How the Flexner Report Changed Medicine

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Welcome to Stuff You Should Know, a production of I Heart Radio.

Hey and welcome to the podcast, I'm Josh and there's Chuck in

Jarger Binks is here too, and this is Stuff You Should Know about the Flexner Report.

That's right.

This was a suggestion by my wife.

Oh, that's a good one.

Yeah, Emily, of course, everyone knows if they listen to the show as an organic gardener

and an herbalist.

She said, has it long asked me to do one on the Flexner Report, which is a report written

in 1910 that did a lot of things, basically kind of revamped how medicine worked in the

United States moving forward in medical school in particular, but Emily was interested

because another thing it did, a byproduct, was it basically completely squashed what we

would now call alternative medicine, homeopathy, basically saying it has zero value and we're

not doing that anymore.

It's your dead, Biff.

Yeah, and it was also racist and sexist and it was definitely of its time.

This was a document used in 1910 for sure, and it definitely stinks of eugenics and all

that.

Yeah, so it's one of those weird things where like you can see it from all sides because

it did a lot of good and it also maybe didn't do some good in certain areas.

Yeah, for sure.

And there's not many people who are like, no, the Flexner Report sucks, it was all bad

because if you enjoy being treated successfully for cancer, you can pretty much thank the Flexner

Report for that.

But at the same time, yeah, if you believe that there are alternative therapies that are

as good or better than medications, then yeah, you probably don't like that part of the

Flexner Report.

But I think on the whole, it was a good thing.

There seems to be now among thinking people who don't just wade and wallow and dogma saying

like we need a new Flexner Report for the 21st century because it's basically run its

course.

And now again, it's become dogma and we need to do something about that.

Right.

I think that's a great setup.

And maybe we should paint a little bit of a picture about what medicine and medical school

look like in the United States, a pre-Flexner Report, who was bad.

It was bad.

I guess quickly we should say that Europe was doing it right before we were in France,

especially.

They had some pretty top-notch medical schools where they embraced real science and were practicing

medicine on people like as practice in colleges and stuff like that.

But in the United States, that was around 1850.

In the US in 1850, they had 52 medical schools.

This is what?

50, 60 years before the Flexner Report.

Medicine was not, you know, to be a doctor was not some prestigious thing.

Medicine was a trade.

If you were associated with the university at all as a medical school, it was a two-year

program.

The curricula was very, very broad.

They were super underfunded.

Even at places like Harvard, they had to pay for their own teaching supplies.

And those were the good ones that were attached to universities.

Right.

Yeah.

I mean, there were plenty of diploma mills.

There were a lot of proprietary medical schools where it was just some people got together

and created a for-profit school where they would teach you how to become a doctor, but

they were not doing a very good job of it.

And your admission requirement was the ability to pay the tuition fees, essentially.

Yeah, for sure.

You might have like redundant classes that literally went over the same things.

You might not have your hands on a scalpel ever.

You might not have an exam ever.

You may not see patients.

You might not have any contact with another human being at that medical school.

It'd be kind of like if you went to go skydive.

And in the class before you go skydive, they just talk about how hard the ground can

be if you hit it.

And then they take you up in a plane and push you out.

It's similar to something like that.

That's good.

Thanks.

I like it.

And everybody, the Civil War came around in the 1860s.

And there was wartime doctrine happening.

And after the Civil War, people came out of that saying, we're in trouble, everybody.

The doctrine wasn't so great in this war and we need to fix this.

Well, what I interpreted is that they went out and got real-world experience and realized

like the stuff they learned at school was not preparing them for actual medicine.

Oh, yeah.

I mean, I think it was a little bit of both.

I think the person who had their leg chopped off unnecessarily complained.

And I think the doctor who did the chopping might have complained as well.

Right.

They didn't teach me that patient's complaint in medical school.

Yeah.

So yes, regardless by the 1860s, like it was quite clear that American medicine was lacking

tremendously.

And the main reason for that was that the doctors who were practicing medicine had virtually

no actual training in medicine.

