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Internal medicine physician Robert C. Smith discusses his article “Why medicine needs a second Flexner Report.” In this episode, Robert explores how modern medical education has fallen behind the science it was built on, leaving today’s physicians unprepared to address mental health, chronic disease, and prevention. He examines how the historical “mind-body split” continues to shape curricula and care delivery, calling for a new nationwide investigation—akin to Abraham Flexner’s 1910 report—to ensure medicine once again aligns with the most current scientific understanding. Viewers will gain insight into how reforming physician training could restore medicine’s scientific integrity, improve health outcomes, and reduce the staggering costs of inefficiency.
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Transcript
Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast. Today we welcome back Robert C. Smith, internal medicine physician. His latest article is “Why medicine needs a second Flexner report.” Robert, welcome back to the show.
Robert C. Smith: Kevin, thanks for having me. I enjoy talking with you.
Kevin Pho: All right, so let’s jump right into your latest KevinMD article. Just give us some context. For those who aren’t familiar with medical education, just define what was the Flexner Report?
Robert C. Smith: Sure. The Flexner Report came about, it was published in 1910, but the investigation began in the late 1800s. At the time, the American Medical Association, which was the main force in medical education, was concerned that there were some 155 medical schools back then. The AMA was concerned that they were not teaching what we all today understand as clinical pathological correlation. Rather, they were concerned that the medical schools were continuing to teach the old four humors theory of disease.
Basically, that means there were four humors: black bile, yellow bile, blood, and phlegm. This dates to the time of Hippocrates in the fifth century BC, so we’re talking about two and a half millennia for this four humors theory. The idea was that an imbalance of these four humors led to disease, or was the disease, and it led to symptoms.
Back in the middle of the 1700s, clinical pathological correlation had been discovered in pathology. That had permeated throughout Europe and became the main focus of teaching, but it had not permeated yet into medical schools in the U.S. except for Johns Hopkins. With the Hopkins model of clinical pathological correlation, the AMA was concerned that all medical schools should be teaching clinical pathological correlation, not the four humors. If you remember, in the four humors, if they were out of balance, that was disease. They put them back in balance by doing bloodletting, putting leeches on to rebalance the humors.
Well, that sets the stage. The American Medical Association commissioned the Carnegie Foundation to investigate to determine if this was in fact the case. That began back in the mid-1800s. There was a several-year study. Back at that time, Flexner, who was head of this, and his team had to literally go out to all the medical schools and investigate what they were doing, talk with people, look at records, and the like.
After they did that, and again through all 155 medical schools, came the Flexner Report in 1910, which said in effect that these schools were continuing to teach the four humors theory and were blatantly non-scientific. They also were not requiring any prior education to get into medical schools. The medical schools only lasted one year, and it was all lectures. The doctors would then simply find a practitioner to preceptor with, and they would then go into practice.
The AMA not only insisted that the Hopkins model of clinical correlation be adopted, but that training with actual patients by trained faculty be implemented and the school be increased first to two years, and then later they got it up to four years, much of what you and I have today, Kevin. With that, there was this dramatic change in the way medicine was practiced, and this was an absolute revolution in what took place.
But that was the original Flexner report. It rooted out unscientific practices and insisted that modern medical education follow them. They closed something close to one hundred, I think it was about ninety-three schools were closed. The remainder were required to make the changes that I’ve just described.
Kevin Pho: Your article calls for a second Flexner report. For those who didn’t get a chance to read your article, tell us what it’s about.
Robert C. Smith: Sure. What has happened is back at the time of Flexner, over a hundred years ago, the most scientific approach to medicine in the medical schools was clinical pathological correlation focused on physical diseases. That’s what the AMA wanted instituted and successfully did.
What has happened then is that model that we have today in medical education has persisted, and it was highly successful. There’s no question about that. Clinical pathological correlation in this isolated focus on physical disease was successful. In the last century, life survival doubled, from 40 years in 1900 to nearly 80 by the end of this century. So it worked, but it largely was clearing out surgical problems, acute medical problems, epidemics, and the like. That’s why they had the vast increase in life survival.
But come the end of the last century and now into this century, medicine’s population has changed. It’s no longer acute surgical and epidemic diseases. Rather, it is mental illness, which is now the most common health condition in the U.S. It’s chronic diseases. It’s prevention. New problems arose, but medicine still adhered to isolated clinical pathological correlation focused just on physical diseases. They excluded the psychological and social.
If you exclude the psychological and the social, you’re obviously ignoring mental illness in your training, and in fact, that’s the case. Mental health training in medical schools is no different now than it was at the time of the Flexner report. 2 percent is the maximum amount of time devoted to mental health across four years of medical school and three to five years of residency. This is what accounts for the mental health crisis today.
The second problem with this isolated focus on physical disease is medicine’s forte: physical disease. We just said how successful. But with chronic disease, the excluded psychological and social factors must be included to treat it. Here’s an example.
Chronic physical diseases are prevalent today. Something like 85 percent of people over 65 have a chronic physical disease. Half of them have two or more chronic physical diseases. The psychological and social factors that medicine ignores are crucial in this respect: these chronic diseases have comorbid mental disorders in 17 percent of the cases. That’s some 30 million Americans.
The comorbid mental disorder has to be treated if the physical disease is to get better, but we don’t do it. Only 12 percent of these comorbid mental disorders ever get treated, and that’s why untrained people like you and me, Kevin, we’ve not been trained in this. It’s not our fault. We simply haven’t been trained.
Here’s another way in which excluding psychosocial factors jeopardizes care in chronic physical diseases: We do not train our doctors in so-called lifestyle factors. Cigarette smoking, alcohol use, overweight, not exercising, stress. All of these are psychosocial factors that cause most chronic physical diseases. 80 percent of heart disease, strokes, and diabetes are caused by these factors and thereby are preventable, but we don’t teach that.
