Medical license: Citizenship Required?

Immigration policy presents one of the most fraught, contentious political issues in America today. While much of the focus in recent years centers on illegal immigration, nearly a century ago, state medical boards grappled with an immigration challenge of their own: Medical professionals educated outside the US and seeking to practice in this country.

Foreign-trained physicians, especially those from England, Germany, Frances, were generally viewed as welcome additions by American doctors in the late 19th and early 20th century. Because of the vast disparities in US medical education at that time, many (if not most) of these foreign practitioners possessed education and training exceeding that of many American physicians. By the 1920s, the socio-political climate in America turned markedly unreceptive to most immigrants, even physicians.

1920-immigration-records_555

Much of this change in sentiment stemmed from a shift in immigration patterns beginning in the 1890s with the start of a large influx of immigrants from southern and eastern Europe. This trend had solidified such that by 1924 federal law introduced immigration quotas distinctly unfavorable to immigrants from areas other than northern and western Europe.

State medical boards soon reflected the tenor of the times. In 1923, New York state amended its medical practice act to require U.S. citizenship as a condition for admission to their licensing exam. By mid-1926, more than half of the states followed suit with varying requirements that linked the acquisition of a medical license to an individual’s citizenship status.

us_naturalization

Eleven states required full citizenship as a requirement for obtaining a medical license: Arizona, Arkansas, Florida, Illinois, Indiana, Kansas, Kentucky, Mississippi, South Dakota, Tennessee, Wyoming

Another ten states required the physician to have taken out their naturalization papers. Alabama, Delaware, Louisiana, Maryland, Michigan, New Hampshire, North Dakota, Oregon, Texas, Virginia.

Five others requiring the physician to declare his/her intent to become a US citizen: Minnesota, Nebraska, New Jersey, New York, Ohio

Medical boards generally supported, and in some cases urged introduction, of these requirements. In so doing, however, the arguments they presented for them often reflected professional concerns rather than those one would categorize as regulatory in nature.

Too often the language accompanying discussion of immigration and requirements specific to international medical graduates (IMGs) featured language that hinted at concerns other than public health or patient safety. Terms like “alien invasion” crept into the editorials on the subject. One writer argued the necessity of linking citizenship status to licensure as a mechanism for keeping out those physicians who were “not properly qualified.” Such a statement seemed reasonable enough on the surface but a nativist sentiment evinced itself with his additional call to keep out those who “in other respects are undesirable.” Exactly what constituted an “undesirable” physician was left unstated.

By the end of the 1930s, all but a handful of states and the District of Columbia required either citizenship or “first papers” for naturalization as a condition for medical licensure. The AMA took a hard line. In 1938, their House of Delegates adopted a resolution calling for all foreign-trained physicians to have full citizenship as a condition for licensure.

Incautious comments from leaders in medical regulation hinted at reasons other than patient safety for the desirability of these requirements. One president of the Federation of State Medical Boards admitted to an “economic aspect” to the immigration issue—an unsurprising admission considering the massive economic downturn in the US in the 1930s and one that feels a bit presumptuous of me to criticize from my comfortable economic vantage point nearly a century later.

But as he continued his comments in 1939, this regulator also spoke vaguely about the need for “tests” of fitness based upon “respect” and “ethical” adherence to democratic principles; even asserting that the “alien who can meet these tests must be the exception.” Today, political pundits and columnists often comment upon politicians speaking to their base through indirect or coded language, e.g., “dog whistling.” While not speaking to a political base, this former FSMB president implicitly signaled his position on physician immigration for reasons other than those appropriate for a regulator.

loyalty reds

Certainly, there were members of state medical boards that balked at proposed litmus test style calls for political loyalty. And in some states, the decision to link medical licensure with citizenship status arose from legislators. Yet there is also evidence that these citizenship requirements arose more often from medical board regulations than state law.

Connecting a physician’s competence with his citizenship proved legally tenuous. The Harvard Law Review examined this issue through a skeptical eye in 1939 and within several years multiple state attorneys general ruled against such requirements. With the outbreak of war in Europe, an influx of refugee physicians to the United States brought immigration back into the headlines but with a more sympathetic view as evidenced by the 1941 report of the National Committee for Resettlement of Foreign Physicians.

refugees

Their report recommended medical boards require only that naturalization papers be filed with a ten-year period to obtain citizenship.

This reactionary spasm against physician immigrants to the United States waned in the early 1940s but renewed focus on IMGs returned in the post-war years. A sharp increase in the number of IMGs, both those displaced by war and those seeking educational opportunities in the US, placed a different question in the forefront: How do we evaluate the credentials and qualifications of these professionals?

The opinions cited are those of the author and do not reflect the views of the Federation of State Medical Boards.

 

Sources

Bulletin of the Federation of State Medical Boards, September 1923

Bulletin of the Federation of State Medical Boards, October 1923

Bulletin of the Federation of State Medical Boards, August 1926

DA Johnson, HJ Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards

The Forgotten Chapter of the Flexner Report

Spend a few cursory hours reading or writing about U.S. medical education and you’ll bump into the “Flexner Report” and its author Abraham Flexner. If you’re reading this blog, it’s safe to assume you’re somewhat familiar with the report and its impact on medical education. The report’s influence has been debated for generations—some point to the report as the main impetus for educational reform, others caution against assigning an overly large causative role. Few today can debate the report’s distinctly negative consequences for historically black medical colleges.  Still, any reasonable assessment acknowledges the report as a significant milestone in U.S. medical education.

220px-Picture_of_Abraham_FlexnerBut for all the supposed familiarity with the report by those who love to reference it, one portion has been largely forgotten and seldom cited—chapter 11 dealing with state medical boards.  I re-read this chapter recently. What struck me most in revisiting the text was Flexner’s juxtaposition of praise and criticism of state medical boards. I found myself momentarily flashing back to 10th grade English, Julius Caesar and Marc Anthony’s funeral oration: “I come not to praise Caesar but to bury him.”

