“It is very rarely that two small bottles prove sufficient….”

 “Have you ever heard of F C Shaklee?”

If you’re like me, the answer—until recently—was no. This question from my wife came after a trip to her mother’s home and a bit of house cleaning that unearthed correspondence from Shaklee to her great Aunt Gertrude and Uncle Earle stretching from 1933 to 1942.

Forrest Clell Shaklee (1894-1985) was a chiropractor and entrepreneur with a keen interest in what we might characterize as nutrition-based holistic health. Shaklee appeared to be inspired early on by the work of Casimir Funk, a Polish chemist generally recognized as the ‘father of vitamins.’ Funk’s research demonstrated a link between deficiency diseases such as scurvy, beriberi and pellagra with the absence of specific organic substances—what he termed “vital amines.”

F. C. Shaklee

Looking back at Shaklee’s career, one can see several influences at work. The most apparent is a focus on alternative treatments to conventional medicine, e.g., 19th century dietary-focused health regimens such as that espoused by Sylvester Graham and the water treatments generally labeled hydropathy. Equally apparent was Shaklee’s business acumen. His use of radio programming in the early 1930s (“Clinic of the Air” on KLX Oakland, KNX Hollywood) spread his treatment philosophy throughout much of California; his use of representatives or agents to sell Shaklee health products mirrored the earlier efforts of 19th century Thomsonian medicine and the later marketing of Amway and other direct to market sales operations.

My wife’s relatives (Gertrude and Earle) were satisfied long-term…customers? patients? I’m not sure how to finish that sentence as it seems clear that while the couple were purchasers of Shaklee products (probably Shaklee Vitalized Minerals), they apparently viewed their relationship with Shaklee as something more than a commercial exchange. Aspects of the arrangement certainly feel medical. They subscribed to his Medical Digest; and the correspondence references urine (and possibly blood) samples and completed health questionnaires supplied to Shaklee for analysis.

Shaklee’s subsequent responses focused heavily on dietary guidelines and various supplements—some of the latter appear to have been over-the-counter commercial products, while others appear to have been proprietary to Shaklee.

One element of Shaklee’s success would seem to be the personalized nature of his interaction with customers/patients. Shaklee prepared dietary guidelines for both Gertrude and Earle with handwritten notation (B=breakfast; L=lunch; D=dinner). Over time a personal relationship developed as evidenced by letters in 1942 indicating Shaklee as a guest for a “fried chicken dinner” on more than one occasion at the couple’s ranch outside Hollister, California.

Shaklee’s career shines a light on the grey space intersecting medicine, health and supplementary products including everything from vitamins to what has broadly been described as ‘patent medicine’ products. Shaklee saw the boundaries of these as less Venn diagram than philosophical distinctions. He claimed medicine as something fundamentally different from his aspirations. “They are trained to treat disease. I am interested in building health.”

Medical regulators of that era, however, operated frequently as hyper-vigilant guardians of the medical profession, quick to spot and shut down individuals and allied health professionals who dared to drift into the scope of practice defined as medicine. Chiropractors, midwives, naturopaths and, in the first decades of the 20th century, osteopathic physicians, were their most frequent targets. Shaklee proved no exception.

F. C. Shaklee graduated from the Palmer School of Chiropractic in 1915. He returned to central Iowa (Fort Dodge) to ostensibly open up a practice. An ambitious young man, he apparently had operations that extended into Illinois soon thereafter as by 1918 he had a case pending before the Illinois Board of Health for “unlawful practice” of medicine. The resolution of the case is unclear. Arrest and a hefty bond ($300 in this instance) often sufficed for the board to shut down the operations of those targeted for unlawful practice.

Shaklee’s pending case is in yellow highlight

A fire in the mid-1920s destroyed Shaklee’s practice in Iowa. He relocated briefly to Oregon before settling in California where he conducted what appears to have been a thriving business. By 1941-42, Shaklee stepped away from his business—perhaps one reason he had time to visit patients like Gertrude and Earle. After an extended period writing several books outlining what he described as “thoughtsmanship” (a lifestyle or philosophy we might see as mindfulness today), Shaklee re-engaged in business affairs. In the mid-1950s, he and his adult sons started Shaklee Corporation selling health and nutritional products.

From a medical regulatory perspective, the Shaklees of the world present something of a challenge. Americans love the quick fix and a cut corner when it comes to their health. We see it today with online and television advertising for “health” products ostensibly addressing everything from probiotic imbalance to low testosterone—a range of products floating outside the FDA approval process. When claims for curative powers accompany such products, it was not surprising for medical regulators in the 1920s and 30s to act—especially when the claims involved eradicating or curing specific diseases. At the same time, other than seeking injunctions, arrest and fines, there was little medical boards could do. Their great weapon was the revocation of a license but as the practitioner was not a physician and had no license at stake…well, you can see the limitation. If Shaklee overstepped into the unlicensed practice of medicine, at least it seems to have involved generally more benign treatments focused on diet. This clearly wasn’t the case with others like John Brinkley,Harold Hoxsey or Norman Baker.

One of my work colleagues great aunts has a Norman Baker connection. I’ll share that story soon.

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

Sources:

 “Farewell Surprise,” Quad City Times, Davenport, Iowa; June 17, 1915

“Casimir Funk: Polish-born American Biochemist” https://www.mayoclinicproceedings.org/article/S0025-6196(12)61343-3/pdf

Robert L. Shook, The Shaklee Story (New York: Harper Collins, 1982)

Liar, liar, pants on fire!

My last blog post shared stories of early instances of cheating on the licensing exams administered by state medical boards. It might be comforting to view such incidents through the gauzy lens of a long-ago yesterday—as problems confined to the dust bin of history. Uh…not quite.