They were as lectures textbooks, that's basically it.

So there was a part of the progressive era, this actually, this push to create a movement

to make medicine in America better.

And by focusing on medical school education that came around in about the 1870s, it was

led by Harvard.

But really Johns Hopkins University was the one that really hopped on it.

Yeah, for sure.

Like Harvard got the ball rolling for a couple of decades.

And by the time Johns Hopkins opened in 1893, they became kind of the standard for the

American model moving forward, which as we see was based on the German model.

Right.

You had to have a first of all, you had to have a college degree just to get in.

And that was previously not necessarily the case.

No.

Unfortunately, they had full-time faculty.

They were medical scientists, so they weren't doctors on the side as well.

They were just fully employed to teach.

And they had a four year, like a full four year course of study, where it was hands-on

and a lot of laboratory work.

Yeah.

And yes, where they were actually working with patients or assisting other actual doctors

in working with patients.

Like it wasn't just like, sit there and listen to this lecture.

Yeah.

That was, and that essentially that Johns Hopkins model is what became the model for American

medical school.

And there's a lot of, there's a lot of talk at parties if you stop and listen about whether

this would have happened on its own or not.

And for the most part, it seems that yes, this progressive era movement would have gotten

there eventually, just because it was a good idea.

The Flexner Report helped it happen on a dime, because not only did it show to everybody

else, this is the way to do it.

It also said, this is very expensive, and here's how we need to get the money for it.

And did get the money for it.

Like that's how it was implemented.

Yeah, for sure.

The American Medical Association was founded in 1847.

And one of the reasons, and again, this is stuff that I learned from sort of Emily's

urgings.

One of the reasons the American Medical Association was founded to begin with was like on a mission

to squash homeopathy.

It says so in its charter.

And when the AMA was founded, they discouraged any association or communication with those

kinds of doctors and had a code of ethics.

It was a clause in there known as a consultation clause that said, if you even talk to a quote

and quote non-regular practitioner, then you're going to lose your license to practice medicine.

They carved out exemptions for Massachusetts in New York because it was, homeopathy was

really, really, really popular at the time among the elite wealthy Americans, like the

major politicians, the corporate leaders.

I think it was Rockefeller, I think it was Rockefeller that was under the care of a homeopathic

doctor for like 50 years.

So they carved out exemptions for those two states for a while until they were able, you

know, all those people died off basically and they were able to completely squash it.

Right.

Rockefeller died.

So I guess the homeopathy didn't work?

Well, he lived another like 48 years after being told he didn't have long to live, I think.

Oh, wow.

So homeopathy works, case closed.

So yes, I think that you've really put your finger on it.

The AMA became the arbiter of what qualifies as medicine in the United States.

Thanks to this Flexner report, it basically strengthened all of its position.

And yes, they were the driving force behind this initially.

They went to the Carnegie Foundation and said, hey, you got a lot of money.

Why don't you help us figure out how to change American medical education in the extraordinary

we want it?

And we'll help you figure out who to do that with.

We like the Johns Hopkins model.

We basically want a report that says the Johns Hopkins model is great.

Let's get an outsider in here.

And that is how Abraham Flexner enters this story.

Yeah.

And you know, this is not to say that he was like cooking the books or anything like that.

No.

And this was all a sham.

But that was just sort of the AMA was definitely after that.

Well, one of the reasons he was selected is he was already a person and educator who

espoused exactly this kind of stuff, just not necessarily as it applied to medical education.

He just wasn't exposed to medical education at the time, but he wasn't educational philosopher

and theorist and he was fully on board with that kind of thinking.

Yeah.

I mean, he wrote a book.

I guess we should say he, he did go to Johns Hopkins, but not for medicine.

I think he studied classic civilizations and he was a teacher in his hometown in Louis

ville, Kentucky.

Uh, eventually he was a private school headmaster that he founded the school.

And after earning a degree in psychology from Harvard, he wrote a book called the American

College, which was sort of the Flexner report of the university system as a whole.