Okay, that may have been a bit much so let me be clear. I’m not accusing of Flexner of being disingenuous or damning state medical boards with faint praise…but he does take the reader on a bit of roller coaster. The opening sentence of chapter 11 set forth the inherent potential for medical boards to bring about pronounced, positive changes to medical education: “The state boards are the instruments through which the reconstruction of medical education will be largely effected.”

Remember, at the time of Flexner’s writing, U.S. medical education featured a wide disparity in the quality of schools (e.g., entrance requirements, facilities, faculty, clinical training, etc) with most schools being private, proprietary endeavors operating without any university and/or hospital affiliations. (These schools were the main target of Flexner and many other educators.) For Flexner, the greatest service state medical boards could provide involved “crushing” the outlier schools proliferating on the fringes of medical educations…what he deemed “notoriously incompetent institutions.”

reportFlexner identified three weapons at the disposal of state medical boards—all of which derived from their statutory authority bestowing varying degrees of oversight/influence on education within their state. These powers included…

  1. Mandating preliminary education requirements for physicians (e.g., 1-year college course work prior to matriculating medical school)
  2. Authority to recognize/approve acceptable medical schools
  3. Authority to require an examination as a condition for medical licensure

Flexner viewed the latter as particularly critical. He characterized the licensing exam as the “lever” with the potential to raise medical education and the profession as a whole. He wasn’t subtle about this either. You can almost sense a Machiavellian relish at the thought of what can be done to those substandard proprietary schools when he writes, “…the power to examine is the power to destroy.”

But then, almost as if he were awakened from his dream of an imagined medical school future, Flexner grumpily catalogs all the nagging contemporary realities of medical regulation…and there were admittedly many that frustrated the reform-minded educator.

Flexner’s lamentations

The composition of state medical boards troubled Flexner greatly—too often they were “not strongly constituted.” He lamented that membership too often featured politically-motivated appointments and that medical school faculty were prohibited from serving.

While a champion of the medical licensing examination, Flexner lamented the boards’ reliance upon written exams and the booming industry in preparation materials (“State Board Questions and Quiz-compends”). For Flexner, only a “practical” exam touched the “heart of the matter,” i.e., the ability and fitness of the physician to treat patients safely. At the time of his report, only Minnesota and Ohio were experimenting with practical exams.

State boards were poorly resourced. Flexner lamented the lack of staff—often just a single person, the board secretary—and inadequate funding. “A bureau properly organized cannot live on small fees.” His list continued, citing the persistence of sectarian (homeopathic, eclectic) licensing boards, unreasonably diverse states laws regulating the practice of medicine, etc.

And yet despite the gloomy depiction throughout much of this chapter on the role of medical boards, Flexner still found reason for optimism. “Despite imperfect and discordant laws and inadequate resources, the state board has abundantly justified itself.” He sensed a motivating esprit de corps and pointed to signs of collaboration (e.g., reciprocity agreements) as reasons for hope.

While he didn’t cite it as a basis for optimism, the greatest hopefulness stemmed from a simple fact: state medical boards were the only entities with the statutory authority to compel change. The Association of American Medical Colleges (AAMC) could promote high standards for education; the AMA Council on Medical Education could survey and categorize schools into Class A, B, C institutions…but only state medical boards could embed best practices and classification systems into law.

It seems that Flexner’s laments on state medical boards stemmed directly from his recognition that they were the 600 lb. gorilla that could bring the future he envisioned just a little closer.

The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards.

“If you know you can do the job, go for it.” Women in medical regulation

I drew the title for this blog entry from a 2012 commentary by Dr. Susan Behrens published in the Journal of Medical Regulation. In her commentary, she reflected on the series of event that led to her becoming the first woman elected as Chair of the Federation of State Medical Boards (FSMB) in the late 1980s.

Behrens_Susan_1Recently, I re-read her commentary; several things stood out to me. One was the strong sense that a woman running for elective office in the 1980s—even within a national association rather than political office—was not a matter to be taken lightly as missteps by a candidate served as potential fodder for the larger narrative of critics. Thus, in mulling over whether to run for the office, Behrens consulted two influential women in medicine at that time: Dr. Edithe Levit, President of the National Board of Medical Examiners and Dr. Nancy Dickey, member of the AMA board of trustees. Their advice boiled down to what you see as the title for this piece.

Another point that caught my eye was a number put forth in the article. Reflecting back on the first FSMB annual meeting she attended in the mid-1980s, Behrens recalled an afternoon gathering of the women members of state medical boards in attendance. As she recalled, “There were about seven of us.” Once my initial reaction (“That’s all?”) wore off, I began thinking seriously about this number. Was the actual number of women serving on state medical boards really that low in the 1980s? Or was this a nostalgic but skewed recollection of a different time? I decided to a closer look.

Starting in the 1980s, the FSMB produced an annual directory (FSMB Handbook) listing key information on every state medical board, including the names of every individual serving on a board. I poured over the handbook for 1985 and applied a crude metric, i.e., categorizing by gender based upon name and google searches to identify individuals whose names seemed non-suggestive of gender.

I know, I know—this is an imprecise methodology considering today’s non-binary gender identification but…sometimes we have to work with what we have, not what we wish we had.

handbook photoThe 1985 FSMB Handbook listed 66 state medical boards with a total of 602 individuals serving throughout the country; only 99 (16%) were women. In fact, most of the women serving on state medical boards were non-physicians in public member or ancillary health profession roles. Dr. Behrens was one of only 40 female physicians serving on medical boards in 1985—6.6% of the total state board membership.

chart 2

Dr. Behren’s memory was probably accurate in remembering about 7 women at the FSMB annual meeting as total attendance was usually at or below 300 attendees in those days.

