To understand the argument, it helps to revisit what Abraham Flexner actually did. Commissioned by the Carnegie Foundation, Flexner toured medical schools across the United States and Canada and delivered a devastating assessment of a profession with weak oversight, inconsistent curricula, and thin scientific grounding. His remedy was sweeping: standardized curricula and assessment, formal university affiliation, faculty scholarship, laboratory training, and a curriculum anchored in basic science and clinical application. Drawing on German models that emphasized research and formal instruction, Flexner sought to make physicians better prepared and patients safer. By those measures, the report succeeded spectacularly, and it established the organizing principles that still govern medical education today.

But the reforms carried a hidden price. Consolidating training within well-resourced academic institutions forced the closure of schools that could not meet the new standards, and the burden fell unevenly. Of the seven historically Black medical schools operating in 1910, five closed, leaving only Howard University and Meharry Medical College. These institutions had been chronically underfunded, excluded from major teaching hospitals, and largely ignored by donors, making them acutely vulnerable to standards they had no resources to meet. Flexner himself held views that reflected the racial attitudes of his era, suggesting that Black physicians should focus on basic care and disease prevention in Black communities rather than full professional equality, a stance that influenced which schools survived.

Women in medicine faced a parallel contraction. Flexner acknowledged that women were formally admitted to most schools but attributed their low enrollment to declining interest rather than structural barriers, and he suggested their aptitude was best suited to fields such as maternal and child health. The closure of women’s medical schools and their consolidation into male-dominated institutions reduced pathways for women physicians and contributed to a prolonged decline in women’s representation across much of the twentieth century. Together, the authors write, these reforms contracted access to medicine for Black individuals and women by a full generation, and surgical education, concentrated ever more tightly within elite academic centers, amplified the exclusion.

The demographic echoes are measurable today. According to data cited in the analysis, Black individuals made up 11.6 percent of the U.S. population in 1900 but only 1.3 percent of physicians; by 1940 the figures were 9.7 percent and 2.8 percent. Currently, Black Americans represent roughly 13.4 percent of the population but only 7.8 percent of general surgery residents, while women account for just 37.9 percent of general surgery residents according to recent Association of American Medical Colleges data. Women comprise approximately 39 percent of fellowship trainees after general surgery residency, a pattern the authors link to persistent attrition discrepancies across the surgical training continuum. Of the four Historically Black Colleges and Universities with affiliated accredited medical schools today, only Howard University and Morehouse School of Medicine operate surgical residency programs, yet HBCUs continue to produce a disproportionately high share of Black physicians, faculty, and academic leaders.

Federal policy has repeatedly tried to repair the damage. Title VII programs, Medicare Graduate Medical Education funding, and affirmative action policies aimed to expand opportunity and address historical inequities. The physician shortage that Flexner-era consolidation helped create was partly offset by the Immigration and Nationality Act of 1965, which opened the door to international medical graduates who became essential to primary care, rural, and safety-net settings. That reliance, however, carries global costs, including the migration of highly trained professionals away from low-resource countries, a phenomenon known as brain drain, along with ongoing workforce inequities for international graduates themselves. The authors argue that the United States built a health system dependent on physicians trained abroad while constructing an immigration environment that keeps their presence perpetually uncertain, a structural inequity deserving the same scrutiny as domestic disparities.

The paper also sounds a contemporary warning. Executive orders issued in 2025, including Orders 14,148, 14,151, and 14,173, revoked workforce guidance for underrepresented groups, paused or rescinded diversity initiatives, and removed race- and gender-based preferences in federal programs. The authors draw a direct line between these actions and Flexner’s reforms: both were presented as neutral and merit-based, yet both risk ignoring unequal starting points and structural barriers that continue to shape outcomes. The lesson, they contend, is that reforms can pursue excellence and still cause harm when they ignore equity, and that good intentions alone are insufficient.

Against this historical backdrop, the analysis examines the machinery of modern evaluation. The Liaison Committee on Medical Education, established in 1942, and the Accreditation Council for Graduate Medical Education now serve as central levers for fairness in training. Although the LCME does not explicitly frame its standards around bias, requirements such as ED-21 and ED-23 mandate education in cultural competence and health disparities, while ED-30, ED-33, and ED-46 emphasize fair assessment and continuous quality improvement, and IS-23 supports holistic admissions. At the residency level, the Clinical Competency Committee, introduced by the ACGME in 2013 alongside the Next Accreditation System and the Milestones Project, replaced informal, program-director-driven assessment with structured, committee-based review of multiple data sources. That group-based deliberation protects individual trainees by reducing reliance on single evaluators and minimizing biased decision-making, and it can surface microaggressions that individual evaluations miss. The Program Evaluation Committee performs the analogous function at the program level, replacing episodic inspection with continuous, data-driven oversight of trainee satisfaction, patient outcomes, and recruitment.

Institutional culture, the authors stress, follows from leadership. They point to Washington University School of Medicine in St. Louis, which through formal anti-racism commitments, health equity curricula, and an Executive Faculty Task Force reported an 82 percent increase in underrepresented faculty and a 46 percent increase in female faculty, evidence that change requires structural investment rather than individual goodwill. Looking forward, the paper proposes evaluation frameworks that extend beyond operative volumes, milestone progression, and board pass rates to measure culture, belonging, mentorship, retention, empowerment, and leadership advancement, pairing quantitative metrics with focus groups, interviews, 360-degree evaluations, and climate surveys. Pathway programs such as Tulane’s IMPRESS and the University of Alabama at Birmingham’s PRISM and SURE initiatives have reported strong outcomes, with more than 93 percent of participants showing increased understanding of healthcare careers and 93 percent describing an enhanced sense of belonging in medicine. Federal agencies including HRSA, the National Institute on Minority Health and Health Disparities, and ARPA-H are increasingly funding such efforts, signaling a policy shift toward investing in human capital as a driver of both equity and excellence.

The ultimate message of the analysis is that excellence is neither static nor value neutral. Flexner established the importance of standards and accountability, yet his legacy demonstrates how reforms that ignore structural inequities can produce lasting harm. Contemporary accreditation, evaluation, and policy frameworks, the authors argue, offer an opportunity to reconcile those lessons by aligning educational quality with inclusion and social responsibility. Only by integrating historical awareness with equity-centered evaluation, they conclude, can the profession sustain a highly skilled and diverse surgical workforce capable of meeting the needs of the patients and societies it serves.

Subject of Research: Historical and equity-informed evaluation of surgical education programs from the Flexner era to modern accreditation policy

Article Title: Program evaluation and policy implications in surgical education: from flexner to the modern pursuit of access and excellence

Article References: Luo, X., Holmes, C., Pai, J., Rhodes, C., Bain, A., Paramesh, A., & Turner, J. (2026). Program evaluation and policy implications in surgical education: from flexner to the modern pursuit of access and excellence. Global Surgical Education – Journal of the Association for Surgical Education, 5(1), Article 141. https://doi.org/10.1007/s44186-026-00546-y

Image Credits: AI Generated

DOI: 10.1007/s44186-026-00546-y

Keywords: Flexner Report, surgical education, medical education, health equity, workforce diversity, ACGME, LCME, program evaluation, international medical graduates, residency training, holistic admissions, pathway programs