The Flexner Report Was Never Neutral. Medicine Is Still Paying the Price.
How an educator’s judgments, backed by organized medicine and philanthropy, helped harm Black physicians' future.
By Shereese Maynard, MS; MBA, Sharp Index Board Member
Medicine teaches its history through breakthroughs, discoveries, and distinguished names. The story becomes less comfortable when we ask who those celebrated achievements excluded. And for those we recognized by sticking their names on buildings and building systems around their “insights, why is there no vetting of their origins or intentions?
The Flexner Report belongs in that uncomfortable conversation.
Published in 1910, it is widely credited with helping modernize American medical education. That description is accurate but incomplete. It needs context. The report also endorsed a racially restricted vision of Black physicians’ work and helped legitimize reforms that devastated Black medical education.
I want physicians, educators, and donors to read it beyond its reputation. Who wrote it? What qualified him to make its judgments? Which institutions gave those judgments power? And whose future became expendable in the process?
These questions matter because the consequences extend beyond closed schools. They reach into the training opportunities, mentorship, professional authority, and community care those schools might have sustained. Medicine cannot understand its present workforce without examining how it narrowed the possibilities of its past.
An educator became an authority on medicine
Abraham Flexner was an educator, not a physician. His professional background included directing a college preparatory school in Louisville, studying education, and writing The American College, a critique of higher education. Henry Smith Pritchett, president of the Carnegie Foundation for the Advancement of Teaching, subsequently invited him to investigate medical education. Institute for Advanced Study
That distinction deserves attention, although it does not automatically invalidate his work. Educational expertise can contribute meaningfully to evaluating professional training. Physicians do not possess exclusive authority over every question involving medical education.
But Flexner’s background does challenge the reverence surrounding his conclusions.
He was not conducting a clinical trial. He inspected institutions and judged them against a preferred educational model. The Carnegie Foundation describes his examination of 155 medical schools as documenting substantial differences in admissions, curricula, facilities, assessment, and graduation requirements. carnegiefoundation.org
Calling the report merely an op-ed (my point of view) would overlook that observational work. Calling it a neutral scientific verdict would overlook its assumptions.
It was an institutional survey joined to a powerful argument about what medicine should become.
That argument required scrutiny. Instead, its authority helped make some judgments seem inevitable.
The racism is in the text
This report was written in 1910; we don’t need to speculate about whether racial hierarchy influenced it. Its chapter on Black medical education makes that hierarchy explicit.
Using the historical term found in the document, Flexner wrote:
“The practice of the negro doctor will be limited to his own race.”
He also justified Black medical education partly through the protection it could provide white communities from communicable disease. Black physicians were assigned a restricted professional future within a segregated society. Wikisource, the free online library
Read that carefully.
This was not simply a recommendation for better laboratories. It was a judgment about whom Black physicians would serve and where their professional contribution belonged.
No classroom inspection could establish that racial boundary. No assessment of equipment could justify it.
Here, Flexner moved from evaluating educational resources to prescribing a racial division of professional life. Scientific language did not make that prescription scientific.
The distinction matters today. We can defend rigorous medical training while rejecting an account of rigor that treats one group’s possibilities as inherently narrower than another’s.
The question is not whether medical education needed improvement. It did. The question is why improvement came with a willingness to sacrifice institutions serving people already excluded elsewhere.
Who gave those judgments power?
The Carnegie Foundation for the Advancement of Teaching published the Flexner Report. The report emerged within a wider reform movement involving the American Medical Association and influential philanthropies. A historical analysis in Academic Medicine describes close cooperation between the Carnegie Foundation and the AMA, followed by philanthropic investment that supported extensive reform at white institutions while providing Black medical schools comparatively little help to acquire the resources those standards demanded. Oxford Academic
That creates a question more revealing than whether individual reformers privately harbored ulterior motives:
Who could afford to become the institution the reformers preferred?
A laboratory requires money. A teaching hospital requires access. Full-time faculty require sustained support. When those resources are distributed unequally, judging institutions by what they possess can turn historical exclusion into a finding of institutional inadequacy.
An underfunded school may genuinely need improvement. That does not establish that closing it is the best response.
The alternative is investment. The alternative is partnership. The alternative is asking how to raise quality while preserving access.
Those alternatives become less likely when the institutions being evaluated have little influence over the standards, financing, or final judgment.
Organized medicine was already excluding Black physicians
The AMA did not need the Flexner Report to invent racial exclusion; it did need it to become the standard for medical education.
Its own historical accounts document a long failure to challenge discriminatory membership practices in affiliated state and local medical societies. Because those societies shaped access to organized medicine, local exclusion could also prevent Black physicians from participating nationally. American Medical Association
The organization formally apologized in 2008 for its history of discrimination against African American physicians. ama-assn.org
I opined at the time (and since) that the apology was performative and self-serving. The AMA's later efforts to appear ready to reckon with its past became a study in futility. But that’s a story for another time, and I do have quite the story, but I digress.
That record supports a serious criticism without requiring an unsupported claim that every reform was secretly designed for monopoly.
Organized medicine benefited from greater authority over professional standards. Black physicians were trying to enter that profession while facing restrictions on membership, training, and institutional access.
Professional standards can protect patients. They can also protect established power when the people setting them fail to examine how exclusion shapes compliance.
