A few weeks ago, I came across the fold out chart pictured below in a May 1934 issue of the Federation Bulletin. The data sheet accompanied a paper presented by Harry Anslinger*, the U.S. Commissioner of Narcotics, at the February 1934 annual meeting of the Federation of State Medical Boards (FSMB). The Bulletin also published a transcription of the subsequent Q&A between presenter and audience.

The commissioner’s responsibilities, established in 1930 as U.S Treasury Department’s Federal Bureau of Narcotics, included determining the quantity of crude opium and coca leaves allowable into the United States for medical and scientific purposes. Dispensing or prescribing derivatives of these materials fell under the Harrison Narcotics Act (1914), legislation ostensibly enacted as a tax/revenue measure though its underlying purpose and subsequent enforcement ultimately regulated and limited access to narcotic drugs such as opium.

The legislation required authorized practitioners (e.g., physicians, dentists) to register with, and pay a small tax to, the federal government (Treasury Dept.) to legally prescribe narcotic drugs. In due course, the legislation helped to effectively criminalize drug addiction rather than handling it as a disease or medical condition requiring treatment.

As interpreted by law enforcement, the Harrison Act also allowed for prosecution of physicians who prescribed to addicts. Authorities pointed to the language in the law describing allowable prescribing as something done “in the course of his professional practice only.” Drug addicts were not patient according to law enforcement. Thus, prescribing to them became illegal. Initially, the US Supreme Court supported this approach with two decisions (Webb v. US, 1919 and US v. Behrman, 1922) that upheld prosecutions against physicians prescribing narcotics to comfort addicts in withdrawal or as part of “cure” programs.

Federal prosecution of physicians under the Harrison Act was later struck down by the U.S. Supreme Court (Linder v. United States, 1925) as the court cited the regulation of the practice of medicine as a state prerogative. Thus, it fell to the individual states to regulate, and if necessary prosecute, illegal prescribing as a violation under their state’s medical practice act.

So how do state medical board figures into all this? Let’s go back to the pictured chart. The data—while confusing with its densely packed columns and small font headings—reflected cases brought by Anslinger’s office against 705 physicians between October 1, 1930 and December 31, 1932.  The commissioner’s office had been working with state boards so that they could take appropriate action involving their licensees.

The commissioner lauded the cooperation his agency had received from multiple state medical boards and, in particular, Dr. Charles Pinkham (Executive Secretary for the California Medical Board).

Yet at the time of his presentation to the FSMB in 1934, 488 cases (nearly 70%) were still pending any formal action by a state medical board. While the wheels of justice understandably turn slow, Anslingre’s presentation sounded a note of concern that they may have ground to a halt entirely in many of these cases.

Explanations for the backlog and what initially appeared to be state board inactivity came out in the Q&A. Much of the problem arose from state law—usually a critical absence of clear authority allowing the board to act. For instance, the medical practice act in several states did not have narcotic violations as a basis for a license revocation. In nearly two dozen states, license revocation was tied to violations of state law—not federal law such as the Harrison Act.

In other instances, license revocation was the only sanction open to the board. For example, in Minnesota, the board’s only option for a physician’s violation of a narcotics law or in cases of drug addiction was to revoke the license. The board did not have the option to temporarily suspend a license for a physician seeking to rehabilitate. Similarly, the board had no authority to reinstate a medical license once it had been revoked. Noting this reality, a Minnesota board member admitted, “We hesitate to revoke.”

Americans have a tendency to wax nostalgic about the past—to view a time period like this one eighty years ago as somehow “simpler” than our world today. I shared this piece from 1934 to underscore the complexity of medical regulation even then. Regulators faced a challenging interplay of state and federal actors and competing philosophies in addressing substance abuse. They labored under imperfectly drawn state laws that sometimes handcuffed them in trying to address (in a fair and reasonable manner) cases involving their licensees.

