Medical specialization in the USA in 2021.

The two reformers

Flexner’s career in medical reform began with his commissioning, by Henry S. Pritchett, to write, for the Carnegie Foundation, the Medical education in the United States and Canada. Wheatley says that Pritchett’s goal concerning this Flexner report was to reshape medical training. But Flexner did not stop there: he wanted to outline new structures for professional education. Thus, Wheatley (op. Cit., P. 46) states: “Flexner was more concerned with creating conditions that would make possible the development of specialized disciplines in medicine. The supremacy of the university form was, therefore, fundamental.”

Flexner made plans and maps to establish the number, allocation, and distribution of medical schools in Canada and the USA. His new proposals were more to cut schools than to increase their number. He was particularly concerned with closing schools that he considered unnecessary and inadequate and openly stated that doctors, especially practitioners, did not have the “scientific spirit” to administer medical education. In reforming the system and building a new one, he clearly advocated a managerial elite, personified in himself (idem, ibidem, pp. 47-56).

Flexner’s opportunity to become part of this ‘managerial elite’ came with the offer of a permanent position on the General Education Board, subsidized by Rockefeller, in 1912. In that position, he expanded his influence and control over US educational institutions with the support of Rockefeller funds. Wheatley (op. Cit., P. 57) states that “the central point is that Flexner kept philanthropy at the forefront of the American organizational revolution, helping to shift its focus from developing and supporting institutions to managing trans-institutional networks.” The whole of Wheatley’s work demonstrates the difficult reality of Flexner’s supposed self-propagation of ideas. As he suggests, in the early years of university reform in the U.S., a small minority directed the changes, initially subsidized by the Rockefeller Foundation, without requiring a broader corporate or governmental approval (idem, ibidem; Veysey, op. cit.). This was a situation quite different from that found by Silva Mello in Brazil in the 1930s.4

Furthermore, although the comparison is difficult, it can be argued that the structures of French medicine, although partially adopted in the North American context, were the backbone of Brazilian traditions and medical power set up during the Empire period.

The anatomy clinical model, which, around 1830, spread from Paris to the rest of the world5, guided the group of Brazilian medical institutions until the 1880s. With its epistemological precepts arising from the sensualism of idéologuesand his clinical practice supported by inspection instruments and techniques – which included physical examination of palpation and auscultation, the stethoscope, medical statistics, systematic teaching at the patient’s bedside, pathological anatomy, and anatomical examination after death – a whole system of professional authority supported by some institutions: the Imperial Academy of Medicine, two medical schools and the Central Board of Public Hygiene. However, around 1870, this model started to be questioned by the main medical authorities of the Empire as obsolete, generating the Savoyard Reformation, in 1882, of Germanic inspiration. The laboratories then implanted (physiology, experimental pathology, histology, parasitology), the bench, the microscope, and the crucible gave materiality,

As in the USA, battles started earlier in Europe later arrived in Brazil. However, contrary to the situation described by Warner in the USA, about the way – weak and partial – with which French ideas were implemented there, in Brazil, they took shape in educational institutions. This legacy would necessarily weigh more here than in the USA.

When Silva Mello’s conclusions about medicine and education were published in 1937, the reforms aimed at the German medical teaching model had been underway in Brazil for at least 57 years. However, while the ideas of many researchers and doctors were changing regarding the best model of science, the changes in the structure of institutions, deeply marked by the anatomic-clinical tradition, proved to be difficult. This was a mission that Silva Mello put to himself; he was a full professor with political contacts with government officials, which he used when he sought to reform the most prestigious medical school in the country, linked to the University of Brazil. The situation was very different from that faced by Flexner,

 

The rhetoric of the university

versus clinical today we abuse the word University and even write it with a big U, as certain spinsters abuse the word, Love, as certain aesthetes abuse the word Art: precisely because we lack university – reality – in our life, as love for the spinster’s life, as art to the life of the exquisite fake full of expensive paintings in the living room. A form of compensation. … A great abuse and mystical use of the word and an almost absolute lack of reality, experience, of university substance in our lives and our culture (Silva Mello, op. Cit., P. 6).