The statistically-minded reader is probably thinking, “Yeah, the numbers were low but put’em in context, Dave!” Okay. In 1980, there were roughly 37,000 women physicians (MDs) in active practice out of a total MD workforce in the U.S. of 459,000. I’ll save you trouble of doing the math—it’s about 8% which makes the 6.6% figure less startling.

But here is something that really blew me away. Forget total numbers of women or women physicians serving. Instead, think in terms of medical boards. How many state medical boards had any gender diversity in those days? Get this. There were 17 state board with no women members serving in 1985. There were another 19 boards with no women physicians serving. In total, over half (36) of the medical boards listed in the FSMB Handbook in 1985 had no women physicians. Let that sink in for a minute. Remember, we’re talking 1985, not 1885. I can’t help but wonder what the impact of this absence was on board discussions and policy-making.

Fast forward to today. The FSMB’s membership database shows a demographic composition slowing aligning to more accurately reflect the physician workforce—though “slowly” seems the operative word.

chart 1

FSMB records list 774 individuals serving on state medical boards nationally at the end of 2018 with women constituting 33.8% of the total. Female physicians are now almost 20% of total state board membership. This sounds pretty good until you realize that’s a still fair distance from their 33% of the national physician workforce with an active license as reported by the FSMB in 2016. Hmm. Glass half full or half empty?

On the plus side, I would point to this. There were only 2 medical boards (out of 70 total) with no women serving in 2018; another 5 boards with no female physician members. Here I see a clear positive sign. What once had been common in the demographic composition of state medical boards is now distinctly atypical. I suspect this trend will continue. Remember, state medical boards were once the exclusive domain of physicians. Now non-physicians constitute about 26% of total board composition.

Seems like the advice Dr. Behrens received more than 35 years ago remains relevant. Whether we’re talking about a job or an appointment or election, keeping the focus on ability while providing fair opportunity, offers at least a chance for the rest to work itself out.

The views expressed are those of the author and do not necessarily reflect those of the Federation of State Medical Boards.

 

 Sources:

FSMB Handbook (Federation of State Medical Boards: Euless, Texas, 1985)

ES Salsberg, GJ Forte, Health Affairs, “Trends in the Physician Workforce,” September/October 2002

A Young, HJ Chaudhry, et. al. “A Census of Actively Licensed Physicians in the United States, 2016,” Journal of Medical Regulation (2017)

The Missouri Medical Diploma Mill

Part 3: The final chapter

One week after Harry Brundidge and the St. Louis Star broke the story of Missouri’s medical diploma mills, Gov. Arthur Hyde invited a nationally prominent medical educator, Dr. Frederick Waite, to conduct “an immediate investigation” of all the state’s medical schools. Waite moved quickly and with the assistance of members of the Missouri Board of Health set forth review criteria and a rapid schedule for the visits. Collectively, they assembled a team for on-site inspections of all six of Missouri’s medical schools. The resulting report characterized the Kansas City College of Medicine and the St. Louis College of Physicians and Surgeons “not reputable under the intent of the [state’s] law.”

Waite’s choice of language (cited above) reflected an earlier twist to the story that underscored the connections and influence of the two diploma mill schools with sympathetic (or perhaps careless? corrupt?) legislators. The Missouri Board of Health had long refused to recognize these schools and license their graduates for practice based upon their substandard facilities and instruction. Both were categorized as substandard Class C schools by the AMA Council on Medical Education. But in 1921, a subtle change in state law directed the board to license graduates of “legally chartered” rather than “reputablemedical schools. This subtle language difference mattered significantly as both schools held a valid charter issued by the state of Missouri. Despite protests from the state medical association, the governor signed the bill into law. The Missouri Board of Health had no choice but to consider individuals holding a degree from either school as eligible for licensure—provided they pass the board’s licensing exam.

Thus, at the time of Waite and board’s report to the governor on the state’s medical schools in late 1923, the Missouri Board of Health lacked authority to deny a medical license to the Kansas City and St. Louis graduates. The report of Waite and the board characterizing the schools as “not reputable under the intent of the law” carried no legal force though it served as a public relations weapon against the schools—an effective one amidst the massive publicity triggered by the case.

adcox front page

The mountain of evidence secured in the fall 1923 and subsequent confessions of key witnesses like Robert Adcox and Williams Sachs brought matters to a head in 1924.  The governor turned to Waite once again to conduct an investigation—this one into the operations of the state’s board of health. Working rapidly, Waite’s interviews and assessment of board practices culminated in a report and a set of recommendations early in 1924. The board agreed to implement several operational measures (recommended by Waite) designed to bolster the integrity of their licensing decisions.  The board agreed that verification of license applicants’ personal information and credentials would be handled by one designated staff member. The board also agreed that, while the investigation by authorities played out, no Kansas City or St. Louis College graduates would be admitted to the examination. By June of that year, both protocols had been violated by the Secretary for the Health Board, Dr. Cortez Enloe.  This may not have surprised knowledgeable insiders, or even Waite, as earlier Enloe had declined to participate in any of the board’s visits to the Missouri medical schools in late 1923.

Despite mounting criticism and calls for his ouster, Enloe held fast to his position as board secretary. He only relinquished this role (though still remaining on the board) until further revelations reached the press concerning his association with a physician named Ray Horton. Horton presented himself as a “personal and political friend” of Enloe and in a later confession, admitted using this connection as a means for soliciting money from the Kansas City school and its degree holders with a promise of access to a Missouri license. The implication was clear: Enloe had some sort of financial relationship with the school through Horton. Governor Samuel Baker finally dismissed the entire board of health in September 1925. However, Enloe’s close friendship with Gov. Baker served him well. He managed to escape formal charges and the governor subsequently appointed Enloe to oversee the state’s Board of Prisons.

