Medical reform in the United States: A comparison between two rhetoric.

ABSTRACT

The genesis of the medical education model proposed by A. Flexner in the United States is discussed here, comparing it with the proposal to apply the German university model to Brazilian medical education, in the 1930s, by Antonio da Silva Mello. We argue that the core of medical reforms – which aimed at introducing the teaching of biomedicine and enhancing scientific careers – did not depend only on the perfect understanding, on the part of the two reformers, of the fundamentals of the new model. Each rhetoric expressed a political arrangement in which expectations of change in the consolidated educational system depended on its power structure and the career expectations enshrined in tradition.

Introduction

Flexner’s reforms made the transition from medicine to modern biomedicine. This is a common assertion in the history of Brazilian medicine.1 In fact, the statement may be true, in the most general sense that Flexner was, for a short time, in the United States, the self-proclaimed leader of a medical education reform movement that would later make him publicly recognized. Flexner, who was not a doctor, had no original ideas about medical teaching (see Starr, 1982, pp. 118-20; Wheatley, 1988, p. Xii). His reforms took advantage of forces and ideas that already existed in the medical education of the USA and Germany but were not often carried out in the way he expected (Starr, op. Cit., Pp. 121 and 355; Wheatley, op cit., pp. 197-9). On the other hand, Flexner was a skilled administrator, a competent manipulator of organized power. Medical reforms in the US could provide a model or an idea for other countries. However, the crucial elements of the actions, namely, the consolidation of opinions in favor of these ideas and implementing the desired objectives, would need to be negotiated again in each national context. This was the case, for example, in Brazil, when the Rockefeller Foundation was willing to finance the construction of the São Paulo School of Medicine (Kemp, 2004).

The situation in Brazil was no less complex than that in which Flexner worked in the USA. At the beginning of the 20th century, Brazilian medical education changed to a standard arguably closer to that of the university and the laboratory. Therefore, it is not difficult to find here characters who, like Flexner in the USA, fought for similar ideas.

Any analysis of the Brazilian change in question must consider the fact that Brazil had, at the beginning of the 20th century and even before, a complex and rich medical tradition that could not easily change at the whim of outside forces.2 The works that exaggerate the guidelines dictated by the innovative centers for their model role – as was the case with French, German and American medical institutions, successively – end up minimizing the role of local medical communities in their interpretation, selection, and adequacy.

That is why we argue that the core of medical reforms did not depend only on changing doctors’ conceptions of what good medicine would be, but on transforming the consolidated educational system; therefore, in its power structure and the career expectations enshrined by tradition. We, therefore, need to investigate what ideas were implemented in Brazilian medical schools, taking into account the conflicts generated in each context.

A complete analysis of the changes in Brazilian medicine at the beginning of the 20th century is beyond the scope of this article. We only intend to show the arguments of two reformers: Abraham Flexner, in the USA, and Antonio da Silva Mello, doctor and Brazilian professor. It is not a matter of demonstrating that Silva Mello was the Flexner of Brazil; on the contrary, the focus of this article is to clarify that Brazilian doctors knew the currents of German and world medicine and, like Flexner, sought to incorporate, selectively, many of its aspects.

Many of Silva Mello’s and Flexner’s arguments are extraordinarily similar. However, we must state right away that the former, like other Brazilian medical leaders who preceded him, was as critical of the liberality and lack of regulation of American medical education as Flexner. Therefore, Silva Mello represents a current of Brazilian medicine concerned with updating and adapting contemporary ideas about medical education. He was not a puppet of Flexner’s ideas. He was a doctor who had studied in Germany and Flexner and had returned in love with the forms and precepts of that country. Silva Mello, also as Flexner, had detailed knowledge of the context in which he was inserted and the forces that opposed him. By comparing the rhetoric of the two reformers, we can first see that German medical reforms were spreading worldwide without Flexner’s help, and then how different these ideas became in the various countries where they spread.

