Homeopaths & Suffragettes: The First Women to Serve on a State Medical Board. Part 2

In March 1899, the Minnesota legislature confirmed a series of appointments by Governor John Lind. Passing largely, but not entirely, unnoticed was the appointment of Dr. Adele Stuart Hutchinson to the Minnesota State Board of Medical Examiners. As the Minneapolis Homeopathic Magazine trumpeted in its headline, Minnesota had placed a woman on their state medical board—a first for the state and the country.

Dr. Hutchinson served two terms (6 years) on the board from 1899-1905. In 1900, her peers on the board selected her as president of the board—a decision drawing a snide comment from one journal, The Medical Advance: “Well! Well! Wouldn’t that agitate your mesentery[sic]?” Hutchinson’s health may already have begun declining by the end of her tenure on the board as she returned to her family home in Andover, Massachusetts in 1906. Though active socially her health worsened steadily and she died in May 1909.

Looking back, the appointment of Hutchinson seems to have led directly to the selection of two of her successors on the board, Drs. Margaret Koch (1905-1911) and Annah Hurd (1911-1917). The linkage between all three was the Minnesota Homeopathic Medical College.

Suffragette Ethel Hurd, MD (back row center); her daughter Dr. Annah Hurd back row 2nd from right. Annah Hurd was third woman to serve on Minnesota Medical Board.

As noted in Part 1 of this blog, Hutchinson was an early founder and supporter of the college. Margaret Koch, the daughter of German-born immigrant parents, graduated from the college in 1895 and two years later was serving as part of its faculty. She and Hutchinson were both active in the state homeopathic medical society. Thus, their paths intersected at several points within what was a small community of women physicians in Minneapolis.

As the end of Hutchinson’s tenure on the medical board drew closer, there were parties determined not to waste the precedent set by Hutchinson’s appointment. The Women’s Medical Club of Minneapolis mounted a campaign for Dr. Koch to fill Hutchinson’s spot on the board.

With Koch’s appointment to the board, a direct connection to the suffrage movement becomes clear. Koch actively worked with the Minnesota Woman Suffrage Association (MWSA) with her office even serving for a period as the organization’s headquarters. Koch served various roles with the organization from 1900 to 1910 (auditor, reporter, treasurer, chairman) and then as Vice-President (1910-1913). Many of the women physicians remembered by Hutchinson in her 1903 article with the newspaper were active in that state’s suffrage movement: Mary Hood, Martha Ripley, Mary Whetstone.

Among Koch’s colleagues in the suffrage movement were a remarkable mother and daughter, Ethel and Annah Hurd. Ethel Hurd was one the mainstays of the movement. The first woman to graduate Knox College in Illinois, Ethel Hurd labored for decades with the Minnesota Women’s Suffrage Association (MWSA) and the Political Equality Committee of Minneapolis. Ethel and Annah both graduated from the Minnesota Homeopathic Medical College. Ethel in 1897 at approximately the age of fifty; Annah in 1900 after earlier graduating from its school of Pharmacy (1896).

 As Koch’s term on the state medical board drew to a close in 1911, the same forces that rallied to place Koch on the board now pressed the case for Annah Hurd. Like Hutchinson and Koch before her, Dr. Annah Hurd served six years on the Minnesota board. She seemed to have been instrumental in that board’s development and administration of its “practical” component to its licensing examination.

The string of appointments placing a woman physician on the board continued in 1917 with Dr. Ida Adams McKeen. Once again personal/professional connection played a pivotal role. Dr. McKeen worked with Annah Hurd as the lead physicians at a private hospital, the Minneapolis Maternity Hospital. Dr. McKeen appears to have served two terms on the Minnesota board (1917-1923).

I have been unable to learn more about Dr. McKeen or find records for the Minnesota board beyond this point. Thus, it is possible that the unique and unprecedented string of appointments placing a woman physician on the board continued beyond 1923…but it also possible Dr. McKeen was the last woman to serve on the Minnesota board before a lapse of many years.

As I reflect on these women and their stories, several thoughts are crowding my mind. First, it strikes me as remarkable that this story has lain buried so long…essentially forgotten today and all but not ignored even at the time it was happening. Keep in mind, I have run across no other instances of a woman serving on a state medical board during this time period. And while I cannot state definitively that no other state had a woman physician serving on their medical board during this period, the best evidence suggests this.

The American Medical Directory from 1921 listed the member of each state’s medical licensing body, i.e., state board of medical examiners or board of health. I found no other women listed as serving that year though it is possible some are hidden in plain sight due to the practice of some states listing people by initial rather than given name, e.g., D. A. Johnson rather than David A. Johnson.

Second, I found the personal histories of Hutchinson, Koch and Hurd striking in one regard. All three women defied their time period’s conventional notions of gender roles and societal norms by remaining unmarried. I find myself wondering whether this was a consciously made choice as perhaps professional and social priorities felt more rewarding? Or was this simply a life that unfolded without the right partner (him or her) ever intersecting with these women?

