Flexner and the Whole-Time System: The
Second Flexner Report and the Whole-Time
System in American Academic Surgery
Josef E. Fischer, MD,
Reform in medical education
started in the mid 19th century and continued
through the early decades of the 20th century.
Both Carnegie and Rockefeller foundation mon-
ies were applied to the process of attempting to
improve medical education. The University of
Cincinnati College of Medicine, associated with a
municipal hospital and a municipally owned uni-
versity, offered a model for improvements in
medical education in other municipal hospitals.
The attempt to institute the “whole-time” (“full-
time” salaried, “University”) system, and restruc-
ture the University of Cincinnati College of Medi-
cine along radical lines hitherto unknown in
much of the country and in particular to the city
of Cincinnati, disturbed the relationship of the
College of Medicine with the community and
echoes to this day. The tensions between the
“University-salaried” professors of clinical sur-
gery and the practitioners attempting to practice
at the institution have abated but remain unre-
The history of the establishment of
the full-time chairs, including the Christian R.
Holmes Chair of Surgery, led to a rethinking of
the role that the full-time system might play in
American medical education. Am J Surg. 1999;
178:2–13. © 1999 by Excerpta Medica, Inc.
uring the latter part of the 19th century, there was
keen interest in educational circles in improving
the quality of medical education. Historically, med-
ical education had been obtained by apprenticeship with
practitioners, generally of good reputation but of unequal
quality. With the establishment of colleges of medicine,
curricula were structured with an underpinning of basic
science courses and subsequent clinically relevant courses.
Some of the better colleges of medicine built laboratories
and attempted to institute a third year with “hands-on”
laboratory science. While some colleges of medicine
adopted these innovations, other resisted, fearing that the
requirement of an additional year would result in the loss of
students and the tuition on which these colleges were
The lecturers and practitioners associated with these col-
leges of medicine were paid in various ways. In some
schools, students bought tickets to lectures (similar to the
English system) and the professors pocketed the proceeds.
In others, tuition went to the school, and professors were
paid a relatively small amount for their tutorial activities.
Prior to the end of the 19th century, no professor in any
American medical school was paid a full salary. All en-
gaged in private practice for the bulk of their income.
However, the “university,” “fully salaried,” or “whole-time”
system (Table I) was operative at many of the great uni-
versities in Europe, in which both the basic science pro-
fessors as well as the clinic professors were paid a full-time
salary by the college of medicine. Most American medical
schools still operated under the volunteer (no payment) or
part-time basis (small payment for the lectures given to the
medical students). A few had begun to consider a geo-
graphic full-time system; that is, while the clinicians billed
and collected their own fees, their activities were limited
geographically by the institution with which they were
ABRAHAM FLEXNER, THE GENERAL
MEDICAL EDUCATION BOARD, THE
CARNEGIE FOUNDATION, AND
REFORM IN AMERICAN MEDICAL
Abraham Flexner (Figure 1) was a member of a promi-
nent Louisville, Kentucky, medical family of which several
members were excellent practitioners of internal medicine.
He spent his lifetime interested in education. After attend-
ing Johns Hopkins University, he returned to Louisville as
a teacher, ﬁnally founding and becoming headmaster of an
excellent women’s high school (the Collegiate School) in
Louisville. However, Flexner’s connections with Johns
Hopkins University continued to pull at him, and his
interest in American medical education continued to dom-
inate his thinking. In 1908, he applied to Henry Pritchett,
the chair of the Carnegie Foundation, for a position.
At the beginning of the 20th century, the philanthropic
leadership of the United States, as exempliﬁed by Rock-
efeller and Carnegie, began to focus on improving educa-
tion in general and medical education in particular by
providing resources. In 1902, John D. Rockefeller created
and endowed the General Education Board. The board
members initially were academic leaders and conﬁdantes of
From the Department of Surgery, University of Cincinnati Med-
ical Center, Cincinnati, Ohio.
Requests for reprints should be addressed to Joseph E.
Fischer, MD, Christian R. Holmes Professor and Chair, Depart-
ment of Surgery, University of Cincinnati Medical Center, 231
Bethesda Avenue (PO Box 670558), Cincinnati, Ohio 45267-
Manuscript submitted June 1, 1999, and accepted in revised
form June 2, 1999.
© 1999 by Excerpta Medica, Inc. 0002-9610/99/$–see front matter
All rights reserved. PII S0002-9610(99)00122-1