The Demise of the National Confederation

If you’ve been reading my blog, you know already that regulating the practice of medicine falls to the individual states under the 10th amendment and the Supreme Court’s articulated doctrine of police powers. What you may not know, however, is that despite this country’s decentralized method for medical regulation, state medical boards have often tried to harness the benefits of a national system while retaining local accountability and oversight, e.g., pushing for uniform standards for medical licensure among all states. They have done so, in part, through their participation in a national membership association.

The first effort at such an association dates back 1890 and the establishment of the National Confederation of State Medical Examining and Licensing Boards. (Happy 130th anniversary!) The National Confederation flourished especially during its first decade under the leadership of this country’s most respected medical regulator, Dr. John Rauch (Illinois) and later Dr. William Warren Potter (New York – pictured below)


To my mind, it flourished in part because of aligned interests. At that time, the medical profession enjoyed relatively strong consensus on the need for higher standards in medical education.  This presented the National Confederation with a clear understanding (or so they believed) of their membership’s priorities—championing medical education reform as the best means to raising standards for medical licensure.

However, reforming medical education to raise standards represented a long-term, strategic goal. Quick fixes were not possible even though rapid changes materialized in medical education beginning around 1905 with the AMA Council on Medical Education’s classification system for medical colleges and the subsequent Flexner Report (1910).

But back to the National Confederation and emerging misalignment. At the dawn of the twentieth century, state medical boards were established in nearly all states and territories…and this decentralized system for licensure had its fair share of imperfections. Enough so that many within the medical licensing community felt the need to focus more on the practical concerns of those already licensed. To be more precise, physicians were increasingly frustrated with the practical hindrances to license portability, e.g., varying standards for licensure among the states, lack of recognition between states of each other’s licensing examination.

The National Confederation’s leadership—working in concert with leadership at the American Medical Association and the Association of American Medical Colleges on educational reform—seems to have initially missed and then deliberately disregarded this shift among some of its members.

At the National Confederation’s meeting in 1900, delegates from Michigan and Wisconsin argued vehemently that educational reform should not come at the expense other important initiatives such as license reciprocity. The National Confederation’s officers expressed strong reservations about losing sight of educational reform to chase narrower licensee interests. Tempers flared, voices grew louder and everyone seemed surprised at just how intense the conversation had become. Appearing to acquiesce, the Confederation’s officers agreed to establish a Committee on Reciprocity to examine the issues raised and report back.

Appearances proved deceiving. Comments made later by the National Confederation’s Secretary acknowledged that they had hoped to “summarily dispose” of the issue by foisting it onto a committee where it might die out once passions cooled. Their terse treatment of the committee report at the following year’s meeting (it was simply “received and filed” and the committee “discharged”) led to an irrevocable breach within the National Confederation.

The result?  In 1902, a second national association representing state medical boards emerged—the American Confederation of Reciprocating Examining and Licensing Boards whose singular focus was on promoting reciprocal licensing agreements among the various state medical boards. StLPost-Dispatch_MedicalBoardFailtoConsolidate

Over the next decade, the interests of state medical boards were championed by two organizations, each with a slightly different focus and set of priorities. This unsatisfactory state-of-affairs continued until the two organizations combined in 1912 to form the Federation of State Medical Boards. Looking back at this this history today, there are several lessons that seem germane more than a century later.


Organizations, like people, need both short-term and long-term goals. The National Confederation and its leadership failed to understand this. Educational reform would indeed pay significant dividends in the long-term as it would allow regulators to painlessly raise standards across the board for medical licensure. But their singular focus on the long-term while ignoring the human desire for short-term gains blinded them to a growing misalignment of interests among their members anxious to deal with problems directly confronting physicians in the present.


Few things in life can trigger a stronger reaction from people than inequitable treatment or handling of a legitimate issue or complaint. The National Confederation’s cavalier dismissal of an issue important to a subset of its membership set in motion a chain of events that ultimately splintered and weakened the ability of state medical boards to speak with a larger unified voice on critical topics.


All of us like to get our way but the wise remember that “adequate” and “ideal” are not opposites. National Confederation President William Warren Potter made this mistake by acting as an idealist tied to sequence rather than a pragmatist open to parallel pursuits. “It is…out of place to expect that…reciprocity can be established…while the methods of education are so different.” He insisted upon relegating the practical issue of license reciprocity as a matter to be dealt with later in the “final stage of the great (educational) reform.”

In being so inflexible regarding his vision predicated on sequenced prioritization, Potter missed the salient point: all of his members wanted to raise standards for medical licensure. They were simply championing different paths to the same destination.


The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards.

Source: See chapter 2 from David Johnson, Humayun Chaudhry. Medical Licensing and Discipline in America (Lexington Books, 2012)

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