It would be naïve to think that this nation’s fraught history with race did not impact medical regulation. The challenge here, as for all the categories explored in this post, is pulling together a reasonable overarching narrative from fifty different states. If we pull back to a thirty-thousand foot view for medical regulation, however, there was one development that carried by far the greatest impact.

Black Americans faced limited opportunities for medical education and, ultimately, licensure in the late 19^th and early 20^th century. These opportunities were curtailed further by reform measures in medical education such as those by the Carnegie Foundation and the AMA Council on Medical Education. While the Carnegie Foundation’s Flexner Report remains the better known of these efforts, the Council on Medical Education’s inspection and rating system for U.S. medical schools proved even more impactful. You may wonder, “How is this relevant to medical regulation?” I’ll explain.

The Council created a 3-tier rating system that categorized all schools as Class A, Class B or Class C. The first two categories either met standards or were deemed capable of doing so with reasonable changes. Class C schools were classified as substandard and deemed unsalvageable. This categorization system carried a profoundly negative impact to historically black medical colleges (HBMCs), nearly all of which fell into the Class C grouping.

With the exception of Howard, HBMCs were proprietary endeavors chronically short on funding and resources. Yet they were often the only option available to black physician hopefuls. As state legislatures and medical boards –desirous of higher standards for medical education and plagued by persistent diploma mill style educational endeavors—eagerly embraced the Council’s rating system. The classification system fit conveniently and without ambiguity into state law and seemed a mom-n-apple pie recipe for improving the quality of this nation’s physicians.

The downside? Once this became a primary basis for licensure, HBMCs routinely found themselves assigned to the Class C category with their graduates’ ineligible for licensure in all but a few states by 1923. This reality contributed to a death spiral for all but two HBMCs (Howard, Meharry) and represented a massive setback for black Americans aspiring to become licensed physicians.

While this systemic factor cannot be emphasized too much, there was also impactful activity happening around licensing decisions specific to individual physicians. Here it is difficult to generalize without succumbing to speculation. So I will offer a few anecdotes though I acknowledge that the plural of anecdote is not evidence!

Justina Ford was the first black female physician licensed in Colorado. The year was 1902. Her encounter with the Colorado board left an indelible memory. As she related the story later, one board member told her: “I’d feel dishonest taking a [licensing] fee from you. You’ve got two strikes against you. First off, you’re a lady and second, you’re colored.” Her low-key response suggested she would be a persistent licensure applicant. “I know it. I thought it all through before I came. This is just the place I want to practice.”

Or take the example of the North Carolina Medical Board. For roughly 40 years, the Board’s administrative practice was to annotate the record of black licensure applicants with a “col” or “colored.” I wrote about this practice recently in the North Carolina Historical Review though the extant evidence and data available were ambiguous as to whether this impacted the scoring of their examination.

It seems highly unlikely that North Carolina was the only state medical board utilizing this annotation practice. It was common to see state medical journals and JAMA publishing updates from medical boards on the administration of their licensing exam…and also common for these narrative pieces to call out the number and/or performance of “colored” candidates. Clearly, someone at these boards was keeping track; and in an era when extended response/essay questions were the norm…well, scoring these licensing exam questions was inherently a subjective matter by the board member(s). Scorer bias—whether racial or subject-matter specific—was impossible to remove from such a testing format.

The Journal of the National Medical Association commented in 1910 on the challenge confronting black physicians to receive due and appropriate credit for their performance on state licensing examinations. Historian Neil McMillian asserted that it was “an article of faith” among black physician candidates in Mississippi that prejudice impacted licensing decisions in that state. The truth behind these concerns and perceptions—to the extent it is recoverable at all—is buried in records dispersed across fifty states. Records that may be suggestive but not explicit about this reality.

Final thoughts

I know that some readers will react to a blog entry like this and think I’m picking at an old wound…that I’m focusing unnecessarily on past shortcomings rather than celebrating the more recent successes in the regulatory narrative. I guess that is one way to interpret this post.

I would hope, however, that readers of this blog over the past few years will see this piece for what I intended—to share what I suspect is a lesser-known aspect of the history of medical regulation; to tell stories—both good and bad—about this unique field; and to inform today’s regulators about the rich history in their field as helpful context for the important work they do today.

Select sources:

Federation Bulletin spanning multiple years from 1915-1926.

“State Board Statistics” in JAMA. This extensive presentation of aggregated information/data appeared annually in April-May.

Marilyn Griggs Riley, High Altitude Attitudes: Six Savvy Colorado Women (Boulder: Johnson Books, 2006)

David Alan Johnson, “The North Carolina Medical Licensing Examination, 1886-1925: Analysis of Performance by Examinees from Historically Black Medical Colleges,” The North Carolina Historical Review (April 2021).

