Towards higher ideals…Reflections on our current and our first accreditation experience

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The first accreditation visit to the Queen’s School of Medicine occurred in October of 1909, and didn’t go particularly well.

flexnerThe reviewer was Abraham Flexner, a rather determined iconoclast and career educator who had been commissioned by the Carnegie Foundation to carry out a review of all North American medical schools. Flexner undertook his charge with a shrewd earnestness that his biographers would later describe as “determination bordering on espionage”. He was both relentless and scrupulous, leaving no stone unturned and taking nothing at face value. He wasn’t above, for example, sneaking back into a school at night after the formal visit had ended to bribe his way into laboratories or wards from which he’d been tactfully steered away during the official tour. Some of his reviews were truly scathing, and would certainly lead to lawsuits today. Of the 155 American and Canadian medical colleges in existence at the time, fully 95 closed within the 20 years following the publication of his report in 1911.

blog58-imageQueen’s, at that time, was one of 8 Canadian schools in existence. Three were in Ontario (Toronto and Western being the others), three in Quebec (McGill and Laval, which had campuses in Montreal and Quebec City), Winnipeg and Halifax Medical Colleges. All were “proprietary” or commercial schools, operated by the medical community who charged students fees for instruction without standards for admissions, qualification of faculty, curriculum, teaching, assessment or any of the issues we take for granted today.

1909In 1909, the population of Kingston was about 20,000. In the School of Medicine 38 faculty (including 16 Professors) were responsible for the teaching of 208 students drawn largely from Ontario. The five-year program was expected to graduate students able to “comply with the requirements of the province in which they expect to practice”. The total income to the school, consisting entirely of student fees, was $19,978.

Flexner’s review was characteristically precise, perceptive and honest. He felt laboratory and library facilities were “adequate”. His major criticisms related to the paucity of clinical experiences – “the opportunities for out patient work are slight”. He expanded:

meded“The future of Queen’s is at least doubtful. It could certainly maintain a two year school; for the Kingston General Hospital would afford pathological and clinical material amply sufficient up to that point. But the clinical years require much more than the town now supplies. Its location – halfway between Montreal and Toronto, on an inconvenient branch line – greatly aggravates the difficulties due to the smallness of the community”.

However, he concluded by describing the school as “a distinct effort towards higher ideals”, and compared it favourably to a number of American schools he’d encountered in similar circumstances, holding out hope with the following observations:

  • “liberal policy has largely overcome the disadvantages of location in a small town”
  • “the thoroughness and continuity with which the cases can be used to train the student in the technique of modern methods go far to offset defects due to limitations in their number and variety”

The leadership of the school at the time was not amused. Dean Cowell’s report to the Board following the publication of Flexner’s report went as follows:

“The report of the Carnegie Foundation relating to Medical Education, published last summer, contained some statements and criticisms which are unfavourable to our school. As these were manifestly based on inadequate knowledge of the actual conditions, they have not been taken very seriously by the Faculty.”
(from Medicine at Queen’s 1854-1920, A.A. Travill).

And that, as they say, was that.

Last week, 105 years after the publication of Flexner’s findings, a team of six visited Kingston and again undertook to review our school, this time utilizing a rather extensive set of standards developed by both Canadian and American accrediting agencies. Although the full report won’t be available for a couple of months, the panel provided a preliminary report that appeared to find little fault with our core educational program, but did contain some rather eerie echoes of Flexner’s observations over a century ago. They felt the caseload available for teaching in some disciplines, for example, is low and the efforts put in place to offset this may require “ongoing monitoring”. At a number of points during the many meetings that occurred over the four day visit, the panel seemed to probe our ability, as a small school, to provide what appeared, almost surprisingly, to be a strong education and learning experience to our students.

The reality is that Kingston and the southeastern Ontario region does have a small and more senior population, tightly bound by our neighbouring schools, much larger and more diverse population centres, and our national border. This is as true today as it was in Flexner’s era.

So how does it work? Why has Flexner’s prediction, honestly and pragmatically derived, not proven true? How is it that this “effort to higher ideals” has not only survived but, I would humbly suggest based on our recent review, flourished despite the geographic and epidemiologic challenges?

