A short history of medical education in the United States

A good place to start considering the history of medical education in the United States (and Canada) is with the Flexner report. In 1910 Abraham Flexner, an educator and member of the research staff of the Carnegie Foundation, published a comprehensive report of the state of medical education in the United States and Canada. The release of this study was the culmination of a two year study during which Flexner surveyed all 155 medical and osteopathic educational institutions in the United States and Canada that granted M. D. or D. O. degrees at the time. You can read the full report here.

Flexner concluded that the education offered by these institutions was substandard, there were too many of them, and that free-standing educational institutions were hard-pressed to produce the funding necessary to maintain a quality level of education. He made several suggestions:

  • the schools should have minimum admission standards: a high school education and at least two years of college level or university science.
  • medical schools should be 4 years in duration: two years of basic sciences and two years clinical.
  • “proprietary” schools should be closed or incorporated into universities.

It’s hard to overestimate the effect of the Flexner Report. From the year of its publication to 1935 89 medical institutions closed their doors. Particularly hard hit were the osteopathic institutions. Some have said that this was part of the assault on competing disciplines launched by the American Medical Association that has continued to this day.

The number of physicians fell from 173 per 100,000 to 125 per 100,000 and it stayed at roughly that level until 1960 as population increased due to a modest expansion in the number of institutions and number of graduates per class. The guiding philosophy was to produce fewer but better doctors and that philosophy has endured to the present day.

In 1959 the Surgeon General Consultant Group on Medical Education produced a report known as the Bane Report which concluded that there was an impending physician shortage of some 40,000 physicians. As a result of this report and intense efforts by the Kennedy and Johnson administration from 1965 to 1980 the number of physicians graduation rose from 7,849 to 16,935, where it’s stayed ever since.

One of the key factors in this increase was the program of Graduate Medical Education subsidies which are provided through the Medicare system. Under this system roughly $80,000 is paid by Medicare for each and every medical resident in the country.

Although the number of physicians trained per year in the United States has remained fairly constant over the last 25 years the number of physicians has managed to keep pace with the natural increase in population over the period by the increasing numbers of International Medical Graduates (IMG’s). In other words we’ve imported enough doctors trained elsewhere to make up for the inadequate supply of medical graduates produced here. Today IMG’s constitute roughly 23% of the total number of physicians (and comprise a substantially higher proportion of doctors in major cities).


In recent weeks there’s been a lively discussion going on in the blogosphere on the subject of reforming the health care system in the United States. The comments to this post at Dean’s World are particularly interesting. Gary Becker and Richard Posner have posted their thoughts on the subject. And economists Mark Thoma and Andrew Samwick have conducted an interesting debate on the subject at WSJ Econoblog.

One thing that many commenters have missed is that in order for market forces to have any real influence on the availability and cost of health care in the United States there must be a functioning market in health care. Some have mentioned the problems of asymmetrical information in this regard.

But it’s clear from the history of medical education in the United States that the supply of physicians has been very carefully regulated and has only been increased as a result of enormous government subsidies. Medical training has not responded either to the increased population in the country or to the larger expenditures on health care per capita and as a percentage of GDP over the period. There are many possible conclusions that could be drawn from this but I see no way to draw the conclusion that medical education responds to anything resembling a market. We aren’t producing more doctors even though we’re spending a lot more money on health care.

In my view we should be producing many, many more physicians—possibly an order of magnitude more—for practical, economic, and moral reasons. We should be training physicians here and exporting them to the world rather than draining the developing world of medical professionals. The application of modern training technology to medicine can more than satisfy the concerns raised by Abraham Flexner nearly a century ago.


The Flexner Report
SciencePolicy: On the physician-supply debate

Economic and Demographic Trends Signal an Impending Physician Shortage, Cooper et al.
Making the Case for More U. S. Medical Students
Re-thinking physician supply: moving beyond the MD, DO, IMG dance
National Issues for the International Medical Graduates (PowerPoint presentation)

12 comments… add one
  • Soldier's Dad Link

    I would conclude there is a “plumbers” crisis as well.
    Any time you allow a “Professional Association” to self license, they will self license a shortage.

  • superb! The gatekeepers on the medical profession function to limit the amount of doctors available and we see this particularly in rural areas. A few brave souls give up the fast track, drop the insurance mess, and live in a community where they know everyone and everyone knows them. When it works, it works beautifully. But you have to be willing to risk and to give up the almighty buck.

    OTOH, the gatekeepers in the humanities open the doors wide, take millions of dollars in post graduate fees and fleece students for whom there are no jobs when they leave academia. I think that’s one of the reasons the residents of the halls of academe are so strange –they’ve had to sell their souls for tenure, many of them.

