4. The Flexner Report and its consequences

The scandal that exposed the poor quality of most U.S. medical schools' degree programs also involved osteopathic institutions and shaped their evolution.

The inadequate conditions of US educational pathways for physicians affected not only osteopathic schools, but also allopathic institutions. Following inspections, it had become apparent that many schools awarding MD degrees had such poor academic standards that the Carnegie Foundation for the Advancement of Teaching and the American Medical Association (AMA) commissioned Abraham Flexner to conduct a survey to evaluate 155 medical schools. His famous report came out in 1910, producing great resonance in the newspapers of the time, and spurring a radical transformation of medicine in America.1

According to Flexner – who held the educational system of German universities as an ideal model – colleges should have come as close as possible to the standards of excellence, consolidate as schools linked to universities and engaging in clinical and academic research. Instead of studying in textbooks and listening to lectures, a “learning by doing” approach would have been more auspicable.2,3

The school that best embodied these ideals in America was the Johns Hopkins University School of Medicine, which opened in 1893: it required a pre-med preparatory degree for admission and imposed a course of study lasting four years of nine months each. Classes were small, students were supervised and tested frequently, the main teaching tools were laboratories and internships, and the faculty was devoted to research as well as teaching.4

Nonetheless, many authoritative voices spoke against these  ideas, starting with William Osler – a celebrated Canadian-born physician referred to as the father of modern medicine – who pointed out the risks of an overly scientific approach that would eventually affect the humanity of the doctor-patient relationship. Yet, the educational theory championed by Flexner was welcomed and put into practice in the sector of Biomedicine, which embarked on a path full of exciting successes.2

In addition, Flexner thought that there were too many schools, so he recommended reducing the number of educational institutions operating in the US and Canada to thirty-one. He was convinced that many schools would have to close, while others could consolidate and conform to his ideal University model.4

In his report, Flexner also analyzed eight osteopathic schools – ASO, S.S. Still College, Pacific College of Osteopathy, Los Angeles College of Osteopathy, Central College of Osteopathy, Philadelphia College of Osteopathy, Massachusetts College of Osteopathy, American College of Osteopathic Medicine and Surgery, Chicago – grouped together in a separate chapter dealing with forms of medicine considered sectarian and titled precisely “Medical Septs.” Osteopathic institutes were considered together with homeopathic, eclectic medicine and “physiomedicine” ones. According to Flexner, the eight osteopathic schools – in which 1,300 students were currently enrolled, shelling out $200,000 a year for tuitions – were profit-oriented. He mantained that their advertising brochures consisted of a mass of hysterical exaggerations, both about the prospective earnings of their graduates and the healing power of osteopathy. As far as the young osteopathic science was concerned, Flexner expressed the idea that all physicians, from any school, were supposed to be able to recognize ongoing pathologies in the patient, regardless of whether they were for or against the administration of conventional drugs.1:163-166

The Flexner Report caused a huge stir and was widely publicized in the press. Its recommendations were accepted, and in the following years more than half of US medical schools were closed. The surviving colleges – also thanks to institutional and private grants – improved dramatically, reaching a level similar to the best European schools.

The AOA responded to Flexner‘s criticism by coming in defense of the colleges. However, that same year – 1910 – an internal report, of the AOA‘s Education Committee pointed out  many of the weaknesses highlighted by Flexner in the osteopathic medical training courses. The quality of the schools was poor because of low admission requirements, insufficiency of the number of laboratories for the study of Basic Science, lack of clinical facilities, and inadequate teaching staff.5:90

The osteopathic training system committed itself through a series of provisions aming at improving the quality of the courses. However, the improvements put into place were slower than those of orthodox medicine. Schools continued to depend on tuition fees for survival and received very little support, so they could not afford to raise their entry requirements. Some of the students admitted did not even possess a high school diploma, whereas MD schools required at least a two-year preparatory University degree. However, osteopathic schools had gained an unexpected advantage from the extension of their course of study: the decrease in enrollments was offset by the extra year of training each student had to pay. Consequently, most institutions did not oppose the introduction of a four-year curriculum, which was imposed by the AOA by the fall of 1916. 5:80-81,6:541,7 In addition, the number of colleges fell from eight to seven as a result of the merger of the Pacific College of Osteopathy with the Los Angeles College of Osteopathy, which, in 1914, took the name of College of Osteopathic Phsicians and Surgeons.8