For his part, Harry Brundidge probably deserved, but did not receive, a Pulitzer Prize for his investigative journalism. It was, however, the start of a stellar career that saw him making headlines many times over…often as a result of his crime stories. His career brought him face to face with murderers, bootleggers, kidnappers, crooked cops, reporters “on the take” and nationally-known personalities like Al Capone and J. Edgar Hoover. (Below: Brundidge seated left of J. Edgard Hoover)

In a radio broadcast nearly three decades later, Brundidge reflected on this period of his journalistic career that frequently brought him into contact with “criminals.” The jaded reporter evinced surprising sympathy for these men.

 “At one time in my life I wrote a great deal about crime and criminals. I don’t know how many criminals I came to know personally while I was a newspaper man…the number is large. It has not been always easy to draw the line of behavior where it belonged, between friendship and the rights of society. But I did my duty on both sides of the line. I had my friends, and I helped the law.

What has not been hard has been to know that there is no line between people. They are all basically alike, all have good in them, all have the potentiality of failure.

I have known some criminals very well indeed. I have known, too, that I was no better than they were, I was only more fortunate. And because of this contact with criminals I have been privileged to have more friends than persons usually have. And the friends I have had, some of them, have been better friends because they weren’t able to make friendships with those on my side of the line. They knew I believed they had good in them. They knew I trusted them. So they trusted me. I am rich because they did.”

retired

Sources:  This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine (ahead of print publication October 2018)

NOTE: The views expressed are those of the author and do not necessarily reflect those of the Federation of State Medical Boards.

The Missouri Medical Diploma Mill

 

Part 2: “Bringing in a gusher”

In part one of this series, I shared how St. Louis Star and reporter Harry Thompson Brundidge infiltrated and exposed the operations of two Missouri medical diploma mills—the Kansas City College of Medicine and the St. Louis College of Physicians and Surgeons. Those two schools represented the tail end of a long period of sporadic medical diploma mill in America. Today’s blog post shares more of Brundidge’s look “behind the curtain” and how his story led investigators to medical licensing boards in Arkansas, Connecticut and Florida.

The story began in early August 1923 when Brundidge’s editor directed him to investigate medical diploma mill activity in the state. He gave his reporter one lead (Dr. Robert Adcox) and a direct order: Get yourself into “the [diploma] mill.”  Brundidge established a new identity as a St. Louis coal salesman, initiated contact with Adcox and soon found himself traveling to Kansas City where he met the self-proclaimed “brains” behind the operation, Dr. Ralph Voigt.

Harry’s first payment of $600 resulted in Adcox (pictured with Brundidge below)

adcox 1

securing a high school certificate for him complements of fellow conspirator William Sachs, the Director of Missouri Public Schools. This certificate and a bogus chiropractic degree served as the basis for advanced standing admission to the Kansas City College of Medicine. While waiting for these credentials, Harry received instruction from Dr. Voigt on an electro-therapy machine—an impressive looking but bogus diagnostic machine with numerous dials and flashing light switches. Voigt’s description of it as a “sucker machine” explained its primary purpose as a means for Harry to fleece unwary patients once they got him a medical license.

Adcox and Voigt then placed Harry in what they characterized as a “ringer class” at the Kansas City College—their reference to a group of sham students apparently mixed in with legitimate students attending the school.  Harry shared his nervousness about being placed in a room with legitimate medical students. Adcox and Voigt’s advice was simple: “Keep your mouth shut and your ears open.” This brought Harry into contact with another conspirator, Dr. Date R. Alexander, Dean of the Kansas City College.

Police raids and arrests of Drs. Adcox, Voigt, Alexander and Sachs in October 1923 secured a mountain of evidence, much of it leading directly to several licensing boards. The first of these was the Arkansas Eclectic Medical Board. Connections between this board and the Kansas City College had raised suspicions as early as 1917. The linkage grew more understandable once it became evident that the Chairman of the Arkansas Eclectic Board chair held a diploma from the Kansas City school.

The Arkansas board provided Kansas City graduates with their most direct route to medical licensure. The board examined 203 Kansas City ‘graduates’ between 1916 and 1924, licensing nearly 82% of these individuals. Amidst the publicity, the board proclaimed its innocence and offered to “throw open its books.” Amazingly, the Arkansas Eclectic Medical Board not only survived the 1923 scandal, it remained in statutory existence until 1955 when the state finally consolidated its separate medical, eclectic and homeopathic licensing boards. This inexplicable reprieve probably occurred because the board had virtually no one to license. Eclectic medical schools were already largely disappearing with them any graduates seeking a medical license.

The evidence acquired in Missouri tied directly to the Connecticut Eclectic Medical Board which presented the main conduit for licensing St. Louis College graduates. That board seemed to “open its doors” abruptly in 1921-22 as more than 140 graduates of substandard schools such as St. Louis College sought a medical license through that board. Political wrangling and closer investigation by a Connecticut grand jury left that state’s governor lamenting how the state had become a haven for unqualified doctors.

st louis

 

The grand jury heard insider testimony from Adcox and Sachs as well as a Connecticut licensee, George Sutcliffe, who had begun cooperating with state authorities began months earlier.

sutcliffe

These confessions implicated the Dean of the St. Louis College (Dr. Waldo Briggs) and an insider (“fixer”) at the Connecticut Eclectic Medical Board—probably board chairman, James Christian.  Adcox’s confession described how advance copies of exam questions, lax proctoring and informal oral exams moved St. Louis grads to a Connecticut license. The police raid of Adcox’s home secured more than a dozen sets of exam questions from the Connecticut board spanning several years. The pipeline into Connecticut proved so lucrative that the conspirators described it as “bringing in a gusher” from the oil fields. The corruption went so deep that even the pre-medical credentials of the board’s chairman were the forged handiwork of Dr. Sachs. The grand jury summarized the situation this way: The eclectic medical board had been a “willing part[y]to fraudulent conduct.”