 

European models of medicine and education

In the first half of the 19th century, state of the art in medical education followed the French model3 , while in the last half of the same century, the influence of the tradition of German medicine and education was increasing. The French anatomical-clinical model presupposed teaching carried out through work and research at the hospital, specialized in the technical observation of the human body. Undoubtedly, research and fine observation were integral parts of the French model, but they were united differently from the German model in this research and practice. As Bonner (1995, p. 144) says:

French studies of anatomy and pathological conditions, aided by new technology for monitoring internal symptoms, have progressed rapidly in the post-Napoleonic clinic. In contrast, the sciences that depend on an accurate study of healthy organisms and the use of animal experiments, above all physiology, proceeded independently in specific scientific institutes, which often had little or no connection with a clinic or medical school; the post-revolutionary cleavage (1792) of the hospital and academic authority thus seemed to make an increasing separation in France between theoretical science and practice inevitably.

To unite medical practice and the emerging areas of experimental research under the new orientation, a new organization of medical education was also needed; in short, since the end of the 19th century, research models could not be separated from the higher education systems of which they were an integral part.

Thus, the anatomic-clinical education model was facilitated by the close relationship between hospitals and medical schools. The former offered a wide field of research next to the patients’ beds, in addition to the anatomical amphitheaters. Colleges could train their students in different diagnostic and therapeutic techniques and have a wide range of clinical research for their teachers. The success achieved by this standard made it difficult to implement the German medical research model, with its penchant for the laboratory, the hierarchy, specialization in the emerging areas of experimental disciplines, and the union of the many research areas to train a doctor.

Like many of the French innovations of the first half of the 19th century, German innovations in medical education and their organization were not imported or exported in their entirety. Some of the ideas and techniques that were in vogue were: to make research possible as a career, without depending on personal wealth or wealthy patrons; the corresponding desire to have status and recognition from the scientific career itself, and not from traditional professions; the autonomy of the educational system, to incorporate new research paths; the central importance of laboratory research (Ben-David, op. cit., pp. 111-24).

What the literature has not pointed out, however, is that there have been as many problems with the German medical education system as with the French. Ben-David showed some of those tensions that arose in the late 19th century. He drew attention to an important aspect of our argument. It is one of the contradictions that compromised the training of students both oriented to medicine and oriented to the scientific career. According to this author (idem, ibidem, p. 140),

… those who were destined to become researchers informally acquired their specialized knowledge and expertise as assistants, working with professors in research institutes, usually linked to their chairs. They had the benefit of serious and contact with several more senior assistants. The degree of mismatch [between research carried out at the institutes and] the undergraduate course [put training at the institute] above that a student who did not intend to enter for research could profitably assimilate was insufficient for those who intended to enter to study. A professional career of researchers. Their training remained informal. Its main flaw was that it made it difficult for a student to acquire complete training in his field because he worked with only one teacher. This system also created a situation of dependence on a teacher who was often conducted in an extremely arbitrary and authoritarian manner, generating insecurity in those aspiring to a research career. Not being assigned to a chair at the university, the student remained stationary, even when he was a high-level researcher, performing important tasks in research and the training of beginners. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. Because he worked only with a teacher. This system also created a situation of dependence on a teacher who was often conducted in an extremely arbitrary and authoritarian manner, generating insecurity in those aspiring to a research career. Not being assigned to a chair at the university, the student remained stationary, even when he was a high-level researcher, performing important tasks in research and the training of beginners. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. Because he worked only with a teacher. This system also created a situation of dependence on a teacher who was often conducted in an extremely arbitrary and authoritarian manner, generating insecurity in those aspiring to a research career. Not being assigned to a chair at the university, the student remained stationary, even when he was a high-level researcher, performing important tasks in research and the training of beginners. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. This system also created a situation of dependence on a teacher who was often conducted in an extremely arbitrary and authoritarian manner, generating insecurity in those aspiring to a research career. Not being assigned to a chair at the university, the student remained stationary, even when he was a high-level researcher, performing important tasks in research and the training of beginners. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. This system also created a situation of dependence on a teacher who was often conducted in an extremely arbitrary and authoritarian manner, generating insecurity in those aspiring to a research career. Not being assigned to a chair at the university, the student remained stationary, even when he was a high-level researcher, performing important tasks in research and the training of beginners. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. The student remained stationary, even when he was a high-level researcher, performing important tasks in research and beginners’ training. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany. The student remained stationary, even when he was a high-level researcher, performing important tasks in research and beginners’ training. But all of these deficiencies were not obvious to American and English students (or, sometimes, from other countries) who were going to Germany.