Finally, I am struck by the power of personal and professional relationships in the appointment of individuals to state medical boards. This is hardly surprising. I suspect if we selected ten people at random from the state board community today we would hear stories from most explaining how a “connection” led them to service. What feels unique with this Minnesota experience from a century ago is that the relationships and connections may have had as much to do with political and social activism as they did with conventional relationships established through medical education and practice.  

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

Sources:

“The First Woman Medical Examiner,” Minneapolis Homeopathic Magazine, Vol 8, no 5, 1899, page 152

“Personals,” The Medical Advance, Vol 37, 1900, page 648

Official Register of Physicians (Minneapolis: State Board of Medical Examiners, 1909)

“News Items,” New York Medical Journal and Philadelphia Medical Journal: A Weekly Review of Medicine, February 11, 1905, p. 300

Biography of Margaret Koch at https://documents.alexanderstreet.com/d/1009932307

Biography of Annah Hurd at https://documents.alexanderstreet.com/d/1009860072

David Johnson, ‘Practical Examinations’: How Minnesota’s Experiments with Assessment Changed Perspectives in the Early 20th Century,” Journal of Medical Regulation, vol 104, no 3, 2018

Polk’s Medical Register and Directory of the United States (Detroit: R.L. Polk and Co., 1917) p 831

American Medical Directory, 7th edition, p. 787…see also 6th edition p. 835

Homeopaths & Suffragettes: The First Women to Serve on a State Medical Board

I first stumbled upon Dr. Adele Hutchinson through a small news item in the Minneapolis Journal newspaper. What caught my eye was the statement that she was entering the last year of her second term on the Minnesota State Board of Medical Examiners. Surprised by this statement of fact, I quickly double checked the date of this news item—November 26, 1903. This meant Dr. Hutchinson had joined the Minnesota board in the mid- to late-1890s! I immediately suspected—and now feel confident in stating—that Adele Hutchinson was the first woman to serve on a state medical board in this country.

This distinction alone makes it worth remembering Dr. Adele Hutchinson but I suspected there was an equally interesting story behind her journey into medicine and later onto the Minnesota board. This news clipping shared just enough about her career to tantalize. Mostly it brought to mind several questions. Who was Adele Hutchinson? What was her life story? How did she end up in Minnesota? How did it come to pass that she was appointed to the board?

Not satisfied to just leave her as the answer to a trivia question, I decided to do a little digging. What I have learned is surprising—not only was Adele Hutchinson the first woman to serve on a medical board but two of her women colleagues succeeded her on the Minnesota board…and that the suffrage movement in Minnesota appears to have played a significant role in these appointments.

But let’s not get ahead of ourselves.

Let’s start by placing some context around women in medical regulation. In 2020, women comprised 36% of all physicians with an active medical license in this country according to the census produced by the Federation of State Medical Boards (FSMB). Similarly, women accounted for 34% of the total membership on state medical boards when last I looked in 2018. These figures aren’t particularly surprising…and yet it is easy to forget that they stand in stark contrast to the fact that at one time the presence of any woman on a state medical board was uncommon—even a rarity.

As recently as 1985, fewer than half of all state medical boards had women serving. Going back even further, and despite the lack of a complete set of board rosters to review, there is photographic evidence that remains quite telling. I reviewed all of the group photos of medical boards published in the Federation Bulletin between 1956-1984. While the photos weren’t inclusive of all medical boards, what was published showed only 6 women out of 256 people captured in these pictures.

To be honest, with this kind of evidence in hand, I was shocked to find Adele Hutchinson serving on a state medical board in the 1890s. If I had been forced to hazard a guess as to when any woman first served on a state medical board, I would’ve selected a much later date, probably the 1920s or ‘30s.

So what do we know about Dr. Adele Hutchinson?

She was born in Andover, Massachusetts sometime in 1847 to Robert Stuart and Helen Christie Hutchinson. Adele attended the Boston University School of Medicine where she graduated in 1877. According to the 1903 news item, Adele and her classmate Mary Swain (also B.U., class of ‘77) arrived in Minneapolis soon after their graduation.

Apparently the two women determined to throw in their lot together practicing medicine. Their decision was a pragmatic one based upon Hutchinson’s statements to the reporter for that 1903 article in which she reminisced on opportunities out West and their comparable lack in the East. Hutchinson cited the strong “prejudice” against women physicians in the East, especially at the time she and Swain graduated. Despite the antipathy of the male-dominated profession, women were obviously interested in the practice of medicine if Hutchinson’s graduating class was any indication—nearly half of her senior class (16:38) were women.

The decision to go West to practice medicine seems a bold move. After all, Hutchinson knew no one in Minneapolis; Swain had only shirttail relations whom she had never met. Hutchinson later laughingly attributed their leap of faith as much to “ignorance” as to courage. Still, Hutchinson felt the West offered a true opportunity for women to be judged based upon their talents rather than their gender. In describing the situation in Minnesota in the late 1870s, she stated: “When a woman failed the blame was not placed at her sex but at her personal ability. It was the individual who could not grasp success, and women were deemed as capable as ever.”