Certainly, they weren’t perfect. A backlog of 488 cases is tough to explain without acknowledging that other factors were probably at work too—resource limitations; protection of fellow physicians, etc. I’ll dedicate space in this blog soon to talk about medial boards’ disciplinary function.

[* If the name Harry Anslinger seems vaguely familiar to you, it is likely because of recent stories concerning the U.S. Dept. of Justice’s pushback against state laws legalizing recreational use of marijuana. Authors studying the criminalization of marijuana in the US point to Anslinger’s controversial efforts and ‘racialization’ of the issue beginning around 1936-37]

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

Sources

H.J. Anslinger, “Traffic in Narcotic Drugs,” Federation Bulletin (May 1934): 136-147.

 

My forthcoming book, Diploma Mill (Kent State Univ. Press, September 2018) shares the story of Dr. John Buchanan and his criminal activities in selling medical diplomas. Without question many of the men purchasing these diplomas were frauds and charlatans eager to cash in on the vulnerability and suffering of unsuspecting patients. These were the early days of medical regulation but already medical boards had the holders of these diploma mill degrees in their sights.

…and yet, there was another group impacted by the rise of medical regulation, a group whose situation deserved genuine consideration. These individuals were neither charlatans nor quacks. The advent of state-based medical regulation and the requirement for a medical license posed a challenge to many practicing physicians. It meant a transition from the long preceding period of American medicine featuring informal or ‘on acceptance’ criteria for those who would practice medicine to a new era characterized by formal requirements (e.g., a medical degree) established under the auspices of a state medical board.

Several generations of physicians in post-Civil War America had been practicing medicine for many years with varying degrees of success in the eyes of their patients and communities. They often possessed no formal medical degree. Their education may have been a full or partial course of lectures from what modestly passed as a medical college. More likely, it may have involved self-study and working for a period of time with a practicing physician—a kind of a mentor/teacher relationship that may even have been sufficiently formalized as to call it a preceptorship. While there were certainly many outright frauds and charlatans who purchased one of Buchanan’s medical degrees, there were likely just as many purchasers—if not many more—who fell into this category. These were individuals with a genuine interest in medicine, who had been practicing for many years but with no formal credential to their name…individuals who saw the acquisition of a diploma as a formality incumbent upon them under the new era of state regulation of medicine.

This transitional era when a profession such as medicine or dentistry moved inexorably toward a formal, state regulatory environment saw its share of casualties in the process. One of the most memorable reflections of this comes from the American writer, Frank Norris, in his 1894 novel, McTeague. 

Norris traced the moral and financial disintegration of a San Francisco dentist and his wife (Mac and Trina McTeague) who failed to navigate the transition from the pre-professional era of uncredentialed practitioners to the professional, state regulatory environment in which a degree (medical or dental) was the expected norm.[1]  McTeague’s undoing comes in the guise of a non-descript letter from the city of San Francisco carrying a notice from the state of California informing him that, lacking a degree from a dental college, he was no longer entitled to work as a dentist. A befuddled McTeague hands the letter to his wife who, in reading it through, slowly begins to understand her husband’s now precarious situation.

“Why, what’s all this?” said Trina, calmly.

“I don’ know,” answered her husband.

“You can’t practice any longer,” continued Trina,— “is herewith prohibited and enjoined from further continuing—“

“I got it this morning,” murmured the dentist. “It just now came. I was making some fillings…”

“Say Mac,” interrupted Trina, looking up from the notice, “didn’t you ever go to a dental college?”

“Huh? What?” exclaimed McTeague.

“How did you learn to be a dentist? Did you go to a college?”

“I went along with a fellow who came to the mine once. My mother sent me. We used to go from one camp to another. I sharpened his excavators for him, and put up his notices in the towns—stuck them up in the post offices and on the doors of the Odd Fellows’ halls. He had a wagon.”

“But didn’t you never go to a college?”

“Huh? College? No, I never went; learned from the fellow…”

“But do you know you can’t practice unless you’re graduated from a college? You haven’t the right to call yourself, doctor.”

