatment of disease (25)
."
Flexner rightly pointed out that:
The sectarian therefore in effect contradicts himself when, having pursued or having agreed to pursue the normal scientific curriculum with his student for two years, he at the beginning of the third year produces a novel principle and requires that thenceforth the student effect a compromise between science and revelation (26)
Not much has seems to have changed in the sectarian academies a century later. They have simply expanded their solid, pre-Flexnerian practices and added didactic science courses to meet licensing requirements. Alas, our "allopathic" medical schools are also reverting to the pre-Flexnerian era. A bottom-line mentality has led some to sell their teaching hospitals and others to sell their souls (i.e., to depend on massive overhead payments for clinical trials rather than the modest overhead generated by RO 1s). "The pinched nerve nonsense" on the one hand and "the pinched pocket nonsense" on the other, have led to a flight from basic science.
I’d argue that time’s ripe for another Flexner Report and the return of medical education to the basic biomedical sciences that FASEB represents.
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FOOTNOTES
The opinions expressed in editorials, essays, letters to the editor, and other articles comprising the Up Front section are those of the authors and do not necessarily reflect the opinions of FASEB or its constituent societies. The FASEB Journal welcomes all points of view and many voices. We look forward to hearing these in the form of op-ed pieces and/or letters from its readers addressed to journals{at}faseb.org.
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