For the Higgy: Abraham Flexner

The word “expert” shares the same root as the word “experience.” Both are derived from the Latin past participle for “try” — having tried. This origin reflects the long held understanding of what makes someone an expert. It is having done something for a long time so as to have attained mastery of the skill and wisdom from the experience.

Our current understanding of what makes someone an expert is having received a credential that certifies expertise. Someone is an expert in public health because they have a degree from a prestigious institution and hold a high office with responsibility over public health. There is no need for them to have had a long record of experience or demonstrate any wisdom. In fact, they can be relatively young and demonstrably foolish, but they have the credential and position and are therefore expert. If the gross malpractice of our public health response to the pandemic revealed anything, it is how destructive our modern notion of expertise has become.

The false and harmful substitution of credential and position for experience and wisdom in defining expertise has spread to almost every occupation. Teachers are deemed expert because they are certified, not because they have learned from practicing their trade and demonstrated effectiveness. Academics are thought to be experts in their areas because they have written on the topic and are faculty in that field, not because they have done relevant things and shown themselves to be wise. The confusion of credentialing for expertise has spread occupational licensing as a barrier to a whole host of careers, from braiding hair to making floral arrangements.

Abraham Flexner played a major role in creating this modern understanding of what makes someone an expert. Flexner earned a BA in classics from Johns Hopkins University at age 19 after only two years of study. He also briefly studied psychology at Harvard and University of Berlin without earning a graduate degree from either institution. He then returned to his native Louisville and opened a private prep school to promote his ideas about education. As Wikipedia describes it, “‘Mr. Flexner’s School’ did not give out traditional grades, used no standard curriculum, refused to impose examinations on students, and kept no academic record of students. Instead, it promoted small learning groups, individual development, and a more hands-on approach to education.”

In 1908 he wrote a book critiquing higher education for its use of lectures and outdated pedagogical techniques. This book impressed the Carnegie Foundation, which commissioned Flexner to investigate medical education and and make recommendations for how best to prepare doctors. The resulting Flexner Report is heralded for having reshaped and remarkably improved the training of doctors. That may be true (although there have been some serious, negative side-effects), but Flexner’s model for training doctors also negatively shaped how we train almost every profession and the associated notions of expertise.

When Flexner wrote his report, doctors were largely trained by a combination of apprenticeship and lectures. Prospective doctors were not required to have attended college. They were not expected to have studied basic sciences. They simply paid existing doctors to shadow them and/or enroll in one of the 155 medical schools, most of which were unaffiliated with a university and owned by doctors who gave lectures.

While condemning almost all of the existing institutions, Flexner praised Johns Hopkins, his alma mater. The correct approach according to Flexner was to require students to have attended college prior to medical education, have medical schools there were attached to universities and licensed by the state, and to emphasize hands-on learning, including laboratory-based science instruction.

These practices, which were quickly and widely adopted, may have been sensible but they may have been unnecessary to mandate and came at a significant cost. Raising the bar for entry into medical school by requiring that students first attend college and raising the expense of medical education by replacing cost-efficient lectures with laboratory science instruction drove almost all of the institutions training black doctors out of business. The quality of medicine may have improved overall but the sudden disappearance of newly trained black doctors and the difficulty of black patients to access white doctors had a negative effect on healthcare in the black community. In addition, state licensing of medical schools with the intentional goal of limiting the supply of newly trained doctors dramatically increased the costs of healthcare.

But the worst part of Flexner’s model for training doctors is that every profession insisted that they should adopt the same approach even if there were no improvements in quality to compensate for the discriminatory and financial costs of raising the barriers to entry through credentialing. The argument was that if you want to have high quality professionals you have to adopt Flexner’s approach. Now teachers, dental hygienists, optometrists, pharmacists, accountants, lawyers, and every other profession needed to be trained like doctors. In all cases, apprenticeship models where people could acquire experience in a professional, master its skills, and demonstrate wisdom were replaced with systems of credentialing.

Credentialing may be warranted in certain circumstances, but the burden of proof for requiring credentials should be on the profession wishing to raise barriers to entry given the discriminatory and financial costs that necessarily follow. We are also weakened in resisting these unwarranted calls for increased credentialing because we have broadly accepted Flexner’s modern understanding of expertise.

It is particularly ironic that Flexner was the champion of this modern notion of expertise as credentialing given how he lacked both the credential and experience as a doctor. Flexner reshaped medical education without ever having studied or practiced medicine. His claim to expertise, such as it was, was in pedagogy, having run a prep school. Lacking experience and wisdom from the practice of medicine, Flexner asserted a false expertise in medical education that made it easier for him to be foolish about the negative side-effects of his recommendations.

For having advanced this false notion of expertise, Flexner significantly worsened the human condition and is (un)worthy of consideration for The William Higinbotham Inhumanitarian of the Year Award.

One Response to For the Higgy: Abraham Flexner

  1. Michael F. Shaughnessy says:

    Another case of shameless self-promotion. This excellent post begins the question of the quality of online classes ( however you define it ) versus face to face interaction with a real live human being.

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