A standard deserves examination on both grounds: what it requires and what opportunities people have to meet it.
Five schools disappeared. Their absence accumulated.
Five of the seven historically Black medical schools associated with this era closed. The surviving institutions, Howard and Meharry, carried an enormous responsibility for educating Black physicians under conditions of continuing segregation. American Medical Association
The lost schools included Flint, Knoxville, Leonard, Louisville National, and the University of West Tennessee.
A 2020 economic evaluation modeled what continued operation and expansion of these schools might have meant for medical graduates. Its estimates describe hypothetical outcomes, not an observed count of physicians who would certainly have existed. The analysis nevertheless illustrates the potentially substantial scale of lost training capacity. JAMA Network
The consequences extend beyond graduation totals.
A medical school develops faculty, research relationships, clinical networks, mentors, and professional pathways. It creates places where students can see themselves as future physicians.
Closing a school removes an institution. Sustaining that absence across generations removes opportunities that might have grown around it.
This is how historical harm can persist without an old policy remaining formally in force. Institutions accumulate resources and influence. Their absence accumulates, too.
Flexner also judged whether social work deserved professional standing
In 1915, Flexner addressed the National Conference of Charities and Correction on the question, Is Social Work a Profession?
His opening acknowledged limited familiarity with social work, its literature, and its practitioners. He nevertheless evaluated it against criteria he derived from recognized professions and concluded that it did not yet fully meet his definition. socialwelfare.library.vcu.edu
It would be unfair to reduce that address to hostility toward all social work. He discussed its functions and recognized the possibility of professional development.
The more revealing issue is his position as an arbiter.
An influential educator could acknowledge limited knowledge of a field and still receive a national platform to judge its professional legitimacy.
That should make us examine how authority travels. Expertise in one domain can become presumed authority in another, especially when powerful institutions welcome the conclusions.
Today, social workers contribute across mental health, care coordination, family support, and responses to the social conditions affecting health. Flexner’s framework was a historically situated judgment. It was never a permanent boundary around the value of their work.
The same scrutiny belongs in discussions of Black medical education.
What should we actually reject?
We should reject the racial restriction of professional possibility.
We should reject the assumption that an institution’s lack of resources proves its community deserves fewer opportunities.
We should reject the idea that scientific training requires indifference to the social conditions shaping who can obtain it.
None of this requires abandoning laboratory science, clinical education, or demanding standards. It requires refusing to make exclusion part of their price.
I find the familiar defense, that Flexner was simply a product of his time, insufficient. Historical context helps explain his judgments. It does not oblige us to keep celebrating them without examining their consequences.
In 2020, the AAMC renamed its Flexner award in recognition of the report’s harm and its author’s discriminatory beliefs. AAMC
Renaming matters. But changing what we honor is only a beginning. The harder work involves examining what we fund, how we evaluate, and whom we support.
The contemporary burden of having your legitimacy questioned
The legacy is not that Flexner personally caused every inequity a Black resident experiences today.
The legacy includes a recurring institutional problem: judgments about marginalized people can acquire authority faster than the people being judged acquire protection or a fair hearing.
Jason Arday’s death has intensified questions about public scrutiny and institutional responsibility in academia. Arday denied plagiarism allegations, and reporting described his family’s concerns about harassment. An inquest opened following his death. These facts do not establish that Nathan Cofnas caused his death, that the death was suicide, or that every allegation had been disproved. reuters.com
We should preserve that distinction out of respect for both evidence and the person.
Academic scrutiny is necessary. So are fair procedures, proportionate communication, and attention to the welfare of those under scrutiny.
An institution should be able to investigate scholarly concerns without surrendering its responsibility to treat the scholar as a human being.
That principle belongs in medicine, too.
Representation has consequences for care
The loss of Black medical training capacity matters partly because representation can affect patients’ engagement with healthcare.
In an Oakland randomized experiment, Black men assigned to Black male physicians were more likely to choose preventive services after consultation than those assigned to non-Black male physicians. The findings were specific to that study and population; they do not establish that shared race automatically guarantees better care. www.aeaweb.org
They do challenge the suggestion that workforce representation is merely symbolic.
Every physician must develop cultural competence, listen carefully, and earn trust. A representative workforce can bring additional perspectives and opportunities for connection.
The physician whose place in medicine is repeatedly questioned may be the person a patient has been waiting to meet.
Repair requires resources and accountability
I want medical institutions to teach the Flexner Report as a contested historical document, including its racial assumptions and the systems that amplified them.
I want donors to examine whether their funding expands training capacity where opportunity has been restricted.
I want residency leaders to review evaluation, research credit, mentorship, and access to confidential support. A trainee should not have to defend their belonging before receiving help.
And I want our concern to produce financial action.
This October, I am collaborating with Sharp Index to raise awareness and funds for health equity in medicine. Scholarships cannot reverse a century of institutional loss. They can help reduce a financial barrier for someone pursuing medical education while we continue demanding broader change.
Please support the campaign through Sharp Index’s 2026 scholarship fund.
Read the original report. Examine whose interests shaped its recommendations. Ask your institution how it distinguishes demanding standards from inherited exclusion.
Flexner’s report was consequential. Its authority should never exempt it from scrutiny.
The physicians who came after it deserve a profession willing to scrutinize itself.
