Prescriptive power and value of the medical license

One of the foremost stories in American medicine continues to be the epidemic of opioid misuse. According to the National Institutes for Health, every day more than ninety Americans die as a result of overdosing on opioids. This translates into roughly 33,000 people annually – the equivalent of a 320-passenger Boeing 777 crashing every three and a half days.

From the perspective of medical regulators, one of the sad realities is the knowledge that a portion of this epidemic stems from the inappropriate (and sometimes illegal) prescribing of opioids by a small number of physicians. Medical boards dedicate significant resources to educating their licensees about appropriate prescribing. They work collaboratively with the pharmacy boards and prescription drug monitoring programs in their states—though the inter-state operability of these programs is frustratingly limited. They work with law enforcement to target and close “pill mill” operations.

I could not help but reflect on this current situation after my recent tweet (@davearlingtontx) about prescribing issues that long pre-date today’s opioid crisis. Notice the photo below and the drug stamps affixed to the back of this 1940 Virginia medical license.

VA back of license

This blog entry, however, is not about prescribing so much as it is about the “value” of the medical license as a credential—one that has served to various degrees as a powerful attractant to a small number of criminally inclined individuals.

Consider this. In the post-Civil War era, individual states adopted laws regulating the practice of medicine. Many of these started as simple registration laws merely requiring that a physician present himself to a county clerk and show a medical degree.  Other states started with comprehensive legislation creating a board of medical examiners to review the credentials and administer examinations of prospective licensees. As medicine developed into a legitimate profession in the last quarter of the nineteenth century, this meant that the medical degree—and by extension the medical license took—on a monetary value not previously associated with it. As professional standards coalesced and solidified, this meant that the medical degree became the gateway credential to a medical license…and with it, after the turn of the century, prescriptive authority enjoyed by few others once the Harrison Narcotic Act (1914) and Volstead Act (1919) took effect.

This is, in part, the reason why medical diploma mills exploded in the last quarter of the nineteenth century. Admittedly, other factors were at work. Here I am thinking of poorly drawn state statutes for issuing educational charters and the absence of any true accrediting body for medical education. Yet make no mistake, the explosion of diploma mills reflected an economic incentive around the new-found monetary “value” of a medical degree and with it, the medical license.

It was no accident that the early issues of the Bulletin of the Federation of State Medical Boards often featured news items reporting a stolen medical license and alerting medical boards’ executive secretaries to be on the lookout. Also common were early 20th century versions of ‘manufactured’ or bogus credentials that were just good enough to get past sometimes weak vetting by medical boards. Another tactic was a kind of medical identity theft. The Bulletin carried numerous stories detailing precisely how unscrupulous individuals assumed the credentials, and thus the identity, of physicians—usually stealing the identity of retired or deceased practitioners.

All of these tactics flourished because of inadequate communication between licensing boards and their use of sometimes lax procedures to verify credentials.  But if you strip away the tactics behind these headline grabbing stories, their overriding motivation rested upon the fundamental shift increasing the value of the medical license. As the medical license grew in its potential for socio-economic advancement and later its authority in prescribing controlled substances, the monetary value of the license grew dramatically. Money attracts—not only those inspired by the humanitarian spirit of the healer but those with criminal intent. In a later blog piece I will share the story of Phillip Dyment, one of the many early 20th century criminals attracted to the medical license as an avenue for illicit financial gain.

The views expressed in this blog are solely those of the author and not that of the FSMB

1961: The End of “Doctors Only”


In 2017, one aspect of medical regulation that those of us involved in the field tend to take for granted is the presence and participation of public members on state medical boards.  We don’t really think too much about this since public members have been part of the regulatory landscape for decades. After all, 22% of the composition of all state medical boards today can be defined as “public” members, i.e., individuals who are neither physicians nor working in an allied health profession. (Note: The percentage rises to 29% if one defines public as non-physician.) Every state medical board with the exception of Alabama, Louisiana and Mississippi have non-physicians sitting as full, voting members on their state medical board. I have to admit that I still find it puzzling that any boards remain outliers in this regard today.

Public members are even a common feature on the governing boards for many of the organizations comprising the “House of Medicine.” [1] Recent research undertaken by the Federation of State Medical Boards looked at the presence of public members on the governing boards of various House of Medicine organizations involved in accrediting, certifying, assessing, educating and licensing physicians. Eleven out of sixteen organizations surveyed report having public members on their board governance.

With public members such an ingrained presence in the current landscape, one might be forgiven for wondering, “Has it ever been any different?”

In 1961, California became the first state to add public members to its state medical board. This represented a significant development in medical regulation as it reflected growing public and media interest in the work of state medical boards…and with this interest, a growing chorus of demands for greater accountability and transparency. No single factor accounted for this shift though the weakening of physician paternalism and the growth of a public/consumer culture played major roles.

Calif book

Through most of their history, state medical boards existed as the exclusive domain of physicians—an extension of their professional responsibility as well as their privilege as an almost completely self-regulated profession. Once California broke ranks, the paradigm shift away from insular, physician-dominated regulation to a more inclusive, transparent model gathered momentum—though admittedly slow and fitful.

By 1976, public members still represented only 10% of all state medical board members nationally. The percentage didn’t approach its current figure until 1996 when it reached 21%. Similarly, more than two decades after California set a new standard, the number of boards with public members had risen to only 28. By the late 1990s, the total reached its current level.

