State medical boards operate under-the-radar of most physicians and the public at large despite the fact they have been integral players in the U.S. medical regulatory system since their appearance in the last quarter of the nineteenth century.
By any objective measure, however, state medical boards exerted their greatest power and influence nearly a century ago. I was reminded of this when I ran across this intriguing chart (below) from the June 1922 issue of the Federation Bulletin.
Take a closer look. The author of the article cobbled together statistics presented in JAMA’s annual report presenting statistics and information on the activities of state medical boards. The chart took a clever approach in consolidating two disparate pieces of information: state medical boards’ decisions to refuse licenses to graduates of certain schools and performance on their examination for medical licensure.
Let’s start on the left with state boards’ recognition of U.S. medical schools. With the exception of Massachusetts, Wyoming and the District of Columbia, every state board flagged a subset of schools that they refused to recognize for the purposes of licensing their graduates. Indeed, most of these boards identified 8-10 schools that they refused to recognize; nearly double that number in states like Pennsylvania and New Hampshire.
You’re probably wondering, “How was it possible someone could graduate from a US medical school and not be eligible for a license in most states?” To answer this question, we have to forget the medical education landscape as we know it in 2018.
We are so accustomed to the presence and function of trusted accrediting bodies for medical education (both undergraduate and graduate) that it’s easy to forget the realities of an earlier era.
In the first decades of the medical licensing (roughly the period from 1870 to 1910) there were no agencies or mechanisms providing assurance that anything substantive stood behind the issuance of a medical degree. At the time that state medical boards were established, they relied on generalized language (either in statute or developed by the board) that spoke in terms of licensing graduates of “reputable” or “legally chartered” schools.
Practical experience soon proved the uselessness of such language. A vague term like “reputable” offered little guidance and no measurable basis for distinguishing reputable from disreputable schools. Similarly, holding a legal charter was no guarantee. Even a medical diploma mill like the Eclectic Medical College of Pennsylvania held a valid, legal charter
Enter Dr. John Rauch and the Illinois Board of Health who quickly became the most influential players in the medical licensing community.
Rauch and his board colleagues embarked upon an ambitious information gathering effort that led to the first list of “approved” medical schools. A listing soon utilized by multiple states and claimed by several historians in recent years as being just as impactful as the later Flexner report.
The American Medical Association (AMA) later took up the mantle of bolstering medical education standards with the creation of its Council on Medical Education. The Council undertook surveys and inspections in 1907-1908 that led to their own assessment of schools and a classification system. The Council classified medical schools into three groups. Schools of the highest quality were categorized as Class A; schools with deficiencies but still salvageable were categorized as Class B. The remainder (Class C) were deemed beyond the pale and believed to be unsalvageable.
By the time of the chart pictured here, medical boards were no longer as involved in investigating and monitoring the quality of medical schools. Instead, they drew upon the Council’s classification system to identify approved or recognized schools (Class A & B) and routinely deny licenses to graduates of Class C schools.
By the end of the 1920s, Class C schools had all but disappeared. Fast forward to 1942. This classification system evolved into the accrediting body that we know today for schools issuing the MD degree—the Liaison Committee for Medical Education (LCME).
Consequently, medical boards no longer have the need for formal lists of approved or recognized schools. The imprimatur of LCME accreditation assures medical boards of the meaningful education experience behind an MD degree.
I would argue that this “lost” power of medical boards is a good thing…a positive reflection of just how far medical education and licensing have come over the past century.
Next time (in Part 2), we’ll look at the right side of this chart and the other “lost” power of state medical boards—state board examinations.
The opinions expressed are those of the author and not the FSMB.
 See Lynn E. Miller, Richard M. Weiss, “Medical Education Reform Efforts and Failures of US Medical Schools, 1870-1930,” Journal of the History of Medicine and Allied Sciences (July 2008)
 The Commission for Osteopathic College Accreditation (COCA) accredits osteopathic medical education programs issuing the D.O. degree.