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.

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.

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.

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, 1^st 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

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

  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 19^th 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.

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.

Even 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.

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. He 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.”   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.

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.

 

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 19^th and early 20^th 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.

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.

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.

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.

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

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.

But 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 10^th 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.”

Flexner 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.

I drew the title for this blog entry from a 2012 commentary by Dr. Susan Behrens published in the Journal of Medical Regulation. In her commentary, she reflected on the series of event that led to her becoming the first woman elected as Chair of the Federation of State Medical Boards (FSMB) in the late 1980s.

Recently, I re-read her commentary; several things stood out to me. One was the strong sense that a woman running for elective office in the 1980s—even within a national association rather than political office—was not a matter to be taken lightly as missteps by a candidate served as potential fodder for the larger narrative of critics. Thus, in mulling over whether to run for the office, Behrens consulted two influential women in medicine at that time: Dr. Edithe Levit, President of the National Board of Medical Examiners and Dr. Nancy Dickey, member of the AMA board of trustees. Their advice boiled down to what you see as the title for this piece.

Another point that caught my eye was a number put forth in the article. Reflecting back on the first FSMB annual meeting she attended in the mid-1980s, Behrens recalled an afternoon gathering of the women members of state medical boards in attendance. As she recalled, “There were about seven of us.” Once my initial reaction (“That’s all?”) wore off, I began thinking seriously about this number. Was the actual number of women serving on state medical boards really that low in the 1980s? Or was this a nostalgic but skewed recollection of a different time? I decided to a closer look.

Starting in the 1980s, the FSMB produced an annual directory (FSMB Handbook) listing key information on every state medical board, including the names of every individual serving on a board. I poured over the handbook for 1985 and applied a crude metric, i.e., categorizing by gender based upon name and google searches to identify individuals whose names seemed non-suggestive of gender.

I know, I know—this is an imprecise methodology considering today’s non-binary gender identification but…sometimes we have to work with what we have, not what we wish we had.

The 1985 FSMB Handbook listed 66 state medical boards with a total of 602 individuals serving throughout the country; only 99 (16%) were women. In fact, most of the women serving on state medical boards were non-physicians in public member or ancillary health profession roles. Dr. Behrens was one of only 40 female physicians serving on medical boards in 1985—6.6% of the total state board membership.

Dr. Behren’s memory was probably accurate in remembering about 7 women at the FSMB annual meeting as total attendance was usually at or below 300 attendees in those days.

The statistically-minded reader is probably thinking, “Yeah, the numbers were low but put’em in context, Dave!” Okay. In 1980, there were roughly 37,000 women physicians (MDs) in active practice out of a total MD workforce in the U.S. of 459,000. I’ll save you trouble of doing the math—it’s about 8% which makes the 6.6% figure less startling.

But here is something that really blew me away. Forget total numbers of women or women physicians serving. Instead, think in terms of medical boards. How many state medical boards had any gender diversity in those days? Get this. There were 17 state boards with no women members serving in 1985. There were another 19 boards with no women physicians serving. In total, over half (36) of the medical boards listed in the FSMB Handbook in 1985 had no women physicians. Let that sink in for a minute. Remember, we’re talking 1985, not 1885. I can’t help but wonder what the impact of this absence was on board discussions and policy-making.

Fast forward to today. The FSMB’s membership database shows a demographic composition slowing aligning to more accurately reflect the physician workforce—though “slowly” seems the operative word.

FSMB records list 774 individuals serving on state medical boards nationally at the end of 2018 with women constituting 33.8% of the total. Female physicians are now almost 20% of total state board membership. This sounds pretty good until you realize that’s a still fair distance from their 33% of the national physician workforce with an active license as reported by the FSMB in 2016. Hmm. Glass half full or half empty?

On the plus side, I would point to this. There were only 2 medical boards (out of 70 total) with no women serving in 2018; another 5 boards with no female physician members. Here I see a clear positive sign. What once had been common in the demographic composition of state medical boards is now distinctly atypical. I suspect this trend will continue. Remember, state medical boards were once the exclusive domain of physicians. Now non-physicians constitute about 26% of total board composition.