And he added (idem, ibidem, p. 140):

One of the results of this erroneous conception was that, when scholars returned to their countries advocating the adoption of the German standard, they were unable to establish any difference between the chair and the institute. Although aware that the German teachers acted individually, they were not aware of the structural counterpart in a very hierarchical way. They could not see how different the departmental structure and the combination of chair and institute were that they had admired and thought they were implementing in their own universities. However, the departmental structure eliminated the existing anomaly, in which a single professor represented an entire field,

In this article, we start from the premise that the medical, educational models that guide the behavior of the reformers are expressions of certain political arrangements, both in the context in which they originated and in those where they later expanded. Such models, so recurrent in the reformers’ rhetoric, are idealizations that need to be reinterpreted when applied to specific cases, reaching new meanings and specific contents when interacting with each institutional structure.

In his work that analyzes the importance and implementation of European medical models in the context of the USA in the 19th century, Warner (1992) shows how different aspects of the French anato-monoclinic model were constructed and mobilized by medical elites to support the structures already established against the assault promoted by the reforms of the Jacksonian period, which were opposed to the professional privileges. The author points out that, at the end of the 19th century, with the appearance of the German model, practical doctors, in alliance with those who had contributed to the construction of their careers anchored in French precepts and practices, began to resist the attacks of the new generation. . The new adherents of experimental medicine, imbued with a spirit of confidence in renewal and an interest in specialization,

In this direction, in his analysis of the import of the German university model into the USA, Veysey (1965) shows the same epistemological and generational conflict that Warner had pointed out in medical education. And he argues (idem, ibidem, p. 439):

Already struggling, his creation [that of the new university model] had become the goal of inspired dreams from abroad – particularly in Germany – when its first leaders began, almost intuitively, to direct the nascent institution in more familiar ways. … But the basic standard of the university, which would reveal itself clearly from 1890 onwards, was that of an undertaking that intended full success and whose less popular possibilities were deliberately tarnished in the words and actions of the official spokesmen. As more Americans began to accept the new institution, opportunities for a derogatory assessment of the movement towards standardization and assimilation became increasingly rare.

Thus, Veysey suggests that subtleties were often lost amid rhetoric in the struggle to legitimize and establish these new forms. A good example of the situation was the categorizations and illusions created by Abraham Flexner in his struggle to establish the German style in medical education and the related style of Johns Hopkins for higher education in the USA. This was the message that they say has been propagated throughout the world. However, if we examine the evolution of his ideas, we will see that they did not occur linearly.

 

The rhetoric of reform

Some of Flexner’s first statements on education reform were against college, but they proposed a model of university education quite different from the one he would later embrace. Flexner stated in The American College: A Criticism, 1908:

The classic curriculum has broken into pieces because it had served a single purpose for a long time. It cannot be redone again: the suggestion itself proves useless. An arbitrary discipline of the classic type is only effective when accepted socially and finds support in the social organization. People have to give you credit, and something must depend on it (Flexner, 1969, p. 18).

Here he suggests that the American higher education system, dominant before the advent of the university, was outdated mainly because it did not prepare students for viable careers. As a way out of this situation, he proposed a new model of the modern school, which, in his later writings, became the model of Johns Hopkins University.

Today, in stark contrast, the modern faculty is impartial, Catholic, democratic. It is concerned with a total field; their responsibility and duty are to society as a whole, not only to this or that of its parts. It, therefore, covers all types of intellectual training, all processes and activities that are characteristic of expression and social development: science, industry, commerce, laws, institutions are its objects and are of equal importance to art, literature, and philosophy (idem, ibidem, p. 36).

In his early writings, Flexner did not really call for the German model. Ben-David demonstrated that the German university did not support technical education or establish new careers. There was indeed the professionalization of pure research, but only for intellectual advancement in itself.

