Finessing Flexner

To the Editor: We agree that Roberts’ June 2021 editorial 1 appropriately cites existing gender and ethnic-based inequities and credits different contributors with proposed solutions. Since a number of these racist and sexist inequities originated from Flexner, the Association of American Medical Colleges (AAMC) appropriately removed Flexner’s name from its highest award for excellence in medical education. But Roberts’ editorial also acknowledges that “The Flexner Report led to greater emphasis on scientific knowledge and the pursuit of science in medical school curricula.” 1 Flexner’s scientific culture spread to the schools’ teaching hospitals, which evolved into cutting-edge academic medical centers. Flexner’s positive scientific advocacy, however, has not penetrated uniformly into all of allopathic medical education. This failure is most apparent in the group of newer allopathic medical schools, termed “community schools.” Using the Research Portfolio Online Reporting Tools that demonstrate funding between 1993 and 2019, 2 we noted that mean levels of funding in 2019 at MD Flexner schools ($120,042,857, n = 120) dwarfed funding at both MD community schools ($6,585,056, n = 33) and DO schools ($1,113,972, n = 33; P < .001). These dramatic differences held for all years, even controlled for school age. The community school movement originated in the 1970s when the AAMC called on academic medical centers to “develop a model of primary care that can be taken into the community.” 3 Around the same time, the Liaison Committee on Medical Education (LCME) called for schools to have “enough” funding to reflect faculty research efforts, but little more. 4 The new community schools resultingly focused on accreditation and not research per se. Medical schools lacking extramural funding limit opportunities for medical students and generate fewer physician–scientists. 5 Such schools fail to catalyze a research culture in their hospitals, which leads to a dramatic lack of clinical trials especially of non-Whites. 6 All of this shortchanges their communities. Failing to uniformly integrate science into medical education thus becomes another insidious path to disparities in health care. Both the LCME and the AAMC can shape the culture of allopathic medical education, especially in the newer community schools. At a minimum, the LCME should mandate a certain level of peer-reviewed extramural support at all candidate schools, requiring incremental increases with progressive stages of accreditation. Since grants beget grants, LCME baseline research requirements would become the nidus on which a research culture would crystallize. The AAMC’s continued advocacy for advancing equity can help ensure that Flexner’s endorsement of science integration into medical education will also achieve equity.