Flexner has fallen: Transitions in medical education system across time, a gradual return to pre-Flexnerian state (de-Flexnerization)

Table 1 Comparison between pre-Flexnerian, Flexnerian and post-Flexnerian era

	Original pre-Flexnerian status (proprietary model) corporate model	The Flexnerian revolution (academic model)	Re-emerging pre-Flexnerian status (re-proprietarization model) re-corporatization model
			The post-Flexnerian regression
Medical school ownership	Private practitioners and hospitals	University-based and academicians	Hospital-based, practitioners-owned
University hospital (academic medical centre) ownership and affiliations	Privately owned and funded	University-owned, publicly and charity funded	University-affiliated, not owned, or more precisely, the hospital owns the school, which is only nominally affiliated with the university, but operated like a proprietary private practice, an appendage accessory facility to a tertiary center
Accreditation and standard setting agency	Absent, determined by the practitioners needs	Rigorous, robust, determined by university and regulated by academicians	Paperwork stamping exercise, and determined by practitioners and hospital’s needs and philosophies
	Private practice ideals and standards	University-based ideals and standards	Private practice ideals and standards
Faculty status	Full-time private practitioners who part-time in teaching, no interest in research, and no academic interests or identity	Full-time academicians, with clear academic identity and values, high sense of scholarship, and education and research	Full-time practitioners who part-time in teaching, and clinical academicians are fulltime in name only
			Hospital job clinicians given academic titles without contributing to education or investigation (research)
Basic sciences status	Irrelevant, no labs, no cadaveric dissections, pure theoretical didactic teaching, no scientific training or engagement	Mandatory, fundamental, laboratory scientific training, powerful separate disciplines, strong scientific identity formation and engagement	Integrated to the point of irrelevancy, no laboratory training or exposure, no cadaveric dissections, just multimedia theoretical instruction, lack of scientific identity and engagement, which made most students look down on basic science
Clinical sciences	No clinical exposure, if any it was ambulatory, no in-patient exposure or involvement in caring activities or educational rounds, no observation of the totality of in-patient journey	Extensive clinical exposure, mainly in-patient, patients assigned to students, involved in caring activities and daily educational rounds, observation of the totality of in-patient journey	Poor clinical exposure, especially hospital based, replaced by community based, mostly ambulatory in nature or imaginary patients and scenarios or simulated clinical environment in skill labs
The profession (clinical practitioners) perceptions of the clinician academician	Negative: waste of talent and time, the clinical mission is the only mission	Positive: the best of the triple worlds (educators, researchers, and clinicians)	Negative: waste of time, irrelevant, postgraduate training is more important than undergraduate education
Basic scientists and non-medical academicians perceptions of clinical faculty	Negative: Not true academicians, nor scientists, just professional practitioners masquerading as academicians and scientists, imposters	Positive: Academic clinicians are investigators, scientists, and educators	Negative: Clinical faculty are academicians in title only, they are not trained in science, or educational theory and practice, they are practitioners who teach by emulation at best, and by telepathy at worst
Research status	Absent, no room for inquiry and discovery	Central, fundamental component of the school mission, faculty and students have to be scientists, not just practitioners	Revenue-generation is the primary motivator, students don’t need to be scientists, they just have to be competent and safe practitioners generating revenue
Student status	Customers, self-learners, no much of instruction	Students were active learners, teacher-centred curriculum, enriched the student-faculty interaction	Customers, student-centred curriculum and learning approach, meant less teaching and more self-learning, which led to low quality interaction between students and faculty, made the faculty redundant and led to disrespect of the faculty
			Teaching is frowned upon and shamed (the T-word), and learning is emphasized instead
			Faculty are not allowed to “hijacking” the educational process by daring to teach, and denying students the opportunity for self-learning, and that student empowerment requires faculty to resist the medieval urge to teach and to practice educational restraint and let students learn as an empowerment strategy
Dominant and major sources of revenues	Private clinical practice, student’s tuitions	Research grants, public funding of under and post graduate education, public and private not for profit charities funding of public clinical services	Expanding private clinical practice, escalating student’s tuitions and students enrolments to the detriment of quality
Aim after graduation	Vocational training and private practice or community hospitals	Academic university based postgraduate education and training, and academic practice	Vocational training and private practice or community hospitals