Even today there are young medical students and physicians reckless enough (or sufficiently desperate) to endanger their career with risky, unethical behaviors related to the United States Medical Licensing Examination (USMLE).

First, let me say that these episodes are outliers. The overwhelming majority of USMLE test administrations (99.9%) take place with no questionable conduct by examinees. At the same time, it’s important not to be lulled into a false sense of security—just because something seldom happens doesn’t mean its potential and impact are somehow lessened.

So what am I talking about specifically? Let me share a few examples of scenarios and cases I’ve seen in more than twenty-two years working with the exam.

Security violations

This category covers a wide range of activities, including standard fare that might immediately come to mind—examinees trying to bring notes or other materials into the exam; as well as the reverse, trying to take test information out of the exam.

Close-up of a hand covered in formulas for a math class exam

Hand of student with cheat sheet for math exam – selective focus

One examinee was caught with a textbook shoved into the waist of their sweatpants!  (How this person thought they would use it with human and video proctoring is still a mystery to me!)

The rise of “smart” devices pose a unique risk. Yet some examinees struggle to understand why their smart phone has no place in the exam room.

Creating a new identity

Among the community of international medical students and graduates there are instances in which a poor start on the exam (e.g., several failed attempts on a Step) leads an individual to try to wipe the slate clean. Because naming practices have features unique to cultures and regions, some individuals attempt to apply using a slight variant on their name and/or biographical information.

fake id

Colleagues at the Educational Commission for Foreign Medical Graduates have become extremely adept at spotting these tactics.

Falsified documents

Examinees have been known to alter documents to their advantage. This involves a degree of premeditation and calculation that is disturbing. For example, the USMLE transcript is produced on a specific paper incorporating multiple security features. Altering such a document is impossible without leaving clear signs of tampering. One examinee solution was to attempt to get their hands on the actual security paper! I can’t offer details but let’s just say this bizarre attempt at subversion didn’t get very far.

The weak point in any security system is most often the human element. The same holds true with falsified documents. Providing USMLE transcripts through secure portals to state medical boards or to residency programs through ERAS eliminates the possibility for falsified documents when they are sent directly to the end user—yet this is dependent upon these same users of the document not accepting an unofficial and/or xerox copies of transcripts or score reports. This is where problems arise.

fakeIn my experience, the ability of an unscrupulous individual to get away with a falsified document is directly a function of their ability to play upon an existing relationship with a staff member or faculty at their school or program. I’ve seen this dynamic play out a number of times as the person asking the examinee for evidence of having tested or passed simply can’t believe that the person standing in front of them would ever do something as unprofessional as falsifying their exam record. In fact, they might even feel awkward or embarrassed about questioning a proffered photocopy of a score report or transcript by a student or resident that they have known perhaps for several years.

Sure, on one level the faculty/staff understand people have been known to alter documents but it seems inconceivable to them that such a thing could or would happen at their institution. “I know David. He would never do something like that.” To reiterate, in my experience, these are precisely the scenarios by which the desperate student/resident attempts to either buy additional time or get out of a troublesome situation relative to the exam. I remember sharing an anecdote of such a case with one program director who seemed genuinely stunned that such things ever happened…and yet I’ve seen cases like this involving Step 3 and residency training in particular.

Sociopathic behavior

Okay, I’m neither a physician nor a clinical psychologist and yet what I have observed on occasion when individuals charged with irregular behavior appear before the USMLE Committee on Individualized Review is almost frightening. I have observed individuals, despite a mountain of physical evidence demonstrating their guilt beyond a reasonable doubt, protest their innocence and feign ignorance of how their signature ended up on a document or how an altered photocopy of a score report made its way to staff at their program.

One thing is certain—the courtroom confession seen on Matlock and Perry Mason is a cheap literary device with virtually no basis in reality. I have only once seen an individual crumble under intense, pointed questioning and ultimately confess to irregular behavior.

matlock

Instead, the norm for those who come in protesting innocence is to double down, conceding nothing and offering explanations involving disgruntled ex-girlfriends, inappropriately helpful family members or an outright “nemesis” bent on ruining them. (Don’t laugh—it has happened)

I know some of you are reading this thinking, “Come on, nobody does that, right?” Wrong. My colleagues and I have often said to each other, “You couldn’t make this stuff up because nobody would believe it.” And yet it’s true.

It is precisely this doubling down behavior rather than expression of remorse that is troubling. Don’t get me wrong. Remember, there are relatively few cases of alleged irregular behavior associated with the exam…and the behavior I just described is a small subset of that. Yet, I’ve seen examinees given every opportunity by the committee to “come clean” with the underlying message that a remorseful admission of guilt would be viewed more favorably…and still the individual persists against the mountain of evidence and with explanations almost contrary to the laws of the physical universe in proclaiming innocence. It is these instances that are truly frightening—of an individual’s ability to present lies and counter arguments beyond all plausible believeability. These are also the cases that those of us in attendance find most troubling.

The traditional professions—clergy, law, medicine—are founded upon a commitment of service to a greater good for the benefit of society; and with a commensurate goal of enforcing high ethical standards for professional conduct. My point in sharing these historical and more recent incidents around the licensing examination is simply to remind us all: human nature does not change based upon the mere bestowal of a credential.

 

Note: The views expressed are those of the author and do not reflect those of the Federation of State Medical Boards or the United States Medical Licensing Examination (USMLE) program.

Cheaters Never Prosper…well, they usually don’t, right?

For as long as there have been written exams, there has been a subset of test-takers that cheat. Despite what we might like to believe, physicians and medicine are no exception. Take this brief description of an incident recorded in the 1899 meeting minutes of the North Carolina Medical Board.