Seems like the advice Dr. Behrens received more than 35 years ago remains relevant. Whether we’re talking about a job or an appointment or election, keeping the focus on ability while providing fair opportunity, offers at least a chance for the rest to work itself out.

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

 

 Sources:

FSMB Handbook (Federation of State Medical Boards: Euless, Texas, 1985)

ES Salsberg, GJ Forte, Health Affairs, “Trends in the Physician Workforce,” September/October 2002

A Young, HJ Chaudhry, et. al. “A Census of Actively Licensed Physicians in the United States, 2016,” Journal of Medical Regulation (2017)

Part 3: The final chapter

One week after Harry Brundidge and the St. Louis Star broke the story of Missouri’s medical diploma mills, Gov. Arthur Hyde invited a nationally prominent medical educator, Dr. Frederick Waite, to conduct “an immediate investigation” of all the state’s medical schools. Waite moved quickly and with the assistance of members of the Missouri Board of Health set forth review criteria and a rapid schedule for the visits. Collectively, they assembled a team for on-site inspections of all six of Missouri’s medical schools. The resulting report characterized the Kansas City College of Medicine and the St. Louis College of Physicians and Surgeons “not reputable under the intent of the [state’s] law.”

Waite’s choice of language (cited above) reflected an earlier twist to the story that underscored the connections and influence of the two diploma mill schools with sympathetic (or perhaps careless? corrupt?) legislators. The Missouri Board of Health had long refused to recognize these schools and license their graduates for practice based upon their substandard facilities and instruction. Both were categorized as substandard Class C schools by the AMA Council on Medical Education. But in 1921, a subtle change in state law directed the board to license graduates of “legally chartered” rather than “reputable” medical schools. This subtle language difference mattered significantly as both schools held a valid charter issued by the state of Missouri. Despite protests from the state medical association, the governor signed the bill into law. The Missouri Board of Health had no choice but to consider individuals holding a degree from either school as eligible for licensure—provided they pass the board’s licensing exam.

Thus, at the time of Waite and board’s report to the governor on the state’s medical schools in late 1923, the Missouri Board of Health lacked authority to deny a medical license to the Kansas City and St. Louis graduates. The report of Waite and the board characterizing the schools as “not reputable under the intent of the law” carried no legal force though it served as a public relations weapon against the schools—an effective one amidst the massive publicity triggered by the case.

The mountain of evidence secured in the fall 1923 and subsequent confessions of key witnesses like Robert Adcox and Williams Sachs brought matters to a head in 1924.  The governor turned to Waite once again to conduct an investigation—this one into the operations of the state’s board of health. Working rapidly, Waite’s interviews and assessment of board practices culminated in a report and a set of recommendations early in 1924. The board agreed to implement several operational measures (recommended by Waite) designed to bolster the integrity of their licensing decisions.  The board agreed that verification of license applicants’ personal information and credentials would be handled by one designated staff member. The board also agreed that, while the investigation by authorities played out, no Kansas City or St. Louis College graduates would be admitted to the examination. By June of that year, both protocols had been violated by the Secretary for the Health Board, Dr. Cortez Enloe.  This may not have surprised knowledgeable insiders, or even Waite, as earlier Enloe had declined to participate in any of the board’s visits to the Missouri medical schools in late 1923.

Despite mounting criticism and calls for his ouster, Enloe held fast to his position as board secretary. He only relinquished this role (though still remaining on the board) until further revelations reached the press concerning his association with a physician named Ray Horton. Horton presented himself as a “personal and political friend” of Enloe and in a later confession, admitted using this connection as a means for soliciting money from the Kansas City school and its degree holders with a promise of access to a Missouri license. The implication was clear: Enloe had some sort of financial relationship with the school through Horton. Governor Samuel Baker finally dismissed the entire board of health in September 1925. However, Enloe’s close friendship with Gov. Baker served him well. He managed to escape formal charges and the governor subsequently appointed Enloe to oversee the state’s Board of Prisons.

