Flexner Revisited

In 1910, Abraham Flexner authored a report to the Carnegie Foundation for the Advancement of Teaching, entitled Medical Education in the United States and Canada (Flexner, 1910). Faced with a landscape of medical education characterized by a lack of consistent admissions, curricular, and graduation standards, and dominated by many stand-alone proprietary colleges, he recommended that the number of colleges be reduced to include only those that were affiliated with universities, employed high admissions standards, and trained physicians to practice evidence-based medicine using the scientific method. With the Johns Hopkins Medical School as a model, he proposed that the curriculum be composed of two years of biomedical science instruction followed by two years of clinical training supervised by university-based clinicians. Within two decades of the report’s publication, more than half of the medical colleges in operation at the time of the report had closed and most of those remaining were connected with universities, with a curricular structure and educational philosophy that were very similar to many medical colleges of today.

While the Flexner Report is credited with accelerating much-needed change in medical education, concerns have been expressed that the heavy emphasis placed on the structured and sequential learning of the biomedical and clinical sciences, and the commitment to a “hyper-rational” philosophy, failed to recognize the experiential manner in with adults learn (Kolb, 1984). As a result, more emphasis was placed on the disease rather than the patient, and on the teacher rather than the student. In their call for the reform of medical education, also commissioned by the Carnegie Foundation and published exactly 100 years after the Flexner Report, Irby, Cooke, and O’Brien (2010) recommended that learning outcomes be standardized, but that the learning process be individualized, knowledge and skills be integrated experientially, habits of inquiry and innovation be inculcated in students, and attention be given to development of a professional identity that recognizes the importance of communication and interpersonal skills, ethical and legal understanding, and aspirational goals in performance excellence, accountability, humanism, and altruism. These recommendations were intended to build on those previously proposed by Flexner and to address concerns that the medical profession was not fully meeting the healthcare needs of the US population.

The system of medical education embraced after publication of the Flexner Report and the need to adapt this to more recent changes in healthcare demands are also reflected in the historical development of veterinary medical education. With few exceptions, most veterinary colleges in the United States and Canada adhere to an educational philosophy that is evidence based, and that assumes that knowledge and skills are best learned by layering clinical training acquired in a teaching hospital on top of preclinical education consisting primarily of lectures and laboratories. Both of these characteristics resonate with Flexner’s Germanic system of medical education. Also, most veterinary colleges are now part of large, comprehensive research universities, although a few recently established colleges are affiliated with smaller health sciences institutions.

Recent Initiatives Driving Changes in Veterinary Medical Education

With regard to recent adaptations, there have been a number of initiatives over the last 20 years designed to assess the status of veterinary medical education and develop strategies for future development. Three of these are noteworthy, because they were national in scope and engaged in a broad representation of nonacademic and academic constituents. The first of these, entitled Future Directions for Veterinary Medicine, was published by the Pew National Veterinary Education Program in 1988 (Pritchard, 1988). Among its 13 recommendations, those addressed to veterinary colleges advised that research be made a focus, that the basic biological science content of the curriculum be strengthened, and that more emphasis be placed on the achievement of diversity. Furthermore, colleges were encouraged to enable students to elect an area of interest focusing on a single species or class of animal, rather than requiring them to gain experience with many animal species, and to shift the emphasis from an almost exclusive concentration on clinical practice to also include public-sector careers. Recommendations in the Pew report relating to the importance of research and basic sciences reaffirmed Flexner’s view, whereas those dealing with diversity and elective opportunity appear to be more in line with more recent trends in medical education in support of providing flexibility to the individual learner and broadening the scope of education beyond the diagnosis and treatment of diseases.

The second major strategic analysis of veterinary medical education employed a process called Foresight Analysis and was published in 2007 under the title Envisioning the Future of Veterinary Medical Education (Willis et al., 2007). Using a number of scenarios selected to envision the future, teams of veterinary professionals developed recommendations in support of a flexible educational system that would be able to prepare graduates for opportunities and challenges over a 20–25-year timeframe. A recurring theme that was threaded through the key recommendations arising from this study proposed that colleges select areas of professional focus and then collaborate to provide a collective suite of educational programs broader in scope than could be offered by individual institutions. This approach is conceptually similar to the recommendations of the Pew report regarding the need to allow students to elect areas of practice emphasis.

The third and most recent strategic initiative was conducted by the North American Veterinary Medical Education Consortium (NAVMEC) and published in 2011 (Shung and Osburn, 2011). The report, entitled Roadmap for Veterinary Medical Education in the 21st Century: Responsive, Collaborative, Flexible, built on the previous two reports by recommending that students attain proficiency in an agreed set of core competencies, including multispecies knowledge, clinical competence in a selected species or discipline, One Health knowledge, and professional competencies (communication, collaboration, management, lifelong learning, leadership, diversity and multicultural awareness, and adaptation to changing environments). Veterinary schools were encouraged to collaborate to enable students to access the full range of core competencies. Consistent with its emphasis on core competencies, the NAVMEC report recommended that veterinary curricula be competency driven and delivered in a time-efficient and flexible manner. In addition, the report advised that urgent action be taken to address the economic challenges facing veterinary schools and veterinary students, and it encouraged further development of innovative ways to solve these and other problems.

In summary, the impacts of the Flexner Report on the institutional organization, curricular structure, and evidence-based philosophy of medical education are also reflected in veterinary medical education. Similarly, both medical and veterinary medical educational systems are now changing in response to economic, curricular, and societal drivers that are causing a second revolution, approximately 100 years after the first one precipitated by Flexner.

Differentiating Characteristics of Veterinary Medical Education