If you attended medical school, you learned in week one that American health care started becoming scientific in 1910, with the publication of the Flexner Report. Before then, only some medical schools were authentic while many others were anything from carnival booths to outright frauds.
Abraham Flexner, a respected educator, had been hired by industrial barons John D. Rockefeller and Andrew Carnegie, who were determined to bring health care out of the horse-and-buggy era. Having visited every medical school, Flexner reported that we were in terrible shape, and recommended that doctors’ training be uniform and based on science.
Though he encountered little opposition, a few senior instructors expressed polite misgivings. One was Dr. William Osler, professor of medicine at Johns Hopkins University and regarded even today as the patriarch of North American medicine. Though Osler revered science, he insisted throughout his career that people couldn’t be healed by science alone.
Wrote Osler, “The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with powders or potions …”
To Osler, art meant treating the patient’s suffering along with the illness. That skill is not a scientific one, but the human one of compassionate relationship.
Flexner prevailed, though, and a frustrated Osler moved on to Oxford University, writing to a colleague, “Now I go, and you have your way.”
Carnegie and Rockefeller’s donation of over a hundred million dollars to America’s major medical schools firmly placed science in the center of medical education. Over the next century, that shift would make possible antibiotics, numerous immunizations, organ transplants, gene recoding, and countless other advances.
But this progress came at a serious cost which we’re finally beginning to recognize. With medicine’s exclusive focus on science, its art continually atrophied, until today we hardly even remember what it is, let alone experience it. We’ve largely come to treat illness rather than patient.
The physical requirements of health care as technology invite commercial exploitation. Where we once practiced medicine as a service, we now labor as employees in an extremely profitable industry. Today’s irritations — the doc’s attention to the laptop rather than the patient; the ridiculous cost of services and pharmaceuticals; increasing physician burnout and patient dissatisfaction — are generated by the institutional preference for profit over the well-being of both patients and practitioners.
What medical students don’t learn is this: As Flexner observed his report’s consequences in ensuing years, he didn’t like much of what he saw. In 1913 he wrote that the typical medical school “… closed down upon the enterprising student .. .with an exhausting and depressing uniformity.”
Students moved through medical school in tight lockstep, he said, and had little time to stop, read, or think. He wrote that scientific medical training was sadly deficient in cultural and philosophical background — indispensable components of medicine’s art. He later claimed that the imposition of rigid standards by accrediting groups was making the medical curriculum “a monstrosity.” I suspect today’s docs will find his criticisms relevant.
Flexner and Osler ultimately agreed that the problem wasn’t science, but its unbalanced exclusivity. Fortunately, medicine’s art isn’t quite dead. There will always be a number of practitioners who maintain its glowing embers. If health care is to be literally worthy of its name, we need to seek them out.
Jeff Kane is a physician and is the author of Healing Healthcare: How Doctors and Patients Can Heal Our Sick System.
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