Contingency and circumstance in history

Anyone with even a passing interest in history recognizes that contingency and circumstance are every bit the featured players in our unfolding human comedy.

My recent tweets (@davearlingtontx) bring to mind the role played by these forces. I have worked for the Federation of State Medical Boards (FSMB) just shy of twenty years. The organization represents an important player in the medical regulatory landscape though atypically its main offices are not in Washington DC or Chicago or Philadelphia like so main key groups and sister organizations. Instead, our main offices are just outside the Dallas-Fort Worth airport in Texas. Many times over the years, a colleague has asked me: “How did the Federation end up in Texas?”

The answer is an illustration of the role played by contingency and circumstance in the history of one organization. Founded in 1912, the FSMB functioned more like a “virtual” organization during its first half century. Lacking paid full-time staff and a permanent national office, the organization’s roots rested in Iowa with its long time Secretary-Treasurer Walter Bierring and a long line of elected presidents each serving a one-year term of office as head of the FSMB’s board of directors.

The arrangement worked well enough provided no one expected too much from the organization’s volunteer leadership and its shoe string budget. That changed by the early 1960s as perspectives on the role of medical boards began to shift along with the regulatory environment and the expectations for FSMB.

Historically, medical boards had long prioritized examining and licensing as their major functions. Discipline seemed a less critical function—and one that, when undertaken, focused more on maintaining professional boundaries, i.e., running off unlicensed practitioners, pushing back against other practitioners (particularly midwives, chiropractors and even osteopathic physicians in the first quarter of the 20th century).

By the early 1960s, this prioritization had shifted. The AMA’s Discipline Committee released a report underscoring the “veil of secrecy” shielding incompetent physicians and those engaged in unprofessional behavior. Even an internal survey conducted by the FSMB underscored how little the state medical boards seemed to value this basic component of their regulatory functions. Discipline may have once seemed like the red-headed stepchild of medical board priorities but as the 1960s unfolded this posture weakened.

As the winds of change altered the regulatory landscape and sentiments shifted on professional accountability, the FSMB and AMA commenced a series of meetings in 1961 that culminated in an offer too good for the FSMB to refuse. The AMA offered a $10,000 grant carrying two major stipulations. FSMB must (1) establish a permanent national office, and (2) create a data base of disciplinary actions taken by state medical boards. Both organizations saw this as a critical development to undercut the persistent historical problem of disciplinary ‘hide and seek’ carried on by rogue physicians bolting from one state to another just ahead, or in advance of, state board action; and with it the inadequate communication of these actions between boards.

So why did Texas become home for the Federation? The Secretary of the FSMB board of directors at that time, Dr. McKinley Crabb, resided in Fort Worth.

1955-president-mh-crabb    Crabb also served as Secretary of the Texas Medical Board—a position he held since 1941. In 1962, the Texas Medical Board also maintained office space in that city’s Medical Arts Building along with its main offices in Austin. Crabb and FSMB President Louis Jones had served as the primary negotiators with the AMA to secure financial support for an FSMB central office.

FSMB 1st offices in old med arts bld in Ft Worth


Thus, circumstances aligned. Discipline slowly began to acquire its greater emphasis; FSMB represented a logical host for a national disciplinary data base; a Fort Worth physician (Crabb) played a key role in the negotiations; the Texas board had office space, etc. Of course, it is just as likely that FSMB could have ended up someplace else as officers and members of the organization’s board came from all over the country: California, Idaho, Louisiana, New Mexico, Oregon, South Carolina. All of these men had personal and professional connections to the respective medical boards in their state. The FSMB could just have easily been headquartered in New Orleans or Charleston or Albuquerque if a medical board in one of those states had an even stronger desire to host the organization.

In brief, there was no grand design or master plan behind the organization’s headquartering…just contingency and circumstance, the usual unsung but featured players in human history.

(The thoughts expressed here are those of the author and do not represent the FSMB.)