The answer to these questions was in evidence this past week when our Dean, Vice-Deans, Associate Deans, Department Heads (every one of them by the way), hospital partners, Program Directors, Course Directors, Competency Leads, Administrative staff and students, met in a series of meetings with the accreditation team. What was apparent to myself and to the review panel as each group came through, was the same spirit of determined commitment to medical education that has sustained our school through the generations since Mr. Flexner’s visit. Such commitment trumps issues of size and location, converts potential liabilities into advantages and results in development of a particular and enviable learning community where education is valued in not only theoretical but also highly practical ways, where students are vitally involved, where innovation is very much encouraged, where conventional thinking is challenged, where problems can be solved with a phone call today rather than a meeting next month, where effort required is no barrier to a good idea, where people know, respect and support each other and share in the common mission because, quite simply, they care. They care about providing the best possible medical education experience for our students, they care about our school, and they care about each other. It’s really that simple, and it’s no secret. An “effort toward higher ideals”, indeed.

Anthony J. Sanfilippo, MD, FRCP(C)
Associate Dean,
Undergraduate Medical Education


A.A. Travill. Medicine at Queen’s 1854-1920: A peculiarly happy relationship. The Hannah Institute for the History of Medicine. 1988.

Abraham Flexner. Medical Education in the United States and Canada. New York. The Carnegie Foundation for the Advancement of Teaching. 1910.

Thomas Neville Bonner. Iconoclast: Abraham Flexner and a Life in Learning. Johns Hopkins University Press. 2002.

4 Responses to Towards higher ideals…Reflections on our current and our first accreditation experience

  1. Dr. Sanfilippo,

    Thanks for providing such a rich historical context and to your hard work throughout the process too.

    I have been interested by the discussion around professional identity formation in medical education and was at first a bit surprised to see this bold statement in an article recently:

    “a principal goal of medical education should be the development of a professional identity and that educational strategies be developed to support this new objective…expanding knowledge of identity formation in medicine and of socialization in the medical environment should lend greater logic and clarity to the educational activities devoted to ensuring that the medical practitioners of the future will possess and demonstrate the qualities of the “good physician.”

    The care and effort “towards higher ideals” that you describe as central to the QMed community creates an environment that undoubtedly supports the professional identity formation that is becoming an increasingly recognized central aspect of medical education.

    Now…how can that be measured that in an MCC objective or documented in an accreditation report???


    • Thanks Eve. In a professional education program, the whole becomes something greater than the sum of the parts. Although the whole is easier to recognize (“you know it when you see it”), the parts are simpler and much easier to objectively measure, and justify. So we must maintain attention on the components while never losing sight of the bigger picture, the “good physician” mentioned in your quote.

  2. Dear Tony: Kingston will always be halfway between Toronto and Montreal but it cannot afford to be halfway in any other domain. Queen’s is a superb medical school, well run, and palpably committed to its trainees. However, ensuring a bright future will require Queen’s affiliated hospitals to support/embrace the training/practice of clinicians who aspire to create and run clinical programs of distinction (i.e. perform high tech medicine and surgery). This will likely require them to reorganize in a more unified governance structure that better integrates care and to allow an integrated use of and accounting for their budgets. In addition, the Medical School should enhance its emphasis training of physicians and hiring faculty who perform research that is competitive internationally. This would better position Queen’s on the map while providing our patients with access to the latest in care. To ensure our continued relevance in Ontario we must be restlessly motivated to be competitive in offering cutting-edge technology and innovative clinical programs to our patients (neurosurgery, dermatology, bariatric surgery, TAVI, advanced heart failure therapies, organ and cell transplantation etc.). We must also recruit more faculty who are either clinical innovators and/or researchers who are successful in obtaining funding from CIHR/NSERC/CFI etc. Only by ensuring clinical and academic excellence will Flexner’s dismissive judgment be fully refuted

    • Very well said Steve. Your comments highlight the tight interplay of our clinical, research and educational missions. The great “learning environment” we all talk about is one in which our students are exposed to the best of clinical care, innovation and research. Complacency in any domain threatens the whole enterprise.

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