Is it time for an NP/PA Flexner Report? Part 1
Many of our podcasts have focused on concerns about the deterioration of nurse practitioner training, with an increase in for-profit schools that compete fiercely for student tuition dollars. These programs often boast 100% acceptance rates -in other words, anyone who applies is accepted. Students who attend programs like these complain about sub-par education including open-book tests that leave graduates inadequately prepared to care for patients.
The rise of these diploma mills has led many to call for reforms to the NP educational process. What many people do not realize is that the medical profession also faced serious reforms in its educational process following the release of the Flexner report which outlined problems in the training of physicians back in 1910. Today I am joined by Dr. John Lafferty to discuss the Flexner report and the importance of standardizing education for medical professionals. Dr. Lafferty is an obstetrician-gynecologist with a special interest in the history of medical education.
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** A personal note about Abraham Flexner. After I recorded this podcast, I downloaded the entire Flexner report and read most of it. While I was not exactly thrilled with his section on women in medicine, I was downright horrified at his section on Black physicians (and thoughts on Black people in general). While I was previously aware that Flexner expressed racist viewpoints (which we discuss in the podcast), reading his actual words, which likely express the feelings of most Americans in 1910, was chilling. Indeed, reading this section opened my eyes even more to the idea of systemic racism in medicine, and I recommend that anyone who is a skeptic read pages 179-182. - RB
Rebekah Bernard MD 00:07
Welcome to patients at risk a discussion of the dangers that patients face when physicians are replaced with nonphysician practitioners. I'm your host and the co-author of the book patients at risk, the rise of the nurse practitioner and physician assistant in health care, Dr. Rebekah Bernard.
Many of our podcasts have focused on concerns about the deterioration of nurse practitioner training, with an increase in for-profit schools that compete fiercely for student tuition dollars. These programs often boast 100% acceptance rates. In other words, anyone who applies is accepted. Students who attend programs like these complain about subpar education with things like open book exams, and they feel that they're graduating without having adequate preparation to take care of patients. The rise of these diploma mills has led many to call for reforms to the nurse practitioner educational process. What many people don't realize is that the medical profession also faced the need for serious reform when its educational processes were evaluated by the Flexner Report back in 1910.
Today I'm being joined by Dr. John Lafferty. He's an obstetrician-gynecologist with a special interest in the history of medical education. And he's here to discuss the Flexner Report and the importance of standardizing education for all medical professionals. Dr. Lafferty Welcome to the show.
John Lafferty MD 01:53
Thank you so much. Glad to be here.
Rebekah Bernard MD 01:55
John, why don't we start out by having you tell our listeners a little bit about yourself and how you became interested in this topic?
John Lafferty MD 02:02
Sure. Well, I've worn many hats. In my professional career, I was in private practice. I have also been an employed physician. I am currently working in a health department. As my career is winding down. I have been on the faculty of clinical faculty of a medical school. And I have been a preceptor for the physician assistant program for a couple of years, I think of more interest in terms of this current topic is that I think I was the first obstetrician in my area to hire nurse-midwives. So I have worked with nonphysician practitioners. My father, I think, was the first pediatrician in the area to hire physician assistants way back when they were all going to brick-and-mortar programs. And we've had a very good relationship with them. And I want to emphasize that.
I have a distinct memory - And I went to med school a long, long time ago - that the first thing that was told us on the first day was, we are lucky to have you, you are lucky to be here. And we all nod our heads knowing how tough it is to get into med school. And he said 'you're going to med school at a marvelous time in history, thanks to the Flexner Report.' And he briefly discussed it and suggested that we go and read it. Five minutes later, we have plunged into anatomy and physiology. And I doubt that anyone delved into this 300-page report. As my career was winding down. And as I started to see some issues that concern me, I went back and read it. And I think that's going to be the thrust of this podcast today.
