In the early decades of the twentieth century, the United States underwent a transformative upheaval in medical education that continues to reverberate through the healthcare system today. This period saw a significant contraction in the number of medical schools, an outcome driven by widespread concerns about inconsistent and often substandard training. A recent groundbreaking study by researchers from Carnegie Mellon University, Stanford University, and Marquette University has now shed new light on the significant consequences of these closures, revealing surprising impacts on physician distribution, nursing trends, and even mortality rates across U.S. counties.
The catalyst for this upheaval was the 1910 Flexner Report, an exhaustive evaluation of medical schools commissioned by the Carnegie Foundation and authored by Abraham Flexner. The report laid bare the disparities and lax standards prevalent in the medical education system, particularly targeting the many proprietary medical schools that had proliferated in the late 1800s. Flexner’s recommendations were uncompromising: the majority of these schools should be shuttered or integrated into university systems to elevate educational quality and professional rigor. Between 1905 and 1915, more than 40% of American medical schools either closed down or merged with other institutions.
Much like an epidemiological event, the closures propagated a ripple effect through local healthcare infrastructures. The study in question meticulously quantified these effects by combining data from U.S. Census records spanning 1900 to 1930 with county-level vital statistics concerning mortality. To measure the intensity of school closures in each county, the researchers crafted an innovative index accounting for proximity to shuttered institutions, the historical output of graduates from these schools, and the timing of the closures. This composite measure allowed them to correlate supply shocks in medical personnel with subsequent health outcomes in a statistically robust manner.
One of the study’s most counterintuitive findings is that medical school closures led to a decline of about 4% in physicians per capita within counties located less than 300 miles from the closed schools. This proximity effect underscores how local medical ecosystems were particularly vulnerable to disruptions in training capacity. Interestingly, the reduction in physician numbers did not equate to poorer health outcomes. On the contrary, infant mortality plunged by 8%, non-infant mortality dropped by 4%, and overall mortality declined by 3% in counties experiencing average closure intensity. These statistics defy simplistic assumptions that fewer doctors necessarily translate to worse public health.
The researchers explored the underlying dynamics driving these counterbalancing effects. Central among them was a change in the quality composition of physicians. Physicians trained at shuttered medical schools suffered reputational damages, affecting their clinical practice and career longevity. Simultaneously, a decline in younger physicians entering the workforce was partially offset by an increase in the retention of older doctors who postponed retirement, thereby stabilizing care availability. Moreover, there was a noted migration of physicians toward areas with higher closure intensity, illustrating adaptive behavior in the medical labor market that mitigated supply shocks.
Parallel to these shifts in physician distribution, the study found a significant rise in nursing personnel—approximately a 7% increase in nurses per capita in affected counties. This surge likely reflects a market adjustment whereby nurses filled gaps left by the tightening supply of physicians and contributed to maintaining or even improving patient care standards. Conversely, midwife numbers remained largely unchanged, indicating that nursing—as opposed to midwifery—was the principal beneficiary of this healthcare restructuring.
Delving deeper into mortality data, the researchers identified that reductions were especially pronounced in diseases sensitive to physician quality. Infectious diseases and conditions prevalent in early infancy, which demand precise diagnosis and treatment, showed the most substantial declines. The study’s scope ruled out confounding influences from factors such as public health department capacity, hospital infrastructure, or municipal sanitation investments, none of which correlated positively with the observed mortality improvements.
This nuanced interplay between supply-demand shocks in medical labor and health outcomes provides pivotal insights into the role of educational quality in shaping public health. While the closures reduced the number of newly minted physicians, they effectively eliminated practitioners with substandard training backgrounds, resulting in an overall uplift to medical care quality. Such a finding challenges conventional wisdom by highlighting how reducing quantity in favor of quality can yield tangible benefits in patient survival.
The implications of this research resonate beyond historical curiosity. Modern healthcare systems grappling with physician shortages, uneven quality training programs, and geographic disparities in care provision may find valuable lessons in the Flexner-era reforms. Policies aiming merely to expand the number of healthcare providers without stringent quality controls might inadvertently compromise population health. Conversely, strategic consolidation and enhancement of medical education infrastructures can foster a more competent and responsive healthcare workforce.
Additionally, the study signals the critical importance of market adjustments and labor mobility in absorbing shocks to medical personnel supply. The observed postponement of physician retirements and inter-county migration highlight the adaptability of healthcare practitioners when faced with systemic disruptions. These mechanisms help buffer patients from potential care deficits during periods of professional scarcity.
Significantly, nursing emerged from this era as a vital pillar of local healthcare ecosystems, augmenting the diminished physician workforce and likely contributing to mortality reductions. This evolution underscores the complementary roles of different healthcare professions and suggests that bolstering nursing capacity can be an effective response to disruptions in physician supply chains.
While the research acknowledges that the specific mechanistic contribution of physicians cannot be fully isolated, the broader evidence supports the hypothesis that improving educational standards and reducing the prevalence of poorly trained doctors can have profound population health benefits. The careful construction of school closure intensity indices and their correlation with robust mortality metrics offers a compelling methodological blueprint for future analyses of educational policies and health outcomes.
In sum, this study illuminates a critical chapter in U.S. medical history with contemporary relevance. The upheaval initiated by the Flexner Report’s recommendations, while initially disruptive, ultimately facilitated a marked improvement in healthcare quality and patient survival. By strategically pruning low-quality medical schools, a substantial number of infant and non-infant lives were saved annually—an estimated total of over 50,000 across the nation.
This research provides a cautionary yet hopeful message for policymakers, educators, and healthcare professionals: quality in medical training is not merely an academic concern but a determinant of life and death. The legacy of the Flexner reforms demonstrates that elevating educational standards can trigger profound positive externalities in public health, a lesson as urgent today as it was over a century ago.
Subject of Research: Effects of early 20th-century U.S. medical school closures on healthcare workforce distribution and mortality rates
Article Title: Medical School Closures, Market Adjustment, and Mortality in the Flexner Report Era
News Publication Date: 18-Jun-2025
Web References: http://dx.doi.org/10.3386/w33937
References:
Carnegie Mellon University, Stanford University, and Marquette University research collaboration; NBER Working Paper W33937
Keywords: Infant mortality, Mortality rates, Medical degrees, Educational attainment, Medical treatments, Preventive medicine, Nursing, Midwifery, Hospitals, Public health