When a patient comes in, say they’ve got diabetes, they’re in heart failure, they’re smoking, they’re overweight and not exercising, and so on. Doctors do no more with them than say, “Well, you ought to lose weight and quit smoking.” Doctors are not taught the labor-intensive and difficult-to-learn motivational interviewing skills required to treat this, and accordingly, very little happens.
Let’s take this idea a little bit further. 80 percent of heart attacks, strokes, and diabetes can be prevented. 40 percent of cancers can be prevented if we address these psychosocial factors, but medicine doesn’t do that. If you go back and take this person sitting in your office right now, they’ve got diabetes, peripheral neuropathy, maybe have some vision trouble from it. They’ve maybe had a heart attack, maybe had a stroke, and are disabled. They’re retiring now. They’re 65 years old, but they’ve got all this medical morbidity.
That’s not a happy retirement. They spend most of their retirement going to the doctor. Don Berwick has raised this issue. Why don’t we have our patients have a happy, healthy retirement, so they don’t have any of these things when they retire? Medicine could do that by going back 40 years earlier in that person’s life and preventing these things from ever happening or interdicting them once they have begun. These diseases, 80 percent are preventable, but medicine doesn’t do it.
Kevin Pho: Now if you were in charge of the Flexner report or the revision of the Flexner report, what kind of changes specifically would you make?
Robert C. Smith: The Flexner report would do exactly what the one in 1910 did. You would form an independent commission. It could be a presidential commission, congressional commission, National Academy of Medicine, Carnegie Foundation, somebody independent of medical education. They would simply investigate medical education for their current practices with the goal of: Are they training competent physicians to care for the most common health conditions today, mental health and chronic physical diseases? Number two, this links back to the original Flexner report: Are they teaching the most scientific approach today? They will be found wanting on both counts.
Now a comment on what’s scientific. This clinical pathological correlation focused on physical disease was the most scientific approach back in the 1900s. What has happened, and again, all sciences back at that time were reductionistic like that. Medicine focused just on physical diseases and excluded psychological and social, but so did mathematics, physics, ecology, etc. They all were reductionistic. That was necessary back when modern science began. It was in an embryonic state, so you focused just on one part.
But come the 1900s, all sciences changed from a reductionistic focus to a so-called systems view. This means that you look at all parts of the problem and their interactions like this, rather than just one part like medicine does. Medicine is the only science among all sciences that continues to practice in a reductionistic way, and you’ve already heard of the downsides from this.
This new Flexner report will find medicine’s current practices are non-scientific, and they are producing clinicians who are not competent to manage the most common health condition they will find and who are also jeopardizing the care of their chronic physical disease patients.
I would add another thing they will probably notice. In a $5 trillion annual health care expenditure that the U.S. has, think of what could happen if we prevented 80 percent of all heart attacks, strokes, and diabetes, and 40 percent of all cancers. You’d save two to $3 trillion a year. That’s $20 to $30 trillion in ten years. This is how the deficit is addressed. This is how you provide health care for everyone free of charge.
This commission is crucial to getting a change right now. The public does not know how derelict medicine is. They assume their mental health care and chronic physical care are good because of their past successes. But medicine has not kept up conceptually. It has failed to adopt a systems approach. That’s the basic problem.
The public will hear this from this federal commission. They will become enraged and inflamed, as they rightly should be, and will insist on change. The first part of that change will be to change medical education so that they’re teaching psychosocial as well as biomedical disease issues in parallel and how they integrate. But it will go more than that. This commission, a federal commission, will now supervise all medical care. This includes not just medical education, but how it is practiced and how it is researched. That will be a brand new way we must go.
Kevin Pho: All right, so we’re talking to Robert Smith, internal medicine physician. His article is “Why medicine needs a second Flexner report.” Robert, let’s end with some takeaway messages you want to leave with the KevinMD audience.
Robert C. Smith: Yes, let’s be hopeful about this. Things have changed in the past. The automobile industry was derelict. Along comes Ralph Nader. Unsafe at Any Speed is his book. He blew the whistle, as it were, on the automobile industry. They had seat belts but wouldn’t put them in cars, even though they knew they worked, because it would cost too much, and a host of other problems. His book came out, inflamed the public, and we had the Traffic Motor Vehicle Safety Act, which is why we now have all these protections in automobiles, including seat belts.
Rachel Carson’s book came out and informed a previously uninformed public about the chemical industry. DDT was in our drinking water. They weren’t cleaning up after themselves. Her book, Silent Spring, came out, inflamed the public. You’ve got to have an informed public. It inflamed the public, and they then insisted their politicians do something, which is the Environmental Protection Agency we have today. That’s why we don’t drink DDT in our water and have a thousand and one other protections. My book hopes to do that.
If you are interested in doing something right now, go to my website. It is RobertCSmithMD.com. Don’t forget the MD; it’s too common a name otherwise. RobertCSmithMD.com. When you click on that, you immediately see something that says “Act now.” Click on that. Up comes a page with the email addresses of the president, the attorney general, the National Academy of Medicine, your congressperson, and your senator. Below that is a sample letter. Plug that sample letter into the email and send it. It is recommending a federal commission of the sort I have just described that will investigate medicine.
That’s the leverage point we need now. The public must become informed about this, and so that, in my opinion, is hopeful. There’s light at the end of the tunnel, but it’s going to take some work.
Kevin Pho: Robert, thank you so much for sharing your perspective and insight. Thanks again for coming back on the show.
Robert C. Smith: Oh, thanks for having me, Kevin. I really appreciate talking with you.