The practice of medicine - before we get into Flexner - it's very hard. I would venture to say that of all occupational groups, we as physicians have the longest formal training of probably any occupation in the United States. And there's a reason for that is that the core duty of a physician is to diagnose and treat disease. The core training of a physician is basically in making a diagnosis. And I hope I've got some heads nodding among all of our physician colleagues. And that was basically what it was. yes, you had to learn the basics. You had to learn anatomy and physiology. But all of our clinical training was directed at a group of people coming in with a group of symptoms and being drilled, day after day, month after month. 'What could this be? What could this not be? What is most likely what is less likely?' And I'm going to throw it out for the Public and for us physicians. that takes an awful long time to learn. And I don't think it can be done in a year or two, any more than you can take a bright and talented piano student and turn them into a concert pianist at Carnegie Hall and a year or two, or a basketball player and turn them into an NBA star. I just think it takes, it takes time.
Rebekah Bernard MD 05:25
No, it really does. And actually in our book Niran, and I talk about the 10,000-hour rule, which is a fairly standard idea that it takes about 10,000 hours to gain expertise in any subject. And it's not just 10,000 hours of, you know, just reading, I mean, it's 10,000 hours of dedicated effort and practice. exactly what you said, I remember when I was interviewing for my residency program and family medicine, and our director sat down with me, and he said, the thing that separates a physician out from any other type of clinician is that you must be a diagnostician. And that is really what all that training is about. We can't follow algorithms, our job is to figure out what is wrong with a person and what is going on with them. Because if you don't have the correct diagnosis, you can't fix anything, you don't have the correct treatment, if you don't have the correct diagnosis, and you will not solve the problem. It all starts there.
John Lafferty MD 06:15
And I will turn the corner to say that I think that physicians in this country, despite the pandemic and all the political stuff are still held in quite high esteem. And I don't think they're held in high esteem because they think we're nice people or well educated or maybe have more money than some people. I think we're held in high esteem because we're very good at what we do. And, again, why are we good at what we do? Let me turn the tables on Rebekah Bernard and be the interviewer and ask her one question. When you were finished, Rebekah, with your fourth year of medical school? Do you feel that the very next week you could go out and hang a shingle and independently and safely and competently diagnose and treat? Basically, anything that came through the door?
Rebekah Bernard MD 07:19
Absolutely no way was I anywhere prepared to care for patients independently. And perhaps even at the end of my three rigorous years of residency. When I started my first real job, it was like another residency because I spent so much time then researching looking things up and continuously learning. So the answer is absolutely not. I was not ready.
John Lafferty MD 07:42
And I have never met a physician that answered that question any other way. So what I did in response to reading your book about three times, was to conservatively add up some 35, 40 years ago when I was in medical school, my clinical hours. And that's where I have a problem with what's going on in this country with nurse practitioners and PAs. I added up conservatively, this does not count the first two years of med school when you're in the lab and studying, it does not count any home study, it only counts the clinical actual face-to-face hours. And I cannot imagine that my experience was terribly different than anyone else's position. And I added up my total medical school clinical hours in the third and fourth years was 4500. I have an additional because in OBGYN We do go four years. So that does vary from specialty to specialty, another almost 13,000 hours.
Now, we know that the clinical face-to-face hours that a lot of nurse practitioners have is something on the order of 500 to 700 hours. And I think the public and the physicians need to reflect on that number. Turning now to the fact that we think that we are competent, not because we're better or because we're smarter. It is because of those hours of training, that every day we were we knew that the attending was going to ask us a lot of tough questions and we had to be ready.
And we talked about how high physicians are held in esteem but it might surprise the public it may surprise some doctors and this is why VAs everyone to read the Flexner Report. At the turn of the century, the educated public viewed most physicians, not all but most as charlatans, hucksters, and quacks, and for good reason. We can look at medical education as going through three distinct phases in the United States. Briefly, In colonial times, we're talking about the times of George Washington and Thomas Jefferson, that era. If you wanted to be a physician in general if you are very wealthy and very rare, you went to the universities in Europe, but most physicians did what amounted to an apprenticeship. They linked themselves to another physician. That was, to the extent that that physician was excellent. It was excellent clinical training, that wasn't a lot of didactic training. And at some point, there were no regulations, you just hung up a shingle.