The Star’s expose and the resulting investigation even reached a defunct medical board! In Florida, the eclectic medical board had links to the Missouri-based diploma activities. As a cooperating witness, Adcox, described how advance copies of exam questions, crib notes and cash payments secured licenses in that state. Little of this reached the newspapers in 1923 as widespread irregularities had already been uncovered leading to the dissolution of that board in 1921. Two members of the Florida Eclectic Board were convicted of felony mail fraud in transacting the medical diploma trade. The board’s former secretary waged a protracted legal battle that culminated in his conviction and five-year prison sentence in 1927.

Not all of the nefarious activity led to licensing boards situated outside Missouri. In the final installment of this series, we’ll double back to see how the scandal imploded the Missouri Board of Health.

Source:  This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine (ahead of print publication October 2018)

 

The views expressed are those of the author and do not necessarily reflect those of the Federation of State Medical Boards.

The Missouri Medical Diploma Mill

Part 1: “Harry, why don’t you become a doctor?”

Harry Thompson stepped out of his rented room in St. Louis on the morning of August 13, 1923, waved to the postman walking past and called out to him—“Can you tell me where the nearest doctor lives?” The postman offered a hurried, “Right there!” pointing several houses down the street toward a man watering plants on his front porch. Dr. Robert Adcox heard the exchange and looked up to see Thompson making his way toward him. After a brief discussion and despite some initial reluctance, Adcox agreed to treat Thompson’s sore throat.

After a follow-up visit and several increasingly friendly conversations, Dr. Adcox presented his young patient with an opportunity—“Harry, why don’t you become a doctor?” Thompson responded with a chuckling protest, citing the obstacles to such a career move, including his lack of a high school diploma. Adcox brushed aside such concerns. “Bunk, Harry, my boy! You wouldn’t have to go to school to become a doctor.” He then explained how a high school diploma could be obtained and all obstacles removed to securing a medical diploma and a license to practice. Skeptical but intrigued, Thompson pressed for details. A smiling Adcox said, “Harry, a good magician never reveals how he does his tricks…be ready to go to Kansas City with me tomorrow night…I’ll show you how it’s done.” Two months later, Harry Thompson (aka Harry T. Brundidge, reporter for the St. Louis Star newspaper) possessed a high school certificate, a medical diploma (backdated to 1916) and a medical license.

Figure 2 St. Louis Star front page

This episode became the opening salvo in Brundidge’s exposé series launched October 15, 1923. The full-story of the Brundidge’s investigation played out on the front page of the Star almost daily over six weeks. The Star related how medical diploma mill activities centered primarily around two Missouri schools (Kansas City College of Medicine and Surgery; St. Louis College of Physicians and Surgeons) served as a pipeline to licensure in several states. The Star also revealed how the main players in the Missouri-based diploma mills (Drs. Robert Adcox, Ralph Voight, Date R. Alexander, Waldo Briggs) were part of a loose national network of medical diploma mills that once touched all regions of the country.

The Star’s first headline, ‘Ring Selling Medical Diplomas throughout the U.S.’ triggered massive national interest, presenting a major embarrassment to medical education and licensing in the United States. That this story has been conveniently forgotten should not be surprising. Fallout from the scandal and its resulting investigations culminated in the dissolution of one medical licensing board (Connecticut), the reorganization of another (Missouri) and a fight for existence in a third (Arkansas). A fourth board (Florida) was spared this ignominy only because earlier malfeasance led that state’s governor to dissolve it before the Star’s story broke. The Star’s reporting brought America’s Class C medical schools outside the whispered circles of medical education and into a national spotlight. A few of these schools operated so far on the fringe of U.S. medical education as to be little more than diploma mills—either explicitly through their design or as once legitimate institutions that drifted into de facto diploma mill activity. These schools represented dying institutions; Harry Thompson Brundidge and the St. Louis Star eagerly helped  to hasten their demise.

Figure 1 harry thompson

The 1923 exposure of the medical diploma mills in Kansas City and St. Louis concluded a sordid chapter in American medical education that saw similar institutions dotting the landscape. Though the most notorious 19th century medical diploma mill (Eclectic Medical College of Pennsylvania) predated the post-Civil War rise of medical licensing laws, most of its rivals in the trade originated alongside the emerging medical legislation in the last quarter of the century. All regions of the country confronted medical diploma mill activity especially in the period before most medical boards had the authority to approve medical schools and thus restrict licensing to graduates of bona fide schools.

The west coast saw medical diploma mills in Washington and California. The Pacific College proved an especially persistent and egregious participant in the diploma trade drawing a protracted effort from the California medical board to force its closure.

New England witnessed its share in the illicit trade. Lax chartering laws in Massachusetts allowed medical diploma mills to flourish briefly in that state: Bellevue Medical College of Massachusetts, American University of Boston, Excelsior Medical College, Druidic University, etc. New Hampshire and Vermont authorities confronted medical diploma mills or fraudulent institutions functioned as well.

From the Atlantic to the Midwest, medical diploma mills operated at various times in the District of Columbia, Michigan, New Jersey, New York, Pennsylvania, Ohio and Wisconsin. Several of these operations originated with co-conspirators in John Buchanan’s Philadelphia diploma mill: Henry Stickney with New England University and Henry S. Thomas’ Detroit Eclectic Medical College. Others emerged from institutions originally founded with apparently legitimate purposes before lapsing into the diploma trade. This appears to have been the case with two similarly titled Cincinnati area schools: Physio-Medical College and the Physio-Eclectic Medical College. More than a dozen medical diploma mills plagued Illinois at various times especially the multiple ventures of Johann Malok in the1890s.

The problem persisted primarily because it represented a potentially lucrative business. The Wisconsin Eclectic Medical College’s owner was arrested in 1897 after lucrative sales earning tens of thousands of dollars. All of these schools were among the forty institutions identified as “fraudulent” by the AMA Council on Medical Education in its review of U.S. medical colleges published in 1918.