“A dastardly attempt was made at this meeting to secure a license by fraud. One C. E. Coppedge of Spring Hope, Nash Co., NC employed Osborne, M.D., intern at hospital in Baltimore, Md. to stand Ex[am] for him, forging his name, etc. Detected and exposed by Sec’y before accomplishing purpose intended.

This may be an extreme example, but it wasn’t the first instance of cheating on the North Carolina examination. The prior year the board rejected four candidates for “copying” during the exam. (I know—such an unimaginative grade school tactic!) copying

In fact, once the board abandoned its oral exam in favor of a written test in 1889, they were forced to take more elaborate measures guarding against exam cheating. The board created a set of “rules” for testing that included proctoring requirements and authority for the board to reject or expel candidates for “cheating.” Examinees were assigned to specific desks for testing with a corresponding number affixed to each; examinees and desk assignment were rearranged after each subject examination.

So what was up with those Tar Heel doctors, right? Well, if you think they cornered the market on duplicitous doctors—think again.

1895 – The Bulletin of the American Academy of Medicine related how a Dr. “G.S.” graduate of Jefferson Medical College successfully duped an unnamed medical board two years earlier by sitting the exam successfully on behalf of his brother-in-law.

1903 – The Washington State Supreme Court upheld a decision by that state’s medical board to deny licenses to a pair of physicians found to have conspired to obtain advance copies of the licensing exam questions.

1904 – The Pennsylvania Board of Medical Examiners expelled four candidates from their exam for cheating.

1906 – President of the Indiana Medical Board reported being approached by a candidate offering $5000 for a passing score on their exam.

1912 – the Illinois Board of Health denied licensure to Charles Bateman based upon evidence he sat the Missouri medical licensing exam as a ringer on behalf of another physician, George W. Carson.

My favorite example of exam cheaters is one described in the October 1905 issue of the State Board Journal of America.

“There is the case of the young man, who, gaining access to the examination room on the night previous to the examination, bored a three-fourths inch hole in the floor so as to communicate with the coal-cellar below, where he next day had a corps of assistants installed with an ample library of modern text and reference books. When he wanted an answer, during the examination, he had only to write the question on a strip of paper, ball it up and drop it into his bureau of information. The question soon reappeared answered, and in the meantime he kept…his foot so adjusted over the aperture as to hide it and yet allow the return of the answered question.”

Talk about an imaginative scheme!

Close-up of a hand covered in formulas for a math class exam

State medical boards of that era were keenly aware of efforts like these and adopted counter measures to combat cheating. For example, some boards stopped using local printers to print their exam questions—opting instead for printers in distant cities. To combat pre-knowledge of exam questions, boards supplied examinees with assigned blue books or colored paper when they arrived on site for writing out their answers. To forestall old fashioned copying by looking at another examinee’s test, boards would mix the order of questions or employ multiple test forms that minimized duplication of test questions.

The use of substitutes or “ringers” (i.e., individuals taking the exam on behalf of someone else) presented a special challenge. Boards ultimately had to introduce practices that  included  photographs of applicants affixed to assigned seats with comparison of signatures onsite during the exam compared to the signature on the license application.  Even this wasn’t foolproof–check out my earlier blog post on Phillip Dyment   By the 1920’s, most state medical boards had become highly versed in exam security and able to provide numerous anecdotes of cheating irregularities they uncovered.

Some readers may be surprised to see such a litany of misconduct—though the reality is that I could easily offer many more historical examples like these.

In relating these episodes, my intent is to prepare readers for the unsavory reality—and to some, the shock—that cheating on the medical licensing exam is not something limited to a bygone era. I’m priming you for my next blog post offering examples of far more recent vintage.

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

Source: North Carolina Medical Board, Registry Book 1859-1908. pdf 73-74, 188-189 https://www.ncmedboard.org/about-the-board/historic-

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)

potter

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.

(Im)Balance

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.

(In)Equity

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.

Pragmatism

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)

The Dirty Little Secret of Medical School?

Movie buffs and those among us of a certain age remember the 1973 film, The Paper Chase. The film depicted the experiences of John Hart (portrayed by actor Timothy Bottoms) and fellow first-year law students at Harvard. John Houseman won an Academy Award for best supporting actor with his portrayal of Charles Kingsfield, the austere and demanding professor of contract law. houseman

I saw the film a couple years later when I was in high school and came away both intrigued, inspired and a bit shocked by the intellectual culture the film suggested. I was too young to fully appreciate the potential for artistic license in the film’s portrait of the culture surrounding an Ivy League law school and too far removed (geographically, intellectually, experientially) to assess its accuracy. But one take away message was crystal clear—law school represented an academic Bataan death march that only the hardiest could survive. Intellectual casualties were a given…it was just a question of “How many will drop out this year?”

Like most Americans, I didn’t attend law school; nor have I attended medical school. The same is true for my immediate and extended family. Thus, like most members of the public, any assumptions I held about law or medicine for many years were predicated upon little more than notions arising from popular culture such as The Paper Chase, popular television shows and books.

What ill-informed assumptions did I have about medical school? There were two actually.

  1. Getting into medical school was difficult—a highly competitive process that weeded many prospects out on the front end.
  2. Once you got into medical school, a similar winnowing occurred perhaps not too unlike that depicted in The Paper Chase.

The overall picture I carried around in my head was simple: It’s tough to get into medical school and tough to make it through once you got there.

