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

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