And this guy named Henry Pritchett, who was the president of Carnegie Foundation at the

time, was like, yeah, like Josh, a clerk of the future will say, this is, this is our

guy.

Because did you see the way he came at the regular universities like wait till he finds

out what's happening in medical schools?

Exactly.

And then one of the other reasons that he was such a great candidate because he was an

outsider in a non-physician is that they were quite aware that there was going to be

a lot of blowback that there were going to be a lot of bruise degos and stepped on toes

and that somebody outside of the profession would be less likely to suffer, say, like a

professional injury or being ostracized for the rest of their career.

Yeah, Flexner was like, I don't care what you think of me, doctors.

That's right.

So he started out by researching the European models, the American models.

Like I said, he was really impressed with the German model.

Yeah.

And in fact, a couple of years after the American and Canadian, as we'll see Flexner

report, he published a European version which critiqued, well, Europe, basically everybody

but Germany.

Right.

He was very uncritical of the German system and we also need to point out some of the

bad things he said.

There were several anti-Semitic passages in the European version of the Flexner report

because he was so enamored of how the Germans did their medicineing.

Yeah.

This was, yeah, that German model also inspired the guy who founded Johns Hopkins Medical

School William Welch and that was essentially, so essentially the Flexner report said the

Johns Hopkins models, what we want, Johns Hopkins said the German models, what we want.

And the Germans said, yeah, yeah, yeah, yeah, yeah, no, this is Russian.

Das Boot.

That's German.

Nice.

What else?

The Heimlich maneuver.

Yeah.

That's it.

Brought worst.

Sider.

Okay.

Yeah.

All that stuff.

Octoberfest.

But with a K.

Should we take a break?

Yeah.

All right.

You're going to think.

Did you say, yeah?

Yeah.

We're going to think of some more German words or Deutsche words and we're going to be back

with more on what Flexner said right after this.

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Chuck, I could only come up with one more and it was strudal, but it's the best one.

Mmm.

Yeah.

Oh, wait.

Frankenstein.

Frankenstein.

Yeah.

That's it.

The bride?

No.

No.

What's his name?

It's a new Frankenstein movie.

I don't know.

The rock.

Who?

No.

No.

The director, Guillermo del Toro's.

Oh, no.

Frankenstein.

What did you think of it?

Well, it was pretty good.

I got a little bored, but it was.

Everyone said it was really great.

I think I was distracted.

Maggie Gyllenhaal is redoing the bride in like a really strange like out there kind of

fashion that looks interesting.

I saw that.

I thought it seemed super interesting.

And I love mags.

So I'm down.

Uh, okay.

Well, that's fine.

I'll allow it.

Uh, so back to the flexing report.

He started that research in 1908.

I think the thing came out in 1910 is like we said.

But he went around all over the place.

He went to 155 medical schools.

148 of which were in the United States.

Seven were in Canada.

Spend a couple of days there with his nose turned up.

And he did this for about 18 months.

Yeah.

And just to be clear here, this guy was not phoning this in.

He definitely took the assignment and did it to like he did it.

Like all of those those 155 medical schools in the US and Canada.

That was every medical school in the US and Canada, including ones that taught alternative

medicine and black medical schools in the United States.

So like he definitely went through the paces.

It wasn't just like a, yeah, let's look at Johns Hopkins and here's my report.

Yeah.

For sure.

And you mentioned the black medical schools because they come up pretty front and center

here in a minute.

Yeah.

But, uh, Johns Hopkins was the like the gold standard.

So that was his comparison point for all of them.

He looked at everything.

He looked at how they financed their school.

He looked at how big the classrooms were, how many teachers they had, per student, uh,

what it like admissions, what it took to get in.

They were actually teaching, um, laboratory stuff, facilities, kind of everything.

And what he came out with was one of three determinations in the end for each school.

Uh, the school is good.

You can stay.

You can keep your doors open.

Um, your school is not so great, but you show promise.

So maybe if you have some more funding and you change these things, you, you can be okay.

And then I'm sorry, please close your doors forever.

Yeah, there was a lot of them that he categorized as hopelessly deficient a lot, most

in fact.