Fast forward to the late 1990s when a job change brought me into regular contact with medical educators. It did not take long for me to absorb their comments and stories and realize that my fundamental assumptions were only partial correct. Yes, it’s tough to get into medical school…but once you get in, everything about medical school culture is designed to make sure that you come out the other end as a physician. The idea of medical education as an experience featuring heavy attrition was an illusion.

Part of what I absorbed from these colleagues was that the culture permeating U.S. medical schools was best described as a “failure to fail” students—at least, those who for whatever reasons (most likely behavioral issues) should not be passed along to graduate medical education and ultimately patient care. secret

These colleagues’ stories lamented this reality either explicitly or tacitly—and almost always with a sense of resignation for the futility of any meaningful change in the broader educational culture.

There are plenty of reasons for this failure—culture is just one though admittedly it is probably the strongest. (The words of business guru Jim Collins spring to mind here: “Culture eats strategy for breakfast.”)

Fear and guilt play a role too. Fear of costly litigation seems to underlie many schools’ reluctance to remove the student whose track record has demonstrated their poor fit for medicine—a poor fit usually stemming from ethical or behavioral deficiencies. And guilt? Oh yeah, I’ve heard medical educators shoulder the blame by pointing to failures in the admission process or lack of timely intervention before the student has progressed too far and accrued massive financial debt.

Members of state medical boards—even those not directly involved in medical education—have some sense of this reality. Most of the disciplinary actions they take against licensees have nothing to do with medical knowledge—instead, they invariably involve what one regulator once called the 3 A’s: Arrogance, Avarice and Addiction. It is not uncommon for state medical boards working through a disciplinary case for professional misconduct to become aware that there were early signs of problematic behavior overlooked, minimized, rationalized or otherwise swept under the rug. Maxine Papadakis’ studies from more than a decade ago came as no surprise to medical regulators—the biggest factor associated with later disciplinary action by a state medical board were (mis)behaviors in medical school.* Indeed, I have heard medical regulators complain that it often feels to them that they are having to clean up issues that shouldn’t been dealt by others far earlier in the physician’s career.

For this reason, I find it heartening to see the commentary in a recent New England Journal of Medicine that acknowledges this “dirty little secret” of medical education—though Santeen and her co-authors call out their colleagues more diplomatically by characterizing the culture as one of “kicking the can down the road.” Cultural change is incredibly difficult but it definitely becomes more likely to occur once an issue moves out of the shadows of hallway conversations and after-hour commiserations to the light of public discourse.

* Further evidence of this phenomenon appears in the current ahead-of-print offerings of Academic Medicine by Edward Krupat and colleagues, “Do Professionalism Lapses in Medical School Predict Problems in Residency and Clinical Practice?”

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

Exiting the Exam Business

It started in North Carolina. In its 1858-59 legislative session, that state established the first state medical board in the era that historians now recognize as the dawn of modern medical regulation. A primary duty of the newly created North Carolina Medical Board required them to “examine” all applicants for a license to practice medicine. As states enacted medical licensing laws in the post-Civil War era, legislatures routinely codified this power into statute.

Over the next century, sitting for a medical licensing examination became a common rite of passage for all newly minted physicians. The rite continues to this day. However, only a small percentage of physicians practicing in 2019 were licensed based upon one of these state-developed exams as they were wholly replaced by nationally administered assessments by the mid-1970s.

So essential was examining prospective licensees to the core functioning of state medical boards that most of these boards’ original title incorporated some variation on “medical examiner,” e.g., the Texas Board of Medical Examiners or Nebraska Board of Medical Examiners.  (Pick any state, insert that name into the title and that was pretty much it) And yet these boards willingly (eagerly?) surrendered this role. Why were state medical boards willing to surrender this long-standing assessment role?  It wouldn’t seem to have been an easy decision considering how fundamental this role was to the identity and purpose of medical licensing boards.

Several critical factors appear to have been at work. First, the science of assessment and testing had progressed significantly by the early 1960s. Few, if any, medical boards employed the technical staff and resources necessary to incorporate the professional standards set forth in the Standards for Educational and Psychological Testing [1966, 1st edition] or its precursor publications.1

Many boards had already tacitly acknowledged this deficiency through their arrangements with the National Board of Medical Examiners (NBME) to utilize content drawn from that organization’s Parts examination.  By the mid-1960s thousands of physicians were taking state exams that contained items from the NBME item bank. Developing a high-quality exam was onerous. If actions speak louder than words, a significant portion of state medical boards were already signaling their willingness to exit the exam business.2

exam photo

Veteran medical regulators like Robert Derbyshire acknowledged the problems with state board exams. Writing in the Federation Bulletin, Derbyshire pointed to the disparate passing standards being applied by boards on their examinations. In some states, few (if any) candidates failed the exam over a multi-year period—raising legitimate questions about both the content and passing standard utilized in these exams.3

Another factor largely forgotten today stems from a mid-1960s federal document: The Report on the President’s Advisory Committee on Health Manpower. This report cast a spotlight on the huge disparity in international medical graduates’ (IMGs) performance on state medical licensing exam—in some states no IMGs failed; in others, nearly 70% failed the exam. The report’s recommendation called for a common standard on licensing examination and suggested the NBME Parts as the tool all examinees, including IMGs.2

However, this recommendation proved problematic in looking to the NBME Parts as a solution. NBME’s three-Part certifying examination was designed to mirror the U.S. medical education curriculum with its heavy pre-clinical emphasis on foundational medical sciences. This content emphasis represented a significant potential hurdle for IMGs. Whether solely because of this or in conjunction with other reasons, the NBME Parts was not open to IMGs in the 1960s. Indeed, the exam had been limited to US graduates for decades.

