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.
The regulatory narrative around IMGs is rather unusual compared to that of other groups. In the late 19th and early 20th 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.
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).