For his part, Harry Brundidge probably deserved, but did not receive, a Pulitzer Prize for his investigative journalism. It was, however, the start of a stellar career that saw him making headlines many times over…often as a result of his crime stories. His career brought him face to face with murderers, bootleggers, kidnappers, crooked cops, reporters “on the take” and nationally-known personalities like Al Capone and J. Edgar Hoover. (Below: Brundidge seated left of J. Edgard Hoover)

In a radio broadcast nearly three decades later, Brundidge reflected on this period of his journalistic career that frequently brought him into contact with “criminals.” The jaded reporter evinced surprising sympathy for these men.

 “At one time in my life I wrote a great deal about crime and criminals. I don’t know how many criminals I came to know personally while I was a newspaper man…the number is large. It has not been always easy to draw the line of behavior where it belonged, between friendship and the rights of society. But I did my duty on both sides of the line. I had my friends, and I helped the law.

What has not been hard has been to know that there is no line between people. They are all basically alike, all have good in them, all have the potentiality of failure.

I have known some criminals very well indeed. I have known, too, that I was no better than they were, I was only more fortunate. And because of this contact with criminals I have been privileged to have more friends than persons usually have. And the friends I have had, some of them, have been better friends because they weren’t able to make friendships with those on my side of the line. They knew I believed they had good in them. They knew I trusted them. So they trusted me. I am rich because they did.”

Sources:  This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine (ahead of print publication October 2018)

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

 

Part 2: “Bringing in a gusher”

In part one of this series, I shared how St. Louis Star and reporter Harry Thompson Brundidge infiltrated and exposed the operations of two Missouri medical diploma mills—the Kansas City College of Medicine and the St. Louis College of Physicians and Surgeons. Those two schools represented the tail end of a long period of sporadic medical diploma mill in America. Today’s blog post shares more of Brundidge’s look “behind the curtain” and how his story led investigators to medical licensing boards in Arkansas, Connecticut and Florida.

The story began in early August 1923 when Brundidge’s editor directed him to investigate medical diploma mill activity in the state. He gave his reporter one lead (Dr. Robert Adcox) and a direct order: Get yourself into “the [diploma] mill.”  Brundidge established a new identity as a St. Louis coal salesman, initiated contact with Adcox and soon found himself traveling to Kansas City where he met the self-proclaimed “brains” behind the operation, Dr. Ralph Voigt.

Harry’s first payment of $600 resulted in Adcox (pictured with Brundidge below)

securing a high school certificate for him complements of fellow conspirator William Sachs, the Director of Missouri Public Schools. This certificate and a bogus chiropractic degree served as the basis for advanced standing admission to the Kansas City College of Medicine. While waiting for these credentials, Harry received instruction from Dr. Voigt on an electro-therapy machine—an impressive looking but bogus diagnostic machine with numerous dials and flashing light switches. Voigt’s description of it as a “sucker machine” explained its primary purpose as a means for Harry to fleece unwary patients once they got him a medical license.

Adcox and Voigt then placed Harry in what they characterized as a “ringer class” at the Kansas City College—their reference to a group of sham students apparently mixed in with legitimate students attending the school.  Harry shared his nervousness about being placed in a room with legitimate medical students. Adcox and Voigt’s advice was simple: “Keep your mouth shut and your ears open.” This brought Harry into contact with another conspirator, Dr. Date R. Alexander, Dean of the Kansas City College.

Police raids and arrests of Drs. Adcox, Voigt, Alexander and Sachs in October 1923 secured a mountain of evidence, much of it leading directly to several licensing boards. The first of these was the Arkansas Eclectic Medical Board. Connections between this board and the Kansas City College had raised suspicions as early as 1917. The linkage grew more understandable once it became evident that the Chairman of the Arkansas Eclectic Board chair held a diploma from the Kansas City school.

