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.

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.

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.