The two women roomed together at 416 Fifth Street in Minneapolis for some time. Swain apparently found their western adventure a bit much and, homesick for family back in Massachusetts, she left Minnesota after a few years.

An important early success for Dr. Hutchinson was her acceptance to the Minnesota Homeopathic Society. This was no accident. The Boston University catalogue makes clear the homeopathic basis for its medical instruction. Hutchinson had a strong education in homeopathic medicine and worked directly with faculty member Dr. Mary J. Safford-Blake who served as preceptor to Adele. Dr. Safford-Blake, with training in the United States, Breslau and Heidelberg, was acknowledged as an expert in gynecology.

Hutchinson and Swain were elected to join the Minnesota Homeopathic Society shortly after their arrival. By the following year, several more women physicians arrived in Minneapolis:  Drs. Mary Hood, Martha Ripley, Mary Whetstone. All of these women put down roots in the area and became deeply engaged in medicine and civic affairs in the region.

Hutchinson established a successful practice for herself in Minnesota. She later served for many years as a physician staff member of the Minneapolis City Hospital…and more importantly she seemed to integrate smoothly into the homeopathic physician community. Hutchinson served as a committee member for the state homeopathic society studying the prospects for a medical college. The group recommended the establishment of a medical college and Hutchinson served as one of the school’s incorporators in 1886. Her engagement with the Minnesota Homeopathic Medical College (later absorbed as the Medical Department of the University of Minnesota) created the path leading not just Hutchinson, but two of her female colleagues at the college, onto the state medical board.

In my next blog post, I’ll explain this journey.

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

Sources:

“Our Pioneer Women Doctors,” Minneapolis Journal. November 26, 1903.

“Adele Stuart Hutchinson,” Andover Townsman. May 28,1909

Boston University School of Medicine Fifth Annual Announcement and Catalogue. June 1877

William Harvey King, History of Homeopathy and its Institutions in America, Vol. 3 (New York: Lewis Publishing Co., 1905), 240-43.

 “The First Woman Medical Examiner,” Minnesota Homeopathic Magazine, Vol 8, no 5, 1899, page 152

The Historian’s Challenge—Sometimes the evidence isn’t definitive

It is human nature to crave certainty…to seek a clear understanding of our world and definitive answers to the questions—big and small—that confront us. There’s a reason for this. Science suggests strongly that we, as humans, are fundamentally hard-wired to seek answers or explanations. Indeed, even when these are not available or immediately apparent, our minds work actively to supply them. Along the way is an accompanying human tendency toward reductivist thinking—the tendency to take complex questions and issues and rework them in order to reduce them to ones offering simplified, general answers.

I offer this as preface to my update from an October 2018 blog entry titled, “Bias in Testing?” In that post from three years ago, I discussed a research project I had undertaken—one looking at the Register (official record) from the North Carolina Medical Board triggered by my finding that for nearly fifty years the board’s practice had been to annotate the record of black physician candidates for licensure. The board annotated these physicians’ record with “c,” “col” or “colored.”

Note the annotation for Drs. Pope and Scroggs

I wondered whether this was a striking but ultimately benign action consistent with administrative practices in other state agencies in North Carolina? Or did this flagging point toward bias in the examining and licensing of these physicians? My research is complete and now appears in the current issue of the North Carolina Historical Review.

Like so much of history, “facts” do not necessarily speak for themself. I know some may balk at this statement fearing it justifies revisionist historical narrative. I will be blunt in my response. That kind of knee jerk reaction championing “facts” reflects a fundamental misunderstanding of the nature of historical inquiry. Placing evidence within an appropriate historical context requires the active participation of a human being —specifically the overlaying element of interpretation of the facts, findings, documents, evidence, etc. Quite simply, someone has to place research findings within a narrative framework to communicate to the rest of the world, whether fellow scholars or the public.

As the historian Nancy Partner once wrote, “Archives contain many interesting things but Truth is not included among them.”

So what did I find in looking at scores and performance on North Carolina’s licensing exam over forty years (1886-1925)? Let’s start with this.

Data analyses showed the exam performance by graduates of historical black medical colleges (HBMCs) as consistently lower than that of graduates from non-HBMC schools throughout the period studied. Those who would argue for letting the “facts” speak would likely point to this data as direct evidence of bias in the North Carolina exam. You may even agree.

But before you leap to that conclusion, what if I told you that the scoring for these exams (comprised of extended response or essay questions) was done in a blinded fashion? The candidates for licensure by examination were issued either a pseudonym or a number by the board Secretary on the day prior to testing. The examinees used this identifier, rather than their actual name, on their examination papers. Thus, the board member scoring the test ostensibly did not know the identity of the examinee.  

You may be thinking several things now. After all, we have the advantage of historical hindsight. We know the segregated nature of much of America at that time so you might ask, “How can we be sure the board followed this safeguard consistently?” Or you might ask, “Wasn’t the board Secretary still in a position where he knew the identity of the examinees?”

