History Lesson: How the Flexner Report Shaped Occupational Therapy Reimbursement in the United States

The Flexner Report had a large influence on the course of healthcare in the US despite being over 100 years old. In the early 1900s, education for physicians was less standardized. There were many for-profit schools with much lacking uniformity. Physicians in the 19th century attained their medical education in 3 possible systems: apprenticeship, proprietary schools (e.g., lectures), or a combination of didactic and clinical training at lecture halls and the hospital. We often think of modern medical students as scientfically-based, but at the time, there was much heterogeneity in education for the physicians in America. Medical schools taught diverse subjects in addition to medicine such as osteopathic, homeopathic, chiropractic, eclectic, and botanical.

So the American Medical Association lobbied for the standardization of American medical education through the second half of the 19th century. An educational reformer, Abraham Flexner was hired by the Carnegie Foundation at the urge of the American Medical Association in response. Flexner was influenced by German Medicine and an approach focused on laboratory sciences and research. Breakthroughs such as clinical and laboratory research showed the effectiveness of treatments such surgery, vaccination, and sanitation in contrast to blistering, bleeding, and purging. Eductors at the time asserted that medical students spend more time engaged in laboratory experimentation and bedside care.

Institutionally, medical schools saw a reform in more standardization and the AMA sought to eliminate schools that failed to adopt these rigorous standards. This is similar to the accreditation process and standards that ACOTE sets for occupational therapy programs. Over time, Flexner visited all of the 155 US medical schools. A side-effect of this was that schools was fewer financial resources had difficulty meeting this criteria and were forced to close. This included many medical schools that served minorities such as students of color and women. Along with this was an increase in the numbers of White male medical students. The consequences allowed only the upper class and upper middle class to afford medical school education. After the Flexner Report, medicine became more standardized and rigorous, but unfortunately, less diverse and attainable.

What about the impact on other professions? The AMA and Flexner’s actions had an effect on the scope of practice for themselves and echoed into other professions. The AMA even opposed the expansion of the scope of practice of nurses. At the time, nurses were trained with responsibilities similar to that of a maid. Unlike today, becoming a nurse at the time did provide one with any social status or financial independence. This likely had an indirect impact on occupational therapy at the time as well – during a time of common mental health practice. The financial issues of the depression had an effect in the development of the profession, but the Flexner report and lobbying as well.

In the 1930s, the American Occupational Therapy Association (AOTA) even asked the AMA to establish standards for training institutions and to take over the accreditation of occupational therapy schools. Also in the 1930s (before NBCOT was created), AOTA was the association that certified occupational therapy practitioners and maintained a registry of qualified individuals. Because the AOTA was concerned with potential antitrust liabilities for being involved in both certification and providing membership services, AOTA decide to create the American Occupational Therapy Certification Board (AOTCB), which was later renamed the NBCOT in 1996.

This extension of the Flexner report’s influences helped to place occupational therapy into ancillary medicine, but it limited nonmedical practice opportunities for the future of occupational therapy. Brenda Howard in the AOTA article, “How High Do We Jump? The Effect of Reimbursement on Occupational Therapy”, mentions how this started the struggle for the profession between mental health from the Moral Treatment movement versus the medical and scientific model from the Flexner Report.



  1. Rothstein WG. American Physicians in the Nineteenth Century: From Sects to Science. Baltimore, Md: Johns Hopkins University Press; 1972.
  2. Ludmerer KM. Learning to Heal. New York, NY: Basic Books; 1985
  3. Prislin, M., Saultz, J., & Geyman, J. (2010). The generalist disciplines in American medicine one hundred years following the Flexner Report: A case study of unintended consequences and some proposals for post-Flexnerian reform. Academic Medicine, 85, 228–235.
  4. Nation. Bd. Certif. Occup. v. Amer. Occup. Therapy, 24 F. Supp. 2d 494 (D. Md. 1998) U.S. District Court for the District of Maryland – 24 F. Supp. 2d 494 (D. Md. 1998) September 30, 1998
  5. Howard, B. (1991). How High Do We Jump? The Effect of Reimbursement on Occupational Therapy. American Journal of Occupational Therapy