Yeah.

And it wasn't just like him being a snooty butthead, like the, as we said, like the

medical schools in the United States were in a lot of cases, hopelessly deficient.

And that's a problem when you're producing doctors, you know?

So he did make a pretty good case that there were a lot they were hopelessly deficient.

But the deficient ones, they actually had different rankings.

For example, Iowa State University's medical school.

He basically said, uh, they're, they know what they're wanting to do, but the hospital

associated with it is too small, um, and the, the, your clinical faculty, the people

who are supposed to be doing research and teaching medicine to the students, they all

have their own private practices because they have to support themselves.

So if, if you gave this, this group enough funding, they could create a top notch medical

school in the Johns Hopkins model.

That was kind of like that deficient category, um, the varying degrees of how much money

you would need and whether you were, you're headed in the right direction.

Yeah.

For sure.

Uh, the way he wrote, uh, and what was called Carnegie Foundation bullets in number four

or medical education in the United States and Canada, aka Flexner Report was that, uh,

very muck raking style, um, it's not the kind of report you would, people wouldn't write

it this way today because he did get a little, it seems like he enjoyed sort of the put

downs and coming up with new ways of saying how bad a school was.

So people would write it that way today and fortunately, well, you're probably right.

One of them, he said apparently the inexcusable degree of ignorance begins just where the

ability to pay fees leaves off.

Right.

Right.

Yeah.

And so he was basically taking them to task over low admission requirements.

If any, but he didn't say low admission requirements.

He also used the word reeks, which you don't usually see in academic, um, studies.

Yeah.

He said that the osteopathic schools in the United States, there are eight of them that

they wreak of commercialism, that they attract students with a mass of hysterical exaggerations

that confidently appeals to the crude boys or disappointed men and women whom it successfully

exploits.

Yeah.

We should say osteopathie isn't accepted, um, form medicine in the United States now,

but a lot of people still view it as a pseudo-scientific alternative medicine.

Yeah.

I mean, he had a site set on them on chiropractors, on, on all kinds of things that, um, a lot

of people put a lot of great value in today.

So he was off based on some stuff for sure, uh, but again, this was 1910.

So, uh, the underfunded medical schools, and this was a problem too.

This is actually what, um, one of the things that befell black medical schools is we'll

see in a minute.

If you were underfunded, that was it.

Sorry.

Yeah.

No amount of funding is going to bring you up.

Well, maybe some amount of funding is going to bring you up to speed, but we need that

money to bring other medical schools that are closer up because they can bring more

of them up to snuff or we can bring fewer up to snuff and basically get the ones that

are the least funded.

His whole premise was just close those poorly funded ones because they're just not going

to be able to do this.

Yeah.

And, you know, he was probably on to something there because there was a glut of bad schools.

And his quote was the curse of medical education is the excessive number of schools.

The situation can improve only as weaker and superfluous schools are extinguished.

Right.

Like I said, it was Canada and the U.S.

Canada faired much better.

Our northern friends up there of the seven Canadian medical schools.

He only recommended one for closure.

So one seventh of them.

That's right.

The 148 medical schools in the United States, uh, more than half of them, he recommended

closing.

And I think it ended up being more than that even, right?

Uh, yeah, he actually recommended reducing the full number of schools in the, um,

U.S. and Canada from 155 down to 31.

Yeah.

That's four fifths.

Uh-huh.

So, yeah, I mean, like he was basically a hatchet man.

They brought him in to basically get rid of competing poorly funded, poorly run medical

schools.

He said, if you're a proprietary medical school, it doesn't matter what you're doing.

You're closed.

He saw, um, med school as a public trust that it should be publicly funded.

Ergo, they should be associated or attached to public universities and that the reason

that doctors were being produced was to help society along that you should not have

a board or stockholders to whom you were really kind of beholden to so they would affect

your decision-making.

No, you needed to be beholden to science, right?

And ideally to patients, although he didn't put much emphasis on that part.

Yeah.

And we'll, we'll talk about that at the end.