Those are fair questions. All we know is what was preserved in the board’s records documenting this process. Absent evidence to the contrary—letting the facts speak without the historian’s involvement as some would demand—means we start with a presumption that this safeguard was followed. Hopefully, however, some of you are thinking again about that Truth and the archives quote.

Let’s consider another question. If we accept the scoring safeguard used by the board and thus the legitimacy of the data, how do we explain the discrepancy in HBMC performance? In the article, I treat this question at length and find strong evidence from contemporary black educators suggesting the performance differential stems from significant challenges presented to HBMC matriculants by inadequate pre-medical education and financial/resource constraints facing these schools. The records of administrative officials at HBMCs are rife with concerns these realities presented in preparing their graduates for state board licensing exams.

Now let’s turn to a second finding from this research. Graduates of HBMCs showed a higher pass rate on the North Carolina exam relative to their performance on other states’ licensing examinations. Indeed, the performance of HBMC grads on the North Carolina exam exceeded (by 12%) the overall pass rate on state board exams collectively during this time period. In essence, the North Carolina presented “no greater hurdle” to licensure than that of most of states.

If we let the facts speak for themselves, this finding suggests that conscious, overt bias in scoring the exam—if it existed—did not play as extreme a role as we might have thought. But as an historian of medical regulation, I am uncomfortable in stopping there (i.e., simply accepting the facts) as opposed to contextualizing this finding.

Black physicians of this era viewed state licensing exams cautiously and with an understandable degree of skepticism. Who wouldn’t wonder what kind of standard was being applied when the New Orleans Medical and Surgical Journal reported that 70% of the 257 applicants for licensure failed Mississippi’s exam in summer 1907 and then nearly 80% passed in December?

The insular nature of the medical boards (almost exclusively all-male and all-white) meant that those outside those demographics held understandable reservations about fairness. What was the purpose of an annotation to a record if not to clearly make someone, in a position of authority and/or control, aware of the race of the licensure applicant? Here I can’t help but remember the story shared by the first black woman licensed in Colorado in 1902. That board’s executive secretary expressed reluctance to accept her license application and fee. With total candor he said, “You’ve got two strikes against you. First off, you’re a lady and second, you’re colored.”

The annotation practice itself? It appears to have been…well, if not ubiquitous, then certainly common enough that it triggered no contemporary comment. The North Carolina nursing board during this period annotated their records for black nurses as well. Updates on state board exams published in medical journals include numerous instances in which “colored” examinees’ performance is called out explicitly.

Thus, even though I had a significant amount of data (“facts”) at my disposal, I found it challenging to present my findings—sometimes mentally second guessing myself in my interpretations. For example, the board’s Register documented a single segregated administration of their exam in 1886, the first year an HBMC grad presented for licensure. The Register doesn’t record a segregated administration again. Does this mean this practice stopped after 1886? Or was it a continued practice so administratively unimportant (or socially presumed) that it didn’t merit documenting in the Register?

Note that the board supplied information to New Orleans Medical & Surgical Journal for 1907 item specifying race of licensees

And what about the role of the board Secretary? The board’s blinded scoring protocol operated as intended only to the extent that the person serving in that role behaved in a manner that preserved the de-identification until after scoring had been completed. Said another way, the efficiency of this safeguard rested upon the integrity of one man. Where does that leave the historian? Am I naïve in presuming the integrity of this safeguard? Is it fair for me to cast suspicion based upon performance differential alone if no other evidence exists suggesting the safeguard was not being utilized?

I found this research project to be both fascinating and discomforting. In 2021, questions of race—even when seen through the lens of an exam discontinued long ago—cause many to give pause and tread lightly. I had professional colleagues reluctant to collaborate on this research project. I had one medical board executive director express early interest in a similar project with their board’s exam; then disengage entirely after I shared details of the North Carolina project. I understand the reaction in both instances.

I hear Nancy Partner yet again: “Archives contain many interesting things but Truth is not included among them.”

In the final draft of the article sharing my findings, I found myself acknowledging an uncomfortable truth common to historical research and writing. “…neither this study’s data analyses nor documentation from the time period provide unambiguous evidence.”

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

Sources:

David Alan Johnson, “The North Carolina Medical Licensing Examination, 1886–1925: Analysis of Performance by Examinees from Historically Black Medical Colleges,” North Carolina Historical Review, April 2021 (152-182)

An Early Victim of Identity Theft

While I have been fortunate never to have been the victim of identity theft, I suspect the feelings of those victimized are similar to those of us who have experienced a home burglary. My wife and I experienced the latter nearly thirty years ago: a daytime smash and grab operation through a backyard window while we were away at work. All we lost physically was a pillowcase filled with some jewelry items. Still, I remember the distinct feelings this crime triggered—a sense of personal violation, insecurity, vulnerability and, of course, anger. I suspect Dr. Emma W. Mooers experienced similar emotions over a century ago.