McTeague stared a moment…“Why, I’ve been practicing ten years. More—nearly twelve.”

“But it’s the law.”

“What’s the law?”

“That you can’t practice, or call yourself doctor, unless you’ve got a diploma.”

“What’s that—a diploma?

“I don’t know exactly. It’s a kind of paper that—that—oh, Mac, we’re ruined.” Trina’s voice rose to a cry.

“What do you mean, Trina? Ain’t I a dentist? Ain’t I a doctor?”

This life altering scene concludes with a ring at his office door. McTeague rises to get up to treat his scheduled patient only to have his wife grab him with a sudden sense of panic. The letter from City Hall has left her fearful of the implications should her husband disregard the letter and continue to practice. “But you can’t. Mac, don’t you see? They’ll arrest you. You’ll go to prison. You can’t work…We’re ruined.”

While McTeague is a work of fiction, Frank Norris embedded his story in the realistic landscape of a late 19^th century American city (San Francisco) as it edged itself into world of professional regulation. Norris wasn’t actually interested in this transition period per se or the workings of an emerging regulatory system. Instead, this transition serves his dramatic purposes for setting in motion the chain of events sending Mac and Trina into downward financial and moral spiral.

…and yet, even with the grandfather clauses that attempted to accommodate so many legitimate practitioners, I can’t help wondering: How many real-life McTeagues were created in the transition to a professional regulatory model?

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

[1] Norris’ McTeague served as the basis for one of the silent era’s greatest films: Erich von Stroheim’s Greed (1924). Still shot below

 

  Few of us spend much time thinking about numbers; yet they’re immersed in our daily lives. Most of the numbers we think about are mundane—shoe sizes, bank statements, calendar dates. Others reflect serious matters such as the 2.0 degree Farenheit increase in the earth’s average surface temperature since the late 19^th century.

We’ve all heard that “numbers don’t lie.” This is true in a manner of speaking as the scoundrel is really their author rather than the number itself. Take, for example, the recent national dialogue concerning wealth and income distribution in the United States. A writer’s decision to report mean rather than median household income may reflect an attempt to minimize such concerns using a valid though misleading number.

We also understand that numbers in the form of data can inform our decision-making in positive ways—including some that are not necessarily intuitive. Michael Lewis’ Moneyball spawned not just a great accompanying movie but a partial reversal of baseball culture as the gut-instinct decisions of scouts, managers and other ‘experts’ and traditional statistics (ERA, batting average) are now tempered by data-driven metrics that reconsider the value of some of these same statistical categories.

Numbers offer a linguistic shorthand. Most of us could list English language idioms featuring numbers: the impossible conundrum is a “catch 22,” to “deep six” a negative report is to metaphorically bury it, the shoplifter’s “five finger discount.”

I say all this to preface a few numbers—and some accompanying thoughts—on the medical licensing exam.

953,000 nine hundred fifty-three thousand 953k

According to the Federation of State Medical Boards, at the end of 2016 there were 953,695 physicians in the United States with an active medical license. It is a diverse group. The majority of these 953k are men (64%) but that figure is sloping slowly downward based upon the enrollment figures showing more women than men in US medical schools. Most of these physicians hold the MD degree but a growing number (8%) are osteopathic physicians holding the DO degree. Many of these licensed physicians are early in their career (22% aged 30-39) though a much larger group is at the backend of their practicing career (29% aged 60-79). In addition, twenty-three percent of this 953k are international medical graduates (IMGs) who graduated from a medical school outside the US. One could dedicate an entire book to exploring the ramifications of these numbers and the trends behind them.

2 two zwei 2

Despite this diversity, there is one thing all 953,000 of these physicians have in common—all of them took a medical licensing examination. Osteopathic physicians generally take the Comprehensive Osteopathic Licensing Examination (COMLEX-USA). However, the vast majority of America’s physicians—including every MD and IMG—took the United States Medical Licensing Examination (USMLE) or one of its predecessor exams.