    Plumbers are another story. I know companies that are willing to pay good wages and benefits if they can get people willing to train…when the Prez did “No Child Left Behind” he excluded the vocational schools. I’m still annoyed at that one.

  • Check out this introduction article on Medical education:
    Medical education

  • PJ Link

    The “draining the developing world of medical professionals” that you mention is not exactly accurate. About 40 to 50% of all new IMG residents are US Citizens or permanent residents. I read that fact within the powerpoint reference that you provided. I also dug a little deeper and it’s true.

    As Ed Salzberg, the AAMC’s Workforce Studies Director points out, “the number of U.S. citizen-IMGs has been increasing, with the majority going to for-profit medical schools in the Caribbean” (Salzberg, 2006).

    Also, check out:
    AAMC Center for Workforce Studies (2006). Schools with the most residents in training, February, 2006.

    Salsberg, E. (May 2006). International medical school graduates in the U.S.: background data. 2006 AAMC Physician Workforce Research Conference. Presentation retrieved on November 2nd, 2006 from http://www.aamc.org/workforce/pwrc06/salsberg_img.ppt.

  • I’m sorry. According to the source cited 12% of the IMG’s are U. S. natives.  That means that 88% aren’t.   Please explain to me how that disproves the point I’m making.

    Of course, it’s not just us. The United Kingdom, Germany, France, and other European countries are also absorbing a substantial number of doctors from Third World countries.

  • Tim Whiting Md Link

    As a physician who “retired early” you have another problem,not only is the supply side the same,but you are now,through specialization and super specialization,partially in response to the “you can’t know everything and if you don’t…… you will be sued rational”,you are losing the “worker Bees”.I can’t quote sources ,but from discussions with people within the educational system,the number of “primary care”, insurance companys now call us “gatekeepers'[by the way ,you ,the what I used to call my patients,are now designated as “loss units”by Ins. Cos} ,coming out of hospital training programs is less than 40% of graduates,that has been a long standing trend due to medicare payments[80% 9f $32.00 for a long discussion and examination of an elderly patient with a hip problem vs $600.00-$1000.00 for a 15 minute “scope” procedure by specialist,and also due to paperwork,expectations,insurance co interference,and now direct to consumer advertising of marginally useful[more importantly marginally profitable and often ‘me too” drugs-“ask your doctor for a weeks free trial of a [in tiny letters here ,potentially addictive} CHRONIC NIGHTLY sleeping pill” is the latest in a stringCan there be anyone out there now who isn’t living under a rock who doesn’t now he can take a pill to get an erection!
    The bigger problem is that many of the’seasoned’ primary care docs are in their 50’s and early 60’s when they leave nurse practitioners and physician’s assistants ,good at triage but not reassurance will be the new ‘GPs’ unless something is done.

  • Jack Link

    Well, I guess I understand your point of view. However, let me provide a completely biased alternative opinion, if I may. Firstly let me address my bias so that its out there. Doctors break their backs, often only spending their days working and sleeping, I know as I am a student currently in my fourth year of medical school. I have observed residents and attending physicians at work for nearly half a decade. They are not allowed to organize and massive organized groups such as insurance companies, government insurance groups and corporations dictate what they can charge, to me that does not sound like a free market at all. To then flood the market with an “order of magnitude” more doctors honestly, I think it would become difficult to justify any of the rigors a physician has to endure.

    Also I disagree on the point that quality could still be maintained. Rather than a homogeneously equal product I think this would likely flood the market with a product that is difficult to sort through. There are enough people, even with the currently rigorous selection process, that make too many medical mistakes. Can you imagine if you simply expanded the pool that was selected to include people who would have previously had to work harder or those who simply lack the compassion or common sense of the current pool? I want you to imagine for a second that you are going to your doctor for an unknown condition, Im sure you already worry that they may be wrong about a treatment or diagnosis, but imagine now that you knew it was say “easy” to become a doctors, would you trust what you were told? Do you really think you have the expertise to wade through a field that is as complicated as medicine and make informed choices as a consumer? You may say yes, but I would encourage you to imagine it was more like taking your car to an unknown mechanic… Its not so simple, currently the selection process is careful of how we select our nations future physicians, to dismantle that process will likely undermine quality. I know there are flaws in this argument, for example you could have internal standards etc. but do you really think the best and the brightest will stay in the field if you continue to chip away at their already deteriorating compensation? Could you still expect the same dedication and self sacrifice? Although doctors are indeed altruistic and joined the field to help human beings in need, this is also their livelihood, and one chosen partly because of its stability. I honestly think that one way or another this would dramatically decrease physician quality in the long term.