Emma W. Mooers graduated from the University of Michigan medical college in 1884. She was one of thirteen women in a 92-member graduating class. She later practiced at McLean Hospital in Waverly, Massachusetts and by 1896 made her way to the Neuropathology Department at Harvard Medical School. Obviously, this was a very talented physician. Shortly before her arrival at Harvard, Dr. Mooers first learned that someone been practicing medicine under her name.

Dr. Emma W. Mooers, University of Michigan medical school, Class of 1884

Sometime in 1894 or ’95, Victor Vaughan (Dean of the Michigan medical school) received a letter of complaint from a physician in a small north Michigan town. The disgruntled doctor claimed a UM grad, Dr. Emma Mooers was practicing nearby; and in a manner he deemed highly “irregular.” However, Vaughan knew that Emma Mooers was in Massachusetts, not Michigan. Vaughan told the doctor they had an imposter in their community and to take action immediately. Before an arrest could be made, the faux Dr. Mooers fled. Vaughan and his colleagues soon tracked the imposter to Chicago but again the faux Dr. Mooers eluded authorities, fleeing before they could arrest her. Then silence—for the next few years nothing more was heard of the faux Dr. Mooers.

Fast forward to the year 1900. The real Dr. Emma Mooers is firmly established at Harvard when Dr. S. D. Van Meter, Secretary for the Colorado Board of Medical Examiners, received an inquiry from Dr. Emma W. Cory for a license. In her application, she supplied a certificate from a Univ. of Michigan official attesting to Emma Mooers graduating in 1884, explained Mooers as her maiden name and that her original diploma had been destroyed in a fire—thus the certificate.  The Colorado board, trusting the UM document and unaware of what Vaughan knew, issued a license. Soon enough, Dr. Cory’s conduct of her practice aroused the board’s suspicions but as Van Meter later wrote, “Suspicions without proof are worthless.”

The faux Mooers, now practicing as Dr. Cory, almost got away with her identity theft. In fact, she would have if she had not run into, and struck up a conversation with, Dr. Laura Leibhardt—Michigan class of 1884! Recall there were only 13 women in that graduating class. Far too few for Leibhardt not to recognize it was an imposter standing before her claiming to be Dr. E. W. M. Cory, class of ’84. Leibhardt alerted the board; they filed formal charges with an arrest warrant forthcoming soon after.

Dr. Laura Leibhardt, UM Class of 1884

“Dr” Cory was probably overconfident. She had kept one step ahead of the authorities at least twice before. Now she even had in her possession an official certificate from UM attesting to her graduation. Why should she run again? Rather than bolt, she remained in state and showed up for her trial. What she didn’t know is that the real Dr. Emma Mooers had boarded a train and had traveled to Denver for the trial!

What an immensely satisfying moment it must have been for Dr. Emma Mooers to see her imposter convicted and sentenced to a year in jail. The Colorado board must have felt similarly. In an era of relatively poor communication and little coordination in verifying credentials, medical imposter stories like this one litter the professional literature. When Dr. Van Meter wrote about the Cory-Mooers case at length many years later, it was just one of a half dozen that he shared for the memorable elements they contained.

If that was all there was to this story, it would still be worth presenting as an interesting saga in its own right. But the epilogue I wish to share ties things up in a rather unexpected way.

For starters, we don’t know who Emma Cory was in reality. Furthermore, we don’t know how or why she selected Dr. Mooers for this identity theft and imposture. Their paths must’ve crossed in some way—tangential or otherwise—but how so remains a mystery.

To the disappointment of the real Dr. Mooers and others, the Colorado district court took pity on the imposter. The court suspended Emma Cory’s one year sentence and placed her on parole. Why? Her attorney undoubtedly placed great emphasis during the sentencing phase on his client’s status as a mother of several children. Cory fulfilled the conditions of her parole and, according to Van Meter, later practiced the “healing arts” as a discipline of Mary Baker Eddy. Otherwise, she seems to have disappeared from the historical record—at least to the extent of my cursory google searches. Perhaps a reader of this blog would like to do a little sleuthing?

And the real Dr. Emma Mooers? A hint of the tragic and the eerie followed her. Having to deal with several years of someone stealing her identity was bad enough. Fate was even less kind as Dr. Mooer’ promising career was cut short. She and a colleague became infected while studying the tissue of a man who died of septic tonsillitis. Her colleague recovered; she did not—dying of streptococcus poisoning on May 31, 1911. She was only 52.

And the eerie element I mentioned? Well…check out the gentleman pictured next to her in their UM class of ’84 photo.

Mooers and H. W. Budgett

His name was Herman Webster Mudgett–at least, that’s how he presented himself to the university. The name doesn’t ring a bell does it? But look closer—the photo may look familiar…you may even get a sense of ‘Where have I seen this guy before?’ if you are a fan of the true crime genre. Let me help.

Think Devil in the White City…think H. H. Holmes, notorious serial killer. Now do you recognize him?  

Mooers, Budgett and Leibhardt, UM Class of 1884

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

Sources:

S. D. Van Meter, “Medical Forgeries,” in Colorado Medicine, C. S. Bluemel, Ed.  (May 1925), 169-77

Victor Vaughn, “Papers Fraudulently Obtained,” JAMA. March 8, 1902, 658-59

A Handbook for Speakers on Public Health (Chicago: AMA Press, 1914) p. 463

Composite Photo, UM School of Medicine, Class of 1884. HS1501

Bentley Historical Library, University of Michigan.