Shortly after the Civil War, the second phase started, and the second phase was what was called the rise of the proprietary medical school. Now, what this was, was one or two physicians would start a medical school, that were no regulations, anybody could do this, they would generally have a series of lectures in the morning, and a series of lectures in the afternoon, it would go for about a year or two, that were generally few if any exams. And at the end of the time, if that one or two Doctor faculty, so to speak, deemed that that person was qualified, they handed them an MD degree. And medical boards were basically powerless to sign up. And they went out and practiced medicine.
The public started to get worried about this and appealed to the Carnegie Foundation to comprehensively study a bunch of things. But the number one report that came out was all medical education. This was led by a man named Abraham Flexner. And we need to know just a little bit about Flexner. And try to deflect some criticisms of him, of which there are some honest criticisms. He was a Hopkins graduate, the newly built excellent University in Baltimore, he graduated from that school and he was not a physician. He was an educator. He developed some educational systems, he did spend some time in Europe. So he got to do two very important things, Rebekah. He got to see what medical education was like in Europe, which was far better than in the United States. And he got to see what he came to probably accurately described as the one medical school in the country that was doing it right, which was Johns Hopkins, he basically did something that is really extraordinary thinking about no airplanes, and trains. That was basically the way he traveled over two years, he went to all 155 medical schools in the United States.
Now, I want you to think about that number. There were more medical schools in the United States in 1900 than there were when I applied to med school in the mid-70s. And almost as many as today.
Rebekah Bernard MD 12:57
Yeah, I think there are 179, last I checked
John Lafferty MD 13:01
Exactly, something on the 175 something in that order.
Now. He basically divided them up. And once he got finished into three groups, and this will really surprise you. There were about 20 of these schools that he deemed to be good. Hopkins was one of them. There were several others. They basically required some college work and very quickly required a baccalaureate degree. They were tied to a university. That's the second thing. They had a faculty that was dedicated to doing nothing but a teaching faculty. And they had a teaching hospital on campus. They required science courses, meaning physics, math, chemistry, biology before you could get in. That was 20 of the 155 schools, about 50 of them.
If you had a high school diploma you are in and the other 80 or so, you didn't even have to have a high school diploma. And remember what the curriculum was one or two years of lectures, and no hands-on, and he was someone who said the hands-on clinical is what makes a good physician. And that will come up later in this podcast, I hope. So he put this out. And today in government and in politics, things get shelved, or certainly, there is immediate opposition and there's lobbying and I have to muse in today's environment as to whether had this come out in a current environment if anything would have happened. But fortunately, in 1910, when this came out, the educated public was outraged at what was happening to their public health.
Let me go ahead and say some things about Flexner. Because at the 100th anniversary of this report, there was some pushback on the way we think about things today. They, as a result of this, they wanted to wipe this thing off the table. Flexner was a white man, he probably was racist. He was probably sexist. However, he did, In terms of sexism, he said some things in his report that I think were remarkably progressive. He said, I think women have a place in medicine, I think that they don't need to be trained separately, as there were separate Women's Medical schools, all of which were closed as a result of his report. But they were all closed, not because they were Women's Medical schools, but because they were substandard. And I think that if we are going to do this, they need to have the same opportunities as men. And it's right there. And it's, I think it's on page 173. So you can go and read it.
But some of the things are just chilling. In the deja vu part of this page 10. 'As a rule, Americans, when they avail themselves of the services of physicians make only the slightest inquiry as to what the previous training and preparation have been. It is clear that as long as a man - and a man, it's pejorative, - is to practice medicine, the public is equally concerned in the right preparation for that profession. The schools that had been ready to assume the responsibility of turning loose upon a helpless community, men licensed to the practice of medicine without any previous thought as to whether they have received fair training are not.' just a lot of stuff in there. That is very, very interesting.
