Some Origins of State-based Medical Regulation

In the years following the American Civil War (1861-65) multiple states and territories passed laws to regulate and limit the practice of medicine—specifically, requiring individuals to meet criteria set by the designated state entity (e.g., state board of medical examiners) and obtain a license before practicing medicine. Half a dozen states established medical licensing boards by the end of the 1870s, another dozen were established in the 1880s and most remaining jurisdictions did so in the 1890s.

For those with any familiarity on the subject, there is nothing new in what I just shared. The “when” in this evolving regulatory system can be presented in a straightforward chronology presenting the introduction of medical practice acts and the establishment of state medical boards.

However, the question of “why” is a different story. Specifically, why did state-based medical regulation emerge at that particular moment in America’s history? People had been practicing medicine long before any state laws regulating the practice—so why did the state legislatures suddenly feel it necessary to begin regulating medicine?

Here we enter speculative grounds but I would offer several reasons for the emergence of medical regulation in the post-Civil War era.

Push back against the “democratization” of medical care

In 1822, the New England folk healer Samuel Thomson published his “New Guide to Health; or Botanic Family Physician.” This modest beginning marked the start of Thomson’s widely successful efforts to re-establish the practice of medicine with its rightful practitioners and materia medica—specifically, family and friends drawing upon herbal or botanic-based remedies. Thomson’s success with direct to consumer guidebooks for medical practice and agents in the field selling his “system” of botanical remedies resonated deeply with Americans of that era increasingly adverse to privilege and hierarchy.

sam thomson

Thomson’s success irked physicians (no surprise!) who felt their knowledge and skill denigrated by home practitioners. When the home medicine-tide finally began to ebb in the post-Civil War era, physicians were already organized (i.e., AMA and state medical societies) and poised to push back. Physicians could point to major advances ongoing in medicine as a basis for establishing themselves as professionals with exclusive control over the practice of medicine. Staking out and securing their “turf” legislatively, including controlling entry into the profession, became a priority for physicians.

Explosive growth in the number of medical schools

At the opening of the 19th century, there were a handful of medical schools in America. By mid-century, there were  50 medical schools. By 1884, there were approximately 100 schools.

US map

Weak chartering laws and the didactic nature of US medical education meant that all that was required to establish a medical school was a building, a minimal amount of materials (books, lab supplies, access to cadavers) and a handful of physicians willing to collaborate as faculty. The result was a sharp increase in the number of individuals holding an actual medical degree and eager to seek a financial return on their modest investment through practicing medicine. Just as important, this era predates even de facto accreditation efforts. Consequently, wide variability in quality characterized US medical education.

From a demographic and educational perspective, this situation posed serious challenges for US physicians seeking to establish medicine as a legitimate profession. To use a metaphor, medical schools were like a faucet with a broken handle gushing forth newly-degreed physicians. It was impossible to cut off the flow; but if one attached new piping to the opening of the faucet, it would be possible to reduce the flow. The “new piping” was state legislation setting forth criteria for the legal practice of medicine and a designated authority (state medical board) empowered to evaluate individual qualifications and issue licenses. Statutory requirements could be set in such a way as to either restrict or encourage the flow of graduates from medical schools. Organized medicine worked doggedly toward restricting the flow.

Rise of the penny press newspaper

Medical societies and individual physicians had another stalking horse at their disposal in arguing for a medical practice act in their state –the quack[1] or the charlatan. Hawkers of medical cures and remedies can be traced into the Middle Ages where they often combined medical, theatrical and itinerant elements. With so many, at best, modestly educated practitioners pouring out of American medical schools—including those with degrees from schools little more than medical diploma mills—the medical establishment could point to outlier practitioners (conveniently labeled quacks or charlatans) as a tangible example of the need for medical legislation. snake oil

Their case was further bolstered by the ready availability of cheap print advertising in the daily penny press newspapers. Wild claims involving all manner of lotions, potions, pills, nostrums and elixirs filled newspapers, short-lived medical journals and circulars. Physicians could point to the over-the-top claims in these ads from outlier practitioners as proof of a danger to the public.

I would argue that all three forces were at work in the post-Civil War years; combining in a mutually reinforcing way that resulted in a steady push toward a state-based system of medical regulation.

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

Resources:

William G. Rothstein, American Physicians in the Nineteenth Century: From Sects to Science (Baltimore: Johns Hopkins Univ. Press, 1985)

John S. Haller, Jr., The People’s Doctors: Samuel Thomson and the American Botanical Movement, 1790-1860 (Carbondale: Southern Illinois Univ. Press, 2000)

M. A. Katritzky, “Marketing Medicine: The early modern mountebank,” Renaissance Studies 15, no. 2 (2001).

 

[1]  Quack derives from the Dutch quacksalver meaning a hawker of salves.

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