Wary of the potential for federal remedies arising from the President’s Health Manpower report and cognizant of the deficiencies of state-developed exams, the Federation of State Medical Boards (FSMB) took this as an opportune time to move state medical boards toward a common examination. Through its Examination Institute, the FSMB had long sought to bring greater quality and consistency to the content of state medical boards’ examination. This effort, while laudable, brought at best mixed results reflective of the swimming upstream challenge it represented to an organization of modest means and resources.

Instead, the Federation approached the NBME about a new examination. Together the two organizations developed the Federation Licensing Examination (FLEX)—an examination open to all physician candidates for licensure. The FLEX drew upon the extensive item pool and test development expertise at the NBME to create a three-day examination that sampled a physician’s basic and clinical science knowledge (Day 1 and 2 respectively) with critical assessment on the third day of clinical competence—a focus on the application of knowledge in a clinical context…or what long-time state board members described as “fitness to practice.”4 The FLEX also used a content-weighting that gave greater priority to clinical medicine. This 3-2-1 formula placed greater emphasis on clinical competence (3) with lesser on clinical science (2) and the least emphasis on basic medical sciences (1).5 Utilizing this weighting alleviated the concerns regarding the appropriateness of the exam for IMGs.

The first administrations of FLEX occurred in June and December 1968 with eight states participating: Illinois, Maine, Nebraska, New Mexico, Ohio, Oregon, West Virginia, Wyoming.5 This modest but promising beginning led the Federation to begin heavily promoting adoption of the FLEX in its  Federation Bulletin and through exhibits at its annual gathering held in conjunction with the yearly meeting of the American Medical Association.

 

 

(Top left: Dr. Fred Merchant at the FLEX display during June 1970 AMA meeting. Top Right: Typewritten text of Merchant’s June 15, 1970 editorial in JAMA; original mock-up created by Merchant for the display)

The timing of FLEX’ introduction seems to have been fortuitous. Despite a century of medical boards “examining” prospective licensees, these boards rapidly abandoned their state exams to adopt the FLEX. By 1970, twenty-five states used FLEX; two years later the total rose to forty-two states.6 By 1973, every state except Florida and Texas were on board (these two joined before the end of the decade).

The careful reader may have deduced that the introduction of FLEX failed to resolve a lingering issue—the existence of two examination pathways to licensure (FLEX and Parts) with only one of these closed to IMGs. One of my next blog posts will pick up this thread of the story leading to the United States Medical Licensing Examination (USMLE).

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

 

1 Technical Recommendations for Psychological and Diagnostic Techniques (1954) by American Psychological Association or Technical Recommendations for Achievement Tests (1955) published by National Education Association.

2 John Hubbard, “The Federation Licensing Examination and the Testing of Clinical Competence,” Federation Bulletin (May 1968): 153.

3 Robert Derbyshire, “How to Obtain a License—In One Easy Lesson,” Federation Bulletin (April 1965): 124-27

3 John Hubbard, “The Federation Licensing Examination and the Testing of Clinical Competence,” Federation Bulletin (May 1968): 153.

4 Frederick Merchant, “A Federation Licensing Examination: Testing for Fitness to Produce,” Federation Bulletin (April 1968): 119.

5 Frederick Merchant, “The Federation Licensing Examination (FLEX)—A Special Report,” Federation Bulletin (January 1969): 6

6 “Dates FLEX First Used,” Federation Bulletin (June 1974): 210


			

Term Limits – they’re not just for politicians

meter  My professional activities bring me into regular contact with current and former members of state medical boards throughout the United States. One of the conversational threads that often arises involves reappointment to the board. Often, I’ve heard phrases like, “I’ve termed out but the governor hasn’t appointed anyone yet to take my place” or “We have a Republican governor now and I was appointed by a Democrat so I’ll have to wait and see if I’m reappointed.”

I know some of you are reading statements like these and perhaps entertaining a few thoughts of your own. “Governors appoint members to state medical boards?”  “How is political affiliation relevant to medicine? “How long do these people serve?”

State medical boards have always been mildly quasi-political creatures. From the time of their creation in the 19th century, most states have authorized their governor to make these appointments—often with input (e.g., suggested nominees) from that state’s medical association. Most of the “political” aspect has been less about party affiliation than gubernatorial largesse as a political appointment.

Prior to the 1960s, medical boards were the exclusive province of physicians. Today, nearly every medical board has public members; many have other allied professionals serving on the board as well.

But this is all background…my focus is on term limits. Today, most state medical boards restrict the amount of time someone can serve on a medical board through the use of term limits. According to the 2018 U.S. Medical Regulatory Trends and Actions all but about a dozen states impose such limits. I would argue that this is a positive—a practice consistent with accountability and good governance; and that failure to impose term limits for service on these critical boards is inconsistent with the public interest.

Granted, the comparison I’m about to make is a little bit of the apples to oranges variety but I’ll share it anyway.

Looking back at over the long span of medical regulation it’s clear that term limits were not always common. My prior reading and researching allows me to list many individuals with unusually long tenures on their state medical board.

Take, for example, Herbert Platter, MD. He first joined the newly established Ohio Medical Board in 1896. He continued serving on that board until the mid-1960s. The man was in his mid-90s and still serving on the board. platter

This may have been an extreme outlier but not by that much. Robert Derbyshire, MD, served on the New Mexico Medical Board from 1952 to 1984. Henry Fitzhugh served 25 years on the Maryland board. Impressive but still less than the 30 years or more service by Roy Harrison (Louisiana), Arthur McCormack (Kentucky), David Strickler (Colorado), George Williamson (North Dakota), Thomas Crowe (Texas), William Scott Nay (Vermont), Charles Pinkham (California) and Beverly Drake Harrison (Michigan)…or 40 years of service by Adam Leighton (Maine).