So every single proprietary school was immediately on the list, basically, from the jump.

Yeah.

Like if you weren't affiliated with the university, you had no hope for surviving this.

All the holistic or what we call alternative medical systems were completely shut down.

Um, five of the seven black medical schools were recommended for closure.

I think Howard University and DC and Mahari Medical College right here in Georgia, he

thought might be salvageable.

But there are a couple of chapters in there, chapter 14 specifically, the medical education

of the Negro was the title of that chapter where he shows a real disdain for black medical

schools.

He said they were wasting money, small sums of money annually, that undiscipline men

whose lack of real training is covered up by imposing MD degrees.

And he basically ended up saying like close most of these and my suggestion is just to

make black medical schools to train black doctors to treat black patients only.

And they should really just concentrate on hygiene.

Yeah.

They should, they should focus on public health in order to keep black people from spreading

disease to white people.

That was essentially his take on the purpose and for the existence of black doctors out

of 346 pages in the initial version of the report to chapter 14 was two pages long.

That is shocking in and of itself.

But the Flexner report was essentially the first like document about medicine in medical

school that even acknowledged the existence of black medical schools up to this point they

were totally invisible, completely ignored.

So the fact in a really silver lining to the cloud way of looking at this, the fact that

Howard University and Mahari Medical College in Georgia made the cut, yeah.

It was really substantial.

Like that was a, that was sadly a really big positive for black medical schools, unfortunately.

Yeah, for sure.

You know, I mentioned sexism to the AMA and the Carnegie Foundation were also not too

hot on the idea of the three women's medical college colleges even existing in Flexner

himself basically came out and said, I don't think women can withstand the mental

rigors of being a doctor.

He never met Elizabeth Blackwell.

Yeah.

No kidding.

And he literally said, you know, women make better patients than doctors.

This is the 1910s.

Yeah, it's not like 1810.

So yeah, so this was, I mean, I guess on the other way of approaching this too.

So we've talked about everything that he was giving the hatchet to.

If you had a version of what made an ideal medical education, and again, it was based on

the German model, which the Johns Hopkins model was based on, and he essentially said,

so you need to have rigorous instruction.

You need to have rigorous admissions requirements and you have to enforce them too.

And in doing so, he basically said, you're going to, you're going to weed out candidates

who aren't, they don't have, they can't make the cut for this new kind of doctor.

So that meant you had to have money to even get started, because this new model was so

much more expensive than the old model.

Three to, like, two wish and I think need to do it and increase three to four times just

to start to meet the funding for this.

So you, like, you just out of the gate had to have money to even try to apply to medical

school.

And then the, the academic requirements meant that even if you had money, if you didn't

have what it took to, like, really dedicate yourself to learning this stuff, you were going

to fail out too.

So in that sense, it, it took doctors from being just ordinary tradespeople and said,

these people are responsible for keeping the, the population of the United States healthy

and we're making sure that they are up to the task in, in return, they're rich now.

That's right.

You know, you know, part of it was, as medical school was expensive was because, or ended up

being more expensive is because they needed better facilities.

They needed better equipment.

I know we already mentioned that teachers were working part-time as doctors just because

they had to make a living.

But one of his big key recommendations was you have to have a full-time faculty that

is just doing biomedical research, like they're not doctoring on the side.

And in order to come up with this kind of money, it was expensive.

The idea of medical philanthropy really, really took off because, you know, John's Hopkins

was one thing.

But if you wanted to have more than one John's Hopkins-like model out there, you had

to lay out this roadmap of basically, you know, starting in 1910 and over the next

like a few decades and continuing today, these huge foundations were created and also local

groups just donating money to make sure the Flexner report was enacted, like the Rockefeller

Foundation, they gave hundreds of millions of dollars to get these programs going across

the country.

Yeah.

And it worked.

But again, it took hundreds of millions of dollars and I think 1910 money too.

Should we take a break?

Let's take a break.

All right.

We'll be right back with the closing act of the Flexner report.

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So we're back.