The opinions expressed are those of the author and do not represent the views of his employer (Federation of State Medical Boards)

In Part 1 of this blog post, we explored medical regulation’s imperfect past, including the barriers that confronted women as well as the nature of the appointment process to state medical boards. In Part 2, we consider the experience of two more groups: international medical graduates (IMGs) and osteopathic physicians.

IMGs

The regulatory narrative around IMGs is rather unusual compared to that of other groups. In the late 19^th and early 20^th century, IMGs—especially those from Europe—often possessed medical education credentials considered every bit as good, if not better, than most US graduates. Licensing presented a modest barrier to these physicians. This was at a time when IMGs numbers were relatively modest–only 3-4% of all the physicians examined in a given year by medical boards. This demographic reality that didn’t change until the wave of refugee and émigré physicians following the Second World War and the rapid expansion of US healthcare demanding more doctors.

All of which makes the anti-IMG sentiment that arose in the 1920s all the more unanticipated. The post-WWI era saw a reactionary wave sweeping American politics and culture with nativist and racist sentiment erupting in 1919. Conditions in medical regulation–once relatively conducive to IMGs–quickly turned uninviting.  

As the primary communication tool among and between state medical boards, the Federation of State Medical Boards’ monthly Bulletin offers a unique look into this deteriorating regulatory landscape in the 1920s. For the first time, inflammatory language began to appear in the Federation Bulletin with phrases like “alien invasion” and “undesirable foreign applicant” entering its editorial pages.

At this same time in the mid-1920s, states targeted IMGs directly with a mix of legislation and licensing requirements mandating full citizenship as a condition for medical licensure or, in some instances, that the individual begin the formal process by filing naturalization papers. Twenty-one states had such requirements in place by 1926 with the number rising to 47 states by 1958. By the 1930s, justification for such restrictions gained an added economic incentive as the country lapsed into the Great Depression.

IMGs were disadvantaged in another way–state medical boards lack of first-hand knowledge regarding the medical education provided even at elite European universities. Thus, the longtime practice by medical boards for using lists of “approved” medical schools whose graduates were deemed eligible for licensure proved problematic for IMGs. Such lists were originally created around US medical schools often based upon informed by information and data via the AMA Council on Medical Education and annual issue of JAMA reporting school performance on state licensing exams. These lists were always subjective to a large decree when considering schools outside the US. Consequently, these lists were a mechanism that could easily shut out IMGs (whether intentionally or not), especially those from lesser-known schools outside of Europe.

Osteopathic physicians

If the language directed against IMGs feels embarrassing to read in 2022, brace yourself for worse. Even harsher statements directed at osteopathic physicians can be found in nearly all the medical journals of the day, including the Federation Bulletin during this same period. The invective is noteworthy for its extreme nature and its frequency and persistence over a prolonged period of time. A few excerpts are representative. In 1915, the Bulletin labeled osteopathic medicine a “fraud” and denigrated its practitioners as a “pseudomedical cult.” The Bulletin editors and contributors questioned whether osteopaths deserved the title of physician and lamented legislative efforts to create separate licensing boards for them. The Bulletin further decried osteopathic medicine’s “fallacious claims,” characterized its treatment regimen as bordering on “criminal” and argued that “no conciliatory tone” should be adopted in interacting with osteopathic physicians.

In one regard this was nothing new in American medicine. The animus directed against osteopathic physicians by medical “regulars” represented another chapter in the profession’s tawdry nineteenth century internecine war against homeopaths, eclectics and other “irregular” practitioners. Yet the lingering effects of this bias are far more significant. The lines of demarcation erected between MD and DO continue to this day, impacting accreditation, licensing, examination and certification related to physicians. Medical regulators of the day fought long and hard to deny legal recognition to osteopaths; and when that failed, they sought to curtail their legal scope of practice and confine them to separate licensing boards. Still not content, the profession succeeded in creating basic science boards in multiple states as a screening tool constructed with with DOs, chiropractors and others in mind. T

Some may be surprised to learn that there are still 13 states with separate MD and DO licensing boards—a questionable decision involving taxpayer dollars with boards performing largely identical functions in verifying credentials, discipline and rule-making. Similar parallel systems are in place for medical school accreditation and even the licensing examination. With any luck, the recent success in consolidating what had been separate accrediting bodies for MD and DO graduate medical education programs will set an example to be followed elsewhere, e.g., medical school accreditation, licensing, examination.

In the final post on this topic, we will consider race and racism in the history of medical regulation.

The opinions expressed are those of the author and do not represent the view of his employer (Federation of State Medical Boards).