Thus, in his early career speeches, Flexner was not a proponent of specialized education, as he would later be. He frequently discussed and advocated changes in higher education because it could help students’ development. For example, “the college is to develop the youth’s power, harden its fiber, strengthen its purposes and inculcate a useful principle in its basic knowledge” (idem, ibidem, p. 161). Nor did he accept that the educational system needed to abandon the idea of training good individuals in favor of the production of knowledge. He said (idem, ibidem, p. 179):

Inevitably, the most recent, most active, and most visible departments will go beyond their limits. The college does not have complete confidence, and the undergraduate department knows exactly what it wants. As a result, interests, ideas, and methods of graduation tend to prevail; and the resources accumulated in the first place for the prosaic purpose of training the boys were diverted, through unorthodox methods, for strange purposes. … universities, in general, assumed that everything that fostered the interests of departments fostered, in equal measure, the interests of students—a hazardous assumption.

His argument, in the early stages of his career, was that college. However, it was a new form of school organization, should be more combative against the powers of the university. Flexner believed that training young people for useful careers at college should not be lost in the unbridled search for new research and university education. He suggested that the research had taken an unfair portion of the resources of the educational system and allocated them to specialized education, distant from the interests of most students. He wrote (idem, ibidem, pp. 216-7):

The way out, in my view, is through the vigorous reaffirmation of the college’s priority as such. The emphasis must be redirected to an earlier point. This is at the heart of the whole issue. Historically, Yale, Columbia, Harvard, Princeton are colleges. The bachelor, not the doctor, is, and always has been, the college man. The college has had rich endowments. It is also from the college, where a young man can be educated with serious interests and control of his power that a nation needs above all. The university level represents further development: an appropriate beneficiary of the college surplus, if any, and not a legitimate usurper on the lion’s share of his income.

In clear anticipation of his future position, he no longer approved the creation of ‘new colleges ‘ with low entry standards, more concerned with commercial gains (idem, ibidem, pp. 228-31). This message is reiterated at a conference announced at the Harvard Faculty of Education in 1927. At that time, he, facing the audience, criticized the expansion of a purely ornamental character, which took the youth away from learning to develop intellectual capacity and effort (idem, 1927, p. 10).

Almost twenty years after the first criticisms of colleges, there was an inflection in their speeches. There were few references now to expanding the individual possibilities of young Americans; on the contrary, the need to professionalize the scientific career was emphasized. Flexner regretted that in the United States, teachers from colleges and secondary schools were treated as subordinates in opposition to other countries and not with the honor they deserved elsewhere (idem, ibidem, p. 12). Besides, he stated that lawyers, doctors, and even company administrators were valued and very well paid in the USA, in contrast to what happened to those focused on university careers (idem, ibidem, p. 16). The solution he proposed included full-time employment, high salaries, merit pay, and high standards for all:

The vast majority of academic professors in the richest country on Earth cannot make a living from their salaries, even when they have reached the peak of their careers; they work part-time. It is not an overly emphatic statement: college and university professors are, for the most part, part-time workers ( part-timers) and for their own teaching needs, and for the passion for research that inspires the best among them, they can dedicate only the time that remains after they complete their academic routine or earn, through lectures, work during the holidays, publicity writings, translations and specialized works, the amounts they need to balance the family budget and, what is worse, to carry out their disciplinary and scientific research (idem, p. 32).

These issues of salary and status, far from being only of American scholars in the early 20th century, were common to groups worldwide who moved towards professionalization. In fact, many of these arguments were also raised by Silva Mello in his work Problems of medical teaching and education, published in 1937.