Dent v. West Virginia

My last post shared the story of Nathan Aiken: the first physician to have his license revoked by a medical board and the subsequent court case presenting the first challenge to a board’s legal right to do so. Aiken v. State Board of Health set the stage for the U.S. Supreme Court’s Dent v. West Virginia (1889). The relatively modest attention devoted to Dent belies its importance to medical regulation…and as the historian James Mohr made clear in Licensed to Practice, the court’s decision was no foregone conclusion.

These are the facts of Dent. The West Virginia legislature established a State Board of Health in 1881.  Along with the usual scope of powers (e.g., sanitary investigation, monitoring water quality, sewage) the board received statutory authority to license individuals for the practice of medicine. Licenses could be obtained by any of three methods: medical degree from a “reputable medical college,” practicing within the state for the prior ten years or passing the board’s licensing exam.  

Frank Dent made inquiries in 1881 only to learn that his seven years practice in the state didn’t satisfy the law; so he journeyed to Ohio and by 1882 gained a medical degree from the American Medical Eclectic College in Cincinnati. He then reapplied and the board turned him down citing the school as “not reputable.” Angry and spoiling for a confrontation, Dent practiced medicine openly hoping to force a legal showdown. The board obliged by notifying the attorney general and soon both parties found themselves in court. Dent lost ($50 fine) but appealed to the state supreme court. He lost again in 1884. Dent persisted by filing with the U. S. Supreme Court in 1885. The stage was set for the Supreme Court to render its first decision on the constitutionality of the medical licensing laws common in most states by then.

The Court’s decisions in the preceding years signaled a general acceptance of states’ authority and latitude in matters of public health and safety. [Thurlow, 1847; Mugler, 1887] The Court seemed also to have accepted state intervention impacting individual private property interests despite the due process guarantees of the Fifth and Fourteenth Amendments. [Slaughterhouse Cases,1873; Munn v. Illinois, 1876].

Still, the Dent decision seemed inevitable only in hindsight. The Court’s composition had shifted toward one reflecting strong pro-business, pro-capital bias favorable to private property interests of individuals as well as corporations. Dent and others argued the medical license as property and the Court remained strongly behind private property rights under the Fourteen Amendment and in keeping with “entrepreneurial liberty.”

Justice Stephen Field wrote the majority opinion. Ironically, if one had been asked to guess the direction of the decision based upon the choice of Field as its author, it would have been understandable to predict an entirely different decision. The wave of medical licensing laws in place by the late 1880s represented some of the most active regulation by the state touching upon matters both economic and legal (private property). Field had dissented in multiple cases in the preceding years in his defense of property rights. In addition, several of the Field’s fellow justices (Samuel Miller, Samuel Blatchford) had personal experience or familial connections to medicine–connections that might have left them sympathetic to Frank Dent’s arguments.

Instead, Dent is a good reminder why one should be careful reading the tea leaves to guess Supreme Court decisions. In January 1889, the Supreme Court ruled decisively against plaintiff, Frank Dent. Justice Field opened by covering the same ground featured in Aiken v. State Board of Health. He acknowledged the right to follow a “lawful calling” but then cited a higher societal right—setting reasonable conditions in the interest of protecting the citizen. Field wrote:

“The power of the state to provide for the general welfare of its people authorizes it to prescribe all such regulations as in its judgment will secure or tend to secure them against the consequences of ignorance and incapacity, as well as deception and fraud.”

However, the state did not enjoy carte blanche. Fields wrote that state authority to set qualifications for practicing a profession were not unlimited. They had to be “appropriate” and “attainable.” 

Dent echoed themes arising from Aiken a decade earlier. Where Judge Williams alluded in Aiken to the unique and privileged position enjoyed by medicine, Justice Field sounded a similar note: “Few professions require more careful preparation…than medicine.”  He cited the “subtle and mysterious influences” at work in the interactions of mind and body, disease and remedy in a passage hinting at the blend of art and science inherent to medicine. Field blended deference to physicians predicated upon their specialized knowledge with a recognition that this distinctive knowledge made regulation by fellow professionals a necessity.

“…few can judge…the qualifications of learning and skill which he [the physician] possesses. Reliance must be placed upon the assurance given by his license, issued by an authority competent to judge in that respect, that he possesses the requisite qualifications.”

The implications of this articulated deference toward medical professionals proved significant. Emphasizing the esoteric nature of medical knowledge reinforced medicine as a field separate from the rest of society. From here it was a short mental leap to asserting the uninitiated (laymen) could not understand the nuances of the field. Thus, only fellow initiates (physicians) could truly understand medicine in all its complexity, including the qualifications for successful practice.