The Arkansas board provided Kansas City graduates with their most direct route to medical licensure. The board examined 203 Kansas City ‘graduates’ between 1916 and 1924, licensing nearly 82% of these individuals. Amidst the publicity, the board proclaimed its innocence and offered to “throw open its books.” Amazingly, the Arkansas Eclectic Medical Board not only survived the 1923 scandal, it remained in statutory existence until 1955 when the state finally consolidated its separate medical, eclectic and homeopathic licensing boards. This inexplicable reprieve probably occurred because the board had virtually no one to license. Eclectic medical schools were already largely disappearing with them any graduates seeking a medical license.

The evidence acquired in Missouri tied directly to the Connecticut Eclectic Medical Board which presented the main conduit for licensing St. Louis College graduates. That board seemed to “open its doors” abruptly in 1921-22 as more than 140 graduates of substandard schools such as St. Louis College sought a medical license through that board. Political wrangling and closer investigation by a Connecticut grand jury left that state’s governor lamenting how the state had become a haven for unqualified doctors.

 

The grand jury heard insider testimony from Adcox and Sachs as well as a Connecticut licensee, George Sutcliffe, who had begun cooperating with state authorities began months earlier.

These confessions implicated the Dean of the St. Louis College (Dr. Waldo Briggs) and an insider (“fixer”) at the Connecticut Eclectic Medical Board—probably board chairman, James Christian.  Adcox’s confession described how advance copies of exam questions, lax proctoring and informal oral exams moved St. Louis grads to a Connecticut license. The police raid of Adcox’s home secured more than a dozen sets of exam questions from the Connecticut board spanning several years. The pipeline into Connecticut proved so lucrative that the conspirators described it as “bringing in a gusher” from the oil fields. The corruption went so deep that even the pre-medical credentials of the board’s chairman were the forged handiwork of Dr. Sachs. The grand jury summarized the situation this way: The eclectic medical board had been a “willing part[y]to fraudulent conduct.”

The Star’s expose and the resulting investigation even reached a defunct medical board! In Florida, the eclectic medical board had links to the Missouri-based diploma activities. As a cooperating witness, Adcox, described how advance copies of exam questions, crib notes and cash payments secured licenses in that state. Little of this reached the newspapers in 1923 as widespread irregularities had already been uncovered leading to the dissolution of that board in 1921. Two members of the Florida Eclectic Board were convicted of felony mail fraud in transacting the medical diploma trade. The board’s former secretary waged a protracted legal battle that culminated in his conviction and five-year prison sentence in 1927.

Not all of the nefarious activity led to licensing boards situated outside Missouri. In the final installment of this series, we’ll double back to see how the scandal imploded the Missouri Board of Health.

Source:  This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine (ahead of print publication October 2018)

 

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

Part 1: “Harry, why don’t you become a doctor?”

Harry Thompson stepped out of his rented room in St. Louis on the morning of August 13, 1923, waved to the postman walking past and called out to him—“Can you tell me where the nearest doctor lives?” The postman offered a hurried, “Right there!” pointing several houses down the street toward a man watering plants on his front porch. Dr. Robert Adcox heard the exchange and looked up to see Thompson making his way toward him. After a brief discussion and despite some initial reluctance, Adcox agreed to treat Thompson’s sore throat.

After a follow-up visit and several increasingly friendly conversations, Dr. Adcox presented his young patient with an opportunity—“Harry, why don’t you become a doctor?” Thompson responded with a chuckling protest, citing the obstacles to such a career move, including his lack of a high school diploma. Adcox brushed aside such concerns. “Bunk, Harry, my boy! You wouldn’t have to go to school to become a doctor.” He then explained how a high school diploma could be obtained and all obstacles removed to securing a medical diploma and a license to practice. Skeptical but intrigued, Thompson pressed for details. A smiling Adcox said, “Harry, a good magician never reveals how he does his tricks…be ready to go to Kansas City with me tomorrow night…I’ll show you how it’s done.” Two months later, Harry Thompson (aka Harry T. Brundidge, reporter for the St. Louis Star newspaper) possessed a high school certificate, a medical diploma (backdated to 1916) and a medical license.