One of the results we talked about was all these school shutting down.

I think more within 10 years, I'm sorry, within five years of the report's release, more

than 50 of the medical schools in the United States shut down.

And 20 years on, only 76 of the original 148 in the United States remained.

Like you said, five of the seven black medical schools, 80% of the alternative medicine

programs were shut down.

And the handful of schools that had admitted women were either shut down or not admitting

women anymore for a while.

Right.

So like this was a huge impact on the way that doctors were created in the United States.

And again, the profession of doctoring in the first place.

And it happened very quickly, as you just mentioned.

And there are a lot of positives to it, but there are a lot of criticisms to the outcomes

too.

One of the big ones is the impact that the Flexner had on producing black doctors in the

United States.

I saw an estimate that had all seven of the black medical schools stayed open and been

funded so that they could follow this model.

Another 30,000 black doctors would have been produced to the United States between 1910

and 2012, I think, which is a big deal because apparently right now, 2% of American doctors

are black.

But the percentage of the black population in the American population overall is 13%.

So they're grossly underrepresented, which is another problem in and of itself because

studies show that black patients are likely to follow the orders and instructions of black

doctors than they are of doctors of other races.

They just, it's just a question of comfort.

Yeah, for sure.

And you could also make an argument that that gave rise to things like the Tuskegee experiments

and other like awful experiments carried out by white doctors on black patients that

led to the cycle of mistrust of the medical profession as a whole.

Yeah, there was a whole, like part of this, this emphasis on science and because Flexner

was not a physician, he really ignored the idea of the physician as a healer.

The physician is somebody who was meant to see their patients as human and instead because

of this focus on rationalism over humanism, the patient became essentially just a walking

bag of medical issues that needed to be diagnosed and treated.

They weren't a person that stuff didn't matter.

The point of the doctor was to treat their illnesses and make them better not to be their

friend.

And in doing that, like the medical profession lost a lot of, I guess, connection with the

rest of us where doctors are kind of looked at as looking at the rest of us is not fully

human.

And that doesn't really jib and feel good when you're a patient.

Yeah, for sure.

I think I can't find it.

It's not in front of me now, but I sent you one study from a few years ago where I think

the long and short, but it was they were surveying people that how happy they were with like

the end of care, care for relatives.

And I think only 40% of the people were satisfied with like how they're the end of the lives

of their relatives went and a lot of that had to do with pain management and that sort

of ties back to what you were saying about just sort of the rigorous, you know, eyeballs

on a microscope and not like eyeballs on a human, you know, it all sort of tied in together

I think.

And the other way that that manifested itself was a huge emphasis on separating academic

physicians from practicing physicians so that the academics could just focus on research

and then they emphasized the research that the academics were producing like that's

the most important thing.

You clinicians listen to the research doctors and what they're finding and then you can go

apply it to your practice.

And so they were like, well, you've taken these people away from patients and they're just

using like this, the scientific mentality and there's no humanism to it.

And they critics say that was one of the ways that this whole idea of science losing

its humanity or medicine losing part of its humanity or soul came about.

Yeah, for sure.

You know, I know we've already mentioned a little bit about eliminating sort of all kinds

of alternative medicines and that homeopathy was homeopathy, homeopathy, what do you say?

I've heard both.

Okay.

I was saying both at the same time was very popular at the time.

I mean, there are people that think that they were doing pretty well with homeopathy and

curing disease with natural remedies.

Other people will say, no, you've got your tinfoil hat on and that's not the case.

They just didn't know real science at the time.

So there's a lot of raging debate online about that kind of stuff.

Another point of this all is that psychiatric medicine lost a lot of, I guess, curricular

elements that were very beneficial at the time for mental health treatment.

They were making a lot of strides at the time with things like meditation and how nutrition,

like food can alter a person's or lifestyle can alter a person's mental health.

And that was all just sort of flesh down the toilet because of this.

And the neurochemical model came out of mental illness.