Regarding the debate on the scope of practice, the approach of the “pure” osteopaths began to be regarded as malpractice by a growing number of “broad” osteopaths, especially following the advances in orthodox medicine and the availability of prophylactic and therapeutic agents to cure ailments such as rabies, diphtheria, tetanus, cholera, plague, and typhoid.5:76 “Broad” osteopaths urged DOs to think about the possible consequences of refusing to use drugs. How could an osteopath who did not use morphine in terminal cancer patients, or Pasteur’s treatment in a patient bitten by a rabid dog, adrenaline on a wound, or digitalis in cases of heart disease, have defended himself against accusations of unprofessionalism? Moreover, it is noteworthy that in 1908 the vice-president of the AOA, who had exclusively administered osteopathic treatmentss to his daughter suffering from diphtheria, was called a criminal by the doctor who intubated the dying child for not using antitoxin.5:78

Even so, the ideas that were more open to orthodox medicine were not shared by all osteopaths. For example, in 1914 it happened that Dr George Still, son of Summerfield Saunders Still – who had established the Des Moines’ College and was himself the son of one of the A. T. Still‘s brothers, James Still – proposed, together with his father and with Charles E. Still, son of A.T. Still, to establish a school of orthodox medicine in Kirksville and made his intention public in the ASO student bulletin. This idea was sharply criticized in the JAOA, where it was questioned why, if there was the availability of such resources, they could not instead be used to improve the curriculum, facilities and taeching staff of the ASO, the existing osteopathic institution.9

The AOA attempted to remain true to A.T. Still‘s original ideas and in 1914 passed a motion that by 1916 any teaching of drug therapies by any member of the association would result in their expulsion, and osteopathic colleges that taught pharmacology would no longer be recognized by the ACO. Two schools, the Central College of Osteopathy and the Massachusetts College of Osteopathy, lost their accreditation because they made arrangements with purely medical institutions in order to also dispense the MD degree.7

Dr. A.T. Still also issued an appeal in 1915, summoning his followers. He asserted that the enemy had broken through the lines of defense and penetrated the schools, and he urged people not to become slaves of orthodox medicine. Moreover, announcing that his strengths no longer allowed him to continue a battle he had sustained alone for forty years, he urged osteopaths not to play defense, not to compromise, and to support research institutes to demonstrate the effectiveness of the young osteopathic discipline.6:442

The debate over the resolution adopted by the AOA also found resonance in the pages of the journal The Osteopathic Physician, and it garnered the support of many “broad” osteopaths, so that in 1915 the resolution passed the previous year was now repealed.

Osteopathy seemed finally on its way to medicalization, but an unexpected chain of events appeared to return the upper hand to the “pure lesionists”, at least for a few years.5:80-81

  1. Flexner, A. Medical Education in the United States and Canada. New York City, The Carnegie Foundation for the Advancement of Teaching, 1910
  2. Duffy TP. The Flexner Report–100 years later. Yale J Biol Med. 2011 Sep;84(3):269-76.
  3. Simmons, JG. Doctors & Discoveries: Lives That Created Today’s Medicine, from Hippocrates to the Present. Houghton Mifflin Company, Boston, USA 2002:223-225. 
  4. Ludmerer, K. M. (2010). Commentary: understanding the Flexner report. Academic Medicine, 85(2), 193-196.
  5. Gevitz N. The DOs. The Johns Hopkins University Press, Baltimora, Maryland, USA 2004. 
  6. Booth. History of Osteopathy and Twentieth-Century Medical Practice, in OsteoLib® – vol. XIII, Jolandos eK, Paehl, Germania 2006 
  7. Gevitz, N. (2009). The transformation of osteopathic medical education. Academic Medicine84(6), 701-706.).
  8. “Pacific College and Los Angeles College Consolidated as College of Osteopathic Physicians and Surgeons”, The Osteopathic Physician, v.26, n.1, July 1914:1.
  9. Chiles HL. A medical college in Kirksville? J Am Osteopath Assoc. 1914;13:379-383. 

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The spread of osteopathy in the United States

6. The 1920s and the historic decision of the AOA

The events causing the turning point that in 1929 determined the beginning and the evolution towards an osteopathic medicine parallel to orthodox medicine, with a similar training and scope of practice.


5. World War I and the Spanish flu pandemic.

The departure for the front lines of regular doctors and the successes achieved in treating influenza gave an encouraging boost to osteopathy.


3. Internal controversies on the development of osteopathy and on osteopaths' professional scope

The debate between osteopaths loyal to tradition and those open to collaboration with orthodox medicine shaped the progress of osteopathy in the United States.


2. The establishment of the American Osteopathic Association (AOA)

The creation of a single registry that held annual conferences and published a monthly newsletter was a key step in the growth of American osteopathy.


1. The first years after the foundation of the ASO and the first legal recognitions

The sensational success of the Kirksville School contributed to the development of osteopathy and to the winning of regulation laws in some American states.


Francesca Galiano


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