We’ve made great progress in getting down to just two exams (see below). I can’t help wondering if ultimately we will end up with a single examination pathway for medical licensure.

50 fifty 50 funfzig 50

Though the USMLE has only been in existence a little over a quarter of century, already 50% of this nation’s physicians with an active medical license have taken all or part of the USMLE sequence. While the testing culture in the United States has come under scrutiny and criticism for some time, one fact remains—the examination required by state medical boards for licensure represents a de facto independent audit of the education and training of these prospective physicians.

This is a far cry from the late 19^th century origins of medical regulation when every state developed and administered its own examination for licensure. One of the predictable outcomes was obvious: Every state had a high degree of satisfaction with their exam while casting a skeptical eye toward just about every other state’s exam. The result being a duplicative approach to licensing that discouraged license portability by usually requiring even the experienced practicing physician to retake a licensing examination.

140,000 one hundred forty thousand 140,000  140k

Collectively, the USMLE administers 140,000 tests each year. This large number may surprise. Now think for a moment about the resources (technical, financial, manpower) required to develop, maintain, administer and oversee a national examination program like this. These demands are significant and well beyond the resources available to individual state medical boards to conduct such a stream of work on their own.

This is the biggest reason why state medical boards got out of the business of developing their own examinations back in the 1960s and 70s. Even Puerto Rico—the only remaining state or territory in the US developing its own medical licensing exam—has finally halted its exam (at least temporarily) under the mounting financial pressures facing that island.

39 thirty-nine 39 trente-neuf 39

In 2016, IMGs accounted for 39% of all USMLE test administrations. A portion of these physicians are seeking to gain certification from the Educational Commission for Foreign Medical Graduates in order to secure residency training in the US before returning to their home country.

However, many, if not most, have aspirations for becoming fully licensed, practicing physicians in the US. This reflects a significant, long-term trend dating back to the massive dislocations arising from World War II and the subsequent influx of émigré and refugee physicians by the late 1940s and early 1950s. Most Americans are blithely ignorant that this country has met, and continues to meet, its physician workforce needs by relying (in part) upon practitioners educated and trained by other countries. Depending on your perspective this is either an unconscionable “brain drain” depriving the host countries of a valuable medical resource or evidence of the continued real and perceived economic opportunities attracting individual physicians to America.

5 cinco 5 five 5

The fail rate for medical students and graduates of US medical school program issuing the M.D. degree and taking the USMLE for the first time is roughly 5%. Non-physicians and those unfamiliar with medical regulation are probably surprised by this number. They wonder, “Shouldn’t it be higher?”  To them, 21^st century medical knowledge is so daunting in its depth, breadth and unfamiliar terminology that achieving anything close to mastery in the field must feel like a Sisyphean task.

But step back for a moment and think about it. Medicine in the United States attracts academic star performers, classic over-achievers and those who excel on standardized tests. Schools already winnow the field of incoming matriculants through a set of criteria demanding academic excellence at the undergraduate level and a strong performance on the Medical College Admission Test (MCAT). Once on campus, educational support systems kick-in to assure success among an already strong talent pool of highly motivated erstwhile physicians.

Of course, we could shade the discussion differently by presenting this figure in a reverse fashion. Instead of sharing a fail rate, we could present this as a 95% pass rate—an approach likely to trigger an opposite reaction, “Why is the pass rate so high?” Uh oh. I seem to have returned to the territory of that “numbers don’t lie” assertion. I’ll stop here…for now.

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

Sources

Young, Chaudhry, Pei, Arnhardt, et. al. A Census of Actively Licensed Physicians in the United States, 2016 (Washington DC: Federation of State Medical Boards, 2017)

Donald E. Melnick, Licensing Examinations in North America: Is External Audit Valuable? Medical Teacher 2009; 31:212-14

USMLE aggregate performance data available at http://www.usmle.org/performance-data/

DA Johnson, HJ Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards (Lanham, MD: Lexington Books, 2012)