The Court embraced a kind of circular logic creating the foundation for an insular community of practitioners who would be given wide latitude in regulating themselves as professionals: The practice of medicine would be a closed community of physicians—entry into the community required a demonstration of specialized knowledge and skills—and those physicians already within the fold (physician serving on state medical boards) would be the primary determinant of entry as the profession’s specialized knowledge precluded lay decision-making.

This deference to medicine and medical professionals would go a long way toward creating a board structure that kept state medical boards the exclusive domain of physicians. Inclusion of non-physicians to this community would not come until the 1960s.

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

Sources:

James MacGregor Burns, Packing the Court: The Rise of Judicial Power and the Coming Crisis of the Supreme Court, 2009

James Mohr, Licensed to Practice: The Supreme Court Defines the American Medical Profession, 2013

Paul Kens, Justice Stephen Field: Shaping Liberty from the Gold Rush to the Gilded Age, 1997

Carl Brent Swisher, Stephen J. Field: Craftsman of the Law, 1969

An Infamous First

History and pop culture love famous “firsts.” Some firsts are understandably famous: Neil Armstrong, Roger Bannister, Kamala Harris. Whether in science, sports, politics or any other field of human endeavor, there have always been trailblazers—brave souls meriting every accolade tossed their way

But what about more dubious firsts? Notable flops or failures? Sometimes even these manage to enter the popular imagination. The Dalton Gang, western outlaws of the 1890s, offer a great example. One of them had the brilliant idea for a daytime simultaneous robbery of two Coffeyville, Kansas banks. As you might guess, it wasn’t quite a Clooney-Pitt Ocean’s Eleven outcome.

Take the case of Dr. Nathan J. Aiken. We don’t know much about him. He was born ca. 1840 in New York state, may have taught school briefly and graduated from the Cincinnati College of Medicine and Surgery in 1865. He entered the historical record in September 1878 in Aiken v. State Board of Health [Illinois].

For several months prior, the Illinois State Board of Health had been sending Aiken letters warning about his “advertising” practices in local newspapers. The board warned Aiken against advertising his “specialties” and, if he persisted, the board might be forced to a finding of “unprofessional conduct” with a loss of his medical license. Aiken ignored the warning. The Illinois board responded by revoking his license; so…Aiken lawyered up and filed suit against the board.

Aiken v. State Board of Health isn’t particularly scintillating but it represents the first court case challenging the authority of a state medical board to revoke a license.  At that time, only about twenty states and territories had laws regulating the practice of medicine; and most of these were just registration laws mandating the person present to the county clerk for inclusion on an official registry of physicians. Illinois was one of only a few states where the board had the legal power to revoke a license.

Thus, it appears Dr. Nathan Aiken holds the unique and dubious distinction for a pair of infamous firsts: the first revocation of a license by a state medical board and the first legal challenge to a medical board’s authority to revoke a license.

The basis for revoking Aiken’s license—advertising—seems like a quaint relic of another era. To be clear, the board didn’t condemn all advertising—they had no objection to what they termed “legitimate” or “honest” advertising. What the Illinois board rejected were the practices of those physicians who “pretend that they can cure everything, and advertise the same….” Such ads stood out even as they vied for newspaper space with the era’s many ads for mail-order patent medicines like Hoofland’s German Bitters, Lydia Pinkham’s Vegetable Compound and Radway’s Regulating Pills.

Lydia Pinkham Pills

Though the ads specific to Aiken’s case haven’t survived, at least two of his newspaper ads from the period survive via the Chicago Daily Inter Ocean. One is a brief note listing his specialties but the other seems likely to have been reflective of what got him into trouble with the board.

     “Exclusively Diseases of Women,

And all office cases, successfully treated by

            Dr. Nathan J. Aikin,

                Offices, 134 Clark St.

    While family doctors wrongly undertake every case they can get (though

of course not able to properly treat certain diseases that should never be

entrusted to them), Dr. Aikin gives his whole attention to the cure of Cancers,

Catarrh, Lungs, Men, Women, Nervous and Special Diseases which belong to

office practice. His wide experience, skill and trustworthiness as a gentleman

in every respect, give a guarantee to all who want professional aid.”

The Illinois board’s views on advertising were not unique. They reflected many, if not most, physicians’ views on the subject as well as those of the American Medical Association. The AMA’s original Code of Ethics from 1847 addresses advertising by directly enjoining physicians from “promising radical cures,” “boasting of…remedies,” or “dispens[ing] a secret nostrum.” In the late 1860s, the AMA came down equally forcefully on physicians advertising themselves as “specialists”—something increasingly occurring with physicians we would recognize as specializing in ophthalmology and obstetrics/gynecology. Aiken appears to have run afoul on both counts if the ad above is any indication.

Aiken lost his case against the board. Indeed, the Illinois court’s ruling sounded themes and principles later reflected in the U.S. Supreme Court decision, Dent v. West Virginia (1889): legal acceptance of self-regulation within a profession by its members, deference to the decision-making of such professionals and the privileged position of medicine among professions. These themes largely shaped medicine and medical regulation for the century that followed.