By 1923 the vast majority of these schools had closed or been publicly identified such that their graduates were nearly unlicenseable. Shutting down the remainder should have represented nothing more than a clean-up exercise. Not so!

I’ll continue the story in Part 2 and share how Harry Brundidge’s story implicated medical licensing boards in Arkansas, Connecticut and Florida.

 

The views expressed are those of the author and do not necessarily reflect those of the Federation of State Medical Boards.

Sources:

This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine (ahead of print publication October 2018)

 

The Medical Regulator’s Bookshelf

Every year roughly 10-15% of all the members serving on state medical boards across the country complete their term of volunteer service and rotate off their board. As this group exits, a new set of board members enter. This diverse group of new board members includes physicians, allied health professionals and members of the public drawn from all walks of life.

To get these new members up-to-speed, every state medical board conducts some type of orientation training for its new members. Invariably, this training focuses on practical matters specific to that state and its medical board, e.g., relevant state law, state ethics policy, board administrative operations, etc.

This training also represents an opportunity for broader, contextual education. It’s appropriate to learn the ins and outs behind state law and board operations but foundational knowledge is important too. It’s not enough to know how the current regulatory system runs; it important to know why the system operates in the shape it does today.

Indulge me as I play Professor Johnson and share my reading list for newbies enrolling in “Medical Regulation 101.”

Origins of Medical Licensure

Our course starts with James Mohr’s Licensed to Practice: The Supreme Court Defines the American Medical Profession. Mohr analyzed the backstory and implications of the US Supreme Court decision in Dent v. West Virginia (1889) that cemented state prerogative to regulate the practice of medicine. mohr book

Mohr does a marvelous job telling his story and teasing out the leap of faith that the justices made to rationalize the broad discretionary authority bestowed upon the profession and, by extension, medical regulators.   As Mohr pointed out, this was a leap of faith well beyond what was easily justifiable by the existing science of that day.  Looking back, the Court’s decision was less inevitable that we might imagine today.

 

An Overview of Medical Regulation

Okay, if I wanted to be humble, I would direct you to a pair of short works dating from the late 1960s by Robert Derbyshire and Richard Shryock…but dating (or in this case, “dated”) is the operative word. These texts were excellent but are now so old as to be of limited value for regulators today.j and h book

Instead, I’m going to assign David Johnson & Humayun Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards.    Yes, I’m recommending my own book and yes, the title suggests an organizational history; but hear me out. This organizational story is nested within a broader narrative tracing multiple main threads in the evolution of the current state-based system of medical regulation. And it addresses everything that followed Derbyshire and Shryock. Trust me, this is a better one-stop option for gaining a sense of the big picture. 

Board Dynamics

So what’s it like to serve on a medical board? How do boards—or more specifically, board members—approach their role, especially in disciplining physicians? Here’s one answer. ruth h book Take a professionally trained sociologist (Ruth Horowitz), place her as a public member on not one but two medical boards over the course of her career and you get this fantastic offering—In the Public Interest: Medical Licensing and the Disciplinary Process. This book should be shared with every new member to a state medical board—especially the public members. Her analysis is spot on and her recommendations apt.

 

 

Disciplinary Role of State Medical Boards

In terms of the disciplinary function of state medical boards, here’s your critical reading: State Medical Boards and the Politics of Public Protection by Carl Ameringer. This relatively slim volume explains the shift that occurred in medical boards’ philosophical approach to discipline beginning in the 1960s and gathering steam in the 1970s and 80s.

carl a bookI don’t want to oversell the shift tin discipline and mindset that occurred. Our system isn’t perfect (see Milwaukee Journal Sentinel). But we are headed the right direction compared to the veiled secrecy that  previously characterized medical boards’ operations in the area of discipline.

Another Ameringer work (The Health Care Revolution: From Medical Monopoly to Market Competition) presents a treat for board attorneys or public members with legal background as it traces the important case law impacting medical regulation.

 

Medical Licensing Examinations

Finally, there is an important 2009 essay by Donald E. Melnick. See “Licensing Examinations in North America: Is External Audit Valuable?” in the journal, Medical Teacher. One thing you’ll soon discover on your medical board is that the boards long ago left the business of writing their own exams and ceded responsibility for assessing prospective licensees to national entities such as the National Board of Medical Examiners, the Federation of State Medical Boards and the National Board of Osteopathic Medical Examiners. That doesn’t mean you have no responsibility or obligation in this area as a medical regulator. Statutes in every state require you to assess prospective candidates knowledge before issuing a license. Dr. Melnick’s short essay makes a persuasive case for the continued value of the assessment role played by state medical boards.

There are other important works I could advocate for but…I’ll stop here. After all this is our introductory course, right? So…you have your reading assignment. Class dismissed.

The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards.

 

Some Origins of State-based Medical Regulation

In the years following the American Civil War (1861-65) multiple states and territories passed laws to regulate and limit the practice of medicine—specifically, requiring individuals to meet criteria set by the designated state entity (e.g., state board of medical examiners) and obtain a license before practicing medicine. Half a dozen states established medical licensing boards by the end of the 1870s, another dozen were established in the 1880s and most remaining jurisdictions did so in the 1890s.

For those with any familiarity on the subject, there is nothing new in what I just shared. The “when” in this evolving regulatory system can be presented in a straightforward chronology presenting the introduction of medical practice acts and the establishment of state medical boards.

However, the question of “why” is a different story. Specifically, why did state-based medical regulation emerge at that particular moment in America’s history? People had been practicing medicine long before any state laws regulating the practice—so why did the state legislatures suddenly feel it necessary to begin regulating medicine?

Here we enter speculative grounds but I would offer several reasons for the emergence of medical regulation in the post-Civil War era.

