The Flexner Report

The so-called "Flexner Report," issued in 1910, was a game-changer in American medical education.

Previously, a man — or woman — could become a physician by sitting through a winter's worth of lectures at a "medical school," which might be some doctor's parlor. Only the more rigorous schools survived after 1910 — all the women's medical schools and most of those that accepted minority candidates closed.

Abraham Flexner

Candidates had to qualify for the schools that remained, and they spent years, not months, learning the craft, which began to include hands-on training with patients. All these innovations impacted the birth story.

Abraham Flexner, who wrote the report for the Carnegie Foundation, was primarily an educator. He got his start with a private laboratory school he founded in his native Louisville, Ky., after graduation from Johns Hopkins University, and wrote a book in 1908, The American College, that brought him national attention.

Flexner was deeply involved in re-structuring the nation's medical schools in the years leading up to World War I. Later, he was the first director of the Institute for Advanced Study, a colossally influential "think tank," founded in 1930 in Princeton, N.J., by Newark retailer Louis Bamberger and his sister Caroline Bamberger Fuld.

At the IAS, Flexner saw opportunity in the political clouds gathering over Europe, recruiting scientists like John von Newmann and Kurt Godel. And, Flexner personally wrote the letter that brought Albert Einstein to the United States in 1933.

The mothers of Johns Hopkins Medicine

Here, just in time for Mother's Day, is a little known story about the enterprise that has set the bar for the practice of medicine in America. When all was said and done, it was women who served as midwives for the dream.

And, it was a woman who insisted on the high standards that have made Johns Hopkins Medicine the paragon it has been.

Women attended medical school in the 19th century; there were even medical schools just for women. However, women had a hard time being taken seriously at most of the top medical schools -- and that is an understatement.

The exception was Johns Hopkins, where three women were part of the first class, and where women have been part of the student body straight through to the present -- very unusual, given all the changes that occurred in medical education early in the 20th century. (More on that in future posts.)

What made the difference? At a crucial point, a savvy, determined group of women held the pursestrings.

The money earmarked for construction of the medical school was underwritten with stock in the Baltimore & Ohio Railroad. In 1888, when the value of that stock plummeted, the fate of the school was uncertain.

Mary Elizabeth Garrett
Mary Elizabeth Garrett

Martha Carey Thomas, Mary Elizabeth Garrett, Elizabeth King, Mary Gwinn and Julia Rogers -- the so-called "Friday Evening Group" -- were wealthy Baltimore feminists, friends, stellar fund-raisers and (except for Rogers) daughters of members of the original board of trustees. They pledged $500,000 to Johns Hopkins Medicine, but only if women were allowed to attend the school. Opposition was fierce, but the women got what they had asked for.

Garrett, who contributed the bulk of the money herself, further demanded that medical-school candidates have a college degree with a concentration in basic science, and be able to speak and read French, German and Latin.

William Welch himself had proposed these requirements years before but they had been dismissed as unrealistic. Now every Hopkins undergraduate, male and female, would have to meet them. As William Osler joked to Welch, "It is lucky that we got in as professors; we could never enter as students."

Of the women in that first class, one quit to become a Christian Scientist and one married her anatomy professor. Only Mary Packard became a doctor. Years later, though, Welch wrote, "We regard co-education a success; those of us who were not enthusiastic at the beginning are now sympathetic and friendly."

Painting by John Singer Sargent

The “Big Four”

The founding faculty of Johns Hopkins School of Medicine comprised some of the most respected medical men of their era. All were innovators with rigorous standards of practice, research and training.

They set the bar high for other medical schools, and many of their graduates went on to establish or transform other programs around the country.

The Big FourWilliam Welch, who helped the university's president, Daniel Coit Gilman, assemble the team, was a pathologist;  William Osler, the internist who oversaw the department of medicine, was a Canadian considered the finest doctor practicing in the United States; William Stewart Halsted headed up surgery; and Howard Kelly, gynecology and obstetrics.

The original "Big Four" are depicted here in John Singer Sargent's "The Four Doctors," which hangs in the medical library on the Johns Hopkins campus.

At a time when individual doctors could be institutions unto themselves, Osler introduced the concept of the medical residency, and Welch a training program in advanced techniques for full-fledged doctors that resembled a modern post-doctoral course. Welch also founded the country's first school of public health. Kelly established his own cancer clinic.

Halsted taught his students to operate at a new level of skill and care, and was responsible for introducing the use of surgical gloves, which in beginning were meant merely to protect doctors' and nurses' hands.

The first woman doctor, U.S. division

As the first woman doctor in the United States, Elizabeth Blackwell had the dubious honor of showing the way for women to qualify for and enter a profession in which, at the time, they were pointedly unwelcome.

Blackwell endured repeated rejections on her way into medical school, where she was shunned by the male students and shut out of clinical opportunities by the teachers. After she finished medical school, when no one would hire her, she founded her own hospital and made her own opportunities.

Elizabeth Blackwell

Elizabeth Blackwell

Blackwell was born in England; her father was a wealthy Quaker and sugar refiner whose business eventually fell on hard times. The large family moved to the United States when Elizabeth was 11 and settled in Cincinnati, Ohio.

Blackwell''s father died when she was a teenager and the family opened a small private school, where Elizabeth began teaching.

When she decided she wanted to be a doctor, she was turned away from 29 medical schools before being accepted by the Geneva Medical School in Geneva, N.Y. In spite of the hostility she encountered there, she graduated at the top of her class in 1849, with plans to become a surgeon.

Blackwell traveled to Paris to take a course in midwifery, where she contracted an infection that cost her the sight in one eye. That put an end to her hopes of becoming a surgeon. Back in the United States, Blackwell found she couldn't get work in a hospital, so she went into private practice.

In 1853, along with her sister Emily, and Marie Zakrzewska, two other early female doctors, Blackwell founded the New York Infirmary for Women and Children, now New York Downtown Hospital. During the Civil War, Blackwell trained nurses to treat soldiers injured on the battlefield.

The Blackwell sisters also founded the Women's Medical College of New York in 1869, but within a few years, Elizabeth went back to England. She was a professor of gynecology at the London School of Medicine for Women for the rest of her working life. Blackwell died at the age of 89, in 1910.