Flexner also became – after his initial interest in the college and his confidence in it – the ardent promoter of the research-driven university, with which he became famous. In three lectures on universities given at Oxford in 1928, he repeated the classification of universities repeatedly, specifically when speaking of the German, English, and American ‘type’. In this discourse, their belligerence is revealed by disregarding Oxford and Cambridge (as well as Yale and Harvard) as major educational institutions. Subsequently, his transformation from the defender (in 1908) of the college model into a lawyer for more specialized training of his students is completed with the following assertion (Flexner, 1930, p. 24):

I do not have in mind the training of practical men who, faced with the responsibility to act, will do the best they can. This is not the task of the university. Therefore, a modern university should strive with the greatest commitment and without reservations to the advancement of knowledge, the study of problems, whatever their origin, and the training of men – all of this is at the highest level of effort possible.

Also, for Silva Mello, the ideal of a German university was used as a weapon against mediocrity, which he perceived as follows:

We are already tired of hearing that the university problem is a problem of culture, which aims to develop intelligence, the improvement of mental faculties, the preparation for the study, and the comprehension of all questions concerning man and nature. The university spirit must be characterized by the superior qualities of the human spirit in the intellectual and moral field. … That was, for example, the feeling recently left by the speeches exchanged between Francisco Campos and Affonso Penna Junior on the occasion of the inauguration of the new rector of the University of the Federal District. Create the University among us! But this has become a real obsession, which is spreading violently across the country. … what is perhaps there is only the sweet naivety of ignorance. We are often victims of words, illusions, superstitions. In recent times, we have been dominated by this idea of ​​the university, and we believe that we will be able to solve all our problems at our expense. We don’t realize that labels and tags cannot magically create content and that our attempts can barely go beyond simple phraseology. In fact, it is not by artificially transplanting old, old-world institutions into our midst that we will be able to find the exact way to solve our difficulties. In the first place, we lack elites but real, capable, superior elites (Silva Mello, op. Cit., P. 187). In recent times, we have been dominated by this idea of ​​the university, and we believe that we will be able to solve all our problems at our expense. We don’t realize that labels and tags cannot magically create content and that our attempts can barely go beyond simple phraseology. In fact, it is not by artificially transplanting old, old-world institutions into our midst that we will be able to find the exact way to solve our difficulties. In the first place, we lack elites but real, capable, superior elites (Silva Mello, op. Cit., P. 187). In recent times,s we have been dominated by this idea of ​​the university, and we believe that we will solve all our problems at our expense. We don’t realize that labels and tags cannot magically create content and that our attempts can barely go beyond simple phraseology. In fact, it is not by artificially transplanting old, old-world institutions into our midst that we will be able to find the exact way to solve our difficulties. In the first place, we lack elites but real, capable, superior elites (Silva Mello, op. Cit., P. 187). and that our attempts can barely go beyond simple phraseology. In fact, it is not by artificially transplanting old, old-world institutions into our midst that we will be able to find the exact way to solve our difficulties. In the first place, we lack elites but real, capable, superior elites (Silva Mello, op. Cit., P. 187). and that our attempts can barely go beyond simple phraseology. In fact, it is not by artificially transplanting old, old-world institutions into our midst that we will be able to find the exact way to solve our difficulties. In the first place, we lack elites but real, capable, superior elites (Silva Mello, op. Cit., P. 187).

As Ben-David pointed out, the German model of medical education and research, as proposed by reformers like Silva Mello and Flexner, hardly resembled the real state of higher education in Germany. Flexner’s claims about German education were generalizing and gave few specific examples. Silva Mello offered a picture with broader nuances of French, English, and German medical education. But in both, the realities of the European systems have been transformed and merged with the needs (political and educational) of the countries themselves.

The two reformers’ claims about medical education inside and outside their respective countries should be read as political statements or fervent calls for reform. Both had made good use of their time in Germany and had celebrated the intellectual climate they experienced as visiting scholars. Both realized that the world was changing and felt that they could provide the vision that would bring their respective nations in line with new trends.

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