This episode became the opening salvo in Brundidge’s exposé series launched October 15, 1923. The full-story of the Brundidge’s investigation played out on the front page of the Star almost daily over six weeks. The Star related how medical diploma mill activities centered primarily around two Missouri schools (Kansas City College of Medicine and Surgery; St. Louis College of Physicians and Surgeons) served as a pipeline to licensure in several states. The Star also revealed how the main players in the Missouri-based diploma mills (Drs. Robert Adcox, Ralph Voight, Date R. Alexander, Waldo Briggs) were part of a loose national network of medical diploma mills that once touched all regions of the country.

The Star’s first headline, ‘Ring Selling Medical Diplomas throughout the U.S.’ triggered massive national interest, presenting a major embarrassment to medical education and licensing in the United States. That this story has been conveniently forgotten should not be surprising. Fallout from the scandal and its resulting investigations culminated in the dissolution of one medical licensing board (Connecticut), the reorganization of another (Missouri) and a fight for existence in a third (Arkansas). A fourth board (Florida) was spared this ignominy only because earlier malfeasance led that state’s governor to dissolve it before the Star’s story broke. The Star’s reporting brought America’s Class C medical schools outside the whispered circles of medical education and into a national spotlight. A few of these schools operated so far on the fringe of U.S. medical education as to be little more than diploma mills—either explicitly through their design or as once legitimate institutions that drifted into de facto diploma mill activity. These schools represented dying institutions; Harry Thompson Brundidge and the St. Louis Star eagerly helped  to hasten their demise.

The 1923 exposure of the medical diploma mills in Kansas City and St. Louis concluded a sordid chapter in American medical education that saw similar institutions dotting the landscape. Though the most notorious 19^th century medical diploma mill (Eclectic Medical College of Pennsylvania) predated the post-Civil War rise of medical licensing laws, most of its rivals in the trade originated alongside the emerging medical legislation in the last quarter of the century. All regions of the country confronted medical diploma mill activity especially in the period before most medical boards had the authority to approve medical schools and thus restrict licensing to graduates of bona fide schools.

The west coast saw medical diploma mills in Washington and California. The Pacific College proved an especially persistent and egregious participant in the diploma trade drawing a protracted effort from the California medical board to force its closure.

New England witnessed its share in the illicit trade. Lax chartering laws in Massachusetts allowed medical diploma mills to flourish briefly in that state: Bellevue Medical College of Massachusetts, American University of Boston, Excelsior Medical College, Druidic University, etc. New Hampshire and Vermont authorities confronted medical diploma mills or fraudulent institutions functioned as well.

From the Atlantic to the Midwest, medical diploma mills operated at various times in the District of Columbia, Michigan, New Jersey, New York, Pennsylvania, Ohio and Wisconsin. Several of these operations originated with co-conspirators in John Buchanan’s Philadelphia diploma mill: Henry Stickney with New England University and Henry S. Thomas’ Detroit Eclectic Medical College. Others emerged from institutions originally founded with apparently legitimate purposes before lapsing into the diploma trade. This appears to have been the case with two similarly titled Cincinnati area schools: Physio-Medical College and the Physio-Eclectic Medical College. More than a dozen medical diploma mills plagued Illinois at various times especially the multiple ventures of Johann Malok in the1890s.

The problem persisted primarily because it represented a potentially lucrative business. The Wisconsin Eclectic Medical College’s owner was arrested in 1897 after lucrative sales earning tens of thousands of dollars. All of these schools were among the forty institutions identified as “fraudulent” by the AMA Council on Medical Education in its review of U.S. medical colleges published in 1918.

By 1923 the vast majority of these schools had closed or been publicly identified such that their graduates were nearly unlicenseable. Shutting down the remainder should have represented nothing more than a clean-up exercise. Not so!

I’ll continue the story in Part 2 and share how Harry Brundidge’s story implicated medical licensing boards in Arkansas, Connecticut and Florida.

 

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

Sources:

This multi-part series is derived from my article “An Underworld in Education: The Demise of Missouri’s Medical Diploma Mills,” Social History of Medicine 33(1): February 2020. To access the pdf version of the full article see https://academic.oup.com/shm/article/33/1/106/5124320?guestAccessKey=e4a2952d-f0be-45a6-b4f3-92ee20bdfb7e