After completing his education in Rio de Janeiro, in the 1910s, Silva Mello deepened his studies in Germany. He returned from this experience with great enthusiasm for the meaning and importance of that medicine, concerned with an education directed towards ‘concrete problems,’ ‘a real practice.’ For him (Silva Mello, 1937, pp. 17-22), the training of the Brazilian physician was “disconnected from reality and centered on the memorization of minutiae.” He further claims that,

… our Faculty of Medicine, due to its refined erudition, reached the absurdity of creating, within the medical career, of all the most practical and objective, a theoretical, doctoral type, of pure bachelor’s degree, which is manufactured in immense series to live by leaps and bounds, it is not uncommon for him to be almost miserable, and who, despite having studied hard, ignores what he needs to know. The student who works with the sole aim of passing the exam and who should not have the right to exist is a creation of this terrible organization. But, equivalent to the theoretical doctor, and even worse than him because he is responsible for his poor training, he is the master, unfortunately so frequent among us, who ignores his role in teaching and the real purpose of his courses. It is such masters who invent absurd programs,

Silva Mello não estava, no entanto, em busca de médicos que não tivessem interesses outros além da medicina, como se dava com Flexner em seus primeiros escritos. Combatia o que considerava anacrônicas forças de morte — o conhecimento clássico, desconectado —, porém se preocupava igualmente com a educação secundária, com o nível cultural da juventude de sua nação e, à diferença de Flexner, afirmava a importância de uma melhor formação cultural na educação do médico.

The doctor must not only acquire scientific knowledge, only consider his culture. He needs to know human problems as well, to understand the sufferings and needs of the individual, to feel them with love and sympathy, to be up to the respect and trust that they can place in him, which is one of the secrets of his efficiency (idem, ibidem, p. 25).

Silva Mello did not want to train doctors who were “traveling dictionaries” (idem, ibidem, p. 26) without any musical or literary interest. However, he endeavored to give arguments against what he considered a flaw in the Brazilian medical education of his time: medical education was only literary or a display of rhetoric. After commenting on how desirable it would be to find broader interests and cultural gifts in a doctor, he stated (idem, ibidem, p. 248):

When this happens, the individual performs both tasks with equal dedication, obeying an internal imperative, which can hardly be avoided. This is very different from this trend so widespread among us, for which the individual seems to be always and only working for the gallery. As a rule, what he lacks are the qualities of a doctor, and neither by the letters nor by the arts, he can be saved. This type of amphibian, which swarms among us, constitutes one of the greatest evils of our medicine and perhaps of our letters. As long as such werewolves maneuver universities and academies, it is natural that we are immersed in the crudest cabotinism.

As we have already seen, Silva Mello was not a follower or apologist of American medical education before the Flexner reform. Concerned about the proliferation of medical schools, guaranteed by the freedom of teaching and by the federative principle, he stated that “where freedom of teaching led to the greatest monstrosities was in North America, where the most varied and unbelievable medical schools abounded” ( idem, ibidem, p. 35). In that sense, he was in complete agreement with Flexner regarding the state of medical education in the United States before the Flexnerian reforms. They were both ardent defenders of the elite – a new form of the elite in their respective countries. Silva Mello declared (idem, ibidem, p. 77):

The number of individuals who are embarking on academic careers today is exceedingly excessive, although the vast majority lack the indispensable intellectual skills. The result of this collective invasion has been a need for leveling down, which has led to the training of surprisingly ignorant doctors and graduates. Among us, most of them, when they graduate, are unable, for example, to write a letter without errors in Portuguese, despite being the simplest evidence that every individual with a university degree should have an obligation to, at least, if you use your mother tongue correctly or decently. They know nothing or almost nothing about art or literature; they read nothing but news from daily newspapers and illustrated periodicals; they don’t know how to talk except cinema tapes and entertainment; they are only concerned with clothing, the radio, with dances, with sports. It is natural that such individuals, so empty and intellectually uninteresting, complain and regard the simplest studies as excessive and complicated.

And ahead (idem, ibidem, pp. 64-5):

The task of universities is not to take advantage of the disabled and inferior, educate them almost compulsorily at the expense of the nation’s money, and provide them with a diploma that gives them advantages and benefits in practical life. The population, who do not need men decorated with titles or diplomas, has the right to demand that their money be invested more just and economically. Doctors are far from studying at their own expense since they cost a large sum to the country. It is in this respect that one also has the right to demand better use of public money: instead of distributing titles and diplomas to the disabled and the underdeveloped,

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