All of these examples are from the first half of the twentieth century. This was a long time ago and one might be excused for thinking, “So what? How is this relevant today?” I would argue this earlier experience is not only relevant but instructive as there were two recognizable problems that arose from the lack of term limits during this period.

Longevity fosters an unhealthy deference

All of us have been in situations where we were the ‘new kid.’ Whether as a new faculty member, a new staff hire or the latest appointee to the medical board, we have all experienced something analogous. We walk in all too aware of our knowledge gaps and inexperience and with all the predictability of a muscle reflex we look (consciously or not) to ‘veteran’ peers to give us guidance. Insider knowledge offered as a helping hand to the newcomer usually includes not only the practical, helpful tips we seek for navigating a new landscape but also that veteran’s subjective views and biases acquired through their tenure in the position. Imagine the deference new board members or even new staff give to the long serving veteran on a state medical board.

This same dynamic worked through several generations of medical boards when lengths of service such as those I mentioned stretched into decades. The deference extended to the views of board members could extend beyond their actual authority. The contemporary writing about this phenomenon asserted that the “professional prestige” acquired through decades of service allowed these board veterans’ pronouncement to carry a de facto “force of law” beyond their statutory authority. And in an era characterized by strong deference to physicians, this combination of a physician credential and longevity on a medical board made it possible for individual board members to carve out a ‘small kingdoms’ within which they enjoyed relatively high degrees of latitude and discretion.

Closing off new ideas/new blood

The absence of term limits and often extreme longevity of service by earlier members of state medical boards likely fostered complacency and reluctance to deviate from the status quo. Change is not something that most of us eagerly embrace. Put us in any position or role, regardless of what it is, and we’ll ultimately develop or establish a routine or pattern for ourselves. It’s one of the most predictable human characteristics—something allowing us to function through daily life.

For all the talents of a Herbert Platter or David Strickler (and there were many!), how many other individuals were denied an opportunity to serve when a single individual commanded a spot on the board for six decades or even three? One trade off with longevity is the lack of a regular, periodic infusion of new blood…and with it new ideas and fresh perspectives on old problems. Or even the naïve but beneficial “Why?” posed by newcomers. This simple but powerful question forces each of us to step back and articulate how we have arrived at the status quo…and by extension, whether where we have landed is still where we want or need to be.

derbyEven one who enjoyed such extreme longevity on his medical board (Robert Derbyshire) acknowledged the trade off this entailed. Yes, the veteran of 20 years on the medical boards may have become expert in disciplinary hearings but, Derby wondered, at what cost in terms of other/new ideas?

I’m not arguing that every state medical board lacking term limits for its members is unhealthy in its deference to veteran board members’ views or that they are lacking in new ideas. What I am arguing is that the lack of term limits inherently fosters an environment potentially (and unnecessarily) vulnerable to these pitfalls.

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

A Medical Diploma Mill Graduate

Book writing tends to be a solitary craft. You find yourself spending a lot of time alone, thinking about your subject and hoping that someone else will find it interesting too. When the book is finished and released into the world, you pray it finds its niche with readers…perhaps even triggering some response along the way. It’s always gratifying when a reader reaches out to an author.

This happened to me recently when Lorrie R. contacted me about Diploma Mill. It seems her great-great-grandfather practiced as a physician and pharmacist in Massachusetts during the last quarter of the nineteenth century. According to his obituary, Dr. John Bradford Wilson obtained a medical degree in Philadelphia ca. 1868. dr john wilsonHe opened a pharmacy in 1875 in Mansfield, Massachusetts and appears to have combined a medical/pharmacy practice. Massachusetts proved rather late in adopting medical legislation. It wasn’t until 1894 that Dr. Wilson had to apply for a medical license with the Massachusetts Board of Medical Registration.

Lorrie contacted me because her ancestor claimed to have received his medical degree from the Eclectic Medical College of Philadelphia. She couldn’t help wondering if this school was the same as John Buchanan’s Eclectic Medical College of Pennsylvania—the focus of my book. Understandably, Lorrie wondered about the medical bona fides of her ancestor.

It’s interesting to think of the “life story” we weave around our ancestors. Usually this derives from some photographs, perhaps a few surviving records and, naturally, family lore passed down through the generations. When an ancestor seems to have been part of a historical trend or scandal, it’s understandable to try teasing out the ‘How?’ and ‘Why?’ In other words, to try to figure out how this person’s life intersected with something that is now the stuff of history for us.

As I mentioned to Lorrie, it is difficult to make definitive statements about her ancestor’s relationship to the school at this late date. The school’s original records have long disappeared. What remains is information derived from miscellaneous sources: the school’s Journal, newspaper accounts, contemporary histories and medical journals. There are several possibilities concerning Dr. Wilson. For example, it is possible he attended the school located at Ninth & Locust Street in Philadelphia and received a diploma. It is also possible that he simply sat for a course of lectures in 1868, considered that sufficient (as many physicians of that era might have done) and later just claimed a degree based upon that experience. It’s also possible that he never set foot in Philadelphia and conducted his ‘education’ wholly through the mail as the purchase of a diploma.

Keep in mind that in 1868 very few states had any medical licensing laws in place. Whether Dr. Wilson attended the school (or not) and whether he received a diploma (or not), his intent in some ways involved legitimizing himself as a physician/pharmacist. Adding a credential such as medical degree, at a time when most people practicing medicine lacked one, made sense. It created the image of a professional…something potentially differentiating him from many other practitioners.