Push back against the “democratization” of medical care

In 1822, the New England folk healer Samuel Thomson published his “New Guide to Health; or Botanic Family Physician.” This modest beginning marked the start of Thomson’s widely successful efforts to re-establish the practice of medicine with its rightful practitioners and materia medica—specifically, family and friends drawing upon herbal or botanic-based remedies. Thomson’s success with direct to consumer guidebooks for medical practice and agents in the field selling his “system” of botanical remedies resonated deeply with Americans of that era increasingly adverse to privilege and hierarchy.

sam thomson

Thomson’s success irked physicians (no surprise!) who felt their knowledge and skill denigrated by home practitioners. When the home medicine-tide finally began to ebb in the post-Civil War era, physicians were already organized (i.e., AMA and state medical societies) and poised to push back. Physicians could point to major advances ongoing in medicine as a basis for establishing themselves as professionals with exclusive control over the practice of medicine. Staking out and securing their “turf” legislatively, including controlling entry into the profession, became a priority for physicians.

Explosive growth in the number of medical schools

At the opening of the 19th century, there were a handful of medical schools in America. By mid-century, there were  50 medical schools. By 1884, there were approximately 100 schools.

US map

Weak chartering laws and the didactic nature of US medical education meant that all that was required to establish a medical school was a building, a minimal amount of materials (books, lab supplies, access to cadavers) and a handful of physicians willing to collaborate as faculty. The result was a sharp increase in the number of individuals holding an actual medical degree and eager to seek a financial return on their modest investment through practicing medicine. Just as important, this era predates even de facto accreditation efforts. Consequently, wide variability in quality characterized US medical education.

From a demographic and educational perspective, this situation posed serious challenges for US physicians seeking to establish medicine as a legitimate profession. To use a metaphor, medical schools were like a faucet with a broken handle gushing forth newly-degreed physicians. It was impossible to cut off the flow; but if one attached new piping to the opening of the faucet, it would be possible to reduce the flow. The “new piping” was state legislation setting forth criteria for the legal practice of medicine and a designated authority (state medical board) empowered to evaluate individual qualifications and issue licenses. Statutory requirements could be set in such a way as to either restrict or encourage the flow of graduates from medical schools. Organized medicine worked doggedly toward restricting the flow.

Rise of the penny press newspaper

Medical societies and individual physicians had another stalking horse at their disposal in arguing for a medical practice act in their state –the quack[1] or the charlatan. Hawkers of medical cures and remedies can be traced into the Middle Ages where they often combined medical, theatrical and itinerant elements. With so many, at best, modestly educated practitioners pouring out of American medical schools—including those with degrees from schools little more than medical diploma mills—the medical establishment could point to outlier practitioners (conveniently labeled quacks or charlatans) as a tangible example of the need for medical legislation. snake oil

Their case was further bolstered by the ready availability of cheap print advertising in the daily penny press newspapers. Wild claims involving all manner of lotions, potions, pills, nostrums and elixirs filled newspapers, short-lived medical journals and circulars. Physicians could point to the over-the-top claims in these ads from outlier practitioners as proof of a danger to the public.

I would argue that all three forces were at work in the post-Civil War years; combining in a mutually reinforcing way that resulted in a steady push toward a state-based system of medical regulation.

The views expressed are those of the author and not the FSMB.

Resources:

William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins Univ. Press, 1985)

John S. Haller, Jr., The People’s Doctors: Samuel Thomson and the American Botanical Movement, 1790-1860 (Carbondale: Southern Illinois Univ. Press, 2000)

M. A. Katritzky, “Marketing Medicine: The early modern mountebank,” Renaissance Studies 15, no. 2 (2001).

 

[1]  Quack derives from the Dutch quacksalver meaning a hawker of salves.

Bias in Testing?

I spent time recently reviewing records from the North Carolina Medical Board spanning the late 19th and early 20th centuries. In doing so, I ran across a small parenthetical item that peaked my interest. Nestled discreetly next to the name of a physician who passed the board’s licensing examination in 1933 was this small notation — (c)

Further review of the board’s records for other years soon confirmed my suspicion as to the meaning of this notation. I found that in other years, the notation appeared as (Col) or (colored). As part of the segregated South, the North Carolina board’s records explicitly identified black physician candidates for medical licensure. (See image below)C designation

This finding did not surprise me considering the socio-politico and legal tenor of the times. But it did raise a question in my mind…or rather a series of questions. Why did the board’s secretary feel compelled to identify black physicians in their records? Was this a benign action merely consistent with routine administrative practices in most or all the state’s agencies? Or did this flagging of black physicians in the record point toward bias in the examining and licensing of these physicians? Ultimately, I found myself wondering, “Was the medical licensing examination in North Carolina conducted in a reasonably fair and unbiased manner for all candidates?”

This question seemed overly ambitious at first; but as I looked deeper into the board’s records, I realized that sufficient details had been captured that answering this question might just be possible. Specifically, the board’s records contained details on the administrative practices and scoring of their examination.

For example, the board’s examination was conducted as an essay exam spanning usually 3-4 days. The day prior to testing the candidates arrived and presented the board Secretary with their completed registration, credentials, references, etc.

A single member of the board was assigned to administer and then score specified content areas. (See the example from 1940 below).

test admin

To guard against potential bias in scoring, the candidates for licensure by examination were issued either a pseudonym or a number by the board Secretary on the day prior to testing. The examinees used this identifier, rather than their actual name, on their examination papers.

roster

Pseudonym shown at far left for examinees

This administrative protocol, if followed correctly, offered a reasonable mechanism to diminish the likelihood of bias.

The North Carolina board’s records also provided critical details related to scoring—specifically, the board routinely listed the actual scores (both passing and failing) for all candidates taking their examination. Similarly, these records capture the board’s composition for each administration of the exam, including identifying specific board members assigned to score papers for designated content areas.

These details make statistical analysis possible along several lines of inquiry. For example, pass percentages and mean and median performance by race and by medical school…and by cohorts reflecting changes in the North Carolina board’s composition.

I have not yet completed my analysis of this fascinating set of records spanning the period from 1886-1925. Stay tuned.