    In conclusion I feel their are two obvious reasons to oppose such an increase, again I am admittedly biased. One, and most importantly, I think this would in fact clearly, and significantly compromise the quality of physicians in this country. This would result in a confused marketplace, similar to the pre-flexner era, in which it would be difficult to determine who would make medically sound choices and who was just blowing hot air (medicine is not completely based on a cook-book). Two, this shows a blatant disregard for the welfare of those individuals who are currently or who have already dedicated themselves to serving the sick and injured of our nation. These are people of achieved significant academic success that could have already been in a more lucrative field had they committed themselves to a less altruistic field (say Investment Banking or something like it). Maybe you are right, but I have some serious doubts about the long term effects of such action, and I would urge anyone who agrees to think about this problem deeply, like most health care issues, it is not as simple as it outwardly appears.

  • Thomas Wells Link

    Medicine is dead. It was a murder/suicide. The Hippocratic physicians were killed off by the poisonous contact with the drug companies,insurance firms ,and government clerks. Other Hippocratic physicians self destructed from a diet of arrogance and money.

    In it’s place,we now have “Treatment inc” ; a putrid slime mold of a party line following mess of comfortable ignorance and deceitfulness.

  • The same philosophy (which quite aptly refers to the ‘gatekeeper regulatory’ mentality) has nowhere been seized so perfectly to artificially limit health care capabilities as in the erstwhile ‘professional nursing’ venue. Today we suffer from not just a physician shortage, but from a nursing shortage as well…thanks to the self-serving and highly protective philosophies implicit in and adopted by the ranks of Registered Nursing.

    In an ostensible effort to ‘improve patient care’ (always the shrill rallying cry of the professional nurses…i.e. ‘Registered Nurses’), requirements for nursing education have continually soared higher and higher into the healthcare stratosphere over the past 50 years.
    Whereas originally there existed a number of entry options for nursing (e.g. consisting of one and two-year ‘diplomate’ programs, and four-year baccalaureates for the most part), a strong determination was made (in the interests of ‘professionalism’) to curtail and eliminate all ‘professional’ nursing training programs except those that resulted in an RN baccalaureate. This effectively eliminated almost half of the prospective professional nurses at the time these constraints were put into effect. Predictably, a shortage of RNs developed, which resulted in a number of major economic trickle-down effects.

    Doctors, who have never really wanted to ‘share power’ with nurses anyway, began (as their own demands increased in scope and burden) to delegate (grudgingly) some of their lesser functions to Registered Nurses, which further increased pressure on the RN population. To deal with that, more sophisticated training programs were instituted for Practical Nurses (regarded as professionally substandard by RNs) so that some of the lesser RN responsibilities could consequently be delegated to LPN/LVNs.

    Further pressures on the top tier (MD level) resulted in grudging ‘power-sharing’ with RNs in the form of ‘Family Nurse Practitioner’ programs, wherein a further trained RN could be licensed to function as a primary care provider or family practitioner. This MD stress-relief action was additionally augmented by the ‘Physician Assistant’ program, which drew from the ranks of skilled EMTs and Paramedic ranks, which functioned similarly to FNP nurses.

    Most of these ‘Little-Dutch-Boy-with-his-finger-in-the-dyke’ contingency measures may be directly attributed to the ‘gatekeeper’ attitude of professionally proprietary self-serving actions, intended to protect and preserve professional status and occupational power-bases. A matter of allegorically allowing a child to manage the candy store, viewed another way. However, to hear the nurses (to focus on focal example), the perpetual (and deliberately created) nursing shortage is blamed on patient quality of care concerns. What they (the nurses) can’t overtly declaim is their desire to preserve proprietary discretion, remuneration and privilege, an effort spearheaded by the tremendously influential nursing lobbies (the professional nursing associations) that wield remarkably strong influence on how healthcare is carried out and developed in America.

    ‘Gatekeeper’ protectionism remains today, in my opinion, as the single most profound obstacle towards any attempt to adequately meet an exponentially expanding patient population, even as Obamacare and the socialized medicine struggles to put even further pressure on healthcare provision, amidst the traditionally self-protective MD/RN power-structure that has grown up over the past half-century.

    As a final word, a thorough familiarity with the works of brilliant Austrian medical economist Ivan Illich is quite helpful in further understanding the full relevance of this matter. It is to me highly ironic that Illich, a profoundly insightful and humane individual, has almost been forgotten in our modern medical age of high-tech medical science.

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