And the same people that were arguing for homeopathy basically said, you know, what the flexion

report really did was among other things was let us down the path of people like the

Rockefeller Foundation, creating big pharma essentially and getting people on endless amounts

of medicine that just don't heal you and they're just never ending and make big pharma

bigger.

Yeah, psychiatric medicine is a good example of that.

They just took the neurochemical model of mental illness and that that was that.

I mean, I think a lot of that stuff has come back now.

Yeah, for sure.

It's just not super funded and you're not going to find any like huge, you know, medical

schools that that tout their homeopathy departments or anything like that.

But I think the there's underground movements for all that stuff like, hey, meditation

can help your mental health.

And maybe these herbs can make you feel better or this honey that you rub on your

cut is better than back teen or whatever.

You really is.

If you see a good psychiatrist, especially probably a younger one these days, one of the

first things are going to ask you is, how are you sleeping?

Are you exercising what you die at like?

Yeah, totally.

And then they'll start to go into meds, but like they're going to say like you need to really

pay attention to these three things.

And if you still need meds, it'll still drastically reduce the kind or amount of

meds you'll probably need.

Right.

If you're taking care of yourself in the other ways, exactly.

So that has definitely come back in psychiatry.

And that's a really good example of what a lot of people point to the flexion

report suppress that for a hundred years.

It derailed black doctors, it derailed women doctors, it derailed alternative

medicines.

It even took the stuff that was part of the medical establishment and twisted it

around and it took a full century for things to start to even come back.

And that again is a really big criticism of the whole thing.

But overall, you can point to a lot of stuff, a lot of lives that were saved, a lot

of lives that were improved, a lot of life spans that were extended because of this

Johns Hopkins German model that the flexion report, essentially with the AMA,

got the Rockefeller foundation to fund and create this new model for America.

Yeah.

This is one of those rare episodes where there's truly like two ways to look at it.

I mean, he'd definitely threw the baby out with the bath water in a lot of cases.

But you could also argue that like it was such a mess that like something drastic

had to happen or else it, you know, who knows how many more decades it would have

taken. I mean, I definitely agree with you that like it would have happened at some

point. I doubt if we'd still be sitting here today, had the flexion report not been

written and like I'm sitting here with like a leech on my forehead.

Right.

I have typhus.

Yeah, exactly.

Yeah, I agree with you.

Chuck, this is a good one.

Thank you, Emily, for it.

Thanks, Josh.

You're welcome.

That was a great Emily.

Nice seeing you in San Francisco, buddy.

Yeah, it was great to see you too.

I don't know why I'm talking like you, but I'm

if you want to know more about the flexion report, go out and read us.

346 pages of muck raking gold.

And since I just wrapped up this episode as if it were from 2010, I think it's

chucked time for listener mail.

That's right.

This is from Kyle.

Hey, guys, I'm sure you've heard this over the years.

Maybe you received snarky emails from people saying, what do you mean?

I should know this.

Oh, yeah, I like this email.

Thanks for picking it.

In a way, it makes it seem like they interpret it as stuff you should already know,

but I always took the approach that a quintessential SYSK episode should slide

on something that a person should know in order to give voice to situations,

regions, historical events, things like that, something we should know today to

help learn and grow.

And Kyle, that's of course always been the case.

Yeah, it's stuff that we think you should know, which we want to share with you.

But it is interesting to learn how the son of the jackhammer works I found.

I see what you're doing there, Kyle.

I found that the Helen Keller and Ann Sullivan episode was exactly what I think of

as a great stuff you should know episode.

My only knowledge of Helen Keller was what I had learned from the late 90s and

ought media and pop culture.

So thank you for showing me how amazing both of them were as people,

activists, advocates and his friends.

The lives of Keller and Sullivan is something everyone should know.

Thank you.

That is from Kyle.

Thank you right back, Kyle.

That was a world class email.

Don't you think Chuck?

Yes, Kyle, that was wonderful.

Yeah.

So if you want to knock it out of the park with an email like Kyle did,

wrap it up, spank it on the bottom and send it off to stuff podcast at iHeartRadio.com.

Stuff you should know is a production of iHeartRadio.

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