 

The  views expressed are those of the author and not the FSMB.

Con Man or White Collar Criminal?

I’ve spent a good deal of time writing and thinking about Dr. John Buchanan in recent years. His colorful career saw him play many roles including physician, author, educator, patent medicine entrepreneur and…criminal. His infamy, despite having been largely forgotten today, rests upon his latter role as the moving force behind America’s largest medical diploma mill in the 19th century. (See my forthcoming book Diploma Mill: The Rise and Fall of Dr. John Buchanan and the Eclectic Medical College of Pennsylvania from Kent State Univ. Press, August 2018.)

Johnson_Diploma Mill_amazon (002)

Over a career spanning roughly four decades, John Buchanan’s transgressive behaviors included the sale of medical degrees, conspiracy to defraud, bribery, apparent theft of corpses for anatomical instruction, allegations of criminal abortion and political chicanery designed to swing a state legislative election to one of his colleagues.

Buchanan’s career, while colorful, is not entirely unique. Scoundrels populate the history of medical regulation in America. The rogues’ gallery where Buchanan resides includes hucksters and charlatans like goat gland specialist John Brinkley, cancer-cure specialists like Norman Baker and Harry Hoxsey, snake-oil salesman Clark Stanley and countless locally infamous rascals that bedeviled state medical boards and the medical profession.[1]

 

(Left to right: John Buchanan, John R. Brinkley, Harry Hoxsey)

One of the questions I have found difficult to answer about Buchanan should be a simple one.  Why did he do it? Why did he risk—and ultimately throw away—a promising medical career at a legitimate educational institution?

Money—that’s the obvious answer, right? The diploma trade proved not only lucrative but relatively easy to conduct during the post-Civil War era despite the periodic outcry of critics.

But that doesn’t really answer the question. Think about it. There is nothing at this moment preventing you or I from engaging in an activity that could reap a financial windfall—drug dealing, income tax evasion, identity theft, various types of fraud, etc. And yet we don’t do these things from a mixture of motives, e.g., our sense of moral or ethical values, our fear of being caught and punished. Indeed, the vast majority of the human population rejects transgressive behavior on a daily basis in favor of our remaining in good standing in what is collectively hopefully a safer, stable, more just social order.

If greed doesn’t explain John Buchanan’s behavior, what does? Here I think it is helpful to see John Buchanan as a specific type of scoundrel in the medico-regulatory world. Not the confidence man of the sort represented by a Brinkley, Baker and their ilk but as a type we more often think of as a creature of the 20th century—the white collar criminal.

The federal prosecutors who charged Buchanan with mail fraud in 1880 attempted to portray him as a con man preying upon the public through his issuance of mail order diplomas that became the basis for some physicians to secure a medical license. While this was a rational argument to present in trying to secure a conviction on mail fraud charges, it represented an overreach. Why? Quite simply, no fraud entered into the transaction between Buchanan and the purchasers of the diplomas as both sides were aware of the true nature of the transaction. The judge agreed, acquitting Buchanan on this specific charge. (below left)

acquittal

No, unlike the con men fleecing naïve but ultimately trusting patients, John Buchanan acted in a manner more consistent with the white collar criminal. The term itself dates to the late 1930s and its introduction by the sociologist Edwin Sutherland. Generally defined as a non-violent offense involving financial motive, we generally think of white collar criminals as professional men who have exploited their position or authority for personal gain, e.g., Bernie Madoff, Jeffrey Skilling (Enron), etc.

Traditionally, scholars explained white collar criminal behavior in wholly rational terms—as individuals engaged in a conscious, almost deliberative mental process involving analysis of risk and reward related to a specific opportunity. More recent research,[2] including interviews with convicted white collar criminals, suggests a more nuanced explanation involving a triangulation of variables:

  • perceived pressure
  • perceived opportunity
  • individual integrity/rationalization

Here I believe we find the more compelling answer to why John Buchanan moved into diploma sales. Financial pressures on Buchanan and his school increased markedly in the early 1860s with the start of the Civil War and the disrupted flow of matriculating students. In his published confession from 1881, Buchanan also cited personal financial pressures.

As for opportunity, at the time Buchanan joined the school faculty in 1860, there were virtually no legal restrictions on the practice of medicine anywhere in the United States. As the professionalizing trend evolved in medicine, pressures mounted to increase standards for medical education, including the issuance of medical degrees. Legitimate degree issuance practices such as ad eundem and honorary degrees and the awarding of advance standing to experienced physicians were practices vulnerable to abuse for those willing to “rationalize” deviations from conventional or accepted standards.

In this regard, Dr. John Buchanan differed markedly from the contemporary charlatans knowingly peddling nostrums based upon hokum and pseudo-science to a gullible public. Buchanan’s downfall derived from the hubris of a criminal who convinced himself that his drift into questionable practices could be justified in the laissez-faire era of lax business practices and that his golden goose (the diploma trade) could lay eggs just a little longer despite the emerging regulatory landscape rapidly changing his world.

The opinions expressed reflect the views of the author and not those of the FSMB.

Sources:

David Alan Johnson. Diploma Mill: The Rise and Fall of Dr. John Buchanan and the Eclectic Medical College of Pennsylvania (Kent State Univ. Press, August 2018)

Bill Barrett. “Inside the Mind of the White Collar Criminal.” Accessed July 24, 2018 at https://www.accountingweb.com/technology/trends/inside-the-mind-of-the-white-collar-criminal

[1] See Pope Brock, Charlatan (New York: Three Rivers Press, 2008) and Eric S. Junhke, Quacks and Crusaders (Lawrence: Univ. of Kansas Press, 2002)

[2] Experts in the field have also identified psychopathic traits commonly seen among white collar criminals. See Isabella Merzagora, et. al., “Psychology and Psychopathology of White Collar Crime,” Organized Crime, Corruption and Crime Prevention October 2013.