And Dr. Aiken? Well, his life story didn’t get much better after his infamous firsts in 1878. He relocated to Michigan and was a defendant in an 1886 criminal trial for manslaughter stemming from the death of a patient in an abortion case. Then he moved to California, gained a medical license and apparently thrived for a while despite periodic legal troubles starting with an extortion case. He later committed suicide (poison) in route to San Quentin prison. A press report identified him as a “notorious abortionist” convicted for using the U.S. mail to solicit criminal abortion.

Sources:

Seventh Annual Report of the State Board of Health of Illinois, 1885

Chicago Tribune, November 2, 1878

The Morning Call [San Francisco, California] June 10, 1894

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

Step 2 Clinical Skills: What now?

The arrival of COVID-19 into the United States and subsequent surge of cases in early 2020 led to significant efforts first at containment and then mitigation of the virus. Looking back from our vantage point a year later, it’s hard to find much that hasn’t been impacted.

One recent notable casualty is the Step 2 Clinical Skills (CS)—the performance-based component within the United States Medical Licensing Examination (USMLE). The exam had been suspended since March 2020 when on January 26 of this year, the USMLE announced its discontinuation. [Note: On February 11, the National Board of Osteopathic Medical Examiners (NBOME) announced that its Level 2-PE was “postponed indefinitely.”] Citing no one factor as the sole determinant, USMLE shut down its CS exam explaining that it had become clear the program would be unable to relaunch with an exam “appreciably better” than its pre-COVID version.

From a medical regulatory perspective, this marks a significant—and one could argue disappointing—milestone in the history of the medical licensing exam. I say this because if we step back to consider the long history of the licensing examination, one can discern a persistent aspiration to assess more fully and deeply into the qualifications of the prospective physician.

Some of the earliest exams for medical licensure were oral exams perhaps not too far akin from traditional academic and ecclesiastical forms of disputation. Before the end of the 19th century most boards committed to a written examination featuring long-answer or essay style questions designed to allow the candidates to demonstrate their depth and breadth of knowledge.

Over time, however, many lamented that these test items relied too often upon simple recall and memorization of specific “facts”—in essence, too little in the way of clinical reasoning that demonstrates the application of medical knowledge. These critics didn’t require Miller’s pyramid of [clinical] competence to recognize the licensing exam should aspire to more. State medical boards desperately sought to assess beyond purely cognitive assessment.

The same era of medical education reforms that delivered the Flexner Report saw state medical boards (starting with Ohio) institute performance-based and/or procedural exams incorporating laboratory work and patient encounters into their licensing exam. By 1919, roughly twenty boards incorporated some type of procedural or skill-based component to their exams. These long-ago predecessors to the NBME Part III bedside and later Step 2CS did not persist as high costs and logistical challenges to such assessments led to their demise over the course of the 1920s.

Illinois was one of many boards to utilize performance/procedural skills in its licensing exam

The late 1960s-70s saw the complete transition to exams wholly developed and administered nationally, e.g., Federation Licensing Exam (FLEX); NBME Parts…and later USMLE and COMLEX. Such exams delivered better-quality assessment with higher reliability and over time a growing technical literature supporting the validity of the licensing decisions made, at least in part, upon passing these tests. The shift to computer-delivery in the early 2000s facilitated the use of new formats better able to assess specific competencies such as patient management with the computer-case simulations on USMLE Step 3.

With the inclusion of Step 2 CS in 2004, licensing boards enjoyed another tool designed to help ensure at least minimal proficiency in communication and clinical skills of their prospective licensees. Throughout the exam’s existence, state medical boards tended to be among its strongest and most reliable supporters.

Future prospects for assessing (within the licensing exam) competencies associated with clinical skills are a work in progress. In the wake of the USMLE decision, several avenues seem open. Some see this as the opportunity for a fresh start—to reimagine assessment of the competencies we associate with clinical skills by drawing upon the formative assessments now embedded in the medical education curriculum since the introduction of CS nearly twenty years ago. Schools are now free from the practical constraints of aligning their OSCEs, at least in part, as assessments that must prepare their students for Step 2CS. With the practical constraints of a “preparatory” role removed, educators should feel empowered to consider innovative approaches to teaching and assessing these critical competencies.

Such enthusiasm leads some to feel that teaching clinical skills can now safely be left to the medical schools—after all, it’s an accreditation standard, right? In fact, why worry about assessment of these competencies within licensing? Why not simply let the schools “attest” to the proficiency of their graduates in the wake of Step 2CS discontinuation. Wouldn’t such an attestation alleviate any lingering concerns among the medical regulatory community?  

One would like to think so yet there are those among us quietly concerned that over time, the financial pressures arising from the cost of maintaining an OSCE-style assessment will chip away at medical schools’ collective commitment to assess these competencies—or at the very least within the context of an OSCE-style format.

We would all be well-advised to monitor closely how schools respond to the discontinuation of Step 2 CS and the current suspension of Level 2-PE. Will this present moment give way to a flowering of innovative assessment…or will the grinding pressures of financial entrenchment prove this moment to be a false spring?

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

“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-