Take for example the photos Lorrie shared of Wilson’s pharmacy. They look every bit the part of a solid, sustained business operation. And yet, how much genuine expertise was behind this solid, professional image he presented to the community? It’s difficult to say. Apparently it was enough to satisfy the community as the pharmacy survived Wilson’s death with one of his sons taking over the pharmacy.

 

Lorrie offered one other interesting tidbit on her ancestor. It seems Dr. Wilson had strong interests in Spiritualism and Mesmerism (i.e., hypnosis)—sufficiently strong that he apparently advertised at one time as an “Eclectic Physician and Clairvoyant.”  early ad He was apparently a prudent business man too. Eventually, he dropped the clairvoyant from his ads as the early enthusiasm for medical hypnosis waned. Later, he dropped eclectic from his physician title as ‘regular’ medicine began to absorb the homeopaths and eclectics who once saw themselves as practitioners offering patients an alternative to conventional medical practice.

Finally, stories like this one involving individuals with degrees from schools like the Eclectic Medical College of Pennsylvania or the Eclectic Medical College of Philadelphia help take us out of our backward glancing historical vantage point and ground us in the contemporary realities facing these people. Dr. Wilson and many others practiced during a period of transition in American medicine—a period witnessing a shift from a pre-professional, no restrictions environment in which medicine was something experienced within the home at the hands of family or friends to a world in which credentials and medical licenses became the norm as medicine shifted steadily away from hearth and home. Navigating this transition couldn’t have been easy.

later ad

Whatever Dr. Wilson’s interaction with the EMC of Philadelphia involved in 1868, we are wise to remember that this preceded the school’s widespread notoriety and public disgrace. This came in 1872 with the Pennsylvania senate investigation that exposed the (at best) questionable diploma issuance practices at this school and by John Buchanan. Was Wilson an opportunist seeking a quick credential or an unfortunate that saw his degree tainted in the school’s subsequent fall from grace? We’ll probably never know.

 

My thanks to Lorrie Renker for the images and information she supplied on her ancestor.

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

 

Medical license: Citizenship Required?

Immigration policy presents one of the most fraught, contentious political issues in America today. While much of the focus in recent years centers on illegal immigration, nearly a century ago, state medical boards grappled with an immigration challenge of their own: Medical professionals educated outside the US and seeking to practice in this country.

Foreign-trained physicians, especially those from England, Germany and France, were generally viewed as welcome additions by American doctors in the late 19th and early 20th century. Because of the vast disparities in US medical education at that time, many (if not most) of these foreign practitioners possessed education and training exceeding that of many American physicians. By the 1920s, the socio-political climate in America turned markedly unreceptive to most immigrants, even physicians.

1920-immigration-records_555

Much of this change in sentiment stemmed from a shift in immigration patterns beginning in the 1890s with the start of a large influx of immigrants from southern and eastern Europe. This trend had solidified such that by 1924 federal law introduced immigration quotas distinctly unfavorable to immigrants from areas other than northern and western Europe.

State medical boards soon reflected the tenor of the times. In 1923, New York state amended its medical practice act to require U.S. citizenship as a condition for admission to their licensing exam. By mid-1926, more than half of the states followed suit with varying requirements that linked the acquisition of a medical license to an individual’s citizenship status.

us_naturalization

Eleven states required full citizenship as a requirement for obtaining a medical license: Arizona, Arkansas, Florida, Illinois, Indiana, Kansas, Kentucky, Mississippi, South Dakota, Tennessee, Wyoming

Another ten states required the physician to have taken out their naturalization papers. Alabama, Delaware, Louisiana, Maryland, Michigan, New Hampshire, North Dakota, Oregon, Texas, Virginia.

Five others required the physician to declare his/her intent to become a US citizen: Minnesota, Nebraska, New Jersey, New York, Ohio

Medical boards generally supported, and in some cases urged introduction, of these requirements. In so doing, however, the arguments they presented often reflected professional concerns rather than those one would categorize as regulatory in nature.

Too often the language accompanying discussion of immigration and requirements specific to international medical graduates (IMGs) featured language that hinted at concerns other than public health or patient safety. Terms like “alien invasion” crept into the editorials on the subject. One writer argued the necessity of linking citizenship status to licensure as a mechanism for keeping out those physicians who were “not properly qualified.” Such a statement seemed reasonable enough on the surface but a nativist sentiment evinced itself with his additional call to keep out those who “in other respects are undesirable.” Exactly what constituted an “undesirable” physician was left unstated.

By the end of the 1930s, all but a handful of states and the District of Columbia required either citizenship or “first papers” for naturalization as a condition for medical licensure. The AMA took a hard line. In 1938, their House of Delegates adopted a resolution calling for all foreign-trained physicians to have full citizenship as a condition for licensure.

Incautious comments from leaders in medical regulation hinted at reasons other than patient safety for the desirability of these requirements. One president of the Federation of State Medical Boards admitted to an “economic aspect” to the immigration issue—an unsurprising admission considering the massive economic downturn in the US in the 1930s and one that feels a bit presumptuous of me to criticize from my comfortable economic vantage point nearly a century later.

But as he continued his comments in 1939, this regulator also spoke vaguely about the need for “tests” of fitness based upon “respect” and “ethical” adherence to democratic principles; even asserting that the “alien who can meet these tests must be the exception.” Today, political pundits and columnists often comment upon politicians speaking to their base through indirect or coded language, e.g., “dog whistling.” While not speaking to a political base, this former FSMB president implicitly signaled his position on physician immigration for reasons other than those appropriate for a regulator.

loyalty reds

Certainly, there were members of state medical boards that balked at proposed litmus test style calls for political loyalty. And in some states, the decision to link medical licensure with citizenship status arose from legislators. Yet there is also evidence that the call for citizenship requirements arose more often from medical board regulations than state law.