Complementing this shift in board demographics, state legislatures in the 1960s and 1970s moved increasingly to shift state medical boards under larger, umbrella agencies (e.g., Department of Health; Department of Professional Regulation). By the mid-1960s, state medical boards resided under umbrella agencies in 16 states. By the mid-1980s, this number nearly doubled with 31 states repositioning state medical boards in this manner. This created lines of accountability directed to individuals (i.e., agency heads) who were neither physicians nor necessarily overtly sympathetic to the medical profession. [2]

In discussing the shift away from a regulatory model drawing solely upon physician regulators to one inclusive of non-physicians, I have focused more on timing and a few numbers. Left unexplored (for now) is the value gained by this new model common to today’s regulatory landscape.

Though I leave that topic for another day, I’ll end with a quote from In the Public Interest (Rutgers, 2013), by the sociologist Ruth Horowitz.

ruth h book cover

With her academic training and stint as a public member on two different state medical boards, Horowitz brings a keen eye to the structure, dynamics and interpersonal factors at work in medical regulation. Reflecting upon the state of medical regulation and her own experiences, Horowitz noted that even well-intentioned professionals accumulate “blind spots” through the inevitable acculturation process of becoming a professional, working among like-minded colleagues, training in similarly-oriented institutions, etc. “History shows that, left to their own devices, doctors tend to police themselves in a manner that does not always coincide with the public good.”  Horowitz sheds no tears for the demise of the old (pre-1961) regulatory model. Neither should we.

Views expressed in this blog are solely those of the author and not that of the FSMB.

[1] P.R. Alper introduced this phrase in his article, “The House of Medicine,” Western Journal of Medicine (1977): 235-36.

[2] See Johnson, Chaudhry, Medical Licensing and Discipline in America, 168-172.

Medical licensing exams ca. 1911

For more than a century, a common rite of passage for physicians in the United States has been to sit an examination for a medical license issued by one of this country’s state medical boards.

One of my recent tweets (@davearlingtontx) shared questions from a 1911 exam conducted by the Nevada Board of Medical Examiners. I suspect those physicians whose test experience derives from their encounters with today’s examinations (USMLE or COMLEX-USA) might feel smug looking at these items from the Nevada board. With a martyr’s pride they might reflect on their long days laboring over 300+ multiple-choice question tests and 12-station standardized patient encounters as part of their multi-step examination process…and maybe hear an Oliver Twist voice in their head saying, “Please, sir, may I have a 10 question test!”

Nevada exam questions

That reaction would be understandable. After all, there is a human tendency in reflecting upon the past to view those periods preceding ours as somehow less sophisticated or lacking the complexity we perceive as uniquely characteristic of our own era.  Of course, this mental filter blinds us to our own bias—one predisposing us to assume greater sophistication for ourselves simply because we enjoy the advantage of hindsight unavailable to those living in the immediate present of a century ago.

Getting back to those questions from the Nevada medical icensing exam, such a reaction is unfair for several other reasons. First, the questions shown here are merely an excerpt—just one small portion of the Nevada exam. These questions derived from just the section on Bacteriology and Hygiene.

Like virtually every state medical board of a century ago, Nevada’s written exam for medical licensure was a multi-day affair.  Instead of the multiple-choice format familiar today to school children and medical students alike, constructed response formats such as open-end extended response or essay questions represented the predominant testing format for most state medical boards. Typically, candidates for licensure faced a battery of exams in multiple subject areas, usually with ten questions in each area.

Take this example from Minnesota. That state’s written exam covered three non-compensatory major topics (medicine, surgery and OB/GYN) and several minor topics (anatomy and physiology; therapeutics; materia medica; diseases of the eye, ears, nose, throat; medical jurisprudence). So the candidate for licensure faced several days of testing to answer roughly eighty extended response test items. And three of the subject areas (medicine, surgery, OB/GYN) each had to be passed outright. Think about the mentally draining task that represented!

However, the medical licensing exam in many states did not stop there. This brings us to the second reason it would be unfair to denigrate the licensing exams of a century ago.  In many states, a multi-day cognitive assessment, focusing heavily on the body of medical knowledge possessed by the licensure applicant, represented just one part of the board’s assessment. It was not uncommon for medical boards to supplement these exams with an oral or interview component as well.

As if a written test and oral exam/interview were not enough, medical boards of a century ago wielded yet one more assessment tool. This one will probably surprise you. In addition to assessing cognitive knowledge, many states required a “practical” examination as well.

Minnesota, Ohio and Massachusetts were among the first states to require a practical exam beginning around 1908-1909. This typically involved real-world physician tasks directly related to patient care: taking a bedside history; conducting a physical examination; rendering a diagnosis. All of these activities then served as the basis for an interview. Within that setting the interviewing board member(s) might explore the clinical reasoning and judgment of the individual examinee.  By 1918, roughly seventeen state medical boards conducted both a cognitive and practical assessment of physician candidates for licensure.

The ambitiousness of this undertaking is all the more remarkable considering efforts like this pre-dated by nearly a decade the first efforts of the National Board of Medical Examiners (NBME) to assess clinical skills in 1916. It would be another century before full-scale efforts at clinical skills assessment figured prominently in the nationally administered examinations for medical licensure: the United States Medical Licensing Examination and the Comprehensive Osteopathic Medical Licensing Examination (2004).

So…next time we feel smug and somewhat wistful for a less-complicated, bygone era, it might be wise to remember the Nevada medical licensing exam of 1911: multiple days of testing; written, oral and practical components; and all done in an un-air conditioned building somewhere in that desert state. Yikes. “Please, sir, may I have drink of water?”