Power, diversity and medical regulation

My recent tweets (@davearlingtontx) in September 2017 featured historical snippets focusing on women in medical regulation. In one I focused on a regulatory trailblazer: Adele Hutchinson, MD. This graduate of Boston University appears to have been the first woman to serve on a state medical board anywhere in the U.S. This occurred surprisingly early–in Minnesota in the 1890s. The fact that two other women (Margaret Koch; Hannah Hurd) succeeded her on the Minnesota medical board seems all the more remarkable considering the male domination of medical boards individually and collectively throughout the majority of their history.

Admittedly, this gender landscape has changed over time. One rough calculation I made in 2011 using records from the Federation of State Medical Boards ( indicated that women comprised 40% nationally of all members serving on state medical boards. Similarly, women served as the executive director (i.e., chief staff member) on half of the boards in 2011; a figure that holds true currently.

I can’t help but think about these otherwise random facts when I reflect on a picture like the one below featuring the board of directors of the Federation of State Medical Boards (FSMB) in 1960. Established in 1912, the FSMB served the individual state medical boards of this country both then and now. I have been proud to work for twenty years with this organization.

FSMB leadership 1960

There is nothing particularly remarkable about the photograph. In fact, I could show many more photos just like it of FSMB leadership. Whether plucked from 1930 or 1950 or 1980, the photos would all look very similar in one regard: leadership involved no one of color and no women. This is what power looked like in this country for many years, indeed the vast majority of this country’s history. Pick virtually any area you wish to analyze: business, government, law, medicine. A picture like this is reflective of where power rested in the United States for a long time. A picture of those holding power in any of these areas (in this example, medical regulation) would look a lot like this.

I think this is part of the reason many people look at the Confederate monuments that harken back to this kind of world and power structure and feel they are no longer appropriate today on multiple levels.

I am proud to say that leadership of the organization I work for no longer resembles a photo like this. Still, it gives pauses to consider just how late it was when change finally arrived in these power dynamics. The first woman (Dorothy Bernstein) did not serve on the FSMB board of directors until the 1970s. Dr. Bernstein, coincidentally, came from the Minnesota medical board. Yet, her brief appointment to serve out a vacancy on the board didn’t translate into a woman being directly elected to FSMB governance until the 1980s. Dr. Susan Behrens (pictured) gained this honor and later was elected to serve as the organization’s board chair, 1989-90. Behrens_Susan_1Another woman, Dr. Barbara Schneidman (1991-92), soon followed. For those interested, Dr. Behren’s shared her personal story in moving amongst governance circles. See vol. 98, no. 2 of the Journal of Medical Regulation

(The opinions expressed here reflect the views of the author and do not represent those of the FSMB.)

Scholarly literature on medical regulation

Scholars working in the history of medicine are plentiful. Relatively few have focused on the history of medical regulation in the United States.

One the earliest was Richard Harrison Shryock (1893-1972), a former historian at Penn and Duke Universities. Yet even Shyrock’s Medical Licensing in America, 1650-1965 (Johns Hopkins Press, 1967) proves slightly disappointing upon closer inspection. The slim volume–at 120 pages it is really more of an extended monograph–signals its intent to provide nothing more than a useful but high-level overview of the topic.

Similarly, the first third of the book focuses on the colonial and antebellum period when regulatory efforts in medicine were predominantly conducted through medical societies rather than more clearly governmental function characterizing the rebirth of licensing laws after the Civil War.

The strongest sections of the book deal with the development of American medical education in the last quarter of the 19th century and first decades of the 20th century. Here Shryock addresses the intertwined nature of medical education reform and improvements with the advent of modern licensing laws.

The period covered by Shryock’s text stops just as medical regulation is moving toward a paradigm shift in the 1960s when discipline (and not simply examining and licensing) became a major focus of state medical board activity. Shryock acknowledges this in his reference to the research conducted by Robert Derbyshire, president of the Federation of State Medical Boards. Derbyshire’s contributions both as a scholar and a leader in medical regulation merit their own blogs so I’ll return to him in the the months ahead.shryock book cover