Connecting a physician’s competence with his citizenship proved legally tenuous. The Harvard Law Review turned a skeptical eye to this issue in 1939 and within several years multiple state attorneys general ruled against such requirements. With the outbreak of war in Europe, an influx of refugee physicians to the United States brought immigration back into the headlines but with a more sympathetic view as evidenced by the 1941 report of the National Committee for Resettlement of Foreign Physicians.

refugees

Their report recommended medical boards require only that naturalization papers be filed with a ten-year period to obtain citizenship.

This reactionary spasm against physician immigrants to the United States waned in the early 1940s but renewed focus on IMGs returned in the post-war years. A sharp increase in the number of IMGs, both those displaced by war and those seeking educational opportunities in the US, placed a different question in the forefront: How do we evaluate the credentials and qualifications of these professionals?

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

 

Sources

Bulletin of the Federation of State Medical Boards, September 1923

Bulletin of the Federation of State Medical Boards, October 1923

Bulletin of the Federation of State Medical Boards, August 1926

DA Johnson, HJ Chaudhry, Medical Licensing and Discipline in America: A History of the Federation of State Medical Boards

The Forgotten Chapter of the Flexner Report

Spend a few cursory hours reading or writing about U.S. medical education and you’ll bump into the “Flexner Report” and its author Abraham Flexner. If you’re reading this blog, it’s safe to assume you’re somewhat familiar with the report and its impact on medical education. The report’s influence has been debated for generations—some point to the report as the main impetus for educational reform, others caution against assigning an overly large causative role. Few today can debate the report’s distinctly negative consequences for historically black medical colleges.  Still, any reasonable assessment acknowledges the report as a significant milestone in U.S. medical education.

220px-Picture_of_Abraham_FlexnerBut for all the supposed familiarity with the report by those who love to reference it, one portion has been largely forgotten and seldom cited—chapter 11 dealing with state medical boards.  I re-read this chapter recently. What struck me most in revisiting the text was Flexner’s juxtaposition of praise and criticism of state medical boards. I found myself momentarily flashing back to my 10th grade English class, Julius Caesar and Marc Anthony’s funeral oration: “I come not to praise Caesar but to bury him.”

Okay, that may have been a bit much so let me be clear. I’m not accusing of Flexner of being disingenuous or damning state medical boards with faint praise…but he does take the reader on a bit of roller coaster ride. The opening sentence of chapter 11 set forth the inherent potential for medical boards to bring about pronounced, positive changes to medical education: “The state boards are the instruments through which the reconstruction of medical education will be largely effected.”

Remember, at the time of Flexner’s writing, U.S. medical education featured a wide disparity in the quality of schools (e.g., entrance requirements, facilities, faculty, clinical training, etc) with most schools being private, proprietary endeavors operating without any university and/or hospital affiliations. (These schools were the main target of Flexner and many other educators.) For Flexner, the greatest service state medical boards could provide involved “crushing” the outlier schools proliferating on the fringes of medical educations…what he deemed “notoriously incompetent institutions.”

reportFlexner identified three weapons at the disposal of state medical boards—all of which derived from their statutory authority bestowing varying degrees of oversight/influence on education within their state. These powers included…

  1. Mandating preliminary education requirements for physicians (e.g., 1-year college course work prior to matriculating medical school)
  2. Authority to recognize/approve acceptable medical schools
  3. Authority to require an examination as a condition for medical licensure

Flexner viewed the latter as particularly critical. He characterized the licensing exam as the “lever” with the potential to raise medical education and the profession as a whole. He wasn’t subtle about this either. You can almost sense a Machiavellian relish at the thought of what could be done to those substandard proprietary schools when he writes, “…the power to examine is the power to destroy.”

But then, almost as if he were awakened from his dream of an imagined medical school future, Flexner grumpily catalogs all the nagging contemporary realities of medical regulation…and there were admittedly many that frustrated the reform-minded educator.

Flexner’s lamentations

The composition of state medical boards troubled Flexner greatly—too often they were “not strongly constituted.” He lamented that membership too often featured politically-motivated appointments and that medical school faculty were prohibited from serving.

While a champion of the medical licensing examination, Flexner lamented the boards’ reliance upon written exams and the booming industry in preparation materials (“State Board Questions and Quiz-compends”). For Flexner, only a “practical” exam touched the “heart of the matter,” i.e., the ability and fitness of the physician to treat patients safely. At the time of his report, only Minnesota and Ohio were experimenting with practical exams.

State boards were poorly resourced. Flexner lamented the lack of staff—often just a single person, the board secretary—and inadequate funding. “A bureau properly organized cannot live on small fees.” His list continued, citing the persistence of sectarian (homeopathic, eclectic) licensing boards, unreasonably diverse states laws regulating the practice of medicine, etc.

And yet despite the gloomy depiction throughout much of this chapter on the role of medical boards, Flexner still found reason for optimism. “Despite imperfect and discordant laws and inadequate resources, the state board has abundantly justified itself.” He sensed a motivating esprit de corps and pointed to signs of collaboration (e.g., reciprocity agreements) as reasons for hope.

While he didn’t cite it as a basis for optimism, the greatest hopefulness stemmed from a simple fact: state medical boards were the only entities with the statutory authority to compel change. The Association of American Medical Colleges (AAMC) could promote high standards for education; the AMA Council on Medical Education could survey and categorize schools into Class A, B, C institutions…but only state medical boards could embed best practices and classification systems into law.

It seems that Flexner’s laments on state medical boards stemmed directly from his recognition that they were the 600 lb. gorilla that could bring the future he envisioned just a little closer.

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