Mucking about in the online archives

Writing about the history of medical regulation means spending a fair amount of time poking around the internet, browsing through online archives and searching Google Books. While the internet includes plenty of crap, there’s also valuable material hiding in plain sight for those willing to look for it. Take for example what I ran across recently: annual reports published by the Maryland State Board of Medical Examiners.

These reports (1914, 1916, 1918, 1920, 1922, 1923) spanned nearly a decade over a century ago. Now I suspect some of you are thinking: “What possible interest could these have today? Aren’t they just dry as dust reports from government bureaucrats?” I understand that sentiment; yet you’d be surprised by what we can glean from these annual reports.

Notice the audience for the Board’s annual report

First, these reports serve as a reminder that the primary role and function of medical boards has evolved in fundamental ways. Most board carried the title “Board of Medical Examiners” for one reason: the vast majority of their work involved writing and administering a licensing examination twice a year—usually May or June and then again late in the year. Things are much different today. By the mid-1970s state medical boards had collectively removed themselves from writing their own exams in favor of national exams. By 2000, they relinquished administration of the exam to national test entities that developed them.

A century ago, however, state medical boards like that in Maryland did the heavy lifting for these exams. These reports record that Maryland examined 928 physicians over the thirteen test administrations documented here. Their exam consists of ten  extended response items in nine subjects: Chemistry, Anatomy, Physiology, Pathology, Obstetrics, Surgery, Materia Medica, Practice of Medicine, Therapeutics.

Try your hand at a few of these exam questions from 1917

And the exam data from these reports? If we exclude the individuals retesting just the failed portion from a prior exam, there were 706 full test administrations. What can we glean from the data? Several things. First, the exam presented a modest hurdle to prospective licensees.  Of those 706 test administrations, 651 were passing (92%)—a figure not that far removed from USMLE first-taker pass rates for US students/grads.

Licensees were largely drawn from in-state

These reports also tell us a good bit about the demographics of Maryland’s doctors. Specifically, the licensed physician population in Maryland was largely homegrown. The vast majority of physicians tested by the board (86%) graduated from medical schools within the state or the District of Columbia. There wasn’t much diversity either. International graduates were quite uncommon—only fifteen appeared for a licensure over the entire period. A total of 38 graduates from one of the historical black medical colleges of that era presented for licensure.

I mention demographics, in part, because it seems  relevant to my second major observation in reading this reports: There is a distinctly provincial element that I detect in reading these reports—one in which the interests of medical licensure and the medical profession run parallel and often overlap. For example, the board’s twice yearly licensing exams were conducted with a large assist by the Medical Chirurugical Society of Maryland which contributed physical space for the exam. The board apparently reciprocated when it could. One year the board closed its books with excess funds and used the opportunity to contribute $1,000 to the MedChi Society’s building fund. I guess we shouldn’t be surprised as the annual report’s title identified it as a report to “the Medical Chirurgical Faculty of Maryland.”

Now, I don’t wish to overstate this provincial element as these reports also reveal an attentiveness to issues and trends happening outside the state. That was certainly true with the board’s exam. The board’s 1914 report commented favorably on an amendment to state law allowing the board to incorporate a “practical” component to the licensing exam, e.g., lab work, directly observed interaction with a patient, etc. Two years later the board commented favorably on the first administration of the NBME Parts certifying exam. The launch of the NBME was “favorably received” as the opening of a “new era” with board member Dr. Herbert Harlan as one the staunchest supporters of NBME.

Maryland board president Herbert Harlan’s portrait is preserved at the MedChi offices. Example from an era when professional and regulatory interests blurred heavily

Other annual reports commented on leadership changes at the Federation of State Medical Boards and more stringent educational requirements set by the AAMC for the nation’s medical colleges (including the use of matriculation exams) while lamenting the steadily rising cost of medical education. Obviously, Maryland wasn’t a true provincial backwater with Johns Hopkins in state and the District of Columbia on its border.

So what then do I mean by characterizing these reports as provincial? Think of it this way.  Looking at any century old document represents an exercise in “backward reading.” Unlike the writer of the document, we enjoy the luxury of knowing what happened in the century that followed. One of the things that is so striking in reading these reports is the sense that they were written as an intra-professional document intended for the community of Maryland physicians represented by the Society…a sense that the medical regulator writing the report was speaking to a peer, a colleague in medicine, whose duties may not have included the licensing function but whose interests and priorities were shared jointly as medical professionals. In essence, the reports speak far more to the profession than the public.

This is evident with the space given in these reports to initiatives such as the crackdown on illegal practitioners (1914, 1918, 1920, 1922, 1923). This focus on reining in unlicensed physicians and non-physician healers doesn’t surprise me. Read enough of the late 19th and early 20th century medical literature and you realize the medical boards defined “discipline” in a far more limited way in those days. Medical boards pursued discipline as an exercise what I have termed as boundary maintenance, i.e., guarding the profession against scope creep by chiropractors, midwives, optometrists and, in those days, osteopathic physicians. The 1922 report included a lament that somehow this task had been “comparatively eas[ier]” several decades earlier when the boards had simply to chase after “notorious charlatan[s]” and eliminate diploma mill grads. This was probably more rose-colored nostalgia than reality but still…the board felt under assault by illegal practitioners who “resourcefulness” and identity “disguises” seemed unlimited.

This seemingly Sisyphean task exhausted the board and its members if the periodic complaints about the public in these reports are any indication. Irritation with the public expressed itself in various ways—genuine puzzlement as to why the public failed to appreciate the profession’s efforts of their behalf. To the board, continued popularity of medical fads and “cults” simply reflected that the public mind is “uncertain” if not downright fickle. Surprisingly enough, one report ended with a long passage in which the frustrated board offered to simply throw up its hands. Rather than erecting a large mechanism to track down illegal practitioners such as the California board had done, they wondered aloud, “Why bother?”  Maybe the state should just handle medicine as a “local option” issue just like alcohol had been t for treated for so many years prior to Prohibition? If the locals want to license a Christian Scientist, go ahead. If they want non-degreed physicians, why not?

This philosophical throwing up of ends didn’t extend beyond the 1918 report. And yet…it seems that the board’s report pulled back the veil, just briefly, to show its true feelings—feelings seemingly aligned as much with professional pride as a regulatory commitment to public health.  

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