Rebekah Bernard MD 16:54
What I hear with that, is this exactly what you said is happening today, this assumption that, well, if a person is licensed, then surely they must know what they're doing, someone must be supervising this or ensuring that it's being done properly. And it wasn't then. And in some cases, it is cases it isn't now.
John Lafferty MD 17:13
Well, as a result of the Flexner Report, as I mentioned, there was outrage. And basically, the state legislatures and Congress empowered state medical boards to say, set high standards, based upon Flexner. So if you went to a medical school, entered a medical school that didn't have the kinds of Hopkins criteria, we're not going to give you a license. And so as a result, by 1930 the 155, medical schools have been reduced to 66.
Mentioning the traditional African American medical schools, and I do want to say this, yes, there were seven, and it was reduced to two. And he did have some racist things to say about African American physicians, which were just clearly untrue. But he did want to keep the two schools that he thought did pass muster. And they, they stay, they happen to be Howard and Maharry.
So what happened as a result of this was what we would expect the quality of physicians went way up. But the number of physicians as we went into the war, World War 2 declined. And the demand for medical care grew exponentially after World War 2, as the other component of medical schools, which is research and the development of drugs, and the development of therapies that really worked for the first time, when you went to a physician, you probably had a pretty good chance of actually being helped, rather than hurt.
And so the demand for medical services just increased to the point where we get to 1965. And the start of two programs as one solution, one solution was to increase the number of doctors in med school and they started to do this. But they had high standards. And so at Duke University, as you know, they started the PA program. At the Colorado, they started the pediatric nurse practitioner program. Now, let us say that at the beginning, these problems were brick and mortar. They were not online, as there was no online. They were generally nurses that had had at least five years of experience. They were probably the best of the best. And the same for the PAs - They were veteran medics that had been to Vietnam among other folks. And of course, Within 15 years, these two new professions began to ask for increasing practice autonomy, and the problems proliferated. There are now over 400 Nurse Practitioner programs, and 250, PA programs.
My angst started among many things, as I, you know, began to become a preceptor at a PA program and sort of began to see that they were, predictably having great difficulty finding clinical rotations of any quality for the students. The students of our preceptive were uniformly bright, and motivated, but they were not getting the education that they were paying for.
Rebekah Bernard MD 20:50
Do you think the reason? I mean, I'm sure, there are lots of reasons but is it just simply a supply and demand issue? In other words, I mean, now we know that there are Gosh, last time I looked, I think there are over 300,000 nurse practitioners, and there are about a million practicing physicians right now. So the question is that as they rapidly pump out more NPs and PAs, is the problem just that there aren't enough preceptors? Is it that there aren't enough willing preceptors? What do you think the main problem is?
John Lafferty MD 21:22
Well, one, I might not be the expert at this, because I haven't done in a national study. But one would be able to surmise that if you're increasing the number of programs for that degree. And many of the PA programs basically tell you, that you are on your own to find your own clinical rotations. And there are Headhunter firms that will sign just about one I can tell. I could be refuted on this just about anybody that's willing to preset and I don't see them having a lot of control over the kinds of educational experiences they're getting. But I can tell you what it was like in the PA program that I was a preceptor at.
Rebekah Bernard MD 22:12
And that's exactly what we're going to hear about in part two of our podcast with Dr. John Lafferty and discussing the Flexner Report and some of the concerns about training programs today for nonphysician practitioners. I hope you'll join us for part two. If you'd like to learn more about this topic, I encourage you to get the book patients at risk the rise of the nurse practitioner and physician assistant in healthcare. It's available at amazon.com and at Barnes and Noble. And if you're a physician and you'd like to learn more about getting involved with patient safety, and ensuring physician-led care, I would encourage you to join our group. It's called physicians for patient protection or the website is physiciansforpatientprotection